| |

Received: 6 March 2020    Revised: 22 May 2020    Accepted: 7 July 2020

DOI: 10.1111/cdoe.12567

ORIGINAL ARTICLE

Health promotion interventions to improve oral health of

adolescents: A systematic review and meta-analysis

Carrie Tsai1  | Sarah Raphael1 | Caitlin Agnew1,2 | Gordon McDonald3  |

Michelle Irving1

1
Faculty of Medicine and Health, School of
Dentistry, The University of Sydney, Sydney,
NSW, Australia
2
Hospital and Specialist Dentistry, Head
and Neck Services, Auckland District Health
Board, Auckland, New Zealand
3
Sydney Informatics Hub, The University of
Sydney, Sydney, NSW, Australia
Correspondence
Carrie Tsai, Faculty of Medicine and Health,
School of Dentistry, The University of
Sydney, Sydney, NSW, Australia.
Email: carrie.tsai@sydney.edu.au
Abstract
Objectives: To evaluate the effectiveness of health promotion interventions on oral
health knowledge, behaviour and status of healthy adolescents.
Methods: This review included randomized controlled trials (RCTs) of oral health
promotion interventions targeting adolescents. Primary clinical outcomes (gingival
health, plaque scores, caries) and secondary proxy outcomes were evaluated. Meta-
analysis of primary outcomes was conducted where possible, with subgroup analysis
based on intervention (comprehensive health promotion and education-only).
Results: Thirty-seven eligible publications reporting on 28 unique RCTs of oral
health promotion interventions were included. Quality appraisal of studies ranged
from 48% to 96%. Interventions reported ranged from single-session interventions
to community-wide programmes, including clinical preventive procedures and take-
home products. Half used a health behaviour change theory to inform their inter-
vention. The meta-analysis pooling of results favoured the intervention over control
for all clinical outcomes, except DMFS in the education-only subgroup. Stronger in-
tervention effects were seen in the comprehensive intervention subgroup than the
education-only subgroup for DMFS (P = .02). This effect was slight, but not as clear
in all other clinical categories. The majority of studies reported improvements in oral
health knowledge, attitudes and behaviours. More positive outcomes were found
with longer programmes, especially for dental caries outcomes.
Conclusions: Oral health promotion programmes targeting adolescents have the abil-
ity to improve clinical oral health outcomes in the short and long term. Programmes
should use more behavioural theory-based interactive and strategic methods, includ-
ing self-awareness and the use of the wider community and peers for oral health
promotion activities over a longer intervention duration.

KEYWORDS

adolescents, dental health promotion, meta-analysis, oral health, pediatric dentistry

© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Community Dent Oral Epidemiol. 2020;00:1–12.  |

