Abstract
BACKGROUND:
Children with sensory disabilities exhibit a poor oral hygiene and a high prevalence of gingivitis and dental caries. Tailored multisensory oral health education interventions may improve tooth brushing skills and oral health. To develop and validate a multisensory game-based educational intervention to teach tooth brushing to children with visual and hearing impairments.
MATERIALS AND METHODS:
A developmental research design was used. A prototype was developed after literature review and expert interviews. This was validated by dentists and special educators and field tested among 15 children with visual impairment and 15 with hearing impairment with 7 play sessions over 4 weeks. Comprehensibility and acceptability were assessed through structured feedback, and effectiveness was measured by evaluating tooth brushing skills.
RESULTS:
Experts agreed with the relevance, sequential accuracy of the brushing technique, and clarity of the game (Item-level Content Validity Index (I-CVI) and k* =1.00), confirming excellent content validity. Dentists suggested minor modifications regarding sequencing flexibility and a special educator suggested audio/light cues. Children with visual impairment rated the game and the tooth brushing technique as easy to understand and the components easy to handle (I-CVI = 1.00), enjoyable (I-CVI = 0.93), and some suggested larger models. Children with hearing impairment showed perfect agreement across all aspects of the game. The children showed improvements in their tooth brushing skills (W = 0.00, P < 0.05).
CONCLUSION:
The developed game-based educational intervention demonstrates strong validity and acceptability for oral hygiene education among children with sensory impairments. These findings support further evaluation of long-term effectiveness and application in oral health promotion.
Keywords: Games, learning, hearing loss, health education, oral hygiene, sensory disorders, toothbrushing, vision disorders
Introduction
Sensory disabilities are a global public health concern. The estimated prevalence of visual impairment among children in India is around 0.8/1000.[1] The World Health Organization (2018) reports that childhood-onset deafness affects 2% of children in India.[2] The prevalence of gingivitis and dental caries among the sensory disabled children is higher compared to healthy children. This may be due to challenges in oral health education and accessible oral health care.[3] Tooth brushing is a life skill that significantly impacts an individual’s oral health.[4] Systematic tooth brushing is often neglected in daily routines, and teaching effective tooth brushing techniques in early childhood is important.
Traditional oral health education has not been very effective in promoting effective oral hygiene practices among children with hearing and visual impairments. Accommodative tools that foster effective communication and learning are essential to tackle the diverse learning needs of children with sensory disabilities.[5] The use of innovative games in therapeutic settings has expanded substantially, making interventions effective and simple participation in an engaging and interactive game can enable behavior change.[6] Games have been reported to enhance comprehension, cognitive engagement, and information retention, and learning is enhanced through a performance component.[7] Teachers in school settings play a very important role in oral health education and establishing healthy habits. Games, when adapted to provide visual and tactile reinforcement for children with sensory impairments, have been found to be effective tools for oral health education among children with sensory disabilities.[8,9,10,11] Recognizing the need for intervention in this context, we aimed to develop a multisensory game based educational intervention (GBEI) to teach systematic tooth brushing to children with sensory disabilities [Figure 1].
Figure 1.
Theoretical framework illustrating a pathway from barriers to improving oral health outcomes through a multisensory, game-based intervention for children with visual/hearing impairment
The development of an educational board game requires careful design, rules, and enhancements to make it user-friendly and engaging,[12] and hence, we used a developmental study design to create a board game to teach sequential tooth brushing. The novelty of our study lies in the fact that this is the first 3D board game to teach sequential tooth brushing, which can be used among children with visual and hearing impairment as it can provide tactile and visual reinforcement.
Objectives
To develop a game-based educational intervention to teach tooth brushing for children with visual impairment/hearing impairment.
To validate the game-based educational intervention for tooth brushing for children with visual impairment/hearing impairment.
Materials and Methods
Study design: A developmental and exploratory study design.
Study participants and sampling
Six subject experts (2 periodontists, 2 pediatric dentists, 2 public health dentists) from various dental colleges in Tamil Nadu and six Special educators from special schools for the visually/hearing impaired in the Kongu region of Tamil Nadu, with a minimum of 5 years of teaching experience were selected through convenience sampling for expert validation. For the preliminary field testing, 30 children who fulfilled the eligibility criteria were randomly selected, 15 each from Government Middle School for the Blind and the Government High School for the Hearing Impaired, Salem.
