100

95

75

25

0
 !
!
!
iUKGS!

School!Oral!health!
Innovative! !
!
Empowerment!Returns!
!
! !
Writers!
Irene!Adyatmaka!
Andreas!Adyatmaka!
Adang!Bachtiar!

Published*by*

UIPress*

Find!us!on!website!
www.irenedonut.com!
!
EAmail!
Irene_al2000@yahoo.com!
!
First!publication!in!English!
©2013!
!
!
!
ISBN!no.!97809790456053406!

Unless! otherwise! indicated,! all! materials! on! these! pages! are! copyrighted! by! the! writers.! All!
rights! reserved.! No! part! of! these! pages,! either! text! or! image! may! be! used! for! any! purpose!
other!than! personal!use.! Therefore,!reproduction,!modification,!storage!in!a! retrieval! system!
or! retransmission,! in! any! form! or! by! any! means,! electronic,! mechanical! or! otherwise,! for!
reasons!other!than!personal!use,!is!strictly!prohibited!without!prior!written!permission.!!
*

!
 1!

September(2013(|(iUKGS(!

iUKGS(
Empowerment Returns Contents(
!
This!graphical!book!was!made!on!my!17th!years!of!serving!
Preface! ! !!1!
school!oral!health!program,!to!celebrate!the!7th!Asian!
Background! 2!!!
Conference!of!Oral!Health!Promotion!for!School!Children!in!
Bali.!This!book!would!tell!about!the!history!and!set!up!of! History!! 4!
UKGS!Inovatif!(iUKGS)!or!School!Oral!Health!Innovative!in! Stepping!stones! 5!
Indonesia.!Inside!will!be!explained!about!three!important!
3!Components!! 6!
caries!preventive!components!in!iUKGS,!those!are!Risk!
Assessment!Donut!Irene,!Remineralization!Therapy,!and! Donut!Irene!! 8!
Surface!Protection.!The!book!also!highlighted!the!important! Remin!therapy! 10!
empowerment!roles!of!every!stakeholder!that!had!given!big!
Surface!Protection! 12!
contribution!to!the!improvement!of!children’s!oral!health.!To!
those!dedicated!persons!we!would!like!to!extend!our!highest! Strategies! 14!
appreciation!through!this!book.!Hopefully!the!book!can!easily! Result! 17!
guide!the!readers!towards!all!the!processes!that!need!to!be! Timesheet!example! 20!
taken!to!implement!the!iUKGS.!!
Warm!Regards!
Irene!Adyatmaka!

!
!
 (
!
2

Background

Persistent caries problem

Simulation analysis Riskesdas 2007 Data – Andreas Adyatmaka

!
Simulation!Analysis!using!Riskesdas!2007!data!has!been!done!to!predict!the!caries!situation!in!6!years!old!
children!in!Indonesia!to!the!best!guestimate.!It!is!shown!that!each!province!has!different!severity.!
Children!in!Bangka,!were!expected!to!have!2!permanent!teeth!with!obvious!decayed!by!the!time!of!6!
years!old!and!showed!steep!trend!towards!the!ages,!while!children!in!West!Nusa!Tenggara!expected!to!
have!less!than!0.5!permanent!teeth!decayed!and!flatter!trend.!It!was!obvious!that!every!province!would!
have!different!combination!of!caries!risk!factors.!This!suggested!that!current!practices!of!mass!school!oral!
health!program!(one!size!fits!all)!needed!to!be!innovated!to!be!able!to!overcome!the!problem.!!!
!
 3
;

Lorem Ipsum DolorGraphic(Spectrum(Pathogenesis(of(caries(in(deciduous(teeth( Spring 2016

Total!samples!were!Grade!1!children!from!Denpasar!(488),!!
!Jakarta!–!UPDMB!(417),!and!Tarakan!(3,077).!Data!taken!2013.!
W+H(white!spot/!black!fissured!teeth),!d1(enamel!decay),!d2(dentin!decay),!d3(pulp!decay),!R+A(radix/Abscess)!

