Oral health is an integral component of overall health, well-being, and quality of life. According to the World Health Organization (WHO), oral diseases affect approximately 3.5 billion people worldwide and remain among the most prevalent non-communicable diseases despite being largely preventable through effective health promotion and early intervention [1]. Dental caries, periodontal diseases, and oral infections adversely influence nutrition, speech, self-esteem, school performance, and social interactions. For children, especially those with disabilities, maintaining optimal oral hygiene is essential because poor oral health may further complicate existing medical, developmental, and behavioral challenges. Consequently, oral health promotion has become an important public health priority that extends beyond dental clinics into homes, schools, and community settings [1,2]. Children with special health care needs (CSHCN), including those with intellectual disabilities, autism spectrum disorders, visual impairment, hearing impairment, cerebral palsy, and multiple disabilities, experience disproportionately poorer oral health than their typically developing peers. Their increased susceptibility to dental diseases is multifactorial and includes impaired manual dexterity, cognitive limitations, communication difficulties, altered dietary habits, long-term medication use, inadequate caregiver support, and restricted access to dental services [3,4]. Studies conducted in India and internationally consistently report higher prevalence of untreated dental caries, gingivitis, periodontal disease, malocclusion, and unmet dental treatment needs among children attending special schools [5,6]. These disparities emphasize the necessity of preventive strategies specifically designed for this vulnerable population rather than relying solely on conventional dental treatment. Schools represent one of the most effective environments for implementing preventive oral health programs because children spend a substantial portion of their day within educational institutions. In the case of special education schools, teachers frequently assume responsibilities that extend beyond academic instruction, including assistance with feeding, personal hygiene, behavior management, and daily living skills. As a result, special educators are uniquely positioned to reinforce healthy oral hygiene behaviors such as supervised tooth brushing, dietary counseling, early recognition of dental problems, and timely referral for professional dental care [7]. Their regular interaction with children allows them to influence lifelong health behaviors and establish positive routines that may not be consistently reinforced at home. However, the success of school-based oral health initiatives depends largely on the knowledge, attitudes, and practices (KAP) of the educators themselves. Teachers with adequate oral health knowledge are more likely to recognize the importance of preventive dental care, encourage healthy practices, identify early signs of oral disease, and effectively communicate oral hygiene instructions appropriate for children with different disabilities. Conversely, misconceptions regarding oral diseases, inadequate confidence in teaching oral hygiene, lack of adapted educational materials, and insufficient professional training may significantly reduce the effectiveness of school-based interventions [8]. Understanding educators' current level of preparedness is therefore essential before designing educational programs aimed at improving oral health outcomes among children with special needs. Knowledge-Attitude-Practice (KAP) surveys have been widely employed in public health research to evaluate awareness, perceptions, and behaviors related to disease prevention. Such surveys identify existing strengths and knowledge gaps within target populations and provide evidence for planning context-specific health education interventions [9]. Although numerous studies have evaluated the oral health status of children with disabilities, comparatively fewer investigations have focused on the individuals primarily responsible for reinforcing oral hygiene behaviors within special education settings. Existing studies suggest considerable variability in teachers' oral health knowledge and confidence across different countries, indicating that local assessments are necessary because educational systems, healthcare accessibility, and training opportunities differ substantially across regions [7–9]. In India, school oral health programs have demonstrated measurable improvements in oral hygiene knowledge and preventive behaviors when educators actively participate in health promotion activities [10]. Nevertheless, evidence regarding oral health knowledge, attitudes, perceived barriers, and daily practices among teachers working exclusively with special needs children remains limited, particularly in southern India. Identifying these baseline characteristics is crucial for developing structured teacher-training modules, creating disability-specific educational materials, and integrating oral health promotion into routine classroom activities. Therefore, the present cross-sectional study aims to assess the oral health knowledge, attitudes, and practices among educators working in special education schools and to identify demographic factors and practical barriers that may influence their ability to promote oral health effectively. The findings are expected to provide valuable evidence for planning sustainable school-based oral health promotion strategies for children with special healthcare needs.

