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Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 216-220

Coloring sheets for oral health education on prevention of dental caries in children: Development and evaluation

1 Department of Public Health Dentistry, The Oxford Dental College, Bengaluru, Karnataka, India
2 Department of Public Health Dentistry, KVG Dental College and Research Centre, Sullia, Karnataka, India

Date of Submission24-Mar-2020
Date of Decision18-Apr-2020
Date of Acceptance23-Jul-2020
Date of Web Publication24-Oct-2020

Correspondence Address:
Archana Krishna Murthy
Department of Public Health Dentistry, The Oxford Dental College, Hosur Road, Bommanahalli, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_51_20

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Background: Dental caries is a globally prevalent disease among children. Many preventive measures are effective, one among them being oral health education (OHE). OHE using activity-based techniques has been found useful for children. Aim: This study aims to develop and evaluate the coloring sheets (CSs) for educating children on the prevention of dental caries. Subjects and Methods: Activity sheets already existent in the literature were reviewed and content validation using the Lawshe method was applied. In addition, the design, cultural acceptability and suitability of use of the CS were assessed. The resultant CS was applied to 411 7–8-year-old children in their classrooms. The responses were compiled and proportion of correct responses for each item were calculated. Results: Ten items that were protective and harmful to teeth were unanimously accepted by the panelists. It was decided to use a happy or a sad tooth to indicate the choice of the child. A nonglossy paper with white background suitable for coloring with a crayon was used. A revised CS was finalized on the A4-sized sheet. The mean score for correct responses was 9.61 ± 0.54. Compared to other items, milk was scored incorrectly by significantly higher proportion of children. Conclusion: The CS can be used to educate children on the prevention of dental caries.

Keywords: Active learning, children, dental caries, dental health education

How to cite this article:
Murthy AK, Fareed N, Hiremath S S. Coloring sheets for oral health education on prevention of dental caries in children: Development and evaluation. J Indian Assoc Public Health Dent 2020;18:216-20

How to cite this URL:
Murthy AK, Fareed N, Hiremath S S. Coloring sheets for oral health education on prevention of dental caries in children: Development and evaluation. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2022 Dec 3];18:216-20. Available from: https://www.jiaphd.org/text.asp?2020/18/3/216/299004

  Introduction Top

Dental caries is still a significant public health problem among schoolchildren, despite declining prevalence in many countries.[1] Moreover, dental caries exhibits a disproportionate affliction to underprivileged, disadvantaged, and socially backward communities resulting in oral health inequalities.[2]

Since dental caries is preventable, it is imperative to consider school-based interventions that target the greatest number of subjects at a low-cost.[3] Early childhood is an apt time to develop lifelong beliefs, attitudes, and skills.[4] Interventions targeting children in schools can improve health and well-being into adolescence and adulthood.

Promoting health through health education is a proven effective method.[5] Ideal oral health education (OHE) should include oral health instructions and methods to eliminate plaque. Health education programs cannot be given in isolation but be a part of any curative, preventive and promotional health activity.[6] OHE can be reinforced throughout the school years, and one of the ways of achieving the favorable results is to integrate education and entertainment, thus making the process of learning an enjoyable one. A gamut of cost-effective media and materials are available and can be utilized in making learning both interesting and effective.[7]

In dentistry, leaflets, brochures have been the traditional method of conveying health information to consumers.[8] However, reading difficulty, inability to understand and act on health education messages may contribute to health inequality.[9] Activities including games, picture coloring, puzzles, etc., are shown to provide engagement and enjoyment, facilitate in making the right choices, and bring about behavior changes necessary for positive health.[10],[11] Considering these facts, coloring sheets (CSs) were incorporated as an OHE tool in a caries preventive trial carried out among 6–7-year-old children with high caries risk. The present paper describes the steps in the development and evaluation of the CS. The objectives of the CS were to facilitate the children to identify foods and drinks that are good and bad for the teeth and also indicate good daily oral hygiene practices.

