Community Dent Oral Epidemiol 2000; 28: 336–43 Copyright C Munksgaard 2000

Printed in Denmark . All rights reserved

ISSN 0301-5661

Robert J. Hawkins1, Debra L. Zanetti2,

Oral hygiene knowledge of high- Patricia A. Main1,3,
Aleksandra Jokovic1,
John J. M. Dwyer4, Daniel F. Otchere1,2
risk Grade One children: an and David Locker1
1
Community Dental Health Services
Research Unit, Faculty of Dentistry, University

evaluation of two methods of of Toronto, Toronto, 2Community Dental

Services Division, Toronto Public Health
Division, Toronto, 3Region of Durham Health

dental health education Department, Ajax, 4Planning and Policy

Toronto Public Health Division, Toronto,
Canada

Hawkins RJ, Zanetti DL, Main PA, Jokovic A, Dwyer JJM, Otchere DF, Locker D:
Oral hygiene knowledge of high-risk Grade One children: an evaluation of two
methods of dental health education. Community Dent Oral Epidemiol 2000; 28:
336–43. C Munksgaard, 2000

Abstract – The effectiveness of two methods of dental health education (DHE)

for improving oral hygiene knowledge among high-risk Grade One students was
evaluated. Fifty elementary schools in the former City of North York, Canada
were assigned to one of two groups. In one group, students received a classroom-
based DHE lesson which was reinforced by two small-group sessions (nΩ243).
In the other group, students received only a single classroom-based DHE lesson
(nΩ206). After DHE interventions, students in both groups displayed improved
knowledge for most oral hygiene questions (e.g., when should you throw your
Key words: children; dental health education;
toothbrush away?). However, for several questions, a significantly higher propor- dental public health services; oral hygiene
tion of ‘‘classroom plus small-group sessions’’ students displayed improved
knowledge compared to students receiving only a classroom lesson. These items Robert Hawkins, Community Dentistry,
Faculty of Dentistry, University of Toronto,
included: awareness that cavity prevention and removal of germs are two purposes 124 Edward Street, Toronto, Ontario, Canada
of oral hygiene; and knowledge that teeth help people to eat and talk. Results M5G 1G6
suggest a classroom-based lesson combined with small-group sessions is a more e-mail: robert.hawkins/utoronto.ca
effective method of improving oral hygiene knowledge among high-risk Grade Submitted 29 July 1999; accepted 2 February
One students compared to a single classroom-based lesson. 2000

Although various formats of dental health educa-
tion (DHE) have been used, current literature fa-
vours small-group activities over those carried out
in the classroom (1). Small-group participatory ses-
sions allow repetition and reinforcement of learn-
ing, especially for younger children, because too
much information may be covered in a single class-
room session. These sessions also allow material to
be presented at each participant’s level of under-
standing, and allow educators to use an active
‘‘show-and-do’’ approach to learning rather than
the traditional information-oriented, ‘‘show-and-
tell’’ approach. Studies of older children and adults
have found small-group sessions are effective in
improving oral hygiene knowledge and attitudes
(2, 3).
Most school-based programs have employed an
individualistic approach to DHE which focuses on
the psychological factors affecting behaviour, such
as knowledge, attitudes, and beliefs (4). In this ap-
proach, methods of behaviour modification have
included the provision of information, skill devel-
opment, and repetitive learning. For the school
year 1996–1997, dental education for Grade One
students in North York, Ontario, Canada consisted
of a 30-min classroom session for all students and
two follow-up small-group sessions for students
identified as being at high-risk for dental diseases
by the Community Dental Services Division’s
screening program. These programs were estab-
lished in accordance with the Ontario Ministry of
Health’s ‘‘Healthy Growth and Development’’ pro-

