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Annals of Pediatric Cardiology logoLink to Annals of Pediatric Cardiology
. 2026 Jan 1;18(4):365–374. doi: 10.4103/apc.apc_131_25

Impact of mobile application-based oral hygiene education on parental knowledge, attitudes, practices, and oral hygiene of children with congenital heart disease

Aljo Joy 1,2, Lakshmanan Gopichandran 1,3,✉, Latha Venkatesan 1, Saurabh Kumar Gupta 4,✉, Kalpana Bansal 5, Vijay Prakash Mathur 5, Ankur Handa 4
PMCID: PMC12924028  PMID: 41725875

Abstract

Background:

Children with congenital heart disease (CHD) face an elevated risk of infective endocarditis (IE), exacerbated by poor oral hygiene due to limited parental awareness. This study evaluated the effectiveness of a mobile application-based oral hygiene education program in improving parental knowledge, attitudes, practices, and children’s oral hygiene.

Methodology:

We prospectively enrolled 100 children aged 2–14 years with CHD and their parents. A validated questionnaire assessed parental knowledge, attitudes, and practices at baseline, and children’s oral hygiene was assessed using the Silness and Loe plaque index. Parents received mobile application-based oral hygiene education and weekly telephonic reinforcement. Reassessments were performed after 1 month.

Results:

Among 93 participants completing follow-up, children had a mean age of 5.9 ± 2.9 years (62% male); parents had a mean age of 33.2 ± 6.3 years (67% male), with 40% from lower-middle socioeconomic backgrounds. At baseline, only 17.2% of parents had adequate knowledge, 15% had a favorable attitude, and 5.4% practiced satisfactory oral hygiene. Post-intervention, these increased to 85%, 89.2%, and 79.5%, respectively (all P < 0.001). The median Silness and Loe plaque index score decreased from 1.25 to 0.875 (P < 0.001), with children exhibiting good oral hygiene rising from 22.5% to 63.4% (P < 0.001). Although modest, correlations between parental knowledge and both attitude and practice scores improved following the intervention.

Conclusions:

Children with CHD often exhibit poor oral hygiene, compounded by parental unawareness. A mobile application-based education program, combined with conventional methods and reinforcement, significantly improves parental knowledge, attitudes, and practices and children’s oral hygiene. Integrating such interventions into CHD care may reduce IE risk.

Keywords: Congenital heart disease, infective endocarditis, oral hygiene

INTRODUCTION

With a global prevalence of 8–10 cases per 1000 live births, congenital heart disease (CHD) accounts for nearly one-third of all major congenital anomalies.[1,2] Medical advances have significantly improved survival, with most patients with CHD reaching adulthood. However, infective endocarditis (IE) remains a serious complication in these patients. An increasing incidence of IE has accompanied the rising population of individuals with CHD.[3] Globally, IE cases and associated mortality have more than doubled over the past three decades, from 478,000 cases in 1990 to 1,090,530 in 2019, and from 28,750 deaths to 66,320 in the same period.[4] Given its high morbidity, mortality, and prolonged treatment course, IE imposes substantial burdens on patients and healthcare systems.[4]

The development of IE requires a combination of predisposing cardiac pathology, bacterial entry into the bloodstream, and host immune susceptibility. High-risk patients include those with CHD, prosthetic heart valves (surgical or transcatheter), ventricular assist devices, or a previous history of IE, while those with rheumatic heart disease, degenerative valve disease, bicuspid aortic valves, cardiovascular implanted electronic devices, and hypertrophic cardiomyopathy are at intermediate risk.[5,6] Portal of bacterial entry includes infections of the skin, oral cavity, gastrointestinal and genitourinary systems, intravenous drug use, and healthcare-related procedures.[7] Among children with CHD, the incidence of IE is approximately 0.41 cases per 1000 person-years.[8] Studies from India have also shown CHD as an important cause of IE.[9,10] Despite advances in treatment, childhood IE has a mortality of 5%–10%.[11] Children with CHD are more susceptible to dental caries, enamel hypoplasia, and periodontal disease compared to their healthy peers.[12,13] Additionally, certain medications, such as diuretics, may reduce salivary secretion, further compromising oral health.[14]

