Efficacy of a Modified Audio-Tactile Performance Technique with Braille (Atpb) on the Oral Hygiene Status of Visually-Impaired Children

INTRODUCTION

People with disabilities constitute a large percentage of the population and the number of individuals with disabilities is increasing due to significant medical developments in recent years which have enhanced survival [1]. During the early years of life, a child learns to understand and construe their environment with the help of their primary senses, of which vision is the most important. Thus, when sight is impaired or absent in childhood, it can have detrimental effects on their physical, neurological, cognitive and emotional development.

In 2012, the World Health Organization (WHO) estimated that approximately 285 million people were visually impaired, of which 39 million were blind and 246 million had low vision [2]. In India, about 280,000–320,000 children are visually-impaired [3]. As visually- impaired individuals may be able to differentiate images, light and colours or even read large print, the term does not necessarily indicate a complete lack of sight [4]. Nevertheless, the visually-impaired tend to depend on their other senses to adapt themselves to their surroundings, such as sound, speech, and touch [5].

Oral health is fundamental to the overall health of an individual. However, visually-impaired children often have poorer oral hygiene compared to their sighted counterparts and usually experience difficulty in maintaining their oral health as they cannot detect and recognise early signs of dental disease [4, 6, 7]. The absence of visual-motor coordination, insufficient parental supervision and the child’s lack of concern for their appearance are other contributory factors [8]. Visually- impaired children deserve the same opportunities for treatment as those who are otherwise healthy. Unfortunately, factors associated with unmet dental care needs among children with special healthcare needs include living in low-income households or rural areas, a failure to receive adequate medical care, increased special needs severity and lower degree of functioning, poor psychological adjustment and caregiver-related factors such as depression and low levels of functioning [9].

Oral health education is key in the prevention of oral diseases. However, conventional methods of health education may not be effective to motivate visually-impaired children [10]. Various studies have investigated the use of verbal and tactile aids, braille and music-based education programs to educate and train such children on oral hygiene maintenance. Verbal health talks are the most convenient means of delivering such oral health education.

Braille is a tactile writing system introduced by Louis Braille and is traditionally written on embossed paper. It consists of small rectangular blocks called cells that contain tiny raised dots corresponding to letters of the alphabet. Audio-tactile performance (ATP) is an oral health education technique for the blind that was introduced by Hebbal et al in 2011. In this method, children are taught techniques for brushing their teeth using both audio and tactile aids.11 The aim of the current study was to modify the ATP technique by incorporating braille and to compare its effectiveness with conventional audio methods (AM) and ATP techniques.

MATERIAL AND METHOD

Ninety institutionalized children between 6–15 years old with either total or partial visual impairment were selected from three schools in two adjoining southern states in India. Ethical clearance from our institution’s ethics board and permission from the school authorities was obtained prior to the study. As these children were institutionalised, informed consent for their inclusion in the study was obtained from their parents by the school authorities. The ability to read braille was deemed an essential criterion for inclusion. Subjects were excluded from the study if they had any underlying systemic illnesses or other handicapping conditions, were on any long-term medications or had rampant caries. They were also not included if the child was uncooperative or if they had attended camps or received oral health education in the preceding six months prior to the study.

A randomly selection of 30 children from each school were allocated to one of three groups, with each group receiving a different form of dental health education. The first group received AM, the second received ATP and the third received a modified ATP technique with braille (ATPb). The study comprised four phases, consisting of interaction and collection of baseline data (phase I), oral health education (phase II), a reinforcement period (phase III) and a non-reinforcement period (phase IV). The efficacy of the education techniques was assessed separately among children with total and partial impairment.

RESULTS

A total of ninety visually-impaired children received oral hygiene instructions using three different oral health education techniques. Each group included 30 children from one of three schools. The mean age was 10.23 ± 2.41 years and there were 48% males and 52% females. Overall, 40 children (44.4%) had total visual impairment, while 50 (55.6%) had partial visual impairment. Thirteen (43.3%) of the children in Group I receiving AM oral health education, 13 (43.3%) in Group II receiving ATP oral health education and 14 (46.7%) in Group III receiving modified ATPb oral health education had total blindness (Table 1).

The oral hygiene status of the children was poor, with a mean baseline plaque score of 2.031 ± 0.411. Although the mean plaque scores of the totally visually-impaired children (2.104 ± 0.390) was greater than that of the partially visually-impaired children (1.972 ± 0.422), this difference was not statistically significant (p = 0.13). The demographic characteristics and baseline plaque scores of the different groups are shown in Table 1. In Groups I and III, the partially visually-impaired children had better oral hygiene statuses; in contrast, in Group II, the totally visually-impaired fared better. However, there were no statistically significant differences in mean plaque scores based on degree of blindness within any of the three groups (Figure 1).

