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Year : 2018  |  Volume : 16  |  Issue : 2  |  Page : 116-121

Effectiveness of an integrated handwash and mouthrinse programme on general health of young adolescent school children: A randomized controlled trial

Department of Public Health Dentistry, KVG Dental College and Hospital, Sullia, Karnataka, India

Date of Submission01-Jan-2018
Date of Acceptance24-Apr-2018
Date of Web Publication24-May-2018

Correspondence Address:
Dr. Poulami Mishra
Department of Public Health Dentistry, KVG Dental College and Hospital, Sullia, Dakshina Kannada, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_181_17

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Background: Recently, public attention to the area of personal hygiene has increased for a variety of reasons and one of them is due to the growing awareness that a majority of microbes that cause diseases among humans gain access through various portals of entry and transmitted to these portals mainly through hands. Aim: The aim of this study is to assess the effectiveness of an integrated handwash and mouthrinse programme on the general health of young adolescent school children's in Puttur taluk. Material and Methods: A single-blinded randomized control trial was designed and conducted among school going young adolescents of Puttur taluk in Dakshina Kannada district of Karnataka. Two schools were randomly included as experimental and control group. Mouth rinsing was integrated to handwashing program for the experimental group. Mouth rinsing program was implemented and monitored for 7 months. Statistical Analysis: Descriptive statistics was performed and paired “t” test was used to compare the difference in means. Results: Mean age of the school children was 12.33 ± 1.3 years, gender ratio of male: female was 0.5:1 and 0.7:1 of case and control groups, respectively. Analysis of oral health and general health parameters of study group and control group at final evaluation revealed modified Oral Hygiene Index Scores significantly reduced in study group from 1.52 ± 0.6 to 1.07 ± 0.5 (P < 0.01), Gingival Index scores significantly reduced in study group from 1.12 ± 0.6 to 0.75 ± 0.5 (P < 0.01). Mean incidence of absentees among study group reduced from 5.16 ± 0.5 to 2.45 ± 0.5 (P < 0.001). Conclusions: Integrating a monitored mouth rinsing to existing handwashing program will not incur additional financial or logistic constraints but may have an effect in improving general health, personal hygiene, and oral health among school children.

Keywords: Hygiene, infection, mouth rinse, school absenteeism

How to cite this article:
Mishra P, Fareed N, Battur H, Khanagar S. Effectiveness of an integrated handwash and mouthrinse programme on general health of young adolescent school children: A randomized controlled trial. J Indian Assoc Public Health Dent 2018;16:116-21

How to cite this URL:
Mishra P, Fareed N, Battur H, Khanagar S. Effectiveness of an integrated handwash and mouthrinse programme on general health of young adolescent school children: A randomized controlled trial. J Indian Assoc Public Health Dent [serial online] 2018 [cited 2024 Mar 3];16:116-21. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2018/16/2/116/233067

  Introduction Top

Recently, public attention to the area of personal hygiene has increased for a variety of reasons. One reason is the growing awareness that a majority of microbial pathogens (bacteria, fungi, yeast, molds, and viruses) that cause disease in the human body gain access through various portals of entry (e.g., ears, nose, and mouth) and that these microorganisms are generally introduced into these portals by the hands. In addition to this, various types of microorganisms that cause infections of the nail and skin are also acquired by direct contact with contaminated surfaces, both organic and inorganic, in the environment.[1] It is, therefore, logical to conclude that a large number of illnesses may be prevented by the disinfection of the hands, and of the major portal of entry into the body by way of the mouth, which means the synergistic effect of handwash and mouthrinse.

Since 400 years ago, when Antonie van Leeuwenhoek began using microscopes to study the human body, samples of dental plaque have been studied by several researches around the world.[2]

Many studies confirm that the mouth is a complex ecosystem, which contains many microbial inhabitants including bacteria, viruses, and fungi. It is plausible that the presence of microbial inhabitants represents the principal etiologic agent for several oral diseases including caries and periodontal diseases.[3]

Caries is a disease caused by species such as  Streptococcus mutans Scientific Name Search treptococcus sobrinus.[4] In addition, bacterial species, such as Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans and Fusobacterium nucleatum, have frequently been isolated from periodontal lesions and have been shown to be related to the onset and progression of periodontal disease.[5]

