Development and Evaluation of a Mobile Oral
Health Application for Preschoolers
Luciana F.X.A. Campos, MS,1 Jéssica P. Cavalcante,1
Damile P. Machado,1 Edgar Marçal, PhD,2
D
Paulo G. de B. Silva, PhD,1 and Juliana P.M.L. Rolim, PhD1
1
Department of Dentistry, Christus University Center
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(Unichristus), Fortaleza, Brazil.
2 restricting the consumption of sugars in the diet and me-
Department of Virtual University Institute, Federal University
of Ceará, Fortaleza, Brazil.
Abstract
Background: Dental caries comprises the most prevalent
chronic disease in children worldwide and is considered a
public health problem.
Introduction: Few educational oral health applications, di-
rected to the preschool public, are available. The present
study aimed at developing an educational game in application
format for mobile devices and tested its usability.
Materials and Methods: Forty-three children were randomly
selected to participate in the study. The methodology used in the
development of the application was based on an interactive chil-
dren’s book flux design. The application was elaborated for the
Android and iOS platforms. To evaluate usability, a test method
composed of observation and interview surveying was used, and
the measuring mechanism consisted of the User’s Success Rate.
The sample (N = 43) was randomly composed of preschool stu-
dents (3–5 years of age) from a public school in Brazil.
Results: In the effectiveness tests, the success rates of the
Story and Game Menus were 97.6% and 85.3%, respectively.
In the efficiency tests, the respective rates were 80.2% and
82.1%. The satisfaction evaluation rate was 99.7%.
Discussion: The game ‘‘Put the healthy food into the mouth’’
showed to be difficult in utilization due to the children’s lack
of knowledge concerning healthy foods (p < 0.001 and 95%
confidence interval). Three year olds demonstrated a greater
requirement for assistance during navigation.
Conclusions: The application was successful regarding the
following three assessed attributes: (1) effectiveness, (2) ef-
ficiency, and (3) satisfaction. However, dietary education was
observed to be necessary for the children and their guardians.
Keywords: dental caries, health education, mobile applications
DOI: 10.1089/tmj.2018.0034 ª M A R Y A N N L I E B E R T , I N C .  VOL. 00
Introduction
ental caries, also known as cavities, is a multifac-
torial, biofilm-sucrose-dependent disease, charac-
terized by the progressive destruction of the mineral
structure of dental tissues, that can be controlled by
chanical rupture of the dental biofilm through oral hygiene.1
Dental caries comprises the most prevalent chronic disease in
children worldwide and is considered a public health prob-
lem.2,3 In Latin American and Caribbean countries, more than
half of the preschool children from 5 to 6 years of age are still
affected by this disease.2 In Brazil, according to data from the
last survey carried out in 2010 by the Ministry of Health,
53.4% of 5-year-old children exhibited tooth decay in 2.43
teeth on average, and, at that age, the cavity index was higher
than in the other analyzed age groups.4
Social, economic, and cultural characteristics are associated
with the risk of dental caries. In Brazil, a polarizing tendency
of the prevalence of this disease in low-income and low-
education populations has been verified.5,6 Considering that
the lack of knowledge about the causes associated with the
development of caries is also pointed out as a risk factor,
health education plays a fundamental role in the prevention of
disease and is one of the strategies advocated by the Ministry
of Health to promote oral health since childhood, especially in
the preschool phase, which corresponds to the moment of
habit formation.7
Considering that educational health actions should follow
the current trend of using learning resources that are close to
the reality of the target public, new technologies can facilitate
access to health information for the child population through
mobile learning with the use of digital games in application
format.8,9 These games, which include multimedia and inter-
activity resources, are already part of the daily life of children,
considered digital natives, and can be an alternative to prop-
agate oral health information.9–11 However, few games in ap-
plication format, developed especially for the preschool public,
are focused on oral health education. The available options are
predominantly entertaining and minimally educational.12,13
Therefore, in an attempt to promote access to oral health
information, focusing on the prevention of cavities during
NO. 00  MONTH 2018 TELEMEDICINE and e-HEALTH 1
 CAMPOS ET AL.
childhood through learning resources that are close to the
reality experienced by children, the present study aimed at
