Comparison of Modified Circular and Natural Tooth Brushing Methods in Effectiveness of Dental Plaque Removal in Children Aged 10-12 Years Old
Phase: NA
Conditions: Healthy
Sponsor: Prince of Songkla University

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Comparison of Modified Circular and Natural Tooth Brushing Methods in 
Effectiveness of Dental Plaque Removal 
(Study Protocol, Statistical Analysis Plan, Informed Consent Form, and Results) 
 
 
 
 
 
 
 
 
 
Istiyanti Hapsari 
 
 
 
 
 
Faculty of Dentistry 
Prince of Songkla University 
2018 

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1. Research Title 
Comparison of Modified Circular and Natural Tooth Brushing Methods in Effectiveness 
of Dental Plaque Removal 
2. Researcher Name 
Istiyanti Hapsari       
E-mail address: istiyantihapsari@gmail.com  
 
3. Background information/Significance of Research Project 
Dental caries, or commonly known as tooth decay, is worldwide disease that 
pursues people during their lifetime (1). Dental caries can affect the health and quality of 
life patients so that it is important to focus on caries prevention (2).  Ministry of Health 
Republic of Indonesia in Basic Health Research 2013 (3) showed that DMF-T Index of 
Indonesia for population aged start from 12 years old was 4.6. While the DMF-T Index 
in Yogyakarta province was 5.9, higher than the national index of DMF-T. Not only 
dental caries, gingivitis also being a problem. In Jakarta, 68% children aged 12 years old 
have gingivitis. While, 92% of the children aged 12 years old have substantial amount of 
plaque (4).  
Both of dental caries and gingivitis are caused by dental plaque or known as 
dental biofilm. Gingivitis is built by the accumulated dental plaque that infect soft tissue 
around the teeth (5). Dental caries is caused generally by acid production from bacterial 
fermentation in the dental plaque on the tooth surface (6). 
Dental caries and gingivitis can be prevented by plaque control. Self-performed 
mechanical plaque removal with a manual toothbrush remains the primary method of 
maintaining good oral hygiene for a majority of the population (7). Good oral hygiene 
habit that is built especially in children age will protect permanent teeth that can make it 
lasts a lifetime (8). Oral hygiene instructions should be given to a child considering their 
age and associated with their manual dexterity. Tooth brushing instruction can be 
effectively given in the age start from 10 years old because they can be actively involved 
and have better manual dexterity than children in younger age (9). 
Ideal tooth brushing method is the method that can work for the individual and 
can remove dental plaque without causing damage on the teeth, gingiva, or other tissue 

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(10, 11). The method should clean all tooth surfaces and must be systematically 
organized so that each parts of the dentition is brushed (12, 13). Horizontal motions of 
brushing and parallel positions of the brush with the teeth will cause abrasion (14). 
Brushing force is not specifically determined. If it is too much, it will cause gingival 
trauma (15). Tooth brushing method that is ideal also has to be simple and easy to learn 
(12). 
Tooth brushing will be effective in removing the dental plaque if it is done with 
the sufficient duration at least 2 minutes (16). Frequency of tooth brushing is 
recommended to be done twice a day (17). Tooth brushing type that is used to brush is 
recommended using manual tooth brush with small-headed toothbrush, soft round-ended 
filaments and comfortable handle (18). There are several factors from individual that 
may cause the differences in effectiveness of tooth brushing in plaque removal such as 
age, education, and socioeconomic status (13, 19, 20). 
People, without any training, naturally brush their teeth using horizontal scrub, a 
rotary motion, or simple up and down (21). Many people using natural motion of tooth 
brushing can produce good oral environment that inhospitable to biofilm without any 
damaging effect in their tissue (21, 22). Asadoorian (15) estimated that over 90% of 
people employ their natural tooth brushing method that is personally built. This method 
will remove plaque from  smooth surfaces  of the teeth, but this method have limitation 
that is considered detrimental because it can cause gingival recession and tooth abrasion 
(23). People will pay poor attention to the lingual areas of their teeth while practicing this 
method probably because these areas do not affect the aesthetics and tend to difficult to 
be accessed (24). 
A systematic review by Muller-Bolla and Courson (25) showed that in early 
mixed dentition stage, the most effective tooth brushing technique is horizontal 
technique. McClure (26) comparing tooth brushing efficacy between horizontal Scrub 
and modified Bass method in children aged 10-12 years old reported there were no 
significant differences in plaque removal (P> 0.01) between two methods.  Robinson 
(27) evaluated plaque removal of Scrub and Bass methods in children aged 12-13 years 
old and found that there were no differences between two methods. Smutkeeree et al. 
(28) found that there were no significant differences in gingival condition (Gingivitis 
Index) between Horizontal Scrub and Modified Bass groups (P> 0.05) in children aged 

