Received: 19 August 2016
|
Accepted: 25 June 2017
DOI: 10.1111/cdoe.12325
ORIGINAL ARTICLE
Effectiveness of oral health education on oral hygiene and dental caries in schoolchildren: Systematic review and meta-analysis Caroline Stein1 | Nath alia Maria Lopes Santos1 | Juliana Balbinot Hilgert2 | Fernando Neves Hugo2 1 Postgraduate Studies Program in Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
Abstract Objectives: The objective of this study was to evaluate the effectiveness of oral
2
Department of Preventive and Social Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil Correspondence Fernando Neves Hugo, Faculty of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil. Email:
[email protected] Website: http://www.ufrgs.br/cpos Funding information Coordination for the Improvement of Higher Education Personnel (CAPES)
health educational actions in the school context in improving oral hygiene and dental caries in schoolchildren through systematic review and meta-analysis. Methods: Clinical trials with schoolchildren between 5 and 18 years old were included. Eligible studies were those which had as outcomes caries, plaque accumulation, gingivitis, toothache or tooth loss and which had been published from 1995 to 2015, in any language. The risk of bias was assessed in specific domains according to the Cochrane Handbook. A meta-analysis was carried out using fixed-effects models. Results: A total of 4417 references were found, from which 93 full texts were evaluated and 12 included in this meta-analysis. Five studies showed a reduction in plaque levels, and two studies with gingivitis as the outcome found no effect. There was not enough evidence on the effectiveness of the interventions in reducing dental caries. Conclusions: Traditional oral health educational actions were effective in reducing plaque, but not gingivitis. There is no long-term evidence in respect of the effectiveness of these interventions in preventing plaque accumulation, gingivitis and dental caries in the school environment. KEYWORDS
adolescent, child, dental health education, meta-analysis, review, schools
1 | INTRODUCTION
diseases; health promotion at school should encourage daily toothbrushing, supervised toothbrushing, use of fluoride, and promotion
Oral disorders such as dental caries, periodontal diseases and tooth
of good nutrition, among other strategies.3,4 While reviewing the
loss are critical public health issues around the world, given the fact
evidence on the effectiveness of Dental Health Education (DHE) in
that poor oral health has far-reaching effects on overall health and
1996, Kay and Locker undertook a systematic review which showed
quality of life. There are challenges to overcome in order to improve
no evidence to show that DHE was effective against dental caries.
oral health, particularly in developing countries, in which there is an
They suggested that further efforts are required to synthesize cur-
urgency to globally strength public health programmes by deploying
rent information about DHE.5 However, that review was published
effective preventive measures against diseases while promoting oral
more than two decades ago, with the most recent evidence having
health.1,2
been included from a study published in 1994. Since its publication,
The World Health Organization in 2003 indicated that the focus
a large number of intervention studies assessing the effectiveness of
of Oral Health Education (OHE) actions should be on behaviours and
educational measures have been published, and a more contempo-
conditions that promote oral health or that reduce the risk of oral
rary review is required.
Community Dent Oral Epidemiol. 2017;1–8.
wileyonlinelibrary.com/journal/cdoe
© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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The use of collective actions for oral health education is frequent
[Mesh] AND (“Toothbrushing”[Mesh]) OR “Health Education, Den-
and includes lectures using different types of resources such as flip-
tal”[Mesh] OR “Education”[Mesh] AND (“Oral Health”[Mesh]) OR
charts, video, slide presentation, and other types of actions such as
(“Dental Plaque”[Mesh] OR “Dental Caries”[Mesh] OR “Gingivi-
supervised dental brushing and topical fluoride application. About
tis”[Mesh] OR “Dental Plaque Index”[Mesh] OR “Toothache”[Mesh]
the effectiveness of the latter, there is already strong evidence,
OR “Tooth Injuries”[Mesh] OR “Tooth Loss”[Mesh])). CENTRAL (Cen-
established by systematic review with meta-analysis, setting the
tral Register Cochrane of Controlled Trials) (01/01/1995-13/05/
effectiveness of topical fluoride use on cavity prevention in children
2015). EMBASE (Excerpta Medica Database) (01/01/1995-09/06/
6
and teenagers.
