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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2019  |  Volume : 37  |  Issue : 2  |  Page : 172-176

Effectiveness of “Audio-tactile Performance Technique” to improve the oral hygiene status of visually impaired schoolchildren

Department of Public Health Dentistry, Sharad Pawar Dental College, DMIMS (Deemed to be University), Wardha, Maharashtra, India

Date of Web Publication26-Jun-2019

Correspondence Address:
Dr. Jefry Johny
Quarter No. 2125, Shobhapur Colony, P.O Pathakhera, Betul - 460 449, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.261344

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Background: Maintaining oral hygiene is a challenging task for the visually impaired population. Oral health is often overlooked because of lack of knowledge about oral health practices. Therefore, there was a need to train visually impaired individuals with the aid of customized techniques so that the understanding of brushing technique could be perceived at its best. Aims and Objective: Comparative evaluation to check the effectiveness of “Audio-tactile Performance Technique (ATP)” to improve oral hygiene status of visually impaired schoolchildren. Subjects and Methods: The present study was an interventional study of 92 visually impaired children in Wardha district. Their knowledge regarding oral hygiene practices was tested with a verbal questionnaire in a pre- and post-test to check the improvement in their knowledge after imparting health education. Fones method of toothbrushing was taught by “ATP,” and a health talk was delivered. The plaque scores were recorded using the Quigley–Hein Plaque Index (modified by Turesky et al.) at baseline and at the end of 3 months. Periodic reinforcement was provided twice at an interval of 20 days in between the visits. Statistical Analysis Used: The collected data were tabulated and analyzed using Student's paired t-test in Stata version 15.1, and kappa statistics were done to test inter-rater reliability and agreement was found to be 90%. Results: There was a statistically significant decrease in the postinterventional plaque scores from 2.78 to 1.63 (P < 0.05) and an increase in the posthealth education test scores from 1.98 to 8.21 (P < 0.05). A substantial decrease in the percentage of children, who had high plaque scores initially, was seen postintervention. Conclusions: The “ATP” along with oral health education served as a very effective customized method of teaching oral hygiene practices and its maintenance to the visually impaired children.

Keywords: Fones method, health education, oral hygiene, plaque, visual impairment

How to cite this article:
Deolia S, Johny J, Patil MS, Lanje NR, Patil AV. Effectiveness of “Audio-tactile Performance Technique” to improve the oral hygiene status of visually impaired schoolchildren. J Indian Soc Pedod Prev Dent 2019;37:172-6

How to cite this URL:
Deolia S, Johny J, Patil MS, Lanje NR, Patil AV. Effectiveness of “Audio-tactile Performance Technique” to improve the oral hygiene status of visually impaired schoolchildren. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2023 Feb 3];37:172-6. Available from: http://www.jisppd.com/text.asp?2019/37/2/172/261344

   Introduction Top

Oral health is vital to the general well-being and value of life. Oral and dental anomalies are a common problem for the visually impaired population.[1] It is approximated that a minimum of two lakh children in India are visually impaired, and 15 thousand are enrolled in schools for the visually impaired. Visually impaired population face challenges on a daily basis for carrying out their day-to-day tasks, such as maintaining good oral hygiene. Providing treatment to the visually impaired patients is very challenging to the dentists' skill and knowledge. Standard methods for teaching oral hygiene include the use of visual acuity to visualize the plaque and brushing your teeth to remove it and redisclosing sporadically to supervise their improvement of oral hygiene. Unfortunately, these measures are of no benefit to the visually impaired children who depend much more on feeling and hearing to learn. The major factor for differentiation between the visually impaired and the normal population is the difficulty in removing plaque.[2]

The visually impaired people are at a higher risk to develop caries since they are not able to visualize the initial signs of caries such as discoloration, which is an indicator of the disease process. As the main reason for the increased incidence of caries in the visually impaired children is inadequate plaque removal, they need to be constantly motivated to practice correct oral hygiene procedures to maintain a good oral hygiene. Chemical plaque control is advised in visually impaired children for effective plaque control.

