March, 2002

A Study of Educational Techniques to Promote Oral Health

En Español

Dr. Carlos Orue and Dr. Valentina Ulver de Beluatti

Summary

This paper explores the use of education experiences to modify deeply rooted behavioural patterns in the population. Education is an essential tool that allows the dissemination of information about oral health preventive techniques. There has been a misunderstanding of the term “prevention.” We have been too busy dealing with very modern techniques and have neglected oral health education. Too often excessive emphasis seems to be put on the latest technologies that help treat diseases. Little by little, thus, education loses its role as a means of promoting health. For this reason, working together with schools, community centers and other institutions, educators can be of great help in promoting oral health. The new oral health index called INSAO is a finding that poses the need to start quantifying health for the development of truly preventive plans.

Introduction

Education helps man develop as a whole being, capable of interacting with the world and thus to transform it. Because of this, education should be the first step towards changing deeply rooted habits. It is a tool that dentists can use to promote preventive oral health techniques. [7] The goal of the various health professionals has always been the prevention of pathologies. In the field of dentistry, however it seems to be difficult to effectively prevent oral disorders. [13]

Numerous scientific breakthroughs favored the development of new and more powerful technologies for treating established disease. [2] But the zeal to find ways of treating oral diseases has made dentists forget their main aim: To enable people to increase control over and improve their own oral health. [11]

The interventions carried out with diverse populations helped us discover that working together with health care providers, educators and other health officers, can help dentists promote oral health education messages.

If dentists become more aware of the need to teach children effective oral disease prevention strategies, a gradual awareness of the importance of oral health can be transmitted to the rest of the population. [6,12,15,17]

Objectives

General:

• To make dentists and, pediatric dentists in particular, aware of the importance of using education as an instrument to promote oral health.

Specific:

• To identify and quantify indicators of health, as opposed to indicators of disease
• To go beyond city boundaries
• To educate to promote oral health

Methods and Materials

In order to fulfill these objectives four interventions were carried out with the aid of educators and health officers. [1,4,5,8,9,10,14,18]

1. The teaching of a foreign language as a tool to promote oral health in the city:

   This experience was carried out with two groups of 12-year-old students. One of these was studying English in a private school in Cordoba, Argentina, and the other was studying German in a private school in Buenos Aires, Argentina.

   Basic vocabulary, such as toothpaste, toothbrush, dental floss and so on, was introduced though memory games.

   Figure 1. Memorizing vocabulary through a game

   

   Secondly, the students were given an interview that they had to do in pairs. They had to ask a classmate multiple-choice questions to find out how much the latter knew about dental care. To introduce an element of fun and to decide turn taking a popular game called ” Scissors, Paper, Rock” was played. After the students finished the interview, effective ways of preventing cavities were discussed in class.

   Figure 2. Scissors, Paper, Rock

   

   The same intervention was done with the group studying German in Buenos Aires, Argentina. (Fig 3,4)

   Figure 3. Memory games

   

   Figure 4. Scissors, Paper, Rock

   

2. Visit to a public school in Tostado, Santa Fe, Argentina:

   For this intervention, several talks were organized with teachers and primary school students (486 students) These talks dealt with topics such as basic dental health care and the importance of oral health. Materials such as pictures, puppets and storybooks were used and games such as “Scissors, Paper, Rock” were played. In all of these activities the teachers played an important role and participated actively. (Fig 5,6)

   Figure 5. Teaching and practicing brushing

   

   Figure 6. Interaction between teacher and dentist

   

   Follow-up activities were planned with the help of the school teachers. The purpose of the activities was to practice the newly learned concepts through the various school subjects. In language, fairy tales and stories where a tooth was the main character were told and then sentences were grammatically analyzed. In Math, the students had to solve problems counting the number of decayed teeth versus the number of sound ones. Finally, in art, the students were asked to draw about what they had learned that day. The drawings made by the students helped teachers and dentists find out about the effect the organized activities had on the students. (Fig 7)

   Figure 7. Students’ impressions on the talk

   

3. Socio–pedagogic visit to indigenous groups in Jujuy (North-west of Argentina):

   Small villages far from the capital of Jujuy were visited. Clothes and medicine donations were given to the villagers and basic health services were provided. After examining the villagers’ oral as well as systemic health, a list was made of the pathologies found. Then, centers of infection were eradicated through the extraction of decayed teeth (Fig 8-10). At the same time, intensive oral-health orientation was given to the natives through demonstrations and didactic activities.