For all these different reasons, the regular use of water mouthrinse and antimicrobial mouthrinses may play a key role as adjuncts to brushing and flossing for preventing caries and gingivitis.[2]

Hand hygiene is now regarded as one of the most important elements of infection control activities. In the wake of the growing burden of Health Care-Associated Infections, the increasing severity of illness and complexity of treatment, superimposed by multidrug-resistant pathogen infections, and Health Care Practitioners are reversing back to the basics of infection prevention by simple measures such as hand hygiene.[6] This is because enough scientific evidence supports the observation that if properly implemented, hand hygiene alone can significantly reduce the risk of cross-transmission of infection in Health Care Facilities.

The significance of handwashing inpatient care was conceptualized in the early 19th century. Labarraque provided the first evidence that hand decontamination can markedly reduce the incidence of puerperal fever and maternal mortality.[6]

The impact of hand-hygiene interventions for reducing infectious illnesses in the community is important for several reasons. First, there has been an explosion in the options and use of hand-hygiene products in the community. Second, hand hygiene is considered an important intervention measure for pandemic public health threats such as severe acute respiratory syndrome and avian influenza. Third, research has suggested that there may be risks, including the emergence of antibiotic-resistant bacteria, and associated with the use of some hand-hygiene products such as antibacterial soaps.[7]

Handwashing and mouth rinsing are an integral part of personal hygiene. Integrating them would benefit both oral health and general health. The present study was thus undertaken to assess the effectiveness of integrating a mouthrinse program to an existing handwash programme on the general health of young adolescent school children.

  Materials and Methods Top

A single-blinded randomized, controlled trial wherein the participants were kept unaware of their allotment to experimental or control group was designed and conducted among school going young adolescents of Puttur taluk in Dakshina Kannada district of Karnataka. Ethical clearance was obtained from the Institutional Ethics Committee bearing a registration number IECKVGDCH/SS36/2016-17. Permission and approval to conduct the study were obtained from block education officer. Headmistresses and/headmasters of the included schools were approached, and their cooperation in conducting the study was solicited. Informed consent from the participating children was obtained from the parents through the headmasters/headmistresses. This randomized controlled trial is registered at the Clinical Trials Registry-India bearing a registration number CTRI/2018/03/012539.

Sample size was estimated according to the given formula based on a previous study which reported, a mean absenteeism of 6.3 ± 1.8 school days.[8] The expected difference we anticipated in this study was at least 1.5 days of mean reduction in school absenteeism.

Sample size =

where, SD = Standard deviation; d = precision (effect size)

The estimated sample size was 26.8; an additional 10% was added to the estimated sample size to compensate dropouts if any. Thus, the final sample accounted to 30 participants for each group.

Inclusion criteria

Experimental group

A total of 15 randomly drawn children studying in sixth and seventh standards, from each class of 30 available students of one of the two included schools with informed consent, willing to abide to our suggestions during the period of our study.

Control group

Randomly drawn school children from another school with matched age, gender, socioeconomic status (SES), and clinical parameters.

Exclusion criteria

For (experimental and control groups)

Any systemic condition that could preclude recording of included clinical parameters and/or limit the training of school children for the intervention used in the study.


A list of schools was obtained from Block Education Office of Puttur Taluk. All schools (182 schools) were invited to participate in this study; however, 32 schools agreed to cooperate and participate in the study. Two schools were randomly allocated as experimental and control groups. The chief investigator and a recorder visited the school, performed clinical examination of school children satisfying inclusion/exclusion eligibility criteria were included in the study [Figure 1].
Figure 1: Schematic representation of the study design

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Data collection

Data required for this study was collected on a specially designed structured pro forma comprising two main parts: part A recorded demographic characteristics, the SES was recorded using Kuppuswamy scale (2016), data needed for the same were obtained through school records, Part B recorded personal hygiene, general health, and oral health parameters of the school children.[9] Personal hygiene included the status of hair, nose, elbow, and nails as recorded according to the criteria described in [Table 1]. The scores were summed and dichotomized as satisfactory and unsatisfactory. General health parameters included the episodes of diarrhea reported by the participants for the past 1 month and absenteeism for the past 1 month as evident from the school records (attendance register). The oral health parameters were measured using Simplified Oral Hygiene Index (OHI-S), Gingival Index (GI), and decayed/missing/filled teeth (DMFT).[10],[11],[12]
Table 1: Assessment of personal hygiene parameters incorporated in the study

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Study procedure

The study was conducted over a period of 7 months, during which the investigator herself visited the schools with due permission from the headmistress/headmaster and performed the various stages of the study protocol [Figure 1].