  Subjects and Methods Top

The CS was a part of OHE intervention of a community trial conducted to measure the cost-effectiveness of various caries preventive methods for 3 years (under review). The groups in the trial included use of fluoridated toothpaste along with OHE as the control group and the intervention groups had an additional procedure either in the form of fluoride mouth rinsing, fluoride gel application, application of pit and fissure sealants. The trial was prospectively registered in Clinical Trial Registry-India of National Institute of Medical Statistics, Indian Council of Medical Research with the registration CTRI/2015/06/005946 (Registered on: June 26, 2015) and the study protocol was approved by the Institutional Review Board of The Oxford Dental College, Bengaluru, bearing number 277/201314. Public school children of age 6–7-years belonging to low socioeconomic status and high caries risk were included in this trial. The socio-economic status was assessed by the modified Kuppuswamy scale (2015)[12] and the caries risk was based on the American Academy of Paediatric Dentistry criteria.[13] Sample size of 440 (110 children in four groups) was estimated to detect a clinically significant difference of 20% in caries prevalence between the intervention and the control group using a two-tailed test of proportion with 80% power, 95% level of significance and 15% drop-out rate.

Since CSs were used as OHE tool, the Guideline for Reporting Evidencebased practice Educational interventions and Teaching (GREET) checklist [14] has been used to report this study. The OHE intervention strategies of the above trial comprised of 6 levels passing from passive to active learning to enhance the knowledge and behavior of the children towards oral health.[15] The OHE intervention to the children was based on the theoretical framework of “the Theory of Planned Behavior”[16] and was incorporated in the strategic planning model of “Communication-Behavior Change” to facilitate the developing, managing and evaluating the intervention.[15] Before the start of the trial, in order to formulate the OHE intervention, a baseline survey using a validated, pretested questionnaire was undertaken among the parents of all the study participants to assess the existing oral health behaviors. The survey indicated that more than one-fourth of the children consumed sugar-containing food and drinks more than once a day and nearly 85% consumed sugars between meals. Furthermore, while the majority of the children brushed their teeth, more than 90% either brushed once or less than once a day. Based on these findings, the OHE strategies were planned. The activity involving CSs was the third level intervention which mainly focused on the knowledge aspect.

The CS was developed based on the guidelines laid down by the European Commission for Package Leaflet Preparation.[17] The CS was developed over a period of 2 months. Firstly, the existing literature on caries in children was reviewed, especially on etiology and prevention. A draft of the sheet was prepared with the above-mentioned message and appropriate pictures and subjected to content validation. A method developed by Lawshe in 1975 to determine content validity by quantitative assessment was used.[18] The content evaluation panel composed of 2 Public Health Dentists and 2 Pedodontists. The panel gave verbal consent to participate in the research and the draft of the CS was either E-mailed or given to panel members dependent on the distance from the research center and preference. Apart from scoring the items “essential.” “useful but not essential,” or “not necessary,” the panelists were required to give their feedback on the design, cultural acceptability and suitability of use of the CS.[19] The time frame for validation was 4 weeks. The comments of the panelists were collated and subsequently another draft of the CS was prepared. The content was translated into the local language (Kannada) and consequently the Kannada version was back-translated to the language of the original text (English) to check for the accuracy of the translation process. The translation was done as per the procedure for forward-backward translation and adaptation protocol, recommended by the World Health Organization.[20]

The CS was pilot tested on 10 pediatric patients in the dental college. In the debriefing session after the pilot test, the investigator and the children were enquired about any difficulty faced in understanding and using the CS and no hindrance was reported. In addition, the average time to administer the CS was estimated to be 8 ± 1 min per batch of children. It was decided that the CSs should be applied by the investigator by face-to-face meeting in the classrooms to a batch of upto10 children at a time.

The CS along with a crayon was distributed to each child by the investigator in the classroom. Instructions were given to the children by the investigator to examine the pictures of the items in the sheet and identify whether they were good or bad for the teeth. After deciding between the choices, the children were asked to color the happy tooth if the item in the picture was good for the teeth and the sad tooth if it was bad for the teeth with the crayon provided. Assistance during the coloring session was given to the children, if needed. Subsequently, the sheets were collected back from the children and the investigator had an interaction and discussed the importance of the items in the CS.