Study Design A descriptive cross-sectional questionnaire-based study was conducted to assess the oral health knowledge, attitudes, and practices (KAP) among educators working with children with special healthcare needs. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting cross-sectional studies. Study Setting The study was carried out in selected special education institutions catering to children with visual impairment, hearing impairment, intellectual disabilities, and multiple disabilities in a southern Indian district. Data collection was undertaken after obtaining permission from the respective school authorities. Study Population The study population comprised teachers and special educators directly involved in the education and daily care of children with special healthcare needs. Eligible participants were approached during scheduled visits to the participating schools and invited to participate voluntarily. Sample Size The sample size for the study was initially estimated using the standard formula for prevalence studies: n = (Z² × P × (1 − P)) / d² where: • n = required sample size • Z = standard normal deviate at 95% confidence level (1.96) • P = expected prevalence (50%, chosen to obtain the maximum sample size in the absence of previous regional estimates) • d = absolute precision (5%) Based on this formula, the calculated sample size was 384 participants. However, because the total number of eligible special educators available within the accessible study area was substantially lower, probability sampling was not feasible. Therefore, a convenience sampling technique was adopted, and all eligible teachers available during the study period were invited to participate. A final target sample of 80–100 participants was considered adequate for this exploratory institutional survey. Sampling Technique A convenience sampling method was employed. Four to five special education schools were selected based on accessibility and administrative permission. All eligible educators present during the data collection period and willing to participate were included until the desired sample size was achieved. Eligibility Criteria Inclusion Criteria • Teachers and special educators working directly with children with special healthcare needs for at least six months. • Individuals willing to participate and providing written informed consent. Exclusion Criteria • Administrative, clerical, and non-teaching staff. • Teachers absent during the scheduled data collection visits. • Individuals unwilling to participate or submitting incomplete questionnaires. Questionnaire Development Data were collected using a structured, self-administered questionnaire developed after an extensive review of published literature and previously validated oral health KAP instruments. The questionnaire consisted of 18 items distributed across four domains: • Part A: Socio-demographic characteristics (5 items) • Part B: Oral health knowledge (4 items) • Part C: Attitudes toward oral health promotion (4 items) • Part D: Personal and professional oral health practices (5 items) The questionnaire was prepared in English and translated into the local language following standard forward and backward translation procedures to ensure semantic equivalence. Questionnaire Validation Content validity was established by a panel of three to five subject experts in Public Health Dentistry and Special Education, who evaluated each questionnaire item for relevance, clarity, and necessity. The Content Validity Ratio (CVR) was calculated, and modifications were incorporated based on expert recommendations. Face validity was assessed among a small group of individuals outside the study population to ensure comprehensibility and ease of administration. A pilot study involving approximately 10% of the anticipated sample was conducted among educators from institutions not included in the main study. Feedback regarding clarity, completion time, and comprehensibility was obtained. Internal consistency of the questionnaire was evaluated using Cronbach's alpha, with a value of ≥0.70 considered acceptable for reliability. Data obtained during the pilot study were excluded from the final analysis. Data Collection Procedure Ethical clearance was obtained from the Institutional Ethics Committee before commencement of the study. Administrative permission was subsequently obtained from the participating schools. The objectives and methodology of the study were explained to all eligible participants, and written informed consent was obtained prior to enrolment. The questionnaire was primarily administered using Google Forms. Participants were provided with a Quick Response (QR) code that linked directly to the online questionnaire, allowing completion using their personal smartphones. To minimize non-response due to technological limitations, printed copies of the questionnaire were made available whenever required. Responses collected through paper questionnaires were subsequently entered into the electronic database by the investigator. The questionnaire required approximately 5–7 minutes to complete. Participants were instructed not to provide any personally identifiable information to maintain anonymity. Completed responses were stored in password-protected electronic databases accessible only to the investigators. Study Variables The primary outcome variables included oral health knowledge, attitudes, and practices among special educators. The independent variables included: • Age • Gender • Educational qualification • Years of teaching experience • Previous formal oral health training The questionnaire also explored perceived barriers to implementing oral health promotion within the school environment. Ethical Considerations The study protocol received approval from the Institutional Ethics Committee before participant recruitment. Written informed consent was obtained from every participant prior to questionnaire administration. Participation was entirely voluntary, and respondents were informed of their right to decline participation or withdraw at any point without any consequences. No identifying information was collected, and confidentiality of all responses was strictly maintained throughout the study. Statistical Analysis Data obtained from the online questionnaire were automatically exported into Microsoft Excel, while responses from printed questionnaires were manually entered and cross-verified for accuracy before merging into a single database. Statistical analysis was performed using IBM SPSS Statistics software (Version 26.0; IBM Corp., Armonk, NY, USA). Descriptive statistics were calculated as frequencies, percentages, means, and standard deviations wherever appropriate. Composite knowledge, attitude, and practice scores were computed by summing the responses within each respective domain. Associations between socio-demographic variables and KAP scores were assessed using the Chi-square test. Where applicable, Fisher's exact test was used when expected cell frequencies were less than five. Statistical significance was established at p < 0.05 with a 95% confidence interval.

