Effectiveness of good behavior game on oral health among children - A randomized trial

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1 Research Article Effectiveness of good behavior game on oral health among children - A randomized trial J. Chandrapooja, Ganesh Jeevanandan* ABSTRACT Aim: The aim of this research is to evaluate the effectiveness of the good behavior game (GBG), a pediatric clinic-based contingency dental hygiene program. Background: Oral health education programs have been considered as an important part of oral health policies. There has been a serious lack of effective dental hygiene programs that are taking place in the schools. Reviews show that these are relatively ineffective on the oral health of children. Thus, instructions that modify the behavior of children should be implemented. GBG is a universal intervention which is cost-effective and easy to implement behavior procedure from applied behavior analysis. Materials and Methods: Estimation of debris index simplified (DI-S) and dental caries index was carried out. Children in Group 1 were given oral health education through instructional oral hygiene program. Children in Group 2 were allowed to participate in GBG thrice a week. The DI-S and dental caries index were recorded after 2 weeks and 4 weeks after the intervention in both the groups. Result: In Group 2, the good oral hygiene score increased from 10% to 89% 2 weeks after the intervention. There was a relative decrease in the percentage of children who scored fair and poor also. At the end of 4-week follow-up, 90% of children had good oral hygiene. In Group 1, there was a significant improvement in oral hygiene after 2 weeks, but it was not significant after 4 weeks. Conclusion: This study demonstrated that implementation of GBG-based oral health education program is an easy and cost-effective method for teaching oral health instructions and preventing oral diseases in children. Hence, this study shows that Good Behavior Game (GBG) is an effective intervention for teaching basic oral health concepts among school children. KEY WORDS: Debris index, Dental caries index, Good behavior game INTRODUCTION Dental caries is a global disease with widespread prevalence, particularly among children. One of the reasons for this is due to an increased availability of processed foods and beverages, which contain refined sugars. [1] Oral health education programs have been considered as an important and integral part of oral health policies for a long time. There has been a serious lack of experimentally verified, effective dental hygiene programs in the schools. The most frequently implemented school dental health education program consists of a lecture and demonstration through models, charts, or videotapes. [2] One of the key factors in maintaining good oral health is the knowledge of proper oral hygiene practices. Such knowledge given in the formative years of a child will be there for a lifetime. Access this article online Website: jprsolutions.info ISSN: School age is the formative period physically as well as mentally, transforming the school child into a promising adult. Health habits formed at this stage will be carried to adult age, old age, and even to next generation. Thus, for the prevention of oral health problems, health education of school children has a vital role. [3] For children, school-based health programs are the most common, since such programs can benefit a wide group of children with extremely low cost. [4-6] Schoolbased oral health education has been found effective in improving oral hygiene, oral health knowledge, and behavior. [7] Behavior modification has been used in a children s oral hygiene program by Stacey et al. At a summer camp, children were reinforced with toys and activities to maintain good oral hygiene. Moderately effective results were obtained regarding the improvement of their oral hygiene skills. [8] Health promotion is the process of enabling people to increase control over and to improve their Department of Pediatric and Preventive Dentistry, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai , Tamil Nadu, India *Corresponding author: Dr. Ganesh Jeevanandan, Department of Pediatric and Preventive Dentistry, Saveetha Dental College and Hospitals, Saveetha Institute of Medical And Technical Sciences, Chennai , Tamil Nadu, India. Phone: helloganz@gmail.com Received on: ; Revised on: ; Accepted on: Drug Invention Today Vol 10 Issue

2 health. [9] Oral health education is an important part of oral health promotion and is an essential and basic part of oral health services. [10] It aims to promote oral health through educational means, principally the provision of information to improve oral health knowledge for the adoption of a healthier lifestyle, changed attitudes, and desirable behaviors. [11] Oral health education is essential for promoting oral health in adolescents. [12-14] During adolescence, young people are able to assume responsibility for learning and maintaining health-related attitudes and behaviors that carry over into adulthood. [15] The school system is a logical environment to teach preventive oral health practices and promote oral health. [16,17] In India, the general level of oral health is unsatisfactory, particularly among school children. The National Oral Health Survey of India data show 67.7% prevalence of gingivitis among the 15-year olds. [18] Poor oral hygiene and gingival status characterize the oral health condition of Indian adolescents, [19,20] similar to the situation in many developing countries. [21] School children in the age group of years are in particular need of oral health promotion programs because of high levels of plaque leading to gingivitis and early periodontitis. Hence, it is necessary to motivate year-old school children to improve their oral hygiene. A study conducted in Bengaluru, India, [22] has reported a poor oral health knowledge and behavior among the school children. The utilization of dental services was low and was mainly for relief of pain. Lack of oral health education programs was the main reason that was attributed to the lack of knowledge and poor behavior toward oral health. Short-term oral health education programs have been successful in improving the oral health knowledge and behavior among school children in India. [22-24] A behavioral vaccine is a simple, scientifically proven practice that is