| Abstract|| |
Objective: To evaluate the effectiveness of school dental health education on the oral health status, oral health-related knowledge, and practice behavior of 6–12-year-old children. Methods: Hand search and electronic search based on the keywords on school dental health education in seven search engines till 2017 identified 7434 articles. Trials involving school-based dental health education with a minimum follow-up period of 6 months were screened. Risk of bias assessment was done independently by two authors. Results: Among the 18 articles which fulfilled the eligibility criteria, six were randomized controlled trials (RCTs) and 12 were non-RCTs. Quality assessment showed that 12 trials had a low risk of bias. Oral health-related knowledge improved in children. Oral health-related practice behaviors such as frequency and duration of brushing improved. Use of fluoridated toothpaste was increased. Plaque scores and gingival bleeding scores reduced. Conclusion: School dental health education had a positive impact on the oral health status, knowledge, and practice behavior of children. There is a definite need for high-quality RCTs analyzing the effectiveness of school dental health education on specific oral health outcomes.
Keywords: Oral health education, oral health of schoolchildren, oral health-related knowledge, school dental health education
|How to cite this article:|
Geetha Priya P R, Asokan S, Janani R G, Kandaswamy D. Effectiveness of school dental health education on the oral health status and knowledge of children: A systematic review. Indian J Dent Res 2019;30:437-49
|How to cite this URL:|
Geetha Priya P R, Asokan S, Janani R G, Kandaswamy D. Effectiveness of school dental health education on the oral health status and knowledge of children: A systematic review. Indian J Dent Res [serial online] 2019 [cited 2020 Aug 10];30:437-49. Available from: http://www.ijdr.in/text.asp?2019/30/3/437/264134
| Introduction|| |
School is an important platform for learning. It not only contributes to an individual's education but also to their health and health-related behavior.
In Europe, “healthy school concept” and “health-promoting school concept” have evolved to strengthen the opportunities for promoting oral health., The WHO has provided “information series on school health” to advocate “health-promoting schools.” They have also implemented strategies for oral health promotion in schools. Oral health and dental camps have become an integral part of school curriculum. Indian school textbooks had basic and adequate information on oral health. Literature review showed the wide perspective of school health education with different modes of education, different educators, reinforcements, and follow-up periods in different parts of the world. Research evaluating the effectiveness of various modes of oral health education (OHE) and its different combinations in improving the oral health status of children has been on the rise in the last decade.
Oral health status evaluation includes both objective and subjective parameter components. Kay and Locker  in their systematic review concluded that the quality of evidence pertaining to the effectiveness of dental health education is poor. However, a systematic review by Gambhir et al. assessed the effectiveness of school dental health education in India and found it to be effective, irrespective of their follow-up periods. There is no comprehensive information available in this regard from a global perspective in recent times. Hence, this systematic review was planned to assess the interventional studies on the effectiveness of school dental health education on the oral health-related knowledge, attitude, and practice behavior and oral health status of 6–12-year-old children, with a minimum follow-up period of 6 months.
| Research Protocol|| |
A systematic screening of the available literature and data extraction based on certain eligibility was done independently by two authors (PRG, JRG) and a third author (SA) settled any inconsistencies between the two reviews.
| Literature Search|| |
Literature search was conducted electronically in the following databases; PubMed, IndMED, MEDLINE, Web of science, Cochrane database, EMBASE, Google Scholar, and Grey literature using the following keywords: oral health education, school dental health education, oral health promotion, school based dental health education, dental health education, and school health intervention. The following search strategies were used in PubMed: ((school) OR dental) AND health education, (((oral health) AND intervention) OR education) OR prevention and ((school) AND oral) AND education. In addition to electronic searches, literature was included based on hand search and cross-references in the selected articles that fit the eligibility criteria.