Moreover, the visually impaired population regularly face problems during toothbrushing, including dispensing of toothpaste on the toothbrush and practicing traumatic brushing strokes that may harm their periodontium.[3] As a result, they have more incidences of caries, gingivitis, and periodontitis. There is a great need of exclusive training in oral care to downgrade the occurrence of dental caries among the children.[4]

Chang and Shih[5] found that the oral health awareness among the visually impaired population was inadequate as compared to the normal population. Dental instruction programs aimed at these children must be conducted to increase their knowledge regarding oral health and oral hygiene practices.[6] The school setting is found to be a favorable background for teaching preventive oral health practices and promoting oral health for such a special population.[7] Many similar studies have been formerly conducted, but the main drawback was that they focused only on improving oral hygiene skills,[8] and not on improving their oral health knowledge. Modification of oral health education such as the “Audio-tactile performance technique” and using alternative teaching aids such as the oral health talk (OHT) and by the means of an educative questionnaire, oral health education can be provided to the visually impaired children.

The aim of this study was to investigate the effectiveness of “ATP” designed for children with visual impairment using the Quigley–Hein Index (Modified by Turesky et al., 1970).

   Subjects and Methods Top

A short-term study was conducted among the visually impaired children of Andh Vidya Mandir, Maneri, Taluk-Arvi, District-Wardha, and Rashtriyasant Tukdoji Maharaj Andhvidyalaya, Nalwadi, Wardha. The study was conducted during April 2018–June 2018 after obtaining permission from school authorities and taking an approval of the study protocol from the Institutional Review and Ethical committee. There were 92 visually impaired children. Written proxy consent was obtained from the respective Guardian/Principal before commencing the study. The inclusion criteria were visual impairment that ranged from low vision to total blindness, and the participants with any other disabilities were excluded from the study. Two individuals, who were trained and calibrated before beginning the study to eliminate interexaminer and intraexaminer bias, performed the interview and clinical oral examination. In addition, kappa statistics were done to test interrater reliability, and agreement was found to be 90%. A self-designed pro forma and a close-ended questionnaire were prepared to assess the knowledge of the children regarding oral hygiene practices and its maintenance.

In the first visit, a brief interactive session with the children was carried out. All the demographic details of the children such as name, age, gender, education, and address were recorded. This was followed by conducting a pretest to check the existing knowledge of the children regarding the maintenance of oral hygiene by verbally asking the questions such as the correct method of brushing your teeth, ideal material for cleaning your teeth, correct duration of brushing, and frequency of changing your toothbrush. An oral examination was done at their respective schools, on an ordinary chair and under daylight using a mouth mirror, an explorer and a two-tone disclosing solution to record Quigley–Hein Index (modified by Turesky et al., 1970).

The visually impaired children were educated with a specially designed health education method “Audio-tactile performance technique” (ATP) regarding oral hygiene maintenance. A health talk was delivered about the significance of teeth and oral hygiene practices. Then, they were made to feel the teeth on a large-sized model, followed by brushing on the model using the Fones method with assistance. The process continued for each child individually until they could perform it independently, correctly, and confidently.

At last, a posttest was conducted after the completion of the instructional program by verbally asking the questions to evaluate the level of improvement in the preexisting knowledge regarding maintenance of oral hygiene in the children.

Periodic reinforcement using the same method was performed on the second and third visit, each at an interval of 20 days. The children were asked to recollect what they could remember from the first health education session.

Oral examination was conducted 3 months from the first visit after imparting health education to assess the improvement in plaque scores. The examination was performed by the same examiners and using the same pro forma.

All the data collected were tabulated in an Excel sheet and analyzed using Student's paired t-test in Stata version 15.1. (Statacorp, College Station, TX, USA).

   Results Top

The distribution of children with respect to gender and age is shown in [Table 1]. Out of the total 92 samples, 48 were male and 44 were female. The mean age of the children was 11.4 ± 2.17 years.
Table 1: Demographic variables

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The mean plaque scores are shown in [Table 2]. The preintervention and postintervention plaque scores were 2.78 (±0.78) and 1.63 (±0.19), respectively. The difference was statistically significant (P < 0.05), showing that the implementation of “Audio-tactile Performance technique (ATP)” for teaching maintenance of a good oral hygiene resulted in improved oral hygiene status of the visually impaired children.
Table 2: Comparison of preinterventional and postinterventional plaque scores and test scores

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The prehealth education and posthealth education test scores were 1.98(±0.81) and 8.21 (±0.58), respectively. The difference was statistically significant (P < 0.05), which shows that there was a significant improvement in the knowledge of the children regarding oral hygiene practices and its maintenance after intervention.