wileyonlinelibrary.com/journal/cdoe     1
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1 |  I NTRO D U C TI O N
Health promotion involves combinations of educational, polit-
ical and organizational supports for behaviour and environmen-
tal changes that are conducive to health.1 More specifically, oral
health promotion has been widely used for the prevention of den-
tal caries and periodontal disease, 2,3 concentrating on providing
oral health information and structural supports in various settings,
including schools, community groups and dental clinics, with the
aim to improve knowledge and behaviour for positive personal
oral health practices.
There are many contextual influences that contribute to an in-
dividual's oral health status, including but not limited to socio-eco-
nomic status, parental level of education, resources, access to health
care, and social, cultural and political environment.4,5 Oral health
promotion aims to target these risks through an understanding of
how these contextual risk factors influence the progression of oral
disease.
Adolescence is a time of significant physical, psychological and
behavioural change, when youth develop habits and behaviours
that continue into adulthood. It is also a time period with increased
unique risk factors associated with poor oral health, including more
susceptible tooth surfaces, greater independence, poor nutritional
habits, nicotine experimentation, orthodontic intervention and low
priority for oral hygiene.6 Not surprisingly, this demographic is rec-
7
ognized as having several unmet oral health needs.
Targeted oral health promotion during adolescence may have
long-lasting impacts on oral health throughout life. Attaining im-
proved oral health care during this stage may provide benefits far
beyond the immediate gains, leading to less disruption of work and
school from improved long-term general health.8
Despite this, adolescents are less frequently studied in health
promotion programmes than younger children.9 The evidence re-
garding the best oral health promotion interventions for adolescents
has not been previously examined. The aim of this systematic review
is to evaluate the effectiveness of community oral health interven-
tions in improving the knowledge, behaviour and/or oral health sta-
tus of healthy adolescents, to inform future intervention design.
2 |  M E TH O DS
A systematic search of the literature was conducted in accord-
ance with the Preferred Reporting Items for Systematic reviews
and Meta-analysis (PRISMA) Statement (Appendix S1).10 A broad
search using MEDLINE, Pre-MEDLINE, Embase, PsychINFO and the
Cochrane Database was performed. MeSH terms used were ado-
lescence, intervention, patient education and oral health, with key-
words teenage* and oral (Appendix S1). The protocol was registered
on PROSPERO (http://www.crd.york.ac.uk/PROSP​ERO/displ​ay_re-
cord.php?ID=CRD42​01707​3563).
All randomized controlled trials (RCTs) in any language, pub-
lished from January 1987 to September 2019, reporting oral health
promotion programmes in adolescent populations and quantitatively
assessing outcomes of the interventions were included (for full inclu-
sion/exclusion criteria, refer to Appendix S1). Year restrictions were
used to identify strategies appropriate for current social norms.
Adolescence was defined as 10-19  years of age.11 Eligible studies
with larger age ranges of participants (8-19 years) were only included
when results for the adolescent age group were separately reported
(Appendix S3).
Studies were screened by title to remove those not involving oral
health or adolescents. Non-English-language articles were screened
using language translation. All studies were then independently as-
sessed in full text by two authors (SR and CT) with disagreements
resolved by a third author (MI). Hand-searching the reference lists
of primary studies and review articles was conducted. A final search
for studies was performed prior to completion. A prespecified data
extraction tool was used to report on study design, demographic
characteristics, interventions and oral health outcome measures.
Data were extracted by two authors (SR and CT). Disagreements
were resolved by a third author (MI). The primary outcomes assessed
included gingivitis, plaque levels and dental caries. Secondary out-
come (‘proxy’) measures were improvements in oral health knowl-
edge, attitudes and behaviours.
The Downs and Black12 criteria were used to assess methodolog-
ical quality of included studies as it is a validated tool that examines
validity, bias, power and other study attributes as well as enables
scores to be quantified as percentages13 Each study was inde-
pendently scored by two authors (CT and SR) and cross-checked,
reaching consensus by discussion. A total percentage quality score
was calculated for each study (Appendix S2).
Meta-analysis was conducted on the most predominant index
for each outcome measure: gingival health (Löe and Silness Gingival
Index),14 plaque scores (Silness and Löe Plaque Index)15 and dental
caries (DMFS). In all three categories, the difference in score incre-
ment between intervention and control groups, from baseline to
follow-up, was measured. To address the high heterogeneity of in-
tervention outcomes, common for health promotion studies,16 the
studies were subdivided into simple oral health ‘education-only’ in-
terventions, including lectures, audiovisual presentations, leaflets or
videos or ‘comprehensive’ interventions, defined as those that com-
bined education with broader elements such as family or community
involvement, peer-to-peer workshops, self-diagnosis, needs-related
oral hygiene instruction, dental product use and/or clinical measures
such as fluoride varnish, sealants and restorations. Each overall ef-
fect was calculated as a maximum likelihood estimator, where each
study was weighted by its inverse-square standard error of the
mean. Where studies reported results from different intervention
study arms (eg dentist or teacher-led), they were included in the me-
ta-analysis separately. P values <.05 were considered to be statisti-
cally significant, and heterogeneity was quantified using chi-square
test and I2 statistic. Subgroups were compared using Welch's t test
with Welch-Satterthwaite approximate degrees of freedom. All anal-
yses were conducted in the R (R Core Team 2013) using the metafor
package (Viechtbauer, 2010).
TSAI et al. |
      3

