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0034 7167 Reben 70 03 0519
0034 7167 Reben 70 03 0519
0034 7167 Reben 70 03 0519
II
Universidade de So Paulo, School of Nursing, Postgraduate Program in Primary Care and Family Health. So Paulo, Brazil.
BSTRACT
Objective: To compare the number of appropriate behaviors for tooth brushing before and after a playful learning intervention
with preschool children. Method: A quasi-experimental, quantitative, before and after study design was conducted in an
early childhood educational institution, with children between three and five years of age. The intervention consisted of three
meetings with educational activities about tooth brushing, whose outcome was evaluated by means of observation of ten
behaviors suitable for tooth brushing. Results: Forty-four children participated in the study. The mean of adequate behaviors
was 4.4 before the intervention, and 8.5 after the intervention. A significant increase in the adoption of appropriate behaviors
for tooth brushing (p <0.01) was identified. Conclusion: Nurses can enhance oral health promotion actions with preschoolers
in preschool institution using playful learning interventions
Descriptors: Oral Hygiene; Health Education; Child Health; Child Day Care Centers; Nursing.
RESUMO
Objetivo: Comparar o nmero de comportamentos adequados para a escovao de dentes antes e aps uma interveno
educativa ldica com pr-escolares. Mtodo: Estudo quase-experimental, do tipo antes-depois, com abordagem quantitativa e
conduzido em instituio de educao infantil com crianas entre trs e cinco anos de idade. A interveno consistiu em trs
encontros com atividades educativas ldicas sobre escovao de dentes, cujo efeito foi avaliado por meio da observao de
dez comportamentos adequados para a escovao dos dentes. Resultados: Participaram do estudo 44 crianas. A mdia de
comportamentos adequados foi de 4,4 antes da interveno e 8,5 aps a mesma. Houve um aumento significativo na adoo de
comportamentos adequados para a escovao de dentes (p < 0,01). Concluso: Por meio de intervenes educativas ldicas,
recomenda-se que os enfermeiros potencializem as aes de promoo da sade bucal com pr-escolares em instituies de
educao infantil.
Descritores: Higiene Bucal; Educao em Sade; Sade da Criana; Creches; Enfermagem.
ARESUMEN
Objetivo: Comparar el nmero de comportamientos adecuados para cepillarse los dientes antes y despus de una intervencin
educativa ldica con preescolares. Mtodo: Estudio cuasi-experimental, antes y despus, con enfoque cuantitativo conducido
en una institucin de educacin infantil con nios entre tres y cinco aos de edad. La intervencin consisti en tres sesiones con
actividades educativa ldicas sobre cepillarse los dientes, cuyo efecto se evalu mediante la observacin de diez comportamientos
adecuados para cepillarse los dientes. Resultados: El estudio incluy a 44 nios. El promedio de comportamientos adecuados
fue de 4,4 antes de la intervencin y de 8,5 despus. Hubo un aumento significativo en la adopcin de comportamientos
adecuados para el cepillado de los dientes (p<0,01). Conclusin: A travs de intervenciones educativas ldicas, se recomienda
que los enfermeros potencien las acciones de promocin de la salud bucal de nios preescolares en las instituciones de
educacin infantil.
Descriptores: Higiene Bucal; Educacin en Salud; Salud del Nio; Guarderas Infantiles; Enfermera.
received clarification on the objectives of the study, agreed to At the first meeting, the objective was to improve the chil-
participate, and signed the Terms of Free and Informed Consent drens knowledge regarding the parts of the mouth, their
form, allowing their children to participate. In addition, all the functions and importance of caring for them, as well as to
children showed interest in participating in the meetings, as well warn them about problems associated with inadequate oral
as allowing systematic observation of tooth brushing. hygiene. To do this, a conversation was initiated, aided by the
use of a giant mouth model made for childrens use, allowing
Design, place of study and period them to touch, identify and reflect on the functions and impor-
This was a quasi-experimental, before-after study with a tance of each part that make up the mouth. This was followed
quantitative approach. The manipulation of the independent by the awareness of the need to take care of all parts of the
variable (learning intervention) occurred without designation mouth to maintain health; otherwise problems could occur if
of a control group or randomization of the participants. In there was pronounced or prolonged carelessness. The prob-
before-after studies, a measurement occurred before and after lems were illustrated with the display of figures of children
each participant was exposed to the intervention. Thus, each with decayed teeth, tartar and gingivitis.
