The Effectiveness of Motivational Interviewing in Preventing Early Childhood Caries: A Cluster Randomised Controlled Trial Among Mothers of Infants in Terengganu.
Phase: NA
Conditions: Healthy Women, Caries of Infancy
Sponsor: Universiti Sains Malaysia

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SCHOOL OF DENTAL SCIENCES  
DOCTORATE IN DENTAL PUBLIC HEALTH  
2026  
RESEARCH PROPOSAL   
THE EFFECTIVENESS OF MOTIVATIONAL 
INTERVIEWING IN PREVENTING EARLY 
CHILDHOOD CARIES:  
A CLUSTER RANDOMISED CONTROLLED TRIAL 
AMONG MOTHERS OF INFANTS IN 
TERENGGANU 
 
NOR AIDA BINTI ABDUL MALIK 
(22202901)  
Main Supervisor  
ASSOC. PROF. DR. NORKHAFIZAH BINTI SADDKI   
Co-Supervisor  
DR ZULIANI BINTI MAHMOOD 

ii 
TABLE OF CONTENTS 
TABLE OF CONTENTS ........................................................................................... ii 
LIST OF TABLES ..................................................................................................... v 
LIST OF FIGURES ................................................................................................. vii 
LIST OF ABBREVIATIONS ................................................................................ viii 
LIST OF APPENDICES .......................................................................................... ix 
CHAPTER 1 
INTRODUCTION ........................................................................ 10 
1.1 
Background of Study ...................................................................................... 10 
1.2 
Problem Statement ......................................................................................... 13 
1.3 
Justification of Study ...................................................................................... 15 
1.4 
Research Objectives ....................................................................................... 20 
1.4.1 
General Objectives ......................................................................... 20 
1.4.2 
Specific Objectives ......................................................................... 20 
1.4.3 
Research Questions ........................................................................ 21 
1.4.4 
Research Hypothesis ...................................................................... 22 
1.5 
Conceptual Framework .................................................................................. 23 
CHAPTER 2 
LITERATURE REVIEW ............................................................ 28 
2.1 
Prevention of Early Childhood Caries ........................................................... 28 
2.2 
Anticipatory Guidance in Early Childhood Oral Healthcare and Early 
Childhood Caries Prevention ......................................................................... 31 
2.3 
Barriers among Parents/ Caregivers in Early Childhood Oral Healthcare ..... 33 
2.4 
Methods of Delivering Motivational Interviewing ........................................ 36 
2.5 
Motivational Interviewing as a Behavioral Change Strategy ......................... 38 
2.6 
Motivational Interviewing Principles ............................................................. 40 
2.7 
Motivational Interviewing Tools .................................................................... 42 
2.8 
Motivational Interviewing in Medical Care Settings ..................................... 43 

iii 
2.9 
Motivational Interviewing in Oral Health Care Settings ............................... 45 
2.10 
Motivational Interviewing in Early Childhood Caries Prevention ................. 47 
CHAPTER 3 
MATERIALS AND METHODS ................................................ 49 
3.1 
Study Area ...................................................................................................... 49 
3.2 
Research Design ............................................................................................. 49 
3.3 
Study Population ............................................................................................ 50 
3.3.1 
Reference Population ..................................................................... 50 
3.3.2 
Source Population .......................................................................... 50 
3.3.3 
Sampling Frame ............................................................................. 50 
3.4 
Sample Size Determination ............................................................................ 52 
3.4.1 
Specific Objective 1 ....................................................................... 53 
3.4.2 
Specific Objective 2 ....................................................................... 53 
3.4.3 
Specific Objective 3 ....................................................................... 54 
3.4.4 
Specific Objective 4 ....................................................................... 54 
3.4.5 
Specific Objective 5 ....................................................................... 55 
3.4.6 
Specific Objective 6 ....................................................................... 55 
3.4.7 
Specific Objective 7 ....................................................................... 56 
3.4.8 
Specific Objective 8 ....................................................................... 56 
3.4.9 
Conclusion on Sample Size Determination .................................... 56 
3.5 
Sampling Method ........................................................................................... 57 
3.6 
Variables and Research Tools ........................................................................ 59 
3.6.1 
Variables......................................................................................... 59 
3.6.2 
Research Tools ............................................................................... 60 
3.6.2(a) Motivational Interviewing Protocol ............................... 60 
3.6.2(b) Self-Administered Questionnaire .................................. 72 
3.6.2(c) Incidence of Early Childhood Caries ............................. 77 
3.7 
Operational Definition .................................................................................... 82 

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3.8 
Data Collection ............................................................................................... 83 
3.9 
Flow Chart of the Study ................................................................................. 89 
3.10 
Statistical Analysis ......................................................................................... 90 
3.11 
Ethical Consideration ..................................................................................... 90 
3.11.1 
Subject Vulnerability...................................................................... 90 
3.11.2 
Withdrawal Criteria ........................................................................ 91 
3.11.3 
Risk of Study .................................................................................. 91 
3.11.4 
Declaration of Absence of Conflict of Interest .............................. 92 
3.11.5 
Privacy and Confidentiality ............................................................ 92 
3.11.6 
Community Benefit ........................................................................ 92 
3.11.7 
Study funding ................................................................................. 93 
3.11.8 
Honorarium and Incentives ............................................................ 93 
CHAPTER 4 
EXPECTED RESULTS ............................................................... 94 
CHAPTER 5 
GANTT CHART ........................................................................ 121 
CHAPTER 6 
BUDGET PROPOSAL .............................................................. 122 
REFERENCES ....................................................................................................... 124 
APPENDICES 
 

v 
LIST OF TABLES 
Page 
Table 3.1 
Sample size for specific objective 1 ................................................... 53 
Table 3.2 
Sample size for specific objective 2 ................................................... 54 
Table 3.3 
ICDAS detection codes for coronal caries ......................................... 79 
Table 3.4 
The Silness-Loë index scoring ........................................................... 81 
Table 4.1 
Characteristics of mothers (n=228) .................................................... 94 
Table 4.2 
Knowledge of 6-9 months infant oral health care among mothers 
in the study group (n=228) ................................................................. 96 
Table 4.3 
Practice of 6-9 months infant oral health care among mothers in the 
study group (n=228) ........................................................................... 98 
Table 4.4 
Knowledge of 9-12 months infant oral health care among mothers 
in the study group (n=228) ................................................................. 99 
Table 4.5 
Practice of 9-12 months infant oral health care among mothers in 
the study group (n=228) ................................................................... 101 
Table 4.6 
Knowledge of 6-9 months infant oral health care among mothers 
in the control group (n=228) ............................................................ 102 
Table 4.7 
Practice of 6-9 months infant oral health care among mothers in the 
control group (n=228) ...................................................................... 104 
Table 4.8 
Knowledge of 9-12 months infant oral health care among mothers 
in the control group (n=228) ............................................................ 106 
Table 4.9 
Practice of 9-12 months infant oral health care among mothers in 
the control group (n=228) ................................................................ 108 
Table 4.10 
Knowledge and practice score on infant oral health care of mothers 
in the study group (n=228) ............................................................... 110 
Table 4.11 
Knowledge and practice score on infant oral health care of mothers 
in the control group (n=228) ............................................................ 111 

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Table 4.12 
Knowledge and practice score on infant oral health care between 
mothers in the study and control group (n=228) .............................. 112 
Table 4.13 
Early dental caries lesion of infants in study group (n=114) ........... 113 
Table 4.14 
Caries risk assessment of infants in the study group group (n=114)
 .......................................................................................................... 114 
Table 4.15 
Dental caries risk exposure of infants in the study group (n=114) .. 115 
Table 4.16 
Early dental caries lesion of infants in control group (n=114) ......... 116 
Table 4.17 
Caries risk assessment of infants in the control group (n=114) ....... 117 
Table 4.18 
Dental caries risk exposure of infants in the control group (n=114)
 .......................................................................................................... 118 
Table 4.19 
Early dental caries lesion between infants in the intervention and 
control group (n=114) ....................................................................... 119 
Table 4.20 
Dental caries risk exposure between infants in the intervention and 
control group (n=228) ...................................................................... 120 
Table 5.1 
Gantt chart for research project ........................................................ 121 
Table 6.1 
Budget for research project .............................................................. 122 
 

vii 
LIST OF FIGURES 
Page 
Figure 1.2 Conceptual Framework ............................................................................. 27 
Figure 3.1 Sampling method of the study .................................................................. 59 
Figure 3.2 Flow Chart of the Study ............................................................................ 89 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

viii 
LIST OF ABBREVIATIONS 
     
 
AAPD 
American Academy of Pediatrics Dentistry 
AG 
Anticipatory Guidance 
DT 
Dental Therapist 
ECC 
Early Childhood Caries 
HBM 
Health Belief Model 
MCHC 
Maternal and Child Health Clinic 
MI 
Motivational Interviewing 
MITI 
Motivational Interviewing Treatment Integrity 
MOH 
Ministry of Health  
NOHPS 
National Oral Health Survey of Preschool Children 
UMT 
Universiti Malaysia Terengganu 
WHO 
World Health Organization 

ix 
LIST OF APPENDICES 
 
 
Appendix A 
The Early Childhood Caries Charting form 
Appendix B 
Checklist for Infant Caries-risk Assessment 
Appendix C 
Motivational Interviewing (MI) Script from Harrison et al., 2011 
Appendix D 
Slides from Baby Teeth Talk Study 
Appendix E 
GCP Certificates 
Appendix F 
Email Correspondence Granting Permission from MITI 4.2.1 
Author (Dr. Denise Ernst)   
Appendix G 
Motivational Interviewing Treatment Integrity Coding Manual 
4.2.1   
Appendix H 
Questionnaires for baseline 1/ evaluation 1 from Mukhtar et al., 
2023 
Appendix I 
Questionnaires for baseline 2/ evaluation 2 from Mukhtar et al., 
2023 
 
 
 
 

10 
CHAPTER 1  
 
INTRODUCTION 
1.1 
Background of Study   
 
Early childhood caries (ECC) is defined as the presence of one or more decayed 
(noncavitated or cavitated lesions), missing or filled tooth surfaces (due to caries), in 
any primary teeth of a child under the age of 6 (Ministry of Health, 2012).  In children 
younger than 3 years old, any indication of smooth surface caries is classified as severe 
early childhood caries (S-ECC). S-ECC typically manifests suddenly, spreading 
extensively and swiftly, with a tendency to penetrate deep into the dental pulp in the 
primary teeth of young children. In the past, this condition was known by different 
names including rampant caries, nursing bottle caries, and baby bottle tooth decay 
(Ministry of Health, 2012).  
 
ECC has a profound adverse effect on the oral health related quality of life of 
children. Toothache, painful sensation in the teeth, difficulty in chewing, dissatisfaction 
with teeth, and trouble sleeping are the most common impacts reported by parents 
(Singh et al., 2020). A study by Zaror et al. (2022) explored the links between the 
negative impact on dental condition and orofacial function in young children with 
extensive carious lesions, particularly on children’s ability to chew and swallow. Oral 
pain, orthodontic problems such as malocclusion, enamel defects, and issues with eating 
and speaking can occur, as well as an increased risk for caries development in the 
permanent dentition, are among the long-term impacts of caries in children reported by 
Abanto et al. (2011).  
 

11 
The American Academy of Paediatric Dentistry (AAPD) acknowledges ECC as 
a significant, chronic condition that arises from an interplay of various factors over time 
(AAPD, 2017), and emphasizes the importance of anticipatory guidance (AG) in 
preventing ECC. AG refers to proactive, age-appropriate counselling that promotes 
health and prevents disease. In oral health, AG involves educating mothers and 
caregivers about effective oral health practices tailored to each stage of a child's 
development.   
 
AG focuses on instilling preventive measures early in life (AAPD, 2022). Key 
recommendations include reducing the consumption of sugary liquids and solid foods, 
avoid prolonged breastfeeding (more than 12 months) after the eruption of the first 
primary tooth and the introduction of dietary carbohydrates, discontinuing baby bottle 
use between 12 to 18 months of age, and initiating oral hygiene practices as early as 
possible (AAPD, 2017), toothbrushing assisted by parents twice daily using an 
appropriately sized soft toothbrush with a tiny amount of fluoridated toothpaste (smear 
or rice-sized) for children under three years old while a pea-sized amount for while 
those aged three and above. Furthermore, the AAPD recommends professionally 
applied fluoride varnish treatments for children at risk of ECC and establishing a dental 
home within six months of the first tooth's eruption, but no later than 12 months of age 
(AAPD, 2017).  
 
In Malaysia, the Ministry of Health (MOH) began providing oral healthcare 
services to infants and toddlers in 1991, starting with a pilot project in Sarawak aimed 
at addressing ECC through early intervention. In this project, dental nurses offered AG 
to parents and caregivers while also conducting brief oral examinations on toddlers at 
Maternal and Child Health Clinics (MCHCs). This successful program was later 

12 
adopted by other states and expanded as the Early Childhood Oral Health Programme 
in 2008 to include toddlers at childcare centres (Ministry of Health Malaysia, 2008).  
Besides focusing on captive groups of infants and toddlers who receive immunisations 
and check-ups at the MOH MCHCs, the Early Childhood Oral Health Programme also 
cover toddlers under the care of registered childcare centres and nurseries (Ministry of 
Health Malaysia, 2008).  
 
AG plays a crucial role in early childhood oral healthcare by empowering 
parents and caregivers with knowledge and skills to establish preventive practices. 
Provision of parental education on preventive practices using AG can decrease a child’s 
risks of developing ECC (AAPD, 2017). Delivering cost-effective sustained AG, which 
is periodic or continuous guidance or support provided by the health care workers or 
health care professionals, to the caretakers by education and technology will facilitate 
early diagnosis, improve oral hygiene practices, and initiate early intervention protocols 
that consequently can prevent ECC (Abirami et al., 2021). A study done in Johor, 
Malaysia showed that the provision of oral health knowledge using the AG technique 
in an intervention programme was effective in reducing ECC incidence among young 
children aged six and below, and improved mothers’ oral health literacy after 3 years of 
implementation (Ismail et al., 2018).  
 
Many health care conditions require behaviour change by the patient or parent 
to improve health outcomes. Poor outcomes may be attributed to the lack of adherence 
to the behaviour change recommendations. A shift from the authoritarian, expert 
providing advice to a more family-centred, collaborative model using motivational 
interviewing (MI) results in improved adherence (Gance-Cleveland, 2007) .  
 

13 
MI was introduced by William Miller in 1983 as a counselling method for 
promoting change in behaviour through collaboration and self-reflection (Miller & 
Rollnick, 2002). MI uses an empathic, collaborative style to elicit and build on clients’ 
own reasons for their behavioural change (Hall, 2017; Rollnick et al., 2008). MI was 
proven efficacious with a range of health-related behaviours, including substance abuse, 
diet and exercise, and medication adherence (Hettema et al., 2005; Miller & Rollnick, 
2023).  
 
MI is a client-centred approach designed to enhance intrinsic motivation for 
change by exploring, identifying, and resolving doubts and ambivalence (Miller & 
Rollnick, 2023). A key motivation behind this method is the compassionate desire by 
the motivational interviewer to promote well-being, prevent or alleviate suffering, and 
facilitate positive change in clients. This underlying motivation often draws 
interviewers to roles such as counsellors, educators, or coaches, who accompany people 
on their life journey (Miller & Rollnick, 2023). A study conducted during the COVID-
19 pandemic among mothers with young children aged nine to 24 months in India 
showed that providing AG via online MI improved the level of knowledge of mothers 
and caregivers in the prevention of ECC (Aravind et al., 2023). 
1.2 
Problem Statement  
Despite the implementation of AG through the Early Childhood Oral Health 
Programme for over 15 years, the prevalence of ECC in Malaysia remains high, with 
only a slight reduction in caries prevalence from 2005 to 2015 (Ministry of Health 
Malaysia, 2015). This is evidenced by data from the Malaysian National Oral Health 
Survey of Preschool Children (NOHPS) in 2015, which reported a caries prevalence of 
71.3% among 5-year-old children (Ministry of Health Malaysia, 2015). This figure falls 

14 
significantly short of the target set by the National Oral Health Plan (NOHP) 2011-
2020, which aimed for a 50.0% caries-free rate among 5-year-olds by 2020. Although 
there was a reduction in caries severity, measured by the mean number of decayed and 
filled teeth (dft) from 5.8 in 1995 to 5.5 in 2005 and later to 4.83 in 2015, only a 
reduction of 1.0 was noted over a span of 20 years (Ministry of Health Malaysia, 2015).  
 
Studies have shown that various barriers interfere with the practices of infant 
oral healthcare by parents. A study by Suprabha et al., (2021) showed that even though 
a vast majority of participants were aware of the significance of oral hygiene, they faced 
challenges in implementing proper home hygiene practices and lacked knowledge about 
the type of toothpaste and toothbrush to be used for their children (Suprabha et al., 
2021).  
Another study by Suprabha et al., (2023) showed that in children with ECC, 
infant feeding practices included prolonged breastfeeding or bottle-feeding beyond the 
required age, feeding at bedtime, and feeding sugary drinks. Although parents knew 
these feeding habits could increase the risk for caries, they lacked the self-efficacy to 
translate their knowledge into action during weaning and were unaware of infant oral 
hygiene practices (Suprabha et al., 2023).  
 
In the Child Health 2021-2030: A National Framework to Reduce the Under-5 
Mortality and Support Child Growth and Development by Child Health Sector Family 
Health Development Division, Ministry of Health Malaysia, it is highlighted that health 
education on dental care for children under five years has not been given sufficient 
emphasis. Results from the National Health Morbidity Survey 2016 survey (Institute 
for Public Health Ministry of Health Malaysia, 2016) showed that mothers’ knowledge 
on oral health was low. Among those who received advice from oral healthcare 

15 
practitioners, only 26.5% thought it was very important to look after their child’s oral 
health, indicating that receiving advice alone may not be sufficient to change maternal 
attitudes or increase the perceived importance of early oral healthcare (Institute for 
Public Health Ministry of Health Malaysia, 2016). Therefore, there is a need to 
strengthen the delivery of oral health education for mothers of infants in Malaysia 
(Ministry of Health Malaysia, 2021).  
1.3 
Justification of Study  
The early years of life are a critical period for shaping oral health behaviours, 
and educating parents or caregivers at this stage can significantly influence their child's 
future oral health (Sohl et al., 2016). By assessing potential risk factors such as feeding 
practices, oral hygiene habits, and family history of dental caries, healthcare providers 
can offer tailored recommendations to reduce the likelihood of ECC (AAPD, 2022). 
Early intervention is strongly recommended by the AAPD, which emphasizes that oral 
health promotion should begin as early as infancy to establish lifelong preventive habits 
(AAPD, 2022).  
 
In Malaysia, this responsibility for early oral health promotion is largely carried 
out by dental therapists. First introduced to the public dental workforce in 1948, these 
professionals, formerly known as dental nurses under the Dental Act 1971, offer limited 
dental care to children aged 17 and below under the supervision of dentists (Law of 
Malaysia Act 51, 2005). Their services include diagnosing, scaling and polishing, 
simple restorations, extracting deciduous teeth, applying fluoride varnishes, and placing 
fissure sealants. Beyond clinical procedures, dental therapists also deliver oral health 
education, offering AG to parents or caregivers at MCHCs, primary dental clinics, and 

16 
nurseries or kindergartens (Law of Malaysia Act 51, 2005). The Dental Act 2018 has 
extended their practice to private settings and raised the age limit for their services to 
18 years old. However, their dental tasks remain largely unchanged, encompassing oral 
health promotion, education, and instruction (Laws of Malaysia Act 804, 2018).   
 
