Creative Education
2013. Vol.4, No.1, 45-48
Published Online January 2013 in SciRes (
Copyright © 2013 SciRes. 45
Study of Effects of Drawing and Picture-Based Dental Care
Education on Awareness of Five to Six-Year-Old Children in
Ardabil Province Kindergartens
Manochehr Barak1, Sevil Momeni2, Masoud Shabani1*, Shahnam Hosseini1,
Mahnaz Rahimi1, Arash Siad ati1, Masoud Babaei1
1Deputy for Health, Ardabil University of Medical Sciences, Ardabil, Iran
2Psychology Group, Islamic Azad University, Ardabil Branch, Iran
Email: *
Received August 5th, 2012 ; revised September 10th, 2012; accepted September 22nd, 2012
Background and Objective: Dental and oral health education is an effective method in preventing dental
caries. The objective of the current study was to assess the effects of drawing and picture-based dental
and oral health education on awareness of five to six-year-old children in Ardabil province kindergartens.
Methodology: Four hundred 5 to 6-year-old children were randomly selected from rural and urban kin-
dergartens. First, a picture questionnaire was filled out by them as the pre-test. Then, before the main test,
all children were educated by their trainers using pre-prepared booklet which had been designed as pic-
tures and/or drawing. The education lasted for three months. Also, the parents pursued the training at
home. One month after the education, the questionnaire was re-filled out as the post-test. Finally, the data
were analyzed by SPSS. Findings: The mean post-test marks was significantly better than the pre-test
marks regarding toothbrush and toothpaste, floss, sugar eating and bad habits. Conclusion: The results
showed the importance of drawing and picture-based education by trainers in kindergartens and the pur-
suance of these activities by parents at home. It can be selected as an effective education method in kin-
Keywords: Kindergarten; Dental and Oral Health
One of the most prevailing causes of dental caries and gum
inflammation is the ignorance of prevention methods of dental
diseases and their disregard. Dental caries is a widespread den-
tal disease. It is strongly influenced by habits and life styles
among children, while it is almost completely preventable.
There are reports showing that dental caries has led to even
death in some cases which is a proof of the enormous gap be-
tween what we know about caries and its prevention and what
we do about (David Satcher, 2009; Tibaboff & Reisine, 2009).
The study of dental health status in Iran showed that the dmft of
three-year-old Iranian children was 1.9 which increased to 5 by
the age of six (Oral Health Office, 2004). The caries of the
deciduous teeth tripled within three years which can be a risk
factor in creating caries of permanent teeth. In addition, the
outbreak of ECC among 2.5-year-old children increased by
24% during 1999-2004 which was brought about by inappro-
priate intake of sugars (Shojayizadeh, 2000; Woolley, 1980).
The first stage in changing the behavior of children is to edu-
cate hygiene. Although the education does not suffice by itself
for the prevention of dental caries but hygiene education makes
the pivot of all prevention approaches and is necessary for
changing destructive habits (Frites-Femandez et al., 2002).
It is obvious that one of our main tasks in preventing caries is
to start prevention and education from childhood and the aim of
health education is the change in the harmful behavior and the
health education is more effective in creating of the positive
health behavior (Harthorne & Carstens, 1989). Hartson reported
that the implementation of school oral health education is effec-
tive to enhance the oral health level (Shabani, Hesari, &
Hosseini, 2008). According to Fernandez, the level of oral
health was improved after the oral health education program
(Seyyed Akhavan & Amini, 2002). Various studies show that
the children either are ignorant of correct dental and oral be-
haviors or seldom use toothbrush and fluoride-rich toothpastes.
Hygiene education can considerably raise the awareness
(Woolley, 1980). Regular examination by dentist, regular
brushing by fluoride-rich toothpastes and flossing and eating
less sugar are some positive behaviors and not using desirable
fluoride-rich toothpastes, eating sugars, the occurrence of prior
caries in child or his parents or other family members’ mouth,
leaving microbial plaque on tooth surface and not fissure seal-
ant therapy of sensitive teeth are some factors can lead to dental
caries (Shojayizadeh, 2000; Woolley, 1980; Firrozeh, 2003;
Amini & Vanaki, 2003). Nowadays, drawing and picture are
very effective education tools in making communication with
the addressee (Birang, 2006). There many different education
methods such as gaming, drawing, storytelling, computer
games and picture interpretation, so that Amini used gaming
method in educating tooth brushing (Yeganeh, 2006) and Bi-
rang used picture media method (Oral Health Office, 2004) and
Yeganeh used speech and booklt methods in teaching hygiene
(Mazloomi, 2009). Also, the ministry of health has used a set of
active educations such as storytelling, gaming, field visiting, etc.