child served as his own control for the evaluation of the effects In the second meeting, a conversation circle was conduct-
of a playful learning intervention on tooth brushing. The study ed using large plush dolls with human dental arches and giant
was conducted in a nursery/preschool at a state public uni- toothbrushes, aiming to work on relevant aspects of the tooth
versity in the city of So Paulo, from March to May of 2014. brushing practice, as an effective measure for the health/hy-
giene of the mouth. The following aspects regarding the prac-
Sample, inclusion and exclusion criteria tice of tooth brushing were emphasized: using a small amount
To calculate the sample size, a of 0.05 and of 0.80 was of toothpaste, brushing all the faces of the teeth and tongue,
assumed, in addition to a minimum difference of two adequate mouthwash with water, and finishing with the use of dental
behaviors before and after the intervention, resulting in a mini- floss. After the conversation, the children had the opportunity
mum sample of 32 subjects. The inclusion criteria of the study for, in an unscripted manner, practicing brushing and flossing
population were: children regularly enrolled in kindergarten; the dolls.
age between three and five years. All children who met the inclu- The third and final meeting was aimed at reinforcing the
sion criteria were invited to participate, resulting in 50 children. relevant aspects of tooth brushing, culminating with an experi-
Considering the possibility of losses during the intervention, the ential practice. The meeting began with a viewing of a known
researchers chose to invite all the children who met the inclu- music video for children, the video of R-Tim-Bum Castle,
sion criteria. The exclusion criterion was not participating in the with a rat brushing his teeth, which deals with the subject,
three educational meetings on tooth brushing, which comprised stimulating the children to sing. Next, a set of illustrated cards
the playful learning intervention in this research. with pictures and figures was presented, demonstrating ap-
propriate and inadequate aspects of brushing, so that children
Study protocol could remember and differentiate them. The group was then
First, all children included in the study had their behav- given the opportunity to apply toothpaste that highlight the
iors evaluated during tooth brushing. For this, the researcher bacterial plaque on teeth, explaining the effect of pinking the
(nurse) adopted a list with ten adequate behaviors related to areas of the teeth that needed to be brushed better. To reduce
tooth brushing: 1) put a small amount (small pea or rice grain) the childrens fear, the researcher demonstrated the use of the
of toothpaste on the brush; 2) brush the teeth internally; 3) dentifrice containing a plaque-disclosing agent on himself,
brush the teeth externally; 4) brush anterior teeth (incisors and and made a careful brushing to remove the pink spots, which
canines); 5) brush the posterior teeth (premolars and molars); indicated dirt, from his own teeth and invited those interested
6) brush the contact surface of the teeth; 7) brush the teeth of to participate in the activity. Some children accepted and got
the upper dental arch (maxilla); 8) brush the teeth of the lower excited about the game, others refused because they were
dental arch (mandible); 9) brush the surface of the tongue; and afraid. At the end, all the children performed the practice of
10) rinse the mouth with water at least once. Systematized brushing their own teeth, with a mirror to identify areas that
observations, performed approximately ten days before the demanded more attention during the brushing. The pink col-
beginning of the intervention, were made in groups of three oration was removed with brushing in all children who had
children at a time during tooth brushing, which was consid- the product that marks the bacteria plaque voluntarily applied
ered the evaluation of the pre-intervention behaviors(10). to their teeth.
The intervention consisted of three meetings aimed at edu- The proposal of activities performed with the three groups
cating children to adopt appropriate behaviors related to tooth of children was the same and, in general, great participation of
brushing. The meetings between the researcher and the chil- the children was identified, particularly in the games that in-
dren were consecutive and occurred in the childhood educa- volved the resources of most interest to them: the giant model
tional institutions, with an interval in between them of one to of the mouth, the brushing of the plush dolls with the den-
four days. All had the same sequence and format, allowing tal arch, the music video, and the experience of brushing the
children of different ages to have the same experience. Each teeth after the pinkish coloration of the stained areas (bacterial
meeting lasted approximately 60 minutes, and was conducted plaque). The use of play activities was considered crucial to
by one of the researchers. determine the success of these activities.
Younger children (3 years old) showed fewer appropri- to highlight that none of these studies(9,11-14) was developed by
ate behaviors before and after the intervention. However, all nurses. This demonstrates the need to strengthen and expand
groups presented an increase in the number of appropriate the integration of the nurse in health education activities in
behaviors after the intervention, but without a statistically sig- pre-schools, such as oral health, in addition to producing and
nificant difference. disseminating knowledge related to the topic.