developing an educational game in application format, for
mobile devices, with usability tested for preschoolers under 6
years of age.
Materials and Methods
The study comprised an analytical, transversal, observa-
tional, descriptive, and quantitative assessment. The first stage
consisted of the selection of the target public and the choice of
topics to be explored in the software application, according to
the Basic Attention Guidelines of the Ministry of Health.7
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Next, the development (execution and complementation) of
the application was carried out, from January to July 2017, by
the staff of the Technological Innovation Laboratory of the
Christus University Center (UniChristus), with the participa-
tion of a multidisciplinary team composed of professionals
from the areas of computing, health, and pedagogy.
The study was approved by the Research Ethics Committee
of the Christus University Center, according to the norms that
regulate human research of the National Health Council of
the Ministry of Health (Resolution N. 196 of October 10, 1996
and Resolution N. 251 of August 07, 1997), under Certificate
of Presentation for Ethics Appreciation (CAAE) number
68216617.6.0000.5049.
The interactive children’s book flux design methodology
was used for the conception, ideation, and execution of the
interfaces of the game.14 A digital educational game, named
‘‘1, 2, 3 . Brush!,’’ was developed in the mobile app format.
The game was directed toward preschool children from 3 to 5
years of age and addressed the following topics: dental caries,
healthy diet, cariogenic diet, oral hygiene, bottle feeding, the
relationship between deciduous and permanent teeth, and
prejudicial habits related to malocclusion.7 Two versions of
the application were developed for the major existing mobile
platforms: Android and iOS.
The following stage of the study consisted in determining
the sample for the usability test. During application devel-
opment, it is recommended to perform usability tests to
identify possible problems in the interaction between the user
and the interface, before commercialization.15 An applica-
tion’s usability can be assessed by harmonizing its primary
attributes: the potential of the interface to be understood by
the user (‘‘effectiveness’’), by way of easy navigation (‘‘effi-
ciency’’), that is user friendly (‘‘satisfaction’’).16
To calculate the sample size, it was estimated that 90% of
children would consider the application as usable.17 Con-
sidering an infinite population with a power of 90% and a
level of significance of 95%, an extrapolated N of 43 sample
2 TELEMEDICINE and e-HEALTH M O N T H 2 0 1 8
units was reached. The calculation was performed using the
Epi Info software for Windows, version 7.2 (Centers for
Disease Control and Prevention [CDC], Atlanta). The sample
was randomly composed of preschool students from a public
school of the municipal education network of Fortaleza-CE,
Brazil, through a random lottery executed using the ran-
dom.org website. The students of the Tertuliano Cambraia
Municipal School who studied in the afternoon, which per-
tained to the analyzed age group (from 3 to 5 years) until the
final date of the tests, were included in the lottery. The ex-
clusion criteria comprised neurological conditions that in-
terfered with the use of software applications and the absence
of the children’s compliance.
Thus, the composite sample for the study included twelve
3-year-olds, thirteen 4-year-olds, and eighteen 5-year-olds, to-
taling the 43 calculated sample units. Only one 3-year-old child
did not want to participate in the test and was replaced by the next
child in the lottery. The participation of the children was volun-
tary and required the authorization of their respective guardians
through the signing of a Term of Free and Informed Consent.
The next step of the study consisted in conducting the us-
ability test to evaluate the attributes of effectiveness, effi-
ciency, and satisfaction in the use of the application regarding
its four segments: Home Screen, Character Selection Screen,
Application Exploration Screens (Story Menu), and the Pro-
posed Activity Screens (Game Menu). In the efficiency eval-
uation, the children’s performance was also analyzed in three
activities proposed in the Game Menu, which addressed
healthy diets (to identify cariogenic and noncariogenic foods)
and oral hygiene habits (need for dental brushing after meals
and before bedtime). The performance was analyzed accord-
ing to the number of attempts required for each child to
complete the activities.
Only one evaluator conducted all of the tests to avoid
possible biases. The assays were applied in the library at the
very school where the children study, given that it is a quiet
Fig. 1. Home screen of the application.
ª MARY ANN LIEBERT, INC.

