Effectiveness of school-based oral health education in influencing oral health among school children-systematic review and meta-analysis

P Arathi Menon; Sahana Shivakumar; Garima Bhambani; Tarun Pratap Singh; Anshika Khare; Anuja Pathak

doi:10.4103/jhnps.jhnps_56_21

REVIEW ARTICLE

Year : 2021 | Volume : 9 | Issue : 2 | Page : 100-107

Effectiveness of school-based oral health education in influencing oral health among school children-systematic review and meta-analysis

P Arathi Menon, Sahana Shivakumar, Garima Bhambani, Tarun Pratap Singh, Anshika Khare, Anuja Pathak
Department of Public Health Dentistry, Peoples College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India

Date of Submission	28-Sep-2021
Date of Acceptance	20-Oct-2021
Date of Web Publication	17-Dec-2021

Correspondence Address:
Dr. P Arathi Menon
Department of Public Health Dentistry, Peoples College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jhnps.jhnps_56_21

Abstract

Oral health education (OHE) is considered an effective method to prevent oral diseases. Various studies have been conducted to assess the effectiveness of OHE among school children, and the most desirable person to render the same still remains a question. The aim of the review was to evaluate the effectiveness of OHE rendered by qualified dentists and school teachers in school children in improving oral hygiene and dental caries. Controlled trials with OHE as intervention for not more than 2 years among 4–15 years of age assessing either Sillnes and Loe Plaque index, Loe and Sillness Gingival index, and Decayed, Missing, Filled Teeth (DMFT)/ Decayed, Missing, Filled teeth Surface (DMFS) were included. Studies extracted from various databases were subjected to quantitative and qualitative analysis. The findings from the selected five studies were subjected to quantitative analysis using Review Manager 5.4 version using random effect models. Results showed that OHE provided by school teachers are as effective as those rendered by qualified dentists in improving plaque index (P = 0.81), gingival index (P = 0.55), and caries status (P = 0.77) in school children. OHE is an effective method for reduction of plaque accumulation and improving gingival health though not as effective in reducing dental caries. Improvement in oral hygiene and caries status through OHE is possible irrespective of the person rendering.

Keywords: Dental caries, gingival health, oral health education, school children

How to cite this article:
Menon P A, Shivakumar S, Bhambani G, Singh TP, Khare A, Pathak A. Effectiveness of school-based oral health education in influencing oral health among school children-systematic review and meta-analysis. J Head Neck Physicians Surg 2021;9:100-7

How to cite this URL:
Menon P A, Shivakumar S, Bhambani G, Singh TP, Khare A, Pathak A. Effectiveness of school-based oral health education in influencing oral health among school children-systematic review and meta-analysis. J Head Neck Physicians Surg [serial online] 2021 [cited 2023 Jun 4];9:100-7. Available from: https://www.jhnps.org/text.asp?2021/9/2/100/332724

Introduction

Oral diseases are a major burden for the abridged quality of life in many countries with low and middle socioeconomic status. Dental Caries, periodontal diseases, tooth loss, and oral cancers being the most prevalent.^[1] According to the Global Burden of Disease Survey 2017, untreated dental caries in permanent teeth are the most common dental disease.^[2] Dental caries in primary molars affect more than 530 million young children.^[3] Poor oral health in children increases twelve times the chance of having a detrimental effect on the quality of life affecting their growth and development as well as nutritional status. This adversely affects children's performance in school and oral health in later life.^[4],[5]

Oral health education (OHE) is considered an effective method for oral health promotion from the early times. School dental health education (SDHE) aims to improve oral health-related knowledge, attitude, and practices among children.^[6],[7] Reduction in plaque accumulation and improved gingival health are beneficial impacts of repeated school dental education at different intervals.^[8] Literature evidence prove the effectiveness of traditional SDHE of short duration reducing plaque accumulation, although the efficiency in improving gingivitis and dental caries remains doubtful.^[9] However, short-term intervention of OHE improves knowledge and oral health behavior in children.^[10] A review by Kay and Locker suggests that the short-term OHE were generally effective compared to long-term interventions.^[11] A comprehensive method (educational, preventive, and curative) is much more effective in achieving positive results.^[12]

Various modes are used for imparting OHE such as visual media (posters, flashcards, and videotapes) and traditional lecture methods (chalk and blackboard). Studies suggest both modes improve oral hygiene status in school children.^[6],[13] Even though both dental professionals and school teachers provide one-to-one education, there are little evidence suggesting OHE rendered by whom is perceived better by the school children.

This systematic review and meta-analysis answers the research question “Is school-based OHE intervention rendered by dentists as effective as school teachers in influencing dental caries and gingival health among school children?”

Methods

This systematic review followed the PRISMA checklist by Moher et al. 2009.^[14] This review was registered with PROSPERO with Reg. No: CRD42021230055.