7
For supervised toothbrushing, there is some evi-
dence on its efficacy and cost-effectiveness.8 However, further studies that follow students for longer periods of time, while incorporating economic outcomes, are needed.8
2015). LILACS (Latin-American and Caribbean Literature on Health Sciences/Virtual Health Library (BVS)) (01/01/1995-25/04/2015). The title and the abstract of each study were reviewed and critically assessed by two independent reviewers. Two reviewers are
The objective of this study was to evaluate the effectiveness of
dental surgeons (NMLS, CS) and experienced in the field.
oral health educational actions in the school context on improving
The methods used to apply the selection criteria were the follow-
oral hygiene and dental caries in schoolchildren through systematic
ing: (i) integration of the searched outcomes in the bibliographic refer-
review and meta-analysis.
ence EndNoteWeb software to delete duplicate entries; (ii) examination of titles and abstracts to delete clearly irrelevant articles; (iii) recovery of the full text of potentially relevant articles; (iv) binding
2 | METHODS
and gathering of multiple articles of the very same study; (v) examination of the articles’ full text to verify the degree of compliance that the
A systematic review of literature and meta-analysis was performed.
studies had with the eligibility criteria; (vi) establishing connection with
This methodology followed the Cochrane Handbook for systematic
researchers, if necessary, to clarify the study’s eligibility; (vii) deciding
reviews of interventions, version 5.1.0.9 For further details, see the
about the study’s inclusion and proceeding with data gathering.
online Methods. For this review, studies using randomized controlled
When disagreements between researchers arose, the eligibility
trials methodology were included, with randomization at group
criteria or the codification schemes for data gathering were reviewed
(school and/or classroom) or individual level.
by a third reviewer (FNH) experienced in the content of the review,
Studies in which participants were students with ages ranging
to take the final decision on the articles’ inclusion or exclusion.
from 5 to 18 years were included. This inclusion disregarded the
Data gathering was carried out using a verification list of items
dental caries level at the study’s beginning, exposure to fluoride and
that were considered for data extraction. The main items of this list
current dental treatment. For the purposes of this review, a “school”
were as follows: study definition, risk of bias assessment, total length
is defined as “a space to articulate policies concerning teenagers and
of the study, unit of randomization, unit of analysis, participants’
young people, based on the participation of those individuals in that
characteristics, interventions, outcomes, results and other items.
process: students, families, educational and health professionals.”10
The risk of bias was assessed in five specific domains: selection
Educational actions interventions on oral health carried out by den-
of participants; allocation sequence concealment; blinding of partici-
tal professionals in School Programs were considered. The included
pants and evaluators; incomplete outcome data; and selective out-
educational interventions on oral health were as follows: supervised
come reporting. This was done through the assignment to “low risk
toothbrushing, guidance about toothbrushing, orientation on the main
of bias,” “high risk of bias” or “unclear risk of bias” rulings.9
oral diseases, general orientation on dieting, educational activities,
Measures for continuous data were assessed as follows: mean
among others. Studies were included without time restriction. The inter-
change in Plaque Index (before and after the intervention) and stan-
vention could have been delivered by dentists, dental hygienists or den-
dard deviations; and mean change in gingivitis (before and after the
tal assistants and carried out in the school environment.
intervention) and standard deviations.
The control group was not provided with an educational pro-
The unit of the analysis from the studies was every conglomerate
gramme on oral health; however, it could have been given an action
(class or school) and/or the individual (student) of each study
that belongs to the school’s curricular framework.
included in this review. The estimates of effect and their standard
Primary outcomes: dental caries; plaque accumulation; gingivitis.
errors, deriving from the analysis of group-randomized trials, were
The clinical effectiveness was defined as some change in caries
explored in a meta-analysis using the generic inverse variance
experience or some change in the amount of dental plaque and gin-
method on Review Manager 5.3.
gival bleeding. Secondary outcomes: dental pain and tooth loss,
We sought to identify the variability among the studies, in partic-
before and after the intervention. Articles published from 01/01/
ipants, interventions, outcomes and planning, and risk of bias. The
1995 until 09/06/2015 were searched, without any restriction
chi-square test was used to assess whether the observed differences
concerning the publication’s language.
were homogenous or heterogeneous. The statistic test used to quan-
The following bibliographic databases were searched: MEDLINE/PubMed
(01/01/1995-23/04/2015):
“Child”[Mesh]
OR “Schools”[Mesh] OR “Adolescent”[Mesh] OR “Child, Preschool”
tify the inconsistence between studies was the I². It was interpreted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions.9
STEIN
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Data synthesis was carried out using a descriptive synthesis, with
3
3 | RESULTS
a summary of the characteristics of each included study. For quantitative synthesis, a summary of the combined estimate related to the
The studies selected during the search process, assessed by eligibil-
intervention effect was calculated as a mean of the differences of
ity, included in the review and excluded given the proper reasons,
the effects of intervention in individual studies.
