effectiveness of oral health education programs a systematic review

Effectiveness of oral health education programs: A systematic review

Affiliations.

• 1 Department of Public Health Dentistry, Rama Dental College Hospital and Research Centre, Kanpur, Uttar Pradesh, India.
• 2 Department of Public Health Dentistry, DAPMRV Dental College Hospital and Research Centre, Bengaluru, Karnataka, India.
• PMID: 24778989
• PMCID: PMC4000911
• DOI: 10.4103/2231-0762.127810

In recent years, attention has been drawn toward assessing the effectiveness of oral health education programs. This is in line with demand for evidence based research and will help to inform policy makers on how to allocate resources. (1) Collect and collate all information on oral health education programs. (2) Assess the programs based on various coding criteria. (3) Assess effectiveness of oral health education programs on oral health status and knowledge, attitude and practice. A search of all published articles in Medline was done using the keywords "oral health education, dental health education, oral health promotion". The resulting titles and abstracts provided the basis for initial decisions and selection of articles. Out of the primary list of articles, a total number of 40 articles were selected as they fulfilled the following inclusion criteria: (1). Articles on oral health programs with an oral health education component (2). Articles published after the year 1990 (3). Articles published in English. The full text of the articles was then obtained from either the internet or libraries of dental research colleges and hospitals in and around Bangalore. A set of important variables were identified and grouped under five headings to make them amenable for coding. The coding variables were then described under various subheadings to allow us to compare the chosen articles. Oral health education is effective in improving the knowledge attitude and practice of oral health and in reducing plaque, bleeding on probing of the gingiva and caries increment. This study identifies a few important variables which contribute to the effectiveness of the programs. There is an indication in this review that the most successful oral health programs are labor intensive, involve significant others and has received funding and additional support. A balance between inputs and outputs and health care resources available will determine if the program can be recommended for general use.

Keywords: Effectiveness; oral health education; oral health promotion; programs; systematic review.

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Effectiveness of oral health education programs: A systematic review.

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Research Article

Effectiveness of the school-based oral health promotion programmes from preschool to high school: A systematic review

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Supervision, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

¶ ‡ These authors also contributed equally to this work.

Affiliations Department of Dental Public Health, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia, Dental and Oral Health Committee, Ministry of Health Republic of Indonesia, Jakarta, Indonesia

Contributed equally to this work with: Cornelia Melinda Adi Santoso, Amalia Ayu Zulfiana, Wahyuning Ratih Irmalia

Roles Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Affiliation Faculty of Public Health, University of Debrecen, Debrecen, Hungary

Roles Conceptualization, Data curation, Investigation, Methodology, Writing – review & editing

Affiliation Department of Dental Public Health, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia

Roles Data curation, Formal analysis, Methodology, Resources, Validation, Writing – review & editing

Roles Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Roles Investigation, Methodology, Resources, Writing – review & editing

Affiliation Department of Community Oral Health and Clinical Prevention, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia

Roles Data curation, Investigation, Methodology, Writing – review & editing

Roles Formal analysis, Validation, Writing – review & editing

Affiliation Postgraduate Program, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia

Roles Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing

Affiliation Indonesian Health Innovation and Collaboration Institute, Surabaya, Indonesia

• Taufan Bramantoro, 
• Cornelia Melinda Adi Santoso, 
• Ninuk Hariyani, 
• Dini Setyowati, 
• Amalia Ayu Zulfiana, 
• Nor Azlida Mohd Nor, 
• Attila Nagy, 
• Dyah Nawang Palupi Pratamawari, 
• Wahyuning Ratih Irmalia

• Published: August 11, 2021
• https://doi.org/10.1371/journal.pone.0256007
• Reader Comments

Schools offer an opportunity for oral health promotion in children and adolescents. The purpose of this study was to conduct a systematic review of the influence of school-based oral health promotion programmes on oral health knowledge (OHK), behaviours (OHB), attitude (OHA), status (OHS), and quality of life (OHRQoL) of children and adolescents.

A systematic search on the PubMed and Embase databases was conducted to identify eligible studies. The last search was done on April 24 th , 2020. The quality of the included studies was evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal tools.

Of the 997 articles identified, 31 articles were included in this review. Seven studies targeted students in preschools, seventeen in elementary schools, and seven in high schools. Most of these studies revealed positive outcomes. Some studies showed that the school-based oral health promotion programmes showed better OHK, OHB, OHS, and OHRQoL.

Positive results were obtained through oral health promotion programmes in schools, especially those involving children, teachers, and parents.

Citation: Bramantoro T, Santoso CMA, Hariyani N, Setyowati D, Zulfiana AA, Nor NAM, et al. (2021) Effectiveness of the school-based oral health promotion programmes from preschool to high school: A systematic review. PLoS ONE 16(8): e0256007. https://doi.org/10.1371/journal.pone.0256007

Editor: Susan R. Rittling, Forsyth Institute, UNITED STATES

Received: October 9, 2020; Accepted: July 28, 2021; Published: August 11, 2021

Copyright: © 2021 Bramantoro et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its S1 Checklist .

Funding: Yes - Universitas Airlangga.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Oral diseases pose a significant public health challenge, especially among children and adolescents. Around 60–90% of school children worldwide suffered from caries [ 1 ] and over 531 million children had caries of deciduous teeth [ 2 ]. Moreover, most children and adolescents showed gingivitis symptoms. Approximately 2% of youth had aggressive periodontitis, which might lead to premature tooth loss [ 1 ]. Oral diseases can negatively affect the quality of life, cause pain, limitation in oral functions, impaired nutrition, emotional stress, low self-esteem, and poor school attendance and performance [ 3 – 6 ]. They also impose a considerable economic burden as oral health treatments are often expensive. The treatment cost of dental caries alone for children was estimated to surpass the total budget of healthcare for children in low-income countries [ 7 ].

One of the efforts to improve the oral health of children and adolescents is by implementing school-based oral health promotion programmes, as proposed by the World Health Organisation (WHO) [ 8 ]. Schools serve as ideal settings for health promotion as they can reach most school-aged children and provide important networks to their families and communities [ 8 , 9 ]. School-based programs can also help increase children’s access to dental services, especially those from disadvantaged socio-economic backgrounds [ 10 ]. Moreover, school years cover the life period of childhood and adolescence, during which lifelong sustainable behaviours, beliefs, and attitudes related to health are established [ 8 ].

Several school-based oral health promotion programmes have been proposed, such as oral health education (OHE), tooth-brushing activities, the provision of fissure sealant, or other treatments [ 11 , 12 ]. While the effectiveness of the programs has been investigated, extensive evidence from a global viewpoint is still limited. Moreover, existing systematic reviews only focused on OHE [ 13 – 15 ]. A study providing a complete picture of the effectiveness of different kinds of oral health programmes at various school settings has not yet been available. This information is necessary to help the development of policies and the allocation of resources [ 13 ].

The objective of this study was to systematically review the effectiveness of the school-based oral health promotion programmes on oral health knowledge (OHK), behaviours (OHB), attitude (OHA), status (OHS), and quality of life (OHRQoL) of children and adolescents at preschools, elementary schools, and high schools.

Materials and methods

We systematically reviewed a series of published articles to answer the question–What is the significance of school-based oral health programmes on children and adolescents?

We chose the eligible articles according to the following criteria:

• All types of experimental studies (randomised controlled trials, quasi-experimental studies)
• Written in English;
• Study subjects were pre-schoolers, school children, and school adolescents;
• The intervention included all types of oral health intervention programmes conducted in preschools, elementary schools, or high schools;
• The outcome was OHK, OHB, OHA, OHS, and OHRQoL.

There was no limitation on publication year. Protocols, reviews, editorial letters, and commentaries were excluded.

Search strategy

PubMed and Embase were chosen as the database sources for our study, as they are considered to be the largest pharmaceutical and biomedical databases. The last search was on April 24 th , 2020. We used search terms related to oral health promotion, school, children, adolescents, randomised controlled trial, quasi-experimental study, OHK, OHB, OHA, OHRQoL, oral hygiene, and oral diseases, such as caries, periodontitis, and toothache.

Study selection, data extraction, quality assessment

Two independent reviewers performed the study selection, data extraction, and assessment of the quality of studies. After the records were obtained from the databases and duplicates were eliminated, the titles and abstracts were screened based on the selection criteria. A full-text review was then conducted to identify eligible studies. Data of the included studies was recorded (i.e., author, publication year, country, school setting, study population, interventions, comparator or control group, and results). The quality of the included studies was evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal tools for randomised controlled trials and quasi-experimental studies [ 16 ]. Any disagreements or ambiguities were resolved through discussion.

A total of 997 records were obtained from the databases. After removing duplicates and screening titles and abstracts, 37 articles remained for the full-text review. Of these, 31 studies met the eligibility criteria and were included in our review. The flow diagram of the study selection process can be seen in Fig 1 .

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https://doi.org/10.1371/journal.pone.0256007.g001

Characteristics of the studies

The included studies in this review were from four distinct regions, which were Asia, Europe, Africa, and America. The two largest proportions were from Asia (48%) and Europe (26%). Of the 31 studies included, four were from the United Kingdom; 3 of each were from the following countries: Iran, Brazil, China; 2 of each were from the following countries: India, Pakistan, Hong Kong, and Germany; and one of each was from the following countries: Myanmar, Thailand, Turkey, Switzerland, Sweden, Argentina, the United States, Nigeria, Tanzania, and Zimbabwe. The publication year varied from 1976 to 2019. Twenty-seven studies used randomised clinical trial designs, while four studies used quasi-experimental designs. Seven studies targeted the student populations in preschools, seventeen studies in elementary schools, and seven studies in high schools. All the included studies had sufficient methodological quality.

The effects of school-based oral health promotion programmes on children.