The effectiveness of each oral health education technique was compared separately among the totally and partially visually-impaired children to assess the most effective means of delivering oral hygiene instructions to such children.

Figure 1. Comparison of the mean baseline plaque scores of the totally and partially visually impaired children within the groups.

Children with Total Visual Impairment

Among the totally visually-impaired children, the maximum reduction in plaque scores during the reinforcement period was seen in Group III receiving ATPb education, with a mean difference of 1.119 ± 0.260, followed by Groups II and I receiving ATP and AM education, with mean differences of 0.654 ± 0.239 and 0.237 ± 0.255, respectively (Fig. 2). There were significant differences in effectiveness during this period within each group (p <0.001) (Table 2). When effectiveness between groups was compared, we found significant differences between Groups I and II, Groups I and III and Groups II and III (p <0.001) (Table 3).

Figure 2. Comparison of the effectiveness of the three oral health education techniques on the oral health status of totally visually impaired children.

Table 2.Table showing the effectiveness of the three techniques on the oral hygiene status of the totally and partially visually impaired children during the study period.

		Baseline–Reinforced	Reinforced – Non-reinforced	Baseline- Non- reinforced
Blindness	Groups	0-3 months	3-6 months	0-6 months
		Mean difference	p value	Mean difference	p value	Mean difference	p value
	Group I (AM)	0.237±0.255	<0.001	-0.208±0.267	<0.001	0.029±0.108	<0.001
Total	Group II (ATP)	0.654±0.239		0.083±0.193		0.737±0.317
	Group III (ATPb)	1.119±0.260		0.107±0.160		1.227±0.261
	Group I (AM)	0.118±0.237	<0.001	-0.128±0.114	<0.001	-0.010±0.226	<0.001
Partial	Group II (ATP)	0.762±0.270		0.083±0.169		0.845±0.292
	Group III (ATPb)	0.934±0.279		0.176±0.166		1.109±0.258

Table 3.Table showing the group wise comparison of effectiveness of the three techniques based on the degree of blindness

		Baseline–Reinforced	Reinforced – Non-reinforced	Baseline- Non- reinforced
Blindness	Groups	0-3 months	3-6 months	0-6 months
		Mean difference	p value	Mean difference	p value	Mean difference	p value
	Group I and II (AM and ATP)	0.417	<0.001	0.291	0.000	0.708	<0.001
Total	Group I and III (AM and ATPb)	0.882	<0.001	0.315	0.001	1.198	<0.001
	Group II and III (ATP and ATPb)	0.466	<0.001	0.023	0.157	0.489	<0.001
	Group I and II (AM and ATP)	0.644	<0.001	0.21	<0.001	0.855	<0.001
Partial	Group I and III (AM and ATPb)	0.816	<0.001	0.303	<0.001	1.119	<0.001
	Group II and III (ATP and ATPb)	0.172	0.155	0.092	0.051	0.264	0.015

During the three-month period where there were no attempts at reinforcement, the maximum reduction in scores was seen in Group III, followed by Group II, with mean differences of 0.107 ± 0.160 and 0.083 ± 0.193, respectively. However, in Group I, scores worsened over time, with a mean difference of -0.208 ± 0.267 (Figure 2). There was significant difference in effectiveness within groups during this period (p <0.001) (Table 2). In terms of effectiveness between individual groups, significant differences were noted only between Groups I and II and Groups I and III (p <0.001), with no difference in effectiveness between Groups II and III (p = 0.157) (Table 3).

At the end of the six-month study period (i.e. after both periods of reinforcement and non-reinforcement), the maximum reduction in scores was seen in Group III, followed by Groups II and I. Mean differences during this time were 1.227 ± 0.261, 0.737 ± 0.317 and 0.029 ± 0.108, respectively (Figure 2). There were significant differences in effectiveness within the groups (p <0.001) (Table 2). We also noted significant differences in effectiveness between Groups I and II, Groups I and III and Groups II and III (Table 3).

Children with Partial Visual Impairment

During the reinforcement period, the partially visually-impaired children in Group III showed the greatest reduction in scores, with a mean difference of 0.934 ± 0.279. This was followed by Groups II and I, with mean differences of 0.762 ± 0.270 and 0.118 ± 0.237, respectively (Figure 3). There were significant differences in effectiveness within groups during this period (p <0.001) (Table 2). When effectiveness between groups was compared, there were significant differences between Groups I and II and Groups I and III (p <0.001), but not between Groups II and III (p = 0.155) (Table 3).

