How effective are school based oral health education programs? An evidence based review A number of systematic reviews have been conducted on the the effectiveness of school-based behavioral interventions all over the world. The aim of this presentation is to collect and review these evidences on the effectiveness of these programs and to identify important factors which contribute to the effectiveness of these programs.

1. Impact of oral health education on oral
health status
School based oral health education‐School based oral health education‐
programprogram
Ghada Elmasuri
28-05-2014

2.  Section 1: About oral health
 Section 2:The prevalence and trends of oral diseases
 Section 3: Inequalities relating to oral diseases treatment
 Section 4: School based oral health education
 Section 5: Effectiveness
 Section 6: Understanding the problems
 Section 7: Conclusions and Recommendations
Slides numbers: 50
Estimated time: 30 minutes

3.  In 1948 the World Health Organization defined oral
health as “a complete state of physical, mental, and
social well-being, and not just the absence of
infirmity.”
World Health Organization (WHO). Constitution of the World
Health Organization. Geneva: WHO Basic Documents; 1948.

4.  Physical well–being assumes the ability to function normally in
activities such as speaking, eating, and moving around.
 Mental well–being implies that there is no burden of fear,
anxiety, stress, depression, or other negative emotions.
 Social wellbeing relates to one’s ability to participate in
society, fulfilling roles and duties.
World Health Organization (WHO). Constitution of the World
Health Organization. Geneva: WHO Basic Documents; 1948.

5.  Oral health is fundamental to overall health,
wellbeing and quality of life. A healthy mouth
enables people to eat, speak, work and socialize
without pain, discomfort or embarrassment.
Healthy Mouths, Healthy Lives: Australia’s National Oral Health Plan
2004–13 (2004). Prepared by the National Advisory Committee on
Oral Health.

6. “The mouth is the gateway to the rest
of the body, a mirror of our overall well-
being.”
Along this, oral health must be
perceived as a critical component of
general health.
Harold C. Slavkin, D.D.S. Former Director of the National Institute
of Dental and Craniofacial Research, and Dean of the University of
Southern California School of Dentistry

7.  Dental disease negatively impacts general quality of
life, affecting not only physical wellbeing but also
psychological and social wellbeing.
World Health Organization (WHO). Constitution of the World
Health Organization. Geneva: WHO Basic Documents; 1948.

8. Source: self constructed. Adapted definition of oral
health by WHO 1948

9. Directly associated with deteriorating
diet and compromised nutrition
Locker 1992
 Further, the mouth is often an entry
point for infections, which may spread to
other parts of the body.
US Department of Health and Human Services (2000)
 Locker, D. (1992), ‘The burden of oral health in a population of older adults’, Community Dental Health, June; 9(2),
pp.109–24.
 US Department of Health and Human Services (2000), Oral health in America: A report of the Surgeon General,
Rockville, MD: US Department of Health and Human Services,

10. A person whose appearance and speech are impaired by
dental disease can experience anxiety, depression, poor self–
esteem and social stigma which in turn may inhibit
opportunities for education, employment and alter the ability
to sustain and build social relationships”.
 Ibid, p.137.

11. Oral health problems can affect a person's ability to
maintain a job or get promotions. They can also contribute
to lowered academic achievement and goals. These
effects have increased when a deformity due to the oral
health condition is involved
Hollister & Weintraub, 1993; Reisine, 1989


12. Children face the additional challenge of poor oral health far reaching
effects into their adulthood.
Dental conditions in childhood can restrict children’s participation in
schooling and education through days lost to illness.
Impaired physical appearance due to dental disease can further limit
children’s ability to socialize with confidence and develop social norms and
relationships.


13.  Tooth decay is the most common chronic childhood disease
affecting 60 90% of school children.‑
 It is over five times more prevalent than asthma among
children.
 7 times more common than hay fever.
 52 million school hours missed annually because of oral problems
National Institute of Dental and Craniofacial Research. (2001, Feb).