Maintaining optimal oral hygiene is one of the most effective strategies for reducing IE risk in patients with both operated and unoperated CHD.[7] However, this requires active parental involvement, which is often hindered by limited knowledge about oral hygiene, IE, and antibiotic prophylaxis.[15,16,17] Besides focus on CHD management, socioeconomic factors such as poverty and illiteracy exacerbate these challenges. Fear of bleeding from toothbrushing further discourages many parents from maintaining their children’s oral hygiene. This problem exists worldwide but is more prevalent in developing countries.[4] In India, 85% of parents remain unaware of the importance of oral hygiene, and only 16% of children with CHD have good oral hygiene.[18,19]

Structured educational programs have been shown to improve parental knowledge and attitudes toward oral hygiene,[18,19] leading to better oral health outcomes in children.[18,19] Mobile application-based education has also demonstrated effectiveness in this regard.[20,21,22,23,24,25] Nonetheless, there is a paucity of research on oral hygiene in children with CHD. Hence, this prospective study aimed to evaluate the impact of mobile application-based oral hygiene education on parental knowledge, attitudes, practices, and the oral health of children with CHD.

METHODOLOGY

After obtaining clearance from the Institute Ethics Committee (Ref. No. IECPG-239/24), and registration in the Clinical Trials Registry – India (CTRI) (Reg. No. CTRI/2022/09/045985), children with CHD aged 2–14 years and their parents, attending the Pediatric Cardiology Outpatient Department between October and December 2022, were enrolled in this study. Children with neurodevelopmental delays, genetic syndromes, or other comorbidities were excluded from the study. Additionally, families unable to attend follow-up visits or use the Healthy Smile mobile application were excluded.

Tools

Parental knowledge, attitudes, and practices regarding oral hygiene were assessed using a prespecified, locally developed, and validated questionnaire [Annexure 1]. The questionnaire was developed in consultation with pediatric cardiologists, pediatric dentists, and nursing professionals. Content validity was established through expert review by five medical and four nursing professionals. The content validity index scores exceeded 0.81 for the knowledge scale, 0.83 for the attitude scale, and 0.80 for the practice scale.[26] Reliability was confirmed using the split-half method for the knowledge questionnaire (0.85) and Cronbach’s alpha method for the attitude (0.86) and practice (0.81) scales. The questionnaire was available in both English and Hindi to ensure easy understanding by parents. The questionnaire consisted of three sections:

  1. Knowledge assessment: This section included 14 questions evaluating parental understanding of CHD and oral hygiene, with each correct response awarded one point. Scores were categorized as adequate (11–14), moderate (6–10), and inadequate (≤5)

  2. Attitude assessment: This section comprised 10 items evaluated on a 5-point Likert scale, with five positively and five negatively stated items. The possible scores ranged from 10 to 50, with scores classified as most favorable (36–50), favorable (21–35), and unfavorable (≤20)

  3. Practice assessment: This section included 10 questions, each carrying one point for a correct response, yielding a total possible score of 0–10. Practice scores were categorized as most satisfactory (7–10), satisfactory (4–6), and unsatisfactory (≤3).

A pediatric dentist, blinded to the results of the questionnaire, assessed the oral hygiene of children using the Silness and Loe plaque index [Figure 1]. The Silness and Loe plaque index is a widely used method for assessing dental plaque accumulation and oral hygiene status. It evaluates presence of plaque on four surfaces – buccal, lingual, mesial, and distal – of six representative teeth commonly selected from different areas of the mouth. Each surface is scored on a scale from 0 to 3, where 0 indicates no plaque, 1 represents a thin film detectable by a probe, 2 signifies moderate accumulation visible to the naked eye, and 3 denotes heavy plaque buildup along the gingival margin and interdental spaces. The total plaque scores are averaged across all examined surfaces to determine the final plaque index, which classifies oral hygiene as good (0–0.9), fair (1–1.9), or poor (2–3). This index serves as a valuable tool for dental professionals to monitor plaque control, assess oral hygiene practices, and provide targeted recommendations for improving patient care.[27]

Figure 1.