Statistical analysis

Statistical analyses were conducted using Epi Info™, version statistical software (Centers for Disease Control and Prevention, Atlanta, GA, USA). All the correct responses were given a score of one and incorrect responses were scored zero. Proportion of children having given correct responses to each item were compared using Chi-square test and mean of total scores between genders was compared using Student's t-test. Values of P < 0.05 were considered statistically significant.

  Results Top

During the content validation, the responses of the panelists were recorded under individual items and also for design, cultural acceptability and practicality. All the items in the sheet were unanimously scored as essential by the panelists. According to Lawshe, the minimum content validity ratio (CVR) for 4 panelists is 0.99. Since the calculated CVR for all the items was 1, all the items in the CS were retained. However, numerous suggestions and feedback were given by the panelists regarding the design, cultural acceptability, and practicality of use.


The majority of the panelists were satisfied with the design of the CS which was mainly pictorial with little text. Even so, 2 panelists suggested introducing a happy tooth and a sad tooth to identify good and bad foods, respectively instead of a tick mark and a cross for the children to indicate the above information. This was incorporated as it made the CS activity more interesting to the children. In addition, it was suggested to use either only animated pictures or photographs to indicate various items. After deliberation, it was decided to use animated pictures in the CS. The background was kept white so as it facilitated coloring using any color.

Cultural acceptability

Only foods and oral hygiene products that were locally available and familiar to the children of this social segment were included in the CS. Hence, all the respondents considered the CS as culturally acceptable.

Suitability of use

Panelists suggested to use nonglossy and clear paper that was easier to color than a glossy sheet. In addiiton, the size of the sheet was decided to be A4 as that would provide adequately sized pictures for the children to color. For coloring, a safe nontoxic wax crayon seemed practical to use rather than a colored pencil.

In the second round of consultation process, all the suggested modifications were incorporated in the CS and a revised CS was prepared and sent to the panel members for feedback. The new version was found to be satisfactory to all the panelists. The final CS was designed in the CorelDRAW software, improvements in the layout and presentation were made and printed on A4 size uncoated paper. The CS is presented in [Figure 1].
Figure 1: Colouring sheet

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Since the CS was applied in third level of OHE intervention, 411 (male – 50.6%, female – 49.4%) out of 440 children were available for the CS activity. The mean age of the children was 7.6 ± 0.5 years. The results of the activity are shown in [Table 1]. While fruits, toothpaste and toothbrush, dirty tooth were marked correctly by majority of the children, nearly 7.5% of the children scored milk incorrectly and this difference was found to be statistically significant (P < 0.001). The total mean score of correct responses was 9.61 ± 0.54. Further, when the means of total scores were compared between the genders, there was no significant difference between males and females [Table 2].
Table 1: Distribution of the children according to their responses to the items in the coloring sheets

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Table 2: Comparison of mean scores of the correct response according to gender

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  Discussion Top

While childhood is an important period for the development of intelligence and personality, it is shown that 6–7 years of age is susceptible for dental caries in newly erupted permanent teeth. It is also important to understand the differences in the mental cognitive ability of the children at different ages and the need to develop different intervention programs for different age groups.[21]

School-based OHE programs in the past using traditional lecturing have been found effective in improving knowledge.[22],[23] Game-based health education approach implemented in the classroom have numerous benefits that include motivating pupils to understand and learn the facts about health rather than only memorizing, thereby improving cognitive development and building confidence.[24] A study was conducted to assess the effectiveness of the snake and ladder game on knowledge of prevention of dengue fever among school children and the study revealed that there was a significant difference in the knowledge scores after administrating the intervention.[25] John et al. showed that drama can be used for a better impact on oral health attitudes and practices in preschool children.[26] Ahire et al. showed that the use of a robot (ROBOTUTOR) could effectively demonstrate Bass tooth brushing technique to adults and was also save time.[27]

