effectiveness of oral health education programs a systematic review

• DOI: 10.4103/2231-0762.127810
• Corpus ID: 6209987

Effectiveness of oral health education programs: A systematic review

• Priya Devadas Nakre , AG Harikiran
• Published in Journal of International… 1 July 2013
• Medicine, Education

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The impact of health education interventions on oral health promotion among older people: a systematic review, are educating and promoting interventions effective in oral health: a systematic review, oral health education and promotion activities by early head start programs in the united states: a systematic review., effectiveness of health education models and approaches in creating awareness on oral diseases among adolescents-a systematic review, effect of different methods of education on oral health in children with hearing impairment: a systematic review, oral health education and promotion programmes: meta‐analysis of 17‐year intervention, effectiveness of various methods of educating children and adolescents for the maintenance of oral health: a systematic review of randomized controlled trials., enhancing oral health literacy- a comprehensive review, the impact of dental care programs on individuals and their families: a scoping review, educational intervention of improve student's oral health: a systematic review and meta-analysis school-based, 39 references, is dental health education effective a systematic review of current evidence..

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Theory-based oral health education in adolescents.

A review of the effectiveness of oral health promotion activities among elderly people., the effectiveness of a 6-year oral health education programme for primary schoolchildren., effectiveness of an oral health education programme in primary schools in zimbabwe after 3.5 years., an oral health education programme based on the national curriculum., short-term impact of a national dental education program on children's oral health and knowledge., oral health promotion programme for older migrant adults., oral health care education and its effect on caregivers' knowledge and attitudes: a randomised controlled trial., experiences from a school-based oral health promotion programme in wuhan city, pr china..

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• Published: 23 May 2024

Effectiveness of school oral health programs in children and adolescents: an umbrella review

• Upendra Singh Bhadauria 1 ,
• Harsh Priya 2 ,
• Bharathi Purohit 1 &
• Ankur Singh 3  

Evidence-Based Dentistry ( 2024 ) Cite this article

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To evaluate the systematic reviews assessing the effectiveness of any type of school-based oral health programs in children and adolescents.

Methodology

A two-staged search strategy comprising electronic databases and registries based on systematic reviews was employed to evaluate the effectiveness of school-based interventions. The quality assessment of the systematic reviews was carried out using the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2) tool. The Corrected Covered Area was used to evaluate the degree of overlap.

Nine reviews were included in this umbrella review. The Critical Covered Area reported moderate overlap (5.70%) among the primary studies. The assessment of risk of bias revealed one study with a high level confidence; one with moderate whereas all other studies with critically low confidence. Inconclusive evidence related to improvements in dental caries and gingival status was reported whereas, plaque status improved in a major proportion of the reviews. Knowledge, attitude, and behavior significantly increased in students receiving educational interventions when compared to those receiving usual care.

Conclusions

The evidence points to the positive impact of these interventions in behavioral changes and clinical outcomes only on a short term basis. There is a need for long-term follow-up studies to substantiate the outcomes of these interventions.

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The data are available from the corresponding author on reasonable request.

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Bhadauria, U.S., Priya, H., Purohit, B. et al. Effectiveness of school oral health programs in children and adolescents: an umbrella review. Evid Based Dent (2024). https://doi.org/10.1038/s41432-024-01013-7

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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 .

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

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.

• 1. Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bulletin of the World Health Organization. World Health Organization; 2005. pp. 661–669. https://doi.org//S0042-96862005000900011 pmid:16211157
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• 8. World Health Organisation. WHO Information Series on School Health—Oral Health Promotion: An Essential Element of a Health-Promoting School. Geneva; 2003. Available: https://apps.who.int/iris/bitstream/handle/10665/70207/WHO_NMH_NPH_ORH_School_03.3_eng.pdf?sequence=1&isAllowed=y
• 9. World Health Organisation. School health services. [cited 25 Jul 2020]. Available: https://www.who.int/maternal_child_adolescent/adolescence/school-health-services/en/
• 16. Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Chapter 3: Systematic reviews of effectiveness. In: Aromataris E, Munn Z, editors. Joanna Briggs Institute Reviewer’s Manual. The Joanna Briggs Institute; 2017. Available: http://joannabriggs.org/research/critical-appraisal-tools.html

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.

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I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.

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Effectiveness of oral health education programs

A systematic review.

Nakre, Priya Devadas; Harikiran, A. G. 1

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

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

Corresponding author (email: < [email protected] >) Dr. Priya Devadas Nakre, Department of Public Health Dentistry, Rama Dental College, Hospital and Research Centre, Uttar Pradesh, India.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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 ].

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 ].

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 ].

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 ].

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 ].

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 ].

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 ].

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 ].

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 ].

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 ].

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.

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Effectiveness of oral health education on oral hygiene and dental caries in schoolchildren: Systematic review and meta-analysis

Affiliations.

• 1 Postgraduate Studies Program in Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
• 2 Department of Preventive and Social Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
• PMID: 28815661
• DOI: 10.1111/cdoe.12325

Objectives: The objective of this study was to evaluate the effectiveness of oral 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.

© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

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• Systematic Review
• Open access
• Published: 19 September 2024

Prevalence and causes of self-medication for oral health problems: a systematic review and meta-analysis

• Katayoun Katebi 1 ,
• Hosein Eslami 1 &
• Saba Jabbari 1  

BMC Oral Health volume  24 , Article number:  1115 ( 2024 ) Cite this article

Metrics details

Introduction

Self-medication, particularly for oral and dental health problems, stands as a significant health and social concern. Therefore, the current systematic review and meta-analysis study was conducted to evaluate the prevalence and underlying causes of self-medication for oral and dental health problems.

Articles published until August 30, 2023, were searched in Scopus, PubMed, and Web of Science databases. A manual search was also done in Google Scholar, references, citations, and Gray literature. The screening of articles was done independently by two members of the research team. The quality of reporting in the articles was evaluated using the JBI Critical Appraisal Checklist For Analytical Cross-Sectional Studies. Meta-analysis was performed using the fixed effects model in Stata software (StataCorp, version 16).

The results of 37 studies involving 12,110 participants with a mean age of 32 years and 48% male were analyzed. Most of the studies were conducted in low- and middle-income countries. The overall prevalence of self-medication was estimated at 59% [95%CI: 55–63%], with 58% [95% CI: 53–63%] among dental patients, and 60% [95% CI: 52–67%] in the general public. Analgesics (60%) and antibiotics (19%) were the most commonly used drug categories. In terms of the mean proportion, having previous experience, unbearable pain, and lack of time had the highest percentages, and in terms of the number of repetitions among the reviewed articles, economic problems, lack of time, and limited access were the most repeated reasons. The most significant related factors in self-treatment were female gender, higher education, and occupation. Pharmacies were the primary source of self-treatment medications.

The results showed a very high prevalence of self-medication for oral health problems, necessitating prompt and effective interventions. It is recommended to focus on regulating the consumption of analgesics and antibiotics, addressing financial issues, and overseeing the pharmacy operations.

