An intervention programme to establish regular toothbrushing: understanding parents' beliefs and motivating children

Factors predicting different times for brushing teeth during the day: multilevel analyses

BACKGROUND

The most effective and simple intervention for preventing oral disease is toothbrushing. However, there is substantial variation in the timing of brushing teeth during the day. We aimed to identify a comprehensive set of predictors of toothbrushing after lunch and after dinner and estimated contextual (i.e., geographic) variation in brushing behavior at different times of the day.

METHODS

We constructed a conceptual framework for toothbrushing by reviewing health behavior models. The main data source was the 2017 Community Health Survey. We performed a four-level random intercept logistic regression to predict toothbrushing behavior. (individual, household, Gi/Gun/Gu, and Si/Do).

RESULTS

Individuals under 30 years of age had higher likelihood of brushing after lunch, while brushing after dinner was higher among those aged 40-79 years. People engaged in service/sales, agriculture/fishing/labor/mechanics, as well as student/housewife/unemployed were 0.60, 0.41, and 0.49 times less likely to brush their teeth after lunch, respectively, compared to those working in the office, but the gap narrowed to 0.97, 0.96, 0.94 for brushing after dinner. We also found significant area-level variations in the timing of brushing.

CONCLUSIONS

Different patterns in association with various factors at individual-, household- and Si/Gun/Gu-levels with toothbrushing after lunch versus toothbrushing after dinner suggests a need for tailored interventions to improve toothbrushing behavior depending on the time of day.

Diet, Oral Hygiene Habits, and Approach to Dental Visits of Early School-Aged Children during the COVID-19 Pandemic and Possible Long-Term Health Consequences

INTRODUCTION

Early school-aged children are in a transitional phase from primary to permanent dentition. Established dietary and oral hygiene habits will influence the condition of the oral cavity in the future.

AIM

This study aimed to evaluate alterations in early school children's dietary and oral hygiene practices during the COVID-19 pandemic and to anticipate potential long-term health implications.

MATERIAL AND METHODS

This cross-sectional online study involved guardians of Polish children aged 6-10 years, living in Western Poland, who were socially isolated at home during the COVID-19 pandemic. A total of 180 guardians were invited to participate in this study. The questionnaire included 17 questions divided into four different sections-the child's anthropometric data, dietary habits, oral health, and attitude to dental visits.

RESULTS

The survey was completed by 106 guardians. The mean (standard deviation) age of the children was 8.12 (0.93) years (range 6-10 years). Overall, 24.5% of the surveyed individuals reported buying healthy products (fresh vegetables, fruit) more frequently during the pandemic. Furthermore, 35.8% admitted to snacking between meals more frequently and 16.0% less frequently. Almost one-quarter of the parents acknowledged that their children were less motivated to maintain oral hygiene during the pandemic and 28.3% declared a lower frequency of visits to the dentist from the outbreak of the pandemic for two main reasons: a fear of coronavirus transmission and economic reasons.

CONCLUSIONS

In the group studied, the results of the assessment indicate that the COVID-19 pandemic had some effects on oral health that may lead to an increased risk of oral disease development, such as tooth decay in children. None of the respondents noticed an increase in their child's motivation about good oral hygiene despite spending more time at home. The irregularity of follow-up visits for one-third of the respondents hindered preventive measures and the continuation of dental treatment.

A qualitative study of barriers and facilitators to the implementation of a pilot school-based, toothbrushing programme

Background

While supervised toothbrushing programmes have been established in many countries of the world, little is known about different perspectives on their implementation. The aim of the study was to explore stakeholders' barriers and facilitators to implementation of a school-based toothbrushing programme in Taiwan.

Methods

Focus groups and interviews were used to explore the views of elementary school students, teachers, staff, and nurses in a piloted school-based toothbrushing programme. The topic guides were developed according to the Theoretical Domains Framework (TDF) to cover the behavioural factors systematically and comprehensively. Data were analysed with content analysis.

Results

Overall, 36 students, 29 teachers/staff, and five school nurses (N = 65) were included. The overarching theme was the importance of habit formation for both staff and children to ensure that toothbrushing as part of the programme was embedded into the school schedule and routine. While children did not necessarily appear to retain the dental knowledge which was taught in the programme, the provision of fluoride toothpaste and toothbrush for their use in schools allowing teachers and staff to choose the timing of the brushing and engaging classmates to supervise each other were found to be key factors.

Conclusions

Implementing a school-based toothbrushing programme with the support of staff and active engagement of children can help children to develop a toothbrushing habit. Classmate-supervised toothbrushing may reduce the burden on teachers and staff to implement the programme.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02494-7.

Barriers and enablers in the implementation and sustainability of toothbrushing programs in early childhood settings and primary schools: a systematic review

Background

Untreated dental caries negatively impacts a child's quality of life including overall health and wellbeing, growth and development, social interaction ability, and school attendance. School-based toothbrushing programs have been recognised as an effective intervention to reduce the burden of dental caries. However, limited information is available to understand the real-world enablers and challenges in the implementation and sustainability of toothbrushing programs. This review aims to understand the barriers and enablers in the implementation and sustainability of toothbrushing programs in early childhood settings and primary schools.

