The Effectiveness of Dental Health Education with and without Tooth Brushing Training on Reducing Plaque Scores in Students of SDN 060915 Medan

Efforts to establish proper tooth brushing behaviour for plaque removal can be carried out through education and tooth brushing training. Dental Health Education (DHE) serves as a promotive intervention to improve knowledge and behavior in maintaining oral health. To determine the difference in the effectiveness of Dental Health Education (DHE) with and without tooth brushing training on the reduction of plaque scores. This study employed a quasi-experimental design with a pre-post test control group. A total of 76 students were selected and divided into four groups: a control group without intervention and an intervention group: receiving DHE without tooth brushing training; receiving DHE with tooth brushing training once; receiving DHE with tooth brushing training three times. Plaque measurements were conducted using the Personal Hygiene Performance (PHP) index on the first day and the 21st day. Data were analyzed using the Wilcoxon test and Post Hoc analysis. There was a reduction in the mean plaque score across all groups, with the greatest decrease observed in the group receiving DHE with tooth brushing training three times, amounting to (2,09 ± 0,643). Significant differences were found in all three intervention groups (p < 0,05), except in the control group without intervention (p = 0,062). Additionally, there were significant differences in plaque scores between groups (p < 0,05), except between the group receiving DHE with tooth brushing training once and the group receiving training three times (p = 0,381). Education combined with tooth brushing training is an effective method for reducing plaque scores.

Introduction

Oral and dental health is of great importance and has an impact on overall bodily health. Oral and dental diseases are non-communicable diseases that can cause pain, discomfort, disability, and even death [1]. Based on Riskesdas, the national prevalence of oral and dental health problems in North Sumatra Province is 54,6% [2]. The most prevalent oral and dental health problems to date are dental caries and periodontal diseases. The prevalence of Indonesians experiencing oral health problems, including dental caries and periodontal disease, is 25,9%. Specifically among children, those aged 10–14 years are more frequently affected by oral health problems, with a prevalence of 25,2% [3]. Children between 8 and 10 years old are highly susceptible to dental caries since they frequently consume a wide variety of foods, particularly sugary, cariogenic items like chocolate, candy, and biscuits. Nevertheless, at this stage, school-aged children generally have limited knowledge and awareness regarding appropriate oral and dental hygiene practices [4].

Poor oral hygiene leads to the accumulation of plaque, which contains various types of bacteria. Plaque is a thin, colorless layer consisting of bacterial colonies that adheres to the tooth surface and constantly forms in the oral cavity. When it interacts with sugars from food, it produces acids that trigger demineralization of the tooth’s hard tissues, which, if left untreated, will progress to caries. The oral hygiene status of elementary school children is generally categorized as moderate, while the incidence of gingivitis among this group remains high [5].

Poor oral hygiene conditions can be observed from the accumulation of plaque on tooth surfaces, which can trigger the occurrence of gingivitis. Gingivitis is the most common periodontal disease among children. Excessive plaque accumulation along the gingival margins can lead to inflammation as an immune response to bacterial activity within the plaque, serving as a local factor in the development of gingivitis. Therefore, plaque removal is necessary through efforts to improve the oral and dental health of the community [6]. Proper tooth brushing is an effective method for maintaining oral hygiene, reducing dental caries, and preserving gingival health. However, compliance with learning the correct tooth brushing technique and practicing it regularly at appropriate times for caries prevention remains poor [7].

Education is an effective approach to improve knowledge about oral and dental health and to prevent related problems. Dental Health Education (DHE) provides comprehensive information about oral health, its influencing factors, and proper care methods, and requires well-planned actions by all stakeholders. In DHE, audiovisual materials such as videos and tooth brushing demonstrations are commonly used as educational media [8].

The Fone’s technique is recommended for preschool children for tooth brushing as it is relatively easy to teach, does not cause abrasion, does not irritate the gingiva, and is an appropriate brushing technique during the mixed dentition period [9]. The Fone’s technique involves circular motions applied to all tooth surfaces, including the front, sides, and back.1 This technique is performed by placing the bristles of the toothbrush perpendicular to the tooth surfaces facing the cheeks and lips, with the teeth in occlusion [10].

The Behavior Change Theory suggests that establishing a behavior change over 21 days involves three stages. The first seven days constitute the introduction phase, the second seven days involve revision and practice, and the final seven days focus on reinforcement to stabilize the newly adopted behavior, allowing it to become a permanent habit [11].

