The Effect of Peer Video Modeling and 3D Jaw Video Modeling Training on Oral Health and Toothbrushing Skills in Children With Autism
Phase: NA
Conditions: Autism Spectrum Disorder (ASD, Dental Health, Oral Hygiene, Oral Health, Pediatric Nursing
Sponsor: Ministry of Health, Turkey

02.08.2021 
STUDY PROTOCOL 
 
TITLE:  
THE EFFECT OF PEER VIDEO MODELING AND 3D JAW 
VIDEOMODELING TRAINING ON ORAL HEALTH AND 
TOOTHBRUSHING SKILLS IN CHILDREN WITH AUTISM 
 

Study Protocol 
The primary aim of this study is to determine the nutritional and oral hygiene habits of children 
with autism spectrum disorder (ASD), to examine the effects of these habits on oral and dental 
health, to evaluate their access to necessary dental treatments, and to assess oral health–related 
quality of life from the perspective of parents. In addition, the study aims to improve oral 
hygiene habits using peer video modeling and 3D jaw model video modeling, and to compare 
the effectiveness of these two video modeling methods in improving tooth-brushing 
performance. 
The secondary aim of the study is to incorporate oral hygiene training into individualized 
education programs to enable children with ASD to perform oral care independently, similar to 
typically developing children, without requiring pharmacological support. By promoting 
preventive oral health practices, this approach may help reduce the high costs of dental 
treatments and prevent or decrease dental problems that negatively affect children's quality of 
life. Interventions targeting oral hygiene behaviors in the home environment may represent one 
of the most effective strategies for improving oral hygiene outcomes in this population. In this 
study, children diagnosed with ASD according to the Diagnostic and Statistical Manual of 
Mental Disorders, Fifth Edition (DSM-V) criteria of the American Psychiatric Association 
(APA) will be included. 
Variables 
The dependent variables include tooth-brushing ability (assessed using a scoring system 
ranging from 0 to 3 points) and plaque index scores. 
The independent variables consist of sociodemographic characteristics collected through the 
sociodemographic information form, including gender, parental education level, and 
socioeconomic status. 
Participants and Sample Size 
To determine the sample size, a minimum of 120 children aged 6–12 years diagnosed with 
ASD and enrolled at Istanbul Hamit İbrahimiye Special Education Practice School will be 
included in the study. 
Study Limitations 
The study is limited to children with ASD who attend the Istanbul Hamit İbrahimiye Special 
Education Practice School. Therefore, children with ASD who are not enrolled in or attending 
this center will not be represented in the study population. 
Ethical Considerations 
Because the study involves children under the age of 18 diagnosed with ASD, written 
informed consent will be obtained from parents or legal guardians prior to participation. 
After completion of the study, oral hygiene education will also be provided to participants in 
the sample group. 

Data Collection Instruments 
Sociodemographic Information Form (Form-1) 
The Sociodemographic Information Form, developed based on a literature review, includes 
questions related to the child’s gender, date of birth, parents’ age and educational level, age at 
which the child began special education, duration of special education, parental employment 
status, medications used regularly by the child, presence of systemic diseases, and whether the 
family or the child has previously received oral and dental health education. 
Family and Child Oral-Dental Health Information Form (Form-2) 
The Oral-Dental Health Information Form is designed to assess factors affecting the oral 
health of children participating in the study. Parents will be asked to complete a questionnaire 
including items related to parental education level, oral hygiene habits (tooth-brushing 
practices), and the child’s nutritional behaviors. These include the number of snacks consumed 
daily, meal duration, duration of breastfeeding and bottle use, frequency and duration of tooth 
brushing, brushing technique, the most recent dental visit, number of decayed, missing, or filled 
teeth, and who performs the tooth brushing. Completion of these forms takes approximately 15 
minutes. 
Clinical Oral Examination (Form-3) 
For standardization, all oral examinations will be performed by the same dentist. The number 
of decayed, missing, and filled teeth, plaque index values, and gingival health status will be 
recorded on the anamnesis forms. Disposable instruments will be used for intraoral 
examinations and discarded after use. 
Bacterial plaque will be evaluated using the Modified Silness-Löe Plaque Index, assessing six 
teeth (four posterior and two anterior teeth). Previous studies have reported the use of modified 
indices in children with autism due to their specific behavioral characteristics. For instance, 
Klein et al. reported the use of modified indices when evaluating dental conditions in autistic 
patients, while Pilebro et al. utilized the Modified Silness-Löe Plaque Index for visual plaque 
assessment in oral hygiene education studies among autistic children. Similarly, Lowe et al. 
used the Silness-Löe Plaque Index to evaluate plaque accumulation in autistic patients. 
The Modified Silness-Löe Plaque Index scoring criteria are as follows: 
1. Plaque accumulation at the gingival margin is difficult to detect. 
2. Visible soft deposits are present near the gingival margin but do not completely fill the 
interdental area. 
3. Thick plaque deposits are clearly visible near the gingival margin and extend coronally, 
completely filling the interdental space. 
Gingival health will be evaluated based on color changes. Gingiva will be considered healthy 
if no color change or edema is observed. Gingiva will be classified as unhealthy if there is a 
color change from pink to red and the presence of edema (Pandina et al., 2007). 