3 | R E S U LT S were 13 282 participants overall, with participants ranging from 41

to 1691.
From a search yielding 6568 studies, this review analysed 37 eli- Publication dates ranged from 1992 to 2019 and included interven-
gible publications reporting results on 28 oral health intervention tions from 15 countries (Table 1). Most interventions were conducted
programmes, with 13 included in the meta-analysis (Figure 1). There within school environments with only four17-20 in a clinic setting.

F I G U R E 1   Flow chart of study selection process

TA B L E 1   Demographic characteristics of included studies
|

Wider Clinical Behaviour Post-int

4      

programme Number of prevention/take- change Intervention follow-up

First author, year Country Setting Intervention provider involvement participants Outcomes assessed home products models length (mo) (mo)
a
Albandar 1994   Brazil School Investigator(s) Family 227 PI, GI, ABL, DMFS, TH 1 36 0
KAB
Aleksejuniene Lithuania School Investigator(s) 254 PI 2 SS 12
2012
Anttonen 2011 Finland School Dental Hygienist 769 KAB, LF 12 12
Bagley 1992 USA University Investigator(s) 41 MHLC, PDI, TH 3 SS 6
PHP-MI, FS
Brukiene 2012 Lithuania School Investigator(s) Family 247 PI, OHI 4 3 12
Chandrashekar India School Dentists or Teachers 160 PI, GI, DMFS, OHI TH 6 0
2014
D'Cruz 2013 India School Investigator(s) 600 PI, GI, KAB 6 3
Ekstrand 2000 Russia Clinic Investigator(s) 100 PI, GI, DMFS Clin & TH 30 0
Gholami 2015 Iran School Investigator(s) 166 KAB, TC 5 SS 1
Häggblom 2013 Sweden Dental clinic Dentists 267 DSA 6 36 0
Haleem 2012, Pakistan School Dentist, Teacher, 1657 PI, KAB, OHI, CPI, 7 12 12
2016 Peers DMFT, BI
Hausen 2000 Finland Clinic Dental Hygienists 760 DMFS, KAB, MS/LB Clin & TH 36 0
b
Hausen 2007   Finland School Dental Hygienists Community 1691 PI, DMFS, KAB, Clin & TH 8 36 0
TC, BI
Hebbal 2011 India School Investigator(s) 150 PI, KAB SS 1.5
Hedman 2015 Sweden School Dental Hygienists 534 KAB, DSA Clin 9 24 0
Ivanovic 1996 Yugoslavia Clinic Dental Nurses 240 PI, GI, BI, PD TH 6 6
Khudanov 2018 Uzbekistan School Investigator(s) 100 PI, KAB TH 10 1 1
Marchetti 2018 Brazil School Investigator(s) 291 GI, OHI, KAB 1 3
Mbawalla 2013 Tanzania School Investigator(s) 1077 PI, OHI, TC, BI, DT TH 11 SS 24
Pakpour 2014 Iran School Teachers 372 PI, KAB, TC, CPI, 12 SS 6
PedsQL™
Redmond 1999, England School Dental Facilitators Family 1060 PI, KAB TH 12 0
2001
Sfeatcu 2019 Romania School Dental students 264 GI, OHI, DMFS, 13 16 8
KAB
Shekhawat 2016 India School Investigator(s) Family 264 PI, GI 4 2
Vangipuram 2016 India School Dentist or Peers 450 PI, GI, KAB, OHI SS 6
TSAI et al.