2.500!
TEETH(PER(CHILD(

2.000!
1.500!
1.000!
0.500!
0.000!
W+H! d1! d2! d3! R+A!
DPS! 0.566! 1.467! 0.803! 0.576! 0.988!
UPDMB! 0.643! 1.525! 1.866! 0.935! 1.000!
TRK! 0.514! 2.170! 2.048! 1.831! 2.021!

Spectrum!Pathogenesis!analysis!found!by!Dr!Andreas!Adyatmaka!was!introduced!here.!It!showed!that!
in! grade! 1! children! most! cases! were! d1! cases! (obvious! decay! in! enamel)! and! radix/abscess! cases.! In!
Tarakan! for! example,! per! 1,000! children! have! been! found! 2,170! caries! enamel! cases! and! 2,021!
radix/abscess! cases.! Denpasar! pathogenesis! condition! seemed! to! be! better! than! others.! The! finding!
proposed! that! d1! teeth! could! still! be! saved! by! immediate! treatment,! to! stop! it! progressing! to! d2!
(obvious!decay!in!dentin)!status.!!

Graphic(Spectrum(Pathogenesis(caries(in(Permanent(Teeth(
On! the! contrary,! the! most! cases!
found! in! grade! 1! children! in!
0.700!
permanent!teeth!were!white!spot!
and! black! fissured! teeth.! In! 0.600!
TEETH(PER(CHILD(

Denpasar,! for! every! 1,000! 0.500!

children,! 410! teeth! were! in! 0.400!
susceptible! condition.! This!
0.300!
suggested! that! remineralization!
was! needed! to! stop! them! 0.200!
progressing!to!obvious!decay.!The! 0.100!
progress! of! 119! permanent! teeth!
0.000!
having!enamel!decay!also!needed! W+H! d1! d2! d3! R+A!
to! be! stopped! by! prompt! DPS! 0.410! 0.119! 0.018! 0.000! 0.002!
treatment! surface! protection/! UPDMB! 0.379! 0.180! 0.091! 0.031! 0.005!
ART.!! TRK! 0.642! 0.293! 0.137! 0.083! 0.015!
2
 4!
!

iUKGS

History !

of!the!snowballing!journey!

2013!
Donut!version!animation!launched!
13!cities!self!empowered!running!UKGS!Inovatif!
UKGS!Inovatif!reinvented!into iUKGS to!represent!ownership!of!everyone!
2012!
UKGS!Inovatif!adopted!as!!
! National!Policy!MOH!&!started!in!Bali!
2011!
Training!Request!coming!from!
Tarakan!&!other!places!

2010!
UKGS!Inovatif!ran!in!3!provinces!with!MOEE!IbW!
matching!grant!and!West!Kalimantan!Health!
Province!(3!Years!research!program).!Donut!
Irene!paper!based!version!launched.!

!!!!!!2009!
UKGS!Inovatif!concept!introduced!
to!MoE.!Prof!Fasli!Jalal!endorsed!
UKGS!Inovatif!to!be!diseminate!
in!Indonesia.!UKGS!Inovatif!first!
launched!in!Semarang!using!
MoE!IbM!research!program.!

2008!
Finished!
Dissertation.!
Donut!Irene!ver.1!
launched!

!
 5!

Start
Survey

Donut Irene
(individual/ group)

Surface
Protection
Checklist &
Remin
Data Therapy

Entry

Key Points
" Checklist Donut Irene and Remin therapy are done at home by
parents
" Surface protection is done by health personnel

!
L! orem&Ipsum&
6!

Surface!protection!program!at!Health!District!Tarakan,!Kalimantan!