The planning model of “Communication-Behavior Change,” developed by McGuire W, offers a way of designing public health communication campaigns emphasizing the role of communication in influencing behavior change.[28] In the framework of this model, a hierarchy of activities ranging from passive to active engagement of the child will be used. While the initial 2 levels focused on passive learning by used of leaflet and flipchart, the third level and above were directed toward active learning through coloring activity, counting the number of teeth and demonstration of brushing by the children. The said model, among others, has been selected to be applied in the present study as it has been successfully implemented and found effective in a school-based OHE program in Scotland for 6-year-old children living in disadvantaged communities.[29]

The results of the CS activity indicated that most of the children could identify entities that were beneficial and also deleterious to teeth. The perplexing finding that many children marked milk as nontooth friendly was further explored during the ensuing discussion with the children. It was found that children believed that since milk is sweet to taste, it is harmful to teeth. Hence, it was further clarified to the children that milk with no added sugar was beneficial to the teeth.

The present study has put forth the oral health intervention concept and also the reinforcement of messages on oral health through the play way method. In the present study, health education with CSs as tools was used for children, which would allow them to actively learn about their oral cavity and their influencing factors.

  Conclusion Top

The CS developed in the present study showed good acceptability among the panel of experts involved. It was also found to be easy-to-understand, culturally appropriate, practically useful in educating the children about the prevention of dental caries.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Petersen PE. The World Oral Health Report 2003: Continuous improvement of oral health in the 21st century—the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003;31 Suppl 1:3-23.  Back to cited text no. 1
Jin LJ, Armitage GC, Klinge B, Lang NP, Tonetti M, Williams RC. Global oral health inequalities: Task group—periodontal disease. Adv Dent Res 2011;23:221-6.  Back to cited text no. 2
Savage MF, Lee JY, Kotch JB, Vann WF Jr., Early preventive dental visits: Effects on subsequent utilization and costs. Pediatrics 2004;114:e418-23.  Back to cited text no. 3
Kwan SY, Petersen PE, Pine CM, Borutta A. Health-promoting schools: An opportunity for oral health promotion. Bull World Health Organ 2005;83:677-85.  Back to cited text no. 4
Bhardwaj VK, Sharma KR, Luthra RP, Jhingta P, Sharma D, Justa A. Impact of school-based oral health education program on oral health of 12 and 15 years old school children. J Educ Health Promot 2013;2:33.  Back to cited text no. 5
Jong AW. Community Dental Health. 3rd ed. Bombay: Varghese Publishing House; 1994. p. 197.  Back to cited text no. 6
Kumar Y, Sharath A, Baby J, Thiruvendakam G. Effects of conventional and game-based teaching on oral health status of children: A randomized controlled trial. Int J Clin Pediatr Dent 2015;8:123-6.  Back to cited text no. 7
Ismail AI, Ondersma S, Jedele JM, Little RJ, Lepkowski JM. Evaluation of a brief tailored motivational intervention to prevent early childhood caries. Community Dent Oral Epidemiol 2011;39:433-48.  Back to cited text no. 8
Davidson N, Skull S, Calache H, Chesters D, Chalmers J. Equitable access to dental care for an at-risk group: A review of services for Australian refugees. Aust N Z J Public Health 2007;31:73-80.  Back to cited text no. 9
Hieftje K, Edelman EJ, Camenga DR, Fiellin LE. Electronic media-based health interventions promoting behavior change in youth: A systematic review. JAMA Pediatr 2013;167:574-80.  Back to cited text no. 10
