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Cdoe 12325 PDF
Cdoe 12325 PDF
DOI: 10.1111/cdoe.12325
ORIGINAL ARTICLE
1
Postgraduate Studies Program in Dentistry,
Federal University of Rio Grande do Sul, Abstract
Porto Alegre, Brazil Objectives: The objective of this study was to evaluate the effectiveness of oral
2
Department of Preventive and Social
health educational actions in the school context in improving oral hygiene and den-
Dentistry, Federal University of Rio Grande
do Sul, Porto Alegre, Brazil tal caries in schoolchildren through systematic review and meta-analysis.
Methods: Clinical trials with schoolchildren between 5 and 18 years old were
Correspondence
Fernando Neves Hugo, Faculty of Dentistry, included. Eligible studies were those which had as outcomes caries, plaque accumula-
Federal University of Rio Grande do Sul,
tion, gingivitis, toothache or tooth loss and which had been published from 1995 to
Porto Alegre, Brazil.
Email: fernandoneveshugo@gmail.com 2015, in any language. The risk of bias was assessed in specific domains according to
Website: http://www.ufrgs.br/cpos
the Cochrane Handbook. A meta-analysis was carried out using fixed-effects models.
Funding information Results: A total of 4417 references were found, from which 93 full texts were evalu-
Coordination for the Improvement of Higher
ated and 12 included in this meta-analysis. Five studies showed a reduction in plaque
Education Personnel (CAPES)
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 effective-
ness 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
30 | © 2017 John Wiley & Sons A/S. wileyonlinelibrary.com/journal/cdoe Community Dent Oral Epidemiol. 2018;46:30–37.
Published by John Wiley & Sons Ltd
STEIN ET AL. | 31
The use of collective actions for oral health education is frequent [Mesh] AND (“Toothbrushing”[Mesh]) OR “Health Education, Den-
and includes lectures using different types of resources such as flip- tal”[Mesh] OR “Education”[Mesh] AND (“Oral Health”[Mesh]) OR
charts, video, slide presentation, and other types of actions such as (“Dental Plaque”[Mesh] OR “Dental Caries”[Mesh] OR “Gingivi-
6
supervised dental brushing and topical fluoride application. About tis”[Mesh] OR “Dental Plaque Index”[Mesh] OR “Toothache”[Mesh]
the effectiveness of the latter, there is already strong evidence, OR “Tooth Injuries”[Mesh] OR “Tooth Loss”[Mesh])). CENTRAL (Cen-
established by systematic review with meta-analysis, setting the tral Register Cochrane of Controlled Trials) (01/01/1995-13/05/
effectiveness of topical fluoride use on cavity prevention in children 2015). EMBASE (Excerpta Medica Database) (01/01/1995-09/06/
7
and teenagers. For supervised toothbrushing, there is some evi- 2015). LILACS (Latin-American and Caribbean Literature on Health
dence on its efficacy and cost-effectiveness.8 However, further Sciences/Virtual Health Library (BVS)) (01/01/1995-25/04/2015).
studies that follow students for longer periods of time, while incor- The title and the abstract of each study were reviewed and criti-
porating economic outcomes, are needed.8 cally assessed by two independent reviewers. Two reviewers are
The objective of this study was to evaluate the effectiveness of dental surgeons (NMLS, CS) and experienced in the field.
oral health educational actions in the school context on improving The methods used to apply the selection criteria were the follow-
oral hygiene and dental caries in schoolchildren through systematic ing: (i) integration of the searched outcomes in the bibliographic refer-
review and meta-analysis. ence EndNoteWeb software to delete duplicate entries; (ii)
examination of titles and abstracts to delete clearly irrelevant articles;
(iii) recovery of the full text of potentially relevant articles; (iv) binding
2 | METHODS and gathering of multiple articles of the very same study; (v) examina-
tion of the articles’ full text to verify the degree of compliance that the
A systematic review of literature and meta-analysis was performed. studies had with the eligibility criteria; (vi) establishing connection with
This methodology followed the Cochrane Handbook for systematic researchers, if necessary, to clarify the study’s eligibility; (vii) deciding
reviews of interventions, version 5.1.0.9 For further details, see the about the study’s inclusion and proceeding with data gathering.
online Methods. For this review, studies using randomized controlled When disagreements between researchers arose, the eligibility
trials methodology were included, with randomization at group criteria or the codification schemes for data gathering were reviewed
(school and/or classroom) or individual level. by a third reviewer (FNH) experienced in the content of the review,
Studies in which participants were students with ages ranging to take the final decision on the articles’ inclusion or exclusion.