Peer Review reports

The use of various forms of medications has been recognized as one of the tools in fighting the disease [ 1 ]. However, excessive drug use and self-medication are considered one of the biggest social, health, and economic challenges across many societies. Studies show a discrepancy between drug prescriptions and the actual needs of the population, often attributed to self-medication practices [ 2 ]. The World Health Organization has defined self-medication as the choosing and consumption of medications without a medical prescription to manage a disease or reduce symptoms. The reuse of previously prescribed medications for similar signs and symptoms is also included in this definition [ 3 ]. In some cases, self-treatment may exacerbate or mask symptoms, change the results of diagnostic tests, and delay patients seeking professional care [ 4 , 5 ]. Also, inappropriate or incomplete use of medicines can affect the health of society as well as the individuals, including numerous adverse effects and allergic reactions. Self-treatment in infectious diseases can also increase antibiotic resistance and complicate the issue [ 4 , 6 , 7 ].

Dentistry is one of the fields of medicine where the prevalence of self-medication is notably high leading to adverse consequences. According to the studies, the prevalence of self-treatment for oral and dental health problems is very high [ 8 , 9 , 10 , 11 , 12 ]. The results of the study by Khazir et al., which was conducted in India in 2022, showed that among 500 adults who were referred for dental care, 445 had a self-treatment experience with analgesics being the most frequently used medicine [ 13 ]. Similarly, the results of a study by Idowu et al. (2019) in Nigeria showed that self-medication was 41.5% among adults visiting outpatient dental clinics [ 14 ]. Considering the high frequency of self-medication and its risks, urgent measures are warranted to mitigate its impact. One of the main requirements in this field is to have accurate and reliable information on the prevalence, causes, and other dimensions of self-treatment for oral and dental health problems. While recent years have seen a surge in studies on this topic, many have been limited by small-scale settings and sample sizes, hindering their ability to offer robust insights for decision-makers. Therefore, a systematic review and meta-analysis are crucial to consolidate and present a comprehensive overview of the current landscape, aiding informed decision-making and strategic planning in addressing self-medication in oral health effectively.

This study is a systematic review and meta-analysis conducted in 2023 to estimate the prevalence, causes, and other aspects of self-treatment for oral and dental health problems. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for reporting [ 15 ].

Research question

The research question was formulated using the JBI approach for systematic reviews and meta-analyses of prevalence studies.

The population included all groups except for special patients (such as diabetics or children with special disorders), divided into two categories: general population and dental patients.

All countries.

The prevalence, causes, and other aspects of self-treatment for oral and dental health problems.

Search strategy

An experienced librarian, guided by a subject expert, developed and implemented the search strategy in Scopus, PubMed, and Web of Science databases (Appendix 1 - Search strategy). Articles published until August 30, 2023, were searched using related free and MeSH terms. Manual searches were conducted in reputable journals and Google Scholar to identify more published articles. Reference, citation, and gray literature checks were also performed to increase the confidence in identifying and reviewing existing articles.

Inclusion and exclusion criteria

Inclusion criteria: All studies published in English that reported the prevalence, causes, and other aspects of self-treatment for oral health problems.

Exclusion criteria:

Studies that focused on only one specific drug, such as antibiotics.

Studies that did not specifically examine the topic of self-treatment for oral health problems.

Studies and reports lacking full text or not being able to access their full text.

Articles whose target group was specific patients (diabetes, cancer).

Studies presented at conferences.

Selection/screening of studies

All stages of selection and screening of articles were conducted independently by two members of the research team. First, the titles of all articles were reviewed and the articles that were not compatible with the objectives of the study were excluded. The disputed cases were resolved by discussion, and if necessary, referred to a third researcher. In the next steps, the abstract and the full text of the articles were studied to identify and discard the articles with exclusion criteria or irrelevant to the study objectives. Endnote X5 resource management software was used for organizing, reading titles and abstracts, and identifying duplicates. PRISMA flowchart was used to report the results of the selection and screening process.

Assessing the reporting quality of articles

The reporting quality of all articles was evaluated independently by two evaluators using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies. The evaluation tool, adapted for this study, included seven questions, excluding question three (Was the exposure measured in a valid and reliable way?), which was not applicable. This tool includes Yes, No, Unclear, and Not applicable options. Articles were scored between 0 and 7 based on the number of “yes” responses. According to the study design (cross-sectional studies), no article was excluded from the study due to the quality assessment score. The final evaluation score for each article was given by agreement between two evaluators and disagreements between evaluators were referred to a third evaluator.

Data extraction

A data extraction form was designed manually in Microsoft Word 2013, including information such as author, year, country, participants, sample size, mean age, male percentage, prevalence of self-medication (%), drug groups, significant associated factors, causes of self-medication, and most common drug sources. First, the data from five articles were extracted for these forms, and the deficiencies and problems in the initial form were resolved. The information was extracted by two researchers independently, and ambiguous cases were resolved by consulting the third member.

Data analysis

Meta-analysis using the fixed effects model was performed to estimate the prevalence of self-medication, with Stata software (StataCorp, version 16). Forest plots were used to report the results, where the size of each square represents the sample size, and the lines drawn on each side of the square represent the 95% confidence interval for each study. The I 2 index was used to measure the heterogeneity, with I 2 less than 50% considered low, I 2 between 50 and 74 medium, and above 75% high heterogeneity [ 16 ]. Meta-regression was performed based on mean age (years) and percentage of men. Subgroup analysis was performed based on the participants. Meta-regression was conducted based on the mean age and percentage of men, and subgroup analysis was performed based on participants. Funnel plots, Galbraith diagrams, and Egger’s regression test at a significance level of 0.1% were used to assess publication bias [ 17 ]. Since the probability of publication bias was low, the Trim and Fill test was not used. Other information was summarized and reported using descriptive statistics (mean, percentage, and frequency) in Microsoft Excel 2010 software, which was also used for graph creation.

A total of 423 studies were extracted by searching the databases. After removing duplicate articles using Endnote software, 314 articles entered the screening stage. In this phase, 240 articles were excluded since they were not relevant, and the full text of 3 articles was not accessible. In the second phase of screening, the researchers reviewed the full text of the remaining articles. After reviewing the full text of the articles, 34 other articles were excluded from the study due to being unrelated and not meeting the inclusion criteria, and finally, 37 articles were included in the study [ 9 , 10 , 11 , 13 , 14 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ] (Fig.  1 ).

Screening process of studies related to the prevalence and causes of self-treatment for oral health problems

Study characteristics

The reviewed studies were conducted in 13 different countries, with India having the largest number of studies with 16 studies. Articles were published between 2011 and 2023, with a median publication year of 2018. The total sample size across the 37 articles was 12,110. Dental patients were the focus of 28 studies, while the general public was studied in nine. Participants had an average age of 32.2 years, with 48% being male. Most studies (86.5%) were conducted in middle- and low-income countries (Appendix 2 - Data extraction table).

Prevalence of self-medication for oral health problems

Based on the results of the meta-analysis, the prevalence of self-medication was estimated to be 59% [55–63% with 95% CI] in total. This rate was 58% [53–63% with 95% CI] for dental patients and 60% [67 − 52% with 95% CI] for the general public (Fig.  2 ). Cumulative analysis by publication year showed a slight decreasing trend in self-medication prevalence, though not statistically significant (Appendix 3 - Cumulative Forest plot chart). Heterogeneity testing indicated relatively low heterogeneity in study results (I2 = 46.9, Q = 67.8, p  = 0.00).