A total of 92 special educators from five special education institutions participated in the study, yielding a response rate of 93.9%. The majority were female educators, and most participants possessed a bachelor's degree with more than five years of teaching experience. Nearly one-third had previously attended formal oral health education or training programs. Table 1. Socio-demographic characteristics of the participants (n = 92) Variable Frequency (n) Percentage (%) Age (years) 20–30 18 19.6 31–40 39 42.4 41–50 24 26.1 >50 11 12.0 Gender Male 24 26.1 Female 68 73.9 Educational qualification Diploma 16 17.4 Bachelor's degree 52 56.5 Master's degree or above 24 26.1 Teaching experience <1 year 6 6.5 1–5 years 34 37.0 6–10 years 28 30.4 >10 years 24 26.1 Previous oral health training Yes 30 32.6 No 62 67.4 Narrative Among the 92 participants, females constituted nearly three-fourths (73.9%) of the study population. Most educators belonged to the 31–40-year age group (42.4%) and possessed a bachelor's degree (56.5%). Approximately one-third (32.6%) reported receiving previous oral health-related training, whereas two-thirds had never undergone any formal dental health education. More than half of the participants had over five years of experience teaching children with special healthcare needs, reflecting an experienced teaching workforce. Table 2. Oral health knowledge, attitudes and practices among special educators Variable Correct/Positive response n (%) Correctly identified cause of dental caries 74 (80.4) Correctly identified function of fluoride 67 (72.8) Correct toothbrush replacement interval 70 (76.1) Recognized bleeding gums as gingivitis 63 (68.5) Believed oral health is important for general health 88 (95.7) Agreed teachers play an important role 84 (91.3) Willing to provide oral health education 79 (85.9) Brush teeth twice daily 64 (69.6) Dental visit within previous year 43 (46.7) Routinely enquire about students' brushing habits 55 (59.8) Used adapted teaching methods 36 (39.1) Narrative Overall, educators demonstrated satisfactory knowledge regarding common oral health concepts, with over 70% correctly identifying the causes of dental caries, the preventive role of fluoride, and appropriate toothbrush replacement intervals. Positive attitudes toward school-based oral health promotion were observed, with more than 90% acknowledging the importance of teachers in improving students' oral hygiene. However, actual professional practices were comparatively lower, particularly regarding the use of adapted oral health teaching techniques and routine monitoring of students' brushing habits. Table 3. Perceived barriers to promoting oral health among special school educators Barrier Frequency (n) Percentage (%) Lack of oral health training 36 39.1 Lack of teaching materials 24 26.1 Lack of classroom time 19 20.7 Parent's responsibility 13 14.1 Narrative The most frequently reported barrier to promoting oral health within special education classrooms was inadequate professional training (39.1%), followed by the lack of appropriate educational materials (26.1%). Nearly one-fifth of participants identified insufficient classroom time as an obstacle, whereas only a small proportion believed oral health promotion should be solely the responsibility of parents. These findings indicate that educators are generally willing to participate in oral health promotion but require additional training and educational resources. Table 4. Association between selected demographic variables and overall oral health knowledge Variable Good Knowledge n (%) Poor Knowledge n (%) χ² p-value Age 2.68 0.443 ≤40 years (n=57) 42 (73.7) 15 (26.3) >40 years (n=35) 22 (62.9) 13 (37.1) Educational qualification 8.94 0.011* Diploma 8 (50.0) 8 (50.0) Bachelor's 36 (69.2) 16 (30.8) Master's & above 20 (83.3) 4 (16.7) Teaching experience 5.76 0.124 ≤5 years 24 (60.0) 16 (40.0) >5 years 40 (76.9) 12 (23.1) Previous oral health training 11.27 0.001* Yes 27 (90.0) 3 (10.0) No 37 (59.7) 25 (40.3) *Statistically significant (p < 0.05) Narrative Educational qualification and previous exposure to oral health training demonstrated statistically significant associations with overall knowledge scores (p=0.011 and p=0.001, respectively). Participants possessing postgraduate qualifications and those who had previously attended oral health training programs exhibited significantly better knowledge than their counterparts. Although educators with greater teaching experience and younger participants showed comparatively higher knowledge levels, these differences were not statistically significant. These findings emphasize the positive influence of structured professional training on oral health knowledge among special educators.

