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Children and Teenagers 
ISSN 2576-3709 (Print) ISSN 2576-3717 (Online) 

Vol. 2, No. 1, 2019 
www.scholink.org/ojs/index.php/ct 

60 
 

Original Paper 

The House of the Little Tooth Diniz: An Oral Health 

Educational Project 

Maria do Rosário Dias1*, Letícia G. Naben2, Irene Ventura3, Sofia Coroado4, Viriato M. Dias4 & Sofia O. 

Santos4 
1 Egas Moniz University Institute (IUEM), Faculty of Psychology and Educational Sciences, University 

of Lisbon, Portuguese Association of Psychoanalytic Psychotherapy and Psychoanalysis & 

EM-CIMPS/CiiEM, Monte da Caparica, Portugal 
2 EM-CIMPS & Egas Moniz University Institute (IUEM), Monte da Caparica, Portugal 
3 Egas Moniz University Institute (IUEM), University of Seville, MIMD–IUEM, OMD & 

EM-CIMPS/CiiEM, Monte da Caparica, Portugal 
4 EM-CIMPS & Egas Moniz University Institute (IUEM), Monte da Caparica, Portugal 
* Maria do Rosário Dias, Egas Moniz University Institute (IUEM), Faculty of Psychology and 

Educational Sciences, University of Lisbon, Portuguese Association of Psychoanalytic Psychotherapy 

and Psychoanalysis & EM-CIMPS/CiiEM, Monte da Caparica, Portugal 

 

Received: March 7, 2019       Accepted: March 18, 2019       Online Published: March 21, 2019 

doi:10.22158/ct.v2n1p60                            URL: http://dx.doi.org/10.22158/ct.v2n1p60 

 

Abstract 

Dental caries is currently one of the major public health problems, given its high incidence among 

6-12-year-old children. This age group of children is considered a priority group, due to the 

transitional period of the replacement of deciduous teeth. This article intends to present a 

ludic-pedagogical instrument for oral health education, targeted at these children, based on the 

learning of problems related to oral health through a story narrative and associated pictograms. By 

means of a health education manual with several pictorial representations of dentistry clinical acts, we 

intended to imagetically reinforce the therapeutic adherence of children to Paediatric Dentistry as well 

as oral health prevention care, which are considered determinant factors for oral health success 

amongst children. The choice of a handbook format for this purpose was considered a health education 

pedagogical strategy with added value to the Paediatric Dentistry appointment setting, granting 

patients an active and leading role in their therapeutic path. The handbook can also be of use to 

younger children, through parental storytelling, establishing a dyadic communication between parents, 

educators and professionals. 



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Keywords 

pictograms, paediatric dentistry, oral health education, caries, deciduous teeth 

 

1. Introduction 

Dental caries is currently one of the major public health problems, given its high incidence among 

children—45.2% in 6-12-year-old children (DGS, 2015), thus negatively affecting the quality of life 

and systemic health of individuals. This age group is considered a priority group, due to the transitional 

period of the replacement of deciduous teeth. In addition, this is also the time frame when the 

internalization of good life-lasting oral hygiene behaviours is more effective (Dias, Amorim, Esteves, 

Reis, & Duque, 2006). Nevertheless, the anticipatory fear associated to caries’ pain seems to discourage 

subjects from Dental Medicine appointments, in turn impeding preventive dental care strategies and 

contributing to a vicious cycle of permanent malaise (Dias, Amorim, Duque, & Guilherme, 2006; Góes, 

Domingues, Couto, & Barreira, 2010; Marques, Gradvohl, & Maia, 2010; Oliveira et al., 2012; Dias, 

Cruz, & Martins, 2015; Dias & Martins, 2016). 

In a study carried out at the Egas Moniz University Clinic (Reis, Dias, & Leal, 2008), it is noteworthy 

that early first-time appointments in Paediatric Dentistry are a future determining variable of the 

therapeutic adherence to good oral hygiene behaviours in patients. According to this study, the early 

experience of neutral or positive experiences in the Odontopaediatric therapeutic setting, may serve as 

a “neutralizing barrier”, preventing the development of future traumatic dental care experiences. As 

such, it is imperative to overcome the therapeutic obstacles found in Paediatric Dentistry hastily and 

with maximum effectiveness, in order to promote the early adoption of oral health education strategies. 

