UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
PERSPECTIVE ARTICLE DOI: https://doi.org/10.4322/bds.2025.e4653
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Braz Dent Sci 2025 Jan/Mar;28 (1): e4653
This is an Open Access article distributed under the terms of the Creative Commons Attribution license (https://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Effect of oral health education model on tooth brushing behavior
and oral hygiene among children with intellectual disabilities
Efeito de um modelo de educação em saúde bucal no comportamento da escovação dentária e na higiene bucal em crianças
com deficiências intelectuais
Muhammad Fiqih SABILILLAH1,2 , Hari KUSNANTO3 , Lisdrianto HANINDRIYO4 , Sri KUSWANDARI5
1 - Universitas Gadjah Mada, Faculty of Dentistry, Doctoral Program. Yogyakarta, Indonesia.
2 - Health Polytechnic of Ministry of Health, Dental Health Department. Tasikmalaya, Indonesia.
3 - Universitas Gadjah Mada, Faculty of Medicine, Public Health and Nursing, Primary Care Family Medicine Program. Yogyakarta,
Indonesia.
4 - Universitas Gadjah Mada, Faculty of Dentistry, Preventive and Community Dentistry Department. Yogyakarta, Indonesia.
5 - Universitas Gadjah Mada, Faculty of Dentistry, Pediatric Dentistry Program. Yogyakarta, Indonesia.
How to cite: Sabilillah MF, Kusnanto H, Hanindriyo L, Kuswandari S. Effect of oral health education model on tooth brushing behavior and
oral hygiene among children with intellectual disabilities. Braz Dent Sci. 2025;28(1):e4653. https://doi.org/10.4322/bds.2025.e4653
ABSTRACT
Objective: The aim of this study was to evaluate the effectiveness of an oral health education model in improving
tooth brushing behavior and oral hygiene among children with intellectual disabilities. Material and Methods:
This study used a quasi-experimental design with a pretest-posttest control group. The intervention involves
implementing the “Tell-Show-Feel-Do” educational model for the intervention group, while the control group
receives standard oral health education. Data collection is conducted at baseline and after the intervention
period 21 day. The Tell-Show-Feel-Do (TSFD) educational model was implemented in three sessions, with a
4-day gap between each session, and each session lasting 120 minutes. Participants were selected using simple
random sampling, focusing on children with intellectual disabilities attending a Special School for Children
with Disabilities. A total of 52 children were recruited, divided equally into two groups: 26 in the intervention
group and 26 in the control group, taken from September 02 to October 11, 2024. Results: The analysis seen
signicant differences in the changes in tooth brushing behavior and oral hygiene between the intervention and
control groups, as determined by an independent sample t-test (p<0.001). This suggests that the intervention
was effective in improving oral hygiene outcomes compared to the control group, where no notable improvement
was observed. Conclusion: This study conrms that structured oral health education improves tooth brushing
and hygiene in children with intellectual disabilities. Implementing such programs in special education settings,
school curricula, and community initiatives can enhance long-term oral health outcomes and overall well-being.
KEYWORDS
Child; Health education, dental; Intellectual disability; Oral hygiene; Toothbrushing.
RESUMO
Objetivo: O objetivo deste estudo foi avaliar a efetividade de um modelo de educação em saúde bucal para
melhorar a comportamento da escovação dentária e a higiene bucal em crianças com deciências intelectuais.
Material e Métodos: Este estudo usou um modelo quase-experimental com um grupo controle pré-teste-pós-
teste. A intervenção envolveu a implementação do modelo educacional “Falar-Mostrar-Sentir-Fazer” para o
grupo intervenção, enquanto o grupo controle recebeu a educação em saúde bucal padronizada. Os dados foram
realizados antes e após a intervenção de 21 dias. O modelo educacional Falar-Mostrar-Sentir-Fazer (CMSF) foi
implementado através de três sessões durante 21 dias, com 4 dias de intervalo entre cada sessão, com duração
120 minutos/cada. Os participantes foram selecionados usando amostragem intencional, focando em crianças
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Sabilillah MF et al.
Effect of oral health education model on tooth brushing behavior and oral hygiene among children with intellectual disabilities
Sabilillah MF et al. Effect of oral health education model on tooth brushing
behavior and oral hygiene among children with intellectual
disabilities
INTRODUCTION
Oral health is a critical component of overall
well-being and quality of life, particularly for
children with intellectual disabilities [1], who
often face unique challenges in maintaining
proper oral hygiene due to limited cognitive and
motor skills [2]. These difculties hinder their
ability to perform daily activities such as tooth
brushing [3], leading to serious consequences like
dental caries, periodontal disease, and systemic
health issues [4]. Sensory sensitivities [5],
communication barriers [6], and lack of motivation
further exacerbate these issues [7], making it
difcult for children to understand the importance
of oral hygiene and follow proper brushing
techniques [8]. Addressing these challenges
requires tailored educational interventions that
equip children with essential skills and knowledge
to improve their oral health outcomes [9].