The eligibility criteria included (a) articles that have been published on any mode of OHE for schoolchildren aged 6–12 years with a minimum follow-up period of 6 months and (b) articles published in English till 2017, irrespective of the region where the study was conducted. Articles on school dental health education for children with special needs were excluded.
| Data Extraction|| |
This systematic review was carried out based on the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. The steps involved in search strategy have been shown in PRISMA [Flowchart 1]. Published literature pertaining to the review was accessed through various databases, and a total of 7434 articles were obtained. Four hundred and thirty-five human clinical trials on children aged 6–12 years were selected. After cross-searching the reference articles in the databases and hand search by author SA, nine additional studies were added for a total of 444 articles. Two examiners GPR and JRG individually examined the titles and abstracts to remove duplicates and reports that were irrelevant. Seventy-two studies were selected after reading the title, and 33 articles were eliminated after reading the abstract. Full-texts of the potentially relevant studies were sought. Individual studies were assessed to check if they fit all the eligibility criteria and 21 articles were eliminated. Hence, 18 studies were included for this systematic review and subjected to data collection.
| Quality Appraisal|| |
The studies were subjected to qualitative assessment using Cochrane risk of bias assessment tools. Revised Cochrane risk of bias tool for randomized trials (RoB 2.0) was used for randomized controlled trials (RCTs) and, risk of bias in non-randomized studies of interventions  (ROBINS-I) was used for non-randomized controlled trials (NRCTs). Authors GPR and JRG carried out the bias assessment individually. The third reviewer SA was consulted to settle any disagreement between the two authors. RoB assessment done is shown in [Table 1] and [Table 2].
Out of the 18 studies considered for analysis, six studies,,,,, were RCTs and 12 studies ,,,,,,,,,,,, were NRCTs. Among the RCTs, three studies fell in the low-risk category, and the studies by Redmond et al., Worthington et al., and Esfahanizadeh, which failed to provide details on the blinding process, were placed in “some concerns” category. Nine out of the 12 NRCT studies fell in the low-risk category. In the study by Karim et al., children belonging to different shifts of the same school were selected. There was a possibility of exchange of knowledge between the control and experimental groups. Naidu and Nandlal  have not mentioned whether the outcome assessor was aware of the intervention provided to the study participants. Hence, these articles were categorized in the moderate-risk category. A study by Frencken et al. showed serious risk of bias due to missing participants and reshuffling of the groups in the middle of the study.
| Data Analysis and Results|| |
Data collection done independently by the review authors included both descriptive and quantitative information. This included the title, author's name, study design, year of the study, age group of participants, study sample, mode of educational intervention, aids used, primary educator, training sessions for the educators, reinforcements/supervision, oral health status, gingival index scores, plaque index scores, oral health-related knowledge-attitude-practice questionnaire scores, results of baseline, results in follow-up visits, and authors' conclusion. Description of the studies included and the details of their target population, intervention, control, and outcomes (PICO) are extensively summarized in [Table 3] and [Table 4], respectively.
|Table 4: Population, intervention, control and outcome elements of the studies included|
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| Interventions|| |
In the 18 studies selected, different health education modes such as lectures, models, projects, activity-based strategies, and audiovisual aids were used to gain the children's attention. Six authors ,,,,, used lecture-based methods of OHE delivered either by a teacher, dentist, facilitator, or peer. Audiovisual aids such as videos, powerpoint presentations, and posters were used by three authors.,, Five authors ,,,, used combination of models, lectures, audiovisual aids, and classroom activities.
Seven studies ,,,,,, were teacher-led, seven studies ,,,,,, were dentist-led, and three studies ,, were led by dental facilitators. There was one parent-led  and peer-led  study each in the extracted data. A study by Haleem et al. compared the effectiveness of teacher-, dentist-, and peer-led groups in providing health education. All the three groups were equally effective in increasing oral health-related knowledge. Interestingly, oral health behavior was almost equally improved in both the peer-led group and the dentist-led group.