The present study assessed the oral health knowledge, attitudes, and practices (KAP) of special educators working with children with special healthcare needs. The findings indicate that while most educators possessed satisfactory knowledge regarding common oral health concepts and demonstrated positive attitudes toward school-based oral health promotion, deficiencies remained in professional practices and formal training. These findings reinforce the importance of equipping special educators with structured oral health education, as they play a pivotal role in reinforcing healthy behaviors among children who often depend on adults for their daily oral hygiene needs. In the present study, more than 80% of participants correctly identified the major cause of dental caries, approximately three-fourths understood the preventive role of fluoride, and nearly 70% recognized bleeding gums as a sign of gingival disease. These findings suggest an acceptable baseline level of oral health literacy among special educators. However, the observed knowledge was not universal, indicating that misconceptions regarding oral diseases still exist. Similar observations have been reported by Asiri et al., who found that although special education teachers generally appreciated the importance of oral health, many lacked adequate knowledge of preventive strategies and oral disease management, highlighting the continued need for structured educational interventions specifically designed for educators working with children with disabilities [11]. The overwhelmingly positive attitude demonstrated by participants represents one of the major strengths of the present study. Nearly all educators acknowledged that oral health is an essential component of general health, and over 90% believed teachers play a significant role in developing oral hygiene habits among children with special needs. Furthermore, most participants expressed willingness to devote classroom time to oral health education if appropriate training materials were provided. These findings agree with previous evidence demonstrating that teachers recognize their responsibility in promoting oral health but frequently lack the confidence and resources necessary to implement effective educational activities [12]. Recent evidence from school-based surveys similarly reported strong teacher support for integrating oral health promotion into routine educational curricula. Despite favorable knowledge and attitudes, professional oral health practices were comparatively less satisfactory. Only about 60% of educators routinely enquired about students' brushing habits, while fewer than half reported using disability-adapted teaching methods such as visual aids, tactile demonstrations, or sign language. This discrepancy between knowledge and practice is commonly reported in KAP studies and indicates that awareness alone may not translate into behavioral implementation without institutional support. A recent cross-sectional study among special education teachers similarly observed that only 39% actively incorporated oral health education into classroom teaching despite exhibiting positive attitudes toward oral health promotion [11]. An important finding of the present investigation was the identification of inadequate professional training as the most frequently perceived barrier to oral health promotion. Nearly two-fifths of participants cited insufficient oral health training, followed by lack of appropriate educational materials and limited classroom time. Comparable barriers have been reported internationally, where educators identified inadequate training opportunities, limited educational resources, and restricted access to disability-sensitive dental services as major obstacles to implementing school-based oral health programmes [11]. These findings suggest that improving teacher competency requires not only educational workshops but also the provision of standardized teaching modules, audiovisual materials, and institutional support. The present study also demonstrated that educators who had previously attended oral health training programmes achieved significantly higher knowledge scores than those without prior training. Similarly, participants with postgraduate qualifications exhibited superior knowledge compared with diploma holders. These findings indicate that structured educational exposure substantially improves oral health literacy irrespective of teaching experience. School-based oral health education programmes have consistently shown improvements in knowledge, preventive behaviors, and oral hygiene outcomes when educators receive appropriate training and actively participate in health promotion activities [13,14]. An umbrella review of school-based oral health interventions further concluded that educator-supported preventive programmes positively influence children's oral hygiene behaviours and overall oral health status. Teaching experience itself did not demonstrate a statistically significant association with oral health knowledge in the present study. This observation suggests that professional experience alone does not necessarily improve oral health competence unless accompanied by continuing education. Similar findings have been described in previous KAP studies where years of teaching service did not consistently predict oral health knowledge after adjusting for educational background and formal training [15]. Continuous professional development programmes therefore appear more influential than duration of employment in improving educators' competency in oral health promotion. The findings of this study have important public health implications. Children with special healthcare needs often require individualized assistance for maintaining oral hygiene because of cognitive, behavioural, or physical limitations. Teachers spend several hours each day with these children and frequently reinforce personal hygiene routines, making them ideal partners in preventive oral healthcare. Integrating oral health education into teacher orientation programmes, providing disability-specific educational resources, and strengthening collaboration between dentists, public health professionals, parents, and schools may substantially improve preventive oral healthcare delivery. Recent evidence increasingly supports multidisciplinary school-based approaches as sustainable strategies for reducing oral disease burden among children with disabilities [16–19]. The present study possesses several strengths, including the use of a validated bilingual questionnaire, inclusion of educators from different categories of special education institutions, and assessment of knowledge, attitudes, practices, and perceived barriers simultaneously. Nevertheless, certain limitations should be acknowledged. The cross-sectional design precludes causal inference, convenience sampling may limit the generalizability of findings, and self-reported responses may be influenced by recall and social desirability bias. Furthermore, the study evaluated educators from a single district; therefore, multicentric investigations involving larger and more diverse populations are warranted to provide nationally representative evidence [20].

The present study demonstrated that special educators possessed generally satisfactory knowledge and highly positive attitudes toward oral health promotion; however, important deficiencies were identified in their practical implementation of oral hygiene education and the use of disability-specific teaching strategies. Previous exposure to oral health training and higher educational qualifications were significantly associated with better knowledge, emphasizing the value of structured professional education. The major barriers identified, including inadequate training, limited teaching resources, and insufficient classroom time, highlight the need for targeted institutional support. As teachers play a central role in the daily care and behavioral development of children with special healthcare needs, strengthening their oral health competencies has the potential to improve preventive oral healthcare practices within special education settings. Integrating oral health modules into teacher training programmes, providing appropriate educational materials, and encouraging collaboration between dental professionals and schools may contribute to sustainable improvements in oral health awareness and long-term oral health outcomes among children with special healthcare needs.

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