   Figure 8. Motivating the indigenous to teach them

   

   Figure 9. Brushing the teeth by a stream

   

   Dental care techniques

   Figure 10. Disclosing bacterial plaque

   

   Activities such as demonstrations and talks were given to several age groups to teach some basic strategies for maintaining and improving oral health. This was done through story telling, cartoon –like pictures, demonstrations and games. The people joined in willingly although they were initially motivated by the strangeness of the event. This experience was multifaceted since doctors, teachers, high school students and dentists participated.

4. Educational, social and sanitary visit to an indigenous group in Tostado. (Santa Fe, Argentina)

   The group visited was an indigenous community belonging to a group called “Mocovies”, an originally nomadic tribe, living in Tostado since 1959. They give great importance to traditions, so before conducting this experience, motivational strategies were developed to approach this group effectively. Although their literacy level is low, the “Mocovies” are very keen on learning. A temporary dispensary was used to offer medical assistance to the community. An oral examination was given by a trained dentist (Fig 11,12) that helped fill in an oral health file and an oral health index (OHI). Both files were designed so as to quantify the oral health status (Table 13,14). Activities such as practical demonstrations, didactic games and cartoon-like teeth pictures were used to motivate the “Mocoví” people (Fig 15,16).

   Figures 11-12. oral examination

   

   Figure 13. References

   ORAL HEALTH FILE
   NAME	AGE	SOUND TEETH caries free, or filled in perfect condition			BACTERIAL PLAQUE YES-NO	SOUND GUMS YES-NO	TOOTHBRUSH Do they have a toothbrush YES-NO	BRUSHING Do they brush YES-NO	FREQUENCY D – Daily W – Weekly M – Monthly N – Never	ORAL HEALTH INDEX INSAO (see Fig 14) T – Total R – Relative
   		TEMPORARY	PERMANENT	TOTAL total amount of teeth present in the mouth
   C.G.	5	12	6	20	YES	YES	NO	NO	-	R90a
   C.C.	13	-	16	28	YES	NO	NO	NO	-	R57b
   M.C.	16	-	15	28	YES	NO	NO	NO	-	R53b
   C.R.	8	7	6	24	YES	NO	NO	NO	-	R46b
   F.M.	11	12	12	24	YES	YES	NO	NO	-	Ta
   F.C.	11	-	16	24	YES	NO	NO	NO	-	R66b
   G.M.	13	-	18	26	YES	NO	NO	NO	-	R69b
   J.A.	16	-	19	28	YES	NO	YES	YES	1/W	R67b
   F.G.	13	-	28	28	YES	YES	NO	NO	-	Ta
   L.M.	3	20	-	20	YES	YES	NO	NO	-	Ta
   E.M.	2	16	-	16	YES	YES	NO	NO	-	Ta
   F.M.	5	15	-	20	YES	YES	NO	NO	-	R75a
   G.R.	4	12	-	20	YES	YES	NO	NO	-	R60a
   D.M	8	9	15	24	YES	YES	NO	NO	-	Ta
   A.R.	6	20	-	20	YES	YES	NO	NO	-	Ta
   T.M.	5	16	4	22	YES	YES	NO	NO	-	R81a
   M.S.	7	3	4	24	YES	YES	NO	NO	-	R29a
   M.R.	4	19	-	20	YES	YES	NO	NO	-	R95a
   C.C.	14	-	28	28	YES	YES	NO	NO	-	Ta
   E.R.	3	20	-	20	YES	YES	NO	NO	-	Ta
   M.G.	30	-	3	30	YES	NO	NO	NO	-	R10b
   J.A.	30	-	20	32	YES	NO	NO	NO	-	R62b
   M.S.	31	-	9	28	YES	NO	NO	NO	-	R32b
   O.B.	31	-	27	32	YES	YES	YES	YES	1/D	R84a
   N.R.	27	-	8	32	YES	NO	NO	NO	-	R25b

