HEALTH PROMOTION INTERNATIONAL
3
Oxford University Press 1996
Impact of oral health education on primary school
children before and after teachers9 training in Tanzania
URSULINE NYANDINDI
Department of Preventive and Community Dentistry, University of Dar es Salaam, Tanzania
ANNELI MBLEN
Health and Development Cooperation Group, National Agency for Welfare and Health in Finland,
Helsinki, Finland
TUIJA PALIN-PALOKAS
Department of Preventive Dentistry and Cariology, University of Kuopio, Finland
VALERIE ROBISON
Department of Dental Ecology, University of North Carolina, USA
SUMMARY
Oral health education is part of the primary school
curriculum in Tanzania. However, most of the teachers
responsible for it lack training and motivation for the
task. Their oral health education sessions are deficient in
content and in methods, only addressing oral hygiene by
lectures. Thus, modified oral health education was
designed and teacher training workshops were carried
out in one district by a dental team in liaison with school
administrators. After training, the teachers taught a
variety of oral health issues and pupils actively studied
the concepts and practical skills for dietary choices and
toothbrushing. This report describes the impact of oral
health education given by teachers before and after they
had been trained in the workshops. The impact of the
sessions was assessed as changes in the pupils' oral health
Key words: impact, oral health education, schools, Tanzania
INTRODUCTION
As compared with the prevailing fatal diseases,
mainly communicable diseases like malaria,
pneumonia and diarrhoea, oral diseases are not
a major health problem in Tanzania. Oral
tumours and injuries are rare. However, the
majority of adults and school-age children in
Tanzania are affected by gum disease and/or
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knowledge, attitudes and practices. Three random sam-
ples, each with 200 pupils, including conventional and
modified session groups and a reference group not given
oral health education at school, were interviewed and
examined. The group that received modified oral health
education had better knowledge of oral health, reported
reduced consumption of sugary foods and increased
toothbrushing frequency, and had better 'mswaki'
(chewing-stick) making skills and slightly improved
oral hygiene; in comparison with the referents. The
group with conventional oral health education had some-
what better oral health knowledge but their practices
were no better than the referents'. The results emphasize
the needfor providing training, guidance andfeedback to
implementors of oral health education programmes.
dental caries (Ministry of Health and Social
Welfare, 1988; Mosha el al., 1994).
Among primary school-age children in Tanza-
nia toothbrushing seems to be prevalent but oral
hygiene is, nevertheless, poor and gingivitis is
common (Frencken et al., 1986; Kerosuo et al.,
1986; Mandari, 1988; Nyandindi, 1988; Normark
193
194 U. Nyandindi et al.
and Mosha, 1989; Mumghamba, 1990; Nyan-
dindi et al, 1994a). Studies undertaken among
the children in this age group also indicate low
consumption of sugary foods but wide preference
for them (Nyandindi, 1988; N0rmark and
Mosha, 1989; Nyandindi et al, 1994a). Caries
affects about a third of the primary school-age
children (Frencken et al., 1986, 1990; Kerosuo et
al., 1986; Mandari, 1988; Nyerere, 1988; Bloch et
al., 1989; Axell and Johansson, 1993; Mosha et
al., 1994). The average number of decayed, miss-
ing and filled teeth per child (dmft or DMFT) is
low; for example, the DMFT index for 12-year-
olds is within the global goal of three or less by
the year 2000. Oral health knowledge among the
children is poor (Nermark and Mosha, 1989;
Nyandindi et al., 1994a).
An oral health education programme aimed at
fostering proper oral health behaviour among
school-age children was started in Tanzania in