repeated to increase wellbeing. The hallmark of the behavioral vaccine is that a simple action yields large results and is typically very inexpensive. Good behavior game (GBG) is a classroom-wide, teacher-implemented intervention that aims to improve classroom behavior and introduce young children to the role of being a student and a member of the classroom community. [9] The smiles, giggles, laughs, and even pointed taunting from other students were reinforcing the high rate of the behaviors that teachers found so difficult to handle or harmful to the learning process. In this context and time, the graduate students and senior scientists reasoned that some kind of group-based reward for inhibiting negative behavior might be a boon for classrooms. The idea for the GBG was born. [25] Implementation of crossword game-based oral health education program is an easy and effective aid for teaching oral health instructions and preventing oral diseases in children as the knowledge scores of children increased considerably when the game-based teaching intervention was used. [26] Hence, the present study was planned to compare the effectiveness of conventional (instructional) dental hygiene program and GBG (contingency dental hygiene program a behavioral vaccine) on the practice of oral hygiene among 5 7-year-old children. The rationale for the study was to advance the area of oral health intervention by proper implementation of behavioral principles in game-based teaching, which the conventional intervention program does not focus and behavioral vaccine as an alternative for teaching basic oral health concepts in younger children. The present study was undertaken to advance the area of behavioral vaccine as an alternative for teaching basic oral health concepts in children. Behavior management is widely agreed to be a key factor supplying dental care for children. Certainly, if a child s behavior in the dental surgery/office cannot be managed, then it is not easy to carry out any dental care that is needed. A wide variety of behavioural management techniques are available to pediatric dentists which must be used as appropriate taking into account cultural, philosophical, and legal requirements in the country of dental practice of every dentist concerned with the dental care of children, solely for the benefits of the child. [27] Hence, this article is to evaluate the effectiveness of the GBG, a pediatric clinic-based contingency dental hygiene program. MATERIALS AND METHODS A randomized controlled intervention study was carried out after the study protocol was analyzed and approved by the Institutional Review Board of Saveetha Dental College and Hospital. Written consent was obtained from the parents of all the participating children. The study was conducted in the patients in Saveetha Dental Hospital, Tamil Nadu, India. The school had 60 children aged 5 14 years. Among them, 30 children were randomly selected for the study group using a software-generated table of random numbers. These 30 children were assigned into Group 1 - the conventional health education group - and 30 children to Group 2 - the GBG group. To have uniform assessment criteria and minimum variability during the clinical examination, four undergraduate dental students (interns) were trained by the authors of this project. The oral hygiene status was assessed by the primary interns using the debris index simplified (DI S) proposed by Greene and Vermillion and modified by Greene. It was estimated by running the side of the explorer along the tooth surface being examined. Six 1483

3 selected index teeth and six surfaces were considered for the estimation of DI-S. The score ranged from 0 to 3. A group of children was selected and examined for DI-S. 20% of the children were reexamined on successive days to check for the reliability. The kappa statistics score for interexaminer variability was 0.8 and for intraexaminer variability was 0.9. The dental health education followed the oral examination. Thirty children in Group 1 were given oral health education through instructional dental hygiene program, i.e., a conventional teaching method for thrice a week. The undergraduate dental students carried out the educational approach. A 20- min lecture on oral health, brushing technique, healthy snacking, and diet was delivered. The dental students were trained for the presentation before delivering the lecture in the school. A contingency dental hygiene program was designed for 30 children in Group 2, and they were allowed to participate in the GBG. First, all the behaviors needed to establish good oral health such as twice a day brushing and regular dental checkup were listed out to these children. These were labeled as good oral health behavior we all want. The behaviors that would interfere with the desired outcomes were labeled as fouls, i.e., Bad oral health behavior we all need to quit (e.g., How many times should brush your teeth daily? Once). Second, examples of both were presented visually in a large poster format. Children in this group were divided into six teams, five children per team. A specially designed pro forma with 10 closed-ended questions regarding oral health behavior was used. It was recorded for each team by a calibrated interviewer. Each question was scored as 0 ( foul wrong answer) or 1 (correct answer), and hence, the total score ranged from 0 to 10. The team with fewer fouls, i.e., more good behavior, has happened would win the game. Winning teams received reward as material reinforcers. A weekly scoreboard is highly visible, just like the scoreboard of baseball or football, with fouls much smaller than wins. The investigator explained the rules for the game, and they were allowed to play once daily for a week. The children in both the groups were assessed for the DI-S on the 8 th day of the program. A follow-up score was also recorded after 4 weeks. The resulting data were coded and analyzed to assess intergroup differences. RESULT Table 1 shows the changes in the DI-S score inference in both Group 1 and Group 2 in two periods: 2 weeks and 4 weeks after the intervention. In Group 2, the good oral hygiene score dramatically increased from baseline and 2 weeks after the intervention. There was a relative decrease in the fair and poor debris scores also. At the end of 4-week follow-up, 90% of children had good oral hygiene. The scores were well above the baseline. There