Figure 1

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Application and interpretation of Silness and Loe plaque index. PI: Plaque index

Parents then participated in a 30-min structured educational session on oral hygiene. The session covered key topics, including CHD, the risk of IE, and the importance of maintaining optimal oral health. Additionally, parents were educated on proper oral hygiene techniques. The session included training for the use of the Healthy Smile-Swasth Muskaan mobile application [Figure 2]. This mobile application was conceptualized and developed by the Department of Pediatric and Preventive Dentistry at the Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi. The application is available for the Android platform on the Google Play Store in two languages, Hindi and English. It is a musical companion for children and their parents. The application guides parents to maintain the oral health of their children at home with simple measures. The mobile application also helps parents and children learn the timing and technique of toothbrushing. Separate sets of how-to-brush videos are available for children of different age groups. The application also has a 2-min brushing timer, brushing reminder, dental care tips, dietary instructions for oral health, answers to frequently asked questions, and motivational videos.

Figure 2.

Figure 2

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Snapshot demonstrating salient features of the Healthy Smile-Swasth Muskaan mobile application available for the Android mobile platform on the Google Play Store

Parents were instructed to use the Healthy Smile application twice daily for 1 month, with weekly telephone reminders to ensure compliance. After a month, parental knowledge, attitude, and practices regarding oral hygiene and the risk of IE were reassessed using a structured questionnaire, while a pediatric dentist evaluated the children’s plaque index on the same day.

Statistical analysis

A pilot study conducted on ten patients yielded a mean plaque index score of 0.97 ± 0.5 at baseline and 0.92 ± 0.5 after 1 month of dental education. Based on these findings, with a 5% level of significance and 80% power, the sample size was calculated as 80 participants. To account for a 20% dropout rate, the final recruitment target was set at 100 children with CHD and their parents.

Data analysis was performed using STATA version 12.1 (StataCorp LLC, Texas, USA). Descriptive statistics were used to summarize demographic characteristics. The Shapiro–Wilk test assessed data normality. Inferential statistics, including the Wilcoxon signed-rank test and Fisher’s exact test, were employed to compare median scores and examine associations. Spearman’s rank correlation coefficient was used to assess correlations. P < 0.05 was considered statistically significant for all analyses.

RESULTS

A total of 93 participants completed the study [Figure 3] and were included in the analysis. The mean parental age was 33.2 ± 6.3 years 67% males, and only 51% had completed higher secondary education or beyond. Based on the modified Kuppuswamy socioeconomic scale, none of the parents belonged to the upper class. The distribution across socioeconomic classes was as follows: 28% from the upper middle class, 39% from the lower middle class, 30% from the upper lower class, and 3% from the lower class. The number of children per household varied: 15 families had one child, 34 had two, 29 had three, 13 had four, and 2 had more than four children. The mean age of the children was 5.9 ± 2.9 years, with 59 (63.4%) and 34 (36.6%) having acyanotic and cyanotic CHD, respectively. While 69 (74%) patients were awaiting cardiac surgery, 24 (26%) patients were on follow-up after cardiac surgery. There were 58 males and 35 female children. First tooth erupted at 6-7 months in 20 children, 8-9 months in 28, and 10-12 months in 17, while in 28 cases, parents could not recall the timing. Toothbrushing habits also differed, with no child starting to brush teeth before 1 year, 38 children began brushing teeth between 1 and 2 years, 47 between 2 and 3 years, and one between 3 and 4 years. In 7 cases, parents could not recall the exact age. While 33 parents used alternative methods to clean their child's teeth before brushing was introduced, 60 reported no oral hygiene practices.

Figure 3.

Figure 3

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Study flow diagram. CHD: Congenital heart disease, OPD: Outpatient department

There was no association between key demographic variables, including age, gender, place of residence, education level, occupation, and household income, with baseline parental knowledge, attitude, and practice scores.