Meta-analysis of the prevalence of self-medication for oral health problems based on the fixed effects model

Publication bias was found to be low (Egger test P  = 0.122 Z=-1.55) (Appendix 4 Galbraith chart, Funnel Plot). The results of meta-regression with a random effects model based on the variables of the mean age (years) and the percentage of men showed that only the average age of the participants significantly predicts the prevalence of self-treatment for oral health problems (R Coefficient = 0.010, P  = 0.003).

Medication groups and materials used in self-treatment for oral health problems

Based on the results of the included studies, five drug groups were commonly used for self-treatment in oral and dental health problems. Analgesics had the highest mean proportion of consumption, with about 60%, followed by antibiotics, with about 19% (Fig.  3 ).

The frequency of drug categories used in self-treatment of oral and dental health problems

The causes of self-treatment for oral health problems

Based on the results of the reviewed articles, nine of the most important causes of self-treatment for oral health problems were extracted. In terms of the mean proportion, having previous experience, unbearable pain, and lack of time had the highest percentages, and in terms of the number of repetitions among the reviewed articles, economic problems, lack of time, and limited access were the most repeated reasons (Fig.  4 ).

Mean ratio and frequency of self-treatment causes for oral health problems

Factors influencing self-treatment

From 10 studies, 22 factors (including repeated cases) that were significantly effective in self-treatment for oral and dental health problems were extracted (factors that were not significant were not extracted). The most significant extracted factors included female gender, higher education, and occupation.

Source of medication for self-treatment

Pharmacies emerged as the primary source of medication for self-treatment in 18 out of 19 studies, accounting for 61% of cases. In one study, street vendors were reported as the main drug supply source, comprising about 36% [ 14 ].

The results of evaluating the quality of reporting

The mean score of the reporting quality of the articles was estimated to be 3.82 out of 7 (median = 4). The most important weaknesses of the articles were related to confounding variables. Also, most of the articles did not use appropriate statistical methods to report the results. Most articles relied on descriptive statistics, lacking advanced analytical methods like regression (Appendix 5 - Results of the evaluation of the quality of reporting of articles).

The overall prevalence of self-medication was estimated at 59%. Analgesics, with about 60%, and antibiotics, with about 19%, were the most common medication categories used in self-medication for oral and dental health problems. In terms of the mean proportion, having previous experience, unbearable pain, and lack of time were the most important reasons for self-treatment, and in terms of the number of repetitions among the reviewed articles, economic problems, lack of time, and limited access were the most repeated reasons. The most significant contributing factors in self-treatment for oral and dental health problems were female gender, higher education, and occupation. Pharmacies were the most important source of medication for self-treatment of oral and dental health problems.

The results of similar systematic review studies in other fields, ethnic groups, and specific countries also show that the prevalence of self-medication is very high, and it is one of the major health and social concerns [ 50 , 51 , 52 , 53 ]. Therefore, special attention should be paid to designing and implementing effective interventions to reduce this problem. Interventions such as increasing the level of public awareness about the adverse effects of self-medication, regulating policies in pharmacies and drug prescriptions, and promoting the policy of returning unused drugs to pharmacies are among the most important interventions that can be considered by relevant authorities [ 54 , 55 , 56 ]. Most of the studies reviewed in this study were conducted on the prevalence of self-medication for oral health problems in low- and middle-income countries. The systematic review studies of Limaye, in 2017, which examined 154 articles related to self-medication [ 57 ], Gualano et al. (2015), which examined the prevalence of self-medication among adolescents [ 58 ], and the study by Shaghaghi et al. (2014) who investigated the behaviors that determine self-treatment [ 59 ], also reported the same results. This issue can have two major possible reasons; one is that countries with high income are facing less of such a problem, or at least they were able to solve this problem to some extent. Second, due to the existence of strong information systems in these countries, up-to-date and accurate statistics are available, and researchers are less willing to conduct prevalence studies to estimate the extent of this problem. However, considering the high prevalence of self-medication in low- and middle-income countries and its high complications, it is recommended that coherent and efficient online information systems for collecting, analyzing, and continuously reporting information related to self-medication be designed.

In this study, based on the results of the reviewed articles, nine of the most important causes of self-treatment for oral health problems were extracted. Examining the pattern of these causes with other studies shows the high similarity and overlap of these cases [ 60 ]. An important point that should be noted is that many of these causes, regardless of the socio-economic factors, culture, and healthcare systems of the countries, are to a large extent similar between all countries, and therefore, using the experiences of the leading countries in controlling and reducing self-treatment can result in successes in this field.

The results of the present study showed that analgesics and antibiotics were the most commonly used drug groups in self-treatment for oral and dental health problems. This finding is consistent with the results of previous systematic review studies [ 50 , 59 , 61 , 62 , 63 ]. In addition to the easy access to these drugs in most countries, which are considered Over-the-counter (OTC) drugs, the public’s belief in the harmlessness of these drugs can be another important factor in the widespread arbitrary use of these drug groups. Therefore, increasing people’s awareness about the side effects of taking these medications without a prescription seems necessary. Due to severe toothache and the urgent need to reduce the pain, people take this type of medicine arbitrarily.

In the field of oral and dental health problems, it seems that, along with other important causes, economic problems are very important, and this issue can have two main reasons; one is that, as mentioned, most of the studies were conducted in middle and low-income countries and therefore, people are facing economic problems. The second reason for this could be the high costs of dentistry in these countries and the lack of adequate insurance coverage for these services. This issue has been reported in high-income countries as well [ 64 , 65 , 66 ].

Similar to many studies, the results of this study showed that pharmacies are the most important source of self-medication. This issue can be an indicator of extensive flaws in drug distribution networks in various countries, especially in low- and middle-income countries. Therefore, greater control and sensitivity by pharmacies in the field of providing drugs without a prescription and informing people about the side effects of self-medication can have a great impact on the management of this issue.

The most significant effective factors in self-treatment for oral and dental health problems included female gender, higher education, and occupation, which are highly similar to other studies conducted in other fields and groups [ 62 , 67 ].

The present study had several limitations. Therefore, it is recommended to interpret the conclusions with caution. One of the most important of them is the limitation of searches to English. If the results of studies published in other languages were included in the analysis, the results might have been different. One of the problems in the reporting of the articles was the limited and sometimes ineffective statistical methods. Few studies have used advanced statistics such as odds ratio. Therefore, in addition to the need for more studies on the effective factors and the mechanism of their impact in the field of self-treatment, focusing on the identified factors can increase the effectiveness of interventions and self-treatment control programs.