1982, and is being implemented by teachers at
primary schools (Ministry of Health and Social
Welfare, 1988). There are 10 437 primary schools
(first to seventh grades) attended by 3.5 million
children (~ 15% of the total population) in a year
(Ministry of Education and Culture, 1992). Oral
health education is scheduled for first-grade as
part of health lessons taught by the classroom
teachers in two 30-min lessons a week (Taasisi ya
Elimu, 1987). Considering the oral health situa-
tion of school-age children in Tanzania, current
oral health education does not seem adequate in
content and methods. It consists mainly of oral
hygiene issues taught in lectures only (Taasisi ya
Elimu, 1987; Nyandindi et al, 1995). Moreover,
the Tanzanian primary school teachers' knowl-
edge, skills and motivation for giving oral health
education are poor and most of them have had
no training for the task (Nyandindi et al, 1994b).
With the aim of improving the quality of
school oral health education within the limited
resources in Tanzania, a new manual for teaching
the subject and a teacher's training programme
were designed and provided to the teachers of one
district, Ilala. These actions were organized by a
team consisting of the present researchers, the
district's dental personnel and the district's
school administrators. The manual and training
were planned to meet the surveyed oral health
education needs of pupils and to suit local reali-
ties. All teachers (n = 125) in the district super-
vising first-grade classes, in which oral health
education is scheduled, attended the training
workshops and were provided with the manual
as well as some other teaching aids. The district
dental personnel carried out the workshops.
The teachers' performance in teaching the oral
subject was assessed by observing their oral
health education sessions 2 months after the
training. The sessions had improved substantially
in both content and methods in comparison to
those observed before the teachers' training. The
teachers now addressed both oral hygiene and
diet, and used demonstration and practical meth-
ods to teach pupils the practical skills for healthy
dietary choices and effective toothbrushing
(Nyandindi et al, 1995).
The aim of this study was to further evaluate
the impact of the teachers' training, by assessing
the improvements in their pupils' oral health
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knowledge, attitudes, practices and skills, in com-
parison with the pupils' situation before the
teachers' training.
SUBJECTS AND METHODS
Study design and samples
The evaluation of the impact of the conventional
and the modified oral health education among
pupils was conducted at five (out of 35) urban
primary schools and five (out of nine) rural
primary schools which were randomly selected
from urban and rural areas in the Ilala district. A
between-group study design (Adams and Schva-
neveldt, 1985) involving three samples of pupils
was used: a reference group, a conventional ses-
sion group and a modified session group.
Each sample (group) consisted of 200 first-
grade pupils who were randomly chosen from
each of the ten schools involved. In these schools,
first-graders had been divided into two or more
streams (classes) of usually over 50 pupils each.
One of the school-entering classes of 1990 at each
of the ten schools was randomly chosen and
stratified by gender. Then, ten boys and ten
girls were randomly chosen from each stratum
to form the reference group (aged 5-15 years,
mean 8.99, SD 1.84 years). These children had
not received oral health education at school at the
time of study but would be given it later in the
year as scheduled in their curriculum. Another
randomly chosen first-grade class of 1990 in each
of the ten schools was given oral health education
by their classroom teachers, in their usual way.
Each of these classes was also stratified by gender
and ten boys and ten girls were randomly selected