environment, with minimal external stimuli that could in-
terfere with the user’s application experience. Images of the
home screen of the application and a child executing the us-
ability test are shown in Figures 1 and 2.
Observation and interview surveying comprised the used
techniques to evaluate effectiveness/efficiency and satisfac-
tion, respectively, since these methods are used in usability
tests with children who have not yet mastered the written
language.18,19 The measuring mechanism applied to assess
effectiveness and efficiency was the User’s Success Rate, ex-
pressed as a percentage and calculated using specific equa-
tions,17,19 which consists of the sum of tasks performed
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correctly during the use of the application (such as selecting a
menu or dragging objects). A task that was concluded suc-
cessfully (‘‘Yes’’) equaled 100%; tasks completed with diffi-
culty (‘‘Partial’’) represented 50% of success, and uncompleted
tasks (‘‘No’’) corresponded to 0%.15,16 To measure satisfaction,
a structured script form that had already been validated in the
literature was used and it evaluated the following aspects: fun,
ease of use of the application, user affinity with the character,
interest of the user to repeat the user experience, and interest
of the user to use the application at home.18–20
Fig. 2. Child executing the usability test.
ª M A R Y A N N L I E B E R T , I N C .  VOL. 00
ORAL HEALTH APPLICATION FOR PRESCHOOLERS
After concluding the test phase, a sociodemographic
questionnaire was applied to the child’s respective guardian,
in which the family income, the experience regarding the use
of mobile devices by the child, and the purpose of their use
were discussed.
The data collected in the assessments were analyzed by
Fisher’s exact test and the chi-square test, with a 95% confi-
dence interval, using the SPSS software, version 20.0.
Results
The results obtained in the usability test regarding the ef-
fectiveness and efficiency of the application are described
below in relation to the total number of children in the study
(N = 43) and by age group (Tables 1 and 2). Accordingly, the
results concerning the satisfaction assessment are shown in
Table 3. The p > 0.05 demonstrates that there was no statistical
difference between the groups due to the high number of
successfully executed tasks by the children during the us-
ability test.
Regarding the performance in the three evaluated activities
proposed in the Game Menu, the percentages of children of 3,
4, and 5 years of age, who selected all of the healthy foods on
the first attempt in the game ‘‘Put the healthy food into the
mouth,’’ were 25%, 76.9%, and 44.4%, respectively. In the
postmeal oral hygiene game (‘‘I just ate. What should I do?’’),
the percentages of the 3, 4, and 5 year olds that solved the
activity on the first attempt were 91.6%, 76.9%, and 66.6%,
respectively. In the game addressing the need for dental
brushing before bedtime (‘‘What to do before bedtime?’’), the
respective percentages of the 3, 4, and 5-year-old children
that executed the activity on the first attempt were 91.6%,
76.9%, and 77.7%.
In the effectiveness and efficiency assessments of the Pro-
posed Activity screens, the evaluated elements ‘‘The child did
not have problems in solving the activities proposed in the
application’’ and ‘‘The child managed to put the healthy food
into the character’s mouth’’ displayed different patterns of
response compared to the other elements ( p < 0.05), given that
significant ‘‘Partial’’ and ‘‘No’’ results were observed in the 5-
year-old children.
According to the data obtained from the sociodemographic
questionnaire, 55.8% and 41.8% of the children had family
incomes that were equal to or less than one minimum wage,
and most of the children in the sample already used mobile
devices (86%). Statistical analysis using Fisher’s exact test and
the chi-square test showed that the results obtained in the
usability assessments did not exhibit a significant relationship
with the family income and the use of mobile devices
( p > 0.05).
NO. 00  MONTH 2018 TELEMEDICINE and e-HEALTH 3
 CAMPOS ET AL.