Search strategy for selection of studies

The search strategy included keywords and MESH terms including (OHE OR oral health promotion OR health education intervention) AND (school children OR student OR school teacher OR dentist) AND (oral health OR dental Caries OR gingival health OR dental plaque OR dental plaque index OR gingival index). Care was taken to use the combinations only once to avoid repetition of the appearance of articles. Articles were retrieved from electronic databases such as Pubmed, Embase, Ovid, Elsevier, and Journal on web databases published during the year 200–-2020. To remove duplicates for the same type of article in more than one database the EndNote ver. 2.0 software (Clarivate Analysis) was used. Articles published in the English language were only eligible.

Eligibility criteria

This review included studies of randomized and nonrandomized controlled trials done to assess improvement in gingival health, dental caries status, and oral hygiene among school children after an educational intervention for oral health promotion. The studies included were in line with the PICOS criteria:

Population– studies that included children of both gender, in the age range of 4–15 years enrolled in private and government schools
Intervention–school-based OHE intervention rendered by school teachers or by dental professionals for a duration of not more than 2 years
Comparison-studies providing any sort of OHE intervention were considered as experimental group and those groups with no means of OHE were in the control group
Outcome-Studies assessing the mean scores of Sillness and Loe Plaque Index ([1964), Loe and Sillness Gingival Index (1964), and DMFT/DMFS before and after the intervention
Setting-Studies conducted in schools under both public and private sectors.

Exclusion criteria

The review excluded studies done on differently abled, physically challenged, or blind children. Studies including intervention based on diet and behavior of school children and intervention for more than a period of 2 years were excluded. Articles those unpublished or in the process of publishing were not included.

Data collection, screening, and data extraction

The search strategy was performed by two of the review authors (AM, SS). Data extraction was independently done by two reviewers (GB, TPS). In case of disagreement, reviewers' AM and SS were consolidated. The full-text articles were carefully reviewed, and data were collected and recorded in the data extraction table which included Study ID, Age, sample size, mode of OHE, duration of intervention, and outcome measures. Outcome scores assessed for mean Plaque index with standard deviation, mean Gingival index with standard deviation, and caries status in mean scores of DMFT/DMFS with standard deviation prior and after the intervention were recorded.

Risk of bias assessed for individual studies according to the Cochrane Collaboration's tool for assessing the risk of bias, with seven specific domains: Random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias.^[15] Each study was assigned to the domains as “low risk,” “high risk,” and “unclear risk” of bias.

Data synthesis

Nine articles were reviewed, in which 5 were eligible for meta-analysis. In 3 of the reviewed articles, outcome data were not mentioned in mean values [Table 1].

Table 1: General characteristics of the studies

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The level of evidence of the included studies was justified following the criteria of the Oxford Centre for Evidence-Based Medicine.^[23]

Statistical analysis

Statistical analysis was performed using RevMan 5.4 software (Cochrane Review Group) using random-effect model. The results were considered significant with P ≤ 0.05. The heterogeneity of the studies was statistically evaluated using I² statistics. The standard mean difference of the variables was used as mean difference with standard deviation of plaque index scores, gingival index scores, and DMFT/DMFS scores before and after the intervention.

Results

Out of the 835 manuscripts retrieved by search criteria, 289 were excluded as not relevant to the review. Due to the variances in abstract and titles 230 articles were not included. 35 articles omitted due to duplication. 273 articles were excluded as parameters other than PI, GI, and DMFT/DMFS are assessed. 3 studies excluded from quantitative analysis as plaque and gingivitis measured as absent or present or mean caries status not recorded. Five studies were subjected to quantitative analysis [Figure 1].

Figure 1: PRISMA flow chart

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Nine studies included in the systematic review were intervention studies with or without randomization rendered OHE through a professional dentist or school teacher among schoolchildren of 4–15 years of age. Modes of OHE used among the studied varied from using traditional lecture method using chalk and blackboards to visual aids such as posters and demonstration of oral hygiene practices. The general characteristics of the studies are presented in [Table 1].

Six studies with various modes of intervention at different durations effectively reduced plaque accumulation.^{[13],[18],[20],[21],[22]} Studies assessing gingival status after intervention showed a significant decrease in gingivitis.^{[13],[19],[20],[21],[22]} Dental caries status showed no significant improvement in any of the reviewed studies. Untreated dental caries significantly reduced after intervention suggesting OHE could improve the attitude towards dental treatment. Knowledge, attitude and practices of oral hygiene also enhanced after the intervention.^{[16],[17],[19],[20]}

Reduction in plaque accumulation

Two studies were subjected to the meta-analysis of plaque index at baseline and follow-up after interventions in dentist-led and teachers-led groups. At baseline, a total of 65 individuals in the experimental and 69 in the control group were evaluated for the plaque index. There was no significant difference noted between the studies at P = 0.28. This suggests an equal efficiency of the OHE by dentists and teachers. On the evaluation of the two studies following intervention at the final examination, there was no significant difference in the overall effect between the two studies, P = 0.81 [Figure 2].

Figure 2: Comparison of plaque index measured at final examination

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At baseline 178 students in the dentist-led group and 320 in the control group at baseline were evaluated for plaque index mean scores. There were no significant differences between dentist-led and control groups in both the studies (P = 0.08).

