Effectiveness of an Oral-Health Education Program using a Modified Toothbrush to Improve Parental Knowledge in Caring for Children with Cerebral Palsy at YPAC Surabaya

International Journal of Medical Science and Clinical Research Studies ISSN(print): 2767-8326, ISSN(online): 2767-8342 Volume 05 Issue 11 November 2025 Page No: 1904-1908 DOI: https://doi.org/10.47191/ijmscrs/v5-i11-18, Impact Factor: 8.188 1904 Volume 05 Issue 11 November 2025 Corresponding Author: Yulie Emilda Akwan Effectiveness of an Oral-Health Education Program using a Modified Toothbrush to Improve Parental Knowledge in Caring for Children with Cerebral Palsy at YPAC Surabaya Diana Soesilo1, Yulie Emilda Akwan1, Wanda Rahma Syanti2 1Faculty of Dentistry Universitas Hang Tuah 2Faculty of Psychology Universitas Hang Tuah ABSTRACT ARTICLE DETAILS Background: Children with cerebral palsy experience motor impairments that limit their ability to perform daily oral hygiene, increasing the risk of dental problems. Parental support is therefore essential, and structured oral-health education may strengthen their ability to assist with tooth brushing using adaptive tools. Objective: This study aimed to assess the effectiveness of an oral-health education program incorporating modified toothbrush training in improving parents’ knowledge of tooth-brushing techniques for children with cerebral palsy. Methods: A pre-experimental one-group pretest–posttest design was conducted at YPAC Surabaya. Parents received oral-health education through lectures, demonstrations, and hands-on training in creating modified toothbrush handles using clay-based materials. Parental knowledge was assessed using validated pretest and posttest questionnaires. Children’s oral hygiene was evaluated using plaque index and halitosis measurements. Data were analyzed with the Wilcoxon signed-rank test. Results: Twenty-four parents participated. Posttest scores showed a significant improvement in parental knowledge compared with pretest scores (p = 0.000), demonstrating the effectiveness of the educational intervention. Conclusion: The oral-health education program, combined with practical training on modified toothbrush use, effectively increased parents’ knowledge and readiness to support their children with cerebral palsy in maintaining daily oral hygiene. Broader implementation of such programs is recommended for special-needs educational settings. KEYWORDS: oral hygiene, cerebral palsy, parental knowledge, modified toothbrush, special needs children, health education. Published On: 27 November 2025 Available on: https://ijmscrs.com I. INTRODUCTION Children with disabilities have physical, mental, social, and emotional limitations compared to the average child of their age, which significantly impact their growth and development. These disabilities are accompanied by inadequate motor development. Without early intervention, it is difficult to develop the motor skills that children need to care for themselves.1 Physical and motor limitations in children with disabilities lead to inadequate dental and oral health care. This suboptimal dental and oral health care leads to children with disabilities experiencing dental and oral problems, one of which is tooth decay, which requires further treatment such as fillings or root canal treatment.2,3 Based on the results of the 2018 Basic Health Research (RISKESDAS), as many as 93% of children in Indonesia suffer from dental caries. The prevalence of dental caries in children with disabilities is 92.7%. The high prevalence of dental caries can cause chewing function in the oral cavity to be suboptimal, while childhood is a period of growth and development that requires optimal dental and oral health.4 Despite this crucial role, parents of children with disabilities often lack adequate knowledge or confidence in performing Effectiveness of an Oral-Health Education Program using a Modified Toothbrush to Improve Parental Knowledge in Caring for Children with Cerebral Palsy at YPAC Surabaya 1905 Volume 05 Issue 11 November 2025 Corresponding Author: Yulie Emilda Akwan oral hygiene assistance. Many are unaware of the proper brushing technique or how to modify tools to accommodate the child’s motor limitations. While the literature recognizes the importance of parental involvement,⁵⁻⁶ few communitybased programs in Indonesia have specifically addressed parental education using customized, adaptive toothbrush designs for children with cerebral palsy. This represents a key research gap. Cerebral palsy (CP), characterized by non-progressive motor impairment, presents unique challenges in oral hygiene maintenance due to poor muscle coordination and limited hand control. These difficulties often require adaptive tools such as modified toothbrush handles to facilitate effective cleaning. However, educational programs that teach parents how to construct and use such modifications remain limited. Therefore, this study aimed to evaluate whether an oral-health education program could effectively increase parents’ knowledge regarding proper tooth brushing techniques using a modified toothbrush for children with cerebral palsy at the YPAC Special Needs School in Surabaya. II. MATERIAL AND METHODS The first stage will involve education about oral health and how to properly care for your mouth and teeth. Respondents will be given preand post-test questionnaires to assess their knowledge. Psychological support will also be provided to provide initial motivation to ensure the participants, including students with disabilities, parents, and teachers, are enthusiastic about participating in this project. A. Study Design This study employed a pre-experimental one-group pretest– posttest design, which aimed to evaluate the effect of an educational intervention on parents’ knowledge regarding proper tooth brushing techniques for children with cerebral palsy. B. Study Setting and Period The study was conducted at YPAC Special Needs School, Surabaya, a facility serving children with cerebral palsy. Data collection, including education, pretest, posttest, and oral examinations, was carried out during the academic period of 2024. C. Participants and Sampling Technique Participants consisted of parents of students with cerebral palsy enrolled at YPAC Surabaya. A total sampling approach was used, in which all eligible parents present during the program were recruited. Twenty-four (n = 24) parents participated in both the pretest and posttest phases. Inclusion criteria: 1. Parents or primary caregivers of children diagnosed with cerebral palsy. 2. Willing to participate in the educational session and complete pretest–posttest assessments. 3. Able to understand Indonesian language. Exclusion criteria: 1. Parents unable to attend the full session. 2. Incomplete pretest or posttest data. D. Educational Intervention The intervention included: 1. Oral-health education (lecture and demonstration), 2. Hands-on training on tooth brushing techniques, 3. Training on making modified toothbrush handles using clay, Velcro straps, silicone, or other adaptive materials, aligned with previous recommendations for children with motor impairments.¹²⁻¹³ All sessions were delivered by the Faculty of Dentistry and Faculty of Psychology team, Universitas Hang Tuah. E. Measurement Instruments Two types of measurements were used: 1. Parental Knowledge Assessment : A validated questionnaire consisting of 10 multiple-choice items assessing knowledge of oral hygiene practices, brushing techniques, and appropriate use of modified toothbrushes. • Reliability and structure follow previously used formats in similar Indonesian studies⁵⁻⁶. • The questionnaire was administered before and after the intervention. 2. Children’s Oral Hygiene Assessment Children’s oral health was evaluated using: • Plaque index score measured with a plaque detector, • Halitosis score measured using a halitosis detector. These tools have been shown to provide objective measures of oral cleanliness.¹⁴⁻¹⁵ F. Ethical Considerations The study followed ethical principles based on the Declaration of Helsinki. All parents provided informed consent before participation. Ethical clearance for the program was obtained from the Faculty of Dentistry, Universitas Hang Tuah Ethical Committee G. Data Analysis Data were analyzed using the Wilcoxon signed-rank test to compare pretest and posttest knowledge scores. A significance level of p < 0.05 was considered statistically meaningful. Statistical analysis was supported by SPSS version 25. Pretest and Post-test Questions A. Participant Biodata Name Gender Male / Female Effectiveness of an Oral-Health Education Program using a Modified Toothbrush to Improve Parental Knowledge in Caring for Children with Cerebral Palsy at YPAC Surabaya 1906 Volume 05 Issue 11 November 2025 Corresponding Author: Yulie Emilda Akwan Age B. Multiple-Choice Questions 1. What is the primary purpose of tooth brushing? a. To make the teeth appear shiny b. To enhance one’s smile c. To remove food debris d. To enable proper chewing 