Abstract
Data sources
The methodology followed the Cochrane Handbook for systematic reviews of interventions with MEDLINE/PubMed, CENTRAL, Embase and LILACS databases searched. Publication date was limited to 1995-2015 with no restriction on language.
Study selection
Two independent reviewers selected randomised controlled clinical trials involving oral health education provided by a dental care professional to children aged between five and 18 years old within a school setting. Eligible studies were those which had outcomes including caries, plaque accumulation, gingivitis, toothache or tooth loss. Randomisation was at group (school and/or classroom) or individual level. The control groups were not provided with an educational programme on oral health, however they could have been given an action that belonged to the school's curricular framework.
Data extraction and synthesis
The title and abstract of each study was reviewed and critically assessed by two independent reviewers. Risk of bias was assessed using the Cochrane Handbook. Studies where the data of interest were presented in charts or were of dichotomous data were not included in meta-analysis.
Results
Twelve studies were included in this systematic review. Five studies showed plaque level reduction in the intervention groups and two studies found no effect of the interventions on gingivitis. There was insufficient evidence on effectiveness of the interventions in reducing dental caries.
Conclusions
Traditional oral health educational actions were effective in reducing plaque in the short-term, but not gingivitis. There was no long-term evidence regarding the effectiveness of traditional oral health educational actions in the school environment on preventing plaque accumulation, gingivitis and dental caries in schoolchildren.
Acknowledgements This study was funded in part by the Coordination for the Improvement of Higher Education Personnel (CAPES).
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Commentary
With dental extractions being the most common reason for a child between five and nine years of age in England to have a general anaesthetic, the need for effective methods of improving oral health in children cannot be underestimated.1 Oral health education in a school setting may be an effective part of the preventive armamentarium to improve schoolchildren's oral health; the aim of this systematic review was to determine if such interventions might improve oral health in terms of reduced plaque levels, gingivitis and dental caries.
The literature search for this review was limited to 1995-2015 with the rationale for this having been the most recent similar systematic review was completed in 1994;2 the search for this earlier review combed the Medline database between 1982-1994 using only the subject headings ‘dental health education, oral health promotion and effectiveness’. In addition, a scoring system was used in this earlier review and papers excluded below a certain score. As such there is potential risk that other suitable publications were not identified for inclusion in the current review.
Studies were included ‘without time restriction’ and as such there was no minimum follow-up period for included studies. As a result there was a varied follow-up period in the included studies, eg one month to four years. The authors highlight the need for longer-term studies to be carried out, particularly to identify any changes in dental caries.
The authors make note that ‘significant methodological variability was found among the interventions performed in the included studies’. Of note, the inclusion of studies ‘disregarded the dental caries level at the study's beginning, exposure to fluoride and current dental treatment’. This clinical heterogeneity (which also included variable sample population demographics, follow-up times and interventions), may have warranted a descriptive analysis rather than meta-analysis of the data. Although statistical homogeneity was observed, it was largely due to the low number of studies and small sample size. Indeed, a number of oral health promotion reviews have noted similar heterogeneity between included studies with no meta-analyses having been carried out as a result.3, 4, 5
Risk of bias assessment was completed for all included studies; the authors made no comment on the impact that the risk of bias may have had on the results with the risk of bias table highlighting that none of the included studies was at overall low risk of bias.
Though not specifically part of this review, the authors make no mention regarding the need for future studies to include appropriate and validated child-centred outcome measures, though they do note the need to determine the cost effectiveness of oral health education interventions.
Although the authors reach the distinct conclusion that traditional oral health educational actions were effective in reducing plaque in the short-term, but not gingivitis, perhaps there should be more caution in their interpretation of the results given the clinical heterogeneity and risk of bias of the studies included. Overall, there remains a need for further well designed randomised controlled studies with longer follow-up periods to determine the most effective methods of school-setting oral health education for improved oral health in children.
References
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Address for correspondence: Fernando Neves Hugo, Faculty of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil. E-mail: fernandoneveshugo@gmail.com
Stein C, Santos NML, Hilgert JB, Hugo FN. Effectiveness of oral health education on oral hygiene and dental caries in schoolchildren: Systematic review and meta-analysis. Community Dent Oral Epidemiol 2018; 46: 30–37. doi:10.1111/cdoe.12325. [Epub ahead of print] PubMed PMID: 28815661.
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Soldani, F., Wu, J. School based oral health education. Evid Based Dent 19, 36–37 (2018). https://doi.org/10.1038/sj.ebd.6401298
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DOI: https://doi.org/10.1038/sj.ebd.6401298