(Continues)
 TSAI et al. |
      5

Interventions ranged from single sessions to 3  years and follow-up

decayed surfaces; DT, decayed teeth; FS, Flossing score; GI, Gingival index; KAB, Self-reported oral health knowledge, attitudes, behaviour; LF, Laser fluorescence values; MHLC, Multidimensional Health
Parenting Model; 5; Health action process approach; 6: Motivational interviewing; 7: Social cognitive theory; 8: Patient and empowerment health counselling; 9: Values clarification; 10: Extended parallel

Abbreviations: ABL, Alveolar bone loss; BI, Bleeding index; CPI, Community periodontal index; DMFS, Decayed, missing, filled surfaces of teeth; DMFT, Decayed, missing, filled teeth; DSA, Approximal
length ranged from immediately after programme end to 5 years. Only
follow-up

Locus of Control; MS/LB, Streptococcus Mutans/Lactobacilli scores; OHI, Oral hygiene index/level/status; PD, Probing pocket depth; PDI, Periodontal Disease Index; PedsQL™, Paediatric oral health-
Post-int

Note: Clin: Clinical preventive measures; 1: Linking method, social learning visualisation theory; 2: Precaution Adoption Process Model; 3: Multidimensional Health Locus of Control; 4: Authoritative
seven programmes had a follow-up period >12 months.21-27

related quality of life; PHP-MI, Modified Personal Hygiene Performance Index; PI, Plaque index/scores; TA, Teacher attitude towards programme; TC, Theory constructs; TH, Take-home products.
(mo) The methodological quality scores for the 37 publications ranged
7
0
3
3
from 48% to 96%, with a mean score and standard deviation of
Intervention
length (mo)

73 ± 11%. Main reasons for poor methodological quality were failure

to blind study subjects, describe/adjust for confounders and report

0.5
participant representativeness of the entire recruitment population
4
2
2

(Appendix S2).
Behaviour

Health promotion interventions were diverse, varying from edu-

models
change

cation by leaflets or video, to comprehensive programmes involving

the child, family and larger community. Four interventions17,19,28-32
14

provided clinical preventive measures (dental prophylaxis, fluoride

prevention/take-

varnish/rinse, fissure sealants), while dental take-home products were

home products

supplied in 10 programmes17,19-21,26,29-41 (Table 1, Appendix S3).

The intervention components varied across the studies. Oral
Clinical

health education was an integral part of each intervention, predom-

inantly given by dental personnel (dentists,18,24,25,40,42 dental auxil-
process model; 11: Health promoting schools; 12: Prospect theory; 13: Experiential learning; 14: Health belief model; SS: Single session.

iary2,19,20,27-32,37) or study investigators.21-23,26,33-36,39,41,43-48 Education

Outcomes assessed

KAB, OHI, TC, CPI

was also provided by teachers,24,25,40,49 student peers,24,25,42,50 health

education specialists51 and leaflets/video37,38,52 (Table 1). Three pro-
PI, KAB, TA

grammes compared effectiveness of education given by different

PI, CPI

personnel: dentist versus teachers,40 dentist versus peers42 and a

KAB

comparison of all three.24,25 Fourteen of the 28 programmes employed

health behaviour change theories to design and implement the inter-
participants
Number of

vention, with seven studies 26,29,39,44,49-51 reporting outcomes based on

the theory (Table 1, Appendix S3).
741
135
417
392

Most studies reported more than one outcome category, in-

cluding self-reported knowledge, attitudes and beliefs (including
involvement
programme

oral health-related quality of life [OHRQoL]); clinical measures

(gingival, plaque, caries scores); and behavioural ‘proxy’ measures.
Family

Family
Wider

Heterogeneity of clinical outcomes was high (Table 1, Appendix S4).

Of the 18 studies (in 23 publications) measuring self-reported knowl-
Intervention provider

edge/attitudes/beliefs or OHRQoL, 2,19,21,24,25,27,28,36-39,41-45,47-49,51

Albandar 1994, Albandar 1995, Axelsson 1994, Buischi 1994, Mayer 2003.
Leaflet or Videotape
Health Ed Specialist

89% of studies found statistically significant positive results versus

Investigator(s)

control. 2,21,24,25,28,36-39,41-45,47,49,51 Of the five studies reporting out-

Dental Nurse

Hausen 2007, Tolvanen 2009, Tolvanen 2010a, Tolvanen 2010b.