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10-12 years old. However, the studies about tooth brushing method recommended for 
children in late mixed dentition aged are still limited. 
Children aged 10-12 years old are in late mixed dentition (29), a transitional 
period from children with milk teeth into adult with permanent teeth (30). Tooth 
brushing  technique that is suitable  for  children should  be  simple  to  be performed  so  
that  it  can  be mastered  by  children  and  effectively  remove dental  plaque as well as 
prepare children for adult period and protect permanent teeth that can make it lasts a 
lifetime (8, 31). The review literature by Wainwright and Sheiham (32) showed that the 
Bass and modified Bass methods are the most frequently advocated method for adults. 
The Bass method showed a superiority in plaque removal ability compared with roll, 
circular, and horizontal method (33). The Bass method is good in cleaning the tooth 
tissue adjacent to the gingival tissue, the gingival margins and the gingiva sulcus (34). 
Nevertheless, this method is difficult to exercise (35). Katz et al. (36) recommended the 
Bass method to be combined with roll method to be the Modified Bass to ensure plaque 
removal from gingival margin and coronal surface. Modified Bass is effective in plaque 
removal of supragingival area (37). This method also can reduce chance of developing 
gingival recession and tooth abrasion (28). However, the Modified Bass method still 
have limitation that can cause difficulty in children to replace the brush in gingival sulcus 
position (5). 
Combined tooth brushing technique can be considered as a good method for  
plaque removal (37). The combination should provide satisfactory method that should 
clean all tooth surfaces, the movement of the brush should not injure the soft and hard 
tissue, the technique should be simple and easy to learn, and it must be well organized so 
that each part of the dentition is brushed (12). In the Bass method originated by Bass 
(38), the brush need to be positioned at about a 45 degree to the long way of the teeth and 
then brush forced into crevices and moved short back and forth. Furthermore, most of 
people gradually switch from the correct Bass method with short stroke to be a horizontal 
scrubbing method as the interval since the instruction of the Bass method given (39). 
Eley et al. (12) in their book stated in different way that the Bass method should move 
with small circular motion and this combination can be recommended as the method of 
choice for general use. This method might be benefit for children in late mixed dentition 
because it does not need rolling motion like in the Modified Bass method that cause 
children difficult to replace in gingival sulcus position and the movement is not short 

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back and forth like in the original Bass method that children gradually switch from the 
correct Bass method with short stroke to be a horizontal. 
Delivering better oral health (18) stated that there is no tooth brushing
 
that
 
is 
superior to another and people’s existing method may need to be modified to clean all 
tooth surfaces. A study showed that different surface of the teeth need different technique 
to produce effective plaque removal (24). This study will apply the Modified Circular to 
be used in most of tooth surfaces areas as all labial areas, and posterior lingual/palatal 
areas and combine with vertical technique to be used in anterior lingual areas, and 
horizontal to be used in occlusal areas. To show the possibility that the Modified Circular 
method that can effectively remove plaque in late mixed dentition children, it is needed 
to comparing the Modified Circular method with the natural tooth brushing method. 
 