from each stratum to comprise the conventional
session group (aged 6-15 years, mean 9.55, SD
1.96 years). The same teachers who had con-
ducted the conventional sessions also taught the
modified sessions to their new first-grade classes
the following year (1991), after they had been
trained in the workshops. From each of these new
classes, ten boys and ten girls chosen randomly
from each gender stratum comprised the modi-
fied session group (aged 5-15 years, mean 9.46,
SD 2.05 years).
The oral health education sessions
The content and the methods of the conventional
and modified sessions have been previously
reported (Nyandindi et al., 1995) and are only
briefly described here.
The conventional oral health education ses-
sions were held in classrooms. The classes were
often very large (37-184 pupils), with many
pupils sitting on the floor as there were too few
desks. To teach the conventional sessions, before
the teachers' training, each teacher brought along
the 'Ministry of Education' health education
guide, but no other teaching aids. The teachers
taught oral hygiene for about 30 min (one school
period). Daily toothbrushing was stressed for
prevention of bad breath or tooth decay. The
teachers recommended both factory-made tooth-
brushes and self-made 'miswaki' (chewing-sticks)
as effective but gave no advice on how to produce
or use them. They encouraged pupils to use
toothpaste, but also charcoal and ash as less
costly substitutes. The pupils remained passive
throughout the lectures.
The modified oral health education sessions
given by the teachers after their workshop train-
ing were attended by as large number of pupils as
the conventional sessions. The teachers now used
the new manual and other teaching aids, and the
pupils brought with them materials for practicing
toothbrushing and 'mswaki' making from home.
In accordance with the guidance given, each
teacher conducted the sessions in two successive
parts. The first part took place in a classroom for
30 min; basic functions and morphology of teeth,
and the causes and prevention of gum disease and
tooth decay were discussed. The pupils also prac-
ticed in identifying non-sugary food items harm-
less to teeth. The second part lasted for about one
hour, focused on toothbrushing, and took place
outside the classrooms (due to lack of wash-
basins). The teacher demonstrated and every
child practiced how to make a 'mswaki' and
Impact of oral health education 195
how to brush teeth properly. Each teacher super-
vised the children's performance. They instructed
the children to regularly replace their tooth-
brushes, of any type, and also encouraged them
to use toothpaste, but discouraged brushing with
charcoal and ash. The teachers also asked pupils
to spread their new oral health knowledge and
skills to their families. Unlike the former sessions,
in the modified sessions the pupils were actively
involved throughout the sessions.
Data collection
The samples of pupils given each of the two types
of oral health education were studied 4 months
later. The methods for assessing the impact, as
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regards oral health knowledge, attitudes, prac-
tices and skills of these children, were the same as
those used with the referents and have been
described in a previous report (Nyandindi et al.,
1994a). The children were interviewed in a class-
room by a teacher and a health education worker
trained for the task. For assessment of oral
hygiene, the outer and inner surfaces of each
pupil's 12 index teeth (first permanent molars,
second deciduous molars and permanent central
incisors) were examined by a dentist, who did not
yet know the pupils' status of exposure to oral
health education. This was done outdoors in
daylight in an ordinary chair using only a
dental mirror. Plaque was recorded as present
only when clearly visible on the index surface.
Repeated examination of plaque within the same
day among 20 subjects (10%) examined first in
each sample (referents, conventional and modi-
fied session groups) showed high intra-rater relia-
bility; the mean kappa values were 0.93, 0.95 and
0.93 respectively. The children's abilities to make
a 'mswaki', which is being recommended as a
low-cost alternative to the modern toothbrush,
were also examined. Each child was given a tree-
twig, a knife and a cup of water, and made a
'mswaki', which was recorded as suitable only if
it had soft bristles and was at least 18 cm long so
that one could reach molars with the brush.
The impacts of oral health education on pupils'
oral health knowledge, attitudes, practices and
skills were compared between the conventional
and the modified session groups, and the findings
from each session group were also compared with
the knowledge, attitudes, practices and skills of
the reference children. Chi-square statistics and
Student's /-test were used to evaluate the differ-
ences between the groups.
196 U. Nyandindi et al.
RESULTS
Oral health knowledge
Among the pupils who had participated in the
modified oral health education sessions, knowl-
edge about tooth decay and gum disease (their
occurrence, causes and prevention) was signifi-
cantly better than among the children in the
reference group or conventional session group.
Among the pupils who had attended the conven-
tional oral health education sessions, only knowl-
edge about gum disease was better than among
the referents. Irrespective of their exposure to
school oral health education, the majority of
the children studied said they brushed their
children who had attended the modified oral
health education sessions, sugar consumption
(in tea) was less frequent than among the con-
ventional session group and the referents. The
five most common non-sugary foods eaten the
previous day were hard porridge, rice, vegetables,
meat and cassava. When the most commonly
eaten five sugary and five non-sugary foods
were displayed for each pupil to choose the
favourite one, significantly (p = 0.001) fewer
children in the modified session group (31%)
then in the other groups (40% in the conven-
tional session group, 48% in the reference group)
chose a sugary item. The modified session group
had the best knowledge about the harmfulness of
sugary food items to teeth, whereas many chil-