Elementary school age is an appropriate period to provide education on oral and dental health [1]. Children aged 7–12 years are in the mixed dentition period, during which they are more susceptible to oral health problems such as caries, gingivitis, inflammation, and stomatitis [12]. The World Health Organization recommends the age group of 10–12 years for conducting oral health research. At this age, children have a high interest in learning, supported by strong memory and good ability to grasp and understand the material presented [13]. According to Piaget's theory of cognitive development, children aged 9–12 years are in the concrete operational and formal operational stages, enabling them to categorize information received and think logically. Their motor development also corresponds to their physical growth, making this period ideal for providing education on tooth brushing techniques [14].

A study by Umniyati et al., on the effectiveness of Dental Health Education (DHE) and tooth brushing in reducing plaque scores among elementary school children showed that, among the four groups studied, there was a decrease in mean plaque scores in the group that received only DHE from 3,68 ± 0,88 to 2,90 ± 1,06; in the group that received DHE with tooth brushing training once from 3,60 ± 0,63 to 2,33 ± 0,70; and in the group that received DHE with tooth brushing training four times from 4,01 ± 0,74 to 2,19 ± 0,50. Meanwhile, in the group that did not receive DHE or tooth brushing training, the mean plaque score increased from 3,34 ± 1,09 to 3,50 ± 0,78. There was a significant difference in the reduction of mean plaque scores among the four groups (p = 0,000) [7].

Materials and Methods

This study employed a quasi-experimental design with a pre-test post-test control group approach involving fourth and fifth grade students at SDN 060915 Medan Sunggal, conducted from 31 July to 21 August 2024. The samples were divided into four groups: Group 1, the control group, received neither DHE nor tooth brushing training (n = 19); Group 2 received DHE without tooth brushing training (n = 19); Group 3 received DHE along with a single tooth brushing demonstration (n = 19); and Group 4 received DHE along with tooth brushing demonstrations three times, once per week (n = 19). The researchers used a phantom model, videos, and direct demonstrations to deliver the DHE. Participants in Groups 3 and 4 were taught to brush their teeth using the Fone’s technique.

Plaque scores were assessed using the Personal Hygiene Performance Index (PHP) method with the aid of disclosing solution, a probe, and a mouth mirror. The examination was conducted on the facial or lingual surfaces of the tooth crowns, with each surface divided into five areas: D (distal), G (gingival third), M (mesial), C (middle third), and I/O (incisal or occlusal third) as shown in Fig. 1. This assessment involved six teeth: the labial surface of the upper right central incisor, the labial surface of the lower left central incisor, the buccal surface of the upper right first molar, the buccal surface of the upper left first molar, the lingual surface of the lower left first molar, and the lingual surface of the lower right first molar. The plaque score was calculated by dividing the total plaque scores of all examined surfaces by the number of teeth assessed. A score of 0 was given if no plaque was present, and a score of 1 was given if plaque was present. The PHP plaque score criteria are as follows: 0 = very good, 0,1–1, 7 = good, 1,8–3,4 = fair, and 3,5–5 = poor.

Fig. 1. Subdivision of PHP index check.

Univariate analysis was conducted to describe the characteristics of the respondents. The Wilcoxon test was used to determine the differences in mean plaque scores before and after the intervention within each group. Post Hoc analysis was performed to identify differences in the mean plaque score reductions between groups.

Results

The results of the study showed that, based on age, the majority of respondents were 10 years old (51,3%), and in terms of gender, 51,3% were male. Regarding tooth brushing frequency, most respondents brushed their teeth ≥ 2 times per day (69,7%), with the most common brushing times being after breakfast and before bed (69,7%). Additionally, the majority of respondents brushed all surfaces of their teeth (64,5%). In terms of toothbrush use, most respondents used their own toothbrush (94,7%). Regarding sweet food consumption frequency, the majority of respondents consumed sweet foods more than twice a day (61,8%) (Table I).

Table I. Characteristics of Respondents (n = 76)

Characteristic	Amount (n)	Percent (%)
Gender
Male	39	51,3
Female	37	48,7
Age
8	3	3,9
9	22	28,9
10	39	51,3
11	7	9,2
12	5	6,6
Tooth Brushing Frequency
≥ 2 times	53	69,7
< 2 times	23	30,3
Tooth Brushing Time
After breakfast and before bed	53	69,7
When taking a shower	23	30,3
Brushed Tooth Surface
All Surface	49	64,5
Not All Surface	27	35,5
Toothbrush Use
Using your own toothbrush	72	94,7
Sharing a toothbrush with other family members	4	5,3
Sweet Foods Frequency
≤ 2 times a day	29	38,2
> 2 times a day	47	61,8

The results of the study showed that the mean plaque score before the intervention in the group without DHE and tooth brushing training was 3,66 ± 0,762, in the group with DHE was 3,69 ± 0,457, in the group with DHE and tooth brushing training once was 3,59 ± 0,849, and in the group with DHE and tooth brushing training three times was 3,40 ± 0,500. The findings also indicated that there were no significant differences in mean plaque scores between the groups prior to the intervention (p = 0,265) (Table II).