Inclusion criteria
Full visual/hearing impairment enrolled in the special schools.
No exposure to any form of oral health education in the last 1 year.
Exclusion criteria
No other physical or mental disability that can affect the tooth brushing performance or comprehension of the given oral health education.
Data collection tool and technique
The dentists and special educators were given a validated structured questionnaire to fill out. The principal investigator with assistance from the special educators (verbal and sign language) collected feedback from the children using a validated structured questionnaire. The tooth brushing skill was assessed using an observational checklist index.[13]
Ethical considerations
Ethics approval (MADC/IEC/I/75/2025) and (IEC-FAC/JUN/2025/273) was obtained and the trial was registered (CTRI/2025/11/097735). Informed consent was obtained from all participants. Parental/Legally Authorized Representative (LAR) informed consent and assent from the special children were obtained. Confidentiality was ensured by anonymizing responses. Ethical guidelines were strictly followed and the study ensured accurate reporting of findings without manipulation or misrepresentation of the data.
Statistical analysis method
Descriptive statistics is used for demographic details of the participants of the preliminary trial. Content validity statistics and descriptive statistics (frequencies, percentages) were used for expert validation of the GBEI and feedback from children. Wilcoxon signed-rank test was applied for assessing tooth brushing skill, pre- and postintervention (Wilcoxon signed-rank test calculator).
Development and validation of the GBEI
We followed sequential phases to systematically develop and validate the GBEI for tooth brushing [Figure 2]. The development and validation phases with experts, followed by revision, and preliminary field-testing.[14]
Figure 2.
Research phases and development strategies
Phase 1: Development of the board game
Preparatory Phase: Research and information collection
-
Literature review
Our literature search indicated that sign language or verbal/braille instruction alone was insufficient to teaching systematic tooth brushing to children with hearing/visual impairment. Multisensory, game-based approaches improved oral hygiene knowledge, behaviors, and clinical outcomes, including Oral Hygiene Index- simplified (OHI-S) and plaque scores. Audio-tactile performance interventions with additional music and game-based components,[8] board-game formats, such as a jigsaw puzzle-assisted visual reinforcement,[9] snakes and ladders[10] and lottery-style games,[11] have demonstrated better interest and learning retention by providing an interactive and enjoyable learning experience. These findings provided the rationale for developing an adapted, multisensory, and interactive GBEI for children with sensory disabilities.
-
Interviews with Special Educators
Our qualitative exploration of seven special educators’ perspectives on barriers to oral hygiene indicated significant oral health challenges and failure of traditional oral health education methods in meeting the learning needs of children with sensory disabilities. Educators pointed out that systematic instruction, multisensory approaches that incorporate tactile and visual components for teaching tooth brushing were not widely used for oral health education among these children. They suggested that game-based strategies could be effective in enhancing learning and retention of oral hygiene skills. The educators pressed on the need for affordable, multisensory, game-based oral health education tools to teach, reinforce, and help establish self-reliant oral hygiene maintenance in this population with special needs.
The GBEI tool design
The GBEI tool consists of a 3D numbered grid board (engraved and braille numbers) and detachable models, with toothbrushes positioned on the models representing the chewing, outer, inner (COI) brushing technique.[15] The board can be used as a multisensory storyboard for teaching tooth brushing and as a pattern-recognition puzzle. The game part is to recognize and repair the disrupted pattern. The puzzle can be played individually or competitively with multiple players by timing the completion, at varying difficulty levels.
Phase 2: expert validation
Structured questionnaires were designed specifically and validated for the subject experts and the special educators to evaluate the game. Each item was rated on a 4-point Likert scale with an open-ended question for suggestions for modification.
The tool for the subject experts was to evaluate, the suitability of the COI tooth brushing technique, accuracy and clarity of the 3D models tooth brushing steps and their sequencing, ease of the game instructions and aspects requiring modification to enhance effectiveness. The tool for the special educators was to evaluate, the suitability of the COI tooth brushing technique for children with sensory impairments, clarity and ease of understanding of the 3D models, ease of the game instructions, safety, and ease of handling of the game materials and design or functional suggestions to improve the effectiveness.
Phase 3: revision based on expert evaluation
Based on expert feedback, minor design refinements were incorporated to in the game. The tooth brushing sequence could be modified to each child’s choice. Additionally, the rules were refined to allow flexibility in gameplay, enabling educators to adapt the level of complexity according to individual learning needs.