Effect on parental knowledge, attitude, and practice of oral hygiene

The median baseline knowledge score was 7 (range: 4–12), which significantly improved to 12 (range: 7–14) after 1 month (P < 0.001). Initially, only 16 parents (17.2%) had adequate knowledge, while 22 (23.7%) had inadequate knowledge and 55 (59.1%) had moderate knowledge. After the educational intervention, 79 parents (85%) attained adequate knowledge, while 14 (15%) demonstrated moderate knowledge, marking a substantial improvement. The median baseline attitude score was 28 (interquartile range [IQR]: 23–33), with scores ranging from 17 to 43. Postintervention, the median score significantly increased to 41 (IQR: 38–45), with scores ranging from 32 to 50 (P < 0.001). At baseline, only 15% of parents had the most favorable attitude, which surged to 89.2% (83 parents) after the intervention, indicating a marked improvement. The median baseline practice score was 4 (IQR: 4–5), with scores ranging from 3 to 8. After the mobile application-based education, the median score significantly increased to 7 (IQR: 7–8), with scores ranging from 5 to 9 (P < 0.001). The proportion of parents demonstrating the most satisfactory practices increased from 5.4% at baseline to 79.5% (74 parents) postintervention, highlighting a significant improvement in oral hygiene practices [Table 1].

Table 1.

Parental knowledge, attitude, and practice scores and plaque index before and after mobile application-based educational intervention

Baseline Postintervention P*
Parental knowledge, attitude, and practice questionnaire
    Knowledge score, median (IQR) 7 (6–10) 12 (9–12.5) <0.001
    Attitude score, median (IQR) 28 (23–33) 41 (38–45) <0.001
    Practice scores, median (IQR) 4 (4–5) 7 (7–8) <0.001
Silness and Loe plaque index
    Median score (IQR) 1.25 (1–1.87) 0.875 (0.75–1.45) <0.001
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IQR: Interquartile range

Effect on Silness and Loe plaque index of children

Following educational intervention, the median Silness and Loe plaque index score significantly decreased from 1.25 at baseline to 0.875 (P < 0.001) [Table 1]. Initially, only 21 children (22.5%) had a good oral hygiene index score, which significantly improved to 59 children (63.4%) after the intervention, demonstrating the effectiveness of the educational program in enhancing oral hygiene [Figure 4].

Figure 4.

Figure 4

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Silness and Loe plaque index score of children with congenital heart disease before and after the implementation of the mobile application-based educational intervention

Correlation between parental knowledge, attitude, and practice scores

At baseline, weak positive correlations were noted between knowledge and attitude (r = 0.18, P = 0.088), knowledge and practice (r = 0.16, P = 0.117), and attitude and practice (r = 0.30, P = 0.003). Postintervention, these relationships strengthened, with moderate correlations observed between knowledge and attitude (r = 0.38, P < 0.001), knowledge and practice (r = 0.26, P = 0.010), and a notably strong correlation between attitude and practice (r = 0.52, P < 0.001) [Figure 5].

Figure 5.

Figure 5

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Correlation between parental knowledge, attitude, and practice scores at baseline and postintervention. Panels a-c represent baseline scatter plots: (a) knowledge versus attitude, (c) knowledge versus practice, and (e) attitude versus practice. Panels b, d, and f show corresponding postintervention correlations

DISCUSSION

The comprehensive care of children with CHD extends beyond cardiology and surgical management to include growth monitoring, immunization, and dental care. However, dental care remains an often-overlooked aspect of CHD management. Poor oral hygiene can lead to plaque and calculus buildup, resulting in gingival inflammation and ulceration, which may progress to periodontitis and eventual tooth loss. Lockhart et al.[28] demonstrated a direct link between poor oral hygiene and the risk of bacteremia and IE following daily toothbrushing. Maintaining good oral hygiene and gingival health has been associated with a lower risk of bacteremia, potentially reducing the likelihood of IE.[28]

Only 22.5% of children in our study exhibited good oral hygiene at the baseline. This is similar to the findings from Suvarna et al.,[29] where only 16% of children with CHD demonstrated satisfactory oral hygiene. The study also highlighted limited parental knowledge and awareness regarding their child’s oral care.[29]

Structured education programs are effective in improving oral hygiene knowledge, attitude, and practices.[18,19,20,21,22] In today’s technology-driven world, mobile applications are integral tools for patient education, offering convenient access to essential information while enhancing compliance.[20,23,24,30] The Healthy Smile application, a locally developed mobile application, significantly enhanced parental knowledge regarding oral hygiene in children with CHD. Furthermore, improvement in parental attitudes toward oral hygiene is consistent with findings by Zahid et al.,[21] and Sanadhya et al.,[19] who also reported positive influence of educational programs and mobile applications on attitude toward oral health.