Baseline data were collected over a period of 4 weeks and in the 2nd-month intervention was provided. A standard handwash technique being followed at both the schools was maintained. Children in the experimental group were demonstrated and made to practice a 5-step mouth rinsing program using tap water by the investigator herself.[13] Four sessions of intervention were conducted, two for demonstration, and two for assessing the performance by the students. Students who could not perform adequately were retrained till consistency in performance was achieved. Monitoring for the experimental group was provided by the school teachers, who were trained to do so and regular reinforcement of both the techniques were provided by the investigator herself at intervals.

Statistical analysis

Statistical analysis was done using SPSS version 21, (software package used for logical batched and nonbatched statistical analysis, acquired by IBM in 2012, Armonk, North Castle, New York). Descriptive statistics were performed and presented. Paired “t” test and Student's t-test were performed to compare the intragroup and intergroup differences in the observed mean values. Chi-square analysis was performed to find differences in personal hygiene between experimental and control groups. P < 0.05 considered statistically significant.

  Results Top

Analysis of demographic details at baseline revealed an almost similar gender representation among experimental (Ex) group and controls (Co) and majority were female (Ex - 66.6% and Co - 56.25% [P = 0.7]). Male-to-female ratio for experimental group and control group was 0.5:1 and 0.7:1, respectively. The analysis of SES revealed that 6 (20%) and 11 (34.7%) belonged to upper-lower class and 24 (80%) and 21 (65.6%) belonged to lower class in experimental and control groups respectively [Table 2].
Table 2: Distribution of the study population according to demographic characteristics

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A comparative analysis of experimental and control groups at baseline revealed that there was no statistically significant difference in hygiene and health parameters included in the study. The analysis of previous month's health parameters reported average episodes of diarrhea were 2.12 ± 0.4 versus 2.23 ± 0.4, and the mean number of days of absenteeism was 5.16 ± 0.5 versus 5.01 ± 0.5 among experimental and control groups, respectively [Table 3].
Table 3: Comparison of hygiene, general health and oral health parameters in experimental and control group at baseline

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Mean OHI-S score was (Ex-[1.52 ± 0.6] vs. Co-[1.57 ± 0.4]), mean (GI score was (Ex-[1.12 ± 0.6] vs. Co-[1.24 ± 0.3]), and mean DMFT score was (Ex-[4.0 ± 2.1] vs. Co [4.1 ± 2.1]) [Table 2].

Intragroup analysis of clinical parameters among experimental group at final evaluation revealed a statistically significant reduction in reported mean episodes of diarrhea (past 1 month) ([2.12 ± 0.4] vs. [2.02 ± 0.4] P < 0.001) and absenteeism (past 1 month) ([5.16 ± 0.4] vs. [2.45 ± 0.5] P < 0.001). Significant reduction was also seen in OHI-scores ([1.52 ± 0.6] vs. [1.07 ± 0.5] P < 0.001), (GI scores ([1.12 ± 0.6] vs. [0.75 ± 0.5] P < 0.001) [Table 4].
Table 4: Comparison of hygiene, general health and oral health parameters in experimental group at final evaluation

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Intergroup comparative analysis of general health parameters between experimental and control groups revealed no statistically significant difference in reported mean episodes of diarrhea. However, analysis of absenteeism (past 1 month) revealed statistically significant difference between experimental group and control group at 3.45 ± 0.5 and 5.22 ± 0.5 (P < 0.001), days respectively.

The analysis of oral health parameters at final evaluation revealed statistically significant difference in OHI-S scores and (GI Scores in both intragroup (experimental group) and intergroup comparisons. However, no statistically significant difference was observed in DMFT values [Table 4] and [Table 5].
Table 5: Comparison of hygiene, general health and oral health parameters between experimental and control group at final evaluation

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  Discussion Top

Hygiene is a concept related to cleanliness, health, and medicine, as well as to personal and professional care practices. Hygiene practices are employed as preventive measures to reduce the incidence and spreading of infections and disease. Infections are an important cause of morbidity in rural India. Most common infectious diseases include respiratory tract infections and gastrointestinal (GI) tract infections.