from 5 to 18 years were included. This inclusion disregarded the Data gathering was carried out using a verification list of items
dental caries level at the study’s beginning, exposure to fluoride and that were considered for data extraction. The main items of this list
current dental treatment. For the purposes of this review, a “school” were as follows: study definition, risk of bias assessment, total length
is defined as “a space to articulate policies concerning teenagers and of the study, unit of randomization, unit of analysis, participants’
young people, based on the participation of those individuals in that characteristics, interventions, outcomes, results and other items.
process: students, families, educational and health professionals.”10 The risk of bias was assessed in five specific domains: selection
Educational actions interventions on oral health carried out by den- of participants; allocation sequence concealment; blinding of partici-
tal professionals in School Programs were considered. The included pants and evaluators; incomplete outcome data; and selective out-
educational interventions on oral health were as follows: supervised come reporting. This was done through the assignment to “low risk
toothbrushing, guidance about toothbrushing, orientation on the main of bias,” “high risk of bias” or “unclear risk of bias” rulings.9
oral diseases, general orientation on dieting, educational activities, Measures for continuous data were assessed as follows: mean
among others. Studies were included without time restriction. The inter- change in Plaque Index (before and after the intervention) and stan-
vention could have been delivered by dentists, dental hygienists or den- dard deviations; and mean change in gingivitis (before and after the
tal assistants and carried out in the school environment. intervention) and standard deviations.
The control group was not provided with an educational pro- The unit of the analysis from the studies was every conglomerate
gramme on oral health; however, it could have been given an action (class or school) and/or the individual (student) of each study
that belongs to the school’s curricular framework. included in this review. The estimates of effect and their standard
Primary outcomes: dental caries; plaque accumulation; gingivitis. errors, deriving from the analysis of group-randomized trials, were
The clinical effectiveness was defined as some change in caries explored in a meta-analysis using the generic inverse variance
experience or some change in the amount of dental plaque and gin- method on Review Manager 5.3.
gival bleeding. Secondary outcomes: dental pain and tooth loss, We sought to identify the variability among the studies, in partic-
before and after the intervention. Articles published from 01/01/ ipants, interventions, outcomes and planning, and risk of bias. The
1995 until 09/06/2015 were searched, without any restriction chi-square test was used to assess whether the observed differences
concerning the publication’s language. were homogenous or heterogeneous. The statistic test used to quan-
The following bibliographic databases were searched: tify the inconsistence between studies was the I². It was interpreted
MEDLINE/PubMed (01/01/1995-23/04/2015): “Child”[Mesh] in accordance with the Cochrane Handbook for Systematic Reviews
OR “Schools”[Mesh] OR “Adolescent”[Mesh] OR “Child, Preschool” of Interventions.9
32 | STEIN ET AL.
Data synthesis was carried out using a descriptive synthesis, with 3 | RESULTS
a summary of the characteristics of each included study. For quanti-
tative synthesis, a summary of the combined estimate related to the The studies selected during the search process, assessed by eligibil-
intervention effect was calculated as a mean of the differences of ity, included in the review and excluded given the proper reasons,
the effects of intervention in individual studies. are presented in Figure 1, using a flow diagram. For further details,
The meta-analysis of the continuous outcomes used the fixed- see the online Results.
effect method, which provides exactly the same answers when The characteristics of the studies can be found in Table 1, which
heterogeneity does not exist. To calculate the standard error and the depicts the included studies’ the general characteristics. Among the
standard deviation of the mean differences for the outcomes of 12 included studies, six were randomized by school,11–16 two by
interest, the Comprehensive Meta-Analysis Software was used, and classroom17,18 and four by individuals.19–22
then, mean differences and their standard deviations were analysed The age of the participants ranged from 6 to 15 years old
using Review Manager 5.3. software. throughout the interventions’ conducting period. 3932 participants
FIGURE 3 The effectiveness of oral health educational actions [Colour figure can be viewed at wileyonlinelibrary.com]
environment is to prevent oral diseases and to develop healthier studies with similar outcomes included. The study’s relevance is
behaviours and practices. mainly related to the need to assess the effectiveness of educa-
The last systematic review about the effectiveness of educational tional actions on oral health carried out in school programmes,
actions on the oral health of schoolchildren was published more than given the fact that, according to individual studies and other sys-
two decades ago. Since then, a considerable amount of papers on tematic reviews, a conclusive outcome about their effectiveness is
the subject has been published. Oral health education programmes yet to be established, even though they remain as priority actions
continue to be developed and implemented in school settings, mean- in many countries.