Unlike the study by Sudhadevi,[15] there was no association of parental knowledge, attitude, and practice scores with various demographic parameters. We also did not find a significant association between demographic or clinical parameters, like age, gender, number of siblings, birth order, CHD classification, surgical history, tooth eruption timeline, early oral hygiene practices, and baseline oral hygiene index scores of children. These results are also similar to Kumawat et al.[18] and Zotti et al.,[31] but not as observed by Konwar et al.[32] These differences possibly reflect differences in study design, population characteristics, and methodological approaches.

The postintervention strengthening of correlations between parental knowledge, attitude, and practice scores highlights the effectiveness of the educational intervention. While baseline associations were weak, the stronger postintervention correlations, especially between attitude and practice (r = 0.55), suggest that improved attitudes played a pivotal role in translating knowledge into actionable behavior. This aligns with established behavior change models, where attitude often mediates the transition from awareness to practice. The combination of structured teaching, mobile app-based education, and telephonic reinforcement likely contributed to this alignment, underscoring the value of integrated strategies in promoting oral hygiene among children with CHD.

Given these findings, we believe that all pediatric cardiologists should emphasize the importance of maintaining good oral hygiene to all children with heart disease and their parents. For optimal oral health, children with CHD should have education and a comprehensive evaluation by a pediatric dentist.

Limitations

The study design was quasi-experimental; the study relied on the intervention group alone without a comparative analysis with a control group. Seven participants were lost during follow-up. There was no provision to ensure the use of the app by participants. The study was conducted in one hospital setting only, and the study findings may not be generalizable.

CONCLUSIONS

Most parents of children with CHD are unaware of the importance of oral hygiene, and their children have poor oral hygiene. A focused oral hygiene education combined with the use of a mobile application, Healthy Smile – Swasth Muskaan, improves parental knowledge and attitude toward oral hygiene while also improving their children’s oral hygiene.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

We would like to thank Dr. K. Pavitra Devi from AIIMS, New Delhi for dental plaque index assessment and Dr. Sumit Kumar Das from AIIMS, New Delhi for statistical analysis.

Annexure 1 Questionnaire to assess parental knowledge, attitude, and practice about CHD and oral hygiene of children