4. Conceptual Framework 
Tooth brushing 
Method 
 
 
Modified Circular 
 Small circular 
motion 
Natural 
Uninstructed 
 
 Plaque level 
 Gingivitis level 
Personal Characteristics  
 
Age of participants 
 
Gender of participants 
 
Parent’s education level 
 
Socioeconomic status of parents 
 
Oral health care behaviour 
 
Frequency of tooth brushing  
 
Eating habit 
 

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5. Objectives 
General objectives 
a. 
To compare level of plaque of children aged 10-12 years old that use the 
Modified Circular method and natural tooth brushing method. 
b. 
To compare level of gingivitis of children aged 10-12 years old that use the 
Modified Circular method and natural tooth brushing method. 
Specific objectives 
a. 
To compare level of plaque before and after using the Modified Circular tooth 
brushing method. 
b. 
To compare level of gingivitis before and after using the Modified Circular tooth 
brushing method. 
 
6. Research Procedures 
Participants and setting 
 
One hundred and twenty four students from two state elementary school in 
Yogyakarta, Indonesia participated in this study. The age of the participants were 
between 10 and 12 years old including males and females students. All of the 
participants were fifth graders from Caturtunggal IV State Elementary School and 
Babarsari State Elementary School. To be eligible to participate in this study, each 
participants met the criteria including: students with age 10 to 12 years old and willing as 
well as permitted by the parents/guardian to join thorough the study. The exclusion 
criterias were not being discovered from them, that were being diagnosed having 
developmental disorder, using orthodontic appliances, and using antiseptic mouthwash 
for daily use. 
 
Caturtunggal IV State Elementary School and Babarsari State Elementary School are 
the government’s schools that are placed in the same cluster in one sub-district. These 
two schools have the similar characteristics in social-economy, number of students, and 

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the type of school based on the data and recommendation from Education and Culture 
Office of Sleman District, Yogyakarta, Indonesia. The examinations were done in the 
terrace in front of the classes to get the sufficient lighting. The training session was done 
in the class and the schoolyard. Examination and training each lasted approximately 15 
minutes and 60 minutes. The examinations were done two times; before and after 
training with a distance of one month. While the training session were given one time 
each group after baseline examination. The reinforcement sessions were given to the 
intervention group once a week in a month after the training session. The reinforcement 
sessions lasted approximately 20 minutes for each session. 
Materials and Equipment 
 
The materials being used in training session were posters, dental model, tooth brush, 
rinsing glass, and water bucket. The examiner collected the data using probe, mouth-
mirror, microbrush, disclosing solution, kidney-basin, cotton roll, mask, gloves, rinsing 
glass, bucket, table, and chairs. The data of the examination and interview was collected 
using examination forms, questionnaire, and a pen, while the tooth brushing video was 
recorded using smartphone and the data was written in observational sheet. The materials 
for reinforcement sessions were dental model, tooth brush, rinsing glass, bucket, and 
mirror. Additionally, child size tooth brush and tooth paste were given for each 
participant.  
Dependent Variables and Data Collection 
 
The dependent variables in this study were Plaque Index (PI) and Gingival Index (GI). 
The hypotheses of this study were the plaque level and gingivitis level in subjects using 
the Modified Circular method is different from that in subjects using natural tooth 
brushing method and the level of plaque after using the Modified Circular method is 
different from that before using the method. 

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Plaque Index Examination. Participants’ plaque level was measured using Turesky 
Modification of Quigley Hein (83). Data were collected during baseline and follow-up to 
track the changing of the plaque level before and after intervention. The tools used in this 
examination were micro-brush, mouth mirror and probe under the natural light. The 
procedure was painting all of the exposed tooth surfaces with disclosing solution and the 
participants were asked to rinse one time. Facial and lingual surfaces of the teeth were 
examined except third molars. A score between 0 and 5 was given based on the criteria. 
The plaque scores were recorded on the plaque index examination sheet containing the 
diagram of the teeth with the separated boxes of facial and lingual/palatal areas. The 
index was determined by calculating the total score divided by the numbers of the 
surfaces examined. 
 