Phase 4: preliminary field testing
The first intervention session was followed by weekly reinforcement sessions of 3 in the second week, 2 in the third week, and 1 in the fourth week [Figures 3-5]. Feedback was collected from the children and tooth brushing skill was evaluated.
Figure 3.
Tactile evaluation of the GBEI by a child with visual impairment
Figure 5.
Field testing of the GBEI with a child with hearing impairment
Figure 4.
Field testing of the GBEI with a child with visual impairment
Results
The content validity assessment of the game by the dental specialists demonstrated excellent agreement among the six experts. All four evaluated items, relevance of the COI tooth brushing technique, appropriateness of 3D model representations, clarity of sequence, and ease of understanding instructions, were rated as relevant or highly relevant by all experts, resulting in an Item-level Content Validity Index (I-CVI) of 1.00 for each item. The modified kappa values (k*) were also 1.00, indicating perfect agreement beyond chance and confirming excellent content validity. For the open-ended item assessing the need for modifications, 66.7% of experts (n = 4) suggested that modifications were required, while 33.3% (n = 2) indicated no need for changes. These findings suggest that while the core components of the questionnaire are highly valid, minor refinements primarily related to flexibility in sequencing the tooth brushing steps, may enhance its overall effectiveness [Table 1].
Table 1.
Validation by subject experts (n=6)
| Item | Description | Relevant (A) | I-CVI | k* | Interpretation | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Relevance of COI tooth brushing technique | 6 | 1.00 | 1.00 | Excellent | |||||
| 2 | Appropriateness of 3D model representations | 6 | 1.00 | 1.00 | Excellent | |||||
| 3 | Clarity of sequence in 3D representations | 6 | 1.00 | 1.00 | Excellent | |||||
| 4 | Clarity and understandability of instructions | 6 | 1.00 | 1.00 | Excellent | |||||
| 5 | Need for modifications | Yes: 4 (66.7%), No: 2 (33.3%) | ||||||||
*I-CVI=Item-level Content Validity Index; *k=Modified Kappa Ratings of 3 (relevant/appropriate) and 4 (highly relevant/appropriate) were considered acceptable. Item number 5 was an additional open-ended item, and responses were analyzed descriptively using frequencies and percentages
The special educators’ evaluation of the game similarly demonstrated high content validity across all assessed domains. Items evaluating the relevance and usability of the COI tooth brushing technique, 3D model representations of tooth brushing steps, clarity of game instructions, and suitability and handling of game materials were unanimously rated as acceptable (ratings of 3 or 4) by all six experts, yielding I-CVI and modified kappa values of 1.00 for each item. This indicates perfect agreement and strong evidence of the instrument’s validity. Regarding the need for modification, one special educator (16.7%) suggested changes, while the majority (83.3%, n = 5) reported that no modifications were necessary. The modification suggested was to add sound/light indicators to help individual game play without assistance [Table 2].
Table 2.
Validation by special educators (n=6)
| Item | Description | Relevant (A) | I-CVI | k* | Interpretation | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Relevance of COI tooth brushing technique | 6 | 1.00 | 1.00 | Excellent | |||||
| 2 | Understandability of 3D model representations | 6 | 1.00 | 1.00 | Excellent | |||||
| 3 | Clarity of game instructions | 6 | 1.00 | 1.00 | Excellent | |||||
| 4 | Suitability and handling of game materials | 6 | 1.00 | 1.00 | Excellent | |||||
| 5 | Need for modifications | Yes: 1 (16.7%), No: 5 (83.3%) | ||||||||
*I-CVI=Item-level Content Validity Index; k=Modified Kappa. Ratings of 3 and 4 were considered acceptable. Item 5 was analyzed descriptively using frequencies and percentages
Preliminary field testing was conducted with 30 children, 15 children with visual Impairment and 15 with hearing impairment, and the mean age was 11.47 ± 0.96 years and 12.27 ± 1.00, respectively [Table 3].
Table 3.