Given their frontline role in preventive oral healthcare, there is a need for 
effective communication approaches that can enhance the delivery of health messages 
and foster behaviour change among parents. MI is a patient-centered consultation 
method that helps patients change their behaviors with maximum intrinsic motivation 
and minimum resistance (Miller & Rollnick, 2002). MI has been also successfully used 
in establishing preventive behaviors related to diseases such as diabetes, HIV infection, 
and AIDS (Rubak et al., 2005).  
 
In dentistry, Weinstein et al. (2004) were the first to apply this technique. Their 
study focused on comparing the effectiveness of MI with traditional counselling 
methods (such as video and pamphlet) in promoting preventive behaviours among 
mothers of infants at high risk of developing caries. This pioneering work demonstrated 
the potential of MI to foster better oral health habits and reduce the incidence of caries 
in high-risk populations (Weinstein et al., 2004). 
 
 
 MI is conducted in a collaborative style that supports the autonomy and self-
efficacy of the patient, using the patient’s own reasons for change. This approach 
increases the patient’s confidence and reduces defensiveness. MI keeps the 
responsibility for change with the patient and/or parent, which also help to decrease 

17 
staff burnout by reducing the pressure on healthcare providers (American Academy of 
Paediatric Dentistry, 2024).  
 
In dentistry, this MI skill is very useful in counseling on brushing, flossing, 
fluoride varnish, reducing sugar sweetened beverages, and smoking cessation. The use 
of open-ended questions, affirmations, reflective listening, and summarizing (OARS) 
forms the foundation of a patient-centered approach. This approach is especially useful 
when dealing with resistance, emotional distress, or long-standing behavioural patterns. 
By promoting collaboration and respect, MI empowers both staff and patients while 
deliberately steering away from adversarial or shaming interactions (American 
Academy of Paediatric Dentistry, 2024).  
 
MI is grounded in the establishment of dialogue and confidence between the 
patient and the instructing health professional. Conversations are guided to allow 
patients to define behavioral changes on their own accord, with a view to obtaining 
personal benefit (González-Del-Castillo-McGrath et al., 2014). Once patients identify 
their personal motivation for change, the instructor provides the information needed to 
achieve such change, based on a range of strategies selected by the patients and 
incorporated into their daily life, in accordance with the capacity of each individual 
(González-Del-Castillo-McGrath et al., 2014).  
 
Jamieson et al. (2018) conducted a study on the dental disease outcomes 
following a 2-year oral health promotion program for Australian aboriginal children and 
their families. This study included MI interventions for mothers during pregnancy and 
when children were aged six months, 12 months and 18 months, along with the 

18 
provision of dental care to mothers during pregnancy, application of fluoride varnish to 
the teeth of the children, and delivery of AG. Findings from this study showed that the 
mean number of decayed teeth in children aged two years was lower in the intervention 
group (0.62) than children in the control group (0.89).  
 
Jamieson et al. (2019) then conducted a secondary analysis of a randomized 
clinical trial to test the efficacy of similar interventions when participating children 
reached the age of five years. The study included 448 mother or caregiver–child dyads 
enrolled between February 2010 and May 2011. Participants were randomized into 
either the immediate intervention group or the delayed intervention group. The 
interventions, similar to those given in the previous study (Jamieson et al., 2018), 
included dental care to mothers during pregnancy, application of fluoride varnish to 
children’s teeth, MI for pregnant mothers, and AG in the form of oral health educational 
packages.  
 
Children in the immediate intervention group received these interventions at 
ages six months, 12 months, and 18 months, while those in the delayed intervention 
group received them at ages 24, 30, and 36 months. The mean number of decayed, 
missing or filled teeth (dmft) was 2.10 for the immediate intervention group and 2.91 
for the delayed intervention group. This finding indicates that children in the delayed 
intervention group had a mean of 1.0 more whole tooth that had experienced dental 
disease than children in the immediate intervention group. Hence, this trial found that a 
multifaceted initiative including MI to reduce ECC continued to be efficacious in 
participating indigenous children aged five years, especially those residing in 

19 
nonmetropolitan locations and with teeth missing because of dental disease (Jamieson 
et al., 2019). 
 
A study by Almugairin et al. (2025) revealed that while most mothers possessed 
moderate awareness of the harmful effects of prolonged oral habits, there remained a 
significant discrepancy between their knowledge and actual practices. This is evidenced 
by the results from the study that showed most mothers (92.9%) never consulted a 
dentist regarding their child’s ongoing oral habits. The study highlights the importance 
of educational programs aimed at enhancing parental knowledge, attitudes, and 
practices concerning children’s oral habits. It also underscores the need for improved 
dentist–parent communication about ongoing oral behaviours. Furthermore, tackling 
cultural beliefs and financial barriers may encourage greater use of dental services and 
lead to better oral health outcomes for children (Almugairin et al., 2025).  
By incorporating MI into educational programs, a systematic review and meta-
analysis by Colvara et al. (2021) demonstrated that MI can effectively modify 
knowledge and behaviours to reduce ECC, with a more significant impact on children 
with high caries experience. Additionally, another meta-analysis highlights the crucial 
role of MI in preventing ECC (Jahanshahi et al., 2022). The study concluded that the 
mere provision of information and oral care tools is inadequate; instead, MI promotes a 
deeper family-level understanding of oral health, resulting in more effective preventive 
practices (Jahanshahi et al., 2022).  
In addition, MI is effective across all age groups, including both infants and 
children. The quality of each session often has a greater impact than its frequency. To 
achieve lasting behavioural change, consistent follow-up and ongoing support are 

20 
essential (Jahanshahi et al., 2022). Integrating MI into oral health interventions can play 
a significant role in reducing early childhood caries (ECC), ultimately contributing to 
improved oral health outcomes at the community level (Jahanshahi et al., 2022). 
In light of the above findings, this study is well justified in exploring the use of 
MI to deliver AG to mothers of infants. This approach is essential for bridging the 
persistent gap between knowledge and practice, ensuring that mothers not only receive 
accurate information about infant oral healthcare but are also empowered with the 
motivation and confidence to apply appropriate oral health practices effectively. 
1.4 
Research Objectives   
1.4.1 
General Objectives  
To assess the effectiveness of MI in delivering AG to mothers of infants for the 
prevention of ECC in Terengganu. 
1.4.2 
Specific Objectives  
1) To determine the knowledge and practices regarding infant oral health care 
among mothers in the study group before (at six months) and after (at nine and 
12 months) receiving AG through MI. 
2) To determine the knowledge and practices regarding infant oral health care 
among mothers in the control group before (at six months) and after (at nine and 
12 months) receiving the conventional MOH AG. 
3) To compare the mean knowledge and practices score regarding infant oral health 
care among mothers in the study group before (at six months) and after (at nine 
and 12 months) receiving AG through MI. 

21 
4) To compare the mean knowledge and practices score regarding infant oral health 
care among mothers in the control group before (at six months) and after (at nine 
and 12 months) receiving the conventional MOH AG. 
5) To compare the mean knowledge and practice scores regarding infant oral health 
care between mothers in the study group after receiving AG through MI and 
mothers in the control group after receiving the conventional MOH AG.  
6) To compare the incidence of ECC and dental caries risk status among infants in 
the study group before (at six months) and after (at nine and 12 months) 
receiving AG through MI. 
7) To compare the incidence of ECC and dental caries risk status among infants in 
the control group before (at six months) and after (at nine and 12 months) 
receiving the conventional MOH AG. 
8) To compare the incidence of ECC and dental caries risk status between infants 
in the study group (mothers received AG through MI) and infants in the control 
group (mothers received the conventional MOH AG). 
 
1.4.3 
Research Questions  
 
1) What is the proportion of mothers in the study group with correct knowledge 
and practice regarding infant oral health care before and after receiving AG 
through MI.  
2) What is the proportion of mothers in the control group with correct knowledge 
and practice regarding infant oral health care before and after receiving the 
conventional MOH AG.  

22 
3) What is the difference in knowledge and practice score regarding infant oral 
health care among mothers in the study group before (at six months) and after 
(at nine and 12 months) receiving AG through MI.  
4) What is the difference in knowledge and practice score regarding infant oral 
health care among mothers in the control group before (at six months) and after 
(at nine and 12 months) receiving the conventional MOH AG.  
5) What is the difference in mean knowledge and practice scores regarding infant 
oral health care between mothers in the study group after receiving AG through 
MI and mothers in the control group after receiving the conventional MOH AG.  
6) What is the difference in incidence of ECC and dental caries risk status among 
infants in the study group before (at six months) and after (at nine and 12 
months) receiving AG through MI.  
7) What is the difference in incidence of ECC and dental caries risk status among 
infants in the control group before (at six months) and after (at nine and 12 
months) receiving the conventional MOH AG.  
8) What is the difference in incidence of ECC and dental caries risk status between 
infants in the study group (mothers received AG through MI) and infants in the 
control group (mothers received the conventional MOH AG). 
1.4.4 
Research Hypothesis   
1) The proportions of mothers in the study group with correct knowledge and 
practice regarding infant oral health care are significantly higher after receiving 
AG through MI. 
2) The proportions of mothers in the control group with correct knowledge and 
practice regarding infant oral health care are significantly higher after receiving 
the conventional MOH AG. 

23 
3) There is a significant difference in the mean knowledge and practice scores 
regarding infant oral health care among mothers in the study group before (at 
six months) and after (at nine and 12 months) receiving AG through MI. 
4) There is a significant difference in the mean knowledge and practice scores 
regarding infant oral health care among mothers in the control group before (at 
six months) and after (at nine and 12 months) receiving the conventional MOH 
AG. 
5) The mean knowledge and practice scores regarding infant oral health care 
among mothers in the study group after receiving AG through MI are 
significantly higher compared to those in the control group after receiving the 
conventional MOH AG. 
6) There is a significant difference in the incidence of ECC and dental caries risk 
status among infants in the study group before (at six months) and after (at nine 
and 12 months) receiving AG through MI. 
7) There is a significant difference in the incidence of ECC and dental caries risk 
status among infants in the control group before (at six months) and after (at 
nine and 12 months) receiving the conventional MOH AG. 
8) The incidence of ECC and the proportion of dental caries risk status among 
infants in the study group (whose mothers received AG through MI) is 
significantly lower compared to infants in the control group (whose mothers 
received the conventional MOH AG). 
1.5 
Conceptual Framework  
 
This conceptual framework is adapted from Akhtari-Zavare et al. (2016) and is 
structured around the Health Belief Model (HBM). It illustrates the dynamic interaction 

24 
between individual factors, modifying factors, and outcomes related to mothers’ 
practices in infant oral healthcare. The HBM is a psychological model developed to 
explain and predict health behaviors by focusing on the beliefs and attitudes of 
individuals. It posits that a person’s engagement in health-promoting behavior is 
influenced by their perception of susceptibility to a condition, the perceived severity of 
that condition, perceived benefits of taking preventive action, and perceived barriers to 
taking that action, cues to action and self-efficacy that are considered key components 
that trigger and sustain health behaviors (Alyafei & Easton-Carr, 2024).  
Perceived susceptibility component assesses the probability of acquiring an 
illness or encountering an undesirable outcome while perceived severity means 
understanding the severity of the illness, condition, or unfavourable outcome and what 
could happen if no additional action is taken (Alyafei & Easton-Carr, 2024). Perceived 
benefit means the effectiveness of various available actions to reduce the risk of illness 
are perceived while perceived barriers mean obstacles to performing a recommended 
health action that may stop one from doing what is recommended.  
Self-efficacy component means an individual's belief in their capacity to 
perform a specific behavior or task effectively and the likelihood of a person engaging 
in a desired behavior. Cues to action, whether from one's surroundings or subjective 
experiences means the specific cues that can influence the actions one chooses to take 
or the stimuli that initiate the decision-making process to embrace a recommended 
health intervention (Alyafei & Easton-Carr, 2024).  
In this study, the framework begins with sociodemographic factors, such as age, 
education, income, working status, and past exposure to oral health education, that can 
influence mothers' responses to the oral healthcare intervention as well as influence their 

25 
knowledge on infants’ oral health. The association of ECC with the socioeconomic 
status (SES) has been well studied and documented (Jahanshahi et al., 2022). Studies 
showed that ECC is commonly found in children below the poverty line or with poor 
economic status, ethnic and racial minorities and children with single mothers, whose 
parents (especially mothers) have low educational level (Jahanshahi et al., 2022).  
Meanwhile, the MI serves as a structured approach to improve mothers’ 
knowledge regarding infants’ oral health. A study by Aravind et al., (2023) showed that 
MI provides a better tool for increasing the level of knowledge of mothers and 
caregivers and provides the structural way of AG and self-motivating them to start 
practicing various steps to prevent ECC.  
Towards the acceptance of new behaviour, adoption through a process based on 
knowledge will be longer-lasting than behaviour that is not based on knowledge 
(Parwati et al., 2021). Oral health-related knowledge is widely acknowledged as being 
associated with both adult and child oral health behaviours and outcomes (De Silva-
Sanigorski et al., 2013), indicating that improvements in knowledge may translate into 
long-term behaviour change that supports oral health. Therefore, this framework 
incorporates knowledge of mothers on infant oral health as fundamental component in 
shaping their practices toward their infant oral health. 
Hence, all the three factors which are, the sociodemographic factors, the MI, 
and the knowledge in infants’ oral health will further influence the factors at the core of 
this framework which consists of the HBM components. The first HBM component 
which is perceived susceptibility, where mothers recognize their infant’s risk of 
developing ECC (Liu et al., 2024). Next component is perceived seriousness, where 
they acknowledge the short term or long-term consequences of ECC, such as pain, 

26 
infection, and the need for future dental treatments. These perceptions serve as 
motivators for caregivers to take preventive actions towards ECC (Liu et al., 2024).  
Then, perceived benefits of practicing infants’ oral healthcare, such as improved 
oral health outcomes by reducing the caries lesions and reducing the caries risk exposure 
(Daly et al., 2016) while perceived barriers may include factors such as financial 
constraints, time limitations, or lack of knowledge among the caregivers (Lieneck et al., 
2023). Overcoming these barriers is essential in encouraging behaviour change 
(Lieneck et al., 2023).  
Next component is cues to action, particularly through MI interventions topic, 
that play a crucial role in triggering behavioural changes by enhancing awareness and 
promoting self-motivation. For example, these interventions can act as key triggers that 
prompt mothers to recognize the importance of early oral health care and take 
immediate steps toward adopting positive behaviours (Sidor & Dubin, 2025).  
Another component of this framework is self-efficacy, which refers to the 
confidence of mothers in effectively implementing infants’ oral healthcare practices 
(Finlayson et al., 2007). MI enhances self-efficacy by addressing ambivalence, 
strengthening motivation, and empowering mothers with the knowledge needed to 
establish good oral health routines for their infants (Jiang et al., 2020). 
This, in turn, leads to practicing the infants’ oral healthcare and ultimately 
improving oral health outcomes, including reduced prevalence of early dental caries 
lesions and lower exposure to dental caries risk factors. This is proven by studies, which 
showed that mothers’ behaviours play a key role in a child’s life, including regular 
dental care (Azevedo et al., 2015; Isong et al., 2012).  

27 
 
 
 
Figure 1.1 Conceptual Framework 

28 
CHAPTER 2  
 
LITERATURE REVIEW 
2.1 
Prevention of Early Childhood Caries  
 
The prevention of ECC requires a multi-level approach, emphasizing primary, 
secondary, and tertiary prevention. Early preventive strategies should begin as soon as 
possible, ideally before the eruption of the first primary tooth. Primary prevention plays 
a fundamental role in reducing ECC prevalence by promoting healthy behaviours, 
ensuring proper oral hygiene, and encouraging the use of fluoride. Effective preventive 
measures include early toothbrushing with fluoride toothpaste and addressing socio-
behavioural risk factors such as feeding practices, caregiver awareness, and access to 
dental care. The integration of ECC prevention into existing primary healthcare 
programs, especially within maternal and child health services, is essential (World 
Health Organization, 2017).  
 
Health promotion campaigns should target pregnant women, new mothers, and 
primary caregivers, reinforcing WHO guidelines on exclusive breastfeeding for the first 
six months, avoiding added sugars in complementary feeding up to two years of age, 
and maintaining limited free sugar intake beyond this period (World Health 
Organization, 2017). Caregivers should receive hands-on training on proper 
toothbrushing techniques, including the appropriate use of fluoride toothpaste, from the 
eruption of the first primary tooth. Additionally, early detection of carious lesions 
should be incorporated into routine child health assessments, such as during vaccination 
appointments and scheduled primary care visits (World Health Organization, 2017).  

29 
There is a growing recognition of the significance associated with the early 
detection and diagnosis of carious lesions to prevent their progression into irreversible 
cavitation. Many dental professionals encounter challenges when determining the 
appropriate timing for implementing preventive measures versus intervening in dental 
procedures (Al Saffan, 2023). The importances of early detection of enamel lesions 
include increasing the chance of detecting non-cavitated lesions which allows more 
possibility for non-invasive and micro-invasive treatments to be effective and the 
possibility of monitoring the lesion progression after providing non-invasive and micro-
invasive measures (Mohamed Nur et al., 2023). 
 
 
The successful management of ECC also relies on adequate training for all 
healthcare professionals involved in early childhood healthcare. Othan dental 
professional, the ECC prevention should be embedded within the training curricula of 
medical, and allied health professionals to ensure comprehensive knowledge and skill 
development. Furthermore, public health policies should facilitate access to affordable 
and effective fluoride toothpaste, promote a diet free from added sugars, foster a healthy 
living environment, and encourage community-based fluoride administration.  
 
Secondary prevention focuses on the early detection of carious lesions before 
they progress into more severe forms (World Health Organization, 2017). Establishing 
clear diagnostic criteria for ECC and severe ECC is necessary to enhance early 
recognition. Training should extend beyond dental personnel to include general 
healthcare workers and caregivers, equipping them with the skills to identify early signs 
of tooth decay (World Health Organization, 2017).  
 

30 
However, a study by Blanchet et al. (2023) highlighted a gap in knowledge 
regarding ECC risk factors. While many oral hygiene measures were well understood, 
only about half of the dietary risk factors were recognized. The study also found that 
although healthcare providers frequently examined children’s teeth, carious lesions 
were correctly identified in only half of the cases. Furthermore, a lack of awareness 
regarding the recommended age for a child’s first dental visit was identified as a barrier 
to early intervention, with many children being referred to a dentist only when 
symptoms, such as pain, became evident (Blanchet et al., 2023).  
 
Caries Risk Assessment (CRA) has emerged as a crucial tool in preventing 
dental caries. By systematically evaluating a patient's risk factors, dental professionals 
can tailor prevention strategies to individual needs.  In particular, it aids clinicians in 
planning appropriate treatment modalities and implementing preventive measures 
tailored to individual risk profiles, ultimately contributing to improved clinical 
outcomes. Its widespread application in diverse dental care settings highlights its 
significance in guiding patient-centred care (Santhosh et al., 2019). 
 
Caries risk is shaped by the complex interaction between risk and protective 
factors (Ng et al., 2024). Common risk factors include inadequate oral hygiene, past 
caries experience, a high-sugar diet, low plaque pH, enamel defects, reduced salivary 
flow, and a history of radiotherapy. Fortunately, various preventive strategies such as 
fluoride use, gum chewing, and application of dental sealants can help mitigate caries 
risk (Ng et al., 2024).  
 