Table 1 Scoring criteria of Turesky Modification of Quigley-Hein Index (83) 
Score 
Criteria 
0 
No plaque. 
1 
Separate flecks of plaque at the cervical margin of the 
tooth. 
2 
A thin continuous band of plaque (up to one mm) at the 
cervical margin of the tooth. 
3 
A band of plaque wider than one mm but covering less than 
one-third of the crown of the tooth. 
4 
Plaque covering at least one third but less than two thirds of 
the crown of the tooth. 
5 
Plaque covering two-thirds or more of the crown of the 
tooth. 
 

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Gingival Index Examination. The examination of gingival condition was using the 
Gingival Index (88). Data were collected during baseline and follow-up to track the 
changing of the gingival condition before and after intervention. The tools used in this 
examination were mouth mirror under the natural light. The procedure was examining all 
of the gingiva on the buccal, lingual/palatal, mesial, and distal areas of the teeth. A score 
between 0 and 3 was given based on the criteria. The Gingival Index were recorded on 
the gingival index examination sheet containing the diagram of the teeth with the 
separated boxes of buccal, lingual/palatal, mesial, and distal areas. The index was 
determined by calculating the total score divided by the numbers of the areas examined. 
 
Table 2 Scoring criteria of Gingival Index (88) 
Score 
Criteria 
0 
Normal gingiva. 
1 
Mild inflammation - slight change in color, slight edema. 
No bleeding on probing. 
2 
Moderate inflammation - redness, edema and glazing. 
Bleeding on probing. 
3 
Severe inflammation - marked redness and edema. 
Ulceration.  Tendency to spontaneous bleeding. 
 
Questionnaire. Personal information; oral health knowledge, attitudes, practices; and 
eating habits of the participants were recorded using questionnaire. The questionnaire 
were questioned by interview. Data were collected during baseline and follow-up to 
check the changing of tooth brushing practice and eating habit that may influence the 
plaque and gingival index. The back-translation technique had been used to ensure the 
quality between the English and Indonesian language versions. The interviewer marked 

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X on the box of questionnaire choice of answers in accordance with the answers of 
participants.  
Validity and Reliability 
Validity. Questionnaire had been evaluated for the content, scoring criteria, and 
language compatibility by three experts from Faculty of Dentistry, Prince of Songkla 
University using the face validity. 
 
Standardization of oral examination (Plaque Index and Gingival Index) had been 
evaluated between the examiner and the expert using Cohen’s Kappa index. For the 
Gingival Index, the value of inter-rater calibration was 0.73. The value of intra-rater 
calibration of Plaque Index was 0.77. All of the values were exceeding 0.7 and 
categorized as good by Altman (1999). 
Reliability. The reliability of intra-examiner had been evaluated using Cohen’s Kappa 
Index. The value were 0.76 for the Gingival Index and 0.79 for the Plaque Index. The 
values were exceeding 0.7 and categorized as good by Altman (1999). 
Experimental Design 
The research was using a quasi-experimental study design. Data were gathered from 
two groups of subjects. This research was a single-blind study which the examiner will 
be blinded to the allocation of subjects. 
This study began with selecting two elementary schools in the same district in 
Yogyakarta, Indonesia, that have similarity in socio-economic status and the number of 
the students based on the data and recommendation of Technical Education Service Unit 
of Yogyakarta. The schools met the criteria that was not under any plans of getting other 
interventions of dental health program during one month intervention period of this 
study. All of the fifth graders of the selected schools participated the study. With the coin 
flipping method, a school was allocated to be intervention group and the other was being 
the control group. The participants had been informed about the purpose of the study, the 
procedure, and the right to continue or withdrawn without any penalties. The participants 
had given consent to follow the study. 

