International Journal of Clinical Preventive Dentistry

Volume 7, Number 3, September 2011

Is Joint Tooth Brushing an Effective Program for

Improving Dental Health among Elementary Students?
- A Study from Jakarta, Indonesia
R. R. Darwita, Diah Ayu Maharani, A. Rahardjo, D. P. Puspa, R. Amalia, Sandy D. P.
Department of Preventive and Public Health Dentistry, Faculty of Dentistry, Universitas Indonesia, Jakarta, Indonesia

Objective: To evaluate the effectiveness of a joint tooth brushing program at an elementary school in Jakarta.
Methods: An intervention program to improve the oral health of elementary students was conducted over a 6-month period.
The program consisted of dental health education and daily indoor two-minute sessions of joint tooth brushing. We sampled
a total of 57 students from the first and second grades. Each one was interviewed and was subject to oral examinations before and after the program was implemented. Moreover, questionnaires were also administered to the teachers. Then they
were trained as an instructor for the program. These programs were conducted daily before the beginning of class.
Results: Significant changes in saliva pH and plaque pH scores was found for students. Moreover, teachers awareness of
dental healthcare also increased. Finally, teachers were actively engaged when acting as tooth brushing program instructors.
Conclusion: Teachers conducting daily, indoor, two-minute, joint tooth brushing programs could motivate students to maintain their oral health. This in turn leads to a decreased prevalence of dental caries among elementary school students.

Keywords: oral health, tooth brushing program, elementary school students

Introduction

pervised tooth brushing programs using fluoride toothpaste can

help to reduce the occurrence of caries (4).
Dental health education seeks behavioral change by persuading others to implement healthy dental habits. In addition, oral
health education refers to efforts and activities that not only affect healthy behaviors but also raise awareness about the maintenance of oral health more generally (5). To achieve the goals
of this educational process and to accelerate behavioral
changes, we must seek appropriate ways of approaching the
community. One such approach aimed at elementary school students and outlined by the Indonesian Ministry of Health was the
School Dental Health Program. This program emphasized the
promotion of dental health care as well as prevention. A joint
tooth brushing program for students was also included in this
program. However, this program was conducted neither regularly nor continuously. This may have been due to a lack of participation by both teachers and parents.
Greens theory suggests that motivation and the availability
of health programs are factors that shape health behaviors. We

The health status of the Indonesian people (including their

dental health) has improved significantly, though slowly, over
the last two decades. Improvement in the dental health of the
population depends not only on the general level of social and
economic development but also on improvements in the delivery of dental care services and on community-based dental
health promotion activities (1,2). Some countries have identified poor oral health as a childrens health issue, with significant
long-term societal impacts. As a result, school-based programs
have been adopted, and they have been successful at promoting
the dental health of pupils (3). Research suggests that su-

Corresponding author Diah Ayu Maharani

E-mail: [email protected]
Received June, 11, 2011, Revised August, 4, 2011,
Accepted September, 6, 2011

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International Journal of Clinical Preventive Dentistry

reasoned, therefore, that a continuous dental health education

program coupled with a comprehensive joint tooth brushing
program that was conducted in the schools could improve the
oral hygiene of students. Moreover, such a program could also
lead to decreased DMF-T (Decayed Missing Filling-Tooth)
scores (6). That said, an effective and sustainable approach to
tooth brushing remains to be developed for the School Dental
Health Program. Consequently, this research sought to implement a suitable intervention program in Jakarta that would raise
awareness about the importance of maintaining oral health
while motivating elementary school students and their teachers
to prevent dental and oral diseases.

Material and Methods

This research represents a longitudinal study conducted at a
primary school in Jakarta from July 2009 to January 2010. Our
sample was composed of 57 students from the first and second
grades. For this study, school officers were selected as subjects
in light of their high cooperativeness. In addition, their teachers
were also interviewed. Moreover, this study involved an intervention: a two-minute joint tooth brushing session carried out
each day in the classroom before classes began. Students were
instructed in matters of informed consent and were socialized
into the program itself. Finally, the parents of the students completed both informed consent forms and questionnaires to assess their own behaviors related to oral health maintenance.
Oral examinations of the students were also performed. The
examination consisted of obtaining DMF-T, plaque and saliva
pH scores as well as interviews to assess the students knowledge and their habits related to oral health maintenance. The extent and severity of tooth decay was measured by a universally
adopted measurement, the DMF-T index. Damage caused by
decay to a tooth is irreversible. The following represent the possible visible states of a decayed tooth: decayed and left untreated
(DT), missing (i.e., extracted due to decay) (MT), or filled (FT).
An individuals total number of teeth affected by tooth decay
is the sum of DT+MT+FT, known as the DMF-T value (6). A
measurement of plaque pH was done using the Plaque-Check+
pH kit. In an effort to standardize the sites of collection and to
minimize the variation in pH among subjects, plaque was obtained only from the buccal surface of maxillary posterior teeth.
A compatible excavator was used to collect the plaque samples.
The plaque samples were then checked using the disclosing test
provided by the Plaque-Check + pH Kit. Finally, a Saliva-Check
Buffer kit was used to measure the pH of the saliva (7).
Before student behavior data were collected, the validity and
reliability of the questionnaires to be employed were checked.
After some initial oral examinations, teachers were trained to