comes of behavioural ‘proxy’ measures (Multidimensional Health

Locus of Control, self-efficacy and planning ability, attitudes and in-
tentions, stability of behaviours and stage transitions or components
of the Health Belief Model), all reported statistically significant pos-
itive results.31,39,44,49,51
Setting

School
School
School
School

Five of thirteen studies (38%), including 12 outcomes, could be

included in a gingival health meta-analysis. The improvement in Löe
and Silness Gingival Index (0-3 score range) for intervention ver-
sus control was −0.45 [95% CI: −0.8, −0.1] in the comprehensive
Country

England
Taiwan

intervention subcategory and −0.07 [95% CI: −0.1, −0.05] in the

Iran
Iran
TA B L E 1   (Continued)

education-only subcategory, where more negative results indicate

favouring of intervention (Figure  2). The difference of the means
Worthington 2001

Yekaninejad 2012
First author, year

between comprehensive and education-only interventions was 0.4

Yazdani 2009

(SE = 0.2, P = .1).
Yang 2009

Eight of 21 studies (38%), including 15 outcomes, could be in-

cluded in a plaque score meta-analysis. On the Silness and Löe Plaque
Index (0-3 range), pooled results were −0.43 [95% CI: −0.66, −0.2]
b
a
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6       TSAI et al.

F I G U R E 2   Meta-analysis results for the difference in gingival score increment between intervention and control groups stratified by
intervention subgroup (comprehensive vs education-only)

for the comprehensive intervention subcategory and −0.24 [95%
CI: −0.41, −0.07] for the education-only subcategory (Figure 3). The
difference of the means between intervention subgroups was 0.2
(SE = 0.1, P = .22). Twelve outcomes were reported as statistically
significant with only three interventions,40,42,45 all from the educa-
tion-only subcategory, reporting increases in plaque scores.
For caries, six of nine studies (67%), including 11 outcomes, could
be included in a DMFS meta-analysis (Figure 4).17,19,29,35,40,50 Overall,
the comprehensive intervention subcategory had 1.2 fewer newly
decayed tooth surfaces than the control group (−1.15 [95% CI: −1.9,
−0.41]). There was no significant difference (0.07 [95% CI: −0.06,
0.19]) in the education-only subcategory. The difference of the
means between intervention subgroups was 1.2 (SE = 0.4, P = .01).
Statistically significant results, on any outcome, appeared to be more
frequent in studies with longer duration (≥12  months)­17-19,21,24,25,28-38
than shorter programmes (<12  months).2,20,22,23,26,27,39-47,49,51,52 This
was particularly true with caries outcomes, where all studies with com-
prehensive interventions and duration ≥12 months were statistically sig-
nificant, while shorter term interventions or those with education-only
arms were not.
TSAI et al.
F I G U R E 3   Meta-analysis results for the difference in plaque score per cent increment between intervention and control groups stratified
by intervention subgroup (comprehensive vs education-only)
In general, the heterogeneity was lower in the education-only
meta-analyses and to a large degree, unsuccessful in improving
clinical measures. The meta-analyses involving comprehensive in-
terventions were quite heterogeneous with some components
appearing to show greater efficacy than others. The intervention
characteristics that appeared to contribute to these positive out-
comes were involvement of community2,21,23,29-38,46,51 (13/15 sta-
tistically significant), peer-to-peer learning2,24,25,29-32,42,47 (8/9), use
of behavioural theory18,21-26,28-36,39,41,44,49-51 (18/22) and participant
|
      7
self-diagnosis2,17-23,28-38,41 (15/20), which ranged from participants
identifying their own gingival bleeding sites or plaque levels to re-
ceiving personalized visual tools displaying active caries.
4 | D I S CU S S I O N
This is the first systematic review and meta-analysis to analyse the ef-
fectiveness of oral health promotion strategies specific to adolescents.
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8       TSAI et al.