Table 1. Effectiveness Evaluation

APPLICATION SEGMENT EFFECTIVENESS %, EFFECTIVENESS %, EFFECTIVENESS %, EFFECTIVENESS %,
TOTAL GROUP GROUP 3 YEARS GROUP 4 YEARS GROUP 5 YEARS
EVALUATED ELEMENTSa (N = 43) (N = 12) (N = 13) (N = 18)
Home Screen 99.4 ( p = 0.5675) 100 ( p = 1.0000) 98.0 ( p = 0.5560) 100 ( p = 1.0000)
The child did not have navigation problems

The child did not have problems finding the Story Menu

The graphics on the screen attracted the child’s attention

The sound effects attracted the child’s attention

Character Selection Screen 97.6 ( p = 1.0000) 100 ( p = 1.0000) 92.3 ( p = 1.0000) 100 ( p = 1.0000)
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The child was successful at selecting the desired character

The child did not have navigation problems

Story Menu 97.6 ( p = 0.393) 97.9 ( p = 0.5546) 98.0 ( p = 0.5560) 97.2 ( p = 0.5606)

The child managed to put the tooth paste on the tooth brush

The child was aware of what he/she was doing throughout

the use of the application

The child maintained focus throughout the use of the

application

The child manifested positive reactions during

application use

Game Menu 85.3 ( p < 0.001) 82.8 ( p < 0.001) 86.4 ( p = 0.0024) 85.0 ( p < 0.001)

The child did not have problems solving the proposed

activities in the application

The child managed to execute the activities at the

dentist’s office

The child managed to put on the dentist’s uniform

The child managed to put the healthy food into the

character’s mouth

The child managed to choose what the character should do

after eating

The child managed to brush the character’s teeth

The child managed to choose what the character

did before bedtime

The child understood the general concept of

animation exploration
a
Effectiveness evaluation in the total sample (N = 43) and per age group, by calculating the User’s Success Rate. Data analyzed by Fisher’s exact test and the chi-square
test, with a confidence interval of 95%.

Discussion
Dental caries in childhood is still considered a public health
problem and may have negative repercussions on phonation,
chewing, swallowing, esthetics, and the self-esteem of chil-
dren affected by this disease.2,21 In this sense, educational
strategies for dietary guidance and instruction in oral hygiene
are essential for the prevention of caries and should be in-
troduced as early as possible, thus providing means to pro-
mote self-care.22 These actions must respect the cognitive
characteristics of childhood, as well as prioritize playfulness
as a way of arousing interest and motivation.23
The current model of health education, characterized as an
active process of knowledge construction, has sought to use

4 TELEMEDICINE and e-HEALTH M O N T H 2 0 1 8 ª MARY ANN LIEBERT, INC.

 ORAL HEALTH APPLICATION FOR PRESCHOOLERS

Table 2. Efficiency Evaluation

APPLICATION SEGMENT EFFICIENCY %, EFFICIENCY %, EFFICIENCY %, EFFICIENCY %,
TOTAL GROUP GROUP 3 YEARS GROUP 4 YEARS GROUP 5 YEARS
EVALUATED ELEMENTSa (N = 43) (N = 12) (N = 13) (N = 18)
Home Screen 95.9 (p = 1.0000) 95.8 (p = 1.0000) 100 (p = 1.0000) 94.2 (p = 1.0000)

The child correctly selected the Start Menu on the first attempt

The child easily managed to restart the exercise after his/her mistakes

Character Selection Screen 93.0 (p = 1.0000) 91.6 (p = 1.0000) 100 (p = 1.0000) 88.8 (p = 1.0000)

Large figures of each character helped the child to

decide which one to choose
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Story Menu 80.2 (p = 0.2254) 75.0 (p = 0.2546) 80.7 (p = 0.8022) 83.3 (p = 0.9454)

