An interventional study was conducted among primary, elementary and high school teachers of nine private schools in the Hazaribag town of Jharkhand State in East India to evaluate the knowledge of participants on pediatric oral health. A total of 153 school teachers were randomly selected using a random sampling method.

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Primary, Elementary and High school teachers of private schools in the Hazaribag town of Jharkhand; and

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Primary, Elementary and High school teachers of government schools in the Hazaribag town of Jharkhand; and

A one-day training program was collocated after receiving positive opinions on needs valuation from all participants, one week before the scheduled training program. All the nominated teachers took part in the training as an indispensable segment of a one-week teachers training program organized by the Department of Pediatric and Preventive Dentistry, Hazaribag College of Dental Sciences and Hospital, Hazaribagh from 4th to 10th September 2021.

A self-administered, 30-item questionnaire was formulated as Google Forms in the English language; the design and inclusiveness of the questionnaire was finalized with the support of a team of experts from the Department of Pediatric and Preventive Dentistry, Periodontics and Public Health Dentistry before the study. The questionnaire incorporated two sections: the first section asked about demographic details such as gender, marital status, school location; the second section asked 30 questions on pediatric oral health with three divided subsections: Subsection A (including 7 questions): Questionnaire on general pediatric oral health, B (including 9 questions): Questionnaire on preventive pediatric oral health and C (including 14 questions): Questionnaire on clinical pediatric oral health, to evaluate the knowledge of teachers toward oral health in children. All the questions were in a digital format, uploaded on Google Forms. A pilot study was done antecedent to our study among 12 primary and elementary school teachers and the participants were not counted in the training program. This was done to check the reliability and feasibility of data collection stratagem before beginning of the main study. Any problems and technical hitches, if incurred during the filling of the pilot form were corrected. The pre- and post-training questionnaires can be found in the Extended data.

The training program consisted of four stages as described below.

Stage 1: Pre-training module of knowledge and awareness assessment: A 30-item questionnaire was sent to all the participating school teachers with a title of pre-test questionnaire. This was designed in English language and was emailed to all nominated school teachers participating in the study. The questionnaire included 30 questions in the form of an online self-administered questionnaire (English) and was formatted as Google Forms.

Stage 2: Webinar-based oral health education module: This module comprised of oral health education program to be attended by all participants using a web-based online education training protocol on the Zoom platform. The training included four sessions on oral cavity, plaque and gingiva, gingival problems; morphology of tooth, primary and permanent; tooth brushing techniques in children; dental caries with special reference to ECC (Early Childhood Caries); clinical myths and facts of children dentistry in Indian population with special mention to pulp therapy, dental caries, dental trauma, malocclusion, conscious sedation and general anaesthesia applications and dental fluorosis, home and professional dental practices, prevention of oral diseases. During the training program, four sessions of 30-45 minutes per session were conducted respectively for participating schools teachers.

Stage 3: A panel discussion followed by a dental quiz: After completing each session, a panel discussion was done for 45 minutes with the aim of clarifying individual teacher queries and discussing frequently asked questions regarding pediatric oral health with panellists comprising of professors from departments of Pediatric and Preventive Dentistry, Periodontics and Implantology, Public Health Dentistry and Oral Pathology in Hazaribag College of Dental Sciences and Hospital, Hazaribag. After that, a dental quiz was organized which enabled teachers to actively participate and share the dental knowledge gained through the webinar session.

Stage 4: Post-training module of knowledge and awareness assessment: A 30-item questionnaire which was the same as the pre-test questionnaire was sent to all the participating school teachers with a title of post-test questionnaire and the scores were recorded and compared to pre-test scores. The feedback from the participants regarding the program was also recorded.

Ethical approval was obtained from the Institutional Review Board of Hazaribag College of Dental Sciences and Hospital, Hazaribag, Jharkhand, India (with no. HCDSH/ADM/BNF/2020/214 and dated 25.01.2020). The written informed consent was obtained from all the participants before the start of the study.