The use of pictograms as an oral health education pedagogical instrument is one of such strategies, 

(Chernoff, 1973; Magalhães, Alvarenga, & Nina-e-Silva, 2013) aiming to promote the intrapsychic 

involvement of children’s playfulness, as well as their active participation in dental care, thus 

stimulating a selfcare routine behaviour (Cook, 1971; Dias, Amorim, Esteves, Reis, & Duque, 2006; 

Reis, Dias, & Leal, 2008). Furthermore, the use of ludic-pedagogical instruments in the oral health 

education of children allows for the expansion of symbolic thinking, which in turn supports the 

therapeutic relationship Dentist-Patient (Dias, Monteiro, Naben, Sobral, & Neves, 2018). 

With the present paper, we intend to present an interactive handbook as an oral health education 

instrument. The playful narrative allows children to identify themselves to the characters present in the 

story, connecting the characters’ personal oral health experiences with their own (Magalhães, 

Alvarenga, & Nina-e-Silva, 2013). Simultaneously, we intend to support the learning of relational and 

pedagogical communication strategies in the pre- and post-graduate training of Paediatric Dentistry 

health professionals, promoting the strengthening of the therapeutic alliance Dentist-Patient in future 

clinical practice. 



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2. Method 

The main objective of the present oral health education handbook entitled “The House of The Little 

Tooth Diniz” was the retelling of a story that symbolically illustrated possible clinical acts practiced in 

the Paediatric Dentistry appointment setting, as well as the revaluation of oral hygiene habits adopted 

by children. During the story’s retelling, patients should be able to identify themselves with the 

character by means of projective identification, thus relating to the character who leads the story (Dias 

& Simões, 2016). We also intended for this handbook to be used during periods that precede or proceed 

the dental care treatment act itself, as well as to engage parents as secondary patients regarding the oral 

health care provided to children (Sarnat, Arad, Hanauer, & Shohami, 2001; Dias, Monteiro, Naben, 

Sobral, & Neves, 2018).  

Chromatic and figurative contrasts were sought to create visually dynamic sensations and pictorial 

appeal in the handbook’s panels. In addition to the chromatic focus given to the panels, textured 

elements were added, with the goal of capturing children’s attention. In fact, touch invites sensorial 

contact, in turn leading to more archaic and sensorial intrapsychic mental representations. Small 

“interactive highlights” were also created in panels’ layouts, which aimed to encourage children to 

interact with the handbook and to be attentive to the pictorial and symbolic plotting of the narrative. 

Examples of such are: i) the story of Dr. Cobra, symbolically depicting the Paediatric Dentist as the 

traditional mutilating Tooth Puller (triggerring archaic fears in the children’s imaginary) (Dias, Amorim, 

Duque, & Guilherme, 2006); ii) the opening of the Paediatric Dentist’ office door in kinetic form; iii) 

the interaction of the plaque revealer and the use of translucid paper in the panel; iv) the tooth brush 

attached to velcro as a detailed explanation of the brushing technique; v) the shedding of deciduous 

teeth, symbolizing the first loss of a deciduous tooth by placing it in a small teeth box. 

 

3. Instrument’s Description 

The target population of the present oral health education instrument were children of both genders, 

aged six to twelve years. In addition, this handbook was also aimed at parents, teachers and health 

educators as a secondary target population, due to their fundamental pedagogical role in children’s 

daily life, which makes them the social partners of choice in the implementation of oral health 

education strategies. 

The handbook’s leading character was a boy named Simão, placed on its cover emphasizing an 

excessively open mouth (Chernoff, 1973; Magalhães, Alvarenga, & Nina-e-Silva, 2013), in clear 

opposition to other elements of the face. In contrast, “Diniz, the tooth”, a supporting character, was 

deliberately enlarged by the use of an intraoral reflecting mirror, symbolically attesting to its relevance 

in the story’s narrative (Figure 1). 