150 Vol. 7, No. 3, September 2011

provide dental health education to their students and underwent

the two-minute, single rinse, tooth brushing method that the students would have to do each day before the beginning of class.
Using flipcharts and phantoms, teachers were taught to explain
the tooth brushing program to their students. The program itself
took five minutes before class to complete. This daily, indoor,
two-minute joint tooth brushing program was conducted for six
months. All data gained from the oral examinations and the interviews were statistically analyzed using SPSS 16.

Results
The faculty of Dentistry in the Department of Preventive and
Public Health Dentistry at the University of Indonesia delivered
the dental health promotion and prevention programs to the dental students. The program was designed, consent and baseline
data were obtained, and the program of daily in-school tooth
brushing and in-class education was initiated. Essentially, a
health-promoting pilot school was established; both teachers
and children were engaged in the program. Oral health improved and the emergence of new knowledge and practices was
evident.
Table 1 shows that only 8 of 57 students had DMF-T scores
of 0. Meaning that only 14% of students did not have dental
caries. Forty-two students had DMF-T scores that ranged from
1 to 3. A majority of the sample (86%) exhibited decay, that is,
1 to 3 dental caries per person, and 86% of students had dental
caries. Moreover, Table 2 indicates that there were significant
changes (p0.001) from before to after the program was implemented with respect to both mean plaque pH scores and students behavior. In addition, there were only slight increases in
mean scores for saliva pH and for the buffering capacity of the
saliva. Table 3 highlights the significant mean score changes in
the knowledge, attitudes, actions and behaviors of the teachers
(p0.001) from before to after the implementation of the
six-month joint tooth brushing program.

Table 1. Frequency distribution of student DMF-T scores based on sex

Sex
DMF-T score

0
1-2
3
Total

Male

Female

4
2
19
25

16
8
76
100

4
5
23
32

12.5
15.6
71.9
100

R. R. Darwita, et alSchool-Based Dental Health Program

Table 2. Mean scores before and after the tooth brushing program for
plaque pH, saliva pH, saliva buffering capacity and student behavior
Variable
pH of plaque
pH of saliva
Saliva buffering capacity
Students behavior

Mean
Before

After

6.133
6.688
4.05
32.964

6.474
6.802
3.72
39.4211

p
0.000
0.104
0.397
0.000

Discussion
Dental caries is one of the most prevalent infectious diseases
in Indonesia. More than half of all cases are left untreated (2),
as demonstrated in this study by the low number of students who
did not have caries. This high prevalence of caries might be due
to a lack of dental health education or to poor awareness of oral
health maintenance (8). That said, frequent sugar consumption
and dental cleaning habits among children are also factors that
could affect their oral health status. Children generally like to
eat cariogenic foods such as candies and chocolates. Cariogenic
foods dissolve with saliva and stick to tooth surfaces as pellicle.
Ultimately, this pellicle forms dental plaque. Bacteria, especially Streptococcus mutans, the main etiology of dental caries,
will reproduce in the dental plaque. If tooth brushing is not conducted regularly, this dental plaque will become increasingly
mature and acidic. The acidic metabolic products of Streptococcus mutans will begin to abrade the dental enamel structure,
causing it to demineralize (9).
The initial data showed that the plaque pH mean score was almost in the critical range. This finding may have been a result
of improper tooth brushing habits. Dental plaque had formed,
matured and adhered to tooth surfaces longer than it should. The
increasing amounts of acidic products derived from the bacterias own metabolism generated lower plaque pH scores and
led to a higher risk of caries (10,11). However, after 6 months,
there were significant increases in plaque pH scores. This in turn
could have been caused by regular tooth brushing (12,13). The
habit of tooth brushing twice a day, after breakfast and before
bed, is important in preventing the maturation of dental plaque
on tooth surfaces, as plaque forms and matures within 24-48
hours. If students brush their teeth regularly, mature plaque
would be mechanically and continuously rubbed off, and only
immature plaque would remain on the tooth surface. This would
help maintain childrens scores within the normal range for plaque pH (14).
After the intervention, the scores for the saliva pH increased,
which may have been caused by the 6-month program. This in-