Demographic details of participants of the preliminary trial (n=30)
| Variable | Category | Visually Impaired (n=15) | Hearing Impaired (n=15) | Total (n=30) | ||||
|---|---|---|---|---|---|---|---|---|
| Gender | Male | 9 (60.0%) | 11 (73.3%) | 20 (66.7%) | ||||
| Female | 6 (40.0%) | 4 (26.7%) | 10 (33.3%) | |||||
| Age (years) | 10 | 1 (6.7%) | 1 (6.7%) | 2 (6.7%) | ||||
| 11 | 9 (60.0%) | 2 (13.3%) | 11 (36.7%) | |||||
| 12 | 3 (20.0%) | 5 (33.3%) | 8 (26.7%) | |||||
| 13 | 1 (6.7%) | 6 (40.0%) | 7 (23.3%) | |||||
| 14 | 1 (6.7%) | 1 (6.7%) | 2 (6.7%) | |||||
| Age statistics | Mean±SD | 11.47±0.96 | 12.27±1.00 | 11.87±1.07 |
The content validity assessment of the feedback by children with visual impairment demonstrated high levels of agreement, on the ease of the tooth brushing steps used in the game, the tactile effectiveness of the 3D tactile models, ease of game instructions and ease of handling the models, with all 15 participants rating items 1 to 4 as relevant, resulting in I-CVI and modified kappa (k*) values of 1.00, indicating excellent validity. Item 5 also showed strong agreement, with 14 of the 15 participants rating the game as enjoyable (I-CVI = 0.93; k* =0.93). For item 6 on modifications required, 6 of the participants wanted bigger models [Table 4].
Table 4.
Validation by children with visual impairment
| Item | Description of Item | Relevant (A) | I-CVI | K* | Interpretation | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Ease of tooth brushing technique | 15 | 1.00 | 1.00 | Excellent | |||||
| 2 | Ease of understanding the 3D models | 15 | 1.00 | 1.00 | Excellent | |||||
| 3 | Ease of understanding game instructions | 15 | 1.00 | 1.00 | Excellent | |||||
| 4 | Ease of handling the game parts | 15 | 1.00 | 1.00 | Excellent | |||||
| 5 | Game’s enjoyment factor | 14 | 0.93 | 0.93 | Excellent | |||||
| 6 | Need for modifications | Yes: 6 (40%), No: 9 (60%) | ||||||||
*I-CVI=Item-level Content Validity Index; k=Modified Kappa. Ratings of 3 and 4 were considered acceptable. Item 6 was analyzed descriptively using frequencies and percentages
Among children with hearing impairment, items 1 to 5 demonstrated perfect agreement, with all 15 participants rating them as relevant (I-CVI and kappa values of 1.00), reflecting excellent content validity. For item 6, no modifications were suggested by the children [Table 5].
Table 5.
Validation by children with hearing impairment
| Item | Description | Relevant (A) | I-CVI | K* | Interpretation | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Ease of tooth brushing technique | 15 | 1.00 | 1.00 | Excellent | |||||
| 2 | Ease of understanding the 3D models | 15 | 1.00 | 1.00 | Excellent | |||||
| 3 | Ease of understanding game instructions | 15 | 1.00 | 1.00 | Excellent | |||||
| 4 | Ease of handling the game parts | 15 | 1.00 | 1.00 | Excellent | |||||
| 5 | Game’s enjoyment factor | 15 | 1.00 | 1.00 | Excellent | |||||
| 6 | Need for modifications | No: 15 (100%) | ||||||||
*I-CVI=Item-level Content Validity Index; k=Modified Kappa. Ratings of 3 and 4 were considered acceptable. Item 6 was analyzed descriptively using frequencies and percentages
Evaluation of tooth brushing skill pre- and postintervention among the children with Visual impairment showed that the median tooth brushing skill score increased from 5 (interquartile range, IQR = 1) in the pre-intervention phase to 7 (IQR = 1) post-intervention [Table 6]. Children with hearing impairment also showed a statistically significant improvement, with the median score increasing from 5 (IQR = 1) to 7 (IQR = 1) [Table 7]. Wilcoxon signed-rank test indicated that this improvement was statistically significant (W = 0.00, P < 0.001). The findings suggest that the intervention was effective in enhancing tooth brushing skills among the participants.
Table 6.
Comparison of pre- and postintervention tooth-brushing skill scores among children with visual impairment
| Variable | Median (IQR) | Z | Test Statistic (W) | Effect size (r) | P | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Pre | 5 (1) | 3.414 | 0.00 | 0.88 | 0.0006403* | |||||
| Post | 7 (1) |
*Wilcoxon signed-rank test applied for paired comparison. Values expressed as median (IQR). P<0.05 considered statistically significant
Table 7.