2. What is the minimum recommended frequency for brushing teeth each day? a. Once a day b. Three times a day c. Twice a day d. Five times a day 3. When is the appropriate time to brush your teeth? a. Morning and afternoon after bathing b. Morning after breakfast and at night before sleeping c. Afternoon and evening after bathing d. Evening while bathing and at night before sleeping 4. Toothpaste is ideally formulated with which ingredient? a. Fluoride b. Fruit extracts c. Charcoal d. Minerals 5. What is the proper method for brushing the teeth of children aged 0–5 years with disabilities? a. Brushing while the child is sitting b. Asking the child to brush independently c. Laying the child down between the caregiver’s legs d. Laying the child down and allowing them to brush independently 6. To maintain optimal dental health, how often should routine dental check-ups be conducted? a. Once a month b. Once every three months c. Only when complaints arise d. Once every six months 7. What tool can be used to clean food debris from the tongue? a. Sponge brush b. Towel c. Tongue scraper d. Elastic band 8. How should the lip mucosa be cleaned using a sponge brush? a. Dip the sponge in water and apply it to the lip/cheek mucosa b. Dip the sponge in antiseptic mouthwash and wipe it on the lip mucosa c. Use the sponge with a toothbrush to wipe the lip mucosa d. Use the sponge directly on the lip/cheek mucosa III. RESULTS The level of knowledge of students' parents regarding oral and dental health was measured by administering a pre-test and post-test questionnaire consisting of 10 questions about knowledge of dental health maintenance for children with disabilities. Twenty-four respondents completed the questionnaire. The average results of the respondents' questionnaire answers can be seen in diagram 1. The diagram shows an increase in parents who obtained a score of 100 after being given material presentations by the team from the Faculty of Dentistry and the Faculty of Psychology, Hang Tuah University. DIAGRAM 1. RESULTS OF PRE-TEST AND POSTTEST ON PARENTS OF STUDENTS REGARDING HOW TO MAINTAIN ORAL AND DENTAL HEALTH IN STUDENTS WITH DISABILITIES. The results were then statistically tested using the Wilcoxon test (Table 1) which showed a result of p = 0.000, where p <0.05, which means there is a significant difference between the knowledge of students' parents before and after exposure to oral and dental health education material. Table 1. Results of the wilcoxon test on the pre-test and post-test of parents' knowledge about maintaining the oral and dental health of children with disabilities. IV. DISCUSSION The improvement in parents’ knowledge regarding the maintenance of oral hygiene in children with cerebral 0 5 10 15 10-20 30-40 50-60 70-80 90-100 PRE TEST AND POST TEST RESULT PRE TEST POST TEST Effectiveness of an Oral-Health Education Program using a Modified Toothbrush to Improve Parental Knowledge in Caring for Children with Cerebral Palsy at YPAC Surabaya 1907 Volume 05 Issue 11 November 2025 Corresponding Author: Yulie Emilda Akwan palsy (CP) observed in this study highlights the essential role of structured and family-centered education in supporting oral health care for vulnerable populations. The outreach method implemented in this program incorporated both individual and family-based approaches. For children with cerebral palsy, individualized guidance is crucial due to their unique neuromotor challenges, while a family approach ensures that parents acquire the skills needed to provide daily motor assistance. Outreach activities were supplemented with interactive games to increase motivation and engagement among children with CP, using simple and concrete language for better comprehension. Cerebral palsy is a permanent and non-progressive neurological disorder resulting from early brain injury that impairs normal development, leading to abnormalities in posture, movement, and muscle tone7. The clinical manifestations vary widely and may include impaired body control, difficulties in muscle coordination, abnormal reflexes, and problems with balance. The degree of disability is influenced by access to therapy, environmental stimulation, and the child’s interaction with social surroundings8,9. These impairments directly affect a child's ability to perform oral hygiene tasks independently. Children with CP frequently exhibit oral problems, including high caries prevalence, poor oral hygiene, enamel hypoplasia, delayed tooth eruption, Class II malocclusion, bruxism, abnormal