Table 3. Mean scores before and after the tooth brushing program for
teachers knowledge, attitudes, actions and behaviors
Variable
Teachers knowledge
Teachers attitudes
Teachers actions
Teachers behaviors

Mean

Before

After

16.917
16.750
17.000
50.667

19.667
18.750
18.583
57.000

0.018
0.013
0.036
0.003

crease was not significant, and these scores may have been affected by the speed of saliva production. The age of the students
ranged between six and eight years old. At this point in a childs
growth and development, the salivary glands may not be fully
developed, and thus, there is a lower velocity of saliva production, which could in turn influence the saliva pH. Moreover,
the insignificant decrease in score for the buffering capacity of
the saliva suggests that it could not be affected by external
factors. Instead, the buffering capacity of saliva is likely affected by the velocity of saliva production, which varies between individuals (15). Therefore, the buffering capacity of saliva should not be used as a parameter for determining the success of the program.
Regarding the students maintenance of their oral health, we
witnessed significant improvements in their maintenance behavior, which may be the result of employing a program that
actively involves teachers, intensifying the behavior-changing
effects on students. The significant increase in students oral
health behaviors suggests that first and second grade students
between the ages of six and eight years old were able to adopt
new behaviors. At this stage, students are likely to believe the
new information offered by their teachers. Thus, it is likely that
they believed that regular tooth brushing conferred significant
benefits for which they were also in need. We suggest that
changes based on knowledge and interventions based positive
attitudes and actions are likely to result in long-term positive
oral health maintenance behaviors.
The results showed that the behaviors of teachers toward oral
health could be influenced by their knowledge, attitudes and
habits. There was a significant increase in the behavior scores
of teachers after the 6-month program was completed (p
0.05). This suggests that the teachers themselves had adopted
new behaviors. The process of changing behavior starts with old
behaviors but then proceeds through the following stages:
awareness, interest, desire, trial, adoption, satisfaction and
adoption of a new behavior. In light of this process, intraoral examinations were conducted and the teachers knowledge of
dental health education was assessed before the program began.

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International Journal of Clinical Preventive Dentistry

This was done to increase the teachers awareness of and interest

in the significance of oral health. Following our intervention,
the desire to improve their oral health was increased.
Continuous motivation was also provided to the teachers
through regular dental health education. After the program was
implemented and adopted, teachers were satisfied with the outcomes and thus adopted new behaviors to maintain their oral
health. The teachers came to feel that having healthy teeth was
beneficial. Consequently, they sought to instruct their students
on the importance of maintaining good oral health. The teachers
encouraged and supported their students toward these ends;
they played an important role in motivating students to maintain
their own oral health. Finally, the prevalence of dental caries
among elementary school students may decrease if a sustainable tooth brushing program is implemented.
Despite these results, this study possessed several limitations.
Although we examined an intervention program, our study did
not employ a control group for purposes of comparison. The author only compared mean scores before and after the intervention for the same participants; thus, changes in mean scores
could still have been due to factors other than the intervention.
Additionally, the sample size employed was small, making it
difficult to draw strong conclusions and leading to the potential
for measurement bias. Nonetheless, the joint tooth brushing
program is associated with positive effects on students and
teachers, not only with respect to their greater awareness of dental health but also to the development good dental care
behaviors.

Conclusion
To evaluate the effectiveness of a joint tooth brushing program
at an elementary school in Jakarta. An intervention program to
improve the oral health of elementary students was conducted
over a 6-month period. The program consisted of dental health
education and daily indoor two-minute sessions of joint tooth
brushing. We sampled a total of 57 students from the first and
second grades. Each one was interviewed and was subject to oral examinations before and after the program was implemented.
Moreover, questionnaires were also administered to the teachers. Then they were trained as an instructor for the program.
These programs were conducted daily before the beginning of
class.
1. A majority of the sample (86%) exhibited decay, that is, 1
to 3 dental caries per person, and 86% of students had dental
caries.
2. Indicates that there were significant changes (p0.001)

152 Vol. 7, No. 3, September 2011

from before to after the program was implemented with respect

to both mean plaque pH scores and students behavior.
3. Highlights the significant mean score changes in the knowledge, attitudes, actions and behaviors of the teachers (p
0.001) from before to after the implementation of the
six-month joint tooth brushing program.
Teachers conducting daily, indoor, two-minute, joint tooth
brushing programs could motivate students to maintain their oral health. This in turn leads to a decreased prevalence of dental
caries among elementary school students.

Acknowledgments
The authors gratefully acknowledge the support by the Universitas Indonesia and the Indonesian Ministry of Education.

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