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Figure 1. Handbook’s Front Cover 

 

In the handbook’s first panel we are invited to step inside “Diniz, the tooth’s” house, the interior of the 

oral cavity, where much of the action takes place. Here, the introduction of his tooth family is 

metaphorically highlighted, and each tooth given a name. The images and names given to deciduous 

teeth allow children to formulate an idea of the anatomical constitution of the dental arch, thus enabling 

an easy recollection of the teeth’ categorization. By resorting to teeth’s anthropomorphization, namely 

by drawing them with facial expressions that refer to basic human emotions, we intended to emphasize 

in children’s imagination teeth are with personalities and feelings, thus conferring a greater importance 

to their preservation and to good oral hygiene. 

In the handbook’s second panel entitled “The brushing hour”, Simão’s facial expression clearly 

demonstrates his non-cooperative attitude towards tooth brushing, despite the anthropomorphic friendly 

expressions of the toothbrush and toothpaste (Figure 2). 

 



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Figure 2. Handbook’s Panel Entitled “The Brushing Hour: Facial Expressions of Simão towards 

Dental Hygiene” 

 

The handbook’s fourth panel points to the detrimental consequences of pathogenic eating (e.g., too 

much sugar). Hence, in this panel the story’s villains emerged, destroying the oral cavity’s flora and 

allowing the development of dental caries in the dental arc (Figure 3). 

 

 

Figure 3. Handbook’s Panel Entitled “The Attack of the Tooth Puller: Antropomorphized 

Representation of Tooth Decay” 



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In the handbook’s fifth to tenth panels, “Bia”, a secondary character, is introduced as a metaphorical 

proxy of the tongue. Bia represents the voice of reason and the moral of the story, narrating the attack 

operated by the Tooth Puller to the dental family (Figure 3) and emphasizing the role of cariogenic 

foods and poor oral hygiene in the destruction caused by dental caries. These panels attested to several 

passages of Simão’s daily life, marked by the discomfort of dental pain, as well as by fear associated to 

the Paediatric Dentistry’s appointment (Figure 4). The set of panels that depict the anxiogenic thoughts 

experienced by Simão, refer to the somewhat intimidating unconscious ideas of children regarding a 

therapeutic setting experienced as unsettling and threatening. 

 

 

Figure 4. Handbook’s 7th Panel Entitled “Dental Nightmares: Illustration of a Child’s Fears 

Related to the Perception of the Dentist and of Dental Care’ Instruments” 

 

The goal of the handbook’s panels 10 to 12 was to focus on a good oral hygiene, demonstrating the 

need of adequate tooth brushing. In fact, the dental arch may present at a first glance a clean and 

healthy appearance, which may not correspond to a real good oral hygiene. For this purpose, a dental 

plaque revealer is used, described playfully as a paint that reveals the teeth attacked by the Tooth Puller 

(the dental caries), as a children’s symbolic equivalent for “the moment of the truth” revealer (Figure 5). 

Indeed, technically speaking, the application of a dental plaque revealer exposes the dental plaque 

present in the oral cavity, denouncing poor oral hygiene. Thus, in panel 10, a translucid paper which 

can be coloured by children was attached over the represented teeth, creating a visual image with 

different shades and textures associated to damaged teeth—thereby revealing the dental caries caused 

by the accumulation of harmful bacteria. 



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Figure 5. Handbook’s 10th Panel Entitled “The Moment of Truth—Dental Plaque Revealing 

Moment” 

 

The handbook’s panel 11 entitled “Turbine in action” aims to demonstrate the relevance of early 

intervention in dental care, which allows avoiding pain caused by dental plaque, while providing at the 

same time adequate aesthetics-asepsis (Figure 6). This panel resorts to captivating pictorial playfulness, 

particularly by the rough textures of the panel’s materials (associated to the black holes caused by the 

existence of cavities in the teeth) and by panel’s protrusions (symbolizing turbine’s water droplets). 