336

gram which included dental education as a manda-
tory part of its dental component (5). The objectives
of the North York DHE program were: to provide
high quality education programs to target popula-
tions in a cost-effective manner; to increase the per-
centage of the target population practising good
dental health behaviours; and to increase the den-
tal health awareness, knowledge, and skills of the
target populations. Based on epidemiologic stud-
ies, it was considered justifiable and cost-effective
to focus available resources on the education of
high-risk children. The burden of dental diseases
among children in Ontario is unevenly distributed;
approximately 20% of children experience 80% of
new dental decay (6).
This paper reports the results of an evaluation
which compared the effectiveness of two methods
of DHE for high-risk Grade One students attending
public and separate elementary schools in the for-
mer City of North York. This paper reports the re-
sults for oral hygiene knowledge. The authors dis-
cussed toothbrushing competency outcomes of this
evaluation in a paper currently being reviewed. To
date, there is little information on the oral hygiene
knowledge of young children and the effectiveness
of DHE programs for this age group. Moreover, it
is unknown whether small-group sessions provide
additional benefits to high-risk children.
Material and methods
Participants
The target population was Grade One students, age
range 5-to-7 years, in public and separate schools
in the former City of North York, Canada who
were at high-risk for dental diseases. Children at
high-risk met one of the following conditions: a
need for urgent treatment (open lesion, pain, infec-
tion, trauma, or haemorrhage), as defined by the
Children in Need of Treatment (CINOT) program;
a need for fluoride therapy due to having a smooth
surface carious lesion; or a score of 1 or more on
the Community Periodontal Index Treatment Need
(CPITN).
Evaluation design
A pre- and post-intervention design with two
study groups was utilized. Fifty public or separate
elementary schools were matched according to
geographic planning region and randomly allocat-
ed to one of the two groups. Matched schools
would have had students with similar demogra-
phic characteristics because of the criteria used to
Oral hygiene knowledge of high-risk children
select schools. A high proportion of these students
would have high dental needs, low socioeconomic
status, and a history of recent immigration to Cana-
da. The distance between schools was taken into
account during matching to prevent a spill-over of
dental education information.
Students in one group received one classroom
lesson followed by two small-group sessions,
whereas students in the other group received only
the classroom lesson. The time frame between ob-
servations and interventions was the same for both
groups. For ethical reasons, students in the ‘‘class-
room-based lesson only’’ group also received two
small-group sessions after the post-test.
Oral hygiene knowledge measure
A measure of oral hygiene knowledge for Grade
One children was developed with questions re-
flecting the content of the DHE program for Grade
One. This measure consisted of 6 open-ended ‘‘tell-
me’’ questions and 3 closed-ended ‘‘show-me’’
questions. ‘‘Tell-me’’ questions required verbal re-
sponses which interviewers recorded, using a list
of potential responses on the questionnaire and an
‘‘other (specify)’’ category. ‘‘Show-me’’ questions
used pictures or visual aids, and required non-ver-
bal responses such as pointing to a photograph or
toothbrush. For each question, interviewers could
indicate whether the child did not answer or said
‘‘I don’t know‘‘. The measure was pilot tested with
a sample of high-risk Grade One students. Subse-
quently, revisions were made based on pilot test
information, informal discussions with children,
and comments from an education consultant and
Grade One teachers.
Procedure
In September 1996, dental hygienists employed by
North York Community Dental Services (CDS)
screened children and identified high-risk students
according to previously described criteria. Parents
of selected students were sent a letter of invitation,
accompanied by a consent form asking that their
child participate in the study. Telephone follow-up
was used to increase response rate. Only students
with parental or guardian consent were included in
the study. Schools were sampled until the required
sample size was obtained.
The evaluation was conducted between October
1996 and February 1997. Independent interviewers
who were trained immediately prior to pre-test and
