Hunt 1

Title A bio-behavioral Effectiveness of The Effectiveness of Toothbrushing Promoting

intervention Teaching Methods for Visual Pedagogy for and Oral Care parenting
combining task Toothbrushing in Toothbrushing in Activities of strategies to
analysis with Preschool Children Children with Autism Autistic and Non- improve tooth
skill-based Spectrum Disorder Autistic Latino brushing in
training to train Children children: design of
toothbrushing a non-randomised
among children cluster-controlled
with intellectual trial
disability

Research 1: Evaluate the 1: Assess the 1: Evaluate 1: Examine 1: Evaluate the

Questions application of a effectiveness of 3 toothbrushing videos of oral ‘Uitblinkers’
comprehensive teaching methods for effectiveness in children care routines in intervention.
toothbrushing tooth brushing in with mild and moderate the home to
training program, preschool children: levels of severity of understand the 2: Assess the
which includes audiovisual, child as a autism spectrum particularities of effect of the
task analysis and model and individual disorder (ASD) after how oral care intervention on
a systematic instruction. using visual pedagogy activities, such as children’s dental
behavioral skills toothbrushing, caries experience
training (BST) were performed after 24 months
strategy in by autistic and and on tooth
children with non-autistic brushing-related
Intellectual Latino/a children outcomes,
Disabilities (ID). including 1)
parents’ self-
2: Compare efficacy in
acquisition of brushing their
toothbrushing children’s teeth, 2)
task analysis tooth brushing
steps amongst frequency in
various subtypes children and 3)
of ID. children’s dental
plaque scores

Participants -Children: 120 -Children: 40 children -Children: 31 Children -Children: 6 and -Children: Total of
children between were selected as with ASD aged 5–17 12 years old, 10 330 children. Ten
8-18 years old follows: age between years who were families with 3 to 4 year-old
with ID 3-6 years. diagnosed with mild or autistic children children were
moderate ASD by and eight families selected using a
-Caregiver: Was The children were psychiatrists of the Child with neurotypical simple random
trained to divided into 2 groups and Adolescent Mental non-autistic sampling method
perform the according to age: Health Rajanagarindra children from each general
correct tooth group 1 (G1): 20 Institute were invited into dental practices
brushing subjects – 10 children this study -Caregiver: 18
technique and of 3 years of age and parents who -Caregiver:
given videos of 10 children of 4 years -Caregiver: Parents or spoke English or Parents or legal
instruction for of age; group 2 (G2): legal guardian of the Spanish. Families guardians of the
reinforcement 20 subjects – 10 child signed an informed conducted study child signed an
children of 5 years of consent and were related activities informed consent
-Instructors: Two age and 10 children of advised on how to use in their native
dental public 6 years of age visual pedagogy during language -Instructors: 40
health experts toothbrushing and were general dental
who had field -Caregiver: Parents or encouraged to do so -Instructors: practices: 20
experience of legal guardian of the daily during brushing Authors of the practices in the
greater than 3 child signed an times study intervention group
years informed consent and 20 in the
implemented the -Instructors: Dentists at control group
intervention -Instructors: Authors of the Pediatric Dentistry
the study Clinic, Faculty of
Dentistry, Mahidol
University
 Hunt 2

Setting -Special School -Private nursery school -Child’s home -Child’s home in -General dental
in the State of in Brasília, DF, Brazil Los Angeles practices located
Goa, India -Dental office at the in The
Pediatric Dentistry Netherlands.
Clinic, Faculty of
Dentistry, Mahidol
University

Research -Multiple- - Not listed in the study - Quasi-experimental - Secondary, - Non-randomised

Design baseline-across- study cross-case cluster-controlled
subjects design qualitative trial
analysis of a
larger multi-
method study

Materials -Fluoridated - 2 toothbrushes and -The visual pedagogy in - Waterproof -Caregivers were
toothpaste toothpaste of the same this study had two camera given
brand. One of the formats: the visual Supplementary
-Toothbrushes toothbrushes remained pedagogy table calendar support to adhere
with soft bristles with the dentist and and visual pedagogy to the advice of
the other one with the checklist board twice daily tooth
child brushing with
- Hand towels fluoride
-Self-assessment
toothpaste,
- Rinsing cups following the
-Questionnaire ‘Uitblinkers’
- Sink with a intervention
large mirror over -Toothbrushes
it in which the -Video recorder
child and trainer -Video recorder
could see
themselves.

Toothbrushing - Holding the - Brushing all teeth - Brushing the upper - Toothpaste -Follows the Ivory
Method Used bristles at a 45◦ and surfaces included anterior teeth, upper left used Cross national
angle with the only back-and-forth posterior teeth, upper guideline to
tooth surface movements right posterior teeth, -Brushing (brush toothbrushing:
lower anterior teeth, at gum line,
- Using a circular lower left posterior teeth, length of time, -Brushing twice
"soft-scrub" lower right posterior attempt to brush daily
motion teeth all surfaces)
-Brushing with
- Brushing the -Minimal rinsing or -Floss fluoride
appropriate tooth splitting the remaining supervision by toothpaste
surface in the toothpaste caregiver (verbal
sequence or physical -Reducing the
described in the prompts) frequency of
task analysis carbohydrate
-Mouthwash, intakes to three
- Brushing the supervision by main meals
surface caregiver (verbal
continuously for or physical -A maximum of
at least 5 prompts) four (healthy)
seconds snacks per day,
and avoiding
foods and drinks
before or during
bed time
 Hunt 3