Knowledge domain

CHD & its complications

  1. Congenital heart defects are

    1. Abnormalities of the heart that develop after 1 year of birth

    2. Abnormalities of the heart that are present at birth

    3. Abnormalities of the heart that develop after birth

    4. Abnormalities of the heart that develop after 6 years of birth

  2. The risk of developing heart infection in children with heart disease is

    1. Higher

    2. Lower

    3. Similar

    4. No relation

  3. The risk of developing heart infection in children with poor oral hygiene is

    1. Higher

    2. Lower

    3. Similar

    4. No relation

  4. What is infective endocarditis (heart infection)?

    1. Enlargement of the heart muscle

    2. Infection of the inner lining of the heart

    3. Loss of the pumping ability of the heart

    4. Lack of oxygen supply to the heart muscle

Oral hygiene

  1. What is the age at which temporary/milk/primary teeth start to erupt in the oral cavity?

    1. 6 months

    2. 1 year

    3. 1.5 years

    4. 2 years

  2. Do you think you must supervise the child’s brushing?

    1. No

    2. Yes, occasional

    3. Yes, always until the age of 6 years

    4. Yes, sometimes until the age of 4 years

  3. How many times a day should you brush your child’s teeth?

    1. In the morning, after getting out of bed

    2. At night, before going to bed

    3. After every meal

    4. Both A & B

  4. What type of food should be avoided to prevent dental caries?

    1. Sticky sugars after dinner

    2. Frequent intake of sugar-containing junk foods

    3. Toffees, chocolates, candy, lollipops

    4. All of the above

  5. What type of food should be encouraged to have better oral health?

    1. Fresh fruits, fresh juice, egg, milk& dairy products

    2. Foods like toffees, chocolates, candy, and lollipops

    3. Carbonated beverages, example, Pepsi, Cola, etc.

    4. Sugar-sweetened beverages for a baby on bottle-feeding

  6. How many times is the intake of sweet foods/beverages permitted per day, and with a regular oral hygiene schedule?

    1. Once or twice a day

    2. thrice a day

    3. 4 -5 times a day

    4. As much as the child wants

  7. What oral hygiene habits should be avoided to improve good oral health?

    1. Consider mouthwash

    2. Brushing regularly

    3. Visit the dentist regularly

    4. Regular use of sweets

  8. The warning sign of oral disease?

    1. Jaw & mouth pain

    2. Sore & bleeding gums

    3. Bad breath & tooth discoloration

    4. All of the above

  9. How often should you visit the dentist?

    1. Regularly, every 6 months

    2. When in pain

    3. Occasionally

    4. Never

  10. How much toothpaste is needed for brushing teeth? *

    1. Size of a rice grain

    2. Size of a pea

    3. As much as the child wants

    4. Size of a cashew

*Different correct responses for those younger and older than 3 years

Attitude domain

Item no. Statement Strongly Agree Agree Neutral Disagree Strongly Disagree
1. Oral health is important for general health          
2. Oral hygiene is not important for temporary teeth          
3. The child enjoys the activity of brushing          
4. As a parent, I should supervise my child’s brushing          
5. If the child is unable to do brushing due to illness, it is not necessary to perform oral hygiene          
6. Dental problem is not a serious problem          
7. A dental visit is necessary, if the child has dental pain or food lodgment problems in the teeth          
8. If dental pain is subsiding within a short period, no need to visit the dentist          
9. Regular visits to the dentist are necessary          
10. As my child is affected by congenital heart disease, I feel that oral hygiene is not that much of importance          
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Practice domain

  1. How often does your child brush his/her teeth?

    1. Once a day

    2. Twice a day

    3. Sometimes once a day, and sometimes twice a day

    4. Not every day

  2. How long does your child brush his/her teeth?

    1. Less than a minute

    2. One minute

    3. 1-2 min

    4. Not sure, but less time than a minute

  3. Do you supervise your child’s brushing?

    1. Yes, always

    2. Sometimes

    3. Occasionally

    4. Never

  4. How does your child maintain oral hygiene?

    1. Brushing only

    2. Brushing & tongue cleaning

    3. Only tongue cleaning

    4. Only mouthwash

  5. If your child is not able to do brushing alone, do you do the child’s brushing?

    1. Yes, always

    2. Sometimes

    3. Occasionally

    4. Never

  6. How often should you visit the dentist?

    1. Regularly, every 6 months

    2. Regularly every 1 year

    3. Only dental pain or bleeding occurs

    4. Not at all

  7. What type of food are you avoiding in your child’s diet to prevent dental caries?

    1. Sticky sugars after dinner

    2. Frequent intake of sugar-containing junk foods

    3. Toffees, chocolates, candy, lollipops

    4. All of the above

  8. What type of food are you giving to your child for better oral health?

    1. Fresh fruits, fresh juice, egg, milk & dairy products

    2. Foods like toffees, chocolates, candy, and lollipops

    3. Carbonated beverages, example - Pepsi, Cola, etc.

    4. Sugar-sweetened beverages for a baby on bottle feeding

  9. How many times is the intake of sweet foods/beverages permitted per day for your child?

    1. Once or twice a day

    2. Thrice a day

    3. 4-5 times a day

    4. As much as the child wants

  10. What oral hygiene routines do you follow to maintain your child’s oral health?

    1. Consider mouthwash

    2. Brushing regularly

    3. Visit the dentist regularly

    4. Regular use of sweets

Funding Statement

Nil.

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