The worldwide prevalence of dental disease is a constant reminder of the universal need for effective dental health education programs ¹. School-aged adolescents are in particular need of preventive program to ensure positive long-term oral health and hygiene. World Health Organization reports 70–95% of school-aged children have experienced dental caries in South-East Asia ².59% of adolescents of 12 to 19 yrs have had dental caries in their permanent teeth.20% of adolescents of 12 to 19 yrs have untreated decay. Adolescents have an average of 0.54 decayed or missing permanent teeth and 1.03 decayed permanent surfaces. Mean number of decayed, filled, and decayed or filled permanent teeth among adolescents is 0.39, 1.38, 1.78³.As per multi-centric oral health survey conducted by Ministry of Health -WHO India collaborative bi annum program 2007-08, the prevalence of dental caries among the 12-year-old ranged between 23.0 % to 71.5 %.

 Health education is a key strategy in the process of acquisition of behaviors that promote and maintain health ⁴. Mastrantonio and Garcia point out that it is possible to transform negative attitudes into healthy habits to the population through education ⁴. Oral health is indispensable to general health and quality of life ^5,6. Oral health is multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow, and convey a range of emotions through facial expressions with confidence and without pain, discomfort, and disease of the craniofacial complex. ⁷

WHO defines ’Adolescents’ as individuals in the 10-19 years age group . The American Academy of Paediatric Dentistry (AAPD) recognizes that the adolescent patient has unique needs ⁸. The adolescent patient is recognized as having distinctive needs due to: (1) a potentially high caries rate; (2) a tendency for poor oral hygiene, nutritional habits, and routine oral health care access; (3) increased risk for periodontal disease and traumatic injury; (4) an increased esthetic desire and awareness; (5) increased risk for periodontal disease and traumatic injury.

Adolescence can be a time of heightened caries activity and periodontal disease due to an increased intake of cariogenic substances and inattention to oral hygiene procedures.⁹

According to the cross sectional study it was found that 41% of adolescent brushed twice a day and majority of them stated that they brushed their teeth once a day before the breakfast. 76% brushed their teeth for more than 3 mins.

45% stated that they used 2 cm of toothpaste on a toothbrush. 50% changed their toothbrush after 6 months.57.5% do not know whether their toothpaste is fluoridated or not.

 Adolescent patients need encouragemsent and motivation to brush with fluoridated toothpaste and floss regularly. Discussions regarding oral hygiene can highlight the benefit of the topical effect of fluoride, removal of plaque from tooth surfaces, and also decrease halitosis and improve esthetics. ^{10, 11}

 Age 12  years has been a global indicator for comparisons and surveillance of disease trends at international level ^{12, 13}. Proper use of toothbrush requires a certain degree of dexterity and skill. Nonetheless, children as young as 11  years of age have the ability to brush effectively .¹⁴ It was expected that at this age student can clearly understand the subject being taught to them. They have enough manual dexterity to master the proper technique of brushing .¹⁵They are in the very influential stages of life; the habits, beliefs, skills and attitudes that have developed would tend to last longer .¹⁶ A study conducted by Ingle et al. found that eight years old children are not appropriate group to start with oral health education intervention as they could not follow the oral hygiene instructions properly .¹⁷

Oral health education seeks to enhance oral health through educational means, especially through providing information to enhance oral health knowledge for accommodating a healthier lifestyle, and changing attitudes and behaviors.¹⁸ Oral health behaviors and conditions have been found to be related to psychosocial factors like self-efficacy.¹⁹ Self-efficacy, a concept originally proposed by the psychologist Albert Bandura, refers to an individual’s belief in their capacity to execute behaviors necessary to produce specific performance attainments.²⁰

Some studies indicated the importance of the translation of the theory of self‐efficacy into the field of oral hygiene by focusing on positive relations to plaque levels, brushing frequency, and loss to periodontal follow‐up .²¹ The self-efficacy refers to a person’s belief to do successfully the behavior necessary to produce the desired outcomes. It is considered as the belief related to her or his ability to do and succeed in a particular task.²² Self-efficacy predicts a range of health behaviors including oral self-care.²³ Efficacy, by itself, has four sources including mastery experience, observing learning, verbal persuasion, and physiological and emotional states during behavioral opportunities .²² Self-efficacy predicts a range of health behaviours including oral self-care.²⁴  Self-care behaviors such as brushing teeth, flossing, and regular dental visits are recommended for oral health and gum health.²⁵ Moreover, the lack of self regulatory skills is associated with a reluctance to change health behaviors, including deficits in self-efficacy, planning, and action control.²³ Studies have reported beneficial effects of self-regulatory skills on dental flossing. A combination of self-efficacy and changing oral self-care, self-efficacy, and self-monitoring planning are associated with higher frequency in dental self-care.²⁶

Hypothesis: Oral health knowledge, attitude, behavioral practice, self care ,self efficacy can be improved by Oral health education(OHE) training session through Audio-visual aid among adolescent.