The child executed the proposed activities on the first attempt

The mistakes committed by the child were minimal

The child managed to acknowledge mistakes

The level of interaction between the child and the evaluator

was minimal

Assistance from the evaluator was minimal

Game Menu 82.1 (p < 0.0001) 83.3 (p < 0.0008) 88.4 (p = 0.0036) 76.8 (p = 0.0029)

The child completed the proposed activities on the first attempt

The mistakes committed by the child were minimal

The child knew how to restart the activity after his/her mistakes
a
Efficiency evaluation in the total sample (N = 43) and per age group, by calculating the User’s Success Rate. Data analyzed by Fisher’s exact test and the chi-square test,
with a confidence interval of 95%.

more dynamic approaches with resources that are closer to re-
ality experienced by individuals.24 Few educational oral health
applications, directed at preschoolers, are available. This makes
the comparison between studies limited, given that most of the
softwares that address the issue are aimed at primary school
children.9 The diversity of usability testing methodologies also
hinders this comparison.18 Educational strategies in oral health
for children may follow this trend, using learning resources such
as digital games.9 Based on this, the game, developed in the
present study, was designed to convey oral health information in
a playful manner using mobile devices, which already constitute
as tools in the daily life of children.10,11

Table 3. Satisfaction Evaluation

INTERVIEW SCRIPT SATISFACTION SATISFACTION SATISFACTION SATISFACTION
(%), TOTAL GROUP (%), GROUP 3 (%), GROUP 4 (%), GROUP 5
EVALUATED ELEMENTSa (N = 43) YEARS (N = 12) YEARS (N = 13) YEARS (N = 18)
It was fun 99.7 (p = 0.4035) 99.1 (p = 0.3969) 100 (p = 1.0000) 100 (p = 1.0000)

I thought it was easy to use

I liked the character

I would like to use the application again

I would like to use the application at home

a
Satisfaction evaluation of the total sample (n = 43) and per age group by interview surveying. Data analyzed by Fisher’s exact test and the chi-square test, with a
confidence interval of 95%.