Houle  added additional oral health lessons in the school curriculum. Lai et al. successfully used school dental nurses to give oral hygiene instructions and supervise tooth brushing in schoolchildren. In addition to the OHE, Frencken et al. conducted oral health competitions among schoolchildren. Esfahanizadeh  included parents for giving additional reinforcement of oral hygiene instructions to their children. Topics covered were mostly on the appearance, function of teeth, diet and nutrition, toothbrushing methods, dental caries, gingival health, importance of fluorides, and use of xylitol products. Tolvanen et al. evaluated the presence of soft drinks and candy-vending machines in school environment and discussed their ill effects. Frencken et al. perceived that the lack of workforce and availability of dentists in African population as the main cause for lack of OHE. Hence, they recommended that OHE should be included in the undergraduate curriculum of school teachers.
| Outcomes|| |
The primary outcome was to assess the changes in the knowledge, attitude, and practice behavior of children following school dental health education interventions [Table 5]. The secondary outcomes included the change in oral health status based on plaque scores [Table 6] and gingival health status [Table 7]. The outcomes have been tabulated based on the study design and the level of evidence.
Questionnaires and indices were used by various authors to assess the outcomes of OHE provided. Eleven authors ,,,,,,,,,,, used questionnaires to assess the oral health-related knowledge, attitude, and practice behavior. Worthington et al. and Karim et al. reported that children who received dental health education had better knowledge on toothbrushes. Redmond et al. showed that school-based dental health education program in adolescents, improved their knowledge on dental diseases, and increased their duration of toothbrushing. Angelopoulou et al. showed that the acquired oral health knowledge was maintained till the end of the study at 18 months. However, the behavior and attitude improved at 6 months and declined at 18 months. Lai et al. showed that the dental knowledge and habits significantly improved in children who received oral hygiene program and supervised tooth brushing for one semester. Long-term effectiveness of the oral hygiene program after 10 years follow-up was also evident. In the 11 trials, two RCTs had low RoB and a high level of evidence. Tai et al. showed significant improvement in the percentage of children who brushed twice daily, used fluoridate toothpaste, and had a dental visit in the past 1 year. Tolvanen et al. used a combination of school dental health education and oral health campaigns. Subjects in the combination group showed healthier eating behavior and improved oral health-related behavior but no improvement in oral health-related knowledge and attitude.
Plaque scores were assessed with different indices. Nine authors ,,,,,,,,, used plaque index by Sillness and Loe (1964) and three authors ,, used simplified oral hygiene index by Green and Vermillion (1964). Lai et al. found that the intervention group had point four times risk of having plaque than the control group. Redmond et al. showed that the mean proportion of sites with plaque significantly reduced at 6 months. Worthington et al. showed a significant reduction (17% lower) in the mean plaque scores at the end of 7 months. Houle  used patient hygiene performance (PHP) method in 5-year follow-up study and observed a significant reduction in their plaque scores. Six authors ,,,,, had provided a macromodel demonstration of toothbrushing. Free sample of toothpastes and brushes ,,,,,,, was given to children. Supervised toothbrushing was done in school premises.,,,, In the study by Lai et al., in addition to supervised toothbrushing, the children also performed flossing every day in the school premises. Vanobbergen et al. observed a reduction in the mean buccal plaque score. However, they summarized that the effectiveness of yearly based oral health promotional program on plaque level as inconclusive. Frencken et al. showed no improvement in plaque score after 3½ years of follow-up in Africa. However, the outcome of this study cannot be considered as it had a high risk of bias due to reshuffling of children in the middle of the study. The article by Tai et al. was the only trial with a high level of evidence among the 12 trials which assessed the plaque scores of children. They showed 52% higher reduction in the mean plaque score after 3 years of school dental health education.