The results of the present study showed that the prevalence of self-treatment for oral and dental health problems is high. Analgesics and antibiotics were the most commonly used drug groups. Having previous experience, unbearable pain, and lack of time were the most important reasons for self-treatment. Pharmacies were the most important source of medications for self-treatment. Effective and comprehensive interventions should be designed and implemented to manage this problem. In the implementation of these interventions, it is recommended to focus on analgesics and antibiotics, financial issues, and controlling the pharmacies. It is recommended to identify more contributing factors and use effective and more advanced statistical methods in future studies.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

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Katebi, K., Eslami, H. & Jabbari, S. Prevalence and causes of self-medication for oral health problems: a systematic review and meta-analysis. BMC Oral Health 24 , 1115 (2024). https://doi.org/10.1186/s12903-024-04900-8

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Clinical Effectiveness and Cost-Effectiveness of Oral-Health Promotion in Dental Caries Prevention among Children: Systematic Review and Meta-Analysis

Nadine fraihat.

1 Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, H-4002 Debrecen, Hungary

Saba Madae’en

2 Department of Clinical Pharmacy, Faculty of Pharmacy, University of Jordan, Amman 11942, Jordan

Zsuzsa Bencze

Adrienn herczeg, orsolya varga.

The objective of this study was to evaluate the clinical effectiveness and cost-effectiveness of oral-health promotion programs (OHPPs) aiming to improve children’s knowledge of favorable oral health behavior to lower decayed/-missing/-filled teeth (DMFT) while reducing the financial cost on health institutions. An electronic search was performed in seven databases. Studies were restricted to human interventions published in English. The search study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, and the risk of bias was assessed based on the Drummonds Checklist. A total of 1072 references were found. Among these, 19 full texts were included. Most studies had a strong quality. The overall pooled impact of OHPPs estimates children suffering from DMFT/S to have 81% lower odds of participating in OHPP (95% CI 61–90%, I 2 : 98.3%, p = 0). Furthermore, the program was shown to be effective at lowering the cost in 97 out of 100 OHPPs (95% CI 89–99%, I 2 : 99%, p = 0). Three subgroups analyses (age groups, study countries, studies of the last five years) were performed to evaluate the influence modification on the pooled effect. A comprehensive analysis of the OHPPs confirmed a reduction effect on child DMFT, hence, lowering the financial burden of dental-care treatment on health institutions.

1. Introduction

Dental caries represents a globally known preventable non-communicable diseases which is considered a major public-health problem affecting all age groups, especially children. Health promotion that goes beyond health care puts health on the agenda of policymakers in order to achieve better health outcomes [ 1 ]. Oral health promotion plays an essential part in the health of the general promotion [ 2 ] since the inter-relationship between oral and general health has been approved [ 1 ], for instance, through strong statistical correlation between periodontitis and diabetes [ 3 ]. Thus, oral- and general-health promotion addresses the inseparable issues of all systemic and oral-health-diseases, specifically through general and oral hygiene, general- and oral- health-care attitudes, and general-health and dental-care services [ 2 ]. In fact, dental programs and oral health prevention programs rarely receive the same level of attention as medical care among decision-makers when taking into account the cost-effective allocation of scarce health care resources [ 4 ]. However, to allocate scarce healthcare resources, further information and studies are needed based on health economic evaluation [ 5 ]. Moreover, considering the economic impact of dental caries on different populations in countries around the world would serve health authorities for reaching reliable public-health decisions regarding the cost of oral-health diseases.

In the context of oral health, however, the 2016 Global Burden of Disease Study “estimated that oral diseases globally affect at least 3.58 billion people, with caries of permanent teeth, being the most prevalent of all assessed conditions. Globally, it is estimated that 2.4 billion people suffer from caries of permanent teeth, and 486 million children suffer from caries of primary teeth” [ 6 ]. Dental caries is the most prevalent chronic disease among children, and dental care is the greatest unmet healthcare need [ 7 ]. According to the World Health Organization (WHO), in European countries tooth decay among six-year-old children varies from 20% to 90% [ 8 ]. Approximately, a quarter of five- to six-year-old children experience tooth decay, and the percentage rises above 90% in some low- and middle-income countries, indicating dental caries is a permanent public-health problem [ 9 ]. WHO oral-health goals have been formulated for the year 2020 as part of the WHO Health 21 policy for Europe [ 10 ] suggesting that “by 2020, a percentage of at least “80%” of children at the age six should be caries-free and, on average, no more than 1.5 Decayed/-Missing/-Filled Teeth should be observed for children of 12 years of age”.

Given the extent of the problem, the economic burden of dental caries treatment is a large share of many countries’ healthcare budget. Consequently, a study in Colombia measured the economic impact of dental caries 2011, where the cost of dental caries represented 0.02% of 2011 at the current GDP, which means that there was approximately an expenditure of $1.46 for each Colombian citizen to treat dental caries, where the government could draft cost-effective oral-health policies to reduce dental caries prevalence in Colombia’s population [ 11 ]. In order to estimate dental caries expenses among children, the Medical Expenditure Panel Survey reported in 2006 that approximately 19% of children younger than 5 years old had dental expenditures of $729 million [ 12 ].

Since education and oral -health prevention programs for all family members, children and parents, at all socio-economic levels are the only means to avoid dental caries [ 8 ], dentists and oral healthcare providers prioritize oral-health promotion [ 8 ]. To achieve such goals, Oral Health Promotion Programs (OHPPs) for children are globally implemented in diverse communities and have been shown to be a useful intervention to control dental caries. However, economic evaluation of their cost-effectiveness to determine the programs value for money remains unclear.

This review seeks to determine if implementing an appropriate oral -health promotion program reduces dental caries among children, and the financial cost on healthcare institutions. We hypothesize that exposure to oral health promotion programs reduce dental caries among children, and health care costs.

2. Materials and Methods

The review protocol was registered in the international database of prospectively registered systematic reviews in health and social care (PROSPERO), Centre for Reviews and Dissemination, University of York (No: CRD 42019125611). Although there is no standard protocol for economic evaluation studies, one of the reviews in the literature recommended a protocol to improve the preparation of reviews of healthcare economic evaluation [ 13 ]. The criteria for considering studies for this review are as follows:

2.1. Type of Studies

The review included trial and model-based economic evaluation studies.

2.2. Included Participant, Intervention, Comparator, and Outcome (PICO) Terms

Participants:

• Children aged from 0 to 12 years old who were healthy without health-related diseases except for dental caries.
• Studies of mixed populations of parents and children were included where the data of children were presented separately.

Interventions:

• Community-based oral-health education/training programs related to healthy oral habits.
• Screening of children’s teeth.
• Supervised toothbrushing technique through the provision of toothbrushes, an appropriate amount of fluoride toothpaste, and topical fluoride.
• Advice on dietary control, such as limitation of sugar or carbohydrates consumption, and enhanced fortified nutrition with an appropriate amount of calcium intake.

Comparator: not providing an oral-health promotion program or could have been providing a differing action than the intervention group, within similar conditions.

Context: OHPPs implemented by oral-health professionals in the contexts of home visits, telephone calls, healthcare centers and primary schools.

• Reducing the “Decayed, Missing, Filled Teeth (DMFT) Index for permanent teeth or (DMFT) Index for deciduous teeth” among children.
• OHPP cost, incremental cost (difference between mean costs of intervention and mean costs of the comparator), and cost-effectiveness analysis (CEA).