Figure 3. Comparison of the effectiveness of the three oral health education techniques on the oral hygiene status of the partially visually impaired children.

During the subsequent three-month non-reinforcement period during which no intervention was performed, the greatest reduction in scores was seen in Group III, followed by Group II, with mean differences of 0.176 ± 0.166 and 0.083 ± 0.169, respectively. In Group I, an increase in plaque scores was seen during this period, with a mean difference of -0.128 ± 0.114 (Fig. 3). There were significant differences in effectiveness within groups during this period (p <0.001) (Table 2). In terms of between-group differences, significant differences were noted only between Groups I and II and Groups I and III (p <0.001), with no difference in effectiveness between Groups II and III (p = 0.051) (Table 3).

After six months, the greatest reduction in scores was seen in Group III, with a mean difference of 1.109 ± 0.258, followed by Group II, with 0.845 ± 0.292. However, partially visually-impaired children in Group I showed an overall worsening of scores, with a mean difference of -0.010 ± 0.226 (Fig. 3). There was significant difference in effectiveness within groups (p <0.001) (Table 2). Overall, there were significant differences in effectiveness between Groups I and II, Groups I and III and Groups II and III by the end of the six-month study period (Table 3).

DISCUSSION

The lack of one of the primary senses—in this case, vision— which orients an otherwise healthy individual to their surroundings may be the main reason for poor oral hygiene in the visually impaired. An effective preventive program that focuses on educating and training the child to perform adequate oral hygiene maintenance technique is necessary as such individuals cannot visualise signs of dental disease [13]. We found that adding braille instructions to conventional audio-tactile methods not only resulted in a meaningful reduction in plaque scores, but also continued to improve the scores significantly, even without any additional intervention.

Institutionalised children were chosen in order to avoid any bias in outcome, as all children had similar dietary and oral hygiene practices. Only children aged 6–15 years old were included, as such children would have sufficient manual dexterity to brush their teeth independently and understand instructions clearly [14, 15]. Moreover, schools are considered the best environment to teach preventive oral health practices as schoolchildren are already in a learning environment and are easily accessible [16]. The modified Bass technique is superior to the horizontal scrub technique as the former cleanses the proximal areas as well as the gingival third and sulcular regions of the oral cavity [17, 18]. However, several studies have reported no significant difference in efficacy between these methods [19, 20]. The modified Bass technique, even though time-consuming, was chosen for the current study as it has a wider cleansing zone.

Overall, the oral health status of the visually-impaired children was poor, with a mean baseline plaque score of 2.031 ± 0.411. Previous research has confirmed that visually-impaired often have poor oral hygiene [8, 21, 22, 23, 24, 25]. However, Prashanth et al. reported that only 8% of the blind children in their study population had poor oral hygiene [26]. Reasons for poor oral hygiene among visually-impaired children could be the lack of development of necessary self-maintenance skills, inability to see and remove plaque, lack of supervision while brushing, limited intellectual capacity in some children, lack of knowledge regarding oral hygiene and effective tooth brushing and the reduced amount of time spent brushing their teeth [27, 28, 29]. Local factors like malocclusion and dental crowding may also lead to the accumulation of plaque, contributing to reduced oral health. However, Mitsea et al. observed better oral hygiene among visually- impaired children in comparison to children with cerebral palsy and mental retardation [30]. Institutionalised blind children may have poorer oral hygiene compared to those who are non-institutionalised, possibly due to a lack of caregiver assistance while brushing and during other oral hygiene practices [31]. Lack of supervision and help from parents may affect factors like brushing technique and motor skills [25]. However, this may not always be true and depends to a large extent on the infrastructure of the institution in question and the enforcement of routine hygiene practices [32].

There was no significant difference in oral hygiene status of the totally and partially visually-impaired children as a whole and within groups at baseline. In contrast, Bennadi et al. reported an increase in plaque levels among those who were totally blind [33]. This difference in findings in the present study is probably due to the fact that many were classified medically with partial impairment because of an enhanced sensitivity to light rather than an actual improvement in vision.

Conventional methods of oral health education are directed towards visualising and identifying early signs of dental disease. Naturally, this is near impossible for visually-impaired individuals [26]. Hence, customised methods of education and motivation to correct oral hygiene practices are essential to maintain good oral hygiene. The visually-impaired depend on various other sensations such as sound, speech and touch along with kinaesthetic and olfactory sensations to adapt themselves to their immediate surroundings [34].