Comparison of pre- and postintervention tooth-brushing skill scores among children with hearing impairment
| Variable | Median (IQR) | Z | Test Statistic (W) | Effect size (r) | P | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Pre | 5 (1) | 3.4309 | 0.00 | 0.89 | 0.0006015* | |||||
| Post | 7 (1) |
*Wilcoxon signed-rank test applied for paired comparison. Values expressed as median (IQR). P<0.05 considered statistically significant
Discussion
Oral health education for children with visual and hearing impairments remains limited, with conventional methods often failing to address their unique sensory learning needs. Communication barriers remain a primary challenge when teaching children with sensory disabilities and adaptations in educational strategies are essential to suit specific disabilities. Braille, audio aids, and tactile models significantly improve plaque control and gingival health, as well as oral health knowledge and skill acquisition in children with visual impairment.[16,17] Audio-tactile performance (ATP), a multisensory strategy integrating hearing, touch, and active participation, has been identified as particularly effective in enhancing both understanding and retention of oral hygiene practices among visually impaired children.[18] Among children with hearing impairment, visual methods such as sign language, demonstrations, and pictures help overcome communication barriers as they rely more on visual input for learning. Oral hygiene education using these approaches make it easier for children to understand, imitate, and learn oral hygiene practices.[19]
Game-based interventions are widely recognized as an effective approach in oral health education. They promote oral health by enhancing the understanding of information, through interactive and engaging learning experiences.[20] GBEIs with multisensory components can provide clear information that is enjoyable and easy to remember.[21] and can play a significant role in improving skill acquisition in children with sensory disabilities.
In the above context, we attempted to develop a multisensory game-based educational intervention (GBEI) that can make tooth brushing education effective and enjoyable among children with visual and hearing impairment. We employed a comprehensive literature review and special educator interview process, to develop this GBEI to teach tooth brushing to children with sensory disability. The expert validation of the tool by dental specialists confirmed the clinical appropriateness of the COI tooth brushing technique and its representation within the game. The positive feedback from special educators further validate the tool’s pedagogical soundness and practical applicability in special needs educational settings. This dual validation approach ensured that the intervention meets the standards essential for an oral health education tool in special care settings.
Validation from children with sensory disabilities helped assess the usefulness of the oral health educational tool. The results from preliminary field testing revealed that the children found the GBEI tool with tactile and visual elements of the tooth brushing steps to be engaging and easily understandable. This helped improve their tooth brushing skill, which can be attributed to the multisensory tactile components and visual display that enhance learning among children with special needs.[9,22]
Games have earlier been shown to improve oral hygiene among children with visual and hearing impairment. A specially designed visual pedagogy oral hygiene training among children with hearing disability, improved oral hygiene.[23] The snakes and ladders game was found to improve oral hygiene among children with hearing impairment.[10] Likewise, a playful educational intervention using a card game called “Loti-denti,” with dental and oral health images, produced significant improvements in the oral hygiene status of children with hearing impairment.[11] An interactive jigsaw puzzle-based visual reinforcement technique was more effective than sign language alone, showing greater improvements in oral hygiene knowledge, practice, and plaque scores.[9] An art-based play dough game and music-based education with ATP in children with visual impairment attempted to make oral health education interactive and multisensory. The oral hygiene outcomes improved over time following all the educational interventions and the art-based approach was reported to be enjoyable.[8] Game-based learning theory supports these results, as interactive methods usually improve interest and memory during learning.[24] The strength of our study lies in adding a game concept to the multisensory tooth brushing storyboard turning it into an interactive, enjoyable educational tool.
Limitations
Lack of blinding is a concern for potential bias since the researcher who developed the game did the data collection and validation. Further, children with visual impairment were unable to independently respond to the Likert scale, which may have affected the precision and reliability of self-reported outcomes. While the validation outcomes were encouraging, the clinical effectiveness, including plaque accumulation, gingival status, and caries incidence and comparative effectiveness against traditional educational methods, was not assessed. The sample population chosen, though adequate for initial validation, is insufficient to generalize the results across pediatric populations with diverse sensory impairments.
Strengths
The main strength of our study is that we followed a systematic, phased development and validation process. The board game was built step by step, based on literature review and expert opinion with feedback and refinement along the way. Preliminary field testing with children with visual/hearing impairment helped us to create an engaging, easy-to-understand, multisensory tool to teach tooth brushing that fulfils the learning needs of this cohort.