The search strategy and selection process included relevant PICO terms, prospectively defined, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The initiated search date was 11 December 2018, where the restriction concerning the publications was for the English language. The following bibliographic databases were searched, and Mesh terms and Emtree were used: PubMed: “ “Costs and Cost Analysis”(Mesh) AND (“Oral Health”(Mesh) OR “Dental Caries”(Mesh) OR “Dental Care for Children”(Mesh)) AND (“Child”(Mesh) OR “Child, Preschool”(Mesh))”; Excerpta Medica Database (EMBASE): “(‘mouth hygiene’/exp OR ‘dental caries’/exp OR ‘dental prevention’/exp OR ‘dental procedure’/exp) AND ‘economic evaluation’/exp AND ‘child’/exp”; DARE, NHSEED and HTA: (Oral Health OR Dental Caries OR Dental Care) AND (Child OR Preschool Child OR Infant); Cost-Effectiveness Analysis (CEA) Registry: “Dental Caries, Oral Health, Dental care”, Paediatric Economic Database Evaluation (PEDE): “Dental Caries”.

The title, abstract and full text of each study were screened and accurately assessed. The used method for the selection criteria was importing the searched outcomes in the bibliographic reference software EndNote X7 to remove duplicate records and to precisely screen records through two phase screening. During the first phase screening of titles and abstracts, irrelevant records were basically categorized as intervention, opinion, reviews, participants, outcomes, not English language, the exclusion criteria of irrelevant records were clearly explained as participant with health-related diseases or aged older than 12 years; interventions other than OHPP, such as implant dentistry or other invasive-dentistry programs; other economic-evaluation outcomes such as cost-benefit, cost-utility or cost-minimization; authors’ opinion (unoriginal records); study reviews; and study language other than English. The second-phase screening completely assessed the full article text of articles to verify the level of consistency that the studies had with the eligibility criteria. In addition, data extraction was gathered by formulating two tables using Windows Excel 2013 (Microsoft, Redmond, WA, USA), to separately collect the qualitative and quantitative data. ( Appendix A , Table A1 and Table A2 )

Meanwhile, data that were extracted from the included criteria studies the risk of bias in studies that were detected simultaneously. The Drummond Checklist provides useful guidance applied to clarify the included studies with 10 answerable questions (yes, no, or not available), assuming the assessment result as strong, moderate, or weak, (see Table A3 and Table A4 ) [ 14 ].

Table A3 : represent 10 trial-based economic evaluation studies assessed by 10 questions of the Drummond checklist.

Table A4 : represent nine model-based economic evaluation studies assessed similarly by nine questions of the Drummond checklist.

For meta-analysis, we included eight studies; the missing data dealt with contacting study authors. STATA Software version 14 (StataCorp LP., College Station, TX, USA) was used. Where the pooled figures were multiplied by 100 due to software technical competency, a few missing data were replaced by the number 1 as an integer. The cost in diverse countries with different currencies was converted to 2015 prices of USA dollars. For studies using the USA dollar, we measured the inflation rate for each study considering the 2015 standard year. Data analysis was performed through founded dichotomous outcomes such as the number of children in the intervention and in the control group, the DMFT index in children, and the OHPP cost. Odds ratio (OR) is an effect size with 95% confidence interval (CI) and study weights were estimated from random effects analysis. Forest plots for each needed outcome were demonstrated, and the chi-square test was used to assess whether the observed differences were homogeneous or heterogeneous where a P value of less than 0.1 indicated statistically significant heterogeneity. An I 2 test was used to quantify inconsistencies between studies as the percentage of variation across studies was measured where heterogeneity was quantified as 0% to 40% implying slight heterogeneity, 30% to 60% implied moderate heterogeneity, 50% to 90% implied substantial heterogeneity and 75% to 100% implied very substantial (considerable) heterogeneity. Data synthesis was carried out using narrative demonstration, with a summary of the characteristics of each included study. For quantitative synthesis, a summary of the combined estimation related to the OHPP effect was measured. Due to heterogeneity analysis, three subgroups were performed to assess the modification influence on the pooled effect through the age of the children, studies of the last 5 years and the country of the study. Egger’s regression test and a funnel plot were used to assess and demonstrate publication bias, as publication bias was considered present if the p -value of the Egger test was more than 0.05.

Overall, 1072 records were retrieved for eligibility screening. After removal of duplicates, 404 records were obtained. Screening of titles and abstracts excluded 359 records, given the proper reasons when records were not relevant to the aim of the review. We assessed 45 full texts of articles and identified 19 articles for qualitative synthesis and eight articles for quantitative synthesis. Figure 1 shows the PRISMA flow diagram for the inclusion of studies.

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram for the inclusion of studies.

The 19 included studies [ 5 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ], which are illustrated through the general characteristics, in Table A1 in Appendix A had one or more intervention(s) in the included OHPPs, while the majority of studies examined the implementation of OHPPs in the intervention group compared with dissimilar or absent intervention in the control group.

Furthermore, the included studies originated from diverse countries: United Kingdom (n = 6; 31.6%), Australia ( n = 5; 26%), United States ( n = 3; 16%), Finland ( n = 1; 5%), Japan ( n = 1; 5%), Nigeria ( n = 1; 5%), Singapore ( n = 1; 5%) and Ireland ( n = 1; 5%) with diverse currencies used in different time longevity of the OHPPs. In addition, the review is based on ( n = 9; 47%) trial-based economic-evaluation studies, and ( n = 10; 52%) model-based economic evaluation studies with two different age groups where 14 studies were of younger than 6-year-old children and four studies age were of older than 6 years old, and one study did not mention the age of the children. Of all studies, 47% were published in the last 5 years.

For the quantitative data, Table A2 : presents the cost-effectiveness outcomes of the included studies. Table A2 : presents the cost in the intervention and in the control group, measured by the incremental cost based on the type of found outcomes in the included studies, such as DMFT, Average of dental visits, number of prevented caries teeth, average of cavity-free months, probability of less cost, caries percentages, number of into the mouth of babes program visits (no. of IMB), quality-adjusted life year (QALY) (measure of disease burden, including the quality and the quantity of life lived, it can be used in cost-effectiveness studies to assess the value for money of clinical interventions), cost-effectiveness ratio, and percentages of not having debris. The table also includes the outcome-effect result in the intervention and the control groups, Incremental Cost Effectiveness Ratios (ICERs), cost saving, indirect cost, and total program cost.

Nineteen studies were included in the systematic review and meta-analysis, and the Drummond Checklist [ 14 ] was used to assess the risk of bias in the trial- and model-based economic evaluation studies. The included studies were ten trial-based economic evaluation studies and nine model-based economic evaluation studies. Out of the 19 included studies, 12 studies had a low risk of bias and seven had a moderate risk of bias.

3.1. According to the Review, to Summarize the Studies That Met the Inclusion Criteria

3.1.1. strong-quality “model-based” economic evaluation studies.

A study by Kowash [ 15 ], which was conducted in the UK over three years, aimed to provide a dental health education program of home visits with mothers of eight-month-old young infants to prevent early-childhood caries (ECC). It provides strong evidence for the reductions of dental caries associated with deemed cost saving based on program intervention; DMFT had a 0.29 score in the intervention group, and 1.75 in the comparative group. The author concluded that “oral health-education gave better costs-effectiveness ratios than another preventive program”. In addition, a study by Pukallus [ 16 ] estimated that oral-health advice of oral health therapists, delivered within five and a half years through calling the parents with children with a mean age of 1 year, saved $108,406.92 the year of 2012.