Dental caries status will be assessed according to World Health Organization (WHO) 
criteria, and the DMF-T index for permanent teeth and DMF-s index for primary teeth will 
be used to determine the number of decayed, missing, and filled teeth (WHO, 1997). 
Intervention Procedure 
Following the oral examination and assessment of factors affecting oral health, tooth-brushing 
training will be provided. Participants will be randomly assigned to one of three groups using 
a closed-box drawing method performed by a blinded special education teacher to ensure 
allocation concealment. The groups will consist of: 
 
Peer video modeling group 
 
3D jaw model video modeling group 
 
Control group 
Parents will be instructed not to introduce additional oral hygiene practices such as mouthwash 
or dental floss during the study period. 
The tooth-brushing procedures used in the peer video modeling and 3D jaw video modeling 
interventions will be developed in consultation with a pediatric dentist (pedodontist) to ensure 
that the demonstrated behaviors are performed correctly. 
The Bass tooth-brushing technique will be used in the intervention videos. Previous studies 
have demonstrated that the Bass technique is more effective than the roll technique in removing 
plaque, particularly on lingual and facial surfaces and along the gingival margin and sulcus 
(Gibson et al.). 
Peer Video Modeling 
For the peer video modeling group, a video demonstrating the tooth-brushing procedure 
performed by a healthy peer model (an 11-year-old boy) will be used. The video will present 
the target behavior at a slow pace, and the effective brushing duration will be two minutes. 
Following the procedure described by Charlop and Milstein (1989), the child will first be 
instructed to sit quietly and watch the video displayed on the screen. The researcher will sit next 
to the child and observe whether the child attends to the video. After two presentations of the 
video, the researcher will instruct the child: “Let’s do it the same way as in the video.” The 
child will then be asked to practice tooth brushing in front of a mirror. 
3D Jaw Video Modeling 
In the 3D jaw video modeling group, the tooth-brushing technique will be demonstrated using 
a three-dimensional upper and lower jaw model. Similar to the peer video modeling 
procedure, the child will be encouraged to watch the video demonstration, and positive 
reinforcement will be provided when the child maintains attention to the video. 
Participants will watch the 3D jaw modeling video twice, after which the researcher will say, 
“Let’s do it the same way they did,” and the child will be asked to practice the procedure in 
front of a mirror. Children will be able to observe their own performance in the mirror. 

Performance Evaluation 
Tooth-brushing ability will be evaluated on the same day using a 13-step assessment tool, with 
scores ranging from 0 to 3 points, and the results will be recorded. 
Following the training session, parents will receive feedback regarding their child’s 
performance. For example, parents may be informed that the child performs well in brushing 
the front teeth but requires assistance when brushing the upper posterior teeth. 
Home-Based Intervention 
Parents in the intervention groups will receive the peer video model or 3D jaw video model 
via e-mail or WhatsApp and will be instructed to have their children watch the video once 
daily before tooth brushing. 
The study is planned to last six months, with data collected at baseline, 1 month, 3 months, 
and 6 months. 
Follow-up Assessment 
A questionnaire titled “Tooth-Brushing Compliance Questionnaire” (Form-4) will be 
administered to evaluate children’s adherence and parents’ attitudes toward the intervention. 
The questionnaire will include items such as: 
 
How frequently the educational material was used by the child (1–7 days per week, 
irregularly, or never) 
 
How useful the educational material was perceived (useful, neutral, or unusual) 
The questionnaire will be sent weekly to parents via e-mail or WhatsApp. 
At baseline and at the end of the 1st, 3rd, and 6th months, plaque index values will be 
reassessed in all groups.