F I G U R E 4   Meta-analysis results for the difference in DMFS increment between intervention and control groups stratified by
intervention subgroup (comprehensive vs education-only)

Thirty-seven publications, involving 13 282 adolescents, reported on a
diverse array of interventions and outcomes such as gingivitis, plaque
scores and dental decay, self-reported knowledge/attitudes/beliefs
and OHRQoL. Overall quality of included studies was moderate to
high. The majority of studies assessing improvements in knowledge,
behaviours or beliefs reported positive outcomes. The meta-analysis
showed that a reduction in decay rates was not evident for studies
relying on ‘education-only’ but was evident in more ‘comprehensive’
interventions. There were improvements in plaque scores and gingival
health for both intervention types, but to a higher degree in the com-
prehensive interventions. Heterogeneity was overall high, but higher
in the comprehensive interventions, likely attributed to the diverse
array of intervention strategies employed. Such strategies, including
involving community, use of a behaviour theory, peer-to-peer learning
and an element of self-diagnosis, seemed to be influential in this age
group.
The school years are influential in young people's lives.53 Schools
provide ideal environments for oral health promotion interventions,
TSAI et al.
offering efficient and effective ways to reach adolescents and con-
sequently was where most of the interventions were conducted.
The World Health Organization's Health Promoting Schools initia-
tive has been shown to have some success here.54,55 These holistic
programmes may be more effective as they integrate elements of
55
social and physical environmental factors and policy development.
Oral health promotion programmes within primary schools
usually consist of top-down oral health instruction, with an over-
emphasis on ‘knowledge-based’ behaviour change techniques.56,57
Conversely, adolescent programmes in this review often incorpo-
rated participatory demonstrations, skill sessions and reinforcement
at regular intervals, and involvement of participants in diagnosing
and understanding individual risks for poor oral health. They em-
phasized assessing and improving behaviours through established
health behaviour change theory. This approach is arguably more
meaningful in adolescents with more autonomy in decision-making
and rationalization than younger children.32,35,38
Peer-led education showed promise in adolescents, facilitating
2,24,25,42
dissemination of knowledge and influencing behaviours.
This follows other areas such as healthy lifestyles, sex education,
substance abuse and mental health/suicide prevention in adolescent
58,59
groups. Trained peers can be effective in delivering messages in
a natural and relatable manner. Moreover, as social identity and peer
group acceptance has strong salience during adolescence,38 peer
leaders can be effective in steering group norms and delivering posi-
tive peer group pressure for the adoption of healthy behaviours.59,57
The quantitative findings of this systematic review mirror re-
views of oral health behavioural interventions in other age groups,
suggesting that oral health promotion programmes have significant
short-term improvement effects on plaque and gingivitis but not
necessarily dental caries.3,56,57,60-63 This review's meta-analyses
and subgroup analyses suggest greater improvements result from
programmes with more comprehensive interventions in all clinical
outcome categories studied. The greatest difference was in caries
outcomes, where education-only interventions had no effect on
dental caries.
Programmes incorporating comprehensive interventions in-
volving family, community or food environment helped to identify
and address the wider influences and complexity of targeted be-
haviours. This aligns with the common risk factor approach to oral
health promotion, that advocates for an integrated strategy target-
ing risk factors and underlying determinants common to multiple
chronic diseases. 5 To enhance programme reach and sustainabil-
ity, it has been advocated that interventions are embedded in the
multi-level structure of families, health providers, health organi-
zation settings, local community environments and health policy
environments.64,65
Elements common to the four studies reporting significant im-
provements in DMFS increment included the use of comprehensive
and individualized interventions that were needs- or caries risk-based
and included topical fluorides as part of the programme.17,19,29,35
While difficult to separate the effects of oral health promotion ver-
sus fluoride products, a more holistic view of the findings supports
|
      9
an additive effect of carefully designed behavioural strategies and
preventive measures.66
Shorter programmes have often reported ineffectiveness in car-