Research highlights the effectiveness of
targeted educational approaches in improving
oral health outcomes for children with intellectual
disabilities. For instance, Surija et al. [10]
demonstrated that structured educational
materials, such as electronic books on tooth injuries
for children with Down Syndrome, signicantly
enhance understanding and management of oral
health. These ndings underscore the importance
of integrating tailored interventions that address
the unique needs of children with intellectual
disabilities, reinforcing the value of structured,
interactive learning methods in promoting better
oral hygiene practices [10].
Dental anxiety and disruptions in routine care
present signicant barriers to maintaining oral
health in children with intellectual disabilities [11].
Studies highlight that anxiety can lead to higher
rates of dental caries, emphasizing the need
for supportive interventions [12]. Additionally,
disruptions in oral health maintenance, such
as those seen during the COVID-19 pandemic,
have worsened gingival outcomes for children
with disabilities, reinforcing the importance of
consistent support and education [13]. The “Tell-
Show-Feel-Do” method has emerged as a promising
educational model [14], incorporating step-by-step
instructions, demonstrations, sensory engagement,
and hands-on practice [15]. By aligning with the
cognitive and sensory proles of children with
intellectual disabilities, this approach enhances
their ability to retain and apply oral hygiene
knowledge [16], making it a valuable strategy for
improving oral health outcomes.
Research has highlighted the positive impact
of structured oral health education programs on
the behavior and oral hygiene of children with
disabilities [17]. These programs not only improve
the children’s ability to perform tooth brushing
independently but also enhance their understanding
of the importance of maintaining oral health [18].
Despite these promising ndings, there remains a
lack of widespread implementation of such models,
particularly in resource-limited settings [19].
Oral hygiene, as a measurable outcome,
reects the success of behavioral interventions
and serves as an indicator of the child’s ability
to perform tooth brushing [20]. Studies
suggest that children who receive consistent,
tailored oral health education demonstrate
significant improvements in oral hygiene
indices, highlighting the importance of targeted
educational models [21].
This study aims to explore the effect of the
“Tell-Show-Feel-Do” oral health education model
com deciências intelectuais que frequentam uma Escola Especial para Crianças com Deciências. Um total de 52
crianças foram recrutadas e divididas igualmente em dois grupos: 26 no grupo intervenção e 26 no grupo controle,
no período de 02 de setembro a 11 de outubro de 2024. Resultados: A análise mostrou diferenças signicantes
nas mudanças de comportamento da escovação dentária e na higiene bucal entre os grupos intervenção e controle,
como determinado pelo teste t independente (p<0.001). Isso sugere que a intervenção foi ecaz na melhoria
dos resultados de higiene bucal comparado ao grupo controle, onde não foram observadas melhorias notáveis.
Conclusão: Este estudo conrma que a educação em saúde bucal estruturada melhora a escovação dentária e
a higiene bucal em crianças com deciências intelectuais. A implementação desses programas em ambientes de
educação especial, currículos escolares e iniciativas comunitárias pode melhorar os resultados de saúde bucal
em longo prazo e o bem-estar geral.
PALAVRAS-CHAVE
Criança; Educação em saúde bucal; Deciência intelectual; Higiene bucal; Escovação dentária.
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Sabilillah MF et al.
Effect of oral health education model on tooth brushing behavior and oral hygiene among children with intellectual disabilities
Sabilillah MF et al. Effect of oral health education model on tooth brushing
behavior and oral hygiene among children with intellectual
disabilities
on tooth brushing behavior and oral hygiene among
children with intellectual disabilities. By focusing on
both behavioral and hygiene outcomes, the research
seeks to provide evidence for the efcacy of this
model and its potential for broader application.
Furthermore, addressing the oral health
needs of children with intellectual disabilities
requires innovative, evidence-based educational
approaches. The “Tell-Show-Feel-Do” model
offers a structured and interactive framework for
teaching essential oral hygiene skills, making it
a valuable tool for enhancing the quality of life
for these children. This study seeks to contribute
to the growing body of knowledge on effective
oral health education practices and advocate for
their integration into care programs for children
with intellectual disabilities.
MATERIAL AND METHODS
Research design
This study used a quasi-experimental
design with a pretest-posttest control group
approach to evaluate the effect of an oral
health education model on tooth brushing
behavior and oral hygiene among children
with intellectual disabilities. The intervention
involves implementing the “Tell-Show-Feel-Do”
educational model for the intervention group,
while the control group receives standard oral
health education. Data collection is conducted at
baseline and after the intervention period 21 day.