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teeth to prevent tooth decay. Only among chil-
dren who attended the modified sessions, was
prevention of gum disease one of the motives
for toothbrushing (Table 1).
Dietary practices and attitudes
When asked about their dietary habits 4 months
after the first sessions, about a third of the
children studied, irrespective of their oral health
education exposure, had not eaten any sugary
items during the previous day. The rest, about
two-thirds, had eaten sugary foodstuffs once or
twice, mostly sugared tea, ice-cream, biscuits, soft
drinks or sweets (Table 2). Notably, among the
dren in the reference and conventional session
groups regarded soft drinks and biscuits as harm-
less to teeth (Table 2).
Oral hygiene practices and attitudes
Most children who had participated in the mod-
ified sessions brushed their teeth twice a day,
while in the other groups children usually
brushed only once. About 80% of all children
studied said they used a factory-made tooth-
brush, and 90% or more preferred a factory-
made brush over the traditional 'mswaki'. More
pupils in the modified session group than in the
other groups had the skill for making a proper

Table 1: Oral health knowledge compared between the conventional (C) and modified
(M) session groups, and between each session group and the referents (R)
Referents Pupils who received oral
health education

Conventional Modified
(n = 200) (n = 200) (n = 200)
% % C versus R % M versus R C versus M

Knew about tooth decay

Occurrence (common) 28 35 63 <
** 4 %
Cause (sugary snacks) 39 46 84
24 * *4
Prevention (avoid sugar) 27 50
Knew about gum disease
* *4
Occurrence (common) 11 10 56
*
Cause (poor toothbrushing) 38 65 78
Prevention (toothbrushing) 52 83 80
Motive for toothbrushing
To avoid tooth decay 58 73 * 81
To make teeth white 36 18 6 ** ***
To avoid gum disease 0 1 13 na na
No reason 6 8 0 nu na

Differences between groups evaluated by chi-square statistics (d.f. = 1, *p < 0.05, **p < 0.01,
***p $ 0.001, "" not applicable).
 Impact of oral health education 197

Table 2: Self-reported practices and beliefs about sugary foods compared between the
conventional (C) and modified (M) session groups, and between each session group
and the referents (R)
Referents Pupils who received oral
health education

Conventional Modified
(n = 200) (n = 200) (n = 200)
% % C versus R M versus R C versus M

Pupils who had consumed

sugary items (once or twice)
the previous day
Tea with sugar 65 60 44 **
Sweets 17 11 9 *
Ice-cream 14 12 14
Soda drinks 13 10 10

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Biscuits 11 10 13
Pupils who regarded sugary
items as harmful to teeth
Tea with sugar 76 73 80
Sweets 69 80 89 **
Ice-cream 93 96 84 * *
Soda drinks 37 38 62 ** **
Biscuits 55 54 68 **

Differences between groups evaluated by chi-square statistics (d.f. = 1, *p ^ 0.05, **p < 0.01,
***p s 0.001).

Table 3: Self-reported oral hygiene practices and attitudes compared between the con-
ventional (C) and modified (M) session groups, and between each session group and
the referents (R)
Referents Pupils who> received oral
health education

Conventional Modified
(n = 200) (n = 200) (n = 200)
% % C versus R % M versus R C versus M

Toothbrushing frequency
Once a day 78 57 ** 23 * *
At least twice a day 22 43 77 ** **
Items used for toothbrushing
Industrial toothbrush 80 80 78
Chewing-sticks ('miswaki') 20 20 22
Toothpaste 57 55 57
Charcoal 23 38 ** 26 *
Ash 9 5 1 na na
Skilled in making 'mswaki' 35 37 86 ** **
Type of toothbrush preferred
Industrial 95 92 90
'mswaki' 5 8 10
Regarded toothpaste essential 76 74 75

Differences between groups evaluated by chi-square statistics (d.f. = 1, *p ^ 0.05, **p ^ ".01
***D
*p a 0.001, na not aDDlicableV
s 0.001. applicable).
198 U. Nyandindi et al.
Table 4: Pupils with no visible plaque by the index teeth compared between the con-
ventional (C) and modified (M) session group, and between each session group and
the referents (R)
Referents Pupils who received oral
health education

Conventional Modified
(n = 200) (n = 200) (n = 200)
% % C versus R % M versus R C versus M

Upper teeth
Right first Outer 3 9 18 * *
permanent molar Inner 48 53 51
Right second Outer 19 30 38 **
deciduous molar Inner 70 67 74
Right permanent Outer 83 83 87
central incisor Inner 87 83 83
Left permanent Outer 83 82 90 *

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central incisor Inner 88 82 82
Left second Outer 23 26 30
deciduous molar Inner 77 70 73
4
Left first Outer 7 14 14
permanent molar Inner 54 60 57
Lower teeth
Left first Outer 49 52 61
permanent molar Inner 4 6 5
Left second Outer 73 73 76
deciduous molar Inner 19 16 22
Left permanent Outer 57 61 69 *
central incisor Inner 69 68 78 *
Right permanent Outer 56 61 76 ** **
central incisor Inner 67 69 77
Right second Outer 76 77 77
deciduous molar Inner 18 15 21
Right first Outer 49 52 55
permanent molar Inner 2 3 na 5

Differences between groups evaluated by chi-square statistics (d.f. 1, *p ^0.05, **p S 0.01, ***p
< 0.001, not applicable).