1 . Preschool children . Table 1 shows the summary of studies conducted in preschools. Intervention in all studies involved delivering oral health information to children. OHE for teachers was conducted in three studies [ 17 – 19 ], and for parents in two studies [ 18 , 19 ]. One study investigated the effectiveness of education through games and puppet shows [ 20 ], one study on the methods of education (either delivered by a teacher, a dentist, or role-playing dental residents) [ 21 ], one study on a specific tooth-brushing instruction [ 22 ], and one study on professional cross-brushing on first permanent molar surfaces [ 23 ]. Four studies included supervised tooth-brushing [ 17 – 19 , 23 ], two studies included the provision of fluoridated toothpaste and toothbrushes [ 17 , 18 ], and one study included the application of sodium fluoride phosphate [ 19 ] as part of their interventions.

https://doi.org/10.1371/journal.pone.0256007.t001

Delivering education through games and shows resulted in significantly better oral hygiene knowledge and skills than verbal instructions [ 20 ]. Children receiving a role-playing or drama mode of health education had significantly better oral hygiene than those without interventions or those receiving conventional education from a dentist or a trained teacher [ 21 ]. A specific instruction on oral hygiene is proven to significantly improve children’s oral hygiene [ 22 ]. The addition of educational programmes for parents, teachers, and children as a support to the preventive programmes (application of sodium fluoride phosphate, supervised toothbrushing with fluoride) led to the significant reductions in gingival index and plaque index scores and no changes in dmft and dmfs scores. Meanwhile, the group without the addition of educational programmes showed significant increases in gingival index, plaque index, dmft, and dmfs scores [ 19 ].

Compared to the control group, the group which received a school programme covering OHE for children, teachers, and parents, a supervised toothbrushing, and provision of fluoridated toothpaste and toothbrushes had 30.6% lower dmfs increment and a higher percentage of children brushing twice a day [ 18 ]. A similar programme, comprising of OHE for children and teachers, supervised tooth brushing, and the use of 1100 ppm fluoride dentifrice, also led to a significantly lower dmfs increment than the control group [ 17 ]. Among boys, the school-based supervised tooth-brushing programme that also covered professional cross-brushing on the first permanent molar surfaces led to 50% lower caries incidence density compared to the group receiving only the conventional tooth-brushing programme at school [ 23 ].

2 . Elementary school children . Table 2 shows the summary of studies conducted in elementary schools. Six studies focused on the effectiveness of the OHE programmes [ 11 , 24 – 28 ], one study on the importance of repetition and reinforcement [ 29 ], three studies on supervised toothbrushing [ 30 – 32 ], one study on tooth-brushing training [ 33 ], one study on school dental screening [ 34 ], and two studies on SOC-based interventions [ 35 , 36 ]. Besides involving education as part of the interventions, one study further included dietary counselling, the ingestion of fluoridated drinking water, and supervised toothbrushing [ 37 ], one study included a dental hospital tour programme [ 12 ], two studies included the provision of preventive and restorative care [ 12 , 37 ], three studies included the provision of oral hygiene aids [ 12 , 25 , 37 ], and two studies included competition activities [ 12 , 38 ].

https://doi.org/10.1371/journal.pone.0256007.t002

OHE that was incorporated into a school curriculum lowered the risk of developing new carious lesions by 35%. However, the effect was modified by parental socioeconomic status (SES) since high SES in the intervention group was associated with a 94% incidence rate ratio (IRR) reduction [ 24 ]. One-time teacher training on oral health did not significantly make differences in means of plaque and caries increment scores compared to the control group [ 26 ].

A programme consisting of OHE, teacher supports, and competition had a significant effect on OHK and an effect on OHRQoL [ 38 ]. Those with a comprehensive programme of OHE for children and parents, a contest, dental hospital tour, oral examination, provision of fluoride toothpaste, and preventive and curative treatments showed significantly lower DMFS increment mean score, untreated dental caries scores, higher reductions in plaque and sulcus bleeding scores, higher proportions in restoration and sealants, and showed changes towards good practices of oral care compared to the control group [ 12 ]. Children receiving a comprehensive needs-related oral hygiene training programme had significantly less gingival bleeding and plaque than the control group, whereas there were no differences found between the less comprehensive group and the control group [ 25 ]. Children with a comprehensive OHE targeted for them, their parents, and teachers had significantly better OHB, oral hygiene, and gingival health status than other groups. Children with OHE targeted for only them had significantly better OHB and oral hygiene than the control group, but there was no difference in terms of gingival health [ 11 ]. OHE via parents at home or the combination between parental involvement and class activities significantly improved oral hygiene and gingival health status compared to the control group. Meanwhile, no significant differences were observed between the class-work group and the control group [ 28 ].

Groups receiving OHE led by dentists, teachers, or peers had significantly better OHK, OHB, and oral hygiene status than self-learning or control groups. There were no significant differences in OHK and oral hygiene status between the three educator-led groups. Nevertheless, the peer-led group had a significantly better OHB than the teacher-led group. The self-learning group had a significantly better OHB than the control group, but there were no differences in OHK and oral hygiene status between them [ 27 ].

One-time OHE session had no significant effect on oral hygiene status, regardless of the educators. One-time dentist-led and peer-led OHE sessions significantly increased OHK and OHB related to gingivitis, but there was no significant change in OHB related to oral cancer. One-time teacher-led OHE session had no significant effects on OHK and OHB. However, six months after repeated and reinforced OHE (RR-OHE), the OHK, OHB, and oral hygiene status significantly improved, regardless of the educators. Although 12 months after the RR-OHE, the OHK of the dentist-led and peer-led groups significantly decreased, there were no significant changes in the OHK of the teacher-led group, as well as in the OHB and oral hygiene status of all the groups [ 29 ].

An individual tooth-brushing training programme significantly improved children’s brushing skills compared to the control group [ 33 ]. Children receiving a programme of tooth brushing with fluoride toothpaste supervised by teachers had a significantly less overall caries increment than those in the control group [ 31 ]. The provision of brushing sessions from trained teachers and curative dental care on-demand significantly reduced the plaque and gingival bleeding scores. The reductions of scores were comparable between chewing stick and toothbrush users [ 30 ]. One quasi-experimental study in Burma found that a school-based tooth-brushing programme had no significant effects on plaque and bleeding scores [ 32 ].

Children receiving a 2-month sense of coherence (SOC) intervention from trained teachers had significantly better OHRQoL and SOC improvement than the control group [ 35 ]. Another study also found that the SOC intervention group had significantly better OHRQoL, SOC, oral health beliefs, and gingival health than the control group [ 36 ]. The provision of five preventive and therapeutic measures significantly reduced caries increment compared to the provision of three preventive measures only [ 37 ]. School dental screening, followed by a series of communication to encourage parents into taking their children to a dentist significantly improved dental attendance [ 34 ].

3 . High school children . Table 3 shows the summary of studies conducted in high schools. Two studies investigated the effectiveness of education through posters or pamphlets [ 39 , 40 ]. Besides including education as part of the interventions, one study further explored the effectiveness of the provision of oral hygiene aids [ 41 ] and one study on the use of the different types of oral hygiene instruments [ 42 ]. There was one quasi-experimental study on the evaluation of the Natural Nashers programme in England [ 43 ], one study on the effectiveness of motivational interviewing [ 44 ], and one study on the involvement of dental hygienists at schools (education, open clinic, including fluoride varnish treatments) [ 45 ].

https://doi.org/10.1371/journal.pone.0256007.t003

A two-week display of educational posters concerning dental trauma significantly improved knowledge on dental trauma management [ 39 ]. Children receiving a loss-framed pamphlet intervention had better OHB, attitude, and intention to brush at a 2-week follow-up, less dental plaque, better OHRQOL, and gingival health at a 24-week follow-up compared to other groups [ 40 ]. The Natural Nashers programme generally reduced children’s plaque and gingival scores and improved their OHK and OHA compared to the control group [ 43 ]. Frequent teacher-led OHE sessions along with the provision of oral hygiene aids significantly reduced simplified oral hygiene index (OHI-S), plaque index (PI), and gingival index (GI) scores. In contrast, these scores significantly increased among those receiving infrequent dentist-led OHE sessions or those without intervention. There was no pre-post difference in mean DMF-S score for all groups [ 41 ].

Dental hygienists working in schools to deliver OHE and preventive measures (fluoride varnish treatments) impacted the incidence of enamel caries, but there was no effect on dentin caries. The intervention also improved OHK and oral hygiene, but there was no effect on attitudes toward tobacco [ 45 ]. Following OHE programme, children who were assigned to use toothbrushes had a higher gingivitis occurrence than those assigned to use chewing sticks in Nigeria [ 42 ]. Children receiving a motivational interviewing session had a lower number of new carious teeth, tended to reduce snacking, and increased their tooth-brushing frequency compared to those who received a traditional OHE. The inclusion of caries risk assessment into motivational interviewing provided additional effects only on oral hygiene, but not on the other outcomes [ 44 ].

This study was among the few to provide a comprehensive summary of the effectiveness of oral health promotion programmes in different school settings, ranging from preschools to high schools. One of the limitations was the restriction to take into account only the studies published in English, which might cause language bias. The search for conference proceedings, dissertations, and unpublished studies was not performed. It was challenging to summarise the findings of the studies due to high variabilities in the type and method of interventions, outcome measurements, and age of the samples. Thus, it was not feasible to provide a quantitative comparison, as reported by a previous review [ 15 ]. The strategy or design of oral health promotion programs rather varies across countries, depending on the financing and planning of the health and education sectors, the socioeconomic condition, culture, and the burden of oral diseases in the country [ 46 ].

According to WHO, schools are ideal settings to promote oral health. An individual spends most of their childhood and adolescence time at schools. This period is a critical stage of the life course, during which behavioural patterns are built, and that may indicate their future health status. Moreover, children can learn new information rapidly at this stage. The sooner habits are formed, the longer the impacts last. The messages conveyed in health promotion programmes can be repeated regularly during the school period [ 8 ]. Besides helping children to develop personal skills to choose a healthy lifestyle, oral health promotion may support the creation of a healthy school environment [ 8 , 47 , 48 ]. It is suggested that school-based oral health programs with multiple levels of influence may advance oral health equity [ 10 ].