Methods

Five electronic databases [i.e., CINAHL (EBSCO), Medline (EBSCO), EMBASE (Ovid), Web of Science, and PsycINFO] and backward citation chasing were performed. The last updated databases searches were conducted in May 2022. Studies reporting on barriers and enablers in the implementation and sustainability of toothbrushing programs in early childhood settings or primary schools were included in the review. The methodological quality of included studies was assessed by using Joanna Briggs Institute [JBI] and mixed methods appraisal tool [MMAT] critical appraisal tools and results were reported in accordance with PRISMA guidelines.

Results

A total of six studies met the eligibility criteria and were included in the review. Toothbrushing programs in early childhood settings and primary schools were mostly implemented under the supervision of staff and teachers. A positive attitude of the staff, the flexibility of toothbrushing sessions, involvement of community volunteers and parents were a few of the identified enablers. However, the timing of the communication of the program, inadequate transfer of information among staff, frequent staffing turnover, lack of parental support, and staff feeling overburdened while acting as pseudo parents were frequently reported as barriers.

Conclusion

The results of this systematic review identify key enablers and barriers for toothbrushing programs in early childhood settings and primary schools which need to be considered for developing oral health promotion initiatives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02270-7.

A scoping review of intervention components of school-based oral health-related behavioural interventions using the Theoretical Domains Framework

The aim of this study was to review the intervention components of school-based oral health-related behavioural interventions using the Theoretical Domains Framework (TDF). We identified relevant papers from the review of Cooper et al., and these papers came from both the original inclusion and exclusion article lists. We also modified and updated their search strategies (2013 - April 2019). The 53 included papers reported on 79 interventions (experimental groups = 57 interventions, control groups = 22 interventions). Most of the papers used three to nine domains (average = 5.6) in their experimental interventions, and the most commonly used domains were 'knowledge,' 'skills,' 'social influences,' and 'environmental context and resources.' Considering the complexity of intervention components in one programme, there is no one specific domain or domain set that can determine the success of behavioural interventions. The design of future programmes should be guided by a complex intervention methodology. However, the best combination set might not exist, and the choice of domains should depend on local context or resources. This study can be used as a resource for identifying previous papers, which have used the same domains.

Impact of Oral Health Educational Interventions on Oral Hygiene Status of Children with Hearing Loss: A Randomized Controlled Trial

Introduction

Oral health is considered as one of the essential components of the overall health of every individual. Maintaining oral health is a gradual process that requires commitment. Children who require special care such as hearing impairment experience difficulty in maintaining oral health primarily due to communication difficulties. This study is aimed at using different interventions to evaluate the improvement of oral hygiene in hearing impaired children.

Materials and Methods

Fifty-nine children were recruited in this study that were allocated randomly into each group with twenty children as follows: group 1: pictorial, group 2: video, and group 3: control. Mean plaque and gingival scores were noted before and after the use of different interventions. Oral hygiene was categorized as “excellent,” “good,” and “fair.” Gingival health was categorized as “healthy,” “mild gingivitis,” and “moderate gingivitis.”

Results

Thirty-four children (57.6%) were from 12-13 years of age bracket, and 25 (42.4%) belonged to 14-16 years of age. Regarding gender, there were 37 (62.7%) males and 22 (37.3%) females. About comparison of mean gingival and plaque scores before and after interventions in each group, a significant difference was found in group 1 (p < 0.001) and group 2 (p < 0.001), as compared to group 3 where the difference in scores was not significant (p > 0.05).

Conclusion

Maintaining oral health requires the compliance of individuals to perform different methods of preventive dentistry, such as tooth brushing and use of dental floss. The use of different oral hygiene educational interventions such as pictorial and video methods have been proven and useful for hearing impaired children in improving oral health.

Characteristics and practices of school-based cluster randomised controlled trials for improving health outcomes in pupils in the United Kingdom: a methodological systematic review

Background

Cluster randomised trials (CRTs) are increasingly used to evaluate non-pharmacological interventions for improving child health. Although methodological challenges of CRTs are well documented, the characteristics of school-based CRTs with pupil health outcomes have not been systematically described. Our objective was to describe methodological characteristics of these studies in the United Kingdom (UK).

Methods

MEDLINE was systematically searched from inception to 30^th June 2020. Included studies used the CRT design in schools and measured primary outcomes on pupils. Study characteristics were described using descriptive statistics.

Results

Of 3138 articles identified, 64 were included. CRTs with pupil health outcomes have been increasingly used in the UK school setting since the earliest included paper was published in 1993; 37 (58%) studies were published after 2010. Of the 44 studies that reported information, 93% included state-funded schools. Thirty six (56%) were exclusively in primary schools and 24 (38%) exclusively in secondary schools. Schools were randomised in 56 studies, classrooms in 6 studies, and year groups in 2 studies. Eighty percent of studies used restricted randomisation to balance cluster-level characteristics between trial arms, but few provided justification for their choice of balancing factors. Interventions covered 11 different health areas; 53 (83%) included components that were necessarily administered to entire clusters. The median (interquartile range) number of clusters and pupils recruited was 31.5 (21 to 50) and 1308 (604 to 3201), respectively. In half the studies, at least one cluster dropped out. Only 26 (41%) studies reported the intra-cluster correlation coefficient (ICC) of the primary outcome from the analysis; this was often markedly different to the assumed ICC in the sample size calculation. The median (range) ICC for school clusters was 0.028 (0.0005 to 0.21).