Tai et al. and Vanobbergen et al. used sulcular bleeding index by Muhleman and showed significant reduction in the sulcular bleeding index scores after 3 and 6 years, respectively. Four authors ,,, used gingival index by Loe and Sillness, and Valle et al. used Eastman interdental bleeding index. They found statistically significant reduction in the scores of the indices used. Lai et al. used community periodontal index and showed that the percentage of pocketing was lesser in the intervention group. Peng et al. and Petersen et al. showed significant reduction in the mean bleeding scores. Out of the ten trials which assessed the gingival health of children, there were two RCTs and eight NRCTs. Nine trials (one RCT and all NRCTs) with low risk of bias showed that the school dental health education had a positive influence on the gingival health of children.
Caries status of the children was assessed by 10 authors.,,,,,,,,, Decayed, missing, filled teeth/surface (DMFT/S) index modified by the WHO was used by seven authors.,,,,,, Petersen et al. and Peng et al. used the Danish municipal child health services which recognize handwritten signs as input for identification by a computerized optical reading unit. Naidu and Nandlal  used modified Moller's index for recording caries. After a 10-year study, Lai et al. concluded that the mean DMFT scores reduced in children with supervised toothbrushing. Al-Jundi et al. studied supervised toothbrushing for 4 years and found that control group children had six-point four times more risk of having dental caries than the experimental group. Children in the intervention group showed an increase in the number of filled teeth. Peng et al. found that children in the xylitol chewing gum group had 42% lower mean caries increment after 2 years. Five authors ,,,, showed that OHE did not improve the caries status of children. However, after 3 years of OHE, Tai et al. found an increase in the restored surfaces of the experimental group compared to control groups. Various chemotherapeutic agents such as chewing gums containing sorbitol, xylitol, fluoridated toothpastes/gels, topical fluoride applications, lozenge-containing fluoride, and xylitol were used by different authors. Data on caries status were removed from this systematic review as these agents can mask the actual outcome measured.
Irrespective of the risk of bias, among the 18 studies, nine ,,,,,,,, of them have shown a positive outcome in the parameters they assessed. However, the remaining nine studies ,,,,,,,, had inconclusive outcomes in at least one of the parameters they assessed. In the articles reviewed, the interventions and the outcomes varied to a great extent. These differences and the lack of adequate low risk of bias articles might have contributed to the dispersed results. A meta-analysis was not considered because of the clinical and methodological heterogeneity.
| Interpretation of Results|| |
This review targeted children aged 6–12 years in their mixed dentition stage. School years play a massive role in the development of a child. It covers the most productive years of life from childhood through adolescence. These are crucial stages in one's life where lifelong sustainable behaviors, attitudes, and beliefs are being developed. In terms of Erikson's stages, they fall in the latency period where children compete with their peers. If children can discover pleasure in intellectual stimulation, they develop a sense of competence by being productive and seeking success. This age group also falls under the concrete operational period of Piaget's theory. Children acquire and use cognitive operations such as mental activities that are components of logical thought. Hence, the effect of school dental health education on this age group of children was assessed.
To reduce the effect of short-term learning, this review included studies which had follow-up of 6 months or more. Esfahanizadeh  had the least follow-up of 6 months and Lai et al. had the maximum follow-up period of over 10 years. Children with disabilities were not included in this study as they might lack the cognitive development compared to normal children.
Hawthorne effect is an important parameter to be taken into account. It is the awareness of being observed or assessed. The existence of Hawthorne effect might alter the results of the study. Houle  had conducted unannounced dental health evaluations in school at different time intervals to reduce this effect.
The common health educators were dentists, postgraduate students, school teachers, parents, and dental facilitators such as the school dental hygienist or nurse and peers in school. Chachra et al. provided OHE to 972 children, randomly selected from four schools. The children aged 5–16 years were then assigned to four groups: control, dentist-led, teacher-led, and social organization-led. They concluded that direct communication with the dentist proved to be the most effective communication approach as compared to the other communication approaches. Seven authors ,,,,,, used dentists as the prime health educators and proved them to be effective in providing health education.