The Tell-Show-Feel-Do (TSFD) educational
model was implemented in three sessions, with a
4-day gap between each session, and each session
lasting 120 minutes and was conducted in small
groups of 3–5 children to ensure individualized
attention while maintaining group interaction
benets. The intervention was delivered through
Focus Group Discussions (FGD) involving
children with intellectual disabilities, caregivers,
and trained facilitators. The TSFD method
follows a systematic approach: Tell: Providing
verbal instructions using simple and clear
language tailored to the cognitive abilities of the
children. Show: Demonstrating correct brushing
techniques, toothpaste application, flossing,
and tongue cleaning using visual aids and real-
time demonstrations. Feel: Allowing children
to physically interact with toothbrushes and
hygiene tools to build condence and familiarity.
Do: Encouraging children to practice brushing
under supervision with immediate guidance,
correction, and positive reinforcement.
Parental involvement was emphasized to
reinforce learning at home. Caregivers were
provided with instructional materials and practical
demonstrations to support their children’s oral
hygiene routines. They were encouraged to
monitor and assist their children in brushing
daily and to provide feedback on their progress.
The intervention was conducted by
researchers and trained enumerators who were
randomly assigned. Participants were divided
into two groups:
Intervention Group: Received oral health
education through the Tell-Show-Feel-Do method.
Control Group: Received conventional standard
dental health education through the Tell-Show-Do
method. The control group received a standard
single-session intervention that included:
Tell: Verbal instructions on tooth brushing
techniques, toothpaste application, and general
oral hygiene practices. Show: Demonstration of
brushing techniques using a model or visual aids.
Do: Encouragement for children to imitate the
demonstrated techniques with minimal supervision,
without systematic correction or reinforcement.
Unlike the TSFD method, this approach relied
on repetitive verbal reminders and general
reinforcement without practical correction or
hands-on practice. The education was delivered in a
short, direct manner, primarily focusing on brushing
and basic hygiene practices, without extensive
engagement or positive reinforcement. Both groups
underwent pre-test and post-test assessments to
evaluate the impact of the intervention. The observer
ensured that the study followed the Standard
Operating Procedures (SOPs).
This study was approved by the Ethics
Committee of the Faculty of Dentistry -
Prof. Soedomo Dental Hospital, Universitas
Gadjah Mada (Approval No. 149/UNI/KEP/
FKG-RSGM/EC/2024), ensuring compliance
with ethical standards for research involving
human participants. Furthermore, the study
was conducted in accordance with the principles
outlined in the Declaration of Helsinki.
Sample selection
Participants were selected using simple
random sampling, focusing on children with
intellectual disabilities attending a Special School
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Effect of oral health education model on tooth brushing behavior and oral hygiene among children with intellectual disabilities
Sabilillah MF et al. Effect of oral health education model on tooth brushing
behavior and oral hygiene among children with intellectual
disabilities
for Children with Disabilities. The randomization
was conducted simply by writing the names of
the children and their schools on separate pieces
of paper, which were then sealed in envelopes
by a third party. These envelopes were drawn
by the researcher and an examiner to assign
participants to either the intervention or control
group. The allocation sequence was concealed
in sealed envelopes and remained unknown to
both the researcher and the participants until
the intervention was administered, in order to
prevent selection bias. The random allocation
sequence was generated by a researcher who was
not involved in the recruitment of participants.
Participant enrollment was carried out by the
research team, while assignment to the interven-
tion and control groups was performed by the
principal investigator based on the results of the
sealed envelope draw. The study initially required
36 participants based on G*Power 3.1.9.4 calcula-
tions, with an additional 10% added to anticipate
dropouts. Ultimately, 52 children were included,
evenly divided into intervention (n=26) and
control (n=26) groups, from September 2 to
October 11, 2024.
Dropout criteria included the inability of
a child to fully participate in the intervention.
Children were required to attend Tell-Show-
Feel-Do-based oral health education through
Focus Group Discussions (FGD), facilitated by
the researcher with a moderator and a notetaker,
alongside guidance and counseling. Observers
assisted in ensuring adherence to standard
operating procedures throughout the study.
Inclusion and exclusion criteria
Inclusion criteria:
• Parents/caregivers provided written
informed consent to participate in the study.
• Participants were actively enrolled as
students in a Special School for Children
with Disabilities.
• Age ranged between 6 and 24 years.
• Children were classied as having mild or
moderate intellectual disabilities.
• Availability of a baseline Personal Hygiene
Index-Modied (PHP-M) score.
• Demonstrated the ability to cooperate during
data collection and intervention sessions.
Exclusion criteria:
• Children who were ill or received permission
to miss school during the study period.
• Presence of systemic diseases that could
impair functional ability.