ª M A R Y A N N L I E B E R T , I N C .  VOL. 00 NO. 00  MONTH 2018 TELEMEDICINE and e-HEALTH 5

 CAMPOS ET AL.
Given that in the age group of the application’s target
public, most of the children are not yet literate, which could
generate difficulty in understanding more complex interfaces,
a gamified model (elaborated with elements of game me-
chanics) was employed, using animation and audio resources.
The techniques selected for the usability tests in the present
study are commonly used with children who have not yet
mastered the written language.18,19,25
Usability tests with children present the following limitations
that should be considered: the children’s attention span, their
motivation to please adults, the ability to adapt to new situations,
possible difficulty in verbalizing their opinions, and their ability
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regarding abstract thinking and understanding of the assessed
concepts.25,26 In view of the mentioned limitations, usability tests
with children are generally performed with the use of more than
one technique.19 Thus, in the present study, the evaluation of the
application’s usability was conducted using two methods: ob-
servation and satisfaction interview surveying.18–20
After assessing the effectiveness and efficiency of the Home,
Character Selection, Application Exploration (Story Menu), and
the Proposed Activity Screens, it was verified that the children
understood the objectives of the interfaces, performing the tasks
needed to navigate (such as accessing the start menu, selecting
the desired character, brushing the character’s teeth, and drag-
ging objects) in all segments of the application, even if at some
point they required assistance from the evaluator.
Thus, in the effectiveness and efficiency evaluations, the
software application obtained satisfactory results, given that
in usability tests the value of the success rate of these attri-
butes usually remains around 50% since the user often makes
mistakes the first time he/she uses an application.17 The sat-
isfaction assessment was also considerably positive, demon-
strating the children’s wide acceptance of the application.
The differences observed in the efficiency evaluation possi-
bly occurred due to the inherent characteristics of the children
participating in the study. Three year olds naturally require
navigation assistance, even with applications developed ac-
cording to the cognitive aspects of that age.27 The 5-year-old
children obtained a lower efficiency performance possibly be-
cause they tend to act more untimely, which can be expected
due to the leap that occurs in language development between
5 and 7 years of age (speech planner function), leading to
difficulty in the coordination between thought and action.28
The activity in which the children displayed the most signifi-
cant difficulty in all of the groups was the ‘‘Put the healthy food
into the mouth’’ exercise. According to the obtained results, this
was the game where the largest number of children required two
or more attempts to complete the activity. This effect was ob-
served not to be due to navigability (since the children were able
6 TELEMEDICINE and e-HEALTH M O N T H 2 0 1 8
to carry out the task of dragging objects), but because of the
difficulty in differentiating healthy foods from cariogenic ones.
The choice of sweet foods by children may be related to the
dietary habits of their families. The data obtained through the
sociodemographic questionnaires revealed that almost all of
the participants in the study come from families with incomes
that are equal to or less than a minimum wage. Some studies
correlate the prevalence of cavities in low-income communities
to more substantial consumption of foods rich in sugar.3,29
Few educational oral health applications directed to the pre-
school public are available, which makes the comparison be-
tween studies limited, given that most of the softwares that
address the issue are aimed at primary school children.9 The di-
versity of usability testing methodologies also hinders this
comparison.18
During the usability test, the need to improve some of the
screens to enhance the interaction between the users and the
interface was verified. In the Story Menu, the home screen will
be modified in order for the character to appear in the living
room, with new audio: ‘‘Hello! Let’s learn how to care for our
teeth. Click the arrow below and let’s go! 1, 2, 3 . Brush!.’’
Another alteration to be made will be on the flossing screen so
that the floss always appears next to the bathroom sink. The
dental floss animation will be replaced with an interactive
activity, in which the child can use the floss to assist in the oral
hygiene of the character. Finally, in the Game Menu, ex-
planatory audio will be inserted at the end of the ‘‘Put the
healthy food into the mouth’’ game, since it was the exercise in
which the children exhibited the most difficulty, to emphasize
the relationship between foods rich in sugar and dental caries.
Conclusions
According to the objectives of the present study, an edu-
cational game was developed, in an application format for
mobile devices, with usability for preschoolers between 3 and
5 years of age, given that it obtained excellent results re-
garding the three evaluated aspects (effectiveness, efficiency,
and satisfaction). However, future studies are necessary to
verify the efficacy of the developed interface in the context of
the children’s learning process in health and the promotion of
habits related to healthy diets and oral hygiene for the general
preschool public.
Acknowledgments
The authors thank the support from the Christus University
Center for the development of the application and the col-
laboration of the teachers, coordination, and direction of the
Tertuliano Cambraia Municipal School during the usability
tests. The study did not receive funding during its execution.
ª MARY ANN LIEBERT, INC.

Disclosure Statement
The authors report no conflict of interest. L.F.X.A.C. reports
no salary from the Christus University Center during the con-
duct of this study. J.P.C. reports no salary from the Christus
University Center during the conduct of this study. D.P.M. re-
ports no salary from the Christus University Center during the
conduct of this study. Dr. Edgar Marçal reports salary from
Federal University of Ceará during the conduct of the study. Dr.
Paulo G. de B. Silva reports salary from Christus University
Center during the conduct of the study. J.P.M.L.R. reports salary
from Christus University Center during the conduct of the study.
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Address correspondence to:
Luciana F.X.A. Campos, MD
Christus University Center (Unichristus)
Doutor José Lourenço Road, No. 636, apartment 601
Fortaleza, CE 60115-280
Meireles District
Brazil
E-mail: dra.lucianacampos@outlook.com
Received: February 7, 2018
Revised: May 6, 2018
Accepted: May 7, 2018
Online Publication Date: July 20, 2018
NO. 00  MONTH 2018 TELEMEDICINE and e-HEALTH 7