One of the considerations in designing health education is the age group of the target population. In preschools, OHE sessions that were delivered through fun activities (i.e., via games, drama) were more effective in improving children’s oral hygiene [ 21 ], knowledge, and skills [ 20 ] than the traditional OHE. Activities designed to match children’s developmental levels and interests allow them to learn faster. Through playing, children’s motor and cognitive processes of learning progress more rapidly and at an advanced level [ 20 ]. Moreover, OHE that is given not only for the children but also for the teachers and parents, will encourage children to adopt a good OHB both at school and home. It was found that a comprehensive programme consisting of OHE sessions to children, teachers, and parents, and supervised tooth brushing with fluoride toothpaste, improved children’s OHB and OHS [ 17 – 19 ]. A professional cross-brushing on first permanent molar surfaces was also found to reduce caries [ 23 ].

Similarly, among elementary young students, a programme involving OHE for children, teachers, and parents, was the most effective [ 11 , 25 , 28 ]. In terms of educators, a dentist-led, a teacher-led, and a peer-led OHE were equally effective in improving OHK and oral hygiene status, but the peer-led OHE was better than the teacher-led OHE in enhancing OHB [ 27 ]. Another study, however, gave more emphasis to the importance of repetition and reinforcement in OHE than to the educators [ 29 ]. The effectiveness of combined approaches of OHE and other interventions, such as the provision of preventive and restorative care, fluoride toothpaste, fluoridated drinking water, a tour of a dental hospital, and competition were also observed in several studies [ 12 , 37 , 38 ]. School dental screening, followed by a series of communication to encourage parents into taking their children to the dentists was effective in improving dental attendance [ 34 ].

The positive impacts of tooth-brushing activities were well-demonstrated [ 30 , 31 , 33 ], except for a study in Myanmar that found no impacts following the programme. It was suggested that the factors behind these findings might be the teachers’ lack of skills in giving the instructions as they were not dental professionals, the fact that instructing some groups of young children were not that effective, and children under ten years’ lack of ability to brush [ 32 ]. Another type of intervention was a SOC-based intervention, which was found to improve OHRQoL, SOC [ 35 , 36 ], gingival health, and oral health beliefs [ 36 ]. SOC might influence health through physiological (less stress, less physical or biological effects), behavioural (selection of favorable behaviours), and emotional (better ability to cope with stress) pathways [ 36 ]. The effectiveness of this intervention was consistently reported in two studies from different countries (i.e., Brazil and Thailand) [ 35 , 36 ].

Among adolescents, the educational poster was effective in improving knowledge. Nonetheless, the follow-up period in this study was only two weeks [ 39 ]. In terms of message framing, loss framing was better than gain framing in encouraging OHB among Iranians. It is worth mentioning, however, that the effects of message framing may depend on the cultural backgrounds, varying between countries [ 40 ]. The importance of repetition and reinforcement in OHE, as well as the provision of oral hygiene aids, were also demonstrated [ 41 , 43 ]. Close monitoring was especially needed when unfamiliar oral hygiene procedures were introduced [ 42 ]. An intervention that is noted to be more effective than the traditional OHE for adolescents was motivational interviewing, which was a person-centered counseling strategy [ 44 ]. Meanwhile, a programme involving dental hygienists in Sweden was found to have limited impacts on caries incidence, knowledge, and attitudes, but improved adolescents’ interest in oral health. It was suggested that the participants had already had a favourable knowledge and attitude, and a low caries prevalence at baseline, making further improvement difficult to achieve [ 45 ].

In summary, most studies found that the intervention programmes brought positive outcomes, especially those involving OHE for children, teachers, and parents, supervised toothbrushing, and provision of fluoride toothpaste and toothbrush. The role of repetition and reinforcement in OHE is highlighted, which is possible through continuous programmes. It may also be beneficial to deliver OHE to pre-schoolers through fun activities. Besides the teacher, parental involvement plays a role in determining the success of the programmes, which may indicate the need to conduct oral health training for them. Future studies that assess the efficacy of home-based oral health promotion programs among children and adolescents will be useful to provide more evidence in developing integrated oral health promotion programmes.

Supporting information

S1 checklist. prisma 2009 checklist..

https://doi.org/10.1371/journal.pone.0256007.s001

Acknowledgments

We thank the librarian of the University of Adelaide for the help with the search strategy and the provision of full-text articles.

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Effectiveness of Oral Health Education Interventions on Oral Health Literacy Levels in Adults; A Systematic Review

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Background Oral health literacy within the construct of health literacy may be instrumental in decreasing oral health disparities and promoting oral health. Even though current research links oral health literacy to oral health knowledge and education, the impact of educational intervention on oral health literacy remains controversial. We aimed to identify effective health education interventions delivered with a focus on oral health literacy.

Methods An electronic systematic search in PubMed, Scopus, Web of Science and Cochrane library and gray literatue was performed for relevant studies (1995-2021). Experimental study designs of randomized controlled trials, non-randomized controlled trials, and quasi-experimental studies in which adults aged 18 years or older, male, or female (participants) trained under a health education intervention (intervention) were compared with those with no health education or within the usual care parameters (comparison). An assessment of oral health literacy levels (outcome) were included according to the PICO question. The search was conducted by applying filters for the title, abstract and methodological quality of the data, and English language. Study screening, extraction and critical appraisal was performed by two independent reviewers. Data was extracted from the included studies whereas a meta-analysis was not possible since findings were mostly presented as a narrative format.

Results Eight studies out of the 2783 potentially eligible articles met the selection criteria for this systematic review. The aim of interventions in these studies was 1) improving oral health literacy as the first outcome or 2) improving oral health behavior and oral health skills as the first outcome and assessing oral health literacy as the second outcome. The strength of evidence from the reviewed articles was high and there was an enormous heterogeneity in the study design, OHL measurement instruments and outcomes measure. Interventions were considerably effective in improving oral health literacy.

Conclusion Health education that is tailored to the needs and addresses patients’ barrier to care can improve their oral health literacy level.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Not Applicable

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

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• Research article
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• Published: 02 January 2021

Effectiveness of oral health education on 8- to 10-year-old school children in rural areas of the Magway Region, Myanmar

• Kyu Kyu Swe 1 ,
• Aung Kyaw Soe 2 ,
• Saw Htun Aung 3 &
• Htin Zaw Soe 4  

BMC Oral Health volume  21 , Article number:  2 ( 2021 ) Cite this article

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Oral diseases are common and widespread around the world. The most common oral diseases are preventable, and early onset is reversible. Myanmar faces many challenges in rendering oral health services, because approximately 70% of the total population resides in rural areas. These relate to the availability and accessibility of oral health services. Therefore, oral health education is one key element to prevent oral diseases and to promote oral health.

A quasi-experimental study was carried out at Basic Education Middle Schools in rural areas of Magway Township to study the effectiveness of oral health education on the knowledge and behavior of 8- to 10-year-old school children. A total of 220 school children, 110 from intervention schools and 110 from control schools, participated in this study from 2015 to 2017. Data were collected before and after intervention in the two groups by using a self-administered questionnaire. Tooth brushing method data were collected by direct observation with a checklist. Oral health education was provided at eight weekly intervals for 1 year. At one and a half years, third-time data collection was done on the intervention group to assess retention. Chi-square test, two samples t -test and one-way repeated measure ANOVA were used for data analysis. The study was approved by the Institutional Review Board of the University of Public Health in Yangon, Myanmar.

There were significant differences between the two groups in four out of five knowledge questions ( p  < 0.05) and all behavior questions ( p  < 0.001) after intervention. A positive effect of oral health education for a period of 45 min at eight weekly intervals for 1 year was found in the intervention group. The intervention had a significant effect on the sustainability of the correct knowledge and behavior of the intervention group although the education session was stopped for 6 months ( p  < 0.001). Their mean knowledge and behavioral scores at three different points in time were (2.45 ± 1.12 and1.56 ± 0.90) at baseline, (3.79 ± 1.12 and 3.60 ± 1.21) at 1 year after education and (4.07 ± 0.98 and 3.24 ± 1.31) at 6 months after cessation of education, respectively.

Conclusions

Repeated oral health education was effective in promoting and sustaining oral health knowledge and behavior.