The distribution of children (in percentage) according to plaque scores is shown in [Table 3]. Before intervention, more percentage of children had “high” plaque scores, whereas postintervention, there was a considerable improvement in the oral hygiene status of the visually impaired children and more percentage of children had “low” plaque scores.
Table 3: Distribution of children (percentage) according to plaque scores

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   Discussion Top

Health education is an effective way to help individuals and communities improve their health and prevent disease by increasing their knowledge or influencing their attitudes. Although a significant amount of literature is present on improving the oral health of individuals, very less fraction of it is focused on improving the oral health of those with special health-care needs such as the visually impaired population. Pertaining to the need of the hour, the present study was developed.

Visual impairment is the loss of sight that differs in degree among individuals. It arises from disease, trauma, congenital malformations, or degenerative conditions. These children face difficulty in learning day-to-day skills, maintaining optimal oral hygiene being one among them. When compared with the abled population, the visually impaired children showed poorer oral hygiene status, as concluded in a study by Jain et al.[9] This is mainly attributed to their inability to visualize plaque. Major dental and periodontal problems can be prevented by meticulous removal of dental deposits, for which, the knowledge of correct method of toothbrushing is essential. It is challenging for the children with visual impairment to brush their teeth properly, as they face problems during correct placement of the toothbrush and practicing correct brushing strokes that do not harm the surrounding oral structures because of the doubtful visual clues. Therefore, adequate guidance regarding proper care of the teeth and oral tissues is crucial in these children.[10]

Hebbal and Ankola[11] introduced a customized method of teaching oral hygiene maintenance to the visually impaired children called as “ATP,” which was an effective method as compared to any other conventional method. Although the Modified Bass technique is superior in cleansing the interproximal areas and gingival-third surfaces,[12],[13] best results were given by Fones method. It was easily understood and remembered by the children[14] during the follow-up visit in the present study unlike the Modified Bass Method, which was more difficult to be integrated into everyday life.

The children in the current study were in residential setting, so it was easy for them to learn the brushing technique. Moreover, as the teachers were also given a demonstration about toothbrushing, they were able to provide a positive reinforcement to the children about the importance and the correct method of toothbrushing, which definitely helps in improving the oral health status.

The study was done in schools, where the visually impaired children were living a disciplined life. When a self-prepared questionnaire was used to check the knowledge concerning oral health in these individuals, it was found that they brushed their teeth only once a day and changed the brush every 6 months. The students knew the importance of teeth, but still many of them suffered from oral health problems and lacked knowledge regarding proper brushing techniques. There was a significant increase in their knowledge after imparting oral health education, which was evident from posttest scores. These findings are in accordance with the study performed by Yalcinkaya and Atalay[15] program, the oral health status and knowledge of visually impaired students could be improved.

In the present study, it was showed that the visually impaired children could maintain a satisfactory level of oral hygiene when they were taught by “Audio-tactile method” and health talk with a mean difference of 1.15 between the pre- and post-interventional scores. The results of this study were in accordance with a study conducted by Krishnakumar et al.,[16] who concluded that visually impaired children could maintain a satisfactory level of oral hygiene when taught customized techniques such as audio-tactile technique, with a mean difference of 0.33 between the scores. Qureshi et al.[17] in her study concluded that guided manual brushing technique is effective in improving oral hygiene status of the visually impaired individuals, with a mean difference of 1.58 between the scores.

When postintervention scores were compared, the scores were statistically significant, which conclude that “ATP” is a very effective tool in educating the visually impaired children for maintaining good oral hygiene.

A substantial improvement in the oral hygiene status of the children was seen in the present study who had “high” plaque scores. Most of the children had “low” plaque scores following health education.

The present study showed that the implementation of customized teaching methods such as the “ATP” resulted in substantial improvement in the oral hygiene status of the visually impaired children. It is a very effective method of oral health education, if they are constantly motivated and periodic reinforcements are done.