The 2006 study by Quinonez [ 17 ] aimed to examine the cost-effectiveness of fluoride varnish application by medical providers. The intervention was the application of universal fluoride varnish at 9, 18, 24, and 36 months as cycles extended to 42 months. The study analyzed cavity-free months, which were equal to 31.49 in the intervention group and 29.97 in the control group; in terms of cost, intervention cost was $181.66 in 2003 and $170.73 in the control group in the same year; hence, it increased incremental cost to $10.93 in 2003.

Furthermore, Stearns [ 18 ] estimated the cost-effectiveness of medical office-based preventive oral health, where the program was effective in the terms of cost. The cost of intervention was $54.81 which is less than the cost of control $285.8 as cost-saving reached $33.64 in 2006.

A study by Anopa [ 19 ] which was about a national supervised tooth-brushing program, found the program to save cost. It aimed to compare the cost of providing a supervised toothbrushing program with National Health Service (NHS) cost savings. It assumed the total reduction in tooth decay in five-year-old children was due to the tooth brushing program. The study measured the avoided cost per DMFT as incremental cost about (−) $197.44 in 2009, and the cost-saving was estimated to be $6,912,617 within the same time frame. Thus, the authors speculated that the cost-savings of the tooth brushing program can be successful in most socio-economically deprived children.

Another study by Blaikie [ 20 ] was preliminary economic analysis that was conducted in Australia over seven years from 1970 until 1976 to study the cost of school dental care for school-age children to provide the best care at the lowest cost. It compared the fee-for-services-based program with the regular community dental health branch cost in which the founded costs were $3,259,846 for the free for service an oral screening program and $3,034,576 for community dental health branch in the year of 1976. The author suggested that “the Dental Health Branch was more cost-effective than the proposed fee-for-service alternative as the program is an economically acceptable method of delivering school dental care”.

Moreover, Samnaliev [ 21 ] was entitled to measure the cost-effectiveness of a disease management program for early childhood caries. The caries percentages in the case group were equal to 4.15% compared with the control group which was equal to 22.5%, thus for the incremental cost of the program was equal (−) $8380 in the year of 2011, where the cost-saving reached $904 in the same year. It appeared that “the program is cost-effective and has the potential to reduce healthcare costs”.

3.1.2. Moderate Quality “Model-Based” Economic Evaluation Studies

Takeuchi’s [ 22 ] study was conducted in Japan for 12-year-old children; the study proved its health effect to decrease DMFT score in the intervention group as it was scored (2.2) DMFT compared with (4.86) DMFT score in the control group. It could not prove the effect in the terms of cost when the total program cost reached $2432.52 in 2006. The second moderate quality study was by Plonka [ 23 ]; a longitudinal study of home visits compared to telephone contacts to prevent ECC. The program was effective in terms of health gain, as the caries percentages in the case group reached 2% compared with the control group, which was 15%. The study did not take into account the cost-saving of the program, hence the author concluded: “the home visits and telephone contacts conducted every 6 months from time of birth are effective in reducing ECC prevalence by 24 months”.

3.1.3. Strong-Quality “Trial-Based” Economic Evaluation Studies

Tickle [ 24 ] measured the effects and costs of a dental caries prevention regime for young children. Although the intervention group had lower DMFT than the control group, the intervention program cost was higher, with incremental costs reaching $167.61 in 2015. Additionally, Donaldson [ 25 ], based in the UK, gave additional information about the three-year-long study of caries reduction after topical application of 4% sodium fluoride per oral (NaFPO). Although it reduced caries, the program incremental costs reached $71.97 in 1974.

In contrast, an Irish study by O’Neill [ 26 ] took three years, in which participants were centrally randomized into the intervention of 22,600 ppm fluoride varnish, toothbrush, a 50-mL tube of 1450 ppm fluoride toothpaste, and standardized prevention advice, while the control group with oral health advice only. Although the program was effective in reducing caries, incremental cost in 2014 was $350.06. For older children aged 11–12, a strong-quality study by Hietasalo [ 5 ] assessed the cost-effectiveness of a preventive program including a package of oral health advice, preventive treatment, and free materials that were delivered by dental hygienists for 497 children with at least one active caries lesion. The author estimated an incremental cost per Decayed Missing Filled Surface (DMFS) avoided $87.78 in 2004.

3.1.4. Moderat Quality “Trial-Based” Economic Evaluation Studies

Reiss [ 27 ] encouraged the low-income families of 51 children to seek dental care for their children. The incremental cost in 1976 reached $27.68. Koh [ 28 ] conducted a study over five and a half years that evaluated the cost-effectiveness of home visits and telephone contact in preventing ECC in children aged from six months to six years. The perspective of the analysis was societal, considering the costs to the parent and the health system. Where the program was effective in terms of gained QALY, intervention cost reached $68 in 2014 compared with the control cost which reached $8448 in the same year. Incremental cost reached (−) $8380 in 2014. Another trial, reported by Davies [ 29 ] evaluated the cost-effectiveness of a postal toothpaste program to prevent caries in five-year-old children. The report found that free toothpaste on four occasions a year, and a toothbrush once a year for four years, was effective to reduce the DMFT to a score 2.15 in the intervention group, compared with the control group, with a DMFT score of 2.57. Cost-saving reached $2217.45 in 1992. Economic analysis resulted in an overestimation of the cost and underestimation of the benefits.

3.1.5. Limited Economic-Evaluation Outcomes of Moderate Qualified “Trial-Based’ Economic-Evaluation Studies and “Model-Based” Economic-Evaluation Studies”

Although the three remaining studies (Folayan [ 30 ], Lai [ 31 ], and Gibbs, L [ 32 ]), delivered reliable OHPPs, the economic evaluation of the program could not be demonstrated as needed. Folayan [ 30 ] aimed to determine the association between the use of recommended oral self-care caries (ROSC) prevention tools and the presence of dental caries in children residing in suburban Nigeria. The intervention group were encouraged to brush more than once a day, use fluoridated toothpaste, and to eat sugary snacks between main meals less than once a day. The study intervention used ROSC caries prevention tools in combination. Conversely, the control group was exclusively using ROSC prevention tools. It was found that the use of the combination of ROSC caries prevention tools made the probability less costly and more efficient, as the probability of less cost in the intervention group was 98.6%, while it was 61.5% in the comparative group.

Lai [ 31 ] aimed to examine the clinical efficacy of a two-year oral health program for infants and toddlers. The intervention group undertook oral-health education on tooth brushing and fluoride use, non-nutritional habits, trauma prevention, and use of topical fluoride varnish, and this was compared with no oral-health education. Consequently, mean caries reached seven in the intervention group, whereas, it reached 20 in the control group. However, the odds of severe ECC in the control group were three times higher than the intervention group.