JUSTIFICATION FOR STUDY:

School-aged adolescents are in particular need of Oral health education training program to ensure positive long-term oral health and hygiene. As this age come under second window of infectivity it is very important to educate the adolescent regarding oral health knowledge, attitude , behavioral practice , self care and self efficacy. Doing this with the help of Audio-visual aid may have an additional impact because the oral hygiene measures get well inscripted on the minds of these adolescents

AIM:

To compare the effect of ‘Audio-visual aid guided oral health education intervention’ with conventional oral health education intervention in improving oral health knowledge, attitude, behavioral practice, selfcare, self efficacy among adolescents

OBJECTIVES:

Primary:

·      To compare the effectiveness of ‘Audio-visual aid guided oral health education intervention’ with ‘Conventional oral health education intervention’ in improving oral health knowledge, attitude, behavioral practice among adolescents.

·       To compare the effectiveness of ‘Audio-visual aid guided oral health education intervention’ with ‘conventional oral health education intervention’ on plaque score in adolescents.

·       To compare the effectiveness of ‘Audio-visual aid guided oral health education intervention’ with ‘conventional oral health education intervention’ on self efficacy score in adolescents.

Secondary:

·       To evaluate the effect of Audio-visual as a strategy for improving oral health self efficacy and self care behaviors among adolescents.

MATERIAL AND METHODS:

Study Setting-

The study will be conducted in Post-Graduate Clinic, Department of Paediatric and Preventive Dentistry, Faculty of Dental Sciences, King George’s Medical University, Lucknow, Uttar Pradesh

Study Design: 

The research question will be addressed within a randomized clinical trial study design.

Participants:

Children of any gender in the age group 10-16 years, visiting Department of Paediatric and Preventive Dentistry, FODS, KGMU, Lucknow, UP; shall be screened for following inclusion criteria:

Inclusion criteria:

Ø  Children of 10- 16 yrs of age

Ø  Willingness to participate in the study

Ø  Paediatric patients with moderate/high likelihood of developing dental caries

 Ã˜   Cooperative children who had provided the verbal assent and given permission for oral examination

Exclusion Criteria-

Ø  Patients with systemic medical conditions/special healthcare needs

Ø  Patients requiring any emergency dental treatment

Ø  Patients with missing or congenitally malformed permanent teeth

Paediatric dental patients aged 10 – 16 both male and female, attending Outpatient Department of Paediatric and Preventive Dentistry shall be screened.  In the first visit future oral hygiene for each patient shall be determined using Oral hygiene index simplified (OHI-S) Pediatric patients finally fulfilling all inclusion and exclusion criteria shall be enrolled in the study as participants

Group I : The interventional group will be receiving structured oral health education (OHE) training session through Audio-visual aids

Group II : The control group will receive conventional oral health education in a standard written format as routinely given. 

Sample size:

Sample Size at 80% Power:

Sample size is calculated on the basis of variation in the most dispered study factor in case and control group using the formula,

Where s₁ = 10.8, The final SD of self efficacy (the most dispersed study factor) in case group

s₂ = 14.9,  The final SD of self efficacy (the most dispersed study factor) in control group

(Ref. Hashemi, Z.S., Khorsandi, M., Shamsi, M. et al. Effect combined learning on oral health self-efficacy and self-care behaviors of students: a randomized controlled trial. BMC Oral Health 21, 342 (2021).)

d = min(s₁,s₂), the minimum difference considered to be clinically significant

k = 1.0 the design effect

type I error α = 5% corresponding to 95% confidence level

type II error β = 20% for detecting results with 80% power of study

Data loss factor = 10%

So the required sample size

n = 33 each group 

Randomization:

              A block randomization process shall be followed for allocating participants into control or experimental groups. This involves recruiting participants in short blocks and ensuring that one-half of the participants within each block are allocated to “Group I” and the remaining one half to “Group II” within each block to obtain the different combinations. Blocks of ‘Four’ shall be used to allocate to Group I and II respectively. Within Group II, again blocks of ‘four’ will be created using computer generated sequence to allocate to subgroups.

Procedure:

Data collection tool will be researcher-made validated questionnaire containing questions on self-care, knowledge, attitude, behavioral practice, and self-efficacy , which was developed based on the questionnaires designed by Mohammadi Zeidi et al. ²⁷ and Samiee Roudi et al.^28,29,30. The questionnaire will be given in native language (hindi) also.