Table II. Mean Plaque Score Before Intervention (n = 76)

Groups	Amount (n)	Plaque score before intervention	p-value
Without DHE and tooth brushing training	19	3,66 ± 0,762	0,265
DHE without tooth brushing training	19	3,69 ± 0,457
DHE with tooth brushing training one time	19	3,59 ± 0,849
DHE with tooth brushing training three times	19	3,40 ± 0,500

The results of the study showed that the mean difference in plaque scores between before the intervention and day 21 in the group without DHE and tooth brushing training was 0,25 ± 0,485; in the group with DHE was 0,76 ± 0,654; in the group with DHE and tooth brushing training once was 1,76 ± 1,070; and in the group with DHE and tooth brushing training three times was 2,09 ± 0,643. Statistical analysis showed that there was no significant difference in the mean plaque score reduction between day 1 and day 21 in the group without DHE and tooth brushing training (p = 0,062; p > 0,05). However, there were significant differences in the mean plaque score reductions between day 1 and day 21 in the group with DHE without tooth brushing training (p = 0,000; p < 0,05), in the group with DHE and tooth brushing training once (p = 0,000; p < 0,05), and in the group with DHE and tooth brushing training three times (p = 0,000; p < 0,05) (Table III).

Table III. Differences in Mean Plaque Scores on the First Day and The 21st Day in Each Group (n=76)

Groups	Amount (n)	Plaque score (Mean ± SD)			p-value
		Before intervention	Day-21	Difference
Without DHE and tooth brushing training	19	3,66 ± 0,762	3,41 ± 0,660	0,25 ± 0,485	0,062
DHE without tooth brushing training	19	3,69 ± 0,457	2,93 ± 0,433	0,76 ± 0,654	0,000*
DHE with tooth brushing training one time	19	3,59 ± 0,849	1,83 ± 0,614	1,76 ± 0,070	0,000*
DHE with tooth brushing training three times	19	3,40 ± 0,500	1,32 ± 0,415	2,09 ± 0,643	0,000*

Statistical analysis showed that there was no significant difference in the mean plaque score reduction between day 1 and day 21 between the group with DHE and tooth brushing training once and the group with DHE and tooth brushing training three times (p = 0,381; p > 0,05). However, there were significant differences in the mean plaque score reductions between day 1 and day 21 among the following groups: between the group without DHE and tooth brushing training and the group with DHE without tooth brushing training (p = 0,005; p < 0,05); between the group without DHE and tooth brushing training and the group with DHE and tooth brushing training once (p = 0,000; p < 0,05); between the group without DHE and tooth brushing training and the group with DHE and tooth brushing training three times (p = 0,000; p < 0,05); between the group with DHE without tooth brushing training and the group with DHE and tooth brushing training once (p = 0,003; p < 0,05); and between the group with DHE without tooth brushing training and the group with DHE and tooth brushing training three times (p = 0,000; p < 0,05) (Table IV).

Table IV. Difference in Mean Plaque Scores On Day 1 and Day 21st Between Groups (n = 76)

Groups (Mean ± SD)		p-value
Without DHE and Tooth Brushing Training 0,25 ± 0,485	DHE without tooth brushing training 0,76 ± 0,654	0,005*
	DHE with tooth brushing training one time 1,76 ± 0,070	0,000*
	DHE with tooth brushing training three times 2,09 ± 0,643	0,000*
DHE Without Tooth Brushing Training 0,76 ± 0,654	DHE with tooth brushing training one time 1,76 ± 0,070	0,003*
	DHE with tooth brushing training three times 2,09 ± 0,643	0,000*
DHE with Tooth Brushing Training one time 1,76 ± 0,070	DHE with tooth brushing training three times 2,09 ± 0,643	0,381

Discussion

The results of the study showed that the mean plaque score before the intervention in the group without DHE and tooth brushing training was 3,66 ± 0,762, in the group with DHE without tooth brushing training was 3,69 ± 0,457, in the group with DHE and tooth brushing training once was 3,59 ± 0,849, and in the group with DHE and tooth brushing training three times was 3,40 ± 0,500. The findings also indicated that there were no significant differences in mean plaque scores between the groups prior to the intervention (p = 0,265) Table II. These results are consistent with the study by Umniyati et al., on the effectiveness of DHE and tooth brushing training in reducing plaque scores, which also showed no significant differences in the mean plaque scores of respondents before the intervention (p = 0,127; p > 0,05) [7]. This indicates that the mean plaque scores among the groups were relatively similar. This may be due to the respondents’ characteristic data, which showed little variation, with 69,7% of respondents brushing their teeth ≥ 2 times per day, 69,7% brushing their teeth after breakfast and before bed, and 64,5% brushing all tooth surfaces.