Saied-Moallemi Z, Virtanen JI, Vehkalahti MM, Tehranchi A, Murtomaa H. School-based intervention to promote preadolescents' gingival health: A community trial. Community Dent Oral Epidemiol 2009;37:518-26.  Back to cited text no. 11
Gururaj MS, Shilpa S, Maheshwaran R. Revised socio-economic status scale for urban and rural India-revision for 2015. Socioeconomic. Sci J Theory Pract Socio Econ Dev 2015;4:167-74.  Back to cited text no. 12
Guideline on Caries-Risk Assessment and Management for Infants, Children, and Adolescents. Available from: http://www.aapd.org/media/policies_guidelines/g_cariesriskassessment.pdf. [Last accessed on 2013 Dec 12].  Back to cited text no. 13
Phillips AC, Lewis LK, McEvoy MP, Galipeau J, Glasziou P, Moher D, et al. Development and validation of the guideline for reporting evidence-based practice educational interventions and teaching (GREET). BMC Med Educ 2016;16:237.  Back to cited text no. 14
Pine C. Designing school programmes to be effective vehicles for changing oral hygiene behaviour. Int Dent J 2007;57:377-81.  Back to cited text no. 15
Health Education: Theoretical Concepts, Effective Strategies and Core Competencies. Available from: http://www.emro.who.int/dsaf/emrpub_2012_en_1362.pdf. [Last accessed on 2015 Feb 09].  Back to cited text no. 16
Guideline on the Readability of the Labelling and Package Leaflet of Medicinal Products for Human Use. Available from: https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-2/c/2009_01_12_readability_guideline_final_en.pdf. [Last accessed on 2016 Jul 28].  Back to cited text no. 17
Lawshe CH. A quantitative approach to content validity. Personal Psychol 1975;28:563-75.  Back to cited text no. 18
Blinkhorn F, Wallace J, Smith L, Blinkhorn AS. Developing leaflets to give dental health advice to Aboriginal families with young children. Int Dent J 2014;64:195-9.  Back to cited text no. 19
World Health Organization. Protocol for Translation Back-Translation. Available from: http://www.who.int/substance_abuse/research_tools/translation/en/. [Last accessed on 2016 Jul 28].  Back to cited text no. 20
Maheswari UN, Asokan S, Asokan S, Kumaran ST. Effects of conventional vs game-based oral health education on children's oral health-related knowledge and oral hygiene status-a prospective study. Oral Health Prev Dent 2014;12:331-6.  Back to cited text no. 21
Chandrapooja J, Jeevanandan G. Effectiveness of good behavior game on oral health among children - A randomized trial. Drug Invention Today 2018;10:1482-6.  Back to cited text no. 22
Guidelines for school health programs to promote lifelong healthy eating. J Sch Health 1997;67:9-26.  Back to cited text no. 23
Malik A, Sabharwal S, Kumar A, Singh Samant P, Singh A, Kumar Pandey V. Implementation of game-based oral health education vs. conventional oral health education on children's oral health-related knowledge and oral hygiene status. Int J Clin Pediatr Dent 2017;10:257-60.  Back to cited text no. 24
Shrestha PD. Effectiveness of snake and ladder game on knowledge regarding “dengue fever and its prevention,” among primary school children, Bangalore. Dissertation Submitted to RGUHS; 2012.  Back to cited text no. 25
John BJ, Asokan S, Shankar S. Evaluation of different health education interventions among preschoolers: A randomized controlled pilot trial. J Indian Soc Pedod Prev Dent 2013;31:96-9.  Back to cited text no. 26
[PUBMED]  [Full text]  
Ahire M, Dani N, Muttha R. Dental health education through the brushing ROBOTUTOR: A new learning experience. J Indian Soc Periodontol 2012;16:417-20.  Back to cited text no. 27
[PUBMED]  [Full text]  
Šstrøm AN, Mashoto KO. Changes in oral health related knowledge, attitudes and behaviours following school based oral health education and Atraumatic Restorative Treatment in rural Tanzania. Norsk Epidemiologi 2012;22:21-30.  Back to cited text no. 28
Adair PM, Burnside G, Pine CM. Analysis of health behaviour change interventions for preventing dental caries delivered in primary schools. Caries Res 2013;47 Suppl 1:2-12.  Back to cited text no. 29


  [Figure 1]

  [Table 1], [Table 2]


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