*Corresponding author.
in education dental and oral care for children at school level
(Karimzadeh, 2001). Mazloomi used role model method (WHO
technical report, 1984). The objective of the current study was
to investigate the effects of drawing and picture-based health
education on the knowledge of kindergarten children because it
is critically important to find economical scientific methods in
accordance with the affordability of health education responsi-
ble organizations which are effective in educating children and
applicable at kindergarten level, too.
It was an experimental after-before study which was con-
ducted in 2009. The total number of selected samples was 400
people chosen from all kindergartens of the province including
rural and urban, public and private, etc., so that it had a good
distribution. After listing all kindergartens, the samples size
was randomly selected from the list. The data were gathered by
pictorial questionnaire which included awareness questions
whose reliability was ensured by alpha cronbach’s coefficient
of .8. During the test, first the questions were clearly described
by kindergarten trainer without pointing to the answer.
Then, the children colored the correct choices green and the
harmful choices red. The choices were marked by colorful pen-
cils. Afterwards, the children were actively educated by chil-
dren workbooks, which included drawing and pictorial activi-
ties for one month. The trainers of the kindergartens were re-
sponsible for educating them. The trainers themselves had been
educated in a workshop how to educate the workbooks.
Two weeks after the end of the course, the questionnaires
were re-used and the same questionnaire was filled in accor
dance with samples size. The marks of awareness were ana-
lyzed by the software SPSS and their means were gained by
paired t-test.
In the study, the average age of the children was 4.5 years.
After the educations, the mean mark of toothbrush and tooth-
paste advantages increased from .87 to .91 and the mean mark
of flossing increased from .86 to .97. Another increase was in
the mark of sugar eating and its harms to teeth which increased
from .84 to .87. Moreover, the mark of determining incorrect
and harming habits to teeth increased from .81 to .93. Regard-
ing regular examination by dentists, the mean mark was .85
after the test while it was .74 before the test (Table 1).
There was a significant relation between mean marks before
and after test regarding the awareness about toothbrush and
toothpaste, harmful habits, regular examination by dentist and
flossing. As it has been shown in Table 2 the mean marks of
sugar eating incr e ased after the ed uc ations (P = .00).
The results showed that active education of children by
drawing and picture was effective in enhancing their knowledge
about dental and oral hygiene, so that they were able to signifi-
cantly enhance the awareness about toothbrush and toothpaste
(P < .001), flossing (P < .001), incorrect and harmful habits (P
< .001) and regular examination by dentist (P < .001). In the
case of sugar eating, there was a significant increase in aware-
ness, too. In a study on the effects of education by two speech
and booklet methods on increasing the awareness about break
Table 1.
Distribution of frequency of correct and incorrect answers and mean mark of awareness relative to dental and oral health before and after drawing and
picture-based education in 5 to 6-year-old children in Ardabil kindergartens.
Question Before e d ucation After educ ation
Color the items good for
teeth blue a nd th e ones
bad for teeth in red
answers Incorrect
answers Total Mean awareness
mark Correct
answers Incorrect
answers Total Mean awareness
310 90 400 .78 (±.41) 384 16 400 .96 (±.19)
194 206 400 .47 (±.5) 374 26 400 .94 (±.24)
259 105 400 .74 (±.44) 388 12 400 .97 (±.17)
158 242 400 .4 (±.45) 362 37 400 .9 (±.3)
Copyright © 2013 SciRes.
Table 2.
Means comparison for awareness marks of dental and oral health before and after education of c h il dren (5 to 6-year -old children).
Question Before
education Mean s After
education Means Means
difference Confidence
interval .95 T df
.78 (±.41) .96 (±.19) .18 (±.28) .14 - .22 9 399 P < .001
.47 (±.5) .94 (±.24) .45 (±.49) .4 - .49 18 399 P < .001
.74 (±.44) .97 (±.17) .23 (±.42) .19 -.27 10.9 399 P < .001
.4 (±.45) .9 (±.3) .5 (±.5) .46 - .55 20 399 P < .001
fast eating among children, Yeganeh showed that although
speech was better in enhancing the awareness (Mazloomi,
2009), there was no significant difference between these two
methods. However, they recommended education by booklet
because of its simplicity. This method is economical too be-
cause in speech direct education of individual child is difficult.
Kreisel (2003) studied the effectiveness of education by a
computer training package among nine and ten-year-old chil-
dren and showed that it was significant in increasing children’s
awareness but it was not significant regarding the performance
(Kreisel, 2003). Birang indicated that education by film as a
pictorial media increased the awareness and performance about
dental and oral health among students (Birang, 2006). In a
study on the effects of education with two game and role play-
ing methods on the awareness of 5 and 6-year-old children,
Ahmadi showed that game playing and drawing method was
significant better than role playing method in increasing chil-
dren’s awareness about recognizing food pyramid which is
consistent with the findings of the current study (Amini & Va-
naki, 2003).