The results of the study showed that on day 21, the mean plaque score decreased in all groups: in the group without DHE and tooth brushing training, it decreased from 3,66 ± 0,762 to 3,41 ± 0,660 with a mean difference of 0,25 ± 0,485; in the group with DHE without tooth brushing training, it decreased from 3,69 ± 0,457 to 2,93 ± 0,433 with a mean difference of 0,76 ± 0,654; in the group with DHE and tooth brushing training once, it decreased from 3,59 ± 0,849 to 1,83 ± 0,614 with a mean difference of 1,76 ± 1,070; and in the group with DHE and tooth brushing training three times, it decreased from 3,40 ± 0,500 to 1,32 ± 0,415 with a mean difference of 2,09 ± 0,643 Table III. The greatest reduction in mean plaque score was observed in the group with DHE and tooth brushing training three times. This may be due to the use of audiovisual media and teaching aids such as dental models during the education sessions, which captured the attention of elementary school children by engaging both hearing (audio) and sight (visual), thus making the explanations easier to understand and apply in daily life [7], [13]. Repeated education sessions can change respondents’s behaviours, attitudes, and actions, aligning with Behavioural Change Theory, which demonstrates that behaviour and habit change occurs over 21 days [13], [15]. Djaali defines habit as a way of acting that is acquired through repeated learning, which eventually becomes permanent and automatic, requiring minimal concentration and becoming continuous. Therefore, habit can be understood as something that is routinely done or a behaviour that is frequently repeated by an individual, which over time becomes automatic and permanent [16].

The results of the study showed that there was no significant difference in the mean plaque score reduction between day 1 and day 21 in the group without DHE and tooth brushing training (p = 0,062; p > 0,05). However, significant differences were found in the mean plaque score reductions between day 1 and day 21 in the groups with DHE without tooth brushing training, DHE with tooth brushing training once, and DHE with tooth brushing training three times, each with a p-value of 0,000 (p < 0,05) Table III. These findings are consistent with the study by Muhammad et al., on the effectiveness of tooth brushing in improving oral hygiene among school children in Peshawar, which showed greater reductions in plaque scores in the group that received DHE and tooth brushing demonstrations, as well as in the group that received only DHE. This demonstrates that DHE combined with tooth brushing demonstrations is effective in reducing plaque scores (p = 0,00) [17]. This may be because education accompanied by tooth brushing training is an effective method for reducing plaque scores, as it allows respondents to focus their attention on the tooth brushing process. Additionally, observational learning is more effective than merely listening or reading [7].

The results of the study showed significant differences between the group without DHE and tooth brushing training and the groups with DHE and tooth brushing training once and three times, as well as between the group with DHE without tooth brushing training and the groups with DHE and tooth brushing training once and three times (p < 0.05). These findings are consistent with the study by Eriyati et al., on the effectiveness of DHE combined with tooth brushing demonstrations on oral hygiene among elementary school students, which showed a reduction in mean plaque scores in the group that received both DHE and tooth brushing demonstrations compared to the group that received only DHE. There was a significant difference between the two groups with a p-value of p = 0,00 < 0,05 [12]. This is because tooth brushing is a direct factor in plaque removal and, although it is generally practiced at home, respondents had not been brushing their teeth correctly. Therefore, when training was provided, respondents were able to perform proper brushing techniques at home, resulting in plaque removal. There was no significant difference between the groups with DHE and tooth brushing training once and three times (p = 0,385), although the mean plaque score was lower in the group with tooth brushing training three times. This may be because after receiving training, respondents were able to brush their teeth using the correct technique and continued to do so properly at home, making the frequency of training (once or three times) less impactful, even though repeated training is theoretically more effective in reducing plaque index [7].

Conclusion

DHE accompanied by tooth brushing training is more effective in reducing plaque scores compared to no DHE and tooth brushing training or DHE without tooth brushing training. The frequency of tooth brushing training influences the outcomes, although increasing the training from once to three times did not show a significant difference.

Acknowledgment

We would like to express our profound gratitude to all participants for their equal contributions to this research. Each coauthor played an integral role in the execution of the study, and their collective effort were crucial to the project’s success.

Conflict of Interest

The authors declare that they do not have any conflict of interest.