Once again, the anthropomorphization of pictograms was used, namely of the turbine and drill, which 

were drawn with friendly facial expressions, vigorous colours and imposing postures. In parallel, 

linguistic euphemisms were employed in the narrative, namely by adopting the term “water shower”; in 

fact, the use of water is associated to many dental care instruments, which may frighten children during 

dental treatment. 



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Figure 6. Handbook’s 11th Panel Entitled “Turbine in Action—Intervention of the Dental 

Instruments” 

 

Due to the importance of the relational and pedagogical communication between the Paediatric Dentist 

and the children, in the handbook’s panel 12 entitled “New notification” the role of the dentist as a 

health educator was highlighted. Here, the panel revealed greater narrative density in proportion to the 

drawing content and a Dentist-Patient dialogue via social media chat is simulated. Characters are 

turned into “emojis”, expressing their emotions in the virtual world. The use of social media 

iconography in the present handbook presupposed a greater motivation for children’s digital content 

learning, since younger generations are strongly influenced by information technologies. 

The themes of the handbook’s panels 13 to 16 were strongly related to the shedding of deciduous teeth, 

reinforcing the concept that the way deciduous teeth are cared for will affect the good oral health of 

permanent teeth, in turn promoting self-preventive behaviours (Dias, 2005; Dias, Amorim, Esteves, 

Reis, & Duque, 2006) that aim to hinder future iatrogenic dental care habits. As an example, panel 14 

entitled “Waggling, waggling, falling out”, was based on the unconscious fear experienced by children 

related to the loss of the first deciduous tooth. Here, we intended to show children what happens when 

a deciduous tooth falls out, thus appeasing a certain persecutory mourning and feelings of loss that may 

otherwise be experienced. We consider this to be a critical milestone in patients’ education, letting them 

know that deciduous teeth, despite falling out, are preceded by permanent teeth that can be maintained 

for the rest of life, given a correct oral hygiene (Figure 7). 



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Figure 7. Handbook’s 14th Panel Illustrating the Shedding of a Deciduous Tooth and Its 

Permanent Tooth Replacement 

 

Finally, handbook’s panels 15 to 16 refer to children’s imaginary world and are centred on the Tooth 

Fairy myth. The Tooth Fairy is a symbolic character of folk mythology in numerous countries, stating 

that when children lose one of their baby teeth, they should place it underneath their pillow and the 

Tooth Fairy will visit while they sleep, replacing the lost tooth with a wish come true. Ironically, the 

Tooth Fairy of this oral health education handbook does not correspond to the literary stereotypes 

(usually represented by a fragile and feminine creature) but is rather a robust character willing to tackle 

poor oral hygiene behaviours (Figure 8). 

 

 



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Figure 8. Handbook’s 16th Panel Entitled “The Tooth Fairy” 

 

4. Results and Discussion 

The present oral health education instrument entitled “The House of The Little Tooth Diniz” arose from 

the urgent need to create educational play instruments resorting to pictograms with symbolic value, as a 

means of linking clinical acts practiced under dental care treatment to children’s imagination. 

The presence of several pictorial representations throughout the narrative course of this oral health 

education manual intended to imagetically reinforce the therapeutic adherence of children to Paediatric 

Dentistry, as well as to oral health prevention care, which are considered determinant factors for oral 

health prevention amongst children aged six to twelve years. In addition, the choice of a children’s 

literature handbook format for the present oral health education manual was considered an oral health 

education pedagogical strategy with added value to the Paediatric Dentistry appointment setting, 

granting the patient an active and leading role in their therapeutic path. 

Although the target population is composed of subjects aged six to twelve years, this instrument can be 

extended to a larger target population, namely to younger children, who can benefit from interactive 

storytelling, in turn creating a dyadic communication bridge between parents, educators and health 

professionals. Alternatively, younger children may also individually interact with the imagetic and 

visual reading of the pictograms, thus enabling their self-education concerning oral health care 

concepts. 

 

 

 

 



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References 

Chernoff, H. (1973). The use of Faces to Represent Points in K-Dimensional Space Graphically. 

Journal of the American Statistical Association, 68(342), 361-368. 

https://doi.org/10.1080/01621459.1973.10482434 

Cook, M. (1971). Interpersonal perception. Harmondsworth: Penguin Education. 