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The study began with the baseline data collection. Then it continued with the training 
for the participants about improving the oral hygiene. In this stage, the intervention 
group was demonstrated and instructed to brush their teeth using Modified Circular 
method, while the control group was not given any instruction to brush their teeth using a 
specific tooth brushing method and asked to brush their teeth using the way they brushed 
every day. The period of intervention was started after training and lasted for one month. 
In intervention period, intervention group was observed once a week to ensure that they 
brushed their teeth correctly using Modified Circular method. Finally the evaluation was 
implemented after 1 month of intervention. 
Data collection procedure 
1) The researchers well informed the teachers, parents or guardians, and the children 
about the purpose of the study, the procedure, and the right to continue or 
withdrawn without any penalties. The parents or guardians of the children who 
meet the inclusion criteria were asked by the researcher and teachers the 
permission to their children to participate in this study. Their consent were shown 
by signing of the consent form. 
2) The appointment were made with the teachers to set the time to perform 
examination and intervention to the children.  
3) Baseline data collection were done to all of the student participating of the study. 
The children were interviewed by interviewee using structured-questionnaire 
inside of the class. The oral examinations were done after completing the 
interview. The oral examination began with the examination of gingival condition 
and then continued with plaque level examination. Examination area was set 
outside of the class to get enough light. The children were examined on a chair in 
sitting position using natural sun light. The examiner was blind to the allocation 
of the group, the examiner will not know whether the group examined was 
intervention group or control group. After the oral examination was done, the 
video recording was taken to the children to record the way the children brush 
their teeth. The area recorded was only around their mouth and not showing their 
face. 
4) In the other day, children in each group were given 2 hours for tooth brushing 
training course in small groups containing 4-5 children per group. The instructor 
motivated the children about how to improve oral hygiene for both groups. The 

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children were instructed to brush their teeth two times per day in two minutes. 
The control group were instructed to brush the teeth as how they brushed every 
day. The intervention group were demonstrated about how to brush the teeth 
using Modified Circular method. After the training in the class was completed, 
the activity then continued with practiced brushing together in schoolyard. 
Intervention group were observed once a week to make sure that they did 
Modified Circular method well without any repetition or addition of intervention. 
The researcher provided toothbrush and toothpaste to be used by the children 
during the one-month intervention period.  
5) Follow up examination were done one month after the training by collecting the 
same data as baseline. 
 
7. Statistical analysis 
All of the data were analyzed using IBM SPSS Statistics 21. The data gathered from 
the control and the groups were compared using t-test for the mean and standard 
deviation. A chi-square statistic were used to investigate whether distributions of 
categorical variables differ from one another. The significance level used in this study 
was 0.05 for all of the statistical test. 
 
8. Results 
At the beginning of the study, participants who participated in this study 
amounted to 62 children for control group and 62 children in experimental group. There 
was no number of excluded participants. The schools was not under any plans of getting 
other interventions of dental health program during one month intervention period of this 
study. After random assignment of the groups, all of the participants received the 
intervention. Lost to follow-up were found with the number of 2 in control group and 4 
in intervention group. The participants did not come in the day of follow-up data 
collection with the reason of sick and family occasion. Using the intention-to-treat 
method, the number of data analyzed were following the original number allocated, that 
were 62 for each group. The missing value in follow-up were replaced using the last 
value obtained, in this case the baseline value was used. 
The age of the participants and the percentage of male and female participants 
between control and intervention group were not significantly different (P<0.05). The 

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tooth brushing habit of the participants seen from the frequency and the duration of 
brushing were not significantly different (P<0.05). Snacking and eating frequency that 
reflected the eating habit of the participants were also not different (P<0.05). 
In this study, all of the participants (100%) in the control group can follow the 
protocol to brush their teeth using natural method. In intervention group, 79% of the 
participants followed the protocol to brush their teeth using Modified Brush tooth 
brushing method systematically. 
Plaque index 
Mean of plaque index for all surfaces in baseline were not different (P>0.05). 
Analyzed from each surface of each sextant, right and left upper lingual posterior 
surfaces had statistically different mean plaque index (P<0.05) with the higher number of 
dental plaque in intervention group. However, the anterior upper labial surface of control 
group had approximately 0.4 points higher number of plaque index than the control 
group (P<0.05). In follow up mean of plaque index for all surfaces were significantly 
different (P<0.05) between groups. All of the mean plaque index in intervention group 
analyzed from every sextant had lower score than the control group and almost all of 
them were statistically significant (P<0.05). 
Gingival Index 
 
In baseline, there was no differences in mean of plaque index between groups 
(P>0.05). The intervention group had significant lower mean of gingival index than the 
control group (P<0.05). 