The most common cause of ill health among children is reported to be a transmitted infection, and unclean hands are the most common route for transmission of infection among them.[14] Total bacterial counts on the hands of human beings have been reported to range from 3.9 × 104 to 4.6 × 106 CFU/cm 2. Hand-hygiene program is, therefore, the most important measure to avoid the transmission of harmful germs and to prevent infections.[15] First Global Handwashing Day was held in 2008 when over 120 million children worldwide washed their hands with soap in ≥70 countries; it is a campaign to motivate and mobilize people worldwide to improve their handwashing habits.[16]

Oral health is also an essential component of general well-being. Dental caries and periodontal diseases are the two globally leading oral afflictions, according to the World Oral Health Report 2003.[17] Children frequently have serious general health problems, significant pain, interference with eating, and lost school time if oral disease is left untreated. To the best of knowledge, published literature is not available on the effectiveness of integrated handwash and mouth rinse program. In this study, we have incorporated a simple mouthrinse programme using tap water to an already existing handwash program at the school level. This programme does not incur any financial, logistic, or time constraints on the participants.

The data show that the intervention done in the present study was highly effective in improving hygiene, general health, and oral health of the participants. At final evaluation, mean OHI scores decreased from 1.52 ± 0.6 to 1.07 ± 0.5, in accordance to Santos et al. reported nearly 50% decrease with 0.05% chlorhexidine (CHX) digluconate in the intervention group.[18] The probable reason for a lesser magnitude of decrease in our study could be because we have used plain tap water for mouth rinsing. Throat irritation, dry mouth etc, additionally it may incur logistic and financial constraints at school level, thus it is not a recommended method. Similarly, mean (GI score had decreased from 1.12 ± 0.6 to 0.75 ± 0.5 which was in accordance to the study conducted by Kozlovsky, Avital, et al. where it reduced from 1.30 to 0.62, though with a different intervention two-phase oil: water mouth rinse. Lang et al. have reported a reduction of mean GI scores from 0.80 to 0.24 with 0.2% CHX mouth rinse.[19],[20] Since oral microorganisms possess hydrophobic outer surfaces, the aqueous of this solution includes cetylpyridinium chloride, which is a disinfectant that promotes the adhesion of microorganisms to oil droplets, despite these initial desorption mechanisms of cetylpyridinium chloride, the simple aqueous: oil combinations did not prove, particularly effective in improving oral hygiene over time. Furthermore, the two immiscible oil and water phases posed technical difficulties.

In the present study, the mean episodes of diarrhea among experimental group reduced from 2.1 to 2.02, which was in contrary to the study conducted by Luby, Stephen et al. where it reduced from 8.14 to 4.21. The reason for this difference in magnitude could be attributed to the use of soap water as a handwashing adjuvant in the later study.[21]

The present study revealed statistically significant difference in the reduction of absenteeism in accordance to Guinan et al., who has reported a similar trend in a 3-month study using hand sanitizer as intervention. The reason for improvement of the parameters in this study may or may not be particularly attributed to the integrating mouth rinsing to the handwash program alone. In addition, continuous monitoring of the school children and the role of Hawthorne effect should be considered before interpreting the findings of this study.[8]

The essential requirement of the present study was to develop an effective approach to integrate handwashing with mouth rinsing that could practically not incur any burden regarding finance, logistics, and time on the participants. We recommend that further studies evaluating the long-term effects of behavioral modification and integration of handwash-mouthrinse program to be conducted on a larger and much school going population. In the interim, existing public health programs should experiment with integrating handwashing and mouth rinsing programs promotion into their current activities.

The possible but albeit necessary limitations of the present study could be the consideration of only a few parameters for personal hygiene and general health of the participants. In addition, the role of recall bias in reporting the episodes of diarrhea by the participants (experimental and control groups) should be considered before interpreting the findings of the study.

  Conclusions Top

Based on the findings of our study, we conclude that integrating a monitored mouth rinsing to existing handwashing program may have an effect in improving general health, personal hygiene, and oral health among school children.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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