   Figure 14. Oral health index

   Teeth: T: Total dental health R: Relative dental health (Presence of decayed elements if disease is present) – expressed in % of healthy teeth over the total number of teeth present in the mouth. Gums: a: healthy gums b: unhealthy gums ( extent of disease is not considered) Examples: Ta: Subject with total dental health and healthy gums. Tb: Subject with total dental health and unhealthy gums . R50a: Subject with a 50% relative dental health and healthy gums. R50b: Subject with a 50% relative dental health and unhealthy gums. Knowing the number of subjects with unhealthy gums is important to determine priorities and to design an effective oral-health plan.

   Figures 15-16. Motivating and examining the natives.

   

   The members of the community were summoned by the health officer who was a member of their group. They were willing to cooperate as soon as they discovered our objective. They realized that the purpose was to preserve sound teeth which motivated their interest in learning about inexpensive basic oral care.

Analysis of the results

The interventions were carried out in diverse populations with different literacy levels but despite this, the results did not reveal great differences. The information derived from the interviews and the games can be seen in the following charts: (Tables 17,18)

Figure 17. Interview

Size of the sample:
Private School in Córdoba ( English): 21 students, 12 years old
Private School in Buenos Aires ( German): 21 students, 12 years old
Public school in Tostado, Santa Fe : 21 students, 11 years old

Figure 18. Scissors, Paper, Rock

From these charts it can be seen that the students’ awareness of oral health prevention was quite similar in the three schools. In general they all agree on the reason why they visit the dentist, the need to brush their teeth and the proper time for brushing. The main difference between the schools is the frequency of visits to the dentist. On one hand, 75% of the students studying German go to the dentist once a month and on the other, 90% of the students from Tostado go only once a year. From these results it could be said that it is necessary to promote oral heath beyond city boundaries. At the “Scissors, Paper, Rock” game, the results were similar in the three schools except for their knowledge of the use of fluoride.

It must be noted that these findings could be very useful if translated into strategies designed together with educators. In this way, the students’ misconceptions could be reduced and they could become more aware of the need to protect their teeth on a daily basis.

The communities in Jujuy and Tostado were pleased when they realized that a great number of them had healthy teeth and which enhanced their interest in learning the basics of brushing and flossing. A great number of patients with sound teeth was found and recorded in the health file.

Discussion of the results

The activities organized at the private schools require a great deal of planning and coordination between the dentist and the language teacher. Once this is done, it is the teacher who talks about dental care in the target language with the students and practices the new concepts through several language activities. With constant repetition and little by little, the students will eventually internalize some basic concepts that will in turn become effective oral health habits. Due to the entertaining character of the activities, the German and the English classes enjoyed the games and, without truly being aware of it, they acquired some dental health knowledge. It is necessary to notice, however that for these concepts to be assimilated more practice and creative repetition through games is needed. [6,8]

At the public school in Tostado, the visit was welcomed by the teachers and the students. The students showed enthusiasm during the talks, but some reinforcement visits are necessary. The activities were of a cross-curricular nature since the newly learned concepts were reinforced through activities in Language, Math and Art. [3,5,11]

In Jujuy the experience was favorable since the community was ready to apply what they had learned at the talks and demonstrations. This was evidenced in the fact that they started going for check-ups even when they were not experiencing pain. [1,3,4,13,18]

In Tostado, the “Mocoví” community was at first suspicious regarding the purpose of the visit. Researchers and professionals usually visit them to study their traditions and behavior and they tend to dislike it. When they discovered that the purpose of the visit was to help them take better care of their teeth, they cooperated almost immediately. Some local trainers were selected from their community and they are now in charge of teaching others and reinforcing what was learned. [1,3,14,15]

Conclusion

The interventions were conducted in culturally diverse populations and several conclusions could be drawn from them.