14. Global oral health data bank. Geneva: World Health Organization;
2004.

15. .
There are profound inequalities in caries status,
between countries, and that the distribution of
disease in a population is a changing dynamic.

16. Marmot, M. and Wilkinson, R. (1999), Social determinants of health,
Oxford University Press, Oxford.
Health inequalities are the systematic, structural
differences in health status between and within social
groups within the population.
The term ‘‘health inequalities’’ is closely linked to
‘‘social determinants of health’’.

17. Lack of income, schools, and education, inappropriate
housing, unsafe workplaces and lack of access to
health care systems are some of the social
determinants of health leading to inequalities.
Source: Social Determinants of Health, The Solid Facts. World
Health Organization, 2003

18.  Health inequalities can be seen as an
outcome of Social Inequalities
Source: Social Determinants of Health, The Solid Facts. World
Health Organization, 2003

19. Studies showed Children from
a deprived background may
have five time more tooth
decay than children from more
affluent backgrounds.
National Alliance for Equity in Dental Health, 2004

20. “One of the suggested strategy for reaching
disadvantaged children is by providing school-based
oral and dental health services …
 Grant Makers in Health Issue Dialogue.. (2001, May).
Filling the Gap: Strategies for Improving Oral Health.
Issue Brief.

21.  The World Health Organization advocates using
Health Promoting Schools programs to promote
general and oral health.
 Oral health education is a key component in any
School Oral Health Program.
Kwan SY, Petersen PE, Pine CM, Borutta A. 2005, Health-promoting
schools: an opportunity for oral health promotion, Bulletin of the World
Health Organization, vol. 83, pp. 677-685.

22. “ You cannot educate a child who is not healthy, and you
cannot keep a child healthy who is not educated.”
Jocelyn Elders, Former US Surgeon General
Health education is any combination of learning experiences
designed to facilitate voluntary actions conducive to health.

23. Integration of oral health into the school curriculum

24. 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.

25. Evidence based papersEvidence based papers

26. Google, Google Scholar, the Cochrane Library MEDLINE and
EMBASE electronic databases were searched as well as
hand searching of found references and review articles.

27.  The strength of the evidence to support each intervention is
indicated using the modified Davies et al 2003 hierarchy:
 Type 1 Systematic review
 Type 2 At least one RCT
 Type 3 Non-randomised intervention studies
 Type 4 Observational studies.
Davies R M, Davies G M, Ellwood R P, Kay E J. Prevention. Part 4:
Toothbrushing: What advice should be given to patients? Br Dent J
2003; 195: 135-141.

29. Derek Richards. Centre for Evidence-based Dentistry, Oxford, UK.
Evidence-Based Dentistry (2013) 14, 42-43. doi:10.1038/sj.ebd.6400929

31. Effectiveness of oral health promotion. Health promotion effectiveness
reviews Summary bulletin 7 – 1997 ISBN 0 7521 1039 X
Authors Objective Strength of
evidence
Findings
Kay and Locker
1997
to assess the
effectiveness of
school oral health
interventions
designed to reduce
dental caries
Type 1
systematic review
of 94 scientific
journals,
published between
1984 and 1997.
There is no
evidence in the
literature that
school oral health
education alone
effects caries
rates, even if
changes in behavior
are achieved,
unless
fluoride is being
used.

33. Authors Objective Strength of
evidence
Findings
Khan et al.,
2013
to identify
effectiveness of
school oral hygiene
instructions
Type 1
systematic review
of studies
published between
1990 and 2013.
School oral health
activities have a great
impact for the
improvement of oral
health knowledge among
children However, there
is no evidence that
changes in knowledge
are causally related to
changes in behavior.