Considering the relationship between the childs age and
DISCUSSION the adoption of appropriate behaviors for tooth brushing, the
findings of the present investigation are similar to those of a
The results obtained in the present study reveal the acquisi- study developed at a kindergarten in Braslia-DF (15). The study
tion of adequate behaviors in relation to tooth brushing after showed that children aged 5 to 6 years present a greater ability
the learning intervention with preschool children, demon- to properly brush their teeth when compared to children aged
strating effectiveness. Oral health education interventions in 3 and 4 years, showing that the manual ability for brushing
pre-schools have the potential to encourage children to estab- skills is acquired after a certain age. The study in question
lish and maintain effective oral hygiene routines(5). evaluated the efficacy of educational intervention in children
National and international studies have shown that health based on the reduction of plaque indexes.
education in the school environment favors the involvement Motivation and health education are important tools for
of the child in developing new knowledge, facilitating change promoting the oral health of preschool children. It is under-
in habits. A survey conducted in Pernambuco, with 169 chil- stood that appropriate educational programs on oral hygiene
dren enrolled in pre-school and elementary school, adopted have a potential motivating value, as they constitute a means
lectures and play activities appropriate to the age group to of introducing childrens health care in a pleasant way. Reaf-
promote oral health. The results showed a reduction in the firming the learning intervention implemented in this study for
percentage of deficient brushing from 20.7% to 4.1%, and the effective increase of learning, the construction of knowl-
regular from 62.1% to 49.7%, with an increase in the good edge by children should occur in a relaxed and participative
hygiene index from 8.9% to 32%(9). way. Audiovisuals, games, puppets, theater and dynamics are
A randomized clinical trial aimed at evaluating the effica- recommended as excellent means of promoting learning, pro-
cy of an educational-preventive oral health activity with 38 viding children with a variety of experiences and stimuli in a
children, aged three to five years, showed the effectiveness of fun and enjoyable way, and motivating them for self-care(16-17).
this strategy in reducing visible plaque and gingival bleeding. The use of individual instruction for the practice of oral hy-
The didactic resources used in the educational activities were giene with preschoolers is also suggested, and is considered
theater with puppets, interactive games, macromodels, brush useful because it is an easy and low cost method(15).
and toothpaste, and posters. The activities emphasized topics For better learning in children, it is important that educa-
such as dental caries, gingivitis, brushing with toothpaste, use tional programs are not performed once, but repetitively, evi-
of dental floss, and relationship of diet with dental caries(11). dencing the effectiveness of the reinforcement on the educa-
Another national study evaluated the effectiveness of brush- tion of oral hygiene practices(9).
ing supervision in dental plaque removal and brush damage
in 49 children, aged 3 to 5 years, who received new tooth- Study limitations
brushes and participated in a puppet theater on oral health. Quasi-experimental studies have limitations in controlling
The results showed that professional supervision in multiple factors external to the intervention. Another disadvantage is
sessions was effective in reducing plaque indexes, which were the lack of a control group for comparison. However, as the
not influenced by brush damage, showing the need for con- present study used a before-after design, each child was his
tinuous motivation for oral hygiene(12). own control. Other limitations refer to the unicentric nature
A study in India with 100 preschoolers assessed the impact of the research, and to the limited size of the sample by age
of three different methods of health education. Participants subgroup (three, four and five years).
were randomly selected and divided into four groups. Group
A received oral health education from a dentist. Group B re- Contributions to the area of nursing and public health
ceived it from the class teacher, who was trained by a dentist. Early childhood educational institutions, in partnership
Group C received it from dental residents wearing cartoon with the professionals of the primary health care services, pro-
characters; Group D was the control group. The best indexes of vide privileged space for the promotion of childrens health.
oral health evaluated three months after the intervention were The school health program (Programa Sade na Escola - PSE),
the group that received the intervention in a playful way, that instituted by Presidential Decree No. 6,286, represents a
is, with health professionals imitating cartoon characters(13). means of articulation between school and health units. Inter-
An investigation conducted in Thailand with 3,706 children sectoral and interdisciplinary actions aim to establish practices
evaluated the benefit of a dental health promotion program com- for health promotion and injury prevention in children, ado-
bined with teacher-supervised tooth brushing in pre-schools using lescents, youth and adult students in Brazil(6). In this context,
fluoride toothpaste. After two years of follow-up, the results re- nurses play a crucial role in the promotion of child health, and
vealed significant improvements in dental plaque scores with prevention of disease in kindergarten and pre-school children.
up to a 34% reduction in caries occurrence(14). It is important In partnership, nurses and other health and education
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