• Education is a positive experience that may have long term effects. For the learning to be effective, however, the students’ interest has to be aroused. Because of this, the intervention has to be carefully coordinated and planned between the dentist and the educator in order to motivate the students. Education is a tool that allows dental health professionals to reach a greater part of the population and it can eventually bring about changes in habits that may contribute to a better oral heath. Thus, working together with the aid of other health officers healthy behaviors can be more easily promoted.
• Going beyond city boundaries is an enriching experience since it allows the dentist to have contact with culturally and socially diverse populations, and it helps demonstrate the effectiveness of strategies to raise awareness of the importance of oral health.
• The INSAO (OHI) works as a useful tool to evaluate the oral health of the populations visited and it emphasizes the need to start quantifying oral health.
• The oral health status observed allowed us to develop preventive plans instead of relying on treatment as prevention.
• New insights into the causes of oral diseases and the latest technologies for preventing them are now at our disposal. What is still missing, however, is finding ways of effectively turning these findings into improved prevention.

Bibliography

1. ARNET J., BALLE-JENSEN L. – “Bases Of Risk Behavior: Danish Adolescents” – Child Development 1993; 64:1842-1855.

2. ARREDONDO A. – “Análisis y reflexión sobre modelos teóricos del proceso salud-enfermedad” – Cad. Saúde Públ. 8(3):254-261. Rio de Janeiro, 1992.

3. BRECKON D. J., HARVEY J. R., LANCASTER R. B. – “Community Health Education” – Gaithersburg, Maryland: An Aspen Publication, 1994.

4. CAMPS V. – “Los Valores De La Educación” – Madrid: Alauda, 1993.

5. GREEN L. W., KREUTER M. W. – “Health Promotion Planning: An Environmental And Educational Approach” Mountain View Calif: Mayfield Publishing, 1991.

6. HAWES H. SCOTCHMER Ch. – “Children for Health” – St. Albans, UK: The Child-to-child Trust y UNICEF, 1993.

7. KETHAN J. – “Compendio De La Humana Salud” – Madrid: Arco,1990.

8. MAIBACH E., MURPHY D. A. – “Self Efficacy In Health Promotion Research And Practice: Conceptualization And Measurement” – Health Education Research. Theory and Practice 1995; 10(1):37-50.

9. MIRANDA J. – ” ¿Salut, Forma Física, Estética O Benestar?” – Apunts. Educatió Física, 1991; 61-70.

10. OLIVA A., MENDOZA R., BATISTA-FOGUET J. M. – “Estilos De Vida Relacionados Con La Salud Durante La Transición A La Adolescencia” – 1995.

11. O.M.S. – “Educación Para La Salud” – Manual sobre Educación Sanitaria en atención primaria de salud,(¿es título?) Ginebra: 1989.

12. RODRÍGUEZ MARIN J. – “Psicología Social De La Salud” – Madrid: 1995.

13. SAN MARTÍN H. “La Crisis Mundial De La Salud. Problemas Actuales De Epidemiología Social” – Madrid: Karpos, 1982.

14. SARASON B.R., SARASON I. G., PIERCE G. R. – “Social Support: An International View” – New York: Wiley and Sons, 1990.

15. SIMON M. A. – “Psicología de la Salud” – Madrid: Pirámide, 1993.

16. VALLA V. – “Educación, salud y ciudadanía” – Cad. Saúde Públ. 8(1):30-40. Rio de Janeiro, 1992.

17. VANISTENDAEL S. “Cómo Crecer Superando los Percances. Resiliencia: Capitalizar las Fuerzas del Individuo” – Ginebra: BICE, 1995.

18. ZIONI F. – “Pesquisa participante e cidadania” Pesquisa social em saúde – Cortez, Sao Paulo. 1992.

Contributed by:

Dr. Carlos Orue
Graduate dentist from the Universidad Nacional de Córdoba, Argentina. Since 1999 he has traveled to poor areas in his country to work with natives in an attempt to teach them preventive techniques. He has worked with primary and secondary educators so as to motivate children and teenagers to take better care of their teeth.

Dr. Valentina Ulver de Beluatti, DDS
Doctor of Odonthology, Consultant in Dental Trauma