Future directions
Cluster randomized trials of this GBEI compared with traditional health education approaches are underway among children with visual/hearing impairments to provide definitive evidence of efficacy in plaque control and gingivitis. We aim to adapt the intervention for other special-needs populations and explore the integration of digital technology to enhance independent play.
Conclusion
The developed multisensory game-based educational intervention to teach tooth brushing demonstrated excellent validity, acceptability, and significant improvement in tooth-brushing skills among children with visual and hearing impairments. These findings support its potential as an inclusive oral health promotion tool to address the high burden of preventable oral diseases in this population. Integration into the National Health Mission (Rashtriya Bal Swasthya Karyakram and Samagra Shiksha Abhiyan) could substantially expand the intervention’s reach and impact. Further evaluation of the tool is essential to assess long-term effectiveness and cost-efficiency within the public health system.
AI policy statement
ChatGPT (OpenAI) was used solely to assist in generating the conceptual flow diagram (Figure 1). The authors designed the conceptual framework, reviewed and revised the AI-generated output, and assume full responsibility for the final figure and all content in the manuscript.
Abbreviations
GBEI: game-based educational intervention, HI: hearing impairment, VI: visual impairment, COI: chewing, outer, inner surfaces, ATP: audio-tactile performance, VR: visual reinforcement
Author’s contributions
ENH contributed to the conceptualization, methodology, investigation, data curation, formal analysis, and drafting of the manuscript. PEC, SA and US contributed to the conceptualization, supervision, critical review, and editing of the manuscript. KB and KM contributed to the conceptualization, methodology, and validation of the study. All authors reviewed and approved the final manuscript and agreed to be accountable for all aspects of the work.
Data availability statement
The data supporting the findings of this study are available with the corresponding author and acquired upon reasonable request. Data are not publicly available due to ethical and privacy considerations.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
The authors would like to express their sincere gratitude to the District Disability Welfare Officers of Erode, Coimbatore, and Salem districts of Tamil Nadu for their support. We also thank the special educators of the participating institutions for their cooperation, and the interns from our institution for their assistance during the intervention.
Funding Statement
This study is self- funded.
References
- 1.Wadhwani M, Vashist P, Singh SS, Gupta V, Gupta N, Saxena R. Prevalence and causes of childhood blindness in India: A systematic review. Indian J Ophthalmol. 2020;68:311–5. doi: 10.4103/ijo.IJO_2076_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.World Health Organization. Deafness and hearing loss. Available from: https://www.who.int/news-room/fact-sheets/detail/deafness-and-hearing-loss. [Last accessed on 2026 Apr 5]
- 3.Vishnu P, Mahesh R, Kumar PD, Sharma N. Oral health status and treatment needs of children with sensory deficits in Chennai, India—A cross-sectional study. Indian J Dent Res. 2021;32:236–42. doi: 10.4103/ijdr.IJDR_809_18. [DOI] [PubMed] [Google Scholar]
- 4.Kapila YL. Oral health’s inextricable connection to systemic health. Periodontol 2000. 2021;87:11–16. doi: 10.1111/prd.12398. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Sardana D, Ritto FP, Ciesla D, Fagan TR. Evaluation of oral health education programs for individuals with visual impairment: An umbrella review. Spec Care Dentist. 2023;43:751–64. doi: 10.1111/scd.12873. [DOI] [PubMed] [Google Scholar]
- 6.Benazeera, Aranha PR. Nurse-led play intervention on hospitalization anxiety and fear among children admitted to a tertiary care hospital. J Educ Health Promot. 2025;14:317. doi: 10.4103/jehp.jehp_57_25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Dangi S, Chhabra KG, Naganandini S, Chaudhary P, Singh A, Srivastava H. To contemplate the role of school teachers on oral health promotion: A qualitative study. J Educ Health Promot. 2025;14:165. doi: 10.4103/jehp.jehp_921_24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Sharififard N, Sargeran K, Gholami M, Zayeri F. A music- and game-based oral health education for visually impaired school children: Multilevel analysis of a cluster randomized controlled trial. BMC Oral Health. 2020;20:144. doi: 10.1186/s12903-020-01131-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Santhosh VN, Ankola AV, Sankeshwari RM, et al. Effectiveness of jigsaw puzzle assisted visual reinforcement technique on toothbrushing knowledge, practices and clinical parameters of hearing and speech-impaired adolescents: A single-blind randomized controlled trial. Spec Care Dentist. 2024:1–11. doi: 10.1111/scd.13069. [DOI] [PubMed] [Google Scholar]