There are several well-recognized CRA tools used in dental practice to evaluate 
a patient's risk of developing dental caries. These include Caries Management by Risk 

31 
Assessment (CAMBRA), the American Dental Association (ADA) CRA forms, 
Cariogram, and the AAPD CRA forms that are designed for pediatric age groups: one 
for children aged five years and below, while another one is for those aged six and 
above. These tools consider a range of social, behavioural, general health conditions, as 
well as clinical conditions that include both risk and protective factors (Ng et al., 2024). 
These factors include frequent snacking, use of hypo-salivary medications, visible 
plaque, fluoride exposure, and presence of active carious lesions (American Academy 
of Pediatric Dentistry, 2022).  
 
Given the global burden of ECC, the integration of CRA into paediatric dental 
care is more critical than ever. CRA enables clinicians to identify children at high risk 
and apply preventive strategies early, improving treatment outcomes (Ramos-Gomez et 
al., 2010). A study conducted in the United States utilizing CAMBRA for paediatric 
patients, combined with conventional restorative care and chemical therapy 
(antibacterials and fluoride), resulted in a 20%–38% reduction in caries progression 
among high-risk children (Featherstone & Chaffee, 2018). This finding underscores the 
importance of CRA in guiding evidence-based, preventive-focused oral healthcare for 
the paediatric population. 
 
2.2 
Anticipatory Guidance in Early Childhood Oral Healthcare and Early 
Childhood Caries Prevention 
AG is a proactive approach in early childhood oral healthcare. It involves 
providing practical, age-appropriate advice and information to parents and caregivers 
about what to expect in their child's development and how to handle common issues or 
oral problems such as ECC before they develop. This guidance includes dietary advice 

32 
to encourage healthy eating habits and reduce sugar intake, teaching proper brushing 
and flossing techniques, emphasizing the importance of early and regular dental check-
ups, advising on the use of fluoride toothpaste and treatments, and addressing habits 
like bottle-feeding at bedtime and frequent snacking (AAPD, 2017). By tailoring this 
information to the needs and preferences of parents, using clear and simple language, 
and providing visual aids, AG can be an effective tool in preventing ECC (Abirami et 
al., 2021).  
 
The strength of AG lies in interpersonal dynamics. Traditional disease-based 
preventive programs are often unidirectional, with professionals providing information 
to the consumer (Nowak & Casamassimo, 1995). AG fosters interaction by requiring 
clinicians to seek information about a child's development from the parent and by 
directing clinicians to develop individualized plans or strategies. Motivating parents is 
relatively easy because they are eager to talk about their children. In addition, it is more 
effective for dentists to illustrate important concepts of dental health to parents when 
their own child serves as the model (Nowak & Casamassimo, 1995).  
 
It was found that when parents are shown the anatomical landmarks in their 
child's mouth dental concepts are explained, telephone consultations become easier, 
unnecessary office visits are avoided, and the management of traumatic injuries is 
improved (Nowak & Casamassimo, 1995). AG addresses a long-standing motivational 
issue encountered in traditional disease-based programs: the repetition of simplistic 
messages. The message conveyed in AG changes or evolves as the patient grows 
(Nowak & Casamassimo, 1995).  
 

33 
 In a scoping review by Alshammari et al. (2022) on AG’s role in preventing 
dental caries, four randomized controlled trials found that the proportion of children 
with dental caries was lower in the intervention group compared with children from the 
control group (Ismail et al., 2018; Jamieson et al., 2018; Plutzer & Spencer, 2008; 
Wagner & Heinrich-Weltzien, 2016). 
 
Besides reducing the risk of caries, AG can also include advice to minimize the 
risk for other common oral health problems in children such as malocclusion due to oral 
habits like nonnutritive sucking (e.g., digital and pacifier habits), bruxism, tongue thrust 
swallow, and abnormal tongue position (AAPD, 2022). Although early use of pacifiers 
and digit sucking are considered normal, pacifier use beyond 18 months can influence 
the developing orofacial complex (AAPD, 2024b). Children with nonnutritive sucking 
habits beyond age three have a higher incidence of malocclusions (AAPD, 2024a, 
2024b). Early dental visits provide an opportunity to counsel parents to help their 
children stop sucking habits before malocclusion or skeletal dysplasia’s occur (AAPD, 
2024a, 2024b). 
 
2.3 
Barriers among Parents/ Caregivers in Early Childhood Oral Healthcare  
A study by Poirier et al. (2021) was conducted to develop an understanding of 
the current barriers impeding parental efforts to establish oral health practices among 
indigenous children in Australia. The study utilized a qualitative design, employing an 
MI approach. Among the barriers among the parents discussed were knowledge factors, 
which are critical to ensuring strong oral health practices for their children. Many 
individuals expressed a desire for more education or knowledge in specific areas. 
Limited nutrition knowledge was a prominent theme across all interviews and 

34 
participants, besides concerning topics such as when children should have their first 
dental visit, when to start using a toothbrush, and how much toothpaste is safe for 
children (Poirier et al., 2021).  
 
As a result from limited oral health knowledge, poor parental oral health 
practices, were also discussed as a barrier to establishing child oral health. Parents 
identified themselves as a negative influence on their children's sugar consumption, 
admitting that their own addiction to sugar made it difficult to justify limiting their 
children’s intake (Poirier et al., 2021).  
 
Parents in Australia also encountered challenges prioritising their child’s needs 
and parenting goals. For example, time constraints, especially in the morning, led to 
oral health being considered a lower priority and resulted in toothbrushing not being 
done (Walsh et al., 2025). Parents’ views on the importance of primary teeth influenced 
the oral care they provided. When some parents felt less motivated to establish strict 
oral health routines, believing that primary teeth, being temporary, did not require the 
same level of care as permanent teeth, this perception often led to less active 
engagement with oral health care as the temporary nature of primary teeth reduced the 
perceived urgency (Walsh et al., 2025).  
 
Sullivan et al. (2022) highlighted in a systematic review that many caregivers 
lack the necessary knowledge and skills to promote good oral health practices in young 
children, leading to an increased risk of tooth decay and other oral health problems. 
Besides, the maternal behaviour such as lack of persistence with toothbrushing for the 

35 
children and giving in to the children’s demands for sweet snacks as the barriers that 
can lead to ECC (Kim Seow, 2012).  
 
While a study by Bakhurji et al. (2021) in Saudi Arabia among the dental 
practitioners stated that barriers interfering with performing AG mainly due to parents 
bring their children for the first time to a dentist only for emergency management or to 
address existing conditions. This suggests a lack of parental awareness or prioritization 
of routine dental visits which can contribute to delayed care and higher risk of ECC. 
 
Findings from the National Health and Morbidity Survey (NHMS) 2016 in 
Malaysia revealed several key barriers among parents and caregivers in early childhood 
oral healthcare. A major barrier is the low perceived importance of oral health, as only 
one in four mothers considered it very important to care for their child’s teeth. This is 
compounded by inconsistent oral hygiene practices, with a significant number of 
mothers not brushing or supervising their child’s toothbrushing daily. Lack of 
awareness is also evident, as only about four in ten mothers knew that a child’s first 
dental visit should occur before the age of two behaviour (Institute for Public Health 
Ministry of Health Malaysia, 2016). 
 
Furthermore, most mothers had never taken their child for a dental visit, and 
even among those who were advised to do so, many believed their child was too young 
for treatment. Importantly, even among mothers who valued oral health, few translated 
that belief into action, indicating a gap between awareness and behaviour (Institute for 
Public Health Ministry of Health Malaysia, 2016). 
 

36 
A study conducted in Qatar by Al-Jaber et al. (2022) identified key areas where 
parental knowledge required improvement. These included understanding the 
appropriate amount of toothpaste for brushing and recognizing early signs of tooth 
demineralization. The most commonly incorrect responses were related to the correct 
amount of toothpaste for brushing (67%) and the recognition that white lines or white 
spots on teeth indicate early signs of tooth decay (52%) (Al-Jaber et al., 2022). Hence, 
the study reveals substantial gaps in parental knowledge of early childhood oral health, 
especially concerning the appropriate amount of toothpaste and the early indicators of 
tooth decay. 
2.4 
Methods of Delivering Motivational Interviewing 
Studies have explored different delivery formats of MI. In a study by Weinstein 
et al., 2004), it delivered MI face-to-face to mothers of infants, with each subject 
received a pamphlet and viewed an 11-minute educational video. The MI session was 
conducted in 45 min, followed up with six telephone calls and two postal cards. This 
study reported significant reductions in ECC incidence over one year. Two years later, 
Weinstein et al. (2006) provide additional evidence of the efficacy of MI with mothers 
of young children after two years of follow-up, with enhanced preventive behaviour of 
mothers of young children at high risk of developing caries. 
A systematic review by Colvara et al. (2021) stated that few studies include MI 
intervention with telephone calls as reminders or follow ups to MI face to face sessions 
such as study by Freudenthal & Bowen (2010)  that used individualized MI intervention 
for one session around 20 to 30 minutes, with two telephone calls, whereas a study by 
Mohammadi et al. (2015) include one session of MI for 45 minutes, with six telephone 

37 
calls and two postal cards, while Riedy et al. (2015) include two telephone calls after 
prenatal phase and one telephone call after postpartum phase. Nevertheless, a study by 
Harrison et al. (2011) only included one to seven sessions without any telephone calls.  
Group-based MI are also common as reported by Naidu et al. (2015). reported 
that group MI sessions for parents in a group when delivering oral health information 
had a positive effect on parent/ caregivers’ oral health knowledge, attitudes and 
behaviours compared to traditional DHE (Naidu et al., 2015). Besides, study by 
Makvandi et al. (2015) was done with the first two sessions were a combination of 
interactive lecture and discussion using MI and in the last session, mothers discussed 
about how to overcome potential barriers of cleaning the children's teeth using MI 
approach. 
Gillam & Yusuf (2019) in their literature review on brief MI in dental practice 
showed that skills and methods used to communicate effectively with patients are by 
using OARS which are open-ended questions, affirmations, reflective listening and 
summarizing. A flexible approach must be utilized, partly due to different patients being 
at different levels of readiness. It also highlighted that MI involves four processes which 
are engaging, focusing, evoking, planning, review and guiding, which supports the 
patient towards a positive behaviour change. This review had provided an overview on 
the topic for dental professionals as well as helpful suggestions for supporting a positive 
behaviour change in their dental practices (Gillam & Yusuf, 2019). 
Weinstein et al. (2004) applied MI with mothers of infants and showed that 
building rapport and engagement early in the session was critical to encouraging parents 
to openly discuss their challenges in maintaining oral health routines. Harrison et al. 
(2010, 2011) further operationalized these steps by developing structured MI scripts for 

38 
use with pregnant women and new mothers, which guided practitioners in focusing 
discussions on feeding and brushing practices while evoking mothers’ own motivations 
for change.  
A scoping review done by Seven et al. (2023) on MI interventions aiming to 
improve health behaviours among cancer survivors. It showed that most studies in the 
review used principles of MI such as empathy expression, developing discrepancy, roll 
with resistance, and supporting self-efficacy to improve health behaviours among 
cancer survivors (Seven et al., 2023).  
 
A randomized trial evaluated the effectiveness of a tailored educational 
intervention on oral health behaviours and new untreated carious lesions in low-income 
African- American children in Detroit, Michigan (Ismail et al., 2011). An interviewer 
who was trained in applying MI principles reviewed the dental examination findings 
with caregivers assigned to the intervention group and engaged the caregiver in a 
dialogue on the importance of and potential actions for improving the child’s oral 
health. This study found that a single MI intervention had some reported positive oral 
health behaviours (Ismail et al., 2011). 
2.5 
Motivational Interviewing as a Behavioral Change Strategy 
MI is a collaborative, goal-oriented style of communication designed to 
strengthen personal motivation and commitment to a specific goal by eliciting and 
exploring the person's own reasons for change within an atmosphere of acceptance and 
compassion. The goal of MI is to focus on the 'why' to change health behaviour rather 
than the 'how', and to utilize internal motivation instead of persuasion. This is the reason 
why MI has become a widely accepted evidence-based approach (Pócs et al., 2017).  

39 
MI focuses on the client stating what motivates him/her, whereas in persuasion 
counselling the client is passive and the focus is on the doctor's reasoning (Griffith, 
2008). Another advantage of client involvement is that autonomously motivated 
behaviour change is more durable than forced change (Sohl et al., 2016). However, it is 
not advisable to give full control to the client. The communication style of MI is based 
on building cooperation (guiding style), as opposed to when the doctor leads the 
conversation (directing style) or the client (following style). The controlling style used 
in persuasion counselling creates resistance and hinders the client's behaviour change 
(Dillard & Shen, 2005).  
Discussion about change occurs in almost every branch of medicine and goes 
beyond the “big four” lifestyle habits which are smoking, excessive drinking, lack of 
exercise, and unhealthy diet, besides the use of aids, devices, or medicines. Patients 
often seem ambivalent or unmotivated, and clinicians typically try to advise them to 
change, using a directing style, which in turn generates resistance or passivity in the 
patient. Therefore, MI is an alternative approach to discussing behaviour change that 
fosters a constructive doctor-patient relationship and leads to better outcomes for 
patients (Miller & Rollnick, 2002).  
MI is defined as a person-centred method of guiding to elicit and strengthen 
personal motivation for change. Its core clinical strategies include reflective listening 
and eliciting change talk (Resnicow & McMaster, 2012). MI encourages individuals to 
work through their ambivalence about behaviour change and to explore the discrepancy 
between their current behaviour and broader life goals and values (Resnicow & 
McMaster, 2012).  

40 
2.6 
Motivational Interviewing Principles  
Miller & Rollnick (2013) stated that the change process is difficult as human 
being naturally stay at their comfort zone. However, change sometimes cannot be 
avoidable. Whether they have to adapt themselves into new changes or are the one who 
decided to make the change. This situation put the client in the middle of intersection, 
whether to make change or do not make a change. This is ambivalence (Hall, 2017). 
There are many ways of addressing ambivalence and one of the example is by saying 
this to the client; “Being a parent is a tough role for you and having a new baby is 
another situation requiring you to make certain decisions even though you are not sure 
about it”. This type of statement acknowledges the parent’s mixed feelings while 
normalizing that uncertainty is a natural part of the change process.  
To effectively address ambivalence and guide parents through change, MI is 
built upon several core principles that provide a structured foundation for 
communication and behaviour change. These principles are often summarized by the 
acronym DARES, which stands for developing discrepancy, avoiding argumentation, 
rolling with resistance, expressing empathy, and supporting self-efficacy. 
 The principle of developing discrepancy involves helping clients to recognize 
the inconsistencies between their personal goals and values and their current harmful 
behaviours (Pócs et al., 2017). For example, when discussing night-time bottle feeding, 
the dentist can use developing discrepancy by saying, “You want your baby to have 
strong teeth, but you’re also worried that the bottle at night might cause damage.” This 
helps the mother see the gap between her goals and current behaviour. 

41 
Meanwhile the principle of avoiding argumentation is where practitioners are 
encouraged to lead the conversation in such a way that clients themselves generate 
arguments for change rather than being confronted directly (Pócs et al., 2017). Instead 
of arguing, the dentist applies avoiding argumentation by asking, “What do you think 
are the good and not-so-good things about continuing this habit?” This allows the 
mother to give her own reasons for change. 
Closely related is the principle of rolling with resistance, which emphasizes 
respecting client autonomy, reducing defensiveness, and reinforcing the idea that the 
conversation is centred on the client’s own choices (Pócs et al., 2017). If the mother 
becomes defensive, the dentist shows rolling with resistance by responding, “It sounds 
like the bottle really helps you settle your baby, and that’s important for you.” This 
respects her feelings without creating conflict. 
The principle of expressing empathy highlights the importance of genuinely 
understanding and reflecting the client’s feelings, experiences, and perspectives to build 
trust and rapport (Pócs et al., 2017). The dentist also uses expressing empathy, for 
example, “You must be very tired at night, and brushing can feel like an extra burden.” 
This helps build trust and understanding. 
Finally, supporting self-efficacy stresses that belief both from the client and the 
practitioner in the client’s capacity to change is a crucial factor in promoting and 
sustaining behaviour change (Pócs et al., 2017). The dentist supports self-efficacy by 
highlighting her strengths: You’ve already succeeded in stopping the use of a bottle 
during your infant’s sleep, which shows that you are capable of making changes to 
protect your baby’s teeth.” By acknowledging small but meaningful successes, the 

42 
dentist helps build the mother’s confidence to take further steps toward sustaining 
healthier practices. 
2.7 
Motivational Interviewing Tools 
MI employs a variety of practical tools to facilitate conversations about change 
and to strengthen a client’s motivation. One widely used tool is decisional balance, 
which helps clients explore both the advantages and disadvantages of changing a 
behaviour compared to maintaining the status quo (Griffith, 2008). This tool is 
particularly useful during the focusing and evoking stages, especially when clients feel 
ambivalent. For instance, a dentist may ask a mother to consider about continuing the 
bottle at night, by increasing awareness of the risks and highlight the benefits of making 
a change. 
Another commonly used approach is the readiness ruler (or change ruler 
technique), which invites clients to rate on a scale from 0 to 10 how important, ready, 
and confident they feel about making a change (Pócs et al., 2017). This simple scaling 
method allows for self-assessment, provides a starting point for further discussion, and 
can track motivation or progress over time. For example, if a mother reports being “6” 
on readiness to start brushing her baby’s teeth nightly, the practitioner can follow up by 
asking why she chose 6 instead of 4, or what might help her move closer to 8, subtly 
evoking change talk and encouraging reflection. 
When motivation appears low, the tool of asking about extremes can be 
particularly effective. This involves encouraging clients to imagine the worst possible 
consequences of not changing, as well as the best possible outcomes of making a change  
(Miller & Rollnick, 2002). For example, a dentist might ask a mother, “If you continue 

43 
giving the bottle at night, what do you think might happen to your baby’s teeth in the 
future?” Then the dentist could follow with, “And if you were successful in stopping 
night feeding, what would be the best outcome for your child’s oral health?” 
Finally, MI practitioners often explore past successes to strengthen a client’s 
confidence and self-efficacy (Miller & Rollnick, 2002). For instance, the dentist might 
say, “Can you think of a time when you changed a habit for your baby’s health, like 
adjusting feeding or visiting the clinic regularly? How did you manage that?” By 
recalling her past achievements, the mother is reminded of her own ability to make 
positive changes, which increases her confidence to succeed in the current situation. 
The MI tools described namely the decisional balance, readiness ruler, exploring 
extremes, and recalling past successes will be systematically incorporated into the MI 
protocol to guide the delivery of anticipatory guidance during each intervention session. 
These tools are not stand-alone techniques but are embedded within the focusing and 
evoking processes of MI to support mothers in exploring ambivalence, strengthening 
intrinsic motivation, and enhancing confidence toward oral health–related behaviour 
change. Thus, these tools are integrated as part of the structured MI framework in the 
intervention sessions, consistent with MI principles and stages of change. 
2.8 
Motivational Interviewing in Medical Care Settings 
MI is a shared decision-making strategy for enhancing a patient’s motivation to 
make a behaviour change (Schwartz, 2002). For example, in weight, tobacco, or safety 
counselling, it is a particularly helpful method in addressing resistance to change 
because it helps the healthcare professional to create an alliance with the patient 
irrespective of his or her willingness to make a change. Therefore, these MI methods 

44 
are effective in providing many types of AG in healthcare where a change is needed 
(Schwartz, 2002). 
A randomized controlled trial was done to examine the effects of a MI 
intervention aimed at improving whole-person lifestyle and reducing cardiovascular 
disease risk profile (Sawyer et al., 2020). In the intervention group, the proportion of 
high wellness scores increased after the program. A whole-person lifestyle intervention 
incorporating MI for patients with metabolic syndrome can improve health by 
improving components of the cardiovascular disease risk profile and overall wellness. 
Efforts to improve the health of these patients may include MI to guide goal setting and 
address mental and spiritual health in addition to physical health (Sawyer et al., 2020). 
 