• Classication as having severe or very severe
intellectual disabilities.
• Absence during critical phases of the study.
Research instruments
The feasibility test involved completing a
closed-ended questionnaire assessed on a four-
point Likert scale. Three experts, including a
researcher and educator specializing in dental
health for children with special needs, a pediatric
dentistry specialist, and an expert in media and
dental health education for children with special
needs, evaluated the research materials (format,
content, and language) and research instruments.
This method was applied to calculate content
validity by collecting expert assessment scores
and determining value for each instrument
item. The validation instrument was developed
and adapted based on three key aspects: format
(construct), content, and language. This validation
process aimed to assess the feasibility of the oral
health education model and validate the research
instruments.
Questionnaire and checklist formation,
application, and evaluation
The questionnaire was developed to assess
tooth brushing behavior among children with
intellectual disabilities. It included 12 structured
questions covering aspects such as brushing
frequency, technique, uoride toothpaste use,
parental supervision, and additional oral hygiene
habits (e.g., flossing and mouthwash use).
The questionnaire utilized a four-point Likert
scale to measure clarity, relevance to research
objectives, answer feasibility, and language
accuracy.
The checklist was designed to evaluate
actual brushing performance, including step-
by-step observations of the child’s brushing
behavior, such as applying an appropriate amount
of toothpaste, correct brushing technique, and
rinsing. This checklist was used by trained
observers to ensure standardized assessment of
the participants’ oral hygiene practices.
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Sabilillah MF et al.
Effect of oral health education model on tooth brushing behavior and oral hygiene among children with intellectual disabilities
Sabilillah MF et al. Effect of oral health education model on tooth brushing
behavior and oral hygiene among children with intellectual
disabilities
Validation process
The questionnaire and checklist underwent
a content validity assessment using Aiken’s
V Method, evaluated each item. Reliability
was tested using the Intraclass Correlation
Coefcient (ICC) to ensure consistency across
evaluations. The questionnaire and checklist
were administered before and after the 21-day
intervention to assess changes in oral hygiene
knowledge and brushing behavior.
Data collection
Data were collected using structured
observation tools and validated questionnaires to
assess tooth brushing behavior and oral hygiene.
The PHP-M index was used to quantify oral hygiene
status, while direct observation and caregiver
reports evaluated tooth brushing behavior. Pretest
data were gathered at baseline, and posttest data
were collected 21 day after the intervention.
Research variables
Independent variable:
Oral Health Education Model: The “Tell-
Show-Feel-Do” model for the intervention group
and standard education for the control group.
Dependent variables:
Tooth Brushing Behavior: Measured using a
checklist assessing routine, frequency, duration,
brushing time and technique.
Oral Hygiene: Quantied using the PHP-M
index.
Data analysis
Data were analyzed using application for
statistical signicance. Descriptive statistics (mean,
standard deviation) were used to summarize
demographic data and baseline characteristics.
Paired and independent sample t-tests assessed
within- and between-group differences.
A signicance level of p<0.05. p<0.05 was set
for all analyses.
Interpretation of results
The results of this study are expected to
provide evidence on the efficacy of the “Tell-
Show-Feel-Do” model in improving tooth brushing
behavior and oral hygiene among children with
intellectual disabilities. A statistically signicant
improvement in the intervention group compared
to the control group would underscore the
Table I - Characteristics of Children with Intellectual Disabilities
Variable
Intervention Groups Control Group
n Percentage (%) n Percentage (%)
Gender
Male 20 76.93 18 69.23
Female 6 23.07 8 30.77
Age
6-9 years 1 3.85 1 3.85
10-13 years 11 42.31 11 42.31
14-17 years old 13 50 11 42.31
18-20 years old 1 3.85 3 11.54
Education
Special Needs Primary School 8 30.76 9 34.62
Special Needs Junior High School 14 53.85 9 34.62
Special Needs Senior High School 4 15.39 8 30.76
Capability Categories
Able to educate 11 42.31 13 50
Able to train 15 57.69 13 50
Tooth Arrangement
Normal - 0 - 0
Crowding 26 100 26 100
Crowding Criteria
Mild 13 50 11 42.31
Moderate 10 38.46 7 26.93
Severe 3 11.54 8 30.76
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Sabilillah MF et al.
Effect of oral health education model on tooth brushing behavior and oral hygiene among children with intellectual disabilities
Sabilillah MF et al. Effect of oral health education model on tooth brushing
behavior and oral hygiene among children with intellectual
disabilities
importance of tailored oral health education
models for this population.