3 components iUKGS
Donut&Irene,&Remineralization&Therapy,&
Surface&Protection&

Three!components!are!like!having!3!gates!to!protect!before!it!becomes!decay.!First!gate!is!
Donut!Irene,!which!would!rely!much!on!the!behavior!managements.!Second!gate,!in!case!the!
first!gate!fails!to!protect,!and!there!has!been!sign!of!demineralization,!then!Remin!therapy!
can!be!done!by!parents!at!home.!If!this!fails!too,!there’s!still!the!third!safety!gate,!surface!
protection,!which!can!be!done!by!health!personnel.!So!the!components!emphasize!much!on!
decay!prevention.!!
 iUKGS
L! orem&Ipsum& 7!2&

iUKGS!is an adding of three updated technology into the current school oral health practices. It is
based on early detection and prompt treatment. The new technologies are caries risk assessment
using Donut Irene, Remineralization Therapy, and Surface protecting erupting molars

1. Caries Risk Simulator Donut Irene

Is a caries risk assessment method that is evidence based,
empowering, and suitable with the patients’ need. It enables to
manage caries risk of individual patient, since each patient has
different risk factor and therefore has to be treated differently

2. Remineralization Therapy
Is a home-based daily therapy to bring back tooth minerals
before it becomes decay,! by providing Calcium and phosphate
complexes, and by neutralizing acid environment.
!

3. Surface Protection erupting molars

Is a procedure to maturate erupting molars that are prone
to dental caries. With short working time (3 minutes) and
cost effective, surface protection is indicated also for teeth
with early sign of caries (such as black fissured).
!

Enhancement : Tooth brushing skill practice

Tooth brushing activities are focused on increased skill. That’s
why two tone disclosing gel is used prior to tooth brushing.
Purple plaque means mature plaque community that has been
staying for more than 2 days. New plaque will be shown as
pink colored plaque. Tooth brushing activity in school has
certain schedules.
8

Mrs Desak Asri, Head Master SD Saraswati 5 energized leading the program

1. Donut Irene
Enthusiasm
Energized
Focused
Returns
Donut Irene is an evidence based
method on caries risk assessment,
based on Dr Irene Adyatmaka’s
dissertation, with 2,656 children aged All focused
on how to o
v ercome the
5-7 including their parents as the caries proble
m
subject study. From 50 risk factors,
came up 15 significant risk factors. Purpose
The 15 risk factors then analyzed 1. Give feedback on caries risk factor of
using logistic regression. Finished in each child
2. Give understanding on how to overcome
22 months, the dissertation has been the risk factor
given MURI prestigious award 3. Visualize the magnitude of every risk and
alternative corrective measures
(Indonesia world record). 4. Empowering parents to control children’s
oral health
 9

Donut Irene
Manual version
Donut Irene Manual version is a paper based
computational risk assessment. It has 15 sets of
questions and each questions has been
weighed. Manual version is beneficial when
health educator does a group caries risk
assessment in a class setting. Parents of 30-40 can
gather and fill in the weigh of each question, add up the
numbers, and come up with caries risk prediction in
percentage. Later on, using a checklist, each parent
takes responsibility which risk factor and bad behaviors
from the “menu” that they can and willing to change.
For public health need, Donut Irene can identify risk
factor of a group in community. It is useful for setting
up dental health education material that is suitable and
matched with the risk factors of the group. So it
becomes a personalized education material. Because to
have a successful education material that are able to
persuade others, it is necessary to show the feedback of
present condition, give a menu of advices and let others
choose responsibly according to their capability.
Donut Irene
Computerized
Donut Irene is also available in
computer software. It is a fun,
interactive personal risk assessment
tool that can be used with or without
assistance of health personnel. It is
important that prior to answering
questions, a pH plaque shall be
measured. pH plaque measurement
takes 5 minutes. While waiting, the
parents and children can start
answering questions. After answering
all questions, a simulation of behavior
will be shown. Depends on the parents
ability and willingness, the changing of
behavior will change the percentage of
risk. The report can be printed together
with daily checklist that need to be
monitored by parents.

Key points
Donut Irene has 2 versions, the computerized and the
manual (paper-based: book and flipchart). Computerized
version is indicated for personal risk assessment (only
measure one person at one time). Manual version is
indicated not only for personal risk assessment, but also
for group risk assessment (assessing many people at one
time). Each person/ group has different caries risk factor
combinations. It is important to know each risk factor, to
be able to set up suitable preventive action, so patient
can manage accordingly.

