Indian Pediatr Suppl 2009;46: S86-S90
Effectiveness of a Community Oral Health
MKC Nair, Manju Renjit, KE Siju, ML Leena, Babu George, G
From Child Development Centre, Medical College,
Thiruvananthapuram, Kerala, India.
Correspondence to: Dr MKC Nair, Professor of Pediatrics
and Clinical Epidemiology and, Director,
Child Development Centre, Medical College,
Thiruvananthapuram 695 011, Kerala, India.
To evaluate the effectiveness of a community oral health awareness
program given to mothers through trained community level workers (Junior
Public Health Nurses (JPHNs) and Anganwadi workers (AWWs). Methods:
Oral health education materials were prepared based on the findings
of a knowledge survey among community workers and mothers of children
(0-6 years) in a selected block panchayat in Kerala. Using this
material, classes were held for health workers and through them for the
mothers. Post evaluation for both the groups was done using the same
questionnaire. Results: The post intervention survey among both
the community workers and the mothers showed statistically significant
improvement in knowledge regarding oral hygiene habits, importance of
milk teeth, causes of dental diseases, prevention of dental diseases,
and treatment of certain dental conditions. Conclusion: A
community health awareness program has a positive effect on knowledge of
community workers and thereby in the mothers. The feasibility of
integrating oral health education in the existing primary healthcare
activities needs to be explored.
Keywords: Community workers, Dental caries, India, Oral health
Although the health indicators of Kerala
are comparatively better than that of other states, prevalence of oral
diseases like periodontal disease and dental caries are similar to the
National figures as shown in 2002-03 National Oral Health Survey(1). The
significant dental caries index was highest among the five year-olds in
the state and awareness of oral health problems was also found to be low
in this survey. Dental caries and periodontal disease are two most common
oral diseases in India. A comprehensive review observed a prevalence rate
of 1-12% of early childhood caries in developed countries, and prevalence
as high as 70% in developing countries or within disadvantaged
populations(2). These diseases can affect the growth and development of
the child, by affecting diet and nutrition patterns and leading to chronic
oral infections, pain, suffering and tooth loss. Persistent pain affects
the overall wellbeing of the child. Their impact on individuals and
communities, as a result of pain and suffering, impairment of function,
and reduced quality of life, is considerable. Epidemio-logical studies
have shown that 90% of the Indian population suffers from various type of
dental diseases. The incidence of dental decay and gum disease is as high
as 70% among children. Further, there is a critically low dentist to
population ratio of only 1:100000 in rural areas and 1:35000 in urban
areas(3). Besides this, there is acute shortage of equipment and material
and other essential facilities to run the minimal curative services for
Dental caries and periodontal diseases are both
preventable diseases and significant reduction in the disease pattern has
been demonstrated worldwide by oral health education emphasizing
importance of preventive strategies. As the disease starts in early
childhood with the eruption of the milk tooth, preventive strategies would
be most effective if it is started on or before the time of eruption of
milk tooth at about 6 months of age. Many studies indicate that
educational programs can effectively increase knowledge and improve
attitudes related to infant oral health(5,6). Empowering community workers
like junior public health nurses (JPHNs) of health services and anganwadi
workers (AWW) of Integrated Child Development Services (ICDS), in oral
health, and providing basic oral health awareness to the mothers through
them is a feasible model for a country like India; where oral health is
not a priority in the primary health care as yet. The service of a JPHN is
available for every 5000 population while service of an anganwadi worker
is available for every 1000 population. At the Anganwadis, monthly meeting
of mothers are held and these serve as platforms for health education.
JPHNs and Anganwadi workers get rigorous training in
various health aspects but dental health is not given due importance
during their initial or in-service trainings. Nurses are expected to play
active role in the promotion of health including oral health, particularly
in the rural under-served communities. There is a paucity of oral health
education in nursing curricula(7). Educating mothers on infant dental care
will promote lifelong good oral hygiene habits and will bring down the
prevalence of oral diseases considerably. Various types of oral health
maintenance materials have been used and countless numbers of dental
health information programs have been conducted in schools and other
settings, but not primary health care settings catering to 0-6 year
olds(8-12). The broad objective of the "Oral Health Care Project Kerala"
is to incorporate preventive and promotive oral healthcare in to the
broader concept of primary health care in the state. This report forms the
results of the effectiveness of an education program conducted among
community workers and mothers of under-6 year olds.