Limitations of the study

Children below the age of 6 differ in their cognitive ability and manual dexterity to perform toothbrushing and require more motivation. Since tooth brushing is a fine motor activity, younger children cannot perform it without guidance. The time taken by each child for toothbrushing everyday differs, which can also be considered as a limitation of the present study.

   Conclusion Top

The findings of this study showed that the method of “Audio-tactile performance technique” of oral health education proved to be an effective tool to instill good oral hygiene practice in visually impaired children. Oral health education along with the skills to maintain oral hygiene delivers utmost benefits in the improvement of oral hygiene status of visually impaired children. More research in the direction of customization of educational and oral hygiene aids for visually impaired is the need of the hour. The caregivers, community, and the dentists should work together to improve the life of those with special needs.


The authors would like to express their gratitude to all the participants of the study and also like to acknowledge the authorities of Andh Vidya Mandir, Maneri, Taluk-Arvi, District-Wardha, and Rashtriyasant Tukdoji Maharaj Andhvidyalaya, Nalwadi, Wardha, for their support and cooperation throughout the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Al-Alousi JM. Oral health status and treatment needs among blind children in Iraq. MDJ 2009;6:313-24.  Back to cited text no. 1
AlSarheed M, Bedi R, Alkhatib MN, Hunt NP. Dentists' attitudes and practices toward provision of orthodontic treatment for children with visual and hearing impairments. Spec Care Dentist 2006;26:30-6.  Back to cited text no. 2
Mohd-Dom T, Omar R, Malik NA, Saiman K, Rahmat N, Self-reported oral hygiene practices and periodontal status of visually impaired adults. Glob J Health Sci 2010;2:184-91.  Back to cited text no. 3
Ahmed MS, Jindal MK, Khan S, Hashmi SH. Oral health knowledge, practice, oral hygiene status and dental caries prevalence among visually impaired students in residential institute of Aligarh. J Dent Oral Hyg 2009;1:22-6.  Back to cited text no. 4
Chang CS, Shih Y. Knowledge of dental health and oral hygiene practices of Taiwanese visually impaired and sighted students. J Vis Impair Blind 2004;98:1-27.  Back to cited text no. 5
Kumar K, Fareed N, Shanthi M. The effectiveness of oral health education program with and without involving self-maintainable oral hygiene skills among the visually impaired children. Int J Sci Study 2013;1:51-9.  Back to cited text no. 6
Solanki J, Gupta S, Chand S. Comparison of dental caries and oral hygiene status among blind school children and normal children, Jodhpur city Rajasthan, India. Univ Res J Dent 2014;4:22-5.  Back to cited text no. 7
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Kumar S, Konde S, Raj S, Agarwal M. Effect of oral health education and fluoridated dentifrices on the oral health status of visually impaired children. Contemp Clin Dent 2012;3:398-401.  Back to cited text no. 8
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Jain A, Gupta J, Aggarwal V, Goyal C. To evaluate the comparative status of oral health practices, oral hygiene and periodontal status amongst visually impaired and sighted students. Spec Care Dentist 2013;33:78-84.  Back to cited text no. 9
Greeley CB, Goldstein PA, Forrester DJ. Oral manifestations in a group of blind students. ASDC J Dent Child 1976;43:39-41.  Back to cited text no. 10
Hebbal M, Ankola AV. Development of a new technique (ATP) for training visually impaired children in oral hygiene maintenance. Eur Arch Paediatr Dent 2012;13:244-7.  Back to cited text no. 11
Smutkeeree A, Rojlakkanawong N, Yimcharoen V. A 6-month comparison of toothbrushing efficacy between the horizontal scrub and modified Bass methods in visually impaired students. Int J Paediatr Dent 2011;21:278-83.  Back to cited text no. 12
Poyato-Ferrera M, Segura-Egea JJ, Bullón-Fernández P. Comparison of modified Bass technique with normal toothbrushing practices for efficacy in supragingival plaque removal. Int J Dent Hyg 2003;1:110-4.  Back to cited text no. 13
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Krishnakumar R, Silla SS, Durai SK, Govindarajan M, Ahamed SS, Mathivanan L, et al. Comparative evaluation of audio and audio-tactile methods to improve oral hygiene status of visually impaired school children. CHRISMED J Health Res 2016;3:55-9.  Back to cited text no. 16
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  [Table 1], [Table 2], [Table 3]

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