was no significant difference in the DI-S score in both the time periods in Group 1. Table 1 shows the comparison of the mean DI-S among children in Group 1 and Group 2 at baseline, post-2 weeks, and post-4 weeks. There was a highly significant difference in the mean score in Group 2. In Group 1, there was a significant improvement in oral hygiene after 2 weeks, but it was not significant after 4 weeks. DISCUSSION The history of dentistry has established the fact that prevention through oral health education is a major factor in controlling dental caries and related complications. Childhood is a significant time for intellectual growth and personality development. Young children are particularly receptive during this phase of growth. [28] Henceforth, health educational interventions began to focus more on health promotion strategies. In pediatric dentistry, health education actions should address the process of enabling children to improve their oral health. This can be achieved by providing them with knowledge concerning the prevailing oral health problems and methods for their prevention and control. It also provides them with the skills, social support, and environmental reinforcement they need to adopt long-term healthy behaviors. [29] Oral health education is thus a powerful tool in improving the oral hygiene knowledge and practices, which can lead to better plaque control and subsequent improvement in gingival health. Hands-on training such as tooth brushing drill, flossing, and rinsing can act as motivational tools in the promotion of oral health. Reinforcement of oral health information is of Table 1: DI scores of the study groups Groups DI score inference n (%) Baseline Post 2 weeks Post 4 weeks Group 1 Good Fair Poor Group 2 Good Fair Poor DI: Debris Index 1484

4 utmost importance and is the key to success of any oral health education program. Implementing an easyto-organize and inexpensive school-based educational intervention can improve oral cleanliness and gingival health among school children, in particular in countries with a developing oral health-care system. School-based oral health education programs in the past using traditional lecturing had been found effective in improving knowledge. [30] With a behavioral vaccine, a person might be exposed to a weakened behavioral risk, which could stimulate a protective response or a person might learn a protective program of behavior that attacks, dislodges, or protects against any exposure. [31] The GBG involves concepts and principles of learning, including selflearning, cooperative learning, and participation. [32] It is an adult-supervised education which relies on peers interacting, sharing, planning, and supporting each other. [33] It develops visual alertness, increases attention span, and assists with memory strategies and reasoning. Younger children (<8 years) remember more when participating in cooperative learning. [34,35] In the present study, connect the dots game was developed for educating the children. In cognitive psychology, connecting the dots test (trail making test) was used to provide information about visual search speed, scanning, the speed of processing, mental flexibility, as well as executive functioning. It consists of two parts in which the subject is instructed to connect a set of 25 dots as fast as possible while still maintaining accuracy. [36] The auditory and visual working memory performance in children improves with age. Visual working memory reaches functional maturity earlier than the corresponding auditory system. Hence, younger children rely on visual codes to remember. [37] Game-based health education approach implemented in the classroom has numerous benefits; it is a powerful method of teaching students to adopt thought-provoking means of studying. It helps students to seek reasons for good and bad health. It motivates pupil to understand and learn the facts about health rather than only memorizing, thereby improving cognitive development and building confidence. [38] Oral health education is a planned package of information, learning activities, or experiences that are intended to promote oral health. [39] This level of knowledge is known to be necessary and be one of the key determinants of behavior change. [40] The cornerstone of the prevention of the two major oral diseases, dental caries, and periodontal disease is the maintenance of a clean mouth or a clean tooth surface to be particular, that is, a tooth surface free from dental plaque. Well-planned and executed oral health promotion programs could greatly accelerate the decline of the dental caries problem, periodontal problems, etc. [41] The development of health education as a scientific discipline within dentistry has been slow. All too often action takes precedence over evaluation. This indicated that the instructional-based dental hygiene program did not have a long-term effect in imparting oral health education. However, GBG helped in significant reduction of the debris scores. The changes observed is a sign of improvement in the children s skills to control dental plaque accumulation, one of the essential biological factors associated with oral diseases. In addition, the follow-up data indicated that the oral hygiene status was maintained over a substantial period. The effect of the game was durable over time, and this is important to change the attitude of the child in maintaining good oral health. The present study was undertaken to advance the area of behavioral vaccine as an alternative for teaching basic oral health concepts in younger children. In this study, the GBG was found to be an effective intervention aid for teaching the basic oral health concepts compared to the conventional instructional method of teaching children. In addition, the present study also attempted to find which method of educational motivation is effective. It was seen that although there was an improvement in both the experimental groups, the change was better in the experimental Group II (active group) than in experimental Group I (passive group). These findings show that although a lecture method can improve the knowledge and practices, reinforcing the lecture with individual tooth brushing demonstration can yield better results. This will help a long way in decreasing plaque levels and subsequently improving gingival health. 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