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Introduction

Dental caries, periodontal diseases, and oral cancers are common and affect men, women, and children. Over 3.5 billion people suffer from oral diseases which continued to threaten the health, well-being, the social and economic productivity of millions of people throughout the developing world. Oral diseases are becoming global issues and should be considered as public health importance [ 1 ]. Many behavioral and social characteristics like eating habits, oral health knowledge, practices, availability, and accessibility of oral health services are some of the issues concerning oral health. Behavioral interventions or education to the individual about how to maintain the pleasant condition of a person’s mouth or how to control the mental and social problems that affect the dental health behavior are required to reduce the oral health problems and to promote oral health [ 2 ]. Personal habits like poor oral hygiene, smoking, alcohol drinking, and eating an unhealthy diet are modifiable risk factors that affect the health of gum. Periodontal disease is one of the common oral diseases and can be prevented by maintaining the individual’s good oral health behavior like tooth cleaning with a toothbrush and toothpaste, inter-dental cleaning with dental floss, and other oral hygiene measures [ 3 ]. Health education activities have a powerful effect on the behavioral characteristics of the individual like oral health knowledge, attitude, practice, eating habits, tooth decay, periodontal health, and oral hygiene [ 4 ]. It is estimated that common oral diseases such as tooth decay and gum diseases affect nearly 80% of children who are at school-going age across the globe [ 5 ]. As the lifestyle and behavioral patterns of the people are changing rapidly, these become favorable to the onset of oral diseases. Oral diseases are linked by common preventable risk factors including eating a lot of sweet food, excessive use of tobacco, high alcohol intake [ 5 ]. In Myanmar, knowledge, attitudes and practices on oral health among rural populations were low [ 6 ], and oral health status among 5-year- and 12-year- old children was not satisfactory [ 7 ]. Dental public health care services are required more than before to reduce the high level of dental caries of the 12–13-year age group in Myanmar [ 8 ]. Three-month oral health education had a positive effect on the total knowledge, attitude, and practice (KAP) scores and also plaque scores of the study group of 12-year-old Myanmar school children [ 9 ]. It is estimated that the dentist-to-population ratio in Myanmar is 1:16,000 and the dental professions are taking the responsibility to give oral health care to the whole population [ 10 ]. Besides, there are no dental therapists and dental hygienists. Hence, the Myanmar population has a low opportunity to take sufficient oral health education because of an inadequate dentist population ratio [ 10 ]. To assess the magnitude of the preventive task, it is necessary to know the oral health situation of school children. Approximately 70% of the total population in Myanmar resides in rural areas. These relate to the availability and accessibility of oral health services, and as a consequence, this may have a challenge in rendering oral health services throughout the country. Therefore, oral health education plays a pivotal role in solving oral health problems, preventing common oral diseases, and promoting the oral health of the rural population. The World Health Organization suggested that school oral health promotion activities are effective in preventing oral diseases and promoting oral health among school children [ 4 ]. In Myanmar, oral health education programs are implemented and oral health services are provided to school children yearly by a dental surgeon as part of the functions of the school health team, however, these oral health programs are not strengthened [ 10 ]. Children aged 8–10 years among school children are suitable for identifying oral health situation and for providing primary prevention because they have mixed dentition, both primary teeth and permanent teeth. Hence, the current study was planned to obtain updated information on the oral health situation of school children in Myanmar and supported the role of educational programs in promoting oral health and preventing common oral diseases at an early stage in children. Furthermore, this study was an important foundation to stimulate the development of oral health awareness among the community.

Study design, area, population and period

A quasi-experimental nonequivalent control group study design was carried out in two randomly selected Basic Education Middle Schools (BEMSs) in a rural area of Magway Township from 2015 to 2017 to determine the effectiveness of oral health education on oral health knowledge and behavior of 8- to 10-year-old school children. A total of 220 school children, 110 from intervention school and 110 from control school, participated in this study. 8- to 10-year-old healthy children who were attending the selected middle schools were included, and those who were unwilling to participate in the study and not present on the day of data collection were excluded.

Sample size and sampling procedure

The sample size was calculated by n = (z α  + z 1-β ) 2 (p c q c  + p e q e ) /d 2  + 2/d + 2 = (1.96 + 1.0364) 2 (0.47 × 0.53 + 0.69 × 0.31)/(0.22) 2  + 2/(0.22) + 2 with 85% power and 5% type one error rate. A drop-out rate of 10% for each group was considered. The hypothesized proportions of twice-daily tooth brushing practice after lecturing in the control group and intervention groups were 47% and 69%, respectively [ 11 ]. The sample size for each group was 110 and the total sample size was 220. Prior to conducting the study, permission was obtained from the Township Educational Officer and Township Medical Officer. Out of a total of 47 BEMSs in Magway Township, there were only four in urban areas. To obtain the required sample, in the first stage, two BEMSs from rural areas and in the second stage, 110 students from each school, were randomly selected.

Data collection method

The research question was developed by the author based on the inputs obtained from various scientific articles and face validation was done by an independent subject expert not involved in the study following which the content validity was assessed by three experienced pediatric dental specialists in the field. A pilot survey was conducted on 30 students of the same age in one of the schools in the study area and revised it, as suggested. Attention was paid to ensure the clarity of interpretation, choice of words, and meaningfulness of the questionnaire in order to be easily apprehended by children of this age. A reliability analysis was carried out and cronbach’s alpha was 0.75. It comprised of five knowledge and five behavioral questions. The outcome was reported as correct/incorrect response to knowledge questions and proper/improper response to behavior questions. Oral health education (OHE) was given to the intervention group only at eight weekly intervals for 1 year. An oral health education session for a period of approximately 45 min was prepared on key oral health messages, such as the structure and functions of teeth, types of dentition, causes and prevention of common oral diseases, importance of brushing teeth twice daily, proper tooth brushing technique, importance of regular dental visits. Chalk and blackboard, dent form model, charts, toothbrush and toothpaste were used as oral health education aids. The proper tooth brushing technique (modified bass technique) was demonstrated on a dent form model. After completion of the whole study, an oral health education session was also conducted for the children in the control group. A visit was paid to each school before data collection to discuss the research procedure with the school headmaster, and written informed consent was obtained from the caregivers. At the beginning of the study, the baseline data were collected in both groups by using a self-administered questionnaire except for one behavioral question that is the ‘method of tooth brushing’. It was collected by direct observation with a checklist. The questionnaires, originally constructed in English and translated into Burmese (Myanmar language), were given and completed by the children under the supervision of the research team members with the help of class teachers to ensure that all questions were answered. Interpersonal communications were not allowed during answering. After a 1-year period from the collection of the baseline data, post-intervention data were collected in the two groups using the same questionnaire as at baseline. After 1 year and 6 months, retention of proper knowledge and behavior were determined in the intervention group only. Toothbrush and toothpaste were provided to all participant children in both groups before and after the intervention. The scoring system and operational definitions are shown in ‘Additional file 1 : Table S1’, ‘Additional file 1 : Table S2’ and ‘Additional file 1 : Table S3’.

Data management and analysis

The data were checked for completeness and consistency daily and analyzed by using SPSS version 16.0. Descriptive statistics were computed for all variables. Differences between intervention and control groups responded to the knowledge and behavior questions by correct answers before and after intervention were calculated. The net effect of the intervention program was estimated by subtracting the percentage change pre- to post-intervention in control students from that for the intervention students. One-way repeated measure ANOVA with Bonferroni correction (post hoc test) was used to determine the retention of proper knowledge and behavior on oral health at three different points in time, at baseline, at 1 year after OHE, at 6 months after cessation of OHE, in students who received OHE at eight weekly intervals for 1 year. The level of statistical significance for all tests was set at 0.05.

Table 1 shows the demographic characteristics of the school children in the two groups at baseline and 1 year after oral health education. The age distribution from 8 to 10 years before and after intervention was 19.1%, 58.2%, and 22.7% in the intervention group and 14.6%, 20.9%, and 64.5% in the control group, respectively. According to the gender, boy and girl distribution before and after intervention were 43.6% and 56.4% in the intervention group and 51.8% and 48.2% in the control group, respectively. Table 2 shows correct knowledge and proper behavior on oral health among school children between the two groups. In the intervention group, the correct proportion was higher after intervention than before regarding all knowledge questions, and in the control group, the correct response rates before and after intervention were nearly the same except for the main cause of tooth decay and gum diseases. In comparing the two groups before intervention, approximately 16% of intervention students and 12% of control students gave the true answer with regard to the main cause of tooth decay. The majority of school children in both groups gave the true answer with regard to behavior about devices used in tooth brushing before as well as after intervention. Before intervention, approximately 7% of school children in the intervention group and nearly 5% of school children in the control group used dental floss to remove food debris stuck between the teeth. Regarding the pattern of tooth brushing, nearly 5% in the intervention group and only 3% in the control group brushed their teeth according to the recommended method. Before intervention, no significant differences were found between the two groups in four out of five knowledge questions and in three out of five behavior questions ( p  > 0.05). These were knowledge about the main cause of gum diseases and behavior regarding the frequency and occasion of tooth brushing ( p  < 0.05). After intervention, significant differences were found between the two groups in four out of five knowledge questions and in all behavior questions ( p  < 0.05). The only knowledge question that showed no significant differences between the two groups was ‘foods that can cause dental caries’ ( p  > 0.05). Table 3 shows percentage changes in response to knowledge and behavior on oral health before and after intervention between the two groups, and a positive effect of oral health education for a period of 45 min at eight weekly intervals for 1 year was noted. Table 4 shows the mean knowledge and behavior scores on oral health in the intervention group only. There were 2.45 ± 1.12, 3.79 ± 1.12, and 4.07 ± 0.98 and 1.56 ± 0.90, 3.60 ± 1.21, and 3.24 ± 1.31 at baseline, 1 year after OHE and 6 months after cessation of OHE, respectively. A statistically significant effect of eight weekly intervals for 1-year OHE was found on total knowledge and behavior scores in the intervention group ( p  < 0.001). Table 5 shows highly significant differences between two different points in time (baseline vs 1 year after OHE and baseline vs 6 months after cessation of OHE) regarding total knowledge and behavior scores ( p  < 0.001) and no significant difference between 1 year after OHE and 6 months after cessation of OHE ( p  = 0.159) in knowledge and ( p  = 0.060) in behavior. It was shown that the school children in the intervention group had the ability to maintain the correct knowledge and behavior related to oral health even though the OHE session was stopped for 6 months.