post-test collected the data. During a half-day ses-
sion, the DHE manager provided training to them
337
Hawkins et al.
on how to administer the instrument in a standard-
ized manner. The interviewers were blind to which
students were assigned to each group. At pre-test
and post-test, interviewers led participants one-at-
a-time to the dental or health room of schools dur-
ing regular school hours. Interviewers told each
child, ‘‘(Child’s first name), I want to know what you
know about your teeth and if you don’t know, it’s
OK to say that.’’ Interviewers then read each ques-
tion or statement to the child and recorded re-
sponses on the questionnaire. For questions with
more than one appropriate answer, interviewers
were told to prompt each child by asking, ‘‘Can
you think of anything else?’’
Six trained dental health educators employed by
North York CDS provided DHE sessions after pre-
tests. The content of these sessions included oral
hygiene instruction in brushing and lessons on nut-
rition, injury prevention, the objectives of oral hy-
giene, and practical information about oral hy-
giene. In the classroom lessons equal amounts of
time were devoted to these different topics, but
more time was devoted to oral hygiene instruction
in the small-group sessions. Classroom-based les-
sons were given in October. Each student in the
‘‘classroom plus small-group sessions’’ group re-
ceived a follow-up small-group session in Novem-
ber and January. The first small-group session con-
sisted of 30 min of participatory education fol-
lowed by 15 min of individual education which
included toothbrushing instruction. The second
visit was 15 min in length and included tooth-
brushing instruction. The school-based DHE pro-
gram was an established program which operated
in accordance with the policies of the CDS Division
of the North York Public Health Department. As
part of the DHE program, the DHE manager con-
tinually monitored educators to ensure compliance
with the protocol of the health unit’s quality assur-
ance program. Educators were blind to which
schools were assigned to each group. One educator
provided all education sessions for matched
schools within each region.
Post-tests were done about one month after the
last education session. Both pre-test and post-test
took place over a two-day period at each school. If
children were absent both of these days, they were
likely not included in the study; repeat visits to
schools occurred only if several children were ab-
sent at that school. School teachers and dental edu-
cators were surveyed to determine if any events,
that might have influenced the outcome measures,
occurred in the selected schools during the study.
338
They reported that no such events were known to
have occurred.
Data analysis
Data were analysed using the SPSS/PCπ statistical
package (7). Data from only participants who took
part in both pre-test and post-test were analysed.
Participants were deemed to have problems under-
standing English if they failed to correctly answer
the following questions or requests: what is your
name?; what grade are you in?; point to your teeth;
and point to the toothbrush. Data from students
who did not answer correctly were excluded from
the analysis.
Chi-square tests were done to determine whether
the groups had equivalent pre-test scores. McNem-
ar’s tests were used to compare pre-test and post-
test scores for each group separately, and chi-
square tests were used to compare both groups on
the proportion of students who displayed
increased knowledge from pre-test to post-test.
Results
Eight hundred and seventy-two students were in-
vited to participate in the study (Table 1). However,
the sample was reduced to 449 because of parental
consent forms not being returned, students not
completing both the pre-test and post-test, and stu-
dents having problems comprehending English.
There were 243 students from 26 elementary
schools in the ‘‘classroom plus small-group ses-
sions’’ group and 206 students from 24 elementary
schools in the group receiving only a classroom-
based session.
Both groups had similar pre-test results. They
differed significantly on only one knowledge ques-
tion. Specifically, a higher proportion of students in
the classroom session only group responded that
Table 1. Number of participants remaining at different
phases of the study
Classroom
and Classroom
small-group session
Phase of study sessions only
Invited to participate in study 469 403
Positive consent forms returned 334 273
Participated in pre-test 306 249
Participated in post-test 252 213
Able to adequately comprehend
English 243 206
 Oral hygiene knowledge of high-risk children