RESULTS
The characteristics of children with
intellectual disabilities in this study can be seen
in Table I as follows:
The characteristics of children with intellectual
disabilities in the intervention and control groups
reveal several trends. Males dominate both groups,
with 76.93% in the intervention group and 69.23%
in the control group. Most children fall into the
14-17 years age range (50% in the intervention
group and 42.31% in the control group), followed
by those aged 10-13 years (42.31% in both
groups). Few participants are in the 6-9 years
(3.85% in both groups) and 18-20 years (3.85% in
the intervention group and 11.54% in the control
group).
Educationally, most children in the
intervention group attend Special Needs Junior
High School (53.85%), while the control group is
evenly distributed across Special Needs Primary
School (34.62%), Special Needs Junior High
School (34.62%), and Special Needs Senior
High School (30.76%). Regarding capability, the
intervention group has more children classied as
“able to train” (57.69%), while the control group
has an even distribution (50%). All participants
exhibit crowding in their teeth, with mild cases
being most common in both groups, followed by
moderate and severe crowding. The results of the
bivariate analysis of the research variables with
the paired sample t test
in the intervention group
can be seen in Table II.
The results in Table II seen that signicant
improvements in both tooth brushing behavior
and oral hygiene among participants in the
intervention group after the implementation
of the educational model. The mean score
for tooth brushing behavior increased from
23.46 ± 4.810 before the intervention to 29.52 ±
2.506 afterward, with a statistically signicant
difference (p<0.001). This indicates a meaningful
enhancement in the participants’ ability to
perform proper tooth brushing, likely due to the
tailored oral health education provided during
the intervention.
Similarly, oral hygiene scores demonstrated
a significant improvement. The mean score
decreased from 43.92 ± 9.055 to 19.73 ±
5.977 post-intervention, reecting better oral
hygiene conditions. The significant reduction
(p<0.001) suggests that the intervention
effectively addressed plaque control and
improved overall oral cleanliness. The results of
the bivariate analysis of the research variables
with
the paired sample t test
in the control group
can be seen in Table III
The mean score for tooth brushing behavior
showed a slight increase from 21.40 ± 5.097 before
the intervention to 22.38 + 2.561 after. Despite
this increase, the p>0.205 indicates that the
change is not statistically signicant (p>0.05).
This suggests that the minor improvement
observed is likely due to natural variations
or minimal influences from general practices
rather than the impact of a specic intervention.
Table II - Pre and Post of Research Variables in the Intervention Group
Variable
Pre Post
Sig.*
Mean + SD Mean + SD
Tooth Brushing Behavior 23.46 + 4.810 29.52 + 2.506 <0.001
Oral Hygiene
43.92 + 9.055 19.73 + 5.977 <0.001
*
Paired sample t test
with p<0.05.
Table III - Pre and Post of Research Variables in the Control Group
Variable
Pre Post
Sig.*
Mean + SD Mean + SD
Tooth Brushing Behavior 21.40 + 5.097 22.38 + 2.561 0.205
Oral Hygiene
41.12 + 8.262 42.73 + 7.917 0.226
*
Paired sample t test
with p<0.05.
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Effect of oral health education model on tooth brushing behavior and oral hygiene among children with intellectual disabilities
Sabilillah MF et al. Effect of oral health education model on tooth brushing
behavior and oral hygiene among children with intellectual
disabilities
Consequently, the control group’s tooth brushing
behavior did not show a meaningful enhancement.
For oral hygiene, the mean score experienced
a negligible increase from 41.12 ± 8.262 to 42.73
+ 7.917. The p>0.226 indicates no statistically
signicant change (p>0.05), demonstrating that
the oral hygiene conditions of the control group
remained effectively unchanged. This lack of
signicant improvement points to the insufciency
of standard care routines in producing noticeable
changes in oral health outcomes without a
targeted educational or behavioral intervention.
The results of the bivariate analysis of research
variables using the independent sample t-test
before and after between groups can be seen in
Table IV
The analysis in Table IV seen significant
differences in the changes in tooth brushing
behavior and oral hygiene between the
intervention and control groups, as determined
by an independent sample t-test (p<0.001).
The mean score for tooth brushing behavior in
the intervention group after the intervention
was 1.04 + 0.940, substantially higher than the
control group’s mean score of 0.15 + 0.929.
This indicates that the intervention group
demonstrated a significant improvement in
tooth brushing behavior compared to the control
group. The mean oral hygiene score in the
intervention group was -24.19 + 10.837, much
lower (indicating better oral hygiene) than the
control group’s mean score of 1.62 + 6.634. This
suggests that the intervention was effective in
improving oral hygiene outcomes compared to
the control group, where no notable improvement
was observed.