'mswaki' (Table 3). Three-quarters of all studied
children, regardless of their oral health education
exposure, considered toothpaste essential for
tooth-cleaning, but only about half said they
used it. Among the children in the conventional
session group, brushing with charcoal was more
common compared with the modified session
group or the referents.
The children who had participated in the mod-
ified sessions had slightly better oral hygiene than
the other pupils 4 months after the first sessions.
The mean number of tooth surfaces (24 surfaces
examined) with visible plaque was smaller (10.5,
SD 4.7) among the modified than among the
conventional session group (11.7, SD 4.9) and
the referents (12.0, SD 4.4). The difference was
statistically significant only between the modified
session group and the reference group (r = 3.28,
p = 0.001). In all groups, clean tooth areas were
more often the inner than the outer surfaces of
upper teeth, the outer than the inner surfaces of
lower teeth, and the front than the back teeth.
The children in the modified session group could
clean some of these tooth areas more effectively
than children in the other groups (Table 4). No
association between age and oral hygiene was
found in any of the three groups of children.
DISCUSSION
The between-group study design involving three
cluster samples of first-graders (reference group,
conventional session group and modified session
group), was used to evaluate the impact of the
two types of school oral health education. This

study design prevents carry-over effects as each
study group is exposed to only one type of
intervention, and each group is studied only
once which reduces the chance of their guessing
what they may think the interviewer wants
(Adams and Schvaneveldt, 1985). Spill-over of
the interview or session contents between the
samples was not very likely as the children were
from different classes. The three samples were
randomly chosen and had comparable back-
ground characteristics; they consisted of first-
grade children, had similar age ranges, had
equal proportion of boys and girls and of urban
and rural children, and were from the same
school locations within a district.
The wide age range (5-16 years) among the
first-graders studied is typical of the classes in
Tanzania although the officially recommended
age for children's enrolment into school is
7 years (Ministry of Education and Culture,
1992). Even then, the reference group's oral
health knowledge, attitudes and practices were
found to be almost the same by age (Nyandindi et
al., 1994a). Tanzanian children of any age seem
to have limited opportunities to learn proper
dental ideas or practices before going to school,
as the Tanzanian mothers' own awareness of
dental matters is very limited (Kabalo and
Mosha, 1989). In school, all lessons are taught
by grade levels irrespective of the pupils' ages.
Thus, first-graders, for whom oral health educa-
tion is scheduled (Taasisi ya Elimu, 1987; Wizara
ya Elimu, 1988), notwithstanding their ages, were
involved in the present evaluation.
School oral health education provided by
dental personnel or schoolteachers in developed
countries has usually improved pupils' oral
health knowledge, attitudes or status, but not
always (Frazier, 1992; Brown, 1994). In African
countries, the few available evaluative studies of
school oral health education (Evian et al., 1978;
Olsson, 1978; Doherty, 1983; Hartshorne et al.,
1989; van Palenstein et al., 1992) also show more
elements of success than of failure. The studies
have focused on effects and seldom describe the
input or processes (e.g. teachers' training in oral
health education or the school oral health educa-
tion sessions) which presumably affect the pro-
gramme impact or outcomes among the pupils.
Pupils who attend the conventional oral health
education sessions in the primary schools in
Tanzania seem to gain limited knowledge about
gingival health. Their frequency of toothbrushing
seems to increase. They like to use factory-made
Impact of oral health education 199
toothbrushes rather than 'miswaki' (chewing-
sticks) which are suggested in the conventional
sessions. The current school oral health educa-
tion regime recommends and actually seems to
increase the use of charcoal (a tooth-erosive
substance) as 'toothpaste', a practice common
in Tanzanian society (Sarita and Tuominen,
1992). The pupils hardly seem to learn about
prevention of tooth decay.
Conventional oral health education in Tanza-
nian schools is taught according to the 'Ministry
of Education' curriculum guide (Taasisi ya
Elimu, 1987) which addresses oral hygiene only.
The guide mentions use of practice sessions for
teaching toothbrushing skills, but the sessions
were observed to be mainly lectures (Nyandindi
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et al., 1995) as has been the case in many tradi-
tional programmes (Frazier et al., 1983). Support
from dental personnel is called for in the
National Plan for Oral Health (Ministry of
Health and Social Welfare, 1988), but most pri-
mary school teachers have no training from
dental personnel for the task of oral health