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Appendix 

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Appendix A 
Research Information Sheet/Invitation Letter 
Invitation to participate in research project entitled “Comparison of Modified Circular and 
Natural Tooth Brushing Methods in Effectiveness of Dental Plaque Removal in Children 
Aged 10-12 Years Old” 
Dear Participants, 
 
My name is  Istiyanti Hapsari. I am from Faculty of Dentistry, Prince of Songkla 
University, Prince of Songkla University, Thailand. I would like to explain about research 
project and invite you join this research project as describe below. 
1. Description of the study 
Dental caries and gingivitis prevalences in schoolchildren in Indonesia is high. Dental 
diseases can potentially caused missed school, concentrace disturbance, impaired speech, 
poor self-esteem, and systemic illness. Caries and gingivitis can be prevented by 
maintaining oral hygiene. Toothbrushing is one of oral hygiene method to remove and 
prevent dental plaque that can cause dental caries and gingivitis. The present study aims 
to evaluate the effectiveness plaque removal of two brushing methods, Modified Circular 
and natural tooth brushing methods. 
The result will give the benefit to determine the toothbrushing method that suitable 
and appropriate to be taught to children in Indonesia to prevent dental caries. 
The recruited children will be 10-12 years old. Children will be interviewed about 
their oral hygiene practice and eating habit. Every children also will be given 
examination to record level of plaque and gingivitis. This examination will be conducted 
around 15 minutes. The children then will be given a training about “how to improve oral 
hygiene”. Children will be instructed to brush their teeth two times a day as in the 
morning and before bedtime with the duration of 2 minutes each time. The project will 
provide one toothpaste and one toothbrush. After training course, they will be asked to 
show how they brush their teeth. After one month, children will be evaluated again about 
their levels of plaque and gingivitis.  
 

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2. Risks and Discomfort 
This study will not use any invasive treatment due to oral examination. No drugs or 
chemical materials will be used except nontoxic disclosing agent that will be used only 
2-3 drops for staining the dental plaque. The colors of disclosing agent will gradually 
dissapear and easily removed by brushing. The examination will be done 2 times (in the 
beginning and after 1 month later) and it is does not cost you. 
3. Benefits 
This study will help teachers, parents, and students to know the level of oral 
cleanliness and the effective method of toothbrushing to remove plaque in 
schoolchildren. 
4. Confidentiality 
All information in the present study will be confidential and anonymus. Only the 
researcher is eligible to access the data. Your name, your children name and identifying 
information will not be used in the report of the study. After completing the study, all 
data will be destroyed. 
5. Contact Information 
If you have any question or suggestion, you can directly contact the researcher by 
phone 087737639177 or email to istiyantihapsari@gmail.com. 
 
You have the right to participate or not to participate in this study. You also have te right 
to withdraw from your participation at any time without any cost, impact on your receiving 
service, or impact in any dental treatment or routine care. 
If you have a doubt or any questions in this research, please ask researcher for more 
understanding. 
 
 
Sincerely yours, 
 
 
 
Signature............................................. 
 
(Istiyanti Hapsari) 
 
 
 
Note: Please read carefully before signing and participating this research project 