A study by Gibbs [ 32 ] was based on child oral-health promotion, enrolling migrant families in Australia. The community oral-health education sessions were led by peer educators. Follow-up health messages were given in the intervention group, and the control group had no oral health education. The percentage of not having debris was estimated to be 56% higher in the intervention than the controlled group. The author concluded that intervention of oral-health education session was likely to improve knowledge, behavioral skills, and also adherence to following up. The program cost was $362,329.66 in 2012.

3.2. Meta-Analysis

Findings of the meta-analysis summarized through eight studies [ 5 , 15 , 19 , 22 , 24 , 25 , 26 , 29 ] were included in the quantitative analysis of the effect and cost effect of the OHPPs. The eight selected studies for meta-analysis were analyzed based on the incremental cost of the OHPPs per DMFT and Decayed Filled Teeth (DFT) or DMFS. The cost-effectiveness outcomes are presented in Table A2 , covering incremental cost, type of study outcomes, ICER, cost saving, indirect cost, and total program cost. Major findings of the meta-analysis are presented in Figure 2 , Figure 3 , Figure 4 , Figure 5 and Figure 6 , STATA do-files for analysis of the figures are presented in the ( Appendix B , Figure A1 , Figure A2 , Figure A3 , Figure A4 , Figure A5 and Figure A6 .

Forest plots of Decayed Missing Filled Teeth (DMFT)/S by the participating children.

Forest plot of incremental cost-effectiveness per DMFT/S.

Forest plot of DMFT/S by children age group: 1 as (Age > 6) and 2 as (Age ≤ 6).

Forest plot of the incremental cost-effectiveness of the intervention and the control groups by the age groups: 1 as (Age > 6) and 2 as (Age ≤ 6).

Forest plot for the difference in the DMFT of the intervention group compared to the control group regarding the study years.

Figure 2 shows that the overall pooled impact of OHPP estimates in children who suffer from DMFT/S had 81% lower odds to participate in OHPP (95% CI 61–90%, I 2 : 98.5%, p = 0) with considerable heterogeneity among studies. The reference categories were used in the measurement: “DMFT/S in the intervention group and the number of children in the intervention group”, “DMFT/S in the control group and the number of children in the control group”.

Figure 3 illustrates that the OHPPs had a successful intervention in reducing financial costs in 97 out of 100 OHPPs (95% CI 89–99%, I 2 : 99%, p = 0) with considerable heterogeneity among studies. The reference categories were used in the measurement “the cost of the program in the intervention group and DMFT/S in the intervention group”, and “the cost of the program in the control group and DMFT/S in the control group”.

Due to considerable heterogeneity between the included studies, subgroup analysis was measured to assess the influence modification on the pooled effect by children’s age groups, study countries, and publication date before and after 2015. Figure 4 represents the subgroup analysis according to the age groups.

Studies reported children of less than six years weighted 70.73% with an OR of 0.14 (95% CI, 0.05–0.39, I 2 : 98.5%) had the highest benefit of OHPPs to lower DMFT/S, while studies reporting children aged six years and older weighted 29.27% with an OR of 0.29 (95% CI, 0.08–1.01, I 2 : 99.2% ) had no benefit from OHPPs in lowering DMFT/S. Reference category measurements were: “DMFT/S in the intervention group and the number of children in the intervention group”, and “DMFT/S in the control group and the number of children in the control group” by two age categories.

Figure 5 shows studies that reported children who were less than six years old with an OR of 0.07 (95% CI, 0.02–0.32) revealing no cost-effectiveness effect to reduce OHPP incremental cost, whereas studies reporting children aged six years and older with an OR of 0.0 (95% CI, 0.00–48,704.6) was cost-effective in reducing the OHPPs incremental cost in this age group. The reference category measurements were “DMFT/S in the intervention group and the cost of the program in the intervention group”, “DMFT/S in the control group, the cost of the program in the control group)” by the two age categories.

Studies published after 2015 weighted 51.13% revealed a clinical effect of OHPPs to reduce DMFT as an OR of 0.08 (95% CI 0.01–0.53); studies published before 2015 weighted 48.87% revealed a significant effect of OHPPs to reduce DMFT among children with an OR 0.01 (95% CI 0.00–0.13). The reference category measurements were “DMFT/S in the intervention group and number of children in the intervention group”, “DMFT/S in the control group and the number of children in the control group” by two group study year publishment.

Moreover, the study countries of the OHPPs were analyzed, (see Figure 7 ). The United Kingdom country weighted 59.18%, revealed significant proof that OHPPs had a reducing effect on DMFT/S as an OR of 0.04 (95% CI 0–0.58). The same findings were seen in Japan, Ireland, and Finland, countries with an overall OR of 0.03 (95% CI 0.01–0.11) resulting as “OR 0 (95% CI, 0–0) weighted 10.71%, OR 0.52 (95%CI, 0.45–0.61) weighted 15.06%, and OR 0.48 (95% CI 0.41–0.56) weighted 15.06%” respectively. These countries had significant impact on the overall pooled effect to prove that OHPPs had a reduction effect of DMFT/S among children. The measured reference categories were “DMFT/S in the intervention group and number of children in the intervention group”, “DMFT/S in the control group and the number of children in the control group” by the study countries.

Forest plot for the difference in the DMFT/S of the intervention group compared to the control group by study countries.

Due to considerable heterogeneity, the Eggers regression test was performed to analyze for publication bias. A publication bias is considered present if the p -value of the Egger test is more than 0.05. Major findings of the Eggers regression tests are presented in Figure 8 and Figure 9 .

Eggers regression test to test hypothesis 1.

Eggers regression test to test hypothesis 2.

In this way, we assumed two hypotheses. H null: the result of meta-analysis had no effect of DMFT among children with no small sample size; and H alternative: the result of meta-analysis had a reducing effect of DMFT among children with a small sample size. A p -value of 0.53 was more than 0.05 in the review and publication bias was present; thus, we reject the null hypothesis and accept the alternative hypothesis.

We assumed two hypotheses. H null: the result of meta-analysis had no effect of OHPP to reduce the financial cost on health institutions with no small sample size; and H alternative: the result of the meta-analysis had a reducing effect of OHPP on the financial cost on health institutions with a small sample size. A p -value of 0.39 was more than 0.05 in the review and publication bias was present; thus, we reject the null hypothesis and accept the alternative hypothesis.

We used the “funnel plot” tool to demonstrate the reason for the publication bias in the meta-analysis. It is a simple scatter plot of the treatment effects, as the ratio measures the odds ratio plotted on a log scale estimated from individual studies (horizontal axis) against a measure of the study size (vertical axis), (see Figure 10 ).

Funnel Plot represented from the eight pooled trial and model-based economic-evaluation studies of Oral Health Promotion Programs (OHPPs), with log-odds ratios displayed on the horizontal axis and the standard error of the log-odds ratios displayed on the vertical axis.

Figure 10 illustrates the asymmetrical scatter plot of the program effects estimated from the selected individual studies against a measure of the small study size. The funnel plot is seen in this review as the tendency for the smaller studies in a meta-analysis to show a larger treatment effect, where publication bias is only one of a number of possible causes of funnel plot asymmetry [ 33 ]. Heterogeneity exists in this review for many reasons. We can explain that the review included diverse studies with various risks in the control group and effect size differs according to study size, intensity of intervention, differences in underlying risk and data irregularities between the pooled studies.