At the beginning of the study, the minimum age of the school children in both groups was 8 years and the maximum age was 10 years. The duration of the study lasted for one and a half years. There was no attrition in either group after intervention. On the other hand, some oral health intervention studies reported that there was drop-out of the participants when assessing the effect of OHE on oral health knowledge and behavior in Wuhan City of China [ 12 ], Tehran of Iran [ 13 ], and Riyadh of Saudi Arabia [ 14 ] which are a contrast to the findings of the present study. The result of China documented that the drop-out rate is a small amount and there is no problem in assessing the outcomes [ 12 ]. The correct response rates were more or less the same between the two groups before intervention in almost all of the knowledge questions ( p  > 0.05) except one question concerning the main cause of gum diseases, in which the correct answer rate of control students was significantly greater than that of intervention students ( p  < 0.001). It may be possible that even in the absence of health education, some children might have tried to search and obtain correct answers and gain knowledge through various sources, such as social media, TV, toothpaste advertisements, etc. After a 1-year intervention, significant differences were observed between the two groups in almost all knowledge questions ( p  < 0.05) except one question concerning foods that can cause dental caries ( p  > 0.05). This may be attributed to the school co-curriculum wherein some general information about the unhealthy effect of sweetened foods and drinks on teeth is taught to the school children in the primary classes. No significant differences were found between the two groups before OHE in three out of five behavioral questions ( p  > 0.05), and with regard to frequency and occasion of tooth brushing, significantly more of the students in the intervention group brushed their teeth twice per day and cleaned their teeth in the morning before breakfast and at night before going to bed compared with their control counterparts ( p  < 0.05). This might be due to unequal accessibility and availability of dental health services among the students. However, the proportion of correct behavior was significantly higher in all behavioral items for the intervention group following OHE ( p  < 0.001). This may be because of the methods applied and the materials used in the OHE session. The results of this study are seemed to reaffirm the findings of a study conducted with samples of 1661 female primary school children in Saudi Arabia who are from 6 to 8 years old to assess the effectiveness of oral health education intervention on oral health knowledge and behavior in which there was a significant improvement in all knowledge and behavior questions after intervention ( p  < 0.001) [ 14 ]. A study conducted in China to assess the effect of school-based OHE intervention on children, mothers and school teachers reported that children in the experimental group are more than those in the control group regarding the adoption of regular oral health behavior such as tooth brushing at least twice a day, dental visits annually, use of fluoride toothpaste and less frequent consumption of cakes/biscuits which supports the present study [ 12 ]. The present study is similar to one study in Bangladesh which showed that overall significant improvement was observed in almost all the indicators of knowledge and behavior after OHE compared to before ( p  < 0.001) [ 15 ]. When the present study assessed the percentage changes in response to knowledge and behavior on oral health before and after intervention between the two groups, a positive net effect of intervention was observed. The findings of the present study were in accordance with an intervention study conducted in Ireland wherein an oral health intervention for 6 weeks was performed among primary school children aged 7–12 years and positive changes were observed in oral health knowledge and behaviors [ 16 ]. Other studies performed in Chandigarh, Northern India [ 17 ], Tanzania [ 18 ] and Greece [ 19 ] reported that school-based OHE programs significantly improved knowledge and behavior. In a study performed in Kyauktan and Tharkayta Townships of the Yangon Region in Myanmar, significant improvement of knowledge, attitude and practice scores on oral hygiene was found between the baseline and 3 months after intervention among 12-year-old school children [ 9 ]. In India, a systematic review was conducted in a total of 40 articles to assess the effectiveness of oral health education programs on knowledge, attitude, practice and oral health status. In their review, they reported that oral health education was effective in improving knowledge on oral health in all studies; however, with regard to practice outcome, thirteen studies were found to be effective and two studies were not effective [ 20 ]. Another systematic review was conducted in a total of 18 articles to evaluate the effectiveness of school dental health education on oral health status, oral health-related knowledge and practice of 6 to 12-year-old children in which OHE had a positive impact on oral health status, knowledge and practice, such as frequency and duration of brushing, use of fluoride toothpaste [ 21 ]. These disparities might be due to differences in the target age group, methods and duration of the oral health education program and background characteristics of the study subjects. The present study showed that the eight weekly oral health educations for 1 year had a statistically significant effect on total knowledge and behavior scores of the oral health among the school children in the intervention group even though stopping of the education program for 6 months after 1-year OHE, and it was found that the students in the intervention group had sustainability on positive knowledge and behavior ( p  < 0.001). Similar to the present study, a study performed in India documented that reinforcement through repeated OHE sessions in the intervention schools resulted in significant improvement of oral health knowledge and practice even after cessation of the program [ 22 ]. Another study performed in northwest England reported that schools with more frequent exposures to the program had better scores than schools with fewer exposures [ 23 ]. A study in Karachi of Pakistan showed that one-time teacher-led OHE was ineffective compared to repeated and reinforced OHE in improving oral health knowledge, behavior and oral hygiene status [ 24 ]. Hence, it can be suggested that OHE is a feasible way to reach out to all sections of the children whether rich or poor, near or far, developed or underdeveloped. The provision of OHE services improves the oral health of the students which will be passed on to their family members and neighboring community and has had an effect on the whole community of the country. The results of this study can be generalized to school children in Myanmar because schools and students are randomly selected in collecting the data for measuring the outcome variables. However, the study procedure had some limitations. Teachers and caregivers were not included in the OHE sessions, which might have affected the effectiveness of OHE since they have daily contact with the students and may be essential for the achievement of long-term benefits.

In conclusion, the results indicated that repeated oral health education comprising lecturing with interactive talk, demonstration and supervised tooth brushing methods at eight weekly intervals for 1 year was found to be effective in promoting and sustaining correct knowledge and behavior among school children.

Availability of data and materials

Data are available upon request by coauthors and reviewers.

Abbreviations

Statistical Package for Social Science

• Oral health education

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Acknowledgements

We would like to mention our heartfelt thanks to the Township Medical Officer and Township Educational Officer in Magway Township, Magway Region, Myanmar for their kind permission to conduct this study and school children who actively participated. We also thank Prof. Nay Soe Maung, Rector (retired), University of Public Health, Yangon (Myanmar), Prof. Khay Mar Mya, Rector (retired), University of Public Health, Yangon (Myanmar), Dr. Soe Min Naing, Associate Professor, Department of Preventive and Social Medicine, University of Medicine, Magway (Myanmar) for their kind assistance and advice.

The author (s) received no specific funding for this research project.

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University of Community Health, Magway, Myanmar

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KKS is Principal Investigator as well as first author and developed research protocol, led the research team in data collection, performed data management and report writing. She is also a corresponding author of this original research article. AKS is the second author and observed the tooth brushing method of the school children with the checklist and issued the results. SHA is the third author and gave the advice to conduct the present study and helped in the literature search. HZS is the fourth author and gave guidance and constructive criticism throughout the study. All authors read and approved the final manuscript.

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Ethical clearance was obtained from the Institutional Review Board of the University of Public Health, Yangon, Myanmar. Written informed consent was obtained from the caregivers, and verbal consent was obtained from the school principal and class teachers. Written informed assent was obtained from all participant school children.

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Supplementary information

Additional file 1..

Table S1. Scoring system for knowledge questions on oral health. Table S2. Scoring system for behavioral questions on oral health. Table S3. Operational definitions for the variables in the study.

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Swe, K.K., Soe, A.K., Aung, S.H. et al. Effectiveness of oral health education on 8- to 10-year-old school children in rural areas of the Magway Region, Myanmar. BMC Oral Health 21 , 2 (2021). https://doi.org/10.1186/s12903-020-01368-0

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Received : 19 January 2020

Accepted : 15 December 2020

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DOI : https://doi.org/10.1186/s12903-020-01368-0

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• Oral health knowledge and behavior

BMC Oral Health

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Effectiveness of oral health education programs: A systematic review.

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• Harikiran AG 2

Journal of International Society of Preventive & Community Dentistry , 01 Jul 2013 , 3(2): 103-115 https://doi.org/10.4103/2231-0762.127810   PMID: 24778989  PMCID: PMC4000911

Abstract 

Free full text , effectiveness of oral health education programs: a systematic review, priya devadas nakre.

Department of Public Health Dentistry, Rama Dental College Hospital and Research Centre, Kanpur, Uttar Pradesh, India

A. G. Harikiran

1 Department of Public Health Dentistry, DAPMRV Dental College Hospital and Research Centre, Bengaluru, Karnataka, India

In recent years, attention has been drawn toward assessing the effectiveness of oral health education programs. This is in line with demand for evidence based research and will help to inform policy makers on how to allocate resources. (1) Collect and collate all information on oral health education programs. (2) Assess the programs based on various coding criteria. (3) Assess effectiveness of oral health education programs on oral health status and knowledge, attitude and practice. A search of all published articles in Medline was done using the keywords “oral health education, dental health education, oral health promotion”. The resulting titles and abstracts provided the basis for initial decisions and selection of articles. Out of the primary list of articles, a total number of 40 articles were selected as they fulfilled the following inclusion criteria: (1). Articles on oral health programs with an oral health education component (2). Articles published after the year 1990 (3). Articles published in English. The full text of the articles was then obtained from either the internet or libraries of dental research colleges and hospitals in and around Bangalore. A set of important variables were identified and grouped under five headings to make them amenable for coding. The coding variables were then described under various subheadings to allow us to compare the chosen articles. Oral health education is effective in improving the knowledge attitude and practice of oral health and in reducing plaque, bleeding on probing of the gingiva and caries increment. This study identifies a few important variables which contribute to the effectiveness of the programs. There is an indication in this review that the most successful oral health programs are labor intensive, involve significant others and has received funding and additional support. A balance between inputs and outputs and health care resources available will determine if the program can be recommended for general use.

INTRODUCTION

Oral diseases are one of the most prevalent conditions in the world and are largely preventable.

Dental caries affects 60-90% of school children and most adults in industrialized countries; it is increasingly prevalent in developing countries and highly prevalent in some Asian and Latin American countries.[ 1 ] Periodontal disease is prevalent globally, with severe periodontitis in 5-15% of most populations; clearly associated with diabetes and compromised immunity. According to the National Oral Health Survey, in India dental caries is prevalent among 63.1% of 15-year-old and as much as 80.2% among adults in the age group of 35-44 years. Periodontal diseases are prevalent in 67.7% of 15-year-olds and as much as 89.6% of 35-44 year olds.[ 2 ] Edentulism is high in some countries among adults ages 65 and older. Oral cancer is the 8 th most common cancer world-wide; 3 rd most common in South-central Asia and twice as prevalent in less developed countries than in more developed countries and has shown a sharp increase in incidence rates in some European and other industrialized countries.