19 
 
Appendix B 
Consent Form For Caretaker 
I am, ________________________________________________, as a parent of 
Mr./Ms. _________________________________________________ is invited to join 
research carried out by Istiyanti Hapsari, Faculty of Dentistry, Prince of Songkla University 
who is the researcher of the reaearch entitled “Comparison of Modified Circular and Natural 
Tooth Brushing Methods in Effectiveness of Dental Plaque Removal in Children Aged 10-12 
Years Old”. 
The objective of the study is to evaluate the effectiveness plaque removal of two 
brushing methods, Modified Circular and natural tooth brushing methods, in a sample of 10-
12 years old schoolchildren. It will give benefit to know the effective method of tooth 
brushing to remove plaque in schoolchildren. This study will help teachers, parents, and 
students to know the level of oral cleanliness and the effective method of toothbrushing in 
order to maintain oral hygiene and prevent dental caries and gingivitis. The recruited children 
will be 10-12 years old. Children will be interviewed about their oral hygiene practice and 
eating habit. Every children also will be given examination to record level of plaque and 
gingivitis. This examination will be conducted around 15 minutes. The children then will be 
given a training about “how to improve oral hygiene”. Children will be instructed to brush 
their teeth two times a day as in the morning and before bedtime with the duration of 2 
minutes each time. The project will provide one toothpaste and one toothbrush. After training 
course, they will be asked to show how they brush their teeth. After one month, children will 
be evaluated again about their levels of plaque and gingivitis. 
This study will not hurt my child and the oral examination will not use invasive 
treatment or chemical materials except disclosing agent to see the dental plaque in the tooth 
surfaces. The examination will be done twice (in the beginning and after 1 month later). 
The information will be kept confidential and anonymus by the researcher. If I have 
any queastion or suggestion, I can directly contact the researcher by phone 087737639177 or 
email to istiyantihapsari@gmail.com. 
I have read and understand the information about this research study and its risks and 
benefits. I have had the opportunity to ask question and to have my questions answered to my 
satisfaction. I freely give my consent to participate in this research. 
Date .........................................................................  
Signature .............................................. (Participant) 
Signature ..............................................(Researcher) 
 
(Istiyanti Hapsari) 
Signature .................................................. (Witness) 
Signature .................................................. (Witness) 

20 
 
Appendix C 
Assent Form 
You are given the opportunity to be a participant in this study. This project is 
conducted by Istiyanti Hapsari, Faculty of Dentistry, Prince of Songkla University who is the 
researcher of this project. 
The present study aims to evaluate the effectiveness plaque removal of tooth brushing 
methods in children. This study will help teachers, parents, and students to know the level of 
oral cleanliness and the effective method of toothbrushing in order to maintain oral hygiene 
and prevent dental caries and gingivitis. 
The recruited children will be 10-12 years old. Children will be interviewed about 
their oral hygiene practice and eating habit. Every children also will be given examination to 
record level of plaque and swollen gums. This examination will be conducted around 15 
minutes. The children then will be given a training about “how to improve oral hygiene”. 
Children will be instructed to brush their teeth two times a day as in the morning and before 
bedtime with the duration of 2 minutes each time. The project will provide one toothpaste and 
one toothbrush. After training course, they will be asked to show how they brush their teeth. 
After one month, children will be evaluated again about their levels of plaque and gingivitis.  
This study will not use any invasive treatment due to oral examination. This study 
uses disclosing agent made from a safe food dyes only 2-3 drops for staining the dental 
plaque. The colors of disclosing agent will gradually dissapear and easily removed by 
brushing. The examination will be done 2 times (in the beginning and after 1 month later) and 
it is does not cost you. 
All information in the present study will be confidential and anonymus. Only the 
researcher is eligible to access the data. Your name and identifying information will not be 
used in the report of the study. After completing the study, all data will be destroyed. 
If you have any question or suggestion, you can directly contact the researcher by 
phone +6287737639177 or email to istiyantihapsari@gmail.com. 
If you decide to participate in the project, please sign this form. You have the right to 
participate or not to participate and  to withdraw from your participation at any time without 
any cost, impact on your receiving service, or impact in any dental treatment or routine care. 
--------------------------------------------------------- 
I am, Mr./Ms. ______________________________________________  have been given 
information about this research study and its risks and benefits and have had the opportunity 
to ask questions and to have my questions answered to my satisfaction.  I freely give my 
consent to participate in this research project. 
Date .........................................................................  
Signature .............................................. (Participant) 
Signature ..............................................(Researcher) 
 
(Istiyanti Hapsari) 
Signature .................................................. (Witness) 
Signature .................................................. (Witness) 

21 
 
Appendix D - Ethical Clearance Document 1 

22 
 
Appendix E - Ethical Clearance Document 2