2
1
2

10

Stop the earliest

sign of caries
Happy healthy kids from SD Cipta Dharma

Key Points
2. Remineralization
Therapy
Demineralization of tooth Remineralization Therapy is a daily application of
structure can firstly seen calcium phosphate ions (in the form of CPP ACP) onto
orally as “white spot
lesions”. Continuous the teeth that experience demineralization.
demineralization will lead Demineralization can happened due to prolonged low
to obvious decay.
pH plaque and low saliva pH.

Material : CPP ACP (Casein Phosphopeptide

Amorphous Calcium Phosphate)

Purpose of Remin Therapy

Dr. W
1. Avoid decay by reverting back the calcium and
phosphate ions into the teeth
2. Maintain the balance of oral pH
3. Stop and heal the early process of caries
4. Parents’ empowerment and build responsibility
1
2

11

Lorem Ipsum DolorTherapy

Remineralization [Issue] :: [Date]

byline
[Name]
Instruction of Remin Therapy given by Dr Ayu at SD Cipta Dharma

“… indicated for white spot lesions,

high risk individual, and as a realization of
caries risk simulation Donut Irene”

Application procedures in iUKGS

a. Do a caries risk simulation using
Donut Irene
b. For those at high risk, such as low pH
plaque, and risky behavior, Donut
Irene will recommend application of
CPP ACP. Explain the necessity of
adding external source of minerals for
the teeth to compensate
demineralization.
c. Teach the parent/ child to take a pea-
sized of CPP- ACP crème using clean
finger or cotton bud, and apply onto
the surface of front teeth.
e. Instruct not to eat, drink, rinse for
the first 30 minutes.
f. For normal daily application, CPP-
ACP can be used twice a day after
tooth brushing.
g. For extreme high risk, CPP- ACP
can be used after acid challenge that
cannot be avoided, such as every
after taking bottled milk.
h. As CPP- ACP is derived from Casein
bovine milk, it is safe when
swallowed

d. Spread the CPP- ACP crème with the

tongue onto the whole surface of the
teeth

2
12

iUKGS
the

3. Surface Protection
Save Erupting Molars

How to do
1. Clean erupting molar using dentin
conditioner, to remove smear
layer.

2. Wait for 15 seconds, rinse with

wet cotton pellet. Dry with dry
Dental Nurse Sc
hool Kupang cotton pellet. Isolate the tooth
with cotton roll, and frequently
change the cotton roll when
necessary to keep the working

When is the important stage to

area stay dry.

3. Prepare the glassionomer cement

protect the teeth? (stabilization and protection
material), pink colored.

When the molars are erupting, caries risk increased almost 4. Apply the GIC. Put cocoa butter
in the finger. Press and slide.
doubled. Because when molars are erupting, it is uncomfortable
to clean for the child, plaque retention is then higher, and the 5. Instruct the patient not to eat for 1
hour.
teeth itself is more easily dissolved by acid because it still
carbonate apatite (for maturation, normally needs 3 years after
post eruption). So at this stage, those teeth need extra protection
compared to others.

What is learned
Surface protection is a proactive treatment to maturate erupting
molars. Because erupting molars consisted of carbonate ions that
are easily dissolved by acid. By maturate the teeth, means the
structure of carbonate-apatite is then changed into fluoride- Protect
apatite that is more acid resistant. With this 3 minutes work, e d teeth
, save t
erupting molars can be saved from high risk of decay. he futu
re
 13

THE LOREM IPSUMS S I M P L E 3 M I N U T E S P R O C E D U R E FALL 2016

Purpose
gram
ealth D istrict pro ! Maturate enamel surface of erupting molars, to
Sam bas H
become more acid resistant fluoride apatite
! Protect the blacken fissure in occlusal surface
which is prone to dental decay

Material
• Flowable strontium-based Glass Ionomer for
stabilization and protection material (Pink colored)
• Cotton roll, cotton pellet
• Water in deppen glass
• Standard instrument

Patient Position
In many cases, supination position (horizontal,
TK Nuru sleeping position) has beneficial effect of reducing stress
l Muslim
province in & healt
program h district in children, easier saliva control (because the saliva
automatically went down the throat and do not
obstruct field work).