The data collection, scoring and data analysis was done by a single trained investigator (Dr Annapurna Ahuja) to avoid inter-examiner variability by analysing the pre-questionnaire before online education and post-questionnaire after online education. The scoring was done as ‘1’ for Option A, ‘2’ for option B, ‘3’ for option C. The test-retest reliability of the questionnaire was estimated by providing the same questionnaire to the same participants of a pilot study at different times, and a satisfactory correlation coefficient was established to enhance trustworthiness and credibility of the data analysis.

The collected data were entered into Microsoft Excel 2007 and subjected to statistical analysis using SPSS version 22.0 (IBM Statistics Inc., Chicago, Illinois, USA). The statistical test used was Chi-Square test to assess the categorical difference in scores before and after oral health education. P ≤ 0.05 was considered for statistical significance. The test-retest reliability of the questionnaire was estimated, and a satisfactory correlation coefficient was established to enhance trustworthiness and credibility of the data analysis.

The study included 153 school teachers from Hazaribag City of East India, of which 73.9% were female teachers and 26.1% were male teachers, and the similar percentage with respect to gender of school teachers participated in the study was reported by Dedeke et al. ⁹

School teachers exhibited honourably good basic knowledge on general pediatric dentistry. The majority of them (more than 90%) knew that humans have two sets of dentition—primary and permanent and also primary teeth lay the foundation for permanent teeth and should be taken care of until they shed as mentioned in a study by Johansson et al. ^{10 , 11} Nearly 70% knew about pedodontist as specialized children dentist which was in line with a study by Patil et al. ¹² which concluded that 84.1% of parents will consult a pedodontist for suggestion and is against study by Nagaveni et al. ¹³ where negligible percentage of population knew about specialized pedodontist for children. More than 70% of participants knew about the importance of milk teeth and their role in the growth and development of children which is similar to reports by Nassar et al. ¹⁴ and a fair part of participants knew that milk teeth are more prone to dental caries due to thin enamel and dentin when compared to permanent teeth and is well explained by Lynch. ¹⁰ A highly statistically significant improvement in teachers’ knowledge regarding general pediatric dentistry was observed post webinar oral health education program. In our study, the majority of participants believe that dental education for children should be given to school teachers for the betterment of society. According to Nassar et al., ¹⁴ 98.1% of parents believe that dental health education should be taught in schools for better dissemination of dental knowledge.

School teachers exhibited poor knowledge on preventive pediatric dentistry. Only about 50% school teachers knew that the first dental visit time should be near to the child’s 1st birthday. This lack of awareness is well documented in previous studies by Baltaci, ¹⁵ Nair, ¹⁶ Nayak ¹⁷ where it was also inferred that children never visited a dentist for their first dental visit as an imperative preventive protocol but the main reason for this dental visit was always dental pain. The knowledge of brushing habits forms a mixed response. The majority know about twice daily brushing as an important protocol to prevent decay as mentioned in previous studies by Baltaci, ¹⁵ Al-Jaber, ¹⁸ Adair et al., ¹⁹ Chandran, ²⁰ Özbek ²¹ and Nair ¹⁶ and this may be attributed to frequent media and social messages regarding tooth brushing. Nearly 60% of teachers knew that brushing should start as soon as the first tooth appears in the oral cavity, similar findings were also reported by Al-Jaber et al. ¹⁸ and Baltaci et al. ¹⁵ where 76.9% of parents and 50.4% of teachers answered correctly for the ideal time to start tooth brushing. 54% knew that fluoride can be used after the 1st birthday for topical applications which is in line with study by Basir where 17.1% gave the correct answer. ²² Surprisingly, a huge sample size knew about the fones technique whereas only 15.2% in a study by Ibrahim ²³ responded correctly. The pea size toothpaste recommendation for kids was responded correctly by 86.7% which is in line with a study by Al-Jaber et al. ¹⁸ and as per The American Academy of Pediatric Dentistry (AAPD) recommendations. ²⁴ The majority of the population (84%) knew that separate toothpastes are available for kids and adults. However, many of them were unaware that toothpastes come with fluoride and without fluoride separately. In addition, the majority of the population was aware of the recommendation for kids to brush their teeth twice daily as well as the importance of fluoride as an anti-decay agent. More than half of the respondents were unaware of professionally applied preventive measures, such as fissure sealants, and only 37% of parents responded correctly and their function and the techniques by which they are applied to children as a study by Nassar. ¹⁴