DISCUSSION
The data seen several trends among children
with intellectual disabilities in the intervention
and control groups. The predominance of males
in both groups (76.93% in the intervention group
and 69.23% in the control group) can be explained
by genetic and biological factors. Recent research
conrms that intellectual disabilities are more
prevalent in males, potentially due to X-linked
genetic disorders and inherent differences in male
neurodevelopmental pathways [22,23]. The age
distribution, with a majority of children in the
14-17 years range followed by the 10-13 years
range, could be attributed to the typical stages
of educational transitions. Intellectual disabilities
often become more apparent during school years,
particularly as academic and social demands
increase. As highlighted by Gutman et al. [24],
early adolescence is a critical period for identifying
and addressing developmental delays, which
explains the clustering of interventions during
these years [24]. The age range in this study
(6 to 20 years old) does not impact the ndings,
as chronological age is not the primary factor in
determining the effectiveness of the intervention.
Instead, the study focuses on the social age of
children with intellectual disabilities, which
reects their cognitive and adaptive functioning
rather than their actual age. Therefore, differences
in chronological age do not introduce signicant
variability in the study outcomes. The social age
related to cognitive and adaptive behavior in this
study aligns with the classication of children
with intellectual disabilities into two categories:
educable and trainable, as assessed by the school.
Educational trends show that most children
in the intervention group attend Special Needs
Junior High School (53.85%), whereas the
control group is evenly distributed across different
educational levels. This indicates a strategic focus
on junior high school interventions, aligning
with the ndings of Kuntz and Carter [25], who
emphasize that targeted interventions during
middle school years can signicantly improve
cognitive and social outcomes for children with
intellectual disabilities [25].
Regarding capability, the intervention group
has a higher proportion of children classified
as “able to train” (57.69%), suggesting that
intervention programs are better at identifying
Table IV - Comparison of Pre-Post Change Differences in Variables between the Intervention and Control Groups
Variable
Intervention Control
Sig.*
Mean + SD Mean + SD
Tooth Brushing Behavior 1.04 + 0.940 0.15 + 0.929 0.001
Oral Hygiene
-24.19 + 10.837 1.62 + 6.634 <0.001
*
Independent sample t test
with p<0.05.
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Effect of oral health education model on tooth brushing behavior and oral hygiene among children with intellectual disabilities
Sabilillah MF et al. Effect of oral health education model on tooth brushing
behavior and oral hygiene among children with intellectual
disabilities
and enhancing the abilities of children with
higher functional potential. This aligns with
research by Schalock et al. [26], which highlights
the importance of individualized support plans
in maximizing the developmental potential
of children with intellectual disabilities [26].
Finally, the presence of dental crowding in all
participants, predominantly mild cases, reects
common dental issues in this population. Recent
studies, such as those, have noted a higher
prevalence of dental problems among children
with intellectual disabilities due to factors like
poor oral hygiene, limited access to dental care,
and behavioral challenges [27]. This underscores
the necessity for comprehensive health care
services within educational programs to address
the holistic needs of these children [28].
The data indicates signicant improvements
in both tooth brushing behavior and oral
hygiene among participants in the intervention
group following the implementation of the
educational model. The increase in the mean
score for tooth brushing behavior from 23.46 ±
4.810 to 29.52 + 2.506 (p<0.001) suggests a
substantial enhancement in the participants’
ability to perform proper tooth brushing. This
improvement is likely attributable to the tailored
oral health education provided during the
intervention, which may have included practical
demonstrations, interactive activities, and regular
reinforcement, helping participants internalize
and apply effective brushing techniques.
Similarly, oral hygiene scores showed a
signicant improvement, with the mean score
decreasing from 43.92 ± 9.055 to 19.73 ±
5.977 post-intervention (p<0.001). This reduction
reflects enhanced plaque control and overall
oral cleanliness. The educational model likely
addressed critical areas such as the importance
of oral hygiene, correct brushing methods, and
consistent practice, which collectively contributed
to better oral health outcomes.
Recent research supports these findings.
For, a study by Aljafari et al. [29] demonstrated
that customized oral health education
programs significantly improve oral hygiene
behaviors and outcomes, particularly when
they incorporate engaging and interactive
elements [29]. Additionally, recent research
found that educational interventions effectively
enhance oral hygiene practices and reduce plaque
levels in children with special needs [30]. Both
studies emphasize the critical role of tailored,
interactive education in fostering sustainable
improvements in oral health behaviors and
outcomes, aligning with the results observed in
this intervention [31].
The analysis of the control group’s data
shows a slight increase in the mean score for tooth
brushing behavior from 21.40 ± 5.097 to 22.38 +
2.561, with p > 0.205, indicating that this change
is not statistically signicant (p > 0.05). This
suggests that the observed minor improvement
is likely due to natural variations or the minimal
impact of general routines rather than any specic
intervention. The lack of a structured and focused
educational approach in the control group
likely contributed to the minimal improvement
in tooth brushing behavior. Similarly, the oral
hygiene mean score showed a negligible increase
from 41.12 ± 8.262 to 42.73 + 7.917, with
p > 0.226, indicating no statistically signicant
change (p > 0.05). This reects that the oral
hygiene conditions in the control group remained
effectively unchanged. The absence of a targeted
intervention or educational program likely
prevented any meaningful improvement in oral
hygiene, as standard care routines alone were
insufcient to induce signicant changes.