- 10.A’yun Q, Sulistyani H. Effect of the snake and ladder game on behavior and OHI-S index of deaf children. Int J Multidiscip Res Anal. 2023:6. [Google Scholar]
- 11.Ávila-Curiel BX, Solórzano-Mata CJ, Avendaño-Martínez JA, Luna-Vásquez B, Torres-Rosas R. Playful educational intervention for improvement of oral health in children with hearing impairment. Int J Clin Pediatr Dent. 2019;12:491–3. doi: 10.5005/jp-journals-10005-1701. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Epstein D, Zemski A, Enticott J, Barton C. Tabletop board game elements and gamification interventions for health behavior change: Realist review and proposal of a game design framework. JMIR Serious Games. 2021;9:e23302. doi: 10.2196/23302. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Setiawan AS, Atmadja IT, Andisetyanto P, Indriyanti R, Suryanti N, Juniarti N, et al. Toothbrushing ability, caries burden, and oral health–related quality of life among stunted preschool children in Bandung-Indonesia. BMC Oral Health. 2025;25:1958. doi: 10.1186/s12903-025-07307-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Aka A, Kukuh Integration of Borg and Gall (1983) and Lee and Owen (2004) models as an alternative model of design-based research of interactive multimedia in elementary school. J Phys Conf Ser. 2019;1318:012022. [Google Scholar]
- 15.Günay H, Meyer-Wübbold K. Does “CIOTIPlus” only mean “brushing twice”? Dtsch Zahnärztl Z Int. 2019;1:127–36. [Google Scholar]
- 16.Sardana D, Goyal A, Gauba K, Kapur A, Manchanda S. Effect of specially designed oral health preventive programme on oral health of visually impaired children: Use of audio and tactile aids. Int Dent J. 2019;69:98–106. doi: 10.1111/idj.12436. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Dwivedi R, Gupta P, Jana S, Tiwari RK, Verma R, Singh N, et al. Impact of oral health preventive program using specialized audio and tactile aids in visually impaired school children: A cross-sectional study. J Educ Health Promot. 2024;13:129. doi: 10.4103/jehp.jehp_641_23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Kumaraguru M, Srisakthi D, Yuwanati M, MA I. Effectiveness of audio-tactile performance versus other oral health education methods in improving oral health in visually impaired children and adolescents: A systematic review. Cureus. 2024;16:e66708. doi: 10.7759/cureus.66708. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Shrivastava R, Gupta A, Nishant, Sharda S, Das D, Goyal A. Visual learning strategies for oral health promotion and treatment interventions in children and adolescents with hearing impairment: A systematic review. Spec Care Dentist. 2023;43:597–610. doi: 10.1111/scd.12810. [DOI] [PubMed] [Google Scholar]
- 20.Patil S, Licari FW, Bhandi S, Awan KH, Di Blasio M, Isola G, et al. Effect of game-based teaching on the oral health of children: A systematic review of randomized control trials. J Clin Pediatr Dent. 2024;48:26–37. doi: 10.22514/jocpd.2024.075. [DOI] [PubMed] [Google Scholar]
- 21.Moin M, Haider MM, Rizvi KF, Imtiaz R, Maqsood A, Altamash S, et al. Enhancing oral hygiene in children with hearing impairment: The impact of skit video interventions—A randomized controlled trial. Glob Pediatr Health. 2024;11:2333794–241240302. doi: 10.1177/2333794X241240302. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Deshpande AP, Ankola AV, Sankeshwari R, Jalihal S, Bhat DV, Choudhury AR, et al. Unleashing the most effective oral health education intervention technique for improving oral hygiene status and oral health knowledge in visually impaired young individuals: A systematic review and meta-analysis. J Educ Health Promot. 2023;12:9. doi: 10.4103/jehp.jehp_419_22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Doichinova L, Peneva M. Motivational training programme for oral hygiene of deaf children. Int J Sci Res. 2015;4:1124–6. [Google Scholar]
- 24.Alotaibi MS. Game-based learning in early childhood education: A systematic review and meta-analysis. Front Psychol. 2024;15:1307881. doi: 10.3389/fpsyg.2024.1307881. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are available with the corresponding author and acquired upon reasonable request. Data are not publicly available due to ethical and privacy considerations.