35. Authors Objective Strength of
evidence
Findings
Cooper et al.,
2013
To assess the clinical
effects of school-
based interventions
aimed at changing
behavior related to
tooth brushing habits
and the frequency
of consumption of
cariogenic food and
drink in children (4
to 12 year olds) for
caries prevention.
Type 1
systematic review
of studies
published
between 1950 to
2012.
Currently, there is
insufficient evidence for
the efficacy of primary
school-based behavioral
interventions for reducing
caries. There is
limited evidence for the
effectiveness of these
interventions on plaque
outcomes and on children’s
oral health knowledge gain.
Cooper AM, O’Malley LA, Elison SN, Armstrong R, Burnside G, Adair P, Dugdill L, Pine C. Primary
school-based behavioural interventions for preventing caries. Cochrane Database of Systematic
Reviews 2013, Issue 5. Art. No.: CD009378. DOI: 10.1002/14651858.CD009378.pub2.

36. Poul Erik Petersen, Bin Peng, Baojun Tai, Zhuan Bian and Mingwen
FanEffect of a school-based oral health education programme in
Wuhan City, Peoples Republic of China Int Dent J 54:33-41. 2004

37. Ajithkrishnan CG, Thanveer K, Sudheer H, Abhishek S. Impact of oral
health education on oral health of 12 and 15 year old schoolchildren of
Vadodra city, Gujarat state. J Int Oral Health. 2010;2:15-20.

38. Authors Study Area
-population
Type of
Intervention
Plaque/Gingiv
al Scores
Dental
Caries
Knowledge,
Attitude &
Practice
Petersen
et al.,
2004
China-
primary
school
children
Type 3
“3 years
experimental
trail based on
WHO OHE
program
Positive
effects on
gingival
bleeding
score
No effect
on dental
caries
Prevention
was
observed
positive
effects
Ajithkrish
nan et al.,
2010
India- 12-15
year
Type 3
“3 months
clinical trails”
Reduced
plaque score
but no
reduction in
gingival
scores
No
reduction
in DMFT
scores
-

39. A number of systematic reviews have been conducted on the
available evidence for the effectiveness of school-based
behavioral interventions . 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. However there is a limited
evidence for its effectiveness on children’s oral health in
terms of reducing dental plaque and dental caries.

40. Comments about the findings

41. Oral diseases are multifactorial.
Dahlgren and Whitehead, 1993
Dahlgren G, Whitehead M (1993). Tackling inequalities in health: what
can we learn from what has been tried? Working paper prepared for
the King’s Fund

42. The Ottawa Charter defines
health promotion as ‘the
process of enabling people
to increase control over,
and to improve, their
health’.
The Ottawa Charter for Health Promotion. First International
Conference on Health Promotion, Ottawa, 21 November 1986

43. Basic logic: Can school-based
interventions aimed at
improving health status
works?.........

44. Health education interventions are of limited value and
should be supported by a full range of health promotion
approaches.
Multiple interventions that complement and reinforce each
other, and involve a range of community partners and
stakeholders may be more effective than single
interventions.

45.  Link to the home by actively involve parents in school interventions
 Provide support for teachers or use non-teacher supervisors
 Employ oral health professionals to provide support for Health
Promoting Schools approaches, rather than only provide classroom
lessons
 Involve private dental providers in planning for greater
cooperation
 Integration with other health issues enhances the likelihood of
sustainability.
 Long-term school support is needed.

46. Simpson in 2011 provides a promising multi-stage model based on four
stages: training, adoption, implementation and practice improvement,
along with sustaining influences involving preparation and maintenance.
Simpson DD. Implementing sustainable oral health behavioral and
social interventions. J Public Health Dent. 2011; 71:S84–S94.

47. Address the broader
determinants of health.
Focusing on these
determinants is the key
to preventing disease and
to propose strategies for
overcoming inequalities in
oral health.
Iceberg phenomenon
Ernest Hemingway 1923

48. Individual Factors
Environmental conditions
Water fluoridation
Restricting marketing and
improving labelling of food
products
Social Environment
Marketing healthy
behavior influencing social
and family norms that link
to oral health knowledge,
attitudes, beliefs, values.
 Improve education and awareness
 Reduce barriers to health care seeking
practices
Governments have a responsibility for the health of their
citizen to lead a socially and economically productive life.

49. Combined efforts