Dependent - Child DV:Child’s - Child DV: The - Child DV: Child’s ability - Child DV: - Child DV:
Variables (DV) ability to be amount of plague on to independently brush Child’s ability to Toothbrushing
independent in their teeth their teeth, positive or brush their teeth frequency and
brushing their acceptance to amount of the
teeth and toothbrushing, and the plague on the
following amount of plague on teeth after
directions of their teeth. brushing teeth
brushing their
teeth - Caregiver DV:
Parents’ self-
efficacy in
brushing their
children’s teeth

Independent - Strategies - Strategies - Strategies - Caregivers: - Instructors using

Variable (IV) implemented by implemented by the implemented by the ‘Uitblinkers’
the two dental instructor: Three caregivers and dentist: -Providing verbal intervention:
public health methods of oral or physical
experts: hygiene instruction -Using the visual prompts to -1st identifying
and reinforcement pedagogy to teach how complete barriers to tooth
-Instruction: were applied brush teeth and scoring toothbrushing (no brushing in an
describe each separately for G1 and if the adult had to strategies given interview between
component of the G2. prompt, do the brushing just observations) them and the
toothbrushing for the child, or the child parent and then
task analysis -Method I: audiovisual independently did the
chain) models and slide step on their own - 2nd exploration
projection with of possible
-Three-phase subjects and parenting
modeling: motivation appropriate strategies to
demonstrating for each age group. tackle the
correct brushing identified barriers
using a model -Method II: child as a using principles
and brush in model: the dentist from learning
exaggerated demonstrated theory (operant
motions and toothbrushing conditioning,
providing technique using a child authoritative
examples of as a model. parenting,
good and poor stimulus control,
brushing) -Method III: individual chaining, or role
instruction: each child modeling)
- Physical received individual
guidance :as instruction.
needed for
correction)

-Descriptive
praise: The child
was praised
verbally after
performance of
each correct
component
brushing and was
given a smiley
face to put on a
chart after
brushing)

Results - There was - The total plaque - Toothbrushing ability - Qualitative - N/A intervention
increased index decreased in was significantly findings show was designed with
independence in both groups after the improved at all periods that parental only a pilot study
the performance application of the three of follow-up. involvement was done (not
of toothbrushing methods of instruction Toothbrushing documented released yet).
 Hunt 4

behavior, the and reinforcement. cooperation and the especially in the

mild and However, G2 had dental plaque index case of autistic
moderate ID greater plaque were significantly better children, and that
groups showing reduction than G1 for than before the study at two types of
the most all methods. Method I 4 weeks, 3 months, and modifications,
improvement. applied there was no 6 months of follow-up. habitual and
Steps like oral statistical difference The toothbrushing ability sensory, were
manipulation of between G1 and G2 of subjects with mild observed that
the toothbrush plaque index. After ASD was significantly demonstrated
showed the Method II was applied, better than that of parents being
greatest G2 showed a subjects with moderate aware of the
improvement in significantly greater ASD at 4 weeks and 6 needs of their
the groups.The percentage of zero months of follow-up. The autistic child and
severe ID group plaque compared to toothbrushing modifying the oral
showed G1. Individual cooperation of the mild care activity to
improvement in instruction (Method III) group was significantly meet those
certain showed the greatest better than that of the needs.
skills,while percentage of plaque moderate group at 2
requiring index scores equal to weeks, 4 weeks, and 3
assistance for zero for G2. months. There was no
others that statistically significant
demanded reduction in the plaque
dexterity. index between the two
groups.

Usability - This - These findings - Visual pedagogy is - Practitioners - This intervention

intervention can confirm earlier studies useful for improving can aid parents in can be useful to
be implemented that suggest that toothbrushing improving oral only professionals
by special instruction and effectiveness in children care routines by in dentistry but to
schools and supervision are with mild or moderate providing those in Early
special care important to severity ASD. However, parent/caregiver Intervention to
dentistry centers establishing effective children with moderate education about help with the
to foster tooth brushing habits severity ASD take longer when to use discussion about
autonomy in oral in children. According to improve prompts and barriers and how
self-care skills in to Simmons et al. (17), what type of cues to overcome
the mild and most children between would be most these barriers with
moderate 2 and 4 years of age beneficial, and parents.
IDchildren, and are not able to how to gradually
complemented understand the use of reduce their use
with other prepositions such as to encourage
methods for “on top of”, “inside”, self-reliance,
severe ID “behind”, etc. Thus, when
children. the difficulty found in appropriate.
teaching toothbrushing Dental
skills to these children practitioners in
using just words. collaboration with
Therefore, other healthcare
methods, such as workers such as
audiovisual should be occupational
indicated for preschool therapists can aid
children parents in
identifying their
child’s sensory
sensitivities (i.e.,
taste of
toothpaste, feel
of the bristles,
vibration of the
electric
toothbrush, etc.)
and create an
individualized
plan to adapt the
activity for the
child’s needs. .
 Hunt 5

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Kamath, V., (2002). Effectiveness S., Sasithorn T., & Floríndez, D. C., E., & Duijster D.
Nagarsekar, A., of teaching methods Natchalee S. (2020). Floríndez, F. M., (2019). Promoting
Sanjeevan, V., & for toothbrushing in The Effectiveness of Law, E., Polido, parenting
Kamat, A. K. preschool children. Visual Pedagogy for J. C., & Cermak, strategies to
(2021). A bio‐ Brazilian Dental Toothbrushing in S. A. (2022). improve tooth
behavioral Journal, 13(2), 133– Children with Autism Toothbrushing brushing in
intervention 136. Spectrum Disorder. and Oral Care children: design of
combining task Journal of International Activities of a non-randomised
analysis with Society of Preventive & Autistic and Non- cluster-controlled
skill‐based Community Dentistry, Autistic Latino trial. BMC Oral
training to train 10(4), 415–423. Children. Health, 19(1), 1–
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