Dental trauma in industrialized countries ranges from 16% to 40% among 6-year-olds and from 4% to 33% among 12-14-year-olds; in some Latin American countries, about 15% of schoolchildren; in the Middle East, about 5-12% among 6-12-year-olds.

Oral diseases restrict activities in school, at work and at home causing millions of school and work hours to be lost each year the world over. Moreover, the psychosocial impact of these diseases often significantly diminishes quality of life.[ 1 ]

Prevention of disease, disability and suffering should be a primary goal of any society that hopes to provide a decent quality of life for its people. Prevention on the community or population based level is the most cost effective approach and has the greatest impact on a community or population, whether it is a school, neighborhood, or nation. An effective community prevention program is a planned procedure that prevents the onset of a disease among a group of individuals. Many different approaches to preventing dental diseases exist and the most cost-effective method is health education.

Health education is any combination of learning experiences designed to facilitate voluntary actions conducive to health. These actions or behaviors may be on the part of individuals, families, institutions or communities. Thus the scope of health education may include educational interventions for children, parents, policy makers, or health care providers. It has been well-documented in dentistry and other health areas that correct health information or knowledge alone does not necessarily lead to desirable health behaviors. However knowledge gained may serve as a tool to empower population groups with accurate information about health and health care technologies, enabling them to take action to protect their health.

Treatments for all oral diseases are available generally in industrialized and more developed countries, but may be expensive and not always accessible, many individuals lack access to care, as well as insurance or finances to pay for care. In less developed and poor countries, appropriate treatments are generally not available at all. Diseases of the craniofacial complex greatly affect an individual's quality of life with nutritional, functional and psychosocial consequences. Further, oral diseases are a costly economic burden for individuals, families and nations-both industrialized and developing.

The goal of oral health education is to improve knowledge, which may lead to adoption of favorable oral health behaviors that contribute to better oral health. A basic oral health care program introduced by World Health Organization for less industrialized countries includes oral health education and emphasizes on the integration of health education with other oral health activities such as provision of preventive, restorative and emergency dental care.

In recent years, attention has been drawn toward assessing the effectiveness of oral health education programs. This is in line with demand for evidence based research and will help to inform policy makers on how to allocate resources. A number of systematic reviews have been conducted on the available evidence. These have shown that oral health education can be effective in increasing knowledge in the short term and to some extent, behavior such as tooth brushing and healthy eating.

This review is an addition to the published literature on dental health education, because systematic reviews are only as good as the basic research underpinning them and previous reviews have unanimously pointed out the paucity of good quality studies in this field.

The aim of this paper is to collect and collate information on effectiveness of oral health education programs and to pool data from the studies, which were deemed effective in order to list variables associated and which may have contributed to the success of these programs.

Collect and collate all information on oral health education programs

Assess the programs based on various coding criteria

Assess effectiveness of these oral health education programs on oral health status and knowledge, attitude and practice.

MATERIALS AND METHODS

A search of all published articles in Medline was done using the keywords “oral health education, dental health education, oral health promotion.” The resulting titles and abstracts provided the basis for initial decisions and selection of articles. Out of the primary list of articles, a total number of 40 articles were selected as they fulfilled the following inclusion criteria:

Articles on oral health programs with an oral health education component

Articles published after the year 1990

Articles published in English.

The full text of the articles was then obtained from either the internet or libraries of Dental Research Colleges and Hospitals in and around Bangalore. A set of important variables were identified and grouped under five headings to make them amenable for coding. The coding variables were then described under various subheadings to allow us to compare the chosen articles [ Table 1 ].

Coding variables

The studies were reviewed based on the mentioned variables and results were described and summarized under the same.

Thirteen studies[ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ] showed their effectiveness in terms of change in knowledge, the sample size ranged from 42 to 2678 participants. The oral health education group ranged from 14 to 1339. The target population was mainly schools children and care givers of children and the elderly. The follow-up period ranged from 6 weeks to 6 years.

Six studies targeted a population in the age group 7-13 years old, two studies in the elderly, one study for care givers, one in children 3 years old, one in the infants, one targeted all age groups and one was done in children where the age group was not mentioned. One study was done in the low socio economic status population, one included all socio-economic status groups and the rest did not mention the socio-economic status of the population. All the studies were done involving both genders except one which was done in an orphanage exclusively for girls. The education level of the oral health education target group ranged from primary to professional education. One study was done in an uneducated population of 7-11-year-old orphan girls.

Oral health education was delivered in all studies by professionals – dentists or dental hygienists. 10 studies were done in a city, one in a town, one in a rural area. In seven studies Oral health education was given in a school, two in nursing homes, one in a health center, one in an orphanage, one in a club, one was a campaign and the setting was not mentioned. Nine studies had received funding and the rest did not mention. Eight studies received additional support – in the form of voluntary organizations, Non-Governmental Organizations, local government etc.

All studies delivered oral health education in the form of instructions, in addition to instructions four studies distributed written matter regarding oral health to participants and four studies demonstrated oral hygiene methods to the participants, three studies used videos to educate the participants, one study done by Vachirarojpisan et al .[ 15 ] had group discussions and two studies had campaigns. Twelve studies provided education in groups whereas one to individuals and the training time ranged from 20 min to 2 h. Six studies did not mention the training time. Health promotion was done in four studies. An incentive was given only in one study by Freil et al .[ 7 ] where a smile contest was held at the end of the study. No study had policy backing. Other than oral health education only one study Tai et al .[ 5 ] provided preventive and curative intervention, one study by Freitas et al .[ 8 ] provided oral prophylaxis to the participants [ Table 2 ].

Intervention descriptors for knowledge outcome

All studies were effective in improving the knowledge. Eight studies did not give a quantitative estimate of the improvement, 85% improvement was seen in a case control study done by Buischi et al .,[ 3 ] conducted in 126 children aged 13 years in a school setting for a period of 3 years, oral health education was given in the form of instructions to groups of children [ Table 3 ].

Effectiveness of studies

Four studies[ 5 , 6 , 9 , 16 ] evaluated their effectiveness through change in attitude. The sample size ranged from 198 to 458. The number of subjects in case group ranged from 99 to 458 participants with an average of 239 and in the control group 99-215. Two studies targeted adolescents and two elderly. Follow-up period ranged from 6 months to 6 years. Three studies were case control and one was experimental [ Table 4 ].

Design variables for attitude outcome

Target population in two studies for oral health education was adolescents, one in care givers and one in older migrant adults. Socio-economic status was not mentioned. Education level of the oral health education target group was secondary in the adolescents and not mentioned in the other two studies.

The oral health education in all studies was delivered by professionals. The setting was schools in two studies, one in a nursing home and one in clubs. Funding was provided in three studies. Additional support was given in two studies.

Oral health education in three studies were in the form of instructions, written literature, one study even had demonstrations and one used a video to educate the participants. One study educated the participants by delivering lectures. All studies educated the population in groups. Training time varied from 25 min to 1 h. Health promotion was present in studies which involved adolescents. One study by Tai et al .[ 5 ] provided preventive and curative intervention too.

Two studies did not quantitatively give their results all showed significant improvement, one study showed 74% improvement, one study showed 17% improvement in the attitude of the subjects [ Table 3 ].

Fifteen studies[ 3 , 5 , 7 , 8 , 9 , 10 , 11 , 13 , 14 , 15 , 17 , 18 , 19 , 20 , 21 ] evaluated their effectiveness through change in practices related to oral health. The sample ranged from 42 to 3967 participants, the case group ranged from 14 to 3291 participants. Four studies were done in adolescents, four studies were targeted at mothers and caregivers of infants, one study in the elderly, one among all age groups and five in children. The follow-up period ranged from 6 weeks to 6 months.

The target population was adolescents in four studies, three studies in infants, one study in the elderly, one in migrant adults, one for all age groups and five in children. Low socio-economic status population was taken in studies done by Kowash et al .,[ 18 ] Freitas-Fernandes et al .,[ 8 ] and Azogui-Lévy et al .[ 20 ]

Oral health education in all the studies was provided by professionals. Eight studies used the school as a setting, one was done at homes of the participants and two studies were done at health centers, one at an orphanage, one at clubs and one at nursing homes. Funding was provided in nine studies. Additional support was provided in nine studies.

The studies either educated the participants by giving instructions, showing videos, demonstrating oral hygiene technique or by distributing written literature. Some studies used a combination of these methods; a study by Mariño et al .[ 9 ] used lectures as a medium of education. In studies by Friel et al .[ 7 ] and Peng et al .[ 11 ] campaigns were done. Vachirarojpisan et al .[ 15 ] held group discussions for the participants. Education was imparted in groups in all studies except in Kowash et al .[ 18 ] and Freitas-Fernandes et al .[ 8 ] The training time ranged from 15 min to 11/2 h. Health promotion was provided in six studies. Incentives were provided in the study by Friel et al .[ 7 ] were a smile contest was held at the end of the program and in the study by Azogui-Lévy et al .[ 20 ] where reimbursement was provided for participants who visited the dentist. Vanobbergen et al .[ 21 ] study was based on the Ottawa Charter. Tai et al .[ 5 ] provided preventive and curative care, Freitas-Fernandes et al .[ 8 ] provided oral prophylaxis for the participants and Azogui-Lévy et al .[ 20 ] provided curative care [ Table 5 ].

Intervention descriptors for practice outcome

Thirteen studies were found to be effective and two studies were not effective. Only five studies gave a quantitative estimate of the effectiveness. Of this Rong et al .[ 14 ] showed 45% improvement in practice outcome and Petersen et al .[ 13 ] showed 7% improvement. Other studies showed 30%, 35% and 20% improvement respectively [ Table 3 ].