4. Discussion

The main review objectives were to assess the clinical effectiveness of oral-health promotion programs on the oral health of children, specifically dental caries, as well as the cost-effectiveness of the programs. The review included 19 studies reporting the used OHPPs and the incremental costs within a year’s related costs. The studies were timely diverse publication between 1976 and 2018, with long-term perspectives.

As stated in 1986 by the WHO in the Ottawa Charter for Health Promotion, the aim was “to enable people to increase control over and to improve their health”. Tooth decay is a preventable and controllable disease. Health promotion improves the quality of life, but it requires a commitment to practicing healthier behavior. Subsequently, it can only be achieved when oral-health promotion activities are implemented at the community level.

OHPPs in our review mainly implemented dental-health education, focusing on supervised toothbrushing techniques, using the appropriate type of fluoride toothpaste, following healthy behavior, avoiding unhealthy dietary habits and performing regular dental checkups. Where the included criteria studies were conducted within a time frame that varies from one study to another, some studies agree that the longer the time frame of OHPPs the more effective they are in manifesting a favorable oral health result in children’s teeth. However, most health economic studies in this field are not extensive enough to capture most cost- and clinical- outcome differences between the different programs and interventions.

Our review highlights the limited number of economic studies evaluating one type of dental caries prevention intervention, OHPPs, especially with regards to cost-saving, and how the OHPPs could be cost-effective when tooth decay can be avoided. Contemporary evidence shows that decisions on public health policy, health insurance, and client treatment should incorporate economic factors of health expenses. Health economic research studies are able to answer the practical question of “which intervention gives the greatest benefit proportional to its cost?”, while methods to estimate the economic impact of oral diseases are limited in availability, with no harmonized international reporting standards, resulting in difficulty to estimate the full economic impact of oral diseases [ 34 ].

This review is a reliable indication of the clinical effectiveness and cost-effectiveness of oral-health community programs among children. In a comprehensive way, trial and model-based economic-evaluation studies proved that OHPPs were significantly related to the anticipated review hypothesis regarding the efficacy of dental-health status and financial cost. However, it seems to be inconsequential in terms of OHPP efficacy when comparing two age groups. For clarity, the review found that OHPPs can be clinically effective under the age of six years but in comparison, the program is costly and needs further fiscal management by health authorities. OHPPs, on the other hand, do not reveal higher clinical effectiveness in dental caries reduction among children aged older than six years but they show that the program could not be that much costlier. In the last five years, published studies have also approved the efficacy of OHPPs. Similarly, previous studies represented significantly positive findings of the program, as well as when comparing between several countries. Five studies from the United Kingdom revealed that OHPPs have a significant effect in improving dental health status and reducing the cost of healthcare systems; other countries, namely, Japan, Ireland and Finland, identified the significant effect of the review objectives. Therefore, OHPPs revealed their effects on children’s oral health, on parental dental-treatment expenses, on the health care institutions and on the countries’ GDP. The review findings minimize the knowledge gap between evidence-based research and clinical practice since the program proves the applicability of health promotion in oral healthcare.

Study Limitations

Although the review included timely diverse studies over seventy years that provide an impressive result in the era of dentistry, the economic evaluation of OHPPs fluctuated based on the year to which the program cost is related, offering a slight chance to generalize the pooled findings. On the other hand, the 19 reviewed studies estimated the paid resources cost when OHPPs commenced from comparative health economic studies, where the counted numbers of studies prove the incremental cost is higher when oral-health promotion taking place in local community health programs. In addition, cost-effectiveness is determined in some studies in terms of tooth decay, before applying intervention that resulted in weakness in the generalizability of cost-effectiveness studies in the area of dental care.

The review protocol included settings and interventions that varied, such as providing oral healthcare, dental screening, and the clinical assessment of children’s tooth health status, applying topical fluoride varnishes, and offering oral health care products (for instance, fluoridated toothpaste and toothbrushes) might be expected to confound the estimated effects of oral-health education. Accordingly, economic studies are limited in terms of generalizability of cost-effectiveness related to specific oral-health intervention due to the differential costs between countries. For example, the cost of a dental filling in one country is more expensive than other countries. Moreover, it is not clear how much a national health service is willing to pay per avoided DMFT/S. It is doubtful to interpret the cost-effectiveness findings in terms of dental caries in the absence of valuable distinct indicators.

5. Conclusions

More effort is needed to manage the allocation of scarce resources, taking into account the economic impact of dental caries on healthcare systems. Additionally, more studies are needed regarding caries-prevention methods among young age children in high-, middle- and low-income countries, with follow-up programs to analyze clinical and financial efficacy when conducting well-organized oral-health interventions.

Acknowledgments

The lead author would like to acknowledge, with thanks, the staff members and colleagues in the department of preventive medicine at the University of Debrecen, for their generous support. As well as being grateful to the faculty of public health which guaranteed the necessary facilities to ensure successful settings for this project. OV acknowledges the financial support of the János Bolyai Research Fellowship, Hungarian Academy of Sciences.

The general characteristics of the included studies.

NHS = National Health Service. ECC = early-childhood caries.

Cost-Effectiveness Outcomes of the standardized included studies.

ICER: incremental cost-effectiveness ratios, DMFT: decayed missing filled teeth, QALY: quality-adjusted life year, No. of IMB: number of “into the mouth of babes” program visits.

The Drummond checklist for the risk of bias assessment of the trial-based economic evaluation studies.

The Drummond checklist for the risk of bias assessment of the model-based economic evaluation studies.

STATA do-files for analysis of Figure 2 . “metan DMFTintervention NIntervention, DMFTcontrol Ncontrol, label (namevar = Author, yearvar = year) random or” .

STATA do-file for analysis of Figure 3 . “metan DMFTintervention Costintervetion DMFTcontrol Costcontrol, label (namevar = Author, yearvar = year) random or”.

STATA do-file for analysis of Figure 4 . “metan DMFTintervention NIntervention DMFTcontrol Ncontrol, label (namevar = Author, yearvar = year) by (age) random or” .

STATA do-file for analysis Figure 5 . “metan DMFTintervention Costintervetion DMFTcontrol Costcontrol, label (namevar = Author, yearvar = year) by (age) random or” .

STATA do-files for analysis of Figure 6 . “metan DMFTintervention Costintervetion, DMFTcontrol Costcontrol, label (namevar = Author, yearvar = year) by (One less than 2015 two 2015 onwards) random or” .

STATA do-files for analysis of Figure 7 . “metan DMFTintervention Costintervetion, DMFTcontrol Costcontrol label (namevar = Author, yearvar = year) by (Country) random or” .

Author Contributions

Protocol of this meta-analysis and systematic review was written by N.F. and O.V.; N.F. and S.M. participated in search, selection and data extraction. N.F. and A.H. carried out the statistical analysis. N.F., Z.B. and S.M. wrote the initial draft, which was reviewed and revised by N.F, S.M., Z.B., A.H. and O.V.

This research was funded by Stipendium Hungaricum Scholarship programme and the Tempus Public Foundation.

Conflicts of Interest

All authors declare that they have no conflict of interests.