swallowing patterns, choking, tongue thrusting, mouth breathing, gingival hyperplasia, gag reflex hypersensitivity, erosion and attrition, drooling, and easily bleeding gingiva10,11. These challenges highlight the importance of parental involvement in daily oral hygiene routines. Toothbrush design and usability become critical in this population. Proper brushing depends on technique, supervision, and the child’s ability to hold the toothbrush. Conventional toothbrushes often do not meet the needs of children with neuromotor impairments. Therefore, adaptive toothbrush designs, such as modified handles, are essential. In this program, parents, teachers, and students were trained to create custom-made toothbrush handles using accessible materials such as clay, Velcro straps, silicone, plastazote tubes, sponges, bicycle handle grips, soft rubber, or Styrofoam balls12,13. Handles that are stable, non-slip, and comfortable allow caregivers to guide brushing more effectively. The educational intervention emphasized correct brushing techniques, the use of fluoride toothpaste, brushing frequency, and supervision strategies. This aligns with earlier studies demonstrating that parental knowledge and hands-on training are key determinants of children’s oral health behavior5,6. The significant improvement in post-test scores reflects enhanced parental understanding of essential oral hygiene practices. Parents play a crucial role in establishing daily oral hygiene routines for children with disabilities. Higher parental knowledge has been associated with better oral health outcomes5,6. This study reinforces previous findings showing that targeted education successfully improves parents’ ability to maintain their children’s oral hygiene. Overall, the findings suggest that structured education combined with hands-on training and adaptive tools significantly enhances parental competency in oral hygiene care. These results support the inclusion of parentfocused oral health programs in special education environments and community outreach efforts. This study employed a pre-experimental design without a control group, limiting causal inference. The sample size was relatively small and limited to one specialneeds school, which may affect generalizability. Additionally, long-term retention of knowledge and behavior change were not assessed. Future studies should employ controlled experimental designs, include larger and more diverse samples, and evaluate long-term behavioral outcomes. Further research on the effectiveness of different types of modified toothbrush handles may also contribute to developing standardized recommendations for children with motor impairments. V. CONCLUSION The oral-health education program proved effective in increasing parents’ knowledge about proper tooth-brushing techniques for children with cerebral palsy, as shown by the significant improvement in post-test scores (p = 0.000). These findings indicate that structured, hands-on educational activities can enhance parental readiness and skills in supporting daily oral hygiene at home. Continued implementation of similar programs is recommended to improve oral-health outcomes among children with special needs. ACKNOWLEDGMENT The author would like to thank the Ministry of Education and Science (Kemdiktisaintek) for the grant funds that have been given to the author's team. The author would also like to thank Hang Tuah University for providing a lot of support to the author. His deepest gratitude to Prof. Dr. Ir. Bagiyo Suwasono, ST, MT, FRINA, MCE as the Head of LPPM Hang Tuah University, Mrs. Deasy Arieffiani, S.Si, M.Si as the Head of Community Service of Hang Tuah University, Mrs. Isrumilla, S.Pd, MM as the Principal of SLB YPAC Surabaya for their hospitality and welcome during the implementation of this activity. The author also wishes to thank Prof. Dr. Rima Parwati Sari, drg., M.Kes, PBO, Istien Wardhani, drg., Sp.KGA, Yufita Fitriani, drg., Sp.KGA, Mrs. Fitri Rahayu, Mr. Mohammad Rosyid, Mohammad Vico Khoirul Anas, Mohammad Arib Razzaq, Dea Amanda Leila Effectiveness of an Oral-Health Education Program using a Modified Toothbrush to Improve Parental Knowledge in Caring for Children with Cerebral Palsy at YPAC Surabaya 1908 Volume 05 Issue 11 November 2025 Corresponding Author: Yulie Emilda Akwan Utami and dental profession students from Hang Tuah University for their assistance during the implementation of this activity. REFERENCES I. D. G. 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