Importance of removing smear layer

In any cases, working with Glass ionomer cement
requires several attentions. The use of dentin
conditioner before applying the GIC is meant to
remove the smear layer and prepare the ions to be
interchangeable during the process. Not using dentin
conditioner will reduce the bonding strength by 50%.
IDA Solok &
Moisture control Health district
program

Another big issue is also moisture control. Before

applying GIC, make sure to dry the occlusal surface of
the teeth with DRY cotton pellet only. Air syringe is
prohibited, because GIC need moist to be bonded
chemically by ions exchange. After applying GIC to the
surface of the teeth, take some cocoa butter and use the
finger to do press finger technique. Cocoa butter is
meant to protect GIC within its 24 hours, which is o Univ ersity
den ts M oestop
prone to water absorbing. Dental Stu

2
14
iUKGS

Strategies
1. School empowerment
2. Parents and pupils
involvement

Leader
shi
headma p from Mrs M
ster SD ul
Cipta D yathi,
harma
Success Hints
1st step Leaders’ Advocacy &
Commitment
gathering
1. School empowerment
Roles that are needed to be undertaken by schools :
2nd step Workshop and training
health personnel • Providing necessary basic facilities

Parents’ involvement • Lead the program to be run smoothly

3rd step
and pupils’ • Adjust school schedule to accommodate activities
participation
• Held parents meeting, motivate parents
4th step Running activities • Creativity to maximize the program’s result
Monitoring &
• Create ownership of the program, maintain
Evaluation
sustainability
• Monitor and evaluate
• Always seek an area for improvement

Key Points
To successfully run the oral health program of children, health
personnel need to have close collaboration with schools and
parents. The energy coming from schools and parents are much
e
ion D o n u t I re n bigger than the energy of health personnel working alone.
u s gr o u p discuss
Foc
 15
lorem ipsum dolor issue, date

2. Parents and pupils involvement

“Parents take care of their child” philosophy

Role of parents : What Parents can help at home :

• Motivate children • Help children to brush their teeth
• Take responsibility to do at least night before sleeping
preventive action • Do the checklist as advised in
• Together with the school, Donut Irene simulation
create ownership of the • Checking the children’s teeth
program routinely
• Creativity to maximize the • Reverse early sign of caries by
program’s result doing remineralization therapy
• Find a way to sustain the • Evaluate
program

Every parent has unique involvement, and ..

every involvement matters

Exchange bo
ttle s with glasses
Active sponso
Teach Support rship

2
 17
lorem ipsum dolor issue, date

Result :
iUKGS Ownership

! Build self-supporting school oral health innovative

TK Nurul Muslimin
Kubu Raya ! Motivate parents to set aside Rp 500,- (equal US$
0.05) from their daily shopping and save it for
children’s treatment per month, cost Rp. 4.000,-
! Teachers do Donut Irene assessment to parents
! Bottle milk Graduation to replace bottle with glass
! Integrated Donut Irene assessment into school
raport
! Build up simple but useful tooth brushing facilities
and lead the tooth brushing activities by
themselves
! Use UKGS Inovatif as added value for school
service, to attract new students
! Free 1 coupon in the mall playground, every time
the children have their teeth surface protected.

… and many more

tegrated into Donat Irene

Donat Irene in report
rt Useful tooth Tooth brushing activity done by teach
education repo brushing facili
ties er

3
16

iUKGS
technology transfer . . .
Team
ul We st K alimantan Pontianak Semarang Vietnam
Wonderf Kupang Malaysia
Kubu Raya
Mempawah Bukittinggi Brunei
Sambas Solok Timor Leste
Singkawang Jakarta
Landak Denpasar
Tarakan
Dedicate
d team fr
om Tara
k an

… has been made possible by strong commitment and support from Ministry of
Health Indonesia, to pursue better children’s oral health.