A meta-analyses study revealed statistically significant mean intervention 
effects of MI in medical care with respect to a variety of health-relevant behaviour, in 
comparison to standard treatment and no treatment in the control groups (Bischof et al., 
2020). Statistically significant effect sizes were reported for substance consumption, 
physical activity, body weight, treatment adherence, and willingness to change 
behaviour. Studies of the factors that contribute to the efficacy of MI suggest that it 
exerts its effects largely through the selective reinforcement of statements made by the 
patients themselves about potential changes in their behaviour (Bischof et al., 2020).  
 
The central implication of study by Lundahl et al. (2013) is that MI can 
profitably be delivered by a range of professionals with a minimum investment of time 
in medical care settings in a variety of formats and time frames for patients of different 
ages, genders, and ethnicities. The review suggests medical providers can use MI to 
help patients exercise more, lose weight, lower HIV viral load, blood pressure and 

45 
cholesterol, reduce problematic substance use (perhaps even more effectively than in 
non-medical settings), and boost self-efficacy in their ability to make health-related 
behavioural changes (Lundahl et al., 2013). 
 
A study by Almansour et al. (2023) concluded that lifestyle change is often a 
gradual process involving multiple efforts and setbacks. MI works on the basis the idea 
that change is a process, not an event. This interdisciplinary, whole-system approach 
helps address the known issue of uncertainty regarding change. MI serves people to 
achieve sustainable lifestyle changes and helps avoid the threat of non-communicable 
diseases with the roles of MI practitioners that are critical in obtaining satisfactory 
outcomes. Thus, expert practitioners are expected to commit time and effort, and to be 
interested in increasing skills and gaining methodological knowledge of this 
interdisciplinary approach (Almansour et al., 2023). 
2.9 
Motivational Interviewing in Oral Health Care Settings 
Traditionally, chairside patient education has focused on clinicians exerting 
their expertise on patients. When patients fail to comply, clinicians may feel frustrated, 
potentially leading to 'victim blaming' the patient. Patient-centred methods, such as MI, 
provide a collaborative approach to behaviour change in a safe, non-judgmental, and 
supportive environment. This approach empowers patients to take control of their 
behaviours, increasing the likelihood of successful behaviour change (Gillam & Yusuf, 
2019). This is particularly relevant to dental practice, where patients are seen regularly 
to maintain their oral health or receive dental treatment over repeated visits (Gillam & 
Yusuf, 2019). In studies where MI sessions lasted less than 20 minutes, 64% (7 out of 

46 
11 studies) showed a significant effect on behaviour change. The likelihood of an effect 
increased with the number of encounters and prolonged follow-up (Rubak et al., 2005).  
 
Current evidence indicates that MI is more effective in changing patients’ 
behaviours and improving their oral health compared to traditional health education 
methods that primarily focus on disseminating information and providing normative 
advice (Carra et al., 2020; Gao et al., 2014; Gillam & Yusuf, 2019; Kay et al., 2016). A 
scoping review of the use of MI in oral healthcare settings was conducted to collate 
current knowledge on this topic (Brennan & O’Driscoll, 2021). The findings indicate 
MI training has contributed to increased confidence, professionalism and relationship 
building among oral healthcare practitioners and consequently led to improved oral 
healthcare outcomes in patients across various oral health issues and preventive 
measures (Brennan & O’Driscoll, 2021). 
A systematic review by Kay et al. (2016) found that MI can potentially help 
patients to improve their oral health by increasing their oral health knowledge and 
subsequently their oral health behaviours. The review included seven studies and found 
that MI improved patients’ periodontal health and outperformed traditional methods of 
health education in five out of the seven studies (Kay et al., 2016). Another systematic 
review by Carra et al. (2020) demonstrated that MI promoted positive behaviour change 
and improved the oral health of patients with periodontal diseases. Examples of these 
improvements include decreased plaque levels, decreased bleeding upon probing, 
increased toothbrushing, and increased interdental cleaning (Carra et al., 2020).  
 
The promising effectiveness of MI to promote behaviour change can also impact 
dental health education in dental schools. It is recognized that dental curricula are 

47 
limited in their teaching of behaviour change methods. Implementing MI in the 
curriculum would enable students to benefit from learning new skills to support their 
patients to positive behaviour change in oral health (Davis et al., 2008; Rollnick et al., 
2008). 
2.10 
Motivational Interviewing in Early Childhood Caries Prevention 
Multiple studies have been conducted on the prevention of ECC using MI. Given 
the importance of behaviour in dental disease aetiology, behavioural interventions are 
essential for the prevention and treatment of ECC. MI has been proposed as a potentially 
effective behavioural intervention for ECC prevention. Studies have evaluated the 
effectiveness of MI targeting parents and caregivers in reducing risk-related behaviours 
associated with ECC compared to conventional dental health education. These studies 
concluded that participants’ knowledge significantly improved after the MI intervention 
(Mortazavi et al., 2021;Naidu et al., 2015;Henshaw et al., 2018). Furthermore, studies 
by Colvara et al. (2018); Faustino-Silva et al. (2019); Jiang et al. (2020) and Weinstein 
et al. (2004), found that MI sessions significantly decreased the mean decay-missing-
filled surfaces (dmfs) index during follow-up.  
 
 
A study conducted in Eastern Trinidad by Naidu et al., (2015) compared the 
effects of MI with traditional dental health education on oral health knowledge, 
attitudes, beliefs and behaviours among parents and caregivers of preschool children. 
At four-month follow-up, the test-group showed increases in mean child tooth brushing 
frequency and a reduction in oral health fatalism (Naidu et al., 2015). A reduction in 
oral health fatalism means a decrease in the belief that dental problems are inevitable 
and cannot be prevented or controlled, regardless of one's actions. The MI talk and 
telephone follow-up were well accepted and helpful in supporting parents’ and 

48 
caregivers’ efforts to improve oral health practices for their preschool children (Naidu 
et al., 2015).  
 
 
A study was conducted to evaluate the effectiveness of MI and games in 
changing oral health behaviours among preschool children in Edko Administration, 
Beheira Governorate, Egypt. After six months of follow-up, preschool children in the 
experimental groups had significantly lower mean of Oral Hygiene Index-Simplified 
(OHI-S) scores compared with the control group. Therefore, it can be concluded that 
using MI as an oral health education tool was significantly more effective in promoting 
preschool children's oral hygiene and improving mothers' knowledge, attitude and oral 
health related practices than conventional education alone (Nomair et al., 2020). 
 
 
 

49 
CHAPTER 3  
 
MATERIALS AND METHODS 
3.1 
Study Area 
This study will be conducted at the Ministry of Health (MOH) Maternal and 
Child Health Clinics (MCHC) in Terengganu. These MCHCs potentially can capture 
the target population of this study, who are infants aged six months and their mothers 
when they come to the MCHCs for immunizations. The MCHCs services are generally 
available in all government health clinics (KK) throughout Malaysia (Ministry of Health 
Malaysia, 2025).  
Terengganu is divided into eight districts with 45 health clinics providing health 
services to mothers and children: three health clinics in Kuala Nerus, three health clinics 
in Kuala Terengganu, 12 health clinics in Kemaman, seven health clinics in Dungun, 
seven health clinics in Besut, five health clinics in Hulu Terengganu, five health clinics 
in Marang, and three health clinics in Setiu (Ministry of Health Malaysia, 2022).  
Of the eight districts in Terengganu, Setiu and Hulu Terengganu will be selected 
as the study areas. This is because these districts have similar economic backgrounds 
with a mean monthly household gross income between RM5577.00 to RM 5591.00. 
Additionally, the sex and child population distributions in both districts are relatively 
close (Department of Statistics Malaysia, 2025).  
3.2 
Research Design  
This study is a two-arm, parallel-group cluster-randomized controlled trial with 
an allocation ratio of 1:1. This design assesses research treatments implemented at the 
cluster level in healthcare facilities and minimizes the potential for contact among 

50 
participants in separate groups, to ensure the efficacy of the intervention under 
investigation (Colvara et al., 2018). 
 
The control group will receive the conventional MOH AG while the study group 
will receive AG through MI. This cluster-randomized controlled trial will adhere to the 
CONSORT 2025 recommendations to enhance the reporting of parallel-group 
randomized controlled trials. After obtaining the required ethical permissions, the 
principal investigator will register the trial with ClinicalTrials.gov. 
3.3 
Study Population  
3.3.1 
Reference Population  
Mothers and their infants aged six months attending the MOH MCHCs in 
Terengganu.  
3.3.2 
Source Population  
Mothers and their infants aged six months who attend the MOH MCHCs in Setiu 
and Hulu Terengganu districts. 
 
3.3.3 
Sampling Frame  
Sampling frame will be based on the following: - 
 
The cluster-level inclusion criteria selected for this study is the MCHCs in the 
same building area as the dental clinic that provides primary oral health care. This is to 
minimize the logistical barrier because oral healthcare personnels such as the dental 
officers and dental therapists are expected to deliver the AG on infant oral healthcare to 
parents and caregivers coming to the health clinics as part of the MOH Early Childhood 

51 
Oral Health Care Programme. Besides, since both the control and study groups are 
recruited from MCHCs that are located in the same building as the dental clinics, they 
have equal access to oral healthcare professionals, ensuring comparable exposure to 
dental services.  
 
The sampling frame for infants and their mothers is as follows: - 
Inclusion criteria:  
• Mothers: 
o  Malaysian citizens 
o Can read and understand Bahasa Malaysia 
o Aged 18 years old and above 
• Infants: 
o Aged 6 months old (with or without erupted teeth) 
o Born full-term (≥37 weeks of gestation) 
o Without diagnosed congenital anomalies or syndromes 
 
Exclusion criteria: 
• Mothers 
o Mothers experiencing postpartum depression or other significant 
postnatal issues  
• Infants  
o Diagnosed 
with 
special 
needs, 
chronic 
diseases, 
or 
developmental defects 
o Infants who are at risk for oral health problems due to pre-
existing medical conditions 

52 
o Infants requiring specialized oral healthcare, such as those with 
cleft lip and palate, enamel hypoplasia 
 
Infants aged six months will be included regardless of whether primary teeth 
have erupted or not, as this study aims to provide AG for oral health prior to or at the 
onset of tooth eruption. This is consistent with the MOH Early Childhood Oral 
Healthcare Programme and the AAPD recommendation that the first oral health visit 
and parental counselling occur by the age of one year or within six months of eruption 
of the first tooth (AAPD, 2022). Including infants without erupted teeth or those with 
delayed eruption allows the MI-based AG to address early preventive behaviours before 
tooth eruption, which is critical in preventing Early Childhood Caries (ECC) (M. E. 
Harrison et al., 2018; R. Harrison et al., 2010, 2011; R. L. Harrison et al., 2012; 
Weinstein, 2006; Weinstein et al., 2004, 2006). 
 
While for those who are exclusively breastfed, although exclusive breastfeeding 
is not specifically mentioned in the inclusion or exclusion criteria, such infants will 
automatically be eligible to participate, as long as they meet the general inclusion 
criteria (i.e., healthy infants aged 6 months attending the clinic with their mothers). 
Exclusive breastfeeding is a common feeding practice and does not interfere with the 
objectives or procedures of this study; therefore, it is considered part of the normal 
population represented in this research. 
3.4 
Sample Size Determination  
Sample sizes for specific objectives of the study were calculated. 
 

53 
3.4.1 
Specific Objective 1  
To determine the knowledge and practices regarding infant oral health care 
among mothers in the study group before (at six months) and after (at nine and 12 
months) receiving AG through MI.  
 
The sample size (Table 3.1) was calculated using the single proportion formula 
as follows: 
𝑛= (𝑧
𝛥)
2
⋅𝑝(1 −𝑝)  
Where:  
n=sample size; p=estimated prevalence; =precision; Z = 1.96 for 95% CI 
Table 3.1 
Sample size for specific objective 1 
Outcome 
p 
 
Z 
n 
Knowledge  
 
90.5% parents or caregivers who 
knew the amount of toothpaste to 
be placed on a brush after 
receiving intervention that 
includes MI  (Naidu et al., 2015) 
 
0.05 
1.96 
132 
Practice 
 
95.3% caregivers who gave their 
child healthy meals brush after 
receiving intervention that 
includes MI (Ismail et al., 2011) 
0.05 
1.96 
69 
 
 
 
3.4.2 
Specific Objective 2 
To determine the knowledge and practices regarding infant oral health care among 
mothers in the control group before (at six months) and after (at nine and 12 months) 
receiving the conventional MOH AG. 
 
The sample size (Table 3.2) was calculated using the single proportion formula 
as follows: 

54 
𝑛= (𝑧
𝛥)
2
⋅𝑝(1 −𝑝)  
Where:  
n=sample size; p=estimated prevalence; =precision; Z = 1.96 for 95% CI 
 
Table 3.2 
Sample size for specific objective 2 
Outcome 
p 
 
Z 
n 
Knowledge  
 
90.0% parents or caregivers who 
knew that bacteria on children’s 
teeth can cause cavities after 
receiving intervention that did not 
include MI (Naidu et al., 2015) 
 
0.05 
1.96 
138 
Practice 
 
91.3% caregivers who gave their 
child healthy meals brush after 
receiving intervention that did not 
include MI   
(Ismail et al., 2011) 
0.05 
1.96 
122 
 
3.4.3 
Specific Objective 3  
To compare the mean knowledge and practice scores regarding infant oral health 
care among mothers in the study group before (at six months) and after (at nine and 12 
months) receiving AG through MI.  
 
The sample size was determined using G*Power software, selecting the t-test 
for "Means: Difference between two dependent means (matched pairs)," with the 
following parameters: α (Type I error) = 0.05, power (1-β) = 0.80, two-tailed analysis 
and effect size dz=0.5. The calculated sample size for objective 3 is 34. 
3.4.4 
Specific Objective 4 
To compare the mean knowledge and practice scores regarding infant oral health 
care among mothers in the control group before (at six months) and after (at nine and 
12 months) receiving the conventional MOH AG.  

55 
 
The sample size was determined using G*Power software, selecting the t-test 
for "Means: Difference between two dependent means (matched pairs)," with the 
following parameters using and two-tailed analysis and the values which are: α (Type I 
error) = 0.05, power (1-β) = 0.80, and effect size dz = 0.5. The calculated sample size 
for objective 4 is 34. 
 
3.4.5 
Specific Objective 5 
To compare the mean knowledge and practice scores regarding infant oral health 
care between mothers in the study group after receiving AG through MI and mothers in 
the control group after receiving the conventional MOH AG.  
 
The sample size was determined using G*Power software by selecting the t-test 
for "Means: Difference between two independent means (two groups)," with two-tailed 
analysis and the values in following parameters: α (Type I error) = 0.05, power (1-β) = 
0.80, and effect size d=0.5. Sample size calculated for specific objective 5 is 128. 
3.4.6 
Specific Objective 6 
To compare the incidence of ECC and dental caries risk status among infants in 
the study group before (at six months) and after (at nine and 12 months) receiving AG 
through MI.  
 
The sample size was determined using G*Power software by selecting the Exact 
test family and the McNemar test for matched pairs, with two-tailed analysis and the 
following parameters: α (Type I error) = 0.05, power (1-β) = 0.80, estimated odds ratio 
= 3.2 (Mukhtar et al., 2023) , expected proportion of discordant pairs = 0.5 (Mukhtar et 
al., 2023). The calculated sample size for objective 6 is 60. 
 

56 
3.4.7 
Specific Objective 7 
To compare the incidence of ECC and dental caries risk status among infants in 
the study group before (at six months) and after (at nine and 12 months) receiving 
conventional MOH AG.  
 
The sample size was determined using G*Power software by selecting the Exact 
test family and the McNemar test for matched pairs, with two-tailed analysis and the 
following parameters: α (Type I error) = 0.05, power (1-β) = 0.80, estimated odds ratio 
= 3.2 (Mukhtar et al., 2023) , expected proportion of discordant pairs = 0.5 (Mukhtar et 
al., 2023). The calculated sample size for objective 7 is 60. 
 
3.4.8 
Specific Objective 8 
To compare the incidence of ECC and dental caries risk status between infants 
in the study group (mothers received AG through MI) and infants in the control group 
(mothers received the conventional MOH AG).  
The sample size was determined using G*Power software by selecting the Exact 
test family and the statistical test of “Proportions: inequality, two independent groups 
(unconditional)”, with two-tailed analysis and the following parameters: α (Type I error) 
= 0.05, power (1-β) = 0.80, with estimated odds ratio = 3.2, allocation ratio N2/N1 = 1. 
The calculated sample size for objective 8 is 104. 
3.4.9 
Conclusion on Sample Size Determination 
 
Considering the available resources, a sample size of 138 participants from 
Objective 2 (To determine the knowledge and practices regarding infant oral health care 
among mothers in the control group before (at six months) and after (at nine and 12 
months) receiving the conventional MOH AG is feasible for the study. Accounting for 

57 
a 10% dropout rate, the total sample size will increase to 152 participants. Since cluster 
trials typically require 50 to 100% more participants than individual randomized trials 
to maintain the same statistical power, an additional 76 respondents (50% of the initial 
152 participants) will be included. As a result, a total of 228 infant-mother pairs will be 
recruited for the study. 
3.5 
Sampling Method   
This study will employ a multistage sampling approach. In the first stage, a list 
of districts in Terengganu will be compiled. Two districts, Setiu and Hulu Terengganu, 
were purposively selected based on comparable sociodemographic characteristics, 
population distribution, and the availability of healthcare services from both public and 
private providers. These two districts were then randomized to determine their 
assignment as either the study district or the control district using the lottery method. 
District Setiu was allocated as the study group and Hulu Terengganu as the control 
group.  
In Setiu, all three available MCHCs will be included in the study. In Hulu 
Terengganu, where there are five MCHCs, simple random sampling will be used to 
select three MCHCs. Then, a non-proportionate stratified random sampling method will 
be used, where an equal number of infant-mother pairs will be selected from each clinic, 
regardless of the total number of infants registered in that clinic. Following eligibility 
screening, systematic random sampling will be applied within each clinic stratum to 
recruit participants. This will ensure that every eligible infant-mother pair has an equal 
chance of being selected while maintaining a structured sampling approach.  

58 
As multiple factors are known to influence early childhood caries risk (Foxman 
et al., 2023; Manek et al., 2023; Ramírez‐Trujillo et al., 2022), matching will be applied 
to ensure comparability between the study and control groups. Maternal age group and 
parity will be recorded for all participants to ensure a comparable baseline distribution 
of these characteristics (Foxman et al., 2023). A recruitment monitoring log will be used 
to record the number of participants enrolled in each maternal age group and parity 
category for both groups, and these distributions will be reviewed periodically during 
recruitment to ensure that no substantial imbalance occurs between the intervention and 
control groups (Higgins et al., 2019). 
.  
 