‘‘in the morning’’ was one of the most important
times to brush their teeth. At pre-test, the percen-
tage of participants responding appropriately var-
ied substantially for the nine questions (Table 2).
Although over 90% of participants correctly iden-
tified a picture of a boy brushing his teeth as
‘‘someone doing something to look after his teeth‘‘,
pre-test results for other items were less positive.
About one-half to two-thirds of students displayed
knowledge for a series of questions regarding

Table 2. Percentage of participants who displayed oral hygiene knowledge at pre-test and post-test

Classroom and
small-group sessions Classroom session only

Knowledge item Pre Post Pre Post

What is important to do to
keep your teeth healthy?
(response given: oral hygiene) 67 74 70 72
Why should you brush your teeth?
- to not get cavities 21 40**** 24 33*
- to remove food 6 10 8 4
- to remove germs 10 21*** 8 8
- to make clean/white 49 38** 42 42
- to make strong/healthy 18 21 14 15
Picture of ‘‘boy brushing his teeth’’
identified as ‘‘boy who is doing
something to look after his teeth‘‘a 96 100* 91 98**
What do your teeth help you do?
- they help me eat 64 82**** 62 72**
- they improve appearance 3 5 3 4
- they help me talk 11 30*** 13 18
When is the most important time to brush your teeth?
- before bed 58 76**** 64 74*
- in the morning 55 57 65 62
Why is this girl brushing her teeth?b
- to not get cavities 15 33*** 15 20
- to remove food 7 7 7 7
- to remove germs 4 17**** 6 7
- to make clean/white 56 49 53 48
- to make strong/healthy 22 26 19 25
Show me the toothbrush that is the best size for youc
(correct response: small or medium size) 63 81**** 66 81***
When should you throw your toothbrush away?
- when bristles are frayed 11 46**** 13 30****
- when it is old 19 21 18 21
Show me how much tooth paste you should used
(correct response: smeared or pea size) 65 77** 58 73***

McNemar’s test for differences within each group from pre-test to post-test:
* P⬍0.05,** P⬍0.01,*** P⬍0.001,**** P⬍0.0001.
a
Three pictures of a boy were placed in front of the student. The interviewer asked, ‘‘show me the pictures of the boy who
is doing something to look after his teeth‘‘. Four pictures were shown: boy visiting the dentist (correct); boy eating candy;
boy brushing his teeth (correct); and boy playing.
b
A picture of a girl brushing her teeth was placed in front of the student. The interviewer asked, ‘‘why is this girl brushing
her teeth?’’
c
Three different sized toothbrushes of the same colour were placed in front of the student. The interviewer asked, ‘‘show me
the toothbrush that is the best size for you‘‘. The three sizes were small, medium, and large.
d
Three same sized toothbrushes of the same colour with varying amounts of toothpaste on each brush were placed in front
of the student. The interviewer asked, ‘‘show me how much toothpaste you should use‘‘. The three amounts were: toothpaste
smeared on brush with finger to cover brush; pea size or 1/4’’ of toothpaste; and toothpaste 1/4’’ thick the length of the
bristles.

339
Hawkins et al.

toothbrushing (e.g., when is the most important
time to brush your teeth?); and about two-thirds of
participants were aware that oral hygiene was an
important strategy for oral self-care. The question,
‘‘why should you brush your teeth?’’, produced a
variety of responses, but the most frequent re-
sponse was that the purpose of oral hygiene was
to make teeth clean and/or white. Relatively few
participants, less than 10%, mentioned the removal
of germs as a reason for brushing their teeth. Pre-
test knowledge about when to change a toothbrush
was also poor; just over 10% of participants iden-
tified fraying bristles as a criterion for replacement.
At post-test, improvements in knowledge oc-
curred for both groups, but a higher number of
significant within-group differences from pre-test
to post-test were found for ‘‘classroom plus small-
group’’ students. Significant within-group differ-
ences which occurred only for the ‘‘classroom plus
small-group sessions’’ group were greater knowl-
edge of the rationale for oral hygiene procedures
and improved knowledge of the reasons why teeth
are important.
Many significant between-group differences
were found for oral hygiene knowledge gains (i.e.,
improved knowledge from pre-test to post-test)
(Table 3). In each of these cases, a significantly
higher proportion of ‘‘classroom plus small-group’’
students displayed knowledge gains compared to
students who received only a classroom session.
For example, a higher percentage of ‘‘classroom
plus small-group’’ students mentioned that the re-

Table 3. Percentage of participants displaying improved oral hygiene knowledge at post-test

Classroom and Classroom

Knowledge item small-group sessions session only P-value

What is important to do to
keep your teeth healthy?
(response given: oral hygiene) 23 17 ns
Why should you brush your teeth?
- to not get cavities 27 16 **
- to remove food 9 3 **
- to remove germs 18 8 **
- to make clean/white 14 17 ns
- to make strong/healthy 14 8 *
Picture of ‘‘boy brushing his teeth’’identified as ‘‘boy
who is doing something to look after his teeth‘‘a 4 9 ns
What do your teeth help you do?
- they help me eat 22 15 *
- they improve appearance 5 4 ns
- they help me talk 24 14 **
When is the most important time to brush your teeth?
- before bed 31 21 *
- in the morning 21 14 ns
Why is this girl brushing her teeth?a
- to not get cavities 26 11 ***
- to remove food 7 7 ns
- to remove germs 17 6 ***
- to make clean/white 19 11 *
- to make strong/healthy 14 13 ns
Show me the toothbrush that is the best size for youa
(correct response: small or medium size) 25 23 ns
When should you throw your toothbrush away?
- when bristles are frayed 38 19 ***
- when it is old 19 18 ns
Show me how much tooth paste you should usea
(correct response: smeared or pea size) 21 23 ns

Chi-square test for differences between groups: nsΩnot significant,* P⬍0.05,** P⬍0.01,*** P⬍0.001.
a
Information about these questions is given in Table 2.