[Recipient]
Address Line 1
Address Line 2
Address Line 3
Address Line 4
18

R E S U L T

Improvement
In Oral Health Status

Improvement showed in reduction % children Improvement showed in reduction % children

with deciduous teeth decay > 7 teeth (d>7) with Permanent teeth decay (D>0)

40 30
35 25
30
25 20
20 15
15 Before Before
10
10
5 After 5 After
0 0

Improvement showed in reduction on caries incidence after

surface protection program in Tarakan
Key points
• Children in grade 1
1.2
already have decay in
permanent teeth.
1
• Treatments are needed to
0.8
stop them from
0.6 progressing.
0.4 • Surface protection 2 lower
Caries incidence
0.2 permanent molars are
0 sufficient to reduce caries
Without Protection Protection incidence
protection 2 lower 4 molars
molars

Data 2013 from Puskesmas Sebengkok, Tarakan. Subjects 598

high risk children (had >7 deciduous decays or D>1)
 19

iUKGS
Joyful team

Subject 488 students grade 1

Monitored Oct 2012 – Aug 2013
Great Bali Team
Dr. Yohana, Dr Putu Judy, Dr Alit,
Dr Made Artaya, Dr Sritamin, Dr Sindura,
Dr Ayu, Pande Purwaningsh, Widiastuti

Improvement of % children with Dentally fit

Dentally fit means those 60

with dental decays and all 50
the decays have already
40
been filled. So in the
30 Before
mouth there’s no more
After
20
decay and no missing
10
permanent teeth due to
caries. 0
Sesetan 4 Pedungan Saraswati Cipta
5 Dharma

Improvement of % children with

Caries Free
Caries free means those free of
50 any decay, missing and filling.
45 Means the person has never
40 experienced caries. In this case,
35 children with decays in deciduous
30 teeth can still have the chance to
25 Before
be caries free if the decayed
20 After deciduous teeth have been
15
replaced by healthy and caries
10
free new permanent teeth. Caries
5
free is a powerful indicator of how
0
Sesetan 4 Pedungan Saraswati Cipta successful a preventive program
5 Dharma is.
20

Y E A R L Y T I M E S H E E T E X A M P L E

School name : aiCare ! ! !

Total students grade 1-6 : 600 ! ! !
Total students grade 1 : 100 ! ! !
Frequency of health personnel twice a week
visit (1 dentist/ 1 dental nurse) : (8 times a month) ! ! !
!
!
!
! ! ! ! ! ! ! ! ! ! ! !
Month in 1 school year
Act iv it ies iUKGS
1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11" 12"

Survey grade 1 (1 day = 20 children) x! !! !! !! !! !! !! !! !! !! !! !!

Preparing priority list medical record

!! x! !! !! !! !! !! !! !! !! !! !!
grade 2-6

Parents meeting grade 1 (1 day) !! x! !! !! !! !! x! !! !! !! !! !!

Donut Irene parents grade 1 !! !! !! !! !! !! !!

Personal @ 15 minutes/ parents (1
day = 5 parents ) or class set up @ 45 x! x! x! !! !!
!! !! !! !! !! !! !!
minutes/ class (1 day = 1 class 25
parents)

Donut Irene evaluation (class set up) !! !! !! !! !! !! x! !! !! !! !! !!

Remin Therapy, Surface protection,

ART, extraction deciduous) !! !! !! x! x! x! !! x! x! !! !! !!
(1 day = 10 children)

Toothbrushing skill activities grade

1-3 using disclosing gel
x! x! x! x! x! x! !! x! x! x! x! x!
(1 day = 20 children, each time 10
children)

Survey at year end (grade 1,2,3,4,5,6)

x! x! x!
(1 day = 30 children) !! !! !! !! !! !! !! !! !!
!

!
Most valuable contributions have been coming from ..

Ministry of Education through Prof. Fasli Jalal & Dra Desmelita

Health District Province West Kalimantan through dr Haryagung
And all participating schools in West Kalimantan
Health District Tarakan through dr Chaerul,
dr Siti Hamdiyah, and dr Indra
TK Al Azhar 14 through Pak Salikun
Ministry of Health through dr Sudono & dr Dewi Kartini Sari
Mahasaraswati University through dr Yohana Lily
Poltekesgi Bali through Bpk Budi
SD Cipta Dharma, SD Saraswati 5
SD Sesetan 4, SD Pedungan 6, TK Cipta Dharma
Dental Public Health Department Moestopo, through dr Wilya and friends

And many of special persons

that his/her achievements, hard works, and supports
had touched our hearts…

Thank you