 
 
 
 
 
 
 
 
 

59 
The sampling method flow chart is depicted in Figure 3.1:- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 3.1 Sampling method of the study 
 
The single-blinded method will be applied. The allocation of the intervention 
and control groups will be unknown to the mothers and their infants. Therefore, only 
the study investigator knows which group the participants belong to.  
3.6 
Variables and Research Tools   
3.6.1 
Variables 
The variables of interest in the study are as follows: 
Kuala 
Terengganu 
Kuala 
Nerus 
Setiu 
Besut 
Hulu 
Terengganu 
Marang 
Dungun 
Kemaman 
Control District = Hulu Terengganu 
Study District = Setiu 
2 districts: Setiu and Hulu Terengganu 
In the same building area as the primary dental clinics 
3 MCHCs 
5 MCHCs 
MCHC 
Permaisuri 
MCHC Sg 
Tong 
MCHC Sri 
Langkap 
MCHC 
Kuala Berang 
MCHC Ajil 
MCHC 
Tengkawang 
Enrolment 
Systematic random sampling 
38 infant-
mother 
pairs 
38 infant-
mother 
pairs 
38 infant-
mother 
pairs 
38 infant-
mother 
pairs 
38 infant-
mother 
pairs 
38 infant-
mother 
pairs 
114 infant-mother pairs 
114 infant-mother pairs 
Study sample (n=228 infant-mother pairs) 
Simple random sampling  
Assessed for eligibility  
Terengganu 
Selection based on district with similar characteristics 
Randomization 

60 
1. Characteristics of mothers: age, relationship with the infant, race, monthly 
household income in Ringgit Malaysia (RM), last dental visit, exposure to infant 
oral health education.  
2. Mothers’ knowledge regarding infant oral health care.  
3. Mothers’ practice regarding infant oral health care.  
4. Incidence of ECC of infants.  
5. Dental caries risk status of infants. 
 
3.6.2 
Research Tools 
This study will adopt the fidelity monitoring framework proposed by Bellg et 
al. (2004) which emphasizes three key elements including MI protocol development 
and its delivery steps, MI training, and MI fidelity assessments. 
3.6.2(a) 
Motivational Interviewing Protocol  
MI Protocol Development 
An MI protocol will be developed to enhance the delivery of AG on early 
childhood oral healthcare. The protocol will draw upon foundational and well-
established MI resources, including the work of Weinstein et al. (2004) and Weinstein 
(2006). These references provide a solid theoretical and practical framework for using 
MI techniques specifically within dental settings. 
In addition, this protocol will be informed by MI scripts from a previous trial by 
Harrison et al. (2011), which were tailored for use with pregnant women and new 
mothers from the time of pregnancy through the eruption of their infant’s first teeth up 
to approximately two years of age. The scripts were designed to support oral health 

61 
behaviour change during a critical window of a child's development and are highly 
relevant to the context of AG. The MI script is provided in the Appendix C. 
Furthermore, slides from the Baby Teeth Talk Study which is a significant 
international research project conducted across Canada, New Zealand, and Australia 
(Jamieson et al., 2019) will also contribute to the development of this MI protocol. This 
study focused on reducing ECC through culturally appropriate and motivational 
strategies and offers valuable insights into the design and implementation of effective 
MI interventions in diverse populations. The slides from the Baby Teeth Talk Study are 
documented in Appendix D.  
The development of this MI protocol will be carried out in collaboration with a 
team of experts comprising a dental officer, a dental public health specialist, a paediatric 
dental specialist, and one certified MI counsellor. This multidisciplinary team will 
ensure the protocol is both clinically relevant and methodologically rigorous, while 
maintaining fidelity to core MI principles. 
The MI protocol will be used to standardize the approach across participants, 
ensuring consistency in delivery, and allowing for reliable evaluation of its 
effectiveness (Weinstein et al., 2014). It also provides a structured framework for 
engaging mothers in reflective conversation, identifying individual barriers and 
facilitators to behaviour change, and ultimately, assessing the contribution of MI to 
improved oral health outcomes in early childhood. As such, the protocol plays a central 
role in both the implementation and evaluation of the study (Weinstein et al., 2014).  
Prior to the implementation of the main study, the MI protocol will be pretested 
among 10 mothers of infants attending the Maternal and Child Health (MCH) Clinic in 

62 
Jabi, Besut, Terengganu. These mothers are socio-demographically comparable to the 
target population in Setiu and Hulu Terengganu, where the actual study will be 
conducted (Hurst et al., 2015). The purpose of the pretest is to evaluate the clarity, 
acceptability, and feasibility of the MI protocol among representatives of the intended 
recipients of the intervention (Hurst et al., 2015). A pretest sample of approximately 10 
participants is commonly recommended for preliminary testing to identify potential 
issues in intervention procedures before the main study (Hertzog, 2008). 
All MI sessions conducted during the pretest will be audio-recorded and 
subsequently assessed by trained coder using the Motivational Interviewing Treatment 
Integrity (MITI) version 4.2.1 to evaluate fidelity and to identify areas for refinement 
prior to the full-scale implementation (Spreuwel et al., 2024). 
MI Delivery Steps 
The practical delivery of MI is structured through four interrelated processes. 
These processes which are engaging, focusing, evoking, and planning translate the 
principles into action, providing a clear framework for guiding parents through the 
change process (Miller & Rollnick, 2013). Engaging is for example where the dentist 
builds a trusting relationship with the mother by showing empathy, understanding, and 
genuine interest. Without proper engagement, meaningful change is unlikely. For 
example, a dentist might say, “I understand it can be challenging to keep up with your 
baby’s oral care, especially with so many other responsibilities. I’m here to listen and 
see how we can make things easier for you.” 
Once engagement is established, the process moves to focusing, which means 
agreeing on a clear topic or goal to work on. This helps both the dentist and the mother 

63 
stay aligned, whether the focus is on infant feeding, oral hygiene, or dental visits. An 
example would be, “You mentioned your baby still drinks from the bottle at night. 
Would it be okay if we talked about how night feeding can affect your baby’s teeth?” 
The third process, evoking, is about drawing out the mother’s own reasons for 
change rather than giving direct advice. This helps her express her concerns, abilities, 
and motivation, also known as “change talk.” For instance, a dentist might ask, “What 
worries you most about your baby’s teeth if night bottle feeding continues?” Hearing 
herself explain the reasons can be more motivating than being told what to do. 
When the mother is ready, MI moves to planning. This stage focuses on turning 
intention into action by creating a clear, realistic plan. The dentist may help identify 
steps, explore possible barriers, and strengthen commitment. For example, “You’ve 
decided to stop night bottle feeding. What is the first step you feel ready to take, and 
when would you like to start?” This ensures motivation is translated into action. 
A central concept in MI is ambivalence, the mixed feelings people often have 
about change. According to the Transtheoretical Model by (Prochaska & Di Clemente, 
1982), motivation moves through stages: precontemplation, contemplation, preparation, 
action, maintenance, and relapse. Even when parents are already in the preparation or 
action stage, they may still feel ambivalent. The dentist’s role is to recognize these 
moments and respond in a way that supports progress. 
To manage ambivalence, MI uses tools like OARS (open questions, 
affirmations, reflections, summaries). Open-ended questions encourage the parent to 
talk more and explore their own feelings, rather than giving short yes/no answers. For 
example, the dentist might ask, “What are your thoughts about brushing your baby’s 

64 
teeth every night?” This allows the mother to share her concerns or motivations in 
detail. Affirmations are positive statements that highlight the parent’s strengths and 
efforts, which help build confidence. For instance, the dentist could say, “You clearly 
care about your baby’s health by coming to this appointment and asking questions.” 
This reinforces the mother’s sense of capability. 
Reflections involve listening carefully and then repeating or rephrasing what the 
parent says to show understanding. For example, if the mother says, “It’s hard to brush 
when I’m so tired at night,” the dentist might reflect, “You’re exhausted at the end of 
the day, and brushing feels like an extra task.” This helps the mother feel heard and 
understood. Summaries bring together key points of the conversation to ensure clarity 
and reinforce motivation. For example, the dentist might say, “So you’re worried about 
cavities, you’ve tried brushing but find it difficult when you’re tired, and you’d like to 
find an easier routine. Did I get that right?” Summaries show respect for the parent’s 
perspective and help organize the discussion. 
These conversations often lead naturally to change talk, where the parent begins 
to voice their own reasons, desires, and abilities to change. In MI, change talk is a 
powerful indicator of progress, as the motivation for change comes from the parent 
rather than the practitioner. For example, a mother may say, “I’m too busy with work, 
then I could not focus the baby’s nutrition.” A reflective response could be, “It sounds 
like your career is very important right now, but you also want to support your baby’s 
health.” This helps shift the focus back toward motivation for change. 
Change talk can be divided into two types. DARN (Desire, Ability, Reason, 
Need) reflects intention to change, such as saying, “I want my baby to have healthy 
teeth,” or “I think I can stop night feeds.” Meanwhile, CAT (Commitment, Activation, 

65 
Taking Steps) shows action, such as, “I will start brushing her teeth tonight,” or “I’ve 
already stop night feeds last week.” DARN statements indicate readiness, while CAT 
statements demonstrate that change is already happening. 
Weinstein (2006) can also be referred to in the development of this MI protocol, 
as he outlined several key steps in delivering MI. These steps begin with Step 1, which 
involves building a therapeutic alliance between the interviewer and the mother. 
Establishing rapport and trust is essential, as a strong relationship lays the foundation 
for meaningful change (Weinstein 2006).  
Step 2 involves engaging the mother in a conversation that encourages her to 
articulate reasons for change, such as avoiding sugary foods and drinks for their infants. 
Allowing the mother to voice her concerns helps her identify the problem and fosters 
intrinsic motivation to change. The interviewer acts as a facilitator, while the mother 
retains responsibility for deciding to act or change. Behavioural change is more likely 
when the individual perceives a problem and feels empowered to address it (Weinstein 
2006).  
In Step 3, the interviewer encourages self-motivational statements by asking 
questions, listening for self-motivational statements and paraphrasing them to reinforce 
the mother’s intent and optimism. The more the mother talks about their infants’ oral 
health problems and expresses her intent to act or change, the greater the likelihood of 
initiating change. Hearing herself acknowledge the problem and voice determination to 
solve it, is a key driver of action that facilitates action (Weinstein 2006).  
Step 4 is about helping mother prepares for change. This is when mother makes 
self-motivational statements, and begins contemplating action, and the problems or 

66 
difficulties associated with it. While it is useful to continue encouraging self-
motivational statements, the interviewer should now help identify potential obstacles or 
hurdles that interfere with action. The interviewer should encourage development of a 
plan to minimize or overcome these interferences.  
When it is believed that the mother is very aware of the problem and desires to 
change or act, the interviewer should provide additional directions. The interviewer 
should first ask permission from the mother to solve the problem. Once permission is 
granted, the interviewer should give options to the mother (Weinstein 2006), for 
example by introducing of a menu of caries-preventive options (Weinstein et al., 2004). 
However, this study will utilize the flipcharts developed by Mukhtar et al. (2023) to 
explain on the AG that are relevant for mothers of 6-month-old and 9-month-old infants. 
This is based on study by Jamieson et al. (2018) that was implemented by combining 
the MI intervention with AG. 
Step 5 involves roll with resistance to change (Hambrick, 2019). Where does 
the resistance come from? Resistance is a same side of sustain talk. As sustain talk is 
another side of coin of motivation the change talk.  Resistance is a normal part of the 
change process and should be expected. Resistance should be viewed as the flipside of 
motivation. To foster motivation for change, it is essential to minimize resistance; when 
resistance is allowed to grow unchecked, motivation tends to dissipate. There are 
various forms of resistance, both active and passive. These include arguing, 
interrupting, denying, minimizing the problem, being pessimistic or fatalistic, and 
ignoring or side-tracking the discussion (Weinstein 2006). Addressing resistance with 
empathy and strategic communication helps maintain momentum toward change.  

67 
Step 6 is follow-up and relapse prevention. Relapse should not be seen as a 
failure but as a normal part of the change process. It shows that some steps have not 
been fully completed and that more learning or practice is needed. In this way, relapse 
becomes an opportunity to gain experience and move closer to long-term goals 
(Diclemente, 2007). 
Relapse can occur in three stages. The first is emotional relapse, which happens 
before a person even thinks about returning to old behaviour. For example, a mother 
who feels stressed and exhausted may start neglecting her usual routine of brushing her 
child’s teeth at night. The second stage is mental relapse, where there is an inner conflict 
with part of the mother wants to maintain good oral care, but another part thinks, 
“Skipping one night of brushing won’t hurt.” The final stage is physical relapse, when 
the old behaviour returns. For instance, the mother resumes giving her child a bottle of 
milk at bedtime, despite knowing it increases the risk of ECC. 
Relapse prevention involves helping mothers to recognize early warning signs 
and develop coping strategies. In the above situation, the dentist could work with the 
mother to identify triggers such as fatigue at night and plan alternatives. Strategies may 
include asking another family member to help with brushing, preparing the toothbrush 
earlier in the evening, or using a soothing method other than the bottle to settle the child. 
By anticipating difficult situations and building practical solutions, the mother gains 
confidence and reduces the chance of future relapse. 
Before ending the session, the dentist reassures the mother that setbacks are 
normal and that plans may need adjustments over time. Ongoing support is emphasized, 
such as discussing how to avoid adding sugar to the baby’s bottle or finding easier 
routines that fit into daily life. Regular follow-ups in person by phone, are scheduled to 

68 
revisit goals, troubleshoot barriers, and adapt strategies as needed. These follow-ups 
help maintain motivation and support sustained behaviour change (Weinstein, 2006). 
MI Training  
All MI sessions will be conducted by the principal investigator, who had 
received formal training in MI under a certified MI counsellor at Universiti Malaysia 
Terengganu (UMT). This training has equipped the investigator with the necessary 
communication skills and understanding of MI principles to effectively elicit and 
strengthen the participants’ intrinsic motivation to adopt preventive oral health practices 
for their infants. This training one of the elements that is needed in an MI fidelity 
assessment  
MI Fidelity Assessment 
Once the MI protocol is finalized, and the interventionist is trained, fidelity 
assessment will be conducted to evaluate the researcher’s delivery skills in a real-use 
context (Bellg et al., 2004; Madson & Campbell, 2006). 
According to Bellg et al. (2004), it is recommended that investigators not only 
institute treatment fidelity plans at the outset of the study but also maintain consistent 
efforts to adhere to a comprehensive treatment fidelity plan throughout the study period. 
In line with this recommendation, the fidelity assessment for this study will be 
conducted before and throughout the actual data collection period. This is to prepare the 
investigator (serving as the interventionist) to deliver the MI sessions competently and 
in accordance with MI principles and ensuring that the intervention is implemented 
consistently from the start until the end of the study (Bellg et al., 2004). 

69 
As this fidelity assessment is defined as the degree to which an intervention is 
implemented as intended, as an essential part of intervention research (Bellg et al., 2004; 
Santacroce et al., 2004; Spillane et al., 2007), it is very crucial in MI to ensure that 
treatment outcomes can be confidently attributed to the MI intervention (Atkinson & 
Woods, 2017; M et al., 2015; Madson & Campbell, 2006; Palacio et al., 2016; 
Ripplinger & Cascaes, 2022).  
When assessing the integrity of the intervention, the assessor validates that an 
interventionist adheres to study protocols and avoids behaviours not consistent with 
study protocols (Howard et al., 2009; McHugo et al., 2007; Santacroce et al., 2004). In 
addition, fidelity assessments estimate the degree to which the intervention being 
delivered consistently to all participants in a study and that the intervention delivery 
was true to the theory and goals underlying the research (Bellg et al., 2004). 
The MITI 4.2.1 (Motivational Interviewing Treatment Integrity) is a 
behavioural coding system designed to assess the fidelity of MI delivery (T. B. Moyers 
et al., 2014). It evaluates two main components which are Global Scores reflecting the 
overall spirit of MI across four dimensions (Cultivating Change Talk, Softening Sustain 
Talk, Partnership, and Empathy) and Behaviour Counts, which tally specific clinician 
behaviours such as open questions, affirmations, and reflections.  
The MITI 4.2.1 scoring system provides suggested thresholds for assessing an 
interventionist's basic competence and proficiency in MI. These thresholds, based on 
expert opinion stated that a fair level of relational skills is indicated by a score of 3.5, 
while good technical skills require a score of 4. Interventionist should aim for at least 
40% complex reflections (% CR), a reflection-to-question ratio (R: Q) of 1:1 or higher, 

70 
and a minimum of twice as many MI-adherent (MIA) behaviours compared to non-
adherent (MINA) behaviours (T. B. Moyers et al., 2014). 
This study will adopt a single assessor approach by certified MI counsellor 
(Ripplinger & Cascaes, 2022) with substantial experience in conducting MI. The 
assessor had undergone the MITI 4.2.1 Coding and Coaching Training, through online 
provided by the member of the Motivational Interviewing Network of Trainers (MINT). 
The role of the assessor is to code audio recordings reliably using the MITI framework 
(T. B. Moyers et al., 2014). The scoring will follow the standardized procedures 
outlined in the MITI 4.2.1 coding manual. 
Fidelity coding is typically conducted on a random 20-minute segment of audio-
recorded sessions of 20% to 25% from total MI sessions throughout the study period as 
shown by two previous studies (El-Mallakh et al., 2012; McCarthy et al., 2015). Both 
studies were conducted with only one practitioner delivering the intervention, providing 
an indication of the MI skill fluctuation in the practitioner delivering the intervention 
over time (Jelsma et al., 2015). The consent of clients will be obtained prior to the audio 
recording (Jelsma et al., 2015).  
The selected sessions will be double coded by the assessor to mitigate bias and 
enhance reliability. Intra-reviewer variability, will be measured by intraclass correlation 
(ICC), and will be evaluated using random sample of MI audio recordings, with two 
repeated evaluations 30 days apart (Ripplinger & Cascaes, 2022). This approach 
balances methodological rigor with practical feasibility in fidelity assessment using the 
MITI 4.2.1 framework (T. B. Moyers et al., 2017). As a general rule regarding 
reliability, ICCs below 0.40 are considered poor, 0.40– 0.59 are fair, 0.60– 0.74 are 
good and 0.75 or above are excellent (Cicchetti, 1994; T. B. Moyers et al., 2017). 

71 
The Translation and Adaptation Process of the MITI 4.2.1 
The MITI 4.2.1 will be translated into the Malay language to ensure alignment 
with the language used during MI sessions and to facilitate accurate fidelity coding by 
Malay-speaking coder. According to the authors of the MITI manual, the instrument is 
considered an open-source document that is freely available for use, including 
translation for research, training, and evaluation purposes. Previous translation efforts 
have successfully produced versions in several languages, including Spanish, Danish, 
Dutch, German, Norwegian, Cantonese, Japanese, and Korean, which are available 
through the Center on Alcohol, Substance Use and Addiction (CASAA), University of 
New Mexico website.  
In line with the recommendations provided by the original MITI authors and the 
Scientific Advisory Committee of the Motivational Interviewing Network of Trainers 
(MINT), the translation of the MITI 4.2.1 into Malay will follow a scientifically sound 
translation and adaptation process to ensure conceptual equivalence and maintain the 
validity of the instrument (Moyers et al., 2023). There are two suggested approaches for 
the translation process. The first is a standard forward–backward translation method, 
which involves translation by an MI expert, followed by back-translation by a non-
content expert, and subsequent comparison and refinement to resolve discrepancies. 
The second approach involves independent translation by two MI content experts, 
followed by comparison and consensus to produce a final version. Both approaches are 
considered methodologically rigorous; therefore, this study will adopt the second 
approach as recommended by MINT (Moyers et al., 2023). 
The Malay version of translation was further reviewed by the research team, 
which consisted of an MI expert, a dental officer, a dental public health specialist, and 

72 
a paediatric specialist. The multidisciplinary review aimed to ensure clarity, cultural 
appropriateness, and relevance to the Malaysian healthcare context, particularly for MI 
sessions involving mothers of infants in oral health promotion settings.  
The original MITI author, Dr. Denise Ernst, had expressed her support for the 
use, citation, and translation of the manual for research purposes. In written 
correspondence, she granted permission for the translation and adaptation of the MITI 
Coding Manual into the Malay language and encouraged its use in this study. The 
written permission from Dr. Denise Ernst is included in Appendix F, while the original 
English version of the MITI Coding Manual 4.2.1 is provided in Appendix G. 
3.6.2(b) 
Self-Administered Questionnaire 
Two sets of self-administered questionnaires from Mukhtar et al. (2023) will be 
used in this study as a data collection tool to gather information on maternal 
characteristics, as well as knowledge and practices related to infant oral healthcare at 
six to nine months and nine to 12 months.  
Two items from the original validated questionnaire (Mukhtar et al., 2023) 
which are the participants’ sex and relationship to the infant will be excluded in this 
study as they will not be applicable to the defined target population. This study will 
specifically include only mothers, regardless of biological relation, in accordance with 
the definition under the Laws of Malaysia Act 351 (1961), which are biological mothers, 
legal guardians, and other female caregivers who serve as the infant’s primary caretaker. 
This minor adaptation will not affect the core constructs measured and will be still 
reviewed by two experts which are a dental public health specialist and a paediatric 
dental specialist to ensure the questionnaire’s content validity remained intact. 