The study was conducted in a block panchayat in
Thiruvananthapuram district of Kerala, after obtaining ethical clearance
of the institutional ethical committee. Two separate
interviewer-administered questionnaires, one for the community workers and
the other for mothers of children (0-6 years) were prepared, pretested,
piloted and necessary odifications made. The results of the baseline
survey, conducted among community workers and mothers provided an
understanding of areas where knowledge should be imparted on oral health.
The same was used in developing training materials, which included
audiovisual aids, modules, charts, posters and brochures in the regional
language. After finalization of the training schedule, training classes on
oral health were conducted for JPHNs and AWWs. Training was conducted as
one-day program in four batches of around 50 participants per day. Dental
surgeons conducted the classes with the help of audiovisual aids and the
trainees were given modules and booklets on oral health so as to help them
to conduct training in the community.
Subsequently, the trained JPHNS and AWWs together
conducted oral health classes during mothers’ meetings at Anganwadis.
Classes were conducted in 137 Anganwadis and 2708 mothers were trained
during these meetings. The trained JPHNs and AWWs took classes using the
modules prepared for this purpose. The effectiveness of the program was
evaluated by a post-intervention knowledge survey among JPHNs and AWWs,
and mothers who attended the training sessions, two months after the
training. 115 workers and 232 mothers took part in the pre-intervention
and post-intervention surveys. For statistical analysis, McNemar test
using binomial distribution was used.
In order to assess the effectiveness of intervention,
changes in knowledge level of the participants were analyzed in five
important domains; oral hygiene habits, importance of milk teeth, causes
of dental diseases, prevention of dental diseases and treatment of certain
dental conditions. Results of the pre-and post-intervention among
community level workers showed that statistically significant improvement
in knowledge occurred among the participants in all areas (Table
I). The level of oral health knowledge in pre survey was low among the
participants, which stresses the need for in-service training. Considering
the fact that the training of trainers was given as a one-day program, the
effect created is rather significant.
Effectiveness of Intervention in JPHNs* and AWWs (N=115)
Health workers providing correct response
N=115, n (%)
N=115, n (%)
Knowledge about oral hygiene habits
Amount of toothpaste
Method of cleaning gum pads
Starting of tooth brushing habit in children
Knowledge about importance of milk teeth
Conservation of milk teeth is essential
Reasons for conserving milk teeth
Knowledge about causes of dental diseases
Causative factors in dental caries
Dental decay as an effect of night feeding
Causative factor in gum disease
Knowledge about prevention of dental diseases
Method of prevention of gum disease
Retained milk teeth should be extracted
Knowledge about treatment of certain dental conditions
Filling as treatment option for dental caries
Treatment method of gum disease
First measure for tooth avulsion
Method of treating fractured tooth
public health nurse; AWW: Anganwadi worker
The workers conducted oral health classes at mothers
meetings in the anganwadis. The pre and post comparison of knowledge level
in mothers showed that the classes provided by the workers led to
significant improvement in oral health knowledge of mothers (Table
II). In the pre-intervention survey, only 3% of mothers knew that
professional scaling was a treatment option for gum disease and this
improved to only 10% in the post intervention period. This low improvement
in knowledge gain can be observed in the knowledge change of community
workers also (Table I). Being a one-day program, the
training of trainers may not have covered these areas satisfactorily as
reflected in the results. This highlights the need for incorporating more
information about these aspects in the training program.
Effectiveness of Intervention in Mothers
|Mothers providing correct response
||N=232, n (%)
||N=232, n (%)
|Knowledge about oral hygiene habits
|Starting of tooth brushing habit in
|Knowledge about importance
of milk teeth
|Conservation of milk teeth is essential
|Reason for conserving milk teeth
|Knowledge about causes of
|Causative factors in dental caries
|Causative factor in gum disease
|Causative factor in gum disease
|Knowledge about prevention
of dental diseases
|Method of prevention of gum disease
|Prevention of malocclusion
|Knowledge about treatment of
certain dental conditions
|Filling as treatment option for dental
|Treatment method of gum disease
|First measure for tooth avulsion
|Method of treating fractured tooth
Dental diseases have a very high prevalence. Oral
diseases have health consequences far beyond the oral cavity including
health and developmental problems in children, adverse pregnancy outcomes
and are even implicated in cardiovascular diseases. For optimal oral
health, oral hygiene habits should be instilled at a very young age
itself. Primary dental care is the way of achieving good oral health for
the community. The most feasible and sustainable method to achieve this is
through integration of oral healthcare in the existing primary healthcare
activities, through training of community level workers to identify and
promote oral healthcare practices. This intervention made statistically
significant changes in knowledge level of the participants in the areas of
oral health addressed.