Analysis of mean plaque index values at follow-up showed significant difference with dentist led and control group (P = 0.08), [Figure 3]. Dentist led group had significant improvement in mean plaque scores compared to the control group in both the studies.

Figure 3: Comparison of plaque index measured at final examination (dentist led OHE and control group)

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Reduction in gingivitis

A total of 179 in dentist led and 318 in the control group were evaluated for the gingival index measured at baseline and follow-up among 2 studies were included. The overall effect was not significant from both the studies with P = 0.51, suggesting an equal gingival status among participants during baseline.

The follow-up comparison of gingival index among dentist led and control groups in the two studies, there was no significant overall difference (P = 0.55) observed between the two studies, suggesting the control group could have a cross over the effect of the intervention from the dentist led group [Figure 4]. Both the studies included in the evaluation of the gingival index had a greater difference in the study participant size in both dentist-led and control groups.

Figure 4: Comparison of gingival index measured at follow up examination (dentist led and control group)

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Reduction in dental caries

A total of 294 individuals in 11–12 years of age and 261 in 14–15 years were included for assessing dental caries status at baseline. The mean difference of the two studies was insignificant (P = 0.13). The overall effect of OHE in these age groups showed insignificant differences suggesting that dental health education has incomparable effect on age groups.

The follow-up analysis of caries status in the studies showed significant differences among the studies. Heterogeneity of the two studies was nil though overall nonsignificant differences between both the studies were noted with P = 0.77 suggesting an equal efficiency of OHE among 11–12 years and 14–15 years of age group [Figure 5].

Figure 5: Comparison of follow up values of caries status (11–12 and 14–15 years)

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Discussion

OHE is a traditional method of improving oral health knowledge, behavior, and practices in children and young adults which leads to the adaption of oral health behaviors for better oral health in later life. OHE is most effective when rendered at a younger age.^[23] Hence, studies with the population as school children of 4–15 years of age were included in this systematic review.

The present study ensured good quality as the studies included were all clinical trials, with standard methodological procedures and data reporting [Figure 6]. Owing to the nonstandardization in reporting gingival health, caries status, and plaque accumulation, the quantitative analysis confined to only five studies.

Figure 6: Risk of bias in individual studies

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The modes of OHE for children or school students have been evolved tremendously in recent years. Methods employed and the person rendering OHE among the selected studies varied widely. The traditional chalk and board method along with lectures by trained teachers attained similar effectiveness as demonstrations and lectures provided by dentists.

The present analysis did not make any efforts to differentiate between the type of aids used for OHE considering the scarce literature available and also not being mentioned in the included articles. Even though the OHE rendered by dentists seem to be more precise compared to that of trained school teachers, this study showed an equal effect of OHE in school children by both supported by the results of plaque index, gingival index, and DMFT index (P = 0.77) assessment. This may be because children spent more time with teachers and they are more trained in the process of transferring information. A 2 years or a minimum of 3 months intervention had a positive effect on improving oral hygiene status irrespective of the duration. Repeated sessions of OHE could have a positive effect on school childrens' oral hygiene knowledge as repeated listening can impose a better understanding of the importance of oral health in depth.^[8],[23]

In comparison with the experiment group (group receiving OHE), the control group (group without OHE) also showed some improvement in plaque index (P = 0.81) and gingival index (P = 0.51) after the intervention. The cross-over effect applies to the increased oral health status among the control group as children tend to share the achievements with their peers. Similar results were also demonstrated in three of the studies analyzed.^{[8],[19],[24]} Dental caries status showed no improvement postintervention suggesting OHE has minimal effect on caries prevention in three studies.^{[16],[17],[20]} The heterogeneity of the selected studies was more than 95%. The variability in the methods and materials used, person rendering, and varied duration of OHE used in studies contributes to the high heterogeneity.

Results of this review proposed that OHE rendered by school teachers is as effective as dentists which were similar to the results of the previous reviews conducted.^[9],[25] Better results would have been obtained if standardization in the method of brushing technique, diet counseling, and controlling of sugar intake were incorporated in the OHE. Authors recommend further studies to measure whether the long-term or short-term OHE programs with standardized methods for evaluating the effectiveness in school children.

Conclusion

Adaptation of proper oral hygiene practices at an early age reduces oral diseases. OHE is an effective traditional method of providing knowledge to improve oral health. Through this review, reduction in plaque accumulation and improvement in gingival health was evident through OHE of short time period. The reduction in caries status is in conflict with varying results in the reviewed studies. The long-term effect of the OHE still needs to be evaluated. Though qualified dentists are considered to be most suitable for providing OHE, there is an equal improvement in oral hygiene in school children who received oral education through school teachers. OHE rendered through various Media, also had a little difference in effectiveness when compared. Thus, the mode and person providing the OHE irrespective of the method and individual have positive effects on improving oral health among school children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer-reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee before starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Not applicable as this is a review article with no patients involved.

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