73 
The first set of the questionnaire was designed to assess knowledge and practices 
related to oral healthcare of infants aged six to nine months. The knowledge section 
consists of 15 items distributed across six sub-domains. The first sub-domain, dental 
growth and development, includes two items assessing the knowledge on whether the 
emergence of first primary tooth is during six-month-old and whether the mothers 
recognize that gums, tongue, and teeth are all components of the oral cavity. The second 
sub-domain, oral disease prevention, whether cleaning an infant’s gum pads is 
considered necessary before tooth eruption and whether the most pivotal time for 
infants’ oral hygiene routines is at night before bedtime.  
Next, the third sub-domain is diet and nutrition, which includes items that assess 
mothers’ knowledge on whether after breastfeeding or bottle feeding the teat should be 
removed from the baby’s mouth to prevent milk stagnation, whether early exposure to 
sugary foods before two years of age should be avoided, and whether instant juices and 
flavoured milk can increase the dental caries risk. For the fourth sub-domain on oral 
habits, one item checks whether that teeth eruption causes fever. Another item asks 
whether the objects that are given to infants should be clean and safe to avoid any 
infections or choking risk. For the fifth subdomain on dental injury prevention, the item 
asks whether any possible occurrence of dental injury among infants aged six to nine 
months. These injuries can include bruised lips, ulcerated tongue, burned lips, and 
dislocated tooth.   
Finally, the sixth sub-domain on periodic oral examination assesses the need of 
dental visit for infant with non- erupted teeth, and the second item assess whether such 
early visits can provide parents or caregivers with essential age-appropriate information 
on oral disease prevention.  

74 
There are three response options given for each knowledge statement in all the 
sub-domains which are true, false, and don't know. A score of one was given for correct 
responses and a zero for incorrect responses and don’t know answers. The sum of the 
scores produced the total knowledge score that may range from zero to 15. A higher 
score indicates better knowledge. 
The section on practices regarding oral healthcare of infants aged six to nine 
months has 11 items, distributed across the five sub-domains. The first sub-domain 
which is the oral disease prevention, has four items that asks whether mothers examine 
their baby’s mouth with the answer option of yes or no. If the mothers answer yes, the 
next item asks aspects they examine (such as soft tissue, tooth eruption, tooth count and 
hard tissue or any other aspects not in the list). Next item assesses on the frequency of 
infant oral cleaning (on gums and teeth) with the few answer options (Yes, at least twice 
a day; Yes, once a day; Yes, but not every day; Never; Teeth have not yet erupted) and 
by what tools (e.g., dry cloth, damp cloth, fingers, soft/silicone/finger toothbrush, not 
yet started to clean, teeth not erupted) they clean the infant’s gums and teeth.  
Secondly, in the diet and nutrition sub-domain, there are three items that 
examine whether mothers have ever given their infants drinks other than milk or plain 
water either through bottles or cups/straw and what types of beverages were given, 
either cordial drinks or flavoured milk, or not giving any drinks other than milk or plain 
water or any other drink that is not in the list. It also asks whether the infant has ever 
been offered sugary snacks like creamed bread, biscuits, and cakes.  
Thirdly, for oral habit sub-domain, the item asks whether the mother has ensured 
that objects or toys the baby puts in their mouth are safe and clean and the answer option 
is always, sometimes or never. Fourth sub-domain is oral injury prevention, with one 

75 
item explores whether the mother has ever let the baby to play with objects or engage 
in activities that pose a risk of oral injury. The response options are always, sometimes, 
or never. For periodic oral examination sub-domain, the item asks if the mother has ever 
taken the baby for an oral check-up at a dental clinic, with binary response options either 
yes or no.  
The second set of the questionnaire was designed to assess knowledge and 
practices related to oral healthcare of infants aged nine to 12 months. The knowledge 
section consists of 19 items distributed across six sub-domains. The first sub-domain, 
dental growth and development, includes five items. These items assess knowledge on 
whether white or yellow spots on the surface of the teeth are early signs of dental caries, 
whether plaque is a white film containing bacteria that sticks to the surface of the teeth, 
whether plaque causes dental caries, whether the function of deciduous teeth in 
maintaining space for permanent teeth and whether the deciduous teeth is not important 
due to their temporary nature.  
The second sub-domain, oral disease prevention, gauges the mother’s 
knowledge on whether plaque can be removed by toothbrushing, whether fluoride 
toothpaste can prevent dental caries, and whether brushing a baby’s teeth at night before 
bedtime as the most pivotal time. 
The third sub-domain, diet and nutrition include items that assess mothers’ 
knowledge on whether consumption of sweet snacks (more than three times per day) 
can increase caries risk. Another item explores whether the respondent can correctly 
identify foods containing hidden sugars, specifically in fresh fruits, instant baby puree, 
and instant baby rusks.  

76 
For the fourth sub-domain on oral habits, two items are included. One item 
examines knowledge on whether any risk of dental caries if a baby is let to sleep with 
milk pooling in their mouth. Another item evaluates whether the habits like pacifier use, 
or thumb-sucking should ideally stop by 18 months. The fifth sub-domain on dental 
injury prevention also has two items. One assesses on knowledge whether infants who 
are just learning to walk are at risk of falling and injuring their teeth. The second item 
tests on whether primary tooth trauma does not disturb permanent tooth development. 
The last sub-domain on periodic oral examination includes three items. These 
assess knowledge on whether a baby with only one tooth does not need a dental visit, 
whether regular dental check-ups enable early prevention, and whether the 
recommended age for a baby’s first dental visit should be no later than one year. For all 
knowledge items, three response options are given, which are true, false, and don’t 
know. A score of one was given for correct responses and a zero for incorrect responses 
and don’t know answers. The sum of the scores produced the total knowledge score that 
may range from zero to 19. 
The section on practices regarding oral healthcare of infants aged nine to 12 
months has 12 items, distributed across the five sub-domains. The first sub-domain is 
oral disease prevention that has six items, asking mothers whether they examine their 
infant’s oral cavity at home and what aspects they should check such as the health of 
soft tissues (like the tongue, lips, gums, palate, and cheeks), tooth development, the 
number of teeth present, and the condition of hard tissues (teeth). Mothers are also asked 
whether they have ever cleaned their baby’s teeth with few answer options (Yes, at least 
twice a day; Yes, once a day; Yes, but not every day; Never; Teeth have not yet erupted) 
and whether they have ever performed this cleaning at night before bedtime with answer 

77 
options always, sometimes and never. Additionally, it includes item on the tools used 
to clean infant’s teeth (e.g., dry cloth, damp cloth, fingers, soft-bristled/silicone/finger 
toothbrushes, and whether fluoridated toothpaste is used or not, or toothpaste is not used 
at all. If it is used, mothers are further asked to estimate the size of toothpaste applied, 
using familiar size comparisons such as a grain of rice or a pea or full on the toothbrush. 
In the second sub-domain on diet and nutrition, there are two items that explore 
whether the mothers have ever given sweet snack to the infant with the response options 
are four or more times per day, three or more times per day, not every day or never. 
Next item assesses whether the infant is given commercial baby food products such as 
fruit purees and baby rusks with the answer option is yes or no. For the third sub-domain 
on oral habit, the item asks on whether the mother has started training the baby to drink 
using a cup. The second item evaluates whether the mother lets the baby to fall asleep 
while suckling on breast milk or a bottle containing milk or sweet drinks. Both items 
for this second sub-domain have answer options either yes or no. 
The fourth sub-domain, oral injury prevention, includes a single item that asks 
whether the baby is ever allowed to play with objects or engage in activities that may 
pose a risk of oral injury with answer options of always, sometimes or never. The final 
sub-domain, periodic oral examination, contains one item that assesses whether the 
mother has brought the baby to a dental clinic for an oral health examination with the 
answer of yes or no. Both questionnaires are attached in the Appendix G and H, 
respectively. 
3.6.2(c) 
Incidence of Early Childhood Caries 
 
The oral examination of the children will utilize the International Caries 

78 
Detection and Assessment System (ICDAS) to determine the incidence of ECC 
(Dikmen, 2015). ICDAS is a clinical scoring system that allows for the detection and 
assessment of caries activity. It was developed for use in clinical research, clinical 
practice and epidemiological purposes (Dikmen, 2015). The system is designed to 
detect the caries process at every stage and to characterize the activity status of lesions. 
One of the main advantages of ICDAS is its ability to evaluate non-cavitated lesions 
(Dikmen, 2015). According to Ekstrand et al., (2011),  ICDAS can detect and assess 
approximal caries more successfully through intraoral examination than radiography. 
By identifying and assessing the severity of caries, ICDAS enables more effective 
prevention and treatment strategies.  
 
The ICDAS index has been the primary index used for diagnosing dental caries 
lesions in oral health practices by the Ministry of Health Malaysia since 2013 (Oral 
Health Program, 2020). Clinical oral examination of the infants will be done by the 
principal investigator to determine the prevalence of early dental caries lesions and 
dental caries risk. The estimated time to complete the infant’s clinical oral examination 
is approximately eight minutes. The principal investigator will be calibrated with a 
paediatric dentist at Hospital Pakar Universiti Sains Malaysia (HPUSM). 
 
The ICDAS measures the surface changes due to carious lesions and potential 
histological depth by relying on surface characteristics. The examination of clean and 
dry teeth is the fundamental prerequisite for the application of the ICDAS method. 
The ICDAS examination will be conducted using gauze, which helps remove residual 
plaque and debris while allowing for the assessment of small cavitations, surface 
contour, and the histological depth of carious lesions based on surface characteristics. 

79 
A sharp explorer will not be used, as it does not improve detection accuracy and may 
damage the enamel affected by early carious lesions. Depending on the severity of the 
lesion, ICDAS detection codes for coronal caries range from zero to six. The assigned 
codes and corresponding criteria are summarized in Figure 3.2. 
 
Table 3.3 
ICDAS detection codes for coronal caries 
Code 
Description 
0 
Sound 
1 
First visual change in enamel (seen only after prolonged air drying or 
restricted to the confines of a pit or fissure) 
2 
Distinct visual change in enamel 
3 
Localized enamel breakdown (without clinical visual signs of 
dentinal involvement) 
4 
Underlying dark shadow from dentin 
5 
Distinct cavity with visible dentin 
6 
Extensive distinct cavity with visible dentin 
The classification of ECC in this study was adapted from the ICDAS. However, 
the original seven ICDAS stages were simplified into four categories (0, 1, 2, and 3). In 
both clinical and epidemiological settings, this four-stage ECC classification facilitates 
simpler, faster, and more valid diagnostic decision-making, while also indicating stage-
specific treatment options (Evans et al., 2018). Specifically, the code 0 represents a 
sound tooth, code 1 represents smooth white spot lesion, code 2 represents enamel 
breakdown, and code 3 represents cavity into dentine (Evans et al., 2018). A standard 
charting form will be used to record the clinical findings (Evans et al., 2018), as 
provided in Appendix B. 
3.6.2(d) Dental Caries Risk Assessment 
Caries Risk Assessment (CRA) is an evaluation of a patient’s risk of developing 
caries. The assessment provides information that would be useful in the decision-
making process, including determining additional diagnostic procedures, treatment 
planning, and recall appointments. The CRA also serves as an important tool in the 

80 
management of patients and is focused on the aims of maintaining health and 
preserving tooth structure for effective delivery of risk-based caries care that prevents 
new lesions, controls initial caries non-operatively and always preserves tooth tissue 
(American Academy of Pediatric Dentistry, 2022). 
 
 
In this study, CRA will combine several factors deemed important in caries 
development and progression as follows: 1) presence of an active carious lesion, 2) 
oral hygiene, 3) exposure to sugary drinks and snacks, 4) night-time bottle feeding, 
and 5) fluoride exposure (American Academy of Pediatric Dentistry (2022). The 
following factors will be assessed and for each factor, the child will be categorized as 
having a high risk or not. 
 
1. 
Presence of active carious lesions 
 
A diagnosis of dental caries is made from the clinical examination. The presence of 
one or more active carious lesions (cavitated or non-cavitated) is considered high risk. 
 
2. 
Oral Hygiene 
The oral hygiene status of the infant will be assessed using the Silness-Loë index 
during the clinical examination (World Health Organization, 2013). The measurement 
of the state of oral hygiene is based on recording both soft debris and mineralised 
deposits on the teeth. Each of the four surfaces of the teeth (buccal, lingual, mesial, and 
distal) is given a score from zero to three (Figure 3.3) The presence of at least one 
tooth with a score of 2 is considered a high risk. 
 
 

81 
Table 3.4 
The Silness-Loë index scoring 
Score 
Description 
0 
No plaque 
1 
A film of plaque adhering to the free gingival margin and adjacent area 
of the tooth. The plaque may be seen in situ only after the application 
of the disclosing solution or by using the probe on the tooth surface. 
2 
Moderate accumulation of soft deposits within the gingival pocket, or 
the tooth and gingival margin, which can be seen with the naked eye. 
3 
An abundance of soft matter within the gingival pocket and/or on 
the tooth and gingival margin. 
 
3. Exposure to sugary drinks and snacks 
 
The mothers will be asked about whether their infants are being given between 
meal sugary snacks or beverages more than three times each day within the past 
week. Consumption of sugar-containing snacks or beverages more than three 
times per day is considered high risk. 
 
4. Night-time bottle feeding 
A child who is put to bed with a bottle of milk or other drinks containing natural or 
added sugar is considered at high risk. 
 
5. Fluoride Exposure 
Not using fluoridated toothpaste or using fluoridated toothpaste less than once 
daily is considered high risk.  
 
A checklist was prepared to record the findings in Appendix C. A child is 
considered at high risk for caries if he or she is found at high risk for any of the 
following factors: 
a. Presence of one or more active carious lesions (cavitated or non- 
cavitated).  

82 
b. The presence of at least one tooth with a score 2 for plaque 
accumulation 
c. Consumption of between meals sugar-containing snacks or beverages 
more than three times per day 
d. Putting to bed with a bottle containing natural or added sugar 
3.7 
Operational Definition   
1. MI is a patient-centred guiding method for enhancing motivation to change. MI 
is a collaborative process of decision-making. Its style is empathetic, 
nonjudgmental, supportive, and nonconfrontational. It acknowledges that 
behavior change is driven by motivation, not information (Miller & Rollnick, 
2002). 
2. A mother is defined by (Laws of Malaysia Act 351, 1961) as the primary 
caregiver of an infant, responsible for the child's support, health, and education, 
regardless of biological relation. This includes biological mothers, legal 
guardians, stepmothers, or any female guardian who has custody of the infant 
and takes care of them most of the time. This definition excludes biological 
mothers who work abroad or are unable to provide daily care for the infant. 
a. Duties of Guardian of Person (Section 3): 
i. The guardian (which can be a non-biological caretaker) is 
responsible for the child's custody, support, health, and 
education. 
b. Equality of Parental Rights (Section 5): 
i. The law grants equal rights to both parents regarding 
guardianship, meaning that a non-biological mother (such as a 

83 
stepmother or legal guardian) who takes primary responsibility 
for the child can also be included in the definition. 
c. Appointment of Guardians (Sections 6, 7, and 8): 
i. The surviving parent or a court-appointed guardian (which can 
include 
non-biological 
caregivers) 
may 
assume 
full 
responsibility for the child. 
ii. In cases where both parents are deceased, a legal guardian is 
appointed (which could be a stepmother, foster mother, or other 
non-biological caregivers). 
d. Protector as Temporary Guardian (Section 8A): 
i. In cases where an infant is abandoned or has no biological parent 
available, a temporary guardian (appointed by authorities) takes 
over custody, further supporting the inclusion of non-biological 
caregivers. 
3. An infant refers to children aged one and below (Centres of Control Diseases, 
2025) 
3.8 
Data Collection   
Prior to data collection, the eligibility of participants will be determined based 
on predefined inclusion and exclusion criteria. Eligible participants will be identified 
during their scheduled visits to the MCHCs. A brief verbal screening will be conducted 
to confirm that they meet the inclusion criteria. Those who are found to be eligible will 
be approached by the researcher and invited to participate in the study. 

84 
Following informed consent and confirmation of eligibility, baseline maternal 
information, specifically maternal age and parity will be collected through verification 
from the maternal and child health records available at the clinic. These variables will 
be documented in a recruitment monitoring log to track the distribution of participants 
across maternal age groups and parity categories in both the intervention and control 
districts (Higgins et al., 2019). 
To enhance comparability between groups, each participant in the intervention 
group will be matched with a participant from the control group based on similar 
maternal characteristics. Exact matching will be performed where possible; otherwise, 
the closest match within a predefined acceptable range will be selected. This approach 
maintains the integrity of the initial sampling process while reducing potential 
confounding through matching (Higgins et al., 2019). Maternal age will be categorized 
into four groups (18–24 years, 25–29 years, 30–34 years, and ≥35 years), while parity 
will be classified into two groups: primiparous (one previous birth) and multiparous 
(two or more previous births) (Alcock et al., 2025). 
The purpose of the study, procedures involved, potential risks and benefits, and 
the voluntary nature of participation will be explained in detail to the participants. An 
information sheet will be provided in the Malay language. Participants will be assured 
of the confidentiality of their responses and informed that they may withdraw from the 
study at any time without affecting their access to healthcare services. Written informed 
consent will be obtained prior to any data collection activities. After consent has been 
obtained, the data collection will be proceeded. 
 

85 
Study group  
The eligible six-month-old infants who attend the MCHC for the 
pneumococcal immunization (second dose) will undergo clinical oral examination and 
assessment of caries risk. Their mothers will be given the first set of questionnaires to 
assess knowledge and practices related to oral healthcare of infants aged 6 to 9 months. 
This stage of assessment is called baseline 1. The mothers will then be given the AG 
for six to nine-month-old infants through MI technique.  
The MI session will be conducted one-to-one with the infant’s mother. Each 
session will last approximately 30 minutes, as recommended by prior studies (Harrison 
et al., 2012; Jamieson et al., 2018; Saengtipbovorn, 2017; Weinstein et al., 2004), 
which have shown that such duration is both feasible and effective for facilitating 
meaningful dialogue and behaviour change. 
 