The Variables such as age, grade, gender, etc. will be collected in the demographic section. The questions on self efficacy will be in 5 point Likert scale while for others each correct answer will be marked as 1 and for wrong answer 0. After answering all questions composite scores will be evaluated. The training session is for 30 mins. 

Educational content and methods of training sessions in the case group

The Structured Oral health education (OHE) training session will be conducted in 2 sessions through Audio-visual aid.

Session 1:- Duration:- 15 mins

This session mainly focus on knowledge, information will be provided to the adolescent through videos regarding what are dental caries, causes of dental caries, how to prevent them.

Session 2:-  After first session , second session will be conducted

Duration:- 15 mins

Proper brushing technique, the use of dental floss will be shown through videos. Also the demonstration of same will be conducted. the frequency of brushing, the duration of brushing, choosing the right toothbrush and toothpaste.

Skills will be learned that how to maintain oral hygiene routine in a variety of situations including time of fatigue, illness, lack of toothbrushes, and playing and attending a party etc. through the behavioral chart.

Control group will receive conventional oral health education as routinely given in a written format as follows :-

Brush their teeth twice a day for 2 mins with fluoridated toothpaste

Minimize the consumption of sugary, sticky, and starchy foods.

Regular dental checkup every 3 months.

 Pre and post-intervention data will be collected from the children using a questionnaire. The questionnaires will be completed in the form of structural interviews to explain more details to the patients and provide appropriate an answer.

OUTCOMES:

Primary:

·       Primary outcomes will be evaluated by assessing the improvements in oral hygiene knowledge, attitude , behavioral practice , self care, self efficacy ( correct answers)

·       Changes in plaque scores using Quigley-Hein plaque index

·       New general self efficacy scale

Secondary:

·       Appearance of any new carious lesions on a sound surface

·       Appearance of any new carious lesion on restored surface

Follow-up Timeline:

All outcomes shall be observed at baseline, 4 weeks, 8 weeks and three months post intervention for each participant.

DATA COLLECTION:-

Data for following variables shall be collected as defined in Outcomes as inter and intra group comparison

Number of correct answers (Questionnaire) pre and post intervention

Change in plaque scores

Change in Self- efficacy score

DATA ANALYSIS:-

Data will be analyzed and expressed in mean (SD) or proportion /percentage or Median values depending on type of data.

Types of data that shall be elicited-

Questionnaire ( number of correct answers) : Shall elicit ‘ordinal’/ ‘discrete’ data

Change in Plaque scores: Shall elicit Shall elicit ‘ordinal’/ ‘discrete’ data

Change in self – efficacy score : Shall elicit Shall elicit ‘ordinal’/ ‘discrete’ data

Comparison of pre intervention and post intervention data within each group  shall be done with the help of Wilkoxan signed rank test. Intergroup comparison shall be done by Mann Whitney Test.

REVIEW OF LITERATURE:

Mohammad-Zeidi et al. and Soltani, et al. (2013) conducted the study on the effectiveness of an educational intervention based on the stages-of-change model in improving oral health self-care behaviors among 160 male and female elementary students in Qazvin and found a significant change in the mean score of behavioral intention in the case group after the intervention.

G Rajesh et al (2008) conducted the study in which 880 study subjects aged 13-15 yrs from 6 schools were randomly allocated to 6 groups. Computer method was most effective method in improving oral health knowledge; only computer method and charts-models improved their plaque and gingival status.

Walsh et al (1985) conducted the study in which eight hundred fifty-four boys and girls, 12–14-yr-old students enrolled in San Francisco middle schools, were randomly divided into experimental and control groups. Results showed a significant increase in knowledge for the experimental group (P<0.001), as compared with the control group.

D’Cruz A, Aradhya S. (2013) conducted the study in which three schools were randomly selected and assigned to experimental I, experimental II and control groups. At baseline, a 20-item questionnaire was used to assess the oral hygiene knowledge and practices. There were significant reductions in mean plaque index and gingival index scores in the experimental groups. The control group did not show any significant improvement.

Bhardwaj V, Jhingta P, Justa A, Luthra R, Sharma K, Sharma D. (2013) conducted in Two hundred and seventy six school children participated in the study.Overall mean plaque score and gingival score decreased significantly after oral health education irrespective of gender.

Gauba A, Bal I, Jain A, Mittal H (2013) School oral health promotional intervention carried out in one of the randomly selected school .A total of 100 children with an age range of 10-12 years with no previous history of dental intervention were enrolled. 

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