are presented in Figure 1, using a flow diagram. For further details,
The meta-analysis of the continuous outcomes used the fixed-
see the online Results.
effect method, which provides exactly the same answers when
The characteristics of the studies can be found in Table 1, which
heterogeneity does not exist. To calculate the standard error and the
depicts the included studies’ the general characteristics. Among the
standard deviation of the mean differences for the outcomes of
12 included studies, six were randomized by school,11–16 two by
interest, the Comprehensive Meta-Analysis Software was used, and
classroom17,18 and four by individuals.19–22
then, mean differences and their standard deviations were analysed using Review Manager 5.3. software.
FIGURE 1
Review flow diagram in selection of studies, 2015
The age of the participants ranged from 6 to 15 years old throughout the interventions’ conducting period. 3932 participants
9 mo
6 mo
Chandrashekar 2014
2y
3 mo
D’Cruz 2013
Haleem 2012
3
Yekaninejad 20123
36
143 (intervention II)
141 (intervention I)
303
129
140
195
30
411
20 (Group III)
20 (Group II)
20 (Group I)
146
135
35
284
334
123
340 (Control II)
220 (Control I and dietary intervention)
93
30
397
20
OHE
OHE, OHI and TD (Group II)
OHE (Group I)
OHE, OHI and TD
OHE
OHE, OHI and ST
OHE, OHI and TD
OHE, OHI, TD and ST
OHE, OHI, TD and ST
OHE, OHI and TD (Group III)
OHE and OHI (Group I e II)
OHE, OHI and TD
OHE, OHI, TD and ST and dietary (Group IV)
25 (Group IV)
OHE (Group II)
OHE, OHI, TD ad ST (Group II)
OHE, OHI and TD (Group I)
Intervention1
OHE, OHI, TD and ST (Group III)
25 (Group I)
80
N Control group
25 (Group III)
25 (Group II)
80 (Group II)
80 (Group I)
N Intervention group
15 y
13-15 y
10-11 y
11-12 y
13-14 y
7-15 y
6y
6-11 y
7-9 y
10 y
7-9 y
11-14 y
Age of participants
PI, G and DMFS
PI and GI
PI and GI
CPI
demineralization and remineralization in molars
PI, GI and DMFT
PI, GI, dmf and DMFS
DMFT and dmfs
PI O’Leary
€e PI Silness & Lo
PI O’Leary
PI and GI Silness & Loe
Outcomes assessed2
Dentist
Dentist
Dentist
Dentist
Dental Hygienist
Dentist
Dentist
Dental Hygienist and research assistant
Dentist
Dental Hygienist
Dentist
Dental Hygienist
Who applied the intervention
Interventions: OHE (Oral Health Education: activities with lectures, albums, slides, leaflets, counselling, games, drawings, theatre, dieting guidance); OHI (Oral Health Instruction); TD (Tooth brushing demonstration); ST (supervised tooth brushing). 2 Outcomes assessed: PI (Plaque index), GI (Gingival Index), DMFS (decayed, missed, filled permanent tooth surface); dmfs (decayed, missed, filled primary tooth surface); DMFT (decayed, missed, filled permanent tooth); CPI (Community Periodontal Index). 3 Al-Jundi 2006, Anttonen 2011, de Farias 2009, ²Esteves 1998 (Group IV), Haleem 2012; Yakaninejad 2012 e Zanin 2007, they were not included in the meta-analysis.
1
1 mo
de Farias 20093
9 mo
15 mo
Zanin 20073
Anttonen 2011
4y
Al-Jundi 20063
3
4 mo
1 mo
6 mo
Esteves 1998
Rodrigues 2003
6 mo
Ivanovic 1996
Worthington 2001
Duration of study
Reference (year)
T A B L E 1 General characteristics of the included studies
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| STEIN ET AL.