340

moval of germs was an important reason to brush
their teeth (18% vs. 8%). For toothbrushing items,
the groups differed significantly on knowledge
gains for two items. Again, a higher percentage of
‘‘classroom plus small-group’’ students demon-
strated increased knowledge about when they
should change their toothbrush; and that bedtime
was the most important time to brush their teeth.
Discussion
In Ontario, Canada dental caries remains a signi-
ficant health problem for high-risk children, and
the effectiveness of disease prevention programs
designed for these children needs to be evaluated.
Of these programs, school-based DHE is intuitively
appealing because, at this age, children are assum-
ing greater responsibility for the care of their teeth.
No known studies of oral health knowledge
changes among young children have previously
taken place in Canada.
The evaluation results support the hypothesis
that small-group sessions provide additional
knowledge benefits to high-risk Grade One chil-
dren. Both groups showed significant improve-
ments from pre-test to post-test, but in many sub-
ject areas a significantly higher proportion of
‘‘classroom plus small-group’’ students displayed
knowledge gains compared to those receiving only
a classroom lesson. There were no questions in
which a significantly higher proportion of class-
room-only students demonstrated improvement
compared to ‘‘classroom plus small-group’’ stu-
dents. These findings are consistent with earlier
studies which used a controlled study design to as-
sess the effect of DHE on knowledge among young
children (8–10).
Comparisons with results from other studies are
difficult because few studies have assessed knowl-
edge changes among young children, different
DHE programs were evaluated, and different types
of questions may have been asked. However, sim-
ilar results were found for two questions which
were also asked in a non-controlled study reported
by Towner (11). In that study, the most frequent
response to ‘‘why should you brush your teeth?’’
was ‘‘to keep them clean’’ (29–32%); and ‘‘morning
and bedtime’’ were the most common response to
‘‘when should you brush your teeth?’’ (42–52%).
Towner also found that few children at pre-test and
post-test (0–2%) responded that one reason to
brush your teeth was ‘‘to get germs off them‘‘. In
the present study, a slightly higher percentage of
Oral hygiene knowledge of high-risk children
participants gave this answer, but more students
answered ‘‘to keep teeth clean and/or white‘‘. The
concept of germs does not appear to be easily ac-
quired by young children; even among older chil-
dren misconceptions about plaque are common
(10).
Participants’ responses to several questions indi-
cated the impact that advertising may have upon
young children. Approximately one-half of stu-
dents answered toothbrushing was done to clean
and/or whiten teeth. The message of many dental
advertisements is that teeth should be white and
they are not clean unless they are ‘‘pearl’’ white.
As well, commercials have encouraged the overuse
of toothpaste by having actors dispense liberal
amounts of toothpaste. This is contrary to a recent
Canadian recommendation which advised ‘‘a pea-
sized amount of toothpaste should be dispensed’’
(12). An encouraging finding of this study was that
correct information about toothpaste amount was
easily learned because both groups showed im-
proved knowledge for this question at post-test.
Although this study provides valuable informa-
tion on the positive effects of DHE on oral hygiene
knowledge, there are limitations that must be con-
sidered. First, independent interviewers may be a
source of bias for several reasons. Examiners were
blinded to the group assignment of schools, but
may have became aware of group assignment be-
cause students may have told examiners about the
small-group sessions they had received; or exam-
iners may have been aware that students in a par-
ticular school performed better than students in an-
other school. Also, inter- and intra-rater reliability
were not assessed and systematic differences be-
tween examiners may have accounted for differ-
ences between groups. Finally, interviewers would
likely have been conscious of the pre-post design
of the study and may have unintentionally lowered
baseline scores and raised post-test scores.
A second limitation is that post-test observations
for the group which received small-group sessions
were done about three months after the other
group’s post-test observations. ‘‘Classroom plus
small-group’’ students had received several more
months of lessons and tests at school which may
have resulted in these students being more familiar
with verbal questions and testing situations. This