Considering the positive effects of education, it could be said
that actively educating children by drawing and picture is effec-
tive in increasing their awareness about dental and oral hygiene.
According to the alma-ata conference, the education concerning
prevailing health problems and the method of identifying, pre-
venting, and controlling them as the first of the eight recom-
mended activities making up primary health care (WHO,
1984) .This comment elucidate the role of the health education
as a primary measurement in the health care management. De-
spite the increase in the number of dentists and equipping den-
tal centers, many countries were not able to overcome dental
caries because it is almost a behavioral problem associated with
the ignorance and disregard of positive behaviors by people
(Dye et al., 2007). Mazloomi (2009) and Karimzadeh (2001)
showed that role-playing and child-to-child education methods
were effective in enhancing children’s health awareness, re-
spectively. Smiech (2007) recommends health education and
appropriate food regime as the measures for controlling dental
caries. Conclusion
Considering that drawing and picture-based education is a
simple method and are more practical under the supervision of
trainers or parents, it is better to use this method in other dental
and oral care fields such as motivation and performance fields.
Also, it is recommended to study this method in other fields of
hygiene on children.
The authors appreciate the officials of Ardabil Welfare Of-
fice and all principals and teachers of kindergartens for their
kind cooperation.
Amini, R., & Vanaki, Z. (2003). Study of the extent of the effects of
oral health game education on dental and oral health status among
students in Isfahan, Iran. Journal of Dentistry College, Isfahan, 15,
Birang, S., et al. (2006). Study of effects of picture education method on
enhancing dental and oral health among students (Vol. 9, pp. 1-6).
Isfahan: Dentistry College.
David Satcher (2009). Childrens oral health. The time for change is
now. Academic Pediatrics, 9, 380-382.
Dye, B. A., Tan, S., Smith, V., Lewis, B. G., Barker, L. K., Thorn-
ton-Evans, G. et al. (200 7). Trends in oral health status: United States,
1988-1994 and 1999-2004. National Center for Health Statistics, Vi-
tal Health Stat, 11, 1-92.
Firrozeh, M. (2003). Picture language (Vol. 4, pp. 16-58, 109). Tehran:
Soroosh Press.
Frites-Femandez, L. B., Noraes Junior, A. B., & Fertasa, A. C. (2002).
Effectiveness of an oral hygiene program for brazillian orphoenag.
Brazilian Dental Journal, 13, 44-48.
Harthorne, J. E., & Carstens, I. L. (1989). The effective of a school-
Copyright © 2013 SciRes. 47
based oral health education program—A pilot study. The Journal of
the Dental Association of South Africa, 44, 5-10.
Karimzadeh, F. (2001). Child to child approach. Yasooj University for
Medical Science, 18, 28-33.
Katrin, K. (2003). Evaluation of a computer-based nutrition education
tool. Public Health Nutrition, 7, 271–277.
Mazloomi, M. (2009). Study of effects of the role modeling on enhanc-
ing of oral health knowl e d ge . Journal of I s l am i c De n t i st , 1 ,137-147.
Oral Health Office (2004). Health education in kindergarden (pp. 4-47).
Tehran: Ministry of Health and Medical Educat i on .
Seyyed Akhavan, P., & Amini, N. (2002). Modern prevention methods
in dentistry and estimation of risk of dental and oral diseases (pp.
37-51). Tehran: Teymoorzadeh Press.
Shabani, M., Hesari, H., & Hosseini, S. (2008). Sealant therapy without
trauma. Jame’e Negar ( p p. 135-138). Esfahan: Baghe Rezvan Press.
Shojaeizadeh, S. (2000). Study models of behavior in health education.
Health Education and Communication Office (3rd ed., pp. 201-232).
Tehran: Ministry of Health and Medical Educat i on .
Smiech, S., et al. (2007). The effect of oral health education on dental
plaque development and the level of caries-related Streptococcus
mutans and lactobacillus spp. European Journal of Orthodontics, 29,
157-160. doi:10.1093/ejo/cjm001
Tibaboff, N., & Reisine, S., (2009). Update on early childhood caries
since the Surgeon General’s Report. Academic Pediatrics, 9, 396-
WHO Technical Report Srries No. 713 (1984). Prenention methods and
programmes for oral disease (pp. 24-25). Geneva: WHO Expert
Yeganeh, M. et al. (2006). Comparison of the effects of two breakfast
nutrition educating methods on the performance of the students of
four schools in Tehran, Iran. Journal of Health and Health Research,
4, 65-67.
Copyright © 2013 SciRes.