ies improvements,3,61 but by comparing subsets of studies based on
intervention duration, it appears from this review this may partly be
due to the dynamic nature and slower progression of caries com-
pared to plaque and gingivitis improvements. However, consider-
ing behavioural change theories based on building self-efficacy, it
follows that effective programmes require longer duration, sound
structure and constant reinforcement.
The cost-effectiveness of oral health interventions for adoles-
cents is unknown. Two included studies cited the use of school staff
and low-cost visual aids, as ways to minimize the cost of health inter-
ventions.18,40 Several other studies described uncertainty about the
cost-effectiveness of scaling up their programmes. 20,21,29,35,36 For
improved sustainability, it is recommended that cost-effectiveness/
economic analysis are built into trial designs whenever possible, to
assess the feasibility of maintaining or scaling up interventions.57
When reviewing intervention studies, publication bias must
always be considered, including tendency to publish more studies
with positive findings or highlight positive outcomes. There is a high
chance of publication bias in the studies of this review, but it is im-
possible to determine the effect this has on the findings.
While an attempt has been made to show pooled data for the
clinical outcomes included in the meta-analyses, these findings
should be viewed with caution, as it was only possible to include
one-third of the studies. Although this can still allude to the effec-
tiveness of some intervention types, it does emphasize the need for
standardized reporting methods for dental clinical outcomes of oral
health promotion in the future. While the relatively high heteroge-
neity in these meta-analyses is to be expected due to the diverse
types of interventions, an attempt to minimize this by subgroup anal-
ysis was made based on comprehensiveness of the interventions.
This was more successful in some outcomes than others. In addition
to this, there may have been limitations through the use of proxy
measures of oral health. For example, high plaque scores, although
a risk factor for poor oral health, may not always result in poor oral
health outcomes, especially in the adolescent population. Despite
these factors, the substantial strength of this review was the ability
to assess and examine the effectiveness of the vast array of pro-
grammes targeted at adolescents.
Oral health promotion programmes targeting adolescents are
able to improve clinical outcomes such as gingival health, plaque and
dental caries, especially in the short term. Education-only strategies
are not considered to be very effective. A comprehensive approach
including behavioural techniques and clinical interventions such as
fluoride has shown good results for adolescents. To be successful
in this age group, it is recommended that programmes avoid top-
down, knowledge-based education used predominantly for younger
children and use longer-term, more inclusive, holistic interventions
involving wider social circles, clinical preventive measures and the
use of a behavioural theory. The use of nondental professionals also
shows promise, with peer-to-peer teaching and community figures
 |
10       TSAI et al.
having some success. Economic analysis of interventions is recom-
mended for future studies.
AC K N OW L E D G E M E N T S
The authors wish to acknowledge Professor Anthony Blinkhorn for
his support in initiating this systematic review as well as the sup-
port of the Sydney Informatics Hub, a Core Research Facility of the
University of Sydney.
AU T H O R C O N T R I B U T I O N S
All authors meet the conditions set by the International Committee
of Medical Journal Editors (ICMJE) as having made substantial con-
tribution to the conception, acquisition and design of the study. SR
conducted the systematic searches. SR, CT, CA and MI have been
involved in data extraction. SR and CT have been involved with data
interpretation and quality appraisal with MI consulting on disagree-
ments. CT and SR have been involved with drafting the manuscript
with all authors revising it critically. This manuscript has been read
and approved by all authors, and all authors agree to the submission
of the manuscript for publication in Community Dentistry and Oral
Epidemiology journal.
ORCID
Carrie Tsai  https://orcid.org/0000-0003-2442-8725
Gordon McDonald  https://orcid.org/0000-0002-2890-527X
Michelle Irving  https://orcid.org/0000-0001-7526-6258
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How to cite this article: Tsai C, Raphael S, Agnew C,
McDonald G, Irving M. Health promotion interventions to
improve oral health of adolescents: A systematic review and
meta-analysis. Community Dent Oral Epidemiol. 2020;00:1–12.

S U P P O R T I N G I N FO R M AT I O N https://doi.org/10.1111/cdoe.12567

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