School teachers were considered for health education because of their availability, and the reinforcement children would get on a constant basis. Results of the trial by Chandrashekar et al. proved that frequent OHE by teachers was more effective than the infrequent health education by professionals. Many schools also have a dental hygienist who serves as an authoritative person to care for the oral hygiene of children. Peer-led OHE was as effective as dentist-led education and better than self-learning.
Laiho et al. used three methods of OHE in three secondary schools in Finland. The traditional OHE consisted of a lecture given by a dentist with the aid of transparencies and slides. The peer-led OHE consisted of a lecture given by six pupils from the upper grades. These pupils used transparencies and extracts of video films and had a classroom exhibition with pictures, slogans, dental aids, and instruments. The self-teaching OHE was based on an exhibition from which the pupils searched for the information themselves. The attitudes and opinions were most positive in the peer-led OHE group. The conventional OHE was quite well accepted, but the self-teaching method was not very successful. These results were in accordance with Haleem et al., who proved that the peer-led group was as effective as the dentist-led but better than the teacher-led and self-learning groups.
Nyandindi et al. described the impact of OHE given by teachers before and after they had been trained in workshops. Two hundred children aged 5–15 years were randomly divided into three groups: conventional group, modified session group, or reference group. The conventional group received OHE lectures for 30 min. Modified session group received an additional demonstration on brushing whereas the reference group did not receive any OHE. The group that received modified OHE had better knowledge on oral health and improved oral hygiene. The results emphasize the need to train educators of OHE programs. This systematic review includes eight studies ,,,,,,, that provided specialized oral health training to the primary health educator.
John et al. used drama mode of health education by dental residents dressed mimicking cartoon characters. They proved that drama had a bigger impact on the oral health attitude and practices in preschoolers. Angelopoulou et al. and Tolvanen et al. used theatrical plays along with other modes of health education. Puppet play method of health education was used along with traditional lectures by Valle et al. and Zanin et al.
Plaque and gingival indices were the methods commonly used to evaluate oral hygiene. Plaque index provides information on the oral hygiene status of a child at that examining moment. However, gingival index provides a more accurate picture of the oral hygiene behavior as it reflects the changes in oral hygiene only after a few days. Since epithelial changes and vascular changes are well established, gingival tissues can be provoked to bleed just by touching with a blunt instrument. Hence, gingival bleeding can be used as a key parameter in evaluating the oral hygiene status.
All the articles included in this review did not have similar educators/facilitators to provide dental health education. They used various types/modes of health education. The outcome parameters assessed also varied to a great extent in each article. This complicated our review process, when we attempted to establish the “cause-and-effect' relationship. Overall, the PICO statement seemed to be too broad to arrive at succinct conclusions.
| Conclusion|| |
Within its limitations, the following conclusions can be inferred from this systematic review on the effectiveness of school dental health education in children aged 6–12 years, with a follow-up of at least 6 months:
- Oral health-related knowledge improved in children
- Oral health-related practice behaviors such as frequency and duration of brushing improved. Use of fluoridated toothpaste increased. The frequency of eating candies reduced
- Mean plaque scores and mean proportion of sites with plaque reduced
- Gingival bleeding scores (interdental and sulcular bleeding) reduced
- Dentist-, teacher-, and peer-led educators were more effective than self-learning, in enhancing oral health-related knowledge and oral hygiene status. Peers were as effective as dentists in improving oral health behavior
- Activity-based education, oral health-related lessons in school curriculums, conventional lectures with audiovisual aids were found to be effective in improving oral health-related knowledge, attitude, and behavior.
Among the 18 studies included, only three RCTs had a low risk of bias. Each study in this review was carried out with the focus placed on a different outcome measure. There is a definite need for high-quality RCTs analyzing the effectiveness of school dental health education on specific oral health outcomes.
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Conflicts of interest
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Dr. P R Geetha Priya
Department of Pedodontics and Preventive Dentistry, KSR Institute of Dental Science and Research, Tiruchengode - 637 215, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]