Seven studies[ 10 , 18 , 22 , 23 , 24 , 25 , 26 ] evaluated the change in gingival health. The sample size ranged from 68 to 283. The case group ranged from 39 to 228 participants with an average of 112. Four studies were conducted in children and adolescents, the age of the participants ranged from 5 to 15 years in one study to 11-14 years in another study. One study was done for caregivers of infants, two in adults and one in the elderly. The follow-up period ranged from 1 month in two studies to 3 years in a study done by Kowash et al .[ 18 ] Two studies were done in low socio-economic status participants.

One study targeted infants, one Chilean refugee, one adult, one elderly and the rest adolescents and children. One study was done exclusively in children.

Two studies were conducted in schools, two in clubs, two at homes and one in nursing homes. Only the study conducted by Kowash et al .[ 18 ] was funded.

Oral health education in five studies was provided in the form of only instructions, the other studies had demonstrations, videos or printed matter or a combination of all methods. Training time ranged from 15 min to 1½ h. Zimmerman et al .[ 22 ] and Sgan[ 25 ] provided oral prophylaxis to the case group. And Kara et al .[ 26 ] provided preventive and curative care along with oral health education [ Table 6 ].

Intervention descriptors for gingival status outcome

All studies were effective in improving the gingival status. Five studies gave a quantitative estimate of the effectiveness. The most effective studies were by Zimmerman et al .[ 22 ] and Ivanovic et al .[ 23 ] which showed a 50% improvement and by Beisbork et al .[ 24 ] which showed a 51% improvement. Zimmerman[ 22 ] conducted a study which consisted of 87 Chilean refugees in the case group, for a period of 6 months, the intervention was in the form of oral health education video, instructions and group discussions for a period of 45 min. It was combined with an oral prophylaxis program. The study showed an improvement in knowledge. Ivanovic et al .[ 23 ] conducted a study in adolescents of 160 participants in the case group for a period of 6 month in a school with funding; the intervention was in the form of instructions for a period of 15 min. The study showed an improvement in knowledge [ Table 3 ].

Ten studies showed effectiveness in the plaque outcome category. The sample size ranged from 42 to 2678 participants. The case group ranged from 14 to 1339 participants with the follow-up period ranging from 1 month to 3½ years [ Table 7 ].

Design variables for reduction in plaque outcome

The target population was adolescents and children in seven studies, the age group ranging from 5 to 15 years. Two studies were conducted on adults and one on diabetic patients. One study was done on females exclusively and one study on male diabetic patients.

Five studies were conducted in schools, one in orphanages, one in clubs, one in a workplace and one in a hospital setting. Five studies received funding. Six studies received additional support.

Six studies provided education in the form of instructions, whereas the other studies used a combination of demonstrations, video and printed matter. Three studies provided education to individuals whereas the others provided education to groups. The oral health education was around 20 min. Health promotion was provided in three studies. Oral prophylaxis was provided in studies done by Freitas-Fernandes et al .,[ 8 ] Beisbork et al .[ 24 ] and Sgan et al .[ 30 ] whereas preventive and curative care was provided in the study done by Kara et al .[ 26 ]

Ten studies[ 4 , 8 , 23 , 24 , 26 , 27 , 28 , 29 , 30 , 31 ] were effective in improving the reduction in plaque, one study did not show any statistically significant improvement. Studies by Almas et al .[ 29 ] showed a 50% reduction in plaque scores.

The study by Almas et al .[ 29 ] was done in a sample of 40 diabetic male patients in the case group, for a period of 7 days in a hospital with additional support; education was given in the form of instructions only in groups.

The study which was done by Frencken et al .[ 31 ] did not show a significant improvement, oral health education was provided to school teachers of 450, 8-year-old children for a period of 3½ years, funding was provided along with additional support. The study did not show any improvement in caries increment when compared with the control group [ Table 3 ].

Seven studies[ 8 , 13 , 22 , 23 , 27 , 28 , 30 ] evaluated the effectiveness of their studies through bleeding on probing of the gingiva. The sample size ranged from 42 to 803. The case group ranged from 14 to 404 participants. Two studies were conducted in children, one in adolescents, one in children and adolescents two in adults and one in Chilean refugees. The follow-up period ranged from 1 month to 3 years.

Four studies targeted children and adolescents and three adults. Two studies were done in low socio economic groups. And a study by Freitas-Fernandes et al .[ 8 ] was done in female orphans.

Professionals provided oral health education in all the studies. The setting was a school in three studies, a workplace in one and an orphanage in one and a club in another. Funding and additional support was provided in studies done by Lim et al .,[ 28 ] Freitas-Fernandes et al .[ 8 ] and Petersen et al .[ 13 ]

Education in the form of instructions was given in all studies, along with a combination of printed matter, demonstrations and videos. The training time ranged from 15 to 45 min. Zimmerman et al .,[ 22 ] Freitas-Fernandes et al .[ 8 ] and Sgan et al .[ 30 ] combined Oral prophylaxis with oral health education [ Table 8 ].

Intervention variables for bleeding on probing outcome

All the studies were effective. Study done by Zimmerman et al .[ 22 ] and Freitas-Fernandes et al .[ 8 ] showed 50% reduction in bleeding on probing. Zimmerman et al .[ 22 ] had provided oral health education to a group of 87 Chilean refugees over a period of 6 months; the study was effective in improving the gingival status too. Freitas-Fernandes et al .[ 8 ] had conducted an oral health education program in a case group of 14 orphan children for a period of 6 months. Funding and additional support was received. The study also showed a 35% improvement in plaque scores and a significant improvement in knowledge and practice outcome [ Table 3 ].

Nine studies[ 14 , 15 , 21 , 31 , 32 , 33 , 34 , 35 , 36 ] showed effectiveness through caries increment. The sample in the studies ranged from as low as 81 to 12,500 participants. The case group ranged from 43 to 12,500 participants. The oral health education population ranged from school children, adolescents to teachers and mothers. The follow-up period ranged from 12 months to 6 years.

Study done by Blair et al .[ 36 ] was in low socio economic population. All the studies targeted either children or adolescents.

In the study done by Guennadi et al .[ 33 ] trained personnel gave oral health education. Seven studies were done in a school setting, one at home and one at a health center. Five studies had received funding and additional support [ Table 9 ].

Organization variables for caries increment outcome

All the studies had used instructions to educate the population; some gave printed material to participants while a study by Vachirarojpisan et al .[ 15 ] held group discussions. Oral health promotion was provided in seven studies. study by Vanobbergen et al .[ 21 ] was based on the Ottawa Charter. Axelsson et al .[ 32 ] and Guennadi et al .[ 33 ] used fluoride dentifrice as an additional intervention [ Table 10 ].

Intervention variables for caries increment outcome

Five studies showed a significant decrease in the caries increment. The results of four other studies were not significant. A study by Blair et al .[ 36 ] showed a 20% decrease in caries increment. Rong et al .[ 14 ] had conducted a study in a sample of 731, with a case group of 361 participants and 370 control groups in a school for a period of 2 years in 3-year-old children. Education was done in groups using video and demonstrations. Funding and additional support was provided for the study. The salient features of this study were that it involved significant others like teachers and parents in the program. This showed a significant improvement in practice though. The study which was done by Frencken et al .[ 31 ] did not show a significant improvement either in caries increment or in plaque scores. Oral health education was provided to school teachers of 450, 8-year-old children for a period of 3½ years, funding was provided along with additional support. The study did not show any improvement in caries increment when compared with the control group [ Table 3 ].

For most of this century, dental health education has been considered to be an important and integral part of dental health services and has been delivered to individuals and groups in settings such as dental practice schools, the workplace and day-care and residential settings for older adults etc., The population as a whole has also been targeted using mass media campaigns. The educational interventions used have varied considerably, from the simple provision of information to the use of complex programs involving psychological and behavior change strategies. The goals of the interventions have also been broad and hence knowledge, attitude, intentions, beliefs, behaviors, use of dental services and oral health status have all been targeted for change. These efforts are testimony to dentistry is long-standing and perhaps pioneering concern with the prevention of oral disease via changes in knowledge, attitudes and behaviors and the adoption of healthier life-styles. However, the increasing pressure on health care resources means that questions are being raised about the costs and effectiveness of all forms of health service provision. This is also the case with respect to preventive interventions since they have long been presumed to reduce disease and therefore lower the demand for health services and the resultant costs. Answers to questions concerning the effectiveness of health education will tell us whether or not it is worth doing and if so, what works best under what circumstances. Data from well-designed evaluation studies also have a role to play in the further development of these kinds of interventions. Over the past few years, a substantial literature has emerged describing studies purporting to evaluate the effectiveness of various types and combinations of educational and behavior modification techniques.

A set of coding variables were drawn under which the articles were reviewed to make them amenable for coding, these coding variables were then described under various subheadings so as to allow us to compare articles based on these coding variables:

Design variables

Sample descriptors

Organization variables

Intervention descriptors

Outcome variables.

These coding criteria were drawn so as to identify variables or factors which have contributed or influenced the effectiveness of the program.

However, a number of problems were encountered in this systematic review:

Limited full text articles were available from the Medline search

Many relevant articles were in foreign languages

Attempting to summarize the results of studies was difficult as different outcome measures were used

Most of the studies did not quantify the effectiveness and mentioned only if the results were significant or not.

Similar to the present study Kay and Locker[ 37 ] in their systematic review of oral health education programs faced the problem of summarizing their results due to the differences in which outcomes were measured and reported.

A major limitation is this review is the search strategy which was limited to Medline so articles published in journals not included are either highly specialized and/or of low circulation or have not been peer reviewed. Many of the articles which passed the inclusion criteria during the initial search were available only on payment, mails were sent to the journals/authors requesting a waiver of the same but no response was received, as the study was not funded, these articles were not included. However, it is possible that relevant data may be included in these journals and inclusion of these articles could have thrown a better light on the effectiveness of the oral health programs. A manual search in libraries of the research colleges was just limited to Bangalore, instead extending to the whole of India could have been done but the non-availability of funds crippled the study. Furthermore, conference proceedings, dissertations and government reports are excluded from Medline and important information will undoubtedly be overlooked with a limited search strategy such as that used in the current study.