These ndings are consistent with recent
studies. For instance, Das et al. [32] found that
routine dental care practices without targeted
educational interventions resulted in minimal
improvements in oral health behaviors and
outcomes [32]. Similarly, a study, emphasized
that structured, interactive oral health education
programs are crucial for achieving signicant and
lasting improvements in oral hygiene, particularly
among populations with specific needs [33].
Both studies highlight the importance of tailored
educational approaches to foster meaningful
changes in oral health behaviors, reinforcing
the observed lack of improvement in the control
group [34].
Significant differences between the
intervention and control groups regarding both
tooth brushing behavior and oral hygiene, with a
p<0.001. The intervention group demonstrated
considerable improvements in both areas
compared to the control group, which did not
show signicant changes. The mean score for
tooth brushing behavior in the intervention group
post-intervention was 1.04 + 0.940, signicantly
higher than the control group’s post-intervention
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Effect of oral health education model on tooth brushing behavior and oral hygiene among children with intellectual disabilities
Sabilillah MF et al. Effect of oral health education model on tooth brushing
behavior and oral hygiene among children with intellectual
disabilities
score of 0.15 + 0.929. This difference indicates
that the intervention was effective in signicantly
enhancing tooth brushing behavior in the
intervention group. The substantial improvement
is likely due to the educational model provided,
which likely incorporated interactive learning,
hands-on demonstrations, and consistent
reinforcement of proper brushing techniques,
helping participants internalize and apply
effective tooth brushing habits.
The positive impact of such interventions
aligns with ndings in recent research. According
to a study, interactive and tailored oral health
education programs significantly improve
tooth brushing behavior, particularly among
children with intellectual disabilities [35].
The structured educational approach was
found to help participants learn and maintain
effective oral hygiene habits [36]. Similarly, a
study, demonstrated that tailored oral health
education, especially when it involves active
engagement and continuous feedback, can lead
to signicant improvements in the adoption of
proper tooth brushing techniques [37]. The mean
oral hygiene score in the intervention group was
-24.19 + 10.837, which was substantially lower
(indicating better oral hygiene) compared to
the control group’s score of 1.62 + 6.634. This
difference suggests that the intervention group
had signicantly better oral hygiene after the
intervention, likely due to more effective plaque
control and adherence to recommended oral
hygiene practices, facilitated by the structured
education provided.
This result is consistent with ndings from
recent studies. For a study, highlighted that
targeted educational interventions that focus on
plaque control and oral hygiene techniques result
in significant improvements in oral hygiene,
especially when participants receive personalized
guidance [38]. Another study, emphasized the
importance of continuous education and the
use of individualized strategies to improve oral
hygiene behaviors and outcomes, particularly
in children with intellectual disabilities [39].
Additionally, findings by Surija et al. [10]
reinforce the importance of parental education
in managing the oral health of children with
intellectual disabilities. This underscores the
critical role of equipping parents with adequate
knowledge and tools to support the oral health
of their children effectively [10].
The results suggest that the “Tell-Show-
Feel-Do” model effectively enhances oral hygiene
behavior in children with intellectual disabilities.
These ndings can be applied in special education
settings, dental health programs, and caregiver
training to improve long-term oral health outcomes
for this population. Integrating this method into
school curricula and community health programs
may lead to sustained improvements in dental
hygiene practices, reducing the risk of oral
diseases.
The study has a direct impact on the lives
of children with intellectual disabilities by
promoting better oral health, which contributes
to their overall well-being and quality of life.
Improved oral hygiene reduces the risk of
dental issues, enhances self-care abilities, and
fosters greater independence in daily routines,
ultimately improving their general health and
social inclusion.
The 21-day study period was designed
to assess the short-term effectiveness of the
intervention in improving brushing behavior
and oral hygiene, focusing on immediate
behavioral changes rather than long-term habit
maintenance. Previous studies have shown
that short-term educational interventions can
lead to meaningful improvements in health
behaviors. To reinforce learning at home, parental
involvement was emphasized by providing
caregivers with instructional materials and
practical demonstrations. They were encouraged
to monitor and assist their children in brushing
daily and to provide feedback on their progress,
helping extend the impact of the intervention
beyond the study period.