education. Moreover, they seem to have inade-
quate knowledge, skills and motivation for carry-
ing out this task (Nyandindi et al., 1994b). As
described elsewhere (Bartlett, 1981), the larger
class sizes and the short time allocated to the
topic of health in Tanzanian primary schools can
encourage the use of lectures. With these short-
falls in the implementation of the programme,
successful impact or outcomes cannot be
expected.
The pupils who attended the modified oral
health education sessions seemed to have gained
knowledge about gingival health. Commercial
toothbrushes and toothpaste seem to be relatively
costly and scarce in rural areas for many indivi-
duals in Tanzania to buy regularly (Muya et al.,
1984; Nyandindi et al., 1994c). However, the
effort made during the modified sessions to
encourage the use of 'miswaki', as suggested in
the national guidelines for school oral health
education (Nermark et al., 1986; Taasisi ya
Elimu, 1987), did not succeed. The pupils
gained good skills in making 'miswaki' and prac-
ticed brushing with them, but continued to dislike
them. It has been reported from elsewhere in
Africa (Narmark, 1991) that chewing-sticks are
disliked and regarded as primitive. This suggests
a need to reconsider the type of toothbrush
promoted in Tanzania. The modified sessions
also failed to increase the use of toothpaste
which was considered essential for tooth-cleaning
200 U. Nyandindi et al.
by the pupils, or to reduce the use of charcoal as a
substitute. This seems to be rather a matter of the
children's economic realities.
The modified sessions with supervised brushing
practice seem to have improved the pupils' brush-
ing frequency and, to some extent, their oral
hygiene. Repeated sessions would probably
have brought a better impact in oral hygiene, as
has been emphasized elsewhere (Emler et al.,
1980; Houle, 1982). This could not be accom-
plished prior to this evaluation 4 months after the
sessions, due to the teachers' time pressures.
There are many important topics of health for
first-graders to be covered within the one-hour-a-
week frame (Taasisi ya Elimu, 1987). Neverthe-
less, the teachers agreed that, as part of the
routine morning hygiene checkups of pupils at
school, they would remind pupils to brush their
teeth properly. Another possible factor hindering
further improvement of the pupils' oral hygiene
could be that their commercial toothbrushes had
not been replaced often enough to remain effec-
tive.
The modified session group also seemed to
have gained improved knowledge about the
cause and prevention of tooth decay. Their self-
reported low preference for sugary snacks as
compared with the referent children may, to
some extent, reflect their newly gained knowledge
of expected behaviour. This was their first oral
health education experience at school and the
pupils might have been receptive to the new
ideas. Economic environment, rather than perso-
nal decisions alone, also appears to contribute to
the low frequency of sugar consumption of Tan-
zanian children, even without health education.
Tooth decay is more common in the affluent than
poorer rural people in Tanzania (Mandari, 1988),
and sugary snacks seem expensive for school-age
children from low-income families (Nyandindi et
al., 1994c). Sugar consumption may increase with
improvements in the economy and changes in
lifestyle in Tanzania, thus educating children
about healthy diet is essential in order to prevent
caries in the future.
The results show the importance of assessing
health education activities, as has been empha-
sized previously (Green and Lewis, 1986; Sarvela
and McDermott, 1992). Operational programmes
may not always be implemented in the appro-
priate way, or bring about the desired impact or
outcomes. The conventional oral health educa-
tion in the Tanzanian primary schools does not
seem to be effective. The process appears to be
poor and to lack adequate support to the imple-
mentorsthe schoolteachers. Teacher training
and motivation is needed for their role in health
education (WHO/UNESCO/UNICEF, 1992).
The present results suggest that, with appropriate
training workshops and guidance, teachers may
gain proficiency in teaching oral health matters,
and the gains from school oral health education
among the pupils in Tanzania may improve. The
environments have to be improved and consid-
ered with regard to their support for the chil-
dren's oral health education. An intervention
involving the oral health providers, the school
personnel, and children and their parents needs
to be attempted to see what effect it could have on
impact of school oral health education in Tan-
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zania.
ACKNOWLEDGEMENTS
We thank the pupils and the teachers for co-
operation. This study was supported by the
Muhimbili Dental School Development Project
of the University of Kuopio.
Address for correspondence:
Dr Ursuline Nyandindi
Department of Preventive and Community Dentistry
Faculty of Dentistry
University of Dar es Salaam
PO Box 65014
Dar es Salaam
Tanzania
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