 
After three months, the infants, who will be nine-month-old will undergo 
another clinical oral examination and an assessment of caries risk when they attend the 
MCHC for MMR immunization (first dose). Their mothers will be given the first set 
of questionnaires again to assess knowledge and practices related to oral healthcare of 
infants aged six to nine months. This stage of assessment is called evaluation 1. 
 
Immediately following re-administration of the first set of the questionnaires, 
the second set of the questionnaires to assess knowledge and practices related to oral 
healthcare of infants aged nine to 12 months will be administered. This stage of 
knowledge and practices assessment is called baseline 2. The mothers will then be 
given the AG for nine to 12-month-old infants through MI technique. 

86 
 
After another three months, the infants, who will be 12-month-old will undergo 
the final clinical oral examination and assessment of caries risk when they attend the 
MCHC for MMR immunization (second dose). Their mothers will be given the second 
set of questionnaires again to assess knowledge and practices related to oral healthcare 
of infants aged nine to 12 months. This stage of assessment is called evaluation 2. 
 
The estimated time for each clinical oral examination for infants, including 
assessment of caries risk is eight minutes, and for mothers to complete each set of 
questionnaires is around seven minutes. The AG delivery through MI technique, 
which includes the interactive one-to-one sessions with the mothers, is estimated to 
take approximately 30 minutes (Jamieson et al., 2018).Therefore, the anticipated 
overall duration of each respondent in the study group at 6 months is around 45 
minutes. 
 
At nine months, the data collection time will take approximately 52 minutes, 
covering the infant oral examination and assessment of caries risk, re-administration 
of the knowledge and practices questionnaire for six to nine months, delivery of age-
appropriate AG for nine to 12 months through MI technique, and administration of 
knowledge and practices questionnaires for nine to 12 months. At 12 months, the data 
collection time will be around 15 minutes, covering the infant oral examination and 
assessment of caries risk, and re-administration of knowledge and practices 
questionnaire for nine to 12 months. 
This intervention will be delivered to the selected participants who are waiting 
for their turn to meet the nurses or medical officers or family medicine specialists by 

87 
the well-trained principal investigator in MI. The MI intervention will include an 
interactive one-on-one session using the MI protocol tailored to meet the individual 
needs of each participant. An appropriate room or space will be identified at the selected 
MCHC for the conduct of the intervention  (Harrison et al., 2011; Batliner et al., 2014). 
Two follow up phone calls will be conducted two weeks and one month after each of 
the MI intervention for each participant in the study group (Weinstein, 2006; Weinstein 
et al., 2004).  
Control Group 
The eligible six-month-old infants who attend the MCHC for the pneumococcal 
immunization (second dose) will undergo a clinical oral examination. Their mothers 
will be given the first set of questionnaires to assess knowledge and practices related to 
oral healthcare of infants aged six to nine months. This stage of assessment will be 
referred to as baseline 1. The mothers will then receive the conventional MOH AG 
according to the MOH Early Childhood Oral Healthcare Programme. 
After three months, the infants, who will be nine-month-old, will undergo 
another clinical oral examination when they attend the MCHC for MMR immunization 
(first dose). Their mothers will be given the first set of questionnaires again to assess 
knowledge and practices related to oral healthcare of infants aged six to nine months. 
This stage of assessment will be referred to as evaluation 1. Immediately following re-
administration of the first set of questionnaires, the second set of questionnaires to 
assess knowledge and practices related to oral healthcare of infants aged nine to 12 
months will be administered. This stage of knowledge and practices assessment will be 
referred to as baseline 2. 

88 
After another three months, the infants, who will be 12-month-old, will undergo 
the final clinical oral examination when they attend the MCHC for MMR immunization 
(second dose). Their mothers will be given the second set of questionnaires again to 
assess knowledge and practices related to oral healthcare of infants aged nine to 12 
months. This stage of assessment will be referred to as evaluation 2. 
The estimated time for each clinical oral examination for infants, including the 
assessment of caries risk, will be approximately eight minutes. Completion of each set 
of questionnaires by the mothers is expected to take around seven minutes. Therefore, 
the anticipated overall duration of each respondent in the control group at 6 months 
(baseline 1) is around 15 minutes, covering the infant oral examination and the 
administration of the first set of questionnaires. 
At nine months (evaluation 1), the data collection time is expected to take 
approximately 22 minutes, covering the infant oral examination, re-administration of 
the first set of questionnaires for six to nine months, and administration of the second 
set of questionnaires for nine to 12 months. At 12 months (evaluation 2), the data 
collection time will be approximately 15 minutes, covering the infant oral examination 
and re-administration of the second set of questionnaires for nine to 12 months. The 
intervention in the control group will consist only of the conventional MOH AG. No 
motivational interviewing (MI) or additional AG intervention will be provided to the 
control group. 
 
 
 

89 
3.9 
Flow Chart of the Study 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 3.2 Flow Chart of the Study 
Kuala 
Terengganu 
Kuala 
Nerus 
Setiu 
Besut 
Hulu 
Terengganu 
Marang 
Dungun 
Kemaman 
Terengganu 
Selection based on district with similar characteristics 
Control District = Hulu Terengganu 
Randomization 
Study District = Setiu 
In the same building area as the primary dental clinics 
3 MCHCs 
5 MCHCs 
MCHC 
Permaisuri 
MCHC Sg 
Tong 
MCHC Sri 
Langkap 
MCHC 
Kuala Berang 
MCHC Ajil 
MCHC 
Tengkawang 
Enrolment
Systematic random sampling 
38 infants-
mothers 
38 infants-
mothers 
38 infants-
mothers 
38 infants-
mothers 
38 infants-
mothers 
38 infants-
mothers 
114 infant-mother pairs (study group)  
114 infant-mother pairs (control group)  
Study sample (n=228) 
At 6 months 
1.Infant:ECC & caries risk (baseline 1) 
2.Mother: Knowledge and practice for 6-9 months (baseline 1) 
Follow up 1 
At 9 months 
1.Infant: ECC & caries risk (evaluation 1) 
2.Mother: Knowledge and practice for 6-9 months (evaluation 1) 
& Knowledge and practice for 9-12 months (baseline 2) 
Follow up 2 
At 12 months 
1.Infant: ECC & caries risk (evaluation2) 
2.Mother: Knowledge and practice for 9-12 months (evaluation 2) 
Data entry, analysis and interpretation 
Report writing 
Report submission and presentation 
AG11
At 6 months 
1.Infant:ECC & caries risk (baseline 1) 
2.Mother: Knowledge and practice for 6-9 months (baseline 1) 
Conventional MOH AG  
At 9 months 
1.Infant: ECC & caries risk (evaluationn1) 
2.Mother : Knowledge and practice for 6-9 months (evaluation 1) & 
Knowledge and practice for 9-12 months (baseline 2) (baseline 2). 
At 12 months 
1.Infant: ECC & caries risk (evaluation 2) 
2.Mother: Knowledge and practice for 9-12 months (evaluation 2) 
Simple random sampling  
Assessed for eligibility  
Conventional MOH AG  
AG for 6-9 months using MI technique  
(follow up phone calls after 2 weeks after and 1 month after) 
AG for 9-12 months using MI technique 
(follow up phone calls after 2 weeks and 1 month) 
2 district : Setiu and Hulu Terengganu 

90 
3.10 
Statistical Analysis   
For Objectives 1 and 2, descriptive analysis will be used to summarize the 
knowledge and practices on infant oral health care among mothers in both the study and 
control groups. Frequency and percentages will be used to present the data. For 
Objectives 3 and 4, a paired t-test will be conducted to compare the mean knowledge 
and practice scores regarding infant oral health care before (at six months) and after (at 
nine and 12 months) the respective AG intervention within each group.  
For Objective 5, an independent t-test will be used to compare the mean 
knowledge and practice scores between the study and control groups after they have 
received their respective AG interventions. For Objectives 6 and 7, the McNemar’s test 
will be applied to compare the incidence of ECC and dental caries risk status within 
each group before and after the respective AG intervention.  
For Objective 8, a Chi-Square test will be performed to compare the incidence 
of ECC and dental caries risk status between the study and control groups after the 
respective AG intervention. All analyses will be conducted using SPSS version 29.0, 
with significance set at p < 0.05. 
3.11 
Ethical Consideration   
Ethical approval will be obtained from the Human Research and Ethics 
Committee of Universiti Sains Malaysia, Ministry of Health Malaysian Research Ethics 
Committee and National Medical Research Register, Ministry of Health Malaysia.   
3.11.1 
 Subject Vulnerability  
The research is on mothers and their infants who are considered the vulnerable 
group. Data collection using a self-administered questionnaire will not involve any 

91 
emotional disturbance or psychological distress. Thus, there will be minimal risk 
involved to the mothers and their infants. The clinical oral examination is also a standard 
clinical procedure that is highly recommended for all 6 to 12-month-old infants. The 
mothers of infants will be individually approached by the researcher while waiting for 
their infants’ turn to be examined for vaccination appointment at MCHCs. 
 
3.11.2 
Withdrawal Criteria 
The participants will be made aware that participation in the research is 
completely voluntary, and they have all rights to withdraw from the research at any time 
without any penalty or loss of benefits to which they are otherwise entitled. When 
withdrawing from the study, the participant should inform the research team of his/ her/ 
their decision. A participant may, but is not obligated to, give the research team their 
reason(s) for withdrawing from the study. When a participant withdraws from the study, 
any data collected from them up to the withdrawal will still be used for the study. 
 
3.11.3 
Risk of Study 
The research study will not involve clinical trials, and self-administered questionnaire 
will not cause any emotional disturbance or psychological distress; thus, there will be 
minimal risk involved to the infants ang their mothers in the study as well as control 
group. This study does not impose any topical fluoride application on infants. Infants 
found with early dental caries lesions were referred to the nearest dental clinic for further 
management. 

92 
3.11.4 
Declaration of Absence of Conflict of Interest  
This study is conducted as per requirement to fulfil Doctorate in Dental Public 
Health programme under course GGA 608 (Research Project), thus there shall be no 
conflict of interest at any stage of the study.  
 
3.11.5 
Privacy and Confidentiality 
Information obtained will be entered into SPSS software. Only research team 
members can access the data. The data of subjects will be kept private and confidential. 
All records will be kept confidential and will be available only to professional 
researchers, doctors, and staff. Subjects’ names will be held on a password-protected 
database and will be linked only with a study identification number for this research. 
Instead of patient identifiers, the identification number will be used on the subject data 
sheets. All data will be entered into a computer that is password protected and will be 
maintained for a minimum of five years after the completion of study. 
 
Subjects will not be allowed to view their study data, as it will be consolidated 
into a database. Subjects can write to the investigators to request access to study 
findings. Data obtained from this study will be published for knowledge purposes and 
will be presented as grouped data and thus will not identify the respondents individually. 
The data will not be disclosed to any parties working on this project unrelated to this 
study. The data will be destroyed after five years upon completion of this study. 
 
3.11.6 
Community Benefit  
The questions in the questionnaire may not cause distress or anxiety, nor are 
they socially sensitive. Study procedures will be provided at no cost to the respondents. 
The potential benefit of participation in this study for mothers is an enhancement in 

93 
knowledge concerning the oral healthcare of infants based on their age-appropriate 
interval, as well as a tailored dental consultation in accordance with their child’s 
vaccination appointment at the MCHCs. This study potentially benefit them by 
nurturing the appropriate knowledge and practices on infants’ oral healthcare to 
ultimately reducing the ECC as well as their caries risk. 
3.11.7 
Study funding 
The study is self-funded by researchers. 
3.11.8 
Honorarium and Incentives  
Each respondent will receive a token of appreciation for their participation. 
 
 
 
 
 

94 
 
CHAPTER 4  
 
EXPECTED RESULTS 
Table 4.1 
Characteristics of mothers (n=228) 
 
Frequency (%) 
Characteristics 
Study 
Control 
Total 
Age 
 
 
 
Relationship with infant 
 
 
 
   Biological mother  
 
 
 
   Stepmother 
   Adoptive mother 
 
 
 
   Others  
 
 
 
 
 
 
 
Race 
 
 
 
   Malay 
 
 
 
   Chinese 
 
 
 
   Indian 
 
 
 
   Bumiputera Sabah 
 
 
 
   Bumiputera Sarawak 
 
 
 
Educational background 
 
 
 
   No standard 
 
 
 
   Primary school 
 
 
 
   SRP/ PMR or equivalent 
 
 
 
   SPM or equivalent 
 
 
 
   Vocational training/ certificate 
 
 
 
   STPM/Diploma or equivalent 
 
 
 
   Degree (Bachelor/Master/Doctor of 
Philosophy) 
 
 
 
 
 
Working Status 
 
 
 

95 
 
   Employed 
 
 
 
   Unemployed 
 
 
 
Monthly household income 
 
 
 
<RM4,849 (B40) 
 
 
 
RM4,850 – RM10,959 (M40) 
 
 
 
>RM10,960 (T20) 
 
 
 
Last dental visit 
   Within the past 6 months 
 
 
 
   Within the past 12 months 
 
 
 
   More than 1 year 
 
 
 
   Never 
 
 
 
Exposure to infant oral health education 
   Dentist 
 
 
 
Medical doctor 
 
 
 
Dental nurse 
 
 
 
Medical nurse 
 
 
 
Reading materials 
 
 
 
Family members or friends 
 
 
 
Never had 
 
 
 
*mean (SD) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

96 
 
Table 4.2 
Knowledge of 6-9 months infant oral health care among mothers in the study group (n=228) 
 
 
Frequency (%) 
Variable 
 
Correct response 
Incorrect 
response 
Don’t know response 
Dental growth and development 
 
 
 
 
K01: Emergence of first primary tooth 
 Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
K02: Component of oral cavity 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
Oral Disease Prevention 
 
 
 
 
K03: Need of oral cleaning for gum pads 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
K04: Pivotal time for oral cleaning 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
Diet and Nutrition 
 
 
 
 
K05: Breastfeeding and bottle feeding 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
K06: Sugary food intake 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
K07: Instant juices and flavoured milk intake 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
Oral Habits 
 
 
 
 
K08: Teething 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
K09: Teething objects’ safety and cleanliness 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
Dental Injury Prevention  
 
 
 
 
Possible occurrence of dental injury among infants: 
 
 
 
 
K10: Bruised lips 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
K11: Ulcerated tongue 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
K12: Burned lips 
Baseline 1 
 
 
 

97 
 
 
Evaluation 1 
 
 
 
K13: Dislocated tooth 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
Periodic oral examination 
 
 
 
 
K14: Need of dental visit for infant with non- erupted 
teeth 
Baseline 1 
Evaluation 1 
 
 
 
 
 
 
 
 
K15: Every infant should have an oral health risk 
assessment 
Baseline 1 
Evaluation 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

98 
 
Table 4.3 
Practice of 6-9 months infant oral health care among mothers in the study group (n=228) 
 
 
Frequency (%) 
Variable 
 
Inappropriate response 
Appropriate response 
Oral Disease Prevention 
 
 
 
P01: Examining infant oral cavity 
Baseline 1 
 
 
 
Evaluation 1 
 
 
Frequency of infant oral cleaning: 
 
 
 
P02: Gums 
Baseline 1 
 
 
 
Evaluation 1 
 
 
P03: Teeth 
Baseline 1 
 
 
 
Evaluation 1 
 
 
Tool used to clean infant oral cavity for: 
Evaluation 1 
 
 
P04: Gums 
Baseline 1 
 
 
 
Evaluation 1 
 
 
P05: Teeth 
Baseline 1 
 
 
 
Evaluation 1 
 
 
Diet and Nutrition 
 
 
 
Drinks other than plain water and milk given through: 
 
 
 
P06: Bottle 
Baseline 1 
 
 
 
Evaluation 1 
 
 
P07: Cup or straw 
Baseline 1 
 
 
 
Evaluation 1 
 
 
P08: Sugary food intake 
Baseline 1 
 
 
 
Evaluation 1 
 
 
Oral Habits 
 
 
 
P09 Teething objects’ safety and cleanliness 
Baseline 1 
 
 
 
Evaluation 1 
 
 
Oral Injury Prevention 
 
 
 
P10 Letting infant playing with risky objects 
Evaluation 1 
 
 
 
Baseline 1 
 
 
Periodic oral examination 
 
 
 
P11 Bringing infant to dental clinic 
Baseline 1 
 
 
 
Evaluation 1 
 
 

99 
 
aOnly for infant with erupted teeth 
 
Table 4.4 
Knowledge of 9-12 months infant oral health care among mothers in the study group (n=228) 
Variable 
 
 
Frequency (%) 
 
 
Correct response 
Incorrect response 
Don’t know response 
Dental growth and development 
 
K01: White spots on primary tooth surface 
Baseline 2 
Evaluation 2 
K02: Dental plaque contains bacteria 
Baseline 2 
Evaluation 2 
K03: Dental plaque may cause dental caries 
Baseline 2 
Evaluation 2 
K04: Deciduous teeth function as space maintainer Baseline 2 
 
Evaluation 2 
K05: Deciduous teeth are not important 
Baseline 2 
Evaluation 2 
Oral Disease Prevention 
 
K06: Dental plaque removal with mechanical 
method 
Baseline 2 
 
Evaluation 2 
K07: Fluoride toothpaste helps preventing dental 
caries 
Baseline 2 
 
Evaluation 2 
K08: Pivotal time for toothbrushing 
Baseline 2 
Evaluation 2 
Diet and Nutrition 
K09: Frequent cariogenic food intake causes dental 
caries 
Baseline 2 
Evaluation 2 
Food containing hidden sugar includes: 
K10: Fresh fruits 
Baseline 2 
Evaluation 2 
K11: Instant baby puree 
Baseline 2 

100 
 
Evaluation 2 
K12: Instant baby rusk 
Baseline 2 
Evaluation 2 
Oral Habits 
 
K13: Letting infants fall asleep with milk in the 
mouth 
Baseline 2 
 
Evaluation 2 
K14: Non-nutritive sucking habit should stop at 18 
months 
Baseline 2 
 
Evaluation 2 
Dental Injury Prevention 
 
K15: Dental injury may occur during infant 
walking training 
Baseline 2 
 
Evaluation 2 
K16: Primary tooth trauma influences towards 
permanent tooth development 
Baseline 2 
 
Evaluation 2 
Periodic oral examination 
K17: Need of dental visit for infant with at least 
one erupted tooth 
Baseline 2 
 
Evaluation 2 
K18: Importance of regular infant dental check-ups Baseline 2 
 
Evaluation 2 
K19: First dental visit should be at least at 12 
months old 
Baseline 2 
 
Evaluation 2 

101 
 
Table 4.5 
Practice of 9-12 months infant oral health care among mothers in the study group (n=228) 
 
 
Frequency (%) 
Variable 
 
Inappropriate response 
Appropriate response 
Oral Disease Prevention 
 
 
P01: Examining infant oral cavity 
Baseline 2 
 
 
Evaluation 2 
 
 
P02: Infant toothbrushing practice conduct 
Baseline 2 
 
 
Evaluation 2 
 
 
P03: Infant toothbrushing at night before sleep 
Baseline 2 
 
 
Evaluation 2 
 
 
P04: Tool used for infant toothbrushing 
Baseline 2 
 
 
Evaluation 2 
 
 
P05: Fluoridated toothpaste usage 
Baseline 2 
 
 
Evaluation 2 
 
 
P06: Fluoridated toothpaste amount 
Baseline 2 
 
 
Evaluation 2 
 
 
Diet and Nutrition 
 
 
P07: Sugary snacking habits frequency 
Baseline 2 
 
 
Evaluation 2 
 
 
P08: Feeding infants with instant puree or baby rusk 
Baseline 2 
 
 
Evaluation 2 
 
 
Oral Habits 
 
 
P09: Infant training to sip water from a cup 
Baseline 2 
 
 
Evaluation 2 
 
 
P10: Letting infants fall asleep with milk in the mouth 
Baseline 2 
 
 
Evaluation 2 
 
 
Dental Injury Prevention 
 
 
 