School teachers exhibited inadequate knowledge on clinical pediatric dentistry. A fair amount of knowledge was displayed regarding ECC and bottle feeding at night as the cause for baby teeth decay which was not aligned with Nassar ¹⁴ and Al-Zahrani et al. ²⁵ where more than 50% of subjects were unaware of bottle feeding as the cause of caries and it was also stated that knowledge about ECC should be given to parents. In our study, less than half subjects knew about vertical transmission and that mothers who kiss their children can spread caries, the explanation of which is well explained by Grönroos et al. ²⁶ and Hameş-Kocabaş et al. ²⁷ as mutacins role in vertical transmission of S.mutans from mothers to their children.

In our study, 79.1% of parents knew that medicinal syrups are sugary and improper oral hygiene measures can cause caries which is consistent with a study by Valinoti et al. ²⁸ where it was inferred that pediatric formulations, especially antibiotics, contain a high amount of sucrose and are cariogenic. Neves et al. ²⁹ found that association of parental knowledge regarding sugar-containing pediatric syrups usage and practices, where 28.6% of parents brushed their child’s teeth after giving medications. In our study, it was found that 62.8% of participants gave the correct answer to the question concerning treatment of milk tooth decay with fillings or crowns which is consistent with a study by Nasir et al. ¹⁴ where 56.2% said yes to this question. In our study, half of the participants knew that root canal treatment for children as a treatment protocol for severe milk teeth cavities. This finding aligns with Syriac e t al. ³⁰ where 66% of parents had the knowledge of root canal treatment in deciduous teeth and 43% expressed positive attitude towards their children undergoing pulp therapy.

Only 51% of teachers knew that heat fermentation should be avoided in times of oral swellings and the scientific explanation is that the alkaline phosphatase starts denaturing above 19°C which is the threshold temperature for alveolar bone. The most referenced study inferred that if temperature was raised above 13°C for 1 minute or 10°C for 5 minutes then the alveolar bone tissue showed signs of resorption and no regeneration as a consequence. ³¹ Following thermal damage, the healing of bone tissue was not through hard-tissue formation, but through the induction of connective tissue, suggesting that the threshold temperature increase for bone damage was 10°C. ^{31 , 32} In the present study, nearly half of the teachers did not know about the management of knocked-out tooth, which includes lack of knowledge regarding critical extra-oral survival time and the storage media to carry the avulsed teeth back into the avulsed socket; and these findings are in line with studies by Prasanna et al., ³³ Touré et al. ⁶ and Nashine et al. ³ This is very alarming, since tooth avulsion occurs commonly in school children between 7 and 11 years old so teachers should be made aware of this injury. School teachers showed inadequate knowledge regarding orthodontic correction and the age for children’s first orthodontic consultation visit. According to one study by Aldweesh et al. ³⁴ 79% of the parents thought that their children’s teeth would have a significant impact on their personality and hence correction of malaligned teeth should be done; and a majority of children visited for an orthodontic consultation at the age of 11 years. More than half of the participants were unaware of the Nitrous oxide conscious sedation technique, a behaviour management, in young or fearful children which is not surprising as there is no previous study assessing the teachers’ knowledge or training in conscious sedation. This study inference was similar to Alkandari ³⁵ done in Kuwait which states that 79% of parents do not know about nitrous oxide conscious sedation. In our study, nearly half of the school teachers did not know the importance and protocol for space maintainers which is in line with a study by Ali et al. ³⁶ where only 49.8% showed parental knowledge regarding space maintainers and this knowledge was considered inadequate.

The strengths of this research are outlined as follows: 1. School teacher training at regular intervals should be an imperative part of Pediatric dentistry protocol. 2. If Children are desensitized at a primary level in schools, the fear of dentist and dentistry as a profession might be reduced. 3. Pre and post training shows highly significant results proving that the online oral education tool is well accepted and perceived by school teachers. The limitations of this study are, firstly the limited sample size, and secondly, the oral health knowledge of school teachers if had been compared with the education level of teachers could have added weightage to this research.