This study results suggest that including oral health
education in JPHNs and AWWs training program would enable them to provide
oral healthcare instructions to mothers. The project which aimed to
empower local communities through existing primary healthcare
infrastructure and outreach mechanisms to provide a cost effective,
replicable mechanism of providing primary preventive oral healthcare to
the community proved to be a feasible model. However, for knowledge to be
translated to positive practice and sustained behaviour change, concerted
efforts and long term follow-up is necessary.
Dr K Sandeep, ECSRC; Dr K Nanda Kumar, and Dr Shobha
Kuriakose, Government Dental College, Thiruvananthaupram; Dr Shankara
Sharma, SCTIMST; Asokan N and Muraleedhran K Child Development Centre,
Contributors: MKCN, and MR were involved in
designing the study and preparation of the manuscript and MKCN will act as
guarantor. SKE, LML, and BG were involved in the data collection. SKG
helped in community mobilization.
Funding: European Commission Sector Investment
Programme, Directorate of Health Services, Kerala.
Competing interests: None stated. The findings and
conclusions of this study are those of the authors and do not necessarily
represent the views of the funding agency.
What This Study Adds?
• Knowledge of oral hygiene practices in children
is poor among mothers and community workers.
• Oral health education classes can improve
knowledge of oral hygiene practices of mothers and community
1. National Oral Health Survey and Flouride Mapping,
2002-2003. New Delhi: Dental Council of India, Ministry of Health and
Family Welfare, Govt. of India, 2004.
2. Milnes AR. Description and epidemiology of nursing
caries. J Public Health Dent 1996; 56: 38-50.
3. Indian Dental Association and Colgate launch Colgate
World of Care, Community News. http://www.colgate.co.in. Accessed July 15,
4. Lal S, Paul D, Pankaj V, Vashisht BM. National Oral
Health Care Programme (NOHCP) Implementation Strategies. Indian J Comm Med
2004; 29: 1-9.
5. Friel S, Hope A, Kelleher C, Comer S, Sadlier D.
Impact evaluation of an oral health intervention amongst primary school
children in Ireland. Health Prom Internat 2002; 17: 119-126.
6. Nigg KA, Nowak A, Woldridge P, Williams R, Dawson D.
Effectiveness of an infant oral health educational program delivered to
first-time pregnant Native American women, The IADR/AADR/CADR 80th General
Session (March 6-9, 2002) http://www.iadr.confex.com/iadr/2002
SanDiego/techprogram. Accessed August 23, 2007.
7. Ogunbodede EO, Rudolph MJ, Tsotsi NM, Lewis HA,
IloyaJI. An oral health promotion module for the primary health care
nursing course in Acornhoek, South Africa. Public Hlth Nurs 1999; 16:
8. Thomas S, Tandon S, Nain S, Shobha T. Effect of
dental health education on the oral health status of a rural child
population by involving target groups. J Indian Soc Pedod Prev Dent 2000;
9. Mayer MP, de Paiva Buischi Y, de Oliveira LB, Gjermo
O. Long-term effect of an oral hygiene training program on knowledge and
reported behavior. Oral Health Prev Dent 2003; 21: 37-43.
10. Joshi N, Rajesh R, Sunitha M. Prevalence of dental
caries among school children in Kulasekharam village: A correlated
prevalence survey. J Indian Soc Pedod Prev Dent 2005; 23: 138-140.
11. d'Almeida HB, Kagami N, Maki Y, Takaesu Y.
Self-reported oral hygiene habits, health knowledge and sources of oral
health information in a group of Japanese junior high school students.
Bull Tokyo Dent Coll 1997; 38: 123-131.
12. Golbarani JF, Pack AR. Knowledge, awareness and use
of interdental cleaning aids by dental school patients in New Zealand. JNZ
Soc Periodontol 1994; 78: 7-16.