may account for some of the differences on open-
ended questions which called upon a child’s verbal
skills.
Third, ‘‘classroom plus small-group’’ students
may have felt more comfortable interacting with
341
Hawkins et al.
interviewers because of the small-group sessions
they attended and may have been more willing to
respond to the ‘‘tell-me’’ type questions. Significant
between-group differences mostly occurred for
‘‘tell-me’’ questions; only one significant difference
was found for a ‘‘show-me’’ type item.
Fourth, although educators should have spent
equal amounts of time on each oral hygiene topic,
it is possible that significant differences occurred
between educators; and these differences may have
affected knowledge scores. Program content and
the performance of educators were continually
monitored by the DHE manager, but no formal
process evaluation of the program was done.
Another concern is the refusal by some students
to participate and the loss of participants at dif-
ferent phases of the study. Approximately equal
numbers of students in both groups were lost at
each phase, but the characteristics of participants
lost to follow-up were not examined. Therefore,
differences between the groups for improvements
in knowledge may partly be due to between-group
differences in the characteristics of those students
who were lost to follow-up or who decided not to
participate.
Finally, young children were sampled and this
presented difficulties in obtaining consistent re-
sponses. Some children who responded correctly at
pre-test were found to either respond incorrectly at
post-test or not give a response. This finding was
expected and had been found previously by McIn-
tyre et al. who called these children ‘‘regressing’’
(9). However, it should not be inferred that DHE
has caused a loss of knowledge. Conversely, for
each child who demonstrated an improvement, the
improvement may not be due to a gain in knowl-
edge. Evaluation studies of Grade One students are
difficult because of problems in assessing knowl-
edge of children at the pre-operational stage of cog-
nitive development (13). Young children have the
ability to verbalize their ideas about health and
self-care (14); but talking to young children about
health-related beliefs and behaviours is, neverthe-
less, a daunting methodological task (15).
The ability of oral health knowledge to change
preventive behaviours is a matter of discussion. An
underlying assumption of DHE is that improve-
ments in knowledge will result in long-term posi-
tive changes in preventive behaviours and contrib-
ute to improved oral health. However, reviewers of
DHE have acknowledged the process of changing
behaviour and improving oral health is not
straightforward (1, 4, 16). Although DHE programs
342
have repeatedly been successful at improving
knowledge, studies of oral health outcomes are
equivocal; improvements and minimal or no im-
provements have been reported. A mixture of re-
sults is not surprising, given the complex nature of
human behaviour and the critical role played by
factors other than knowledge, including the influ-
ence of various socialization agents upon children’s
health attitudes and behaviour (e.g., family, peers,
media) (17–19). Knowledge per se is not sufficient
for behavioural change, but knowledge gained
through DHE programs may give children a better
opportunity to establish oral hygiene habits and
thereby achieve oral health.
Conclusion
The effectiveness of two methods of dental health
education for high-risk Grade One students in the
former City of North York was evaluated. At base-
line, the majority of children lacked fundamental
oral hygiene knowledge necessary for the preven-
tion of dental diseases. Following DHE interven-
tions, students in both groups showed favourable
changes in knowledge. However, students who re-
ceived two small-group sessions in addition to a
classroom-based lesson showed the greatest im-
provement. While one must exercise caution in in-
terpreting the results due to several methodologi-
cal limitations, the results suggest that the provi-
sion of small-group sessions as well as an annual
classroom lesson is the more effective means of
DHE for high-risk Grade One students.
Acknowledgements
The Community Dental Health Services Research Unit is a
joint project of the Faculty of Dentistry at the University of
Toronto and the Community Dental Services Division at the
Toronto Public Health Division. It is a Health Systems-
Linked Research Unit funded by the Ontario Ministry of
Health (Grant .04170). The opinions expressed in this report
are those of the authors and no official endorsement by the
Ministry is intended or should be inferred.
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