ing that the critical assessment and summarization of that evidence In conclusion, traditional oral health education was effective in
is important to provide clinicians, stakeholders and decision makers reducing plaque accumulation over a short period. This reduction
with needed information about the cost-effectiveness of education was of small magnitude. OHE was not effective for gingivitis while
based oral health programmes. This is in agreement with the current for caries the findings were conflicting. There is no long-term evi-
23
definition of oral health that was recently published by the FDI. dence on the effectiveness of these interventions in preventing pla-
The several forms of delivery of OHE presented in the studies que accumulation, gingivitis and dental caries in schoolchildren. This
only varied in regard to the deployed educational objects; however, may be due to the variability of OHE methods deployed in the
the methods, as they were developed, were based mainly on infor- individual studies.
mation transfer. The development of evidence-based protocols that
allow the delivery of sound and effective OHE actions is needed ACKNOWLEDGEMENTS
mainly in primary healthcare settings and in school environments. It
is strategic to carry out prevention and health promotion actions This study was funded in part by the Coordination for the Improve-
that are consistent and produce a positive impact on oral health sta- ment of Higher Education Personnel (CAPES).
13. Haleem A, Siddiqui MI, Khan AA. School-based strategies for oral 22. Esteves GV, Navarro RS, Oliveira Ju nior WTd, Youssef MN. Estudo
health education of adolescents-a cluster randomized controlled trial. clınico do comportamento de escolares mediante escovac߀ao supervi-
BMC Oral Health. 2012;54:1-12. sionada, controle da dieta e motivac߀ao para prevenc߀ao da carie e
14. Worthington HV, Hill KB, Mooney J, Hamilton FA, Blinkhorn AS. A doencßa periodontal. Rev Pos-Grad. 1998;5:211-218.
cluster randomized controlled trial of a dental health education pro- 23. Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant
gram for 10-year-old children. J Public Health Dent. 2001;61:22-27. RJ. A new definition for oral health developed by the FDI World
15. Yekaninejad MS, Eshraghian MR, Nourijelyani K, et al. Effect of a Dental Federation opens the door to a universal definition of oral
school-based oral health-education program on Iranian children: results health. J Am Dent Assoc. 2016;147:915-917.
from a group randomized trial. Eur J Oral Sci. 2012;120:429-437. 24. Mialhe FL, Silva CMC, Cunha RB, Possobon RF. Health education.
16. Anttonen V, Sepp€a L, Niinimaa A, Hausen H. Dietary and oral In: Pereira AC, Handbook of Collective Health. Nova Odessa:
hygiene intervention in secondary school pupils. Int J Paediatr Dent. Napole~ ao; 2009:441-485.
2011;22:81-88. 25. Pauleto ARC, Pereira MLT, Cyrino EG. Oral health: a critical review
17. de Farias IA, de Araujo Souza GC, Ferreira MA. A health education about educative programmes for students. Cien Saude Colet.
program for Brazilian public schoolchildren: the effects on dental 2004;9:121-130.
health practice and oral health awareness. J Public Health Dent.
2009;69:225-230.
18. Rodrigues JA, dos Santos PA, Garcia PP, Corona SA, Loffredo LC.
Evaluation of motivation methods used to obtain appropriate oral How to cite this article: Stein C, Santos NML, Hilgert JB,
hygiene levels in schoolchildren. Int J Dent Hyg. 2003;4:227-232. Hugo FN. Effectiveness of oral health education on oral
19. Al-Jundi SH, Hammad M, Alwaeli H. The efficacy of a school-based car-
hygiene and dental caries in schoolchildren: Systematic
ies preventive program: a 4-year study. Int J Dent Hyg. 2006;4:30-34.
20. Ivanovic M, Lekic P. Transient effect of a short-term educational review and meta-analysis. Community Dent Oral Epidemiol.
programme without prophylaxis on control of plaque and gingival 2018;46:30–37. https://doi.org/10.1111/cdoe.12325
inflammation in school children. J Clin Periodontol. 1996;23:750-757.
21. Zanin L, Meneghim MC, Assaf AV, Cortellazzi KL, Pereira AC. Evalu-
ation of an educational program for children with high risk of caries.
J Clin Pediatr Dent. 2007;31:246-250.