Conclusions

The increasing pool of school-based CRTs examining pupil health outcomes provides methodological knowledge and highlights design challenges. Data from these studies should be used to identify the best school-level characteristics for balancing the randomisation. Better information on the ICC of pupil health outcomes is required to aid the planning of future CRTs. Improved reporting of the recruitment process will help to identify barriers to obtaining representative samples of schools.

Toothbrushing and School Refusal in Elementary School: A Longitudinal Study

The aim of this study was to examine the association between toothbrushing frequency and school refusal among elementary school children. We used data from the Adachi Child Health Impact of Living Difficulty (A-CHILD) longitudinal study conducted between 2015 and 2016 in Adachi City, Tokyo, Japan. A questionnaire was distributed to all first-grade children aged 6 to 7 years (N = 3697, follow-up rate: 86.2%). Propensity score (PS) matching was applied to collapse the known covariates on toothbrushing frequency in grade 1 on the association with school refusal in grade 2. Among the followed children, 2.4% showed school refusal in grade 2 (89 children) and 23.5% (870 children) brushed their teeth once or less than once daily in grade 1. After propensity score matching, children with toothbrushing once or less than once daily in grade 1 were 2.25 (95% CI: 1.25–4.05) times more likely to show school refusal in grade 2, compared with those with toothbrushing twice or more a day. Our findings suggest that toothbrushing once or less than once daily is an independent risk factor for school refusal among children. Oral health promotion to recommend toothbrushing more than once a day could prevent school refusal. Further intervention studies investigating the mechanism and causality are warranted.

Use of teachers as agents of oral health education: Intervention study among public secondary school pupils in Lagos

Background:

Common oral diseases are preventable and if detected early are reversible and schools provide a setting in which the oral health behavior of pupils can be influenced. We aimed to assess the effectiveness of using teachers in place of oral health professionals to deliver oral health education (OHE) in public secondary schools in Lagos State.

Methods:

This quasi-experimental study was conducted in four phases from September 2016-April 2017. A multistage sampling method was adopted to enlist the research participants from four enlisted schools, which were randomly assigned into two groups. Trained dentists delivered OHE in the first group of schools while trained teachers did in the second group and the impact of the intervention was assessed over six months. P values for significant differences were set at 0.05.

Results:

At the 3 months evaluation, the mean oral health knowledge (OHK) scores were higher among pupils in the Teachers Intervention Schools (TIS) (71.3 ± 19.3) than that in the Dentist Intervention Schools (DIS) (61.3 ± 17.7) (P = 0.023). Subsequent evaluation sessions from baseline revealed a gradual increase in the proportion of pupils with positive oral health attitude scores; with a higher proportion of pupils in the DIS (34.5%) compared to the TIS (34.0%) at 6 months assessment time. At 6 months evaluation, the proportion of pupils with poor oral health practices decreased in both groups of schools (P = 0.104).

Conclusion:

The proportion of pupils with good OHK was higher in the TIS at post-intervention periods; this difference was statistically significant at 3 months. This result suggests that teachers are as effective as dentists in delivering OHE.

Countering the poor oral health of people with intellectual and developmental disability: a scoping literature review

Background

People with intellectual and developmental disability (IDD) have poor oral health and need support to maintain optimal oral health outcomes. Little is known about how, when and where to intervene for this population. Thus the aim of this review was to summarise the existing evidence surrounding improving oral health outcomes for people with IDD.

Methods

A scoping literature review was conducted focusing on ‘oral health’ and ‘intellectual disability’. Systematic searches of five electronic databases were conducted in line with the study aims and two authors independently examined all records for relevance, with consensus achieved by a third author.

Results

A small number of approaches and interventions were identified to support people with IDD to independently maintain optimal oral hygiene. Identified studies highlighted that caregivers play a vital role in the provision of oral health support, emphasising the effectiveness of educational interventions for caregivers. However, there was uncertainty regarding the efficacy of specific tooth brushing interventions for people with IDD. In cases of more severe IDD and/or dental-related behavioural problems, dental treatment under general anaesthesia was often both a necessary and effective method of oral health care provision. The findings also identified outreach and exclusive oral health services as successful strategies for increasing the limited access of people with IDD to oral care services.

Conclusions

A uniform approach to supporting oral health for people with IDD is unlikely to succeed. A system-based approach is needed to address the diverse needs of the population of people with IDD, their caregivers and service context. Further high quality evidence is required to confirm these findings.

The role of psychological theories in oral health interventions: A systematic review and meta-analysis

OBJECTIVE

In the present study