In the present study, three different approaches of providing oral hygiene instructions were assessed. In each group, the respective method was reinforced for a period of three months, following which there was no intervention for another three months (the non-reinforcement period). Among the children who received oral health education via a verbal health talk, a reduction in plaque scores was seen during the reinforcement period. However, by the end of the study period, the final scores had worsened in comparison to baseline scores. This suggests that even though this technique was capable of marginally improving oral hygiene status, the children could neither improve nor maintain their oral hygiene without intervention.

In contrast, children who took part in the ATP intervention had significantly reduced plaque scores compared to those receiving AM. Although there was only a marginal improvement seen during the non-reinforcement period, there was a significant improvement in mean plaque scores from baseline by the end of the study. This clearly shows that this technique was very effective if reinforced. In the absence of the intervention, the children could maintain their oral hygiene, but could not improve further. Earlier studies have similarly shown significant improvement in oral hygiene using ATP techniques [4, 11]. However, reinforcement in these studies was primarily given by teachers or caregivers and there was no well-demarcated period of reinforcement and non-reinforcement.

Finally, the modified ATP technique with braille resulted in a significant reduction in plaque scores by the end of the reinforcement period. Furthermore, a meaningful improvement in plaque scores was observed even without intervention during the non-reinforcement period. This improvement was greater than that observed in the ATP group during this time, although the difference was not statistically significant. By the end of the study, a significant drop in plaque scores was seen in comparison to baseline scores; moreover, this improvement was greater than that seen during the reinforcement period. Thus, the newly developed technique was very effective in improving and maintaining plaque scores, both with and without reinforcement. The children were able to retain the instructions and incorporate them into their daily practice, thereby considerably improving their oral hygiene.

When the effectiveness of the three techniques was compared, it was observed that the ATPb technique resulted in the greatest reduction in plaque scores during both the reinforcement and non-reinforcement periods. This was probably due to the fact that it was the most customised technique of the three. In addition, the inclusion of braille may have helped to convert the tactile sensations into learned information. Moreover, as the braille pamphlet included a story, it may have been more appealing to the children and therefore better remembered. Possibly, the efficacy of the next best technique, ATP, can be further improved with repeated instructions over longer periods of reinforcement.

Chowdary et al showed that combining verbal, braille and tactile oral hygiene instructions most effectively reduced plaque scores compared to verbal and braille or verbal and tactile means [35]. Surprisingly, a study from Hyderabad of four different oral health education techniques found the highest improvement in scores in the audio group, with the least reduction in those who received instructions via braille alone. In this study, the braille group did not receive individualised attention, which may explain their poor performance [36]. Another study found that tactile and auditory means were equally effective in educating and motivating visually-impaired children and that these methods can be made interesting by utilising braille, plastic models, an audio story or the computer software Job Access With Speech (JAWS) [37].

In the current study, the improvement in plaque scores with the modified ATPb intervention was similar in both totally and partially visually-impaired children. However, in a study done by Joybell et al., it was observed that partially blind children mastered brushing techniques better than totally impaired children following oral health education using the ATP technique [4]. Another study found a greater decrease in plaque control record values among partially visually-impaired children following oral health education, with a definite advantage over completely blind children [34].

In general, the present study clearly indicates that the oral health practices of visually-impaired children can be improved by deviating from traditional approaches of oral health education. We developed a modified ATP technique including braille in order to ensure that visually-impaired children can be taught to perform basic oral hygiene practices independently. Nevertheless, as the study population comprised children from three institutions in three different cities, their dietary and oral hygiene practices could only be standardised to a certain extent; this could be considered a limitation of our study. We recommend that techniques to educate and train visually-impaired children be customised on an individual basis in accordance with their needs. Though most of the techniques follow the principles of ‘tell-feel-do’, no standard technique has been adopted so far. ATPb is a step in that direction to formulate a technique that can be used by everyone with ease to create positive impacts on behavioural outcomes. More studies exploring this approach will definitely reveal more interventions, simple and feasible. Newer technologies should be combined with conventional methods for maximum benefit.

CONCLUSION

The present study aimed to develop a new oral health education program for visually-impaired children to ensure adequate oral hygiene maintenance. While all three methods of oral health education— AM, conventional ATP and modified ATPb techniques—were successful in improving oral hygiene status with reinforcement, only the last two improved oral hygiene even during periods of non-reinforcement. However, the newly developed modified technique using braille, ATPb, was the most effective method with the advantage of encouraging retention of the learned information even without intervention.

Acknowledgements

We would like to thank the Principals, staff and students of the Calicut Higher Secondary School for the Handicapped, Calicut, Kerala; the Government Blind School, Kasargod, Kerala; and the Roman and Catherine School for the Blind, Mangalore, Karnataka, for their cooperation in this study.