The limitations of this study include the
varying needs and abilities of children with
intellectual disabilities, as communication
and comprehension challenges may have
inuenced the outcomes. Parental involvement,
environmental factors, and the consistency
of education also played a role. Additionally,
some children required familiarity and multiple
interactions before they were willing to participate
fully. Another limitation is the relatively short
21-day follow-up period, which may not fully
capture long-term habit retention. While the
intervention effectively improved brushing
behavior and oral hygiene, extended monitoring
in future research could provide deeper insights
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behavior and oral hygiene among children with intellectual
disabilities
into the sustainability of these behavioral changes
and long-term adherence.
CONCLUSION
This research demonstrates that an oral
health education model signicantly improves
tooth brushing behavior and oral hygiene
among children with intellectual disabilities.
The intervention group, receiving structured
and tailored education, showed substantial
improvements compared to the control group,
which had minimal changes. The results
emphasize the effectiveness of personalized,
interactive teaching strategies in enhancing tooth
brushing habits and oral hygiene. These ndings
underscore the importance of targeted oral
health education programs for this population,
promoting better oral health and overall well-
being. Future research should explore the long-
term effects and potential adaptations to further
enhance such interventions.
Acknowledgements
The authors wish to express their sincere
gratitude to Universitas Gadjah Mada and
Poltekkes Kemenkes Tasikmalaya for providing
unlimited access to their extensive e-library
resources. This invaluable access facilitated
the comprehensive literature search and data
collection necessary for the establishment and
completion of this review. The support from
these institutions enabled the authors to explore
a wide range of scholarly articles, databases, and
e-books, signicantly contributing to the depth
and quality of the research presented. Without
this crucial support, the thoroughness and scope
of this review would not have been possible.
Author’s Contributions
MFS: was responsible for the overall concept
and design of the study, data collection, and
analysis. We conducted the intervention sessions,
assessed the outcomes, and were primarily
responsible for writing the manuscript, including
drafting the introduction, methods, results,
and discussion sections. Additionally, reviewed
and revised the manuscript based on feedback
from the co-authors. HK: provided guidance
throughout the research process, including
rening the research design, methodology, and
data analysis approach. As the corresponding
author, handled the manuscript submission,
communication with the journal, and ensured
that all necessary revisions were completed.
Author 2 also contributed to the critical revision
of the manuscript, particularly in the discussion
and conclusion sections. LH: played a key role
in providing methodological and analytical
support, offering suggestions for improving the
study’s design and execution. Contributed to
the interpretation of the results and the final
revision of the manuscript. Author 3 also assisted
in ensuring the scientic accuracy and relevance
of the content related to the education model
used in the study. SK: supported the overall
direction of the research and provided expert
advice in the area of oral health education
and its application in children with intellectual
disabilities. instrumental in reviewing the
manuscript, providing feedback on the content,
and assisting with the nal revisions to ensure
the clarity and completeness of the manuscript.
Conict of Interest
The authors have thoroughly reviewed and
conrmed that there are no conicts of interest
arising from this review. They have diligently
ensured that personal, nancial, and professional
relationships do not influence the objectivity
or integrity of their work. This commitment to
transparency and ethical standards underscores
the credibility and reliability of the ndings and
conclusions. “The authors have no conicts of
interest to declare.”
Funding
This study was supported by funding
from the Ministry of Health of the Republic
of Indonesia and Universitas Gadjah Mada,
reecting a shared commitment to improving
the oral health and quality of life of children
with intellectual disabilities. The Ministry’s
support underscores its dedication to addressing
specific health challenges through tailored
interventions, while Universitas Gadjah Mada’s
contribution highlights its role in advancing
public health research. This collaboration enabled
the successful implementation of the “Tell-
Show-Feel-Do” educational model with rigorous
standards, facilitating data collection, analysis,
and meaningful ndings to inform strategies for
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Effect of oral health education model on tooth brushing behavior and oral hygiene among children with intellectual disabilities
Sabilillah MF et al. Effect of oral health education model on tooth brushing
behavior and oral hygiene among children with intellectual
disabilities
enhancing oral hygiene and well-being in this
vulnerable population.
Regulatory Statement
This study was conducted in accordance
with all provisions of the local human subjects
oversight committee guidelines and policies of
the Ethics Committee of the Faculty of Dentistry
- Prof. Soedomo Dental Hospital, Universitas
Gadjah Mada. The study protocol was reviewed
and approved by the Ethics Committee, with
approval number 149/UNI/KEP/FKG-RSGM/
EC/2024. This ethical approval ensures that the
study complies with established standards for
research involving human participants.
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behavior and oral hygiene among children with intellectual
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Date submitted: 2025 Jan 15
Accept submission: 2025 Feb 25
Hari Kusnanto
(Corresponding address)
Universitas Gadjah Mada, Faculty of Medicine, Public Health and Nursing, Primary
Care Family Medicine Program, Yogyakarta, Indonesia.
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