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reduction in mean plaque levels (MD
0.36, IC 95%:
0.59 a
5
0.13)
(Figure 3, Comparison 1). In comparison 2, studies in which there were groups who got some activity of OHE, OHI and TD were included, vs control groups, concerning plaque outcome (Loe & Silness PI). In this fixed-effects model analysis,14,20 there was a significant difference in the change of the plaque index favouring intervention groups, which showed a better oral hygiene (MD
0.42, IC 95%
0.69 a
0.15) (Figure 3,
Comparison 2). In comparison 3, studies in which there were intervention groups that got any intervention on OHE vs control groups related to gingivitis outcome (Loe & Silness). In this fixed-effects model analysis, two studies11,12 presented data on gingivitis indices at the beginning and at the end of the study. There was no significant difference in the change in gingivitis between the groups (MD
0.07, IC 95%
0.32 a 0.19) (Figure 3, Comparison 3). The studies of de Farias17 and Zanin21 also had the plaque index and gingivitis outcomes in their analysis, but their data for the outcomes of interest were presented in charts, which prevented their inclusion in the meta-analysis. The study of Haleem13 presented results for Plaque Index and gingivitis based on a dichotomous scale for the outcomes of interest. It was not possible to include it in the meta-analysis. This study concluded that the interventions had a rather modest effect on plaque and gingivitis. The study of Yekaninejad15 assessed the effect of OHE on oral hygiene measured using the Community Periodontal Index (CPI), and there was no improvement in the gingival health of the intervention group. The results for gingivitis F I G U R E 2 Summary of the risk of bias: + (low risk of bias); ? (unclear risk of bias); - (high risk of bias)
were presented in estimates from the multilevel ordinal logistic regression model, which precluded its inclusion in the metaanalysis.
were part of the studies’ analyses, with 1864 of those included in
For the dental caries and tooth loss outcomes, four stud11,17,19,21
intervention groups and 2068 in control groups.
ies
presented results using the DMFT, DMFS and dmfs
Significant methodological variability was found among the inter-
indices to evaluate the effectiveness of the OHE sessions. Al-
ventions performed in the included studies. Thus, the interventions
Jundi,19 in a 4-year study, found that caries status of the children in
described by the studies were categorized as follows: (i) Oral Health
the intervention group, which comprised supervised daily tooth-
Education (OHE): activities with lectures, albums, slides, leaflets,
brushing using fluoridated toothpaste, was better than that of the
counselling, games, drawings, theatre, dieting guidance; (ii) Oral
control group and concluded that this preventive programme was
Health Instruction (OHI) reported as additional delivery of informa-
successful in controlling dental caries. In the study of Chan-
tion directed particularly to toothbrushing methods; (iii) Tooth brush-
drashekar,11 for the DMFS outcome, and in the study of Zanin,21
ing demonstration (TD) with macro models or dental dummies; (iv)
with the DMFS and dmfs outcomes, significant changes between the
Supervised Tooth brushing (ST): the intervention study period ranged
groups were not found. According to de Farias,17 the DMFS index
17
from 1 month
19
to 4 years.
Therefore, all interventions selected
for this review are considered traditional oral health education
showed a significant association with the Gingival bleeding index at the end of the study. Anttonen16 assessed the effect of the actions of OHE on the
activities. The presentation of the assessments of the risk of bias was done
monitoring of demineralization and remineralization of tooth sur-
based on Figure 2, using Review Manager 5.3 software. First, studies
faces, based on mean laser fluorescence values and concluded that
with groups that got any sort of OHE intervention vs controls con-
the 1-year OHE was resulted in favourable changes in dietary habits
cerning the Loe and Silness and O’Leary’s plaque indices outcomes
and a decrease in the laser fluorescence values of molars. The results
11,14,18,20,22
were analysed. In the cumulative analysis of five studies
of the study were presented in graphs and the type of measurement
with both indices, there was a significant difference in the change of
for caries condition, precluded its inclusion in the meta-analysis.
the Plaque Index favouring intervention groups, which showed a
Studies with tooth pain as outcomes were not found.
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FIGURE 3
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The effectiveness of oral health educational actions
4 | DISCUSSION
objective of oral health education and evidence to support decision would be of relevance for oral care providers and stakeholders.