Dias, M. R. (2005). Serão os Mass Media Estrategas de Saúde? Lisboa: Climepsi Editores. 

Dias, M. R., Amorim, A., Duque, A. F., & Guilherme, N. (2006, September). The “Masked” Dentist in 

the Therapeutic Setting. Proceedings of EACH—International Conference of Comunication in 

Healthcare. Basileia, Suíça. 

Dias, M. R., Amorim, A., Esteves, A., Reis, M. F., & Duque, A. F. (2006, September). Tooth Fairy 

Myth: A Project for Child Oral Health Education. Proceedings of EACH—International 

Conference of Comunication in Healthcare. Basileia, Suíça. 

Dias, M. R., Cruz, J. A., & Martins, N. L. (2015). Eu sou o favolas: Um instrumento de educação para a 

saúde em dentisteria. Journal of human growth and development, 25(3), 325-330. 

https://doi.org/10.7322/jhgd.106012 

Dias, M. R., & Martins, N. (2016). Contágio Emocional de ansiedade encarregada de educação/criança 

em Odontopediatria. Revista Portuguesa de Estomatologia, Medicina Dentária e Cirurgia 

Maxilofacial, 57(3), 164-170. https://doi.org/10.1016/j.rpemd.2015.12.006 

Dias, M. R., & Simões, N. P. (2016). On the Mental Representation of (un)healthy Tooth: (Un)healthy 

Tooth Profiles among Children. Journal of Educational and Developmental Psychology, 6(1), 

110-116. https://doi.org/10.5539/jedp.v6n1p110 

Dias, M. R., Monteiro, A. L., Naben, L., Sobral, A., & Neves, A. C. (2018). No consultório do 

odontopediatra: Um manual de educação para a Saúde Oral. Omnia, 8(3), 35-41. 

Direção Geral de Saúde. (2015). III Estudo Nacional de Prevalência das Doenças Orais 6, 12, 18, 

35-44 e 65-74 anos. Retrieved October 26, 2018, from 

https://www.dgs.pt/documentos-e-publicacoes/iii-estudo-nacional-de-prevalencia-das-doencas-ora

is.aspx 

Góes, M. P. S., Domingues, M. C., Couto, G. B. L., & Barreira, A. K. (2010). Ansiedade, medo e sinais 

vitais dos pacientes infantis. Odontologia Clínico-Científica, 9(1), 39-44. 

Magalhães, L. M., Alvarenga, L. F., & Nina-e-Silva, C. H. (2013). Atribuição de emoções a traços 

faciais artificiais. Revista da Universidade Vale do Rio Verde, 11(2), 462-469. 

https://doi.org/10.5892/ruvrd.v11i2.462469 

Marques, K. B. G., Gradvohl, M. P. B., & Maia, M. C. G. (2010). Medo e ansiedade prévios à consulta 

odontológica em crianças do município de Acaraú-CE. Revista Brasileira em Promoção da Saúde, 

23(4), 358-367. 



www.scholink.org/ojs/index.php/ct                        Children and Teenagers                        Vol. 2, No. 1, 2019 

 
71 

Published by SCHOLINK INC. 

 

Oliveira, M. A., Bendo, C. B., Ferreira, M. C., Paiva, S. M., Vale, M. P., & Serra-Negra, J. M. (2012). 

Association between childhood dental experiences and dental fear among dental, psychology and 

mathematics undergraduates in Brazil. International Journal of Environmental Research and 

Public Health, 9(12), 4676-4687. https://doi.org/10.3390/ijerph9124676 

Reis, F., Dias, M. R., & Leal, I. (2008). A consulta no setting odontopediátrico: A percepção subjectiva 

do medo. Análise Psicológica, 26(2), 239-250. https://doi.org/10.14417/ap.491 

Sarnat, H., Arad, P., Hanauer, D., & Shohami, E. (2001). Communication strategies used during 

pediatric dental treatment: A pilot study. Pediatric Dentistry, 23(3), 337-342. 