P11: Letting infants play with risky objects 
Baseline 2 
 
 
Evaluation 2 
 
 
Periodic oral examination 
 
 
 
P12 Bringing infant to dental clinic 
Baseline 2 
 
 
Evaluation 2 
 
 

102 
 
aOnly for infant with erupted teeth 
Table 4.6 
Knowledge of 6-9 months infant oral health care among mothers in the control group (n=228) 
) 
 
 
Frequency (%) 
Variables 
 
Correct response Incorrect response 
Don’t know 
response 
Dental growth and development 
 
 
 
K01: Emergence of first primary tooth 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
K02: Component of oral cavity 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
Oral Disease Prevention 
 
 
 
K03: Need of oral cleaning for gum pads 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
K04: Pivotal time for oral cleaning 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
Diet and Nutrition 
 
 
 
K05: Breastfeeding and bottle feeding 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
K06: Sugary food intake 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
K07: Instant juices and flavoured milk intake 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
Oral Habits 
 
 
 
K08: Teething 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
K09: Teething objects’ safety and cleanliness 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 

103 
 
Dental Injury Prevention 
 
 
 
Possible occurrence of dental injury among infants: 
 
 
 
K10: Bruised lips 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
K11: Ulcerated tongue 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
K12: Burned lips 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
K13: Dislocated tooth 
Baseline 1 
 
 
 
Evaluation 1 
 
 
 
Periodic oral examination 
 
 
 
K14: Need of dental visit for infant with non- erupted teeth Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
K15: Every infant should have an oral health risk assessmentBaseline 1 
 
 
 
 
Evaluation 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

104 
 
 
 
Table 4.7 
Practice of 6-9 months infant oral health care among mothers in the control group (n=228) 
 
 
Frequency (%) 
Variable 
 
Inappropriate response 
Appropriate response 
Oral Disease Prevention 
 
 
 
P01: Examining infant oral cavity 
Baseline 1 
 
 
 
Evaluation 1 
 
 
Frequency of infant oral cleaning: 
 
 
 
P02: Gums 
Baseline 1 
 
 
 
Evaluation 1 
 
 
P03: Teeth 
Baseline 1 
 
 
 
Evaluation 1 
 
 
Tool used to clean infant oral cavity for: 
 
 
 
P04: Gums 
Baseline 1 
 
 
 
Evaluation 1 
 
 
P05: Teeth 
Baseline 1 
 
 
 
Evaluation 1 
 
 
Diet and Nutrition 
 
 
 
Drinks other than plain water and milk given through: 
 
 
 
P06: Bottle 
Baseline 1 
 
 
 
Evaluation 1 
 
 
P07: Cup or straw 
Baseline 1 
 
 
 
Evaluation 1 
 
 
P08: Sugary food intake 
Baseline 1 
 
 
 
Evaluation 1 
 
 
Oral Habits 
 
 
 
P09: Teething objects’ safety and cleanliness 
Baseline 1 
 
 
 
Evaluation 1 
 
 
Dental Injury Prevention 
 
 
 
P10: Letting infant playing with risky objects 
Baseline 1 
 
 

105 
 
 
Evaluation 1 
 
 
 
 
Periodic oral examination 
 
 
 
P11: Bringing infant to dental clinic 
Baseline 1 
 
 
 
Evaluation 1 
 
 
aOnly for infant with erupted teetth 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

106 
 
 
Table 4.8 
Knowledge of 9-12 months infant oral health care among mothers in the control group (n=228) 
Variable 
 
Frequency (%) 
 
Correct response 
Incorrect response 
Don’t know response 
Dental growth and development 
 
 
 
 
K01: White spots on primary tooth surface 
Baseline 2 
 
 
 
Evaluation 2 
 
 
 
K02: Dental plaque contains bacteria 
Baseline 2 
 
 
 
Evaluation 2 
 
 
 
K03: Dental plaque may cause dental caries 
Baseline 2 
 
 
 
Evaluation 2 
 
 
 
K04: Deciduous teeth function as space maintainer 
Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
K05: Deciduous teeth are not important 
Baseline 2 
 
 
 
Evaluation 2 
 
 
 
Oral Disease Prevention 
 
 
 
K06: Dental plaque removal with mechanical method 
Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
K07: Fluoride toothpaste helps preventing dental caries 
Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
K08: Pivotal time for toothbrushing 
Baseline 2 
 
 
 
Evaluation 2 
 
 
 
Diet and Nutrition 
 
 
 
K09: Frequent cariogenic food intake causes dental caries 
Baseline 2 
 
 
 
Evaluation 2 
 
 
 
Food containing hidden sugar includes:  
 
 
 
K10: Fresh fruits 
Baseline 2 
 
 
 
Evaluation 2 
 
 
 
K11: Instant baby puree 
Baseline 2 
 
 
 
Evaluation 2 
 
 
 
K12: Instant baby rusk 
Baseline 2 
 
 
 
Evaluation 2 
 
 
 

107 
 
Oral Habits 
 
 
 
 
K13: Letting infants fall asleep with milk in the mouth 
Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
K14: Non-nutritive sucking habit should stop at 18 months 
Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
Dental Injury Prevention 
 
 
 
 
K15: Dental injury may occur during infant walking training Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
K16: Primary tooth trauma influences towards permanent
tooth development 
Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
Periodic oral examination 
 
 
 
K17: Need of dental visit for infant with at least one erupted
tooth 
Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
K18: Importance of regular infant dental check- ups 
Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
K19: First dental visit should be at least at 12 months old 
Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
  
 
 
 
 
 
 
 
 
 

108 
 
Table 4.9 
Practice of 9-12 months infant oral health care among mothers in the control group (n=228) 
 
 
Frequency (%) 
Variables 
 
Inappropriate response 
Appropriate response 
Oral Disease Prevention 
 
 
 
P01: Examining infant oral cavity 
Baseline 2 
 
 
 
Evaluation 2 
 
 
P02: Infant toothbrushing practice conduct 
Baseline 2 
 
 
 
Evaluation 2 
 
 
P03: Infant toothbrushing at night before sleep 
Baseline 2 
 
 
 
Evaluation 2 
 
 
P04: Tool used for infant toothbrushing 
Baseline 2 
 
 
 
Evaluation 2 
 
 
P05: Fluoridated toothpaste usage 
Baseline 2 
 
 
 
Evaluation 2 
 
 
P06: Fluoridated toothpaste amount 
Baseline 2 
 
 
 
Evaluation 2 
 
 
Diet and Nutrition 
 
 
 
P07: Sugary snacking habits frequency 
Baseline 2 
 
 
 
Evaluation 2 
 
 
P08: Feeding infants with instant puree or baby rusk 
Baseline 2 
 
 
 
Evaluation 2 
 
 
Oral Habits 
 
 
 
P09: Infant training to sip water from a cup 
Baseline 2 
 
 
 
Evaluation 2 
 
 
P10: Letting infants fall asleep with milk in the mouth 
Baseline 2 
 
 
 
Evaluation 2 
 
 
Dental Injury Prevention 
 
 
 
P11: Letting infant playing with risky objects 
Baseline 2 
 
 
 
Evaluation 2 
 
 
Periodic oral examination 
 
 
 
P12: Bringing infant to dental clinic 
Baseline 2 
 
 
 
Evaluation 2 
 
 

109 
 
aOnly for infant with erupted teeth 
 

110 
 
Table 4.10 
Knowledge and practice score on infant oral health care of mothers in the 
study group (n=228) 
Variable 
 
Mean 
(SD) 
Mean 
diff 
(95% 
CI) 
t-stat 
(df)a 
p-valuea 
Knowledge score 
Baseline 1 
 
 
 
 
 
Evaluation 1 
 
 
 
 
 
Baseline 2 
 
 
 
 
 
Evaluation 2 
 
 
 
 
Practice score 
Baseline 1 
 
 
 
 
 
Evaluation 1 
 
 
 
 
 
Baseline 2 
 
 
 
 
 
Evaluation 2 
 
 
 
 
aPaired t-test, df= degree of freedom 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

111 
 
Table 4.11 
Knowledge and practice score on infant oral health care of mothers in the 
control group (n=228) 
Variable 
 
Mean 
(SD) 
Mean 
diff 
(95% 
CI) 
t-stat 
(df) 
p-valuea 
Knowledge score 
Baseline 1 
 
 
 
 
 
Evaluation 1 
 
 
 
 
 
Baseline 2 
 
 
 
 
 
Evaluation 2 
 
 
 
 
Practice score 
Baseline 1 
 
 
 
 
 
Evaluation 1 
 
 
 
 
 
Baseline 2 
 
 
 
 
 
Evaluation 2 
 
 
 
 
aPaired t-test, df= degree of freedom 
 

112 
 
 
 
Table 4.12 
Knowledge and practice score on infant oral health care between mothers in 
the study and control group (n=228) 
 
 
 
Mean (SD) 
Variables 
 
Study 
group 
Control 
group 
t-stat (df)a p-valuea 
Knowledge score 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
 
Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
 
Practice score 
Baseline 1 
 
 
 
 
Evaluation 1 
 
 
 
 
Baseline 2 
 
 
 
 
Evaluation 2 
 
 
 
 
aIndependent t-test, df= degree of freedom

113 
 
Table 4.13 
Early dental caries lesion of infants in study group (n=114) 
 
Frequency (%) 
Variables 
Baseline 
Evaluation 1 
Evaluation 2 
Early dental caries lesion 
 
 
 
   Sound 
 
 
 
   Non-cavitated lesion 
 
 
 
   Cavitated lesion 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

114 
 
Table 4.14 
Caries risk assessment of infants in the study group group (n=114) 
 
 
Frequency (%) 
Variable 
 
Not present 
Present 
Risk Factor 1 
Baseline 
 
 
≥1 active carious lesion (cavitated or 
non-cavitated)a 
Evaluation 1 
 
 
 
Evaluation 2 
 
 
Risk Factor 2 
Baseline 
 
 
Visible plaque (having at least 1 tooth 
with grade 2 plaque accumulation- 
Evaluation 1 
 
 
Silness & Löe Plaque Index)a 
Evaluation 2 
 
 
Risk Factor 3 
Baseline 
 
 
between meal sugar-containing snacks 
or beverages >3 times per day 
Evaluation 1 
 
 
 
Evaluation 2 
 
 
Risk Factor 4 
Baseline 
 
 
Child is put to bed with a bottle 
containing natural or added sugar 
Evaluation 1 
 
 
 
Evaluation 2 
 
 
Risk Factor 5 
Baseline 
 
 
Not using fluoridated toothpaste to 
clean the erupted tootha 
Evaluation 1 
 
 
 
Evaluation 2 
 
 
aInfant with erupted teeth 
 
 
 
 
 
 
 
 
 

115 
 
Table 4.15 
Dental caries risk exposure of infants in the study group (n=114) 
 
Percentage (%) 
 
Percentage (%) 
 
Variables 
Baseline 
Evaluation 1 
p-value 
Baseline 
Evaluation 2 
p-value 
Dental caries risk 
exposure 
 
 
 
 
 
 
   Low risk 
 
 
 
 
 
 
   High risk 
 
 
 
 
 
 
aMcNemar test, *statistically significant (p<0.05) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

116 
 
 
Table 4.16 
Early dental caries lesion of infants in control group (n=114) 
 
Frequency (%) 
Variables 
Baseline 
Evaluation 1 
Evaluation 2 
Early dental caries lesion 
 
 
 
   Sound 
 
 
 
   Non-cavitated lesion 
 
 
 
   Cavitated lesion 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

117 
 
Table 4.17 
Caries risk assessment of infants in the control group (n=114) 
Variable 
 
Frequency (%) 
 
 
Not present 
Present 
Risk Factor 1 
 
 
 
≥1 active carious lesion (cavitated or non-cavitated)a 
Baseline 
 
 
 
Evaluation 1 
 
 
 
Evaluation 2 
 
 
Risk Factor 2 
 
 
 
Visible plaque (having at least 1 tooth with grade 2 plaque 
accumulation- Silness & Löe Plaque Index)a 
Baseline 
 
 
 
Evaluation 1 
 
 
 
Evaluation 2 
 
 
Risk Factor 3 
 
 
 
Between meal sugar-containing snacks or beverages >3 times per 
day 
Baseline 
 
 
 
Evaluation 1 
 
 
 
Evaluation 2 
 
 
Risk Factor 4 
 
 
 
Child is put to bed with a bottle containing natural or added sugar Baseline 
 
 
 
Evaluation 1 
 
 
 
Evaluation 2 
 
 
Risk Factor 5 
 
 
 
Not using fluoridated toothpaste to clean the erupted tootha 
Baseline 
 
 
 
Evaluation 1 
 
 
 
Evaluation 2 
 
 
aInfant with erupted teeth 
 
 
 
 
 
 
 
 

118 
 
 
Table 4.18 
Dental caries risk exposure of infants in the control group (n=114) 
 
Percentage (%) 
 
Percentage (%) 
 
Variables 
Baseline 
Evaluation 1 
p-value 
Baseline 
Evaluation 2 
p-value 
Dental caries risk 
exposure 
 
 
 
 
 
 
   Low risk 
 
 
 
 
 
 
   High risk 
 
 
 
 
 
 
aMcNemar test, *statistically significant (p<0.05) 
 
 
 
 
 
 
 

119 
 
Table 4.19 
Early dental caries lesion between infants in the intervention and control 
group (n=114) 
 
 
Frequency (%) 
Variables 
 
Study group 
Control group 
Fisher’s Exact 
Test p valuea 
Early dental 
caries lesion 
Evaluation 1 
 
 
 
 
Sound 
 
 
 
 
Non-cavitated 
 
 
 
 
Cavitated 
 
 
 
Early dental 
caries lesion 
Evaluation 2 
 
 
 
 
Sound 
 
 
 
 
Non-cavitated 
 
 
 
 
Cavitated 
 
 
 
aFisher’s exact test, (early dental caries lesion status is only for infant with erupted teeth) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

120 
 
 
 
Table 4.20 
Dental caries risk exposure between infants in the intervention and control 
group (n=228) 
 
 
 
Frequency 
 
 
Variable 
 
Study group 
Control 
group 
𝛞𝟐 
(df)a 
p 
valuea 
Dental caries 
risk exposure 
Evaluation 1 
 
 
 
 
 
Low risk 
 
 
 
 
 
High risk 
 
 
 
 
Dental caries 
risk exposure 
Evaluation 2 
 
 
 
 
 
Low risk 
 
 
 
 
 
High risk 
 
 
 
 
aChi-square test, df= degree of freedom 

121 
 
 
 
 
CHAPTER 5  
 
GANTT CHART 
Table 5.1 
Gantt chart for research project 
 
Activity 
2024 
2025 
2026 
2027 
  
Oct-Dec  
Jan-Feb   
Mac-Apr 
May 
-
Jun
July-
Aug
Sept-Oct 
Nov-Dec 
Jan-Feb   
Mac-Apr 
May 
–
Jun
July-
Aug
Sept-Oct 
Nov-Dec 
Jan-Feb   
Mac-Apr 
May 
-
Jun
July-
Aug
Preparation of research proposal 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Ethical clearance (JEPEM/MREC) 
Preparation and Development of 
MI Protocol/Script 
Translation/Adaptation of MI 
Script 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pretest at MOH MCHCs Trg 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Data collection 
  
  
  
  
  
  
  
 
  
  
  
  
  
  
  
  
  
Data entry, data analysis 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Report write-up 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Report submission 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

122 
 
 
CHAPTER 6  
 
BUDGET PROPOSAL  
Table 6.1 
Budget for research project 
Vot and Vot Details 
Unit  
Price (RM)/unit  
Expenditure 
(RM) 
Vot 21000: Traveling, Transportation and Cost of living allowance  
Presentation at conference (X 3times ) 
Attending 1 international  
conference  
   Return airfare  
   Lodging/ hotel 
   Subsistence  
   Fare for land transport 
 
 
1 
4 
4 
3 
 
 
1200.00 
300.00 
100.00 
100.00 
 
 
1200.00 
1200.00 
400.00 
300.00 
 Attending 1 local conference  
  Return airfare  
   Lodging/ hotel 
   Subsistence  
   Fare for land transport 
 
1 
3 
3 
2 
 
300.00 
230.00 
70.00 
100.00 
 
300.00 
690.00 
210.00 
200.00 
Subjects recruitment (dental clinics 
in Trg) 
   AG with MI sessions:  
   4 weeks    x travel  
   2x/week x (16km x 0.50 cent) 
   Intervention: 3 x (16km x  
   0.50cent) 
    Post-intervention: 4 weeks x  
    travel 2x/week x (16km x 0.50  
    cent) 
    Parking fee (0.50cent for  
    30minutes) 
 
 
8 
 
3 
 
8 
 
 
19 
 
8 
 
8 
 
8 
 
 
8hours/day (16 
x 0.50cent) 
 
64.00 
 
24.00 
 
64.00 
 
 
152.00 
Vot 23000: Perhubungan Utiliti   
Vot 27000: Research material and supplies 
Office supply 
   A4 papers  
   Clear pocket file 
   Double-sided tape 
   Paper file 
   Ball pens 
3 rim 
130 
5 rim 
130 
200 
 
 
                 13.00 
0.30 
5.00 
0.50 
0.40 
 
 
39.00 
39.00 
25.00 
65.00 
80.00 

123 
 
Oral health assessment  
   Latex gloves  
   Disposable mouth mirror 
 
   Pen torch  
   Facial mask 
 
5 boxes 
2(100/pack) 
1 
2 boxes 
 
13.00 
35.00 
15.00 
50.00 
 
65.00 
70.00 
15.00 
100.00 
Vot 29000: Professional services  
 
Printing  
   Questionnaire, cover letter,  
   inform consent (pre-test) 
   Questionnaire, cover letter,  
   inform consent (baseline,  
   evaluation 1 and 2) 
 
30  
 
130 x 3 
 
 
 
 
1.20  
 
1.20  
 
 
36.00 
 
468.00 
 
 
 
 
Honorarium  
   Pre-test 
   Respondent (MI sessions) 
   Respondent (MI sessions) 
   Respondent (after MI sessions) 
 
 
30 
130 
130 
82 
 
 
10.00 
10.00 
10.00 
10.00 
 
 
300.00 
1300.00 
1300.00 
820.00 
 
Refreshment  
   Refreshment (study subjects) 
   Refreshment (control subjects) 
 
88 
50 
 
10.00 
10.00 
 
880.00 
500.00 
Others  
   Registration fee for attending 1  
   international conference  
   Registration fee for attending 1  
   local conference  
   Workshop fees (statistics  
   workshop, scientific writing,  
   and other relevant workshops)  
   Publication fee 
 
1 
 
1 
 
1200.00 
 
500.00 
 
1200.00 
 
500.00 
 
500.00 
 
 
18,000.00 
Total  
40,995.50 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

124 
 
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APPENDICES 
 
 
 
 
 
 
APPENDIX A  
 
 

 
 
 
 
 
 
 
 
 
 
 
APPENDIX B 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
APPENDIX C 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
APPENDIX D 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  

 
 
 
APPENDIX E 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
APPENDIX F