For the plaque outcome, five studies11,14,18,20,22 were included in
There were only four studies assessing caries as the outcome
the meta-analysis and showed significant differences in the change
included in this review.11,17,19,21 In general, their findings are conflic-
of the plaque index (Loe & Silness and O’Leary) favouring interven-
tive, with three not showing differences between intervention and
tion groups. Although limited, the studies suggest positive effect of
control groups and a larger, longer one showing differences in favour
OHE on plaque levels on short term. On the other hand, the stud-
of oral health education.
ies of Esteves22 and Rodrigues,18 encompassing O’Leary’s Plaque
For such matter, we need to make further progresses in the
Index, did not find significant difference between the groups, which
development and systematic assessment of such actions throughout
can be explained by the small number of participants in the study
longer periods of time. Besides that, the short follow-up time to
groups.
carry out analysis of effectiveness on dental caries must be taken as
For the gingivitis outcome in meta-analysis, the studies of Chan11
12
showed that there was no difference
iod of caries (and tooth loss, consequently), is longer than the fol-
between the groups and revealed that oral health education had no
low-up period of the studies included in this review. This way, there
effect on gingivitis reduction. These studies varied their intervention
is a need to develop long-term studies which can assess the effec-
time from 6 months to 2 years, with participants aged from 10 to
tiveness of the education actions on those outcomes, particularly
15 years old. The prevention of oral diseases is an important
because the goal of the education interventions in the school
drashekar
and D’Cruz
a limitation of the assessed primary studies, because the latency per-
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7
environment is to prevent oral diseases and to develop healthier
studies with similar outcomes included. The study’s relevance is
behaviours and practices.
mainly related to the need to assess the effectiveness of educa-
The last systematic review about the effectiveness of educational
tional actions on oral health carried out in school programmes,
actions on the oral health of schoolchildren was published more than
given the fact that, according to individual studies and other sys-
two decades ago. Since then, a considerable amount of papers on
tematic reviews, a conclusive outcome about their effectiveness is
the subject has been published. Oral health education programmes
yet to be established, even though they remain as priority actions
continue to be developed and implemented in school settings, mean-
in many countries.
ing that the critical assessment and summarization of that evidence
In conclusion, traditional oral health education was effective in
is important to provide clinicians, stakeholders and decision makers
reducing plaque accumulation over a short period. This reduction
with needed information about the cost-effectiveness of education
was of small magnitude. OHE was not effective for gingivitis while
based oral health programmes. This is in agreement with the current
for caries the findings were conflicting. There is no long-term evi-
23
definition of oral health that was recently published by the FDI.
dence on the effectiveness of these interventions in preventing pla-
The several forms of delivery of OHE presented in the studies
que accumulation, gingivitis and dental caries in schoolchildren. This
only varied in regard to the deployed educational objects; however,
may be due to the variability of OHE methods deployed in the
the methods, as they were developed, were based mainly on infor-
individual studies.
mation transfer. The development of evidence-based protocols that allow the delivery of sound and effective OHE actions is needed
ACKNOWLEDGEMENTS
mainly in primary healthcare settings and in school environments. It is strategic to carry out prevention and health promotion actions
This study was funded in part by the Coordination for the Improve-
that are consistent and produce a positive impact on oral health sta-
ment of Higher Education Personnel (CAPES).
tus. It is important to review OHE methods, organizing them according to children’s development period, while also acknowledging a more active engagement hailing from school communities and families, because there is a complexity when it comes to being apt to motivate oneself while promoting changes in persons’ health behaviours.24 As this study only selected interventions carried out by oral health professionals and, considering that throughout the selection process, studies in which interventions were applied by others such as teachers and students’ parents were found, there is a need to also systematically assess the effectiveness of those interventions. In a critical review study on educational programmes for schools, Pauleto25 concluded that education remains strongly based on knowledge transfer practices and that it is necessary to rethink it by using education methods that are focused on problematization. In a previous systematic review about the effectiveness of Oral Health Education actions, Kay5 found that there was a rather small positive effect, however momentary, in the plaque index and not a single perceptible effect about the cavity increase. The present review included papers published after 1994 and showed similar results in respect to plaque accumulation. Furthermore, results in respect to caries were conflictive and no study included important outcomes such as tooth loos or evaluated the cost-effectiveness of OHE interventions. The general applicability of the evidence of the present review is limited, taking into consideration that OHE only contributed to a small reduction over a short period of time in plaque accumulation. Furthermore, oral and psychosocial characteristics are known to vary widely between children in the age range considered in the present systematic review. This is a limitation of this study, and results must be interpreted taking such into account. Subgroup analyses could have been carried out to overcome it; however, this was precluded due to the small number of individual
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How to cite this article: Stein C, Santos NML, Hilgert JB, Hugo FN. Effectiveness of oral health education on oral hygiene and dental caries in schoolchildren: Systematic review and meta-analysis. Community Dent Oral Epidemiol. 2017;00:1–8. https://doi.org/10.1111/cdoe.12325