Out of total of 40 articles 13 articles evaluated the effectiveness of the program through improvement in knowledge, 4 through change in attitude, 15 through improvement in oral health related practices, 8 through improvement in gingival health, 11 through reduction in plaque, 8 through reduction in bleeding on probing, 9 evaluated the caries increment and 9 used other outcome variables to evaluate the effectiveness of the program.

All studies showed an improvement in knowledge, no matter what design, sample, organizational or interventional variables were used. Oral health education was effective in all sample sizes which ranged from as low as 14 to 1339, among all age groups and even over long evaluation periods like 3 years in a study done by Buischi et al .[ 3 ] Oral health education in all settings was effective and funding and additional support did not seem to be a factor that influenced the improvement in knowledge in the oral health education.

Health education was given in the form of instructions, demonstration of oral hygiene practices, group discussions and lectures. Other than oral health education only one study by Tai et al .[ 5 ] provided preventive and curative intervention, a study by Freitas-Fernandes et al .[ 8 ] provided oral prophylaxis to the participants.

Since quantitative estimates of the effectiveness were not given for all the studies it is difficult to list out the factors that would contribute to a successful program. Brown who had reviewed 57 such studies published between 1982 and 1992 concluded that dental health education was less effective in changing the knowledge of the participants when compared to change in practice.[ 37 ]

Kay and Locker[ 37 ] who reviewed 14 studies published between 1982 and 1994 concluded that knowledge could be improved through dental health education. The results of the present study are consistent with this study, which also concludes that oral health education is effective in improving the knowledge of the participants.

Oral health education was shown to be effective in changing the attitude of adolescents and the elderly, even after a follow-up period of 6 years there was a significant change in attitude as shown in the study done by Tai et al .[ 5 ] This review shows that immediate change in attitude is high, i.e. around 74% as shown in study by Laiho et al .,[ 16 ] but the quantum of change in long follow-up periods like 6 years as shown in study by Tai et al .[ 5 ] is less, i.e. around 17%. This review shows that change in attitude is possible in teenagers through a sustained oral health education program.

Brown who had reviewed 57 such studies published between 1982 and 1992 concluded that dental health education was less effective in changing the attitude of the participants when compared to change in practice.[ 37 ]

Kay and Locker[ 37 ] who reviewed 14 studies published between 1982 and 1994 concluded that attitude could be improved through dental health education. The results of the present study are consistent with this study, which also concludes that oral health education is effective in improving the attitude of the participants.

Oral health education in a range of sample sizes were effective in improving oral health related practices. Studies were more effective when oral health education is targeted towards children and when significant others are involved. Studies by Alsada et al .,[ 19 ] Kowash et al .,[ 18 ] Vachirarojpisan et al .[ 15 ] and Rong et al .[ 14 ] showed a significant improvement in oral health related practices and all the above mentioned studies involved significant others like care givers and mothers of children in the education of the target groups which obviously influences the behavior of the target group. Studies which received funding and additional support were more effective.

Brown who had reviewed 57 such studies published between 1982 and 1992 concluded that dental health education was less effective in improving behaviors of the participants which is not consistent with the results of the present study which showed that oral health education improves the behavior of the participants.[ 37 ]

Oral prophylaxis was done along with oral health education in a study done by Zimmerman et al .[ 22 ] done in Chilean refugees who showed an improvement of 50% in gingival health, thus suggesting that an oral prophylaxis component in an oral health education program could contribute to the improvement in the gingival health of the subjects.

Kay and Locker's[ 37 ] systematic review of oral health education programs showed that out of 15 studies published between 1982 and 1994 only eight concluded that gingival bleeding scores could be improved through dental health education. The results of the present study are consistent with this study which also concludes that oral health education is effective in improving the gingival health of the participants after reviewing eight studies.

Sample size of the oral health education group, their age and setting of oral health education did not seem to influence the effectiveness of the study. The range of effectiveness was 3% to a 50% reduction in plaque scores in studies that gave a quantitative estimate of the results. The effectiveness of the studies when the follow-up was of long duration for example a study done by Alabandar[ 7 ] was lower. Frietas et al .[ 8 ] showed a 35% reduction in plaque scores when evaluated at 6 months. Thus oral health education in long term studies was not effective in reduction of plaque. Studies which provided oral prophylaxis regularly along with oral health education were usually more effective.

Kay and Locker's systematic review of oral health education programs showed that out of 15 studies published between 1982 and 1994 only eight concluded that oral health education programs were generally effective in short term but no long term benefits were seen. The results of the present study are consistent with this study which also concludes that oral health education is effective in reduction of plaque in short term studies but was not effective in studies with long follow-up periods.[ 37 ]

All studies were effective, the study done by Zimmerman et al .[ 22 ] in 87 Chilean refugees evaluated after 6 months was the most effective, showing a 50% reduction in bleeding on probing of the gingival.

The sample size, the target population, setting of the study, funding and additional support to the study seemed to have no effect on the effectiveness of the study. Studies in which oral prophylaxis was done along with oral health education showed a comparatively more reduction in bleeding on probing of the gingival as compared to studies in which only oral health education was done.

Nine studies showed effectiveness through caries increment out of these there was significant reduction in caries increment in five studies and in four studies there was no significant change. Only one study gave a quantitative estimate of the effectiveness, i.e. the study done by Blair et al .[ 36 ] in 7012 school children which showed a 20% decrease in caries increment at the end of the 6 year study. The review showed that studies done in schools were effective and health promotion was a salient feature in most of the effective studies.

Seven studies used other outcome measures to evaluate their effectiveness; Laiho et al .[ 16 ] showed an increase in utilization of dental services after an oral health education program in 458 adolescents where health education was done in their school. Guennadi et al .[ 33 ] showed an improvement in oral health awareness after an oral health education program in 3-12 year old children after a 3 year study. Simons et al .[ 35 ] showed a reduction in denture stomatitis in 39 elderly patients after a 12 month oral health education program for their caregivers. Nicol et al .[ 10 ] showed a reduction in oral mucositis and a reduction in denture stomatitis but no significant improvement in denture hygiene in 78 elderly patients after an 18 month oral health education program for their care givers.[ 21 ]

Most of the studies reviewed in this study showed an improvement in the outcome measures no matter what design, sample, organizational or interventional variables were used. Although a few studies showed a better improvement in the outcome variables due to certain salient features: All studies were effective in improving knowledge outcome, change in attitude over a longer time period is possible only through a sustained oral health education program, the involvement of significant others in oral health education programs is more effective, bringing about a higher improvement in practice outcome. An oral prophylaxis component in an oral health education program has shown to bring about a higher quantum of change in the gingival status outcome, bleeping on probing of the gingiva and plaque outcome. Where health promotion was a salient feature a more significant reduction in caries increment was noticed.

Certain studies evaluated their effectiveness through utilization of dental services, an improvement in oral health awareness, reduction in denture stomatitis, reduction and oral mucositis. These studies were reviewed in the study but were not discussed in this article as the outcome measures were beyond the purview of the outcome variables intended to be evaluated in this article.

Oral health education is effective in improving the oral health; this review throws light on the effectiveness of oral health education programs and identifies important variables which contribute to the effectiveness of these programs.

There is an urgent need for more systematic reviews on studies evaluating the effectiveness of oral health education and promotion in the India. Overcoming the limitations of this study, such as research funding and standardizing the outcome variables which, would enable us to have a common measurement tool and systematically reviewing the future programs would help formulate a public health program with the best design.

Recommendations for action:

Oral health education efforts should be focused on children involving the significant others as the benefits are cumulative.

Health education interventions are of limited value and should be supported by a full range of health promotion approaches.

Oral health promotion should particularly be targeted to areas of need so as to address the inequalities.

Non dental personnel involved in primary care such as dais, ASHA and anganwadi workers etc., may help to pass on oral health knowledge and influence choices of a defined target population.

Addressing the oral health issues through the common risk factor approach would reduce the burden on the government by cutting costs.

Realistic measurements of all the costs and benefits of oral health promotion should be included in evaluations, including non-clinical indicators like utilization of health care etc.[ 38 , 39 , 40 ]

This review emphasizes the need for further research in evaluating effectiveness of oral health education; it has shown the limitations in terms of the lack of standardization in evaluating the outcome measures and lack of funding in this field. The government has a key role to play in this process through its policy making. Such a step forward also demands collaboration between academics and professionals to ensure that strategies are developed upon a sound scientific basis and are subject to appropriate evaluation. This may include a range of methodologies which together will illuminate the full costs and benefits of individual health promotion interventions as well as the overall strategic framework.

Oral health education is effective in improving the knowledge attitude and practice regarding oral health and in reducing the plaque, bleeding on probing of the gingival and caries increment and in improving the gingival health.

The present review throws light on the effectiveness of oral health education programs and identifies important variables which contribute to the effectiveness of these programs.

This review has shown that oral health education is effective in improving the knowledge and oral health related practices of the target population when significant others are involved, thus involvement of significant others like teachers and parents especially in oral health education of school children would bring about a higher quantum of change in improving the oral health in children.

Including an oral prophylaxis component in oral health education programs would bring about a higher quantum of improvement in the gingival health. Since oral health promotion programs have shown to be more effective than just oral health education, this approach should be adopted for bringing about an improvement in the target population, in such programs health promotion commits us not only to improving lifestyles but also to improving the environment in which lifestyle choices can be made.

There is indication in this review that the most successful oral health programs are labor intensive, have involved significant others and have received funding and additional support. A balance between inputs and outputs and health care resources available will determine if the program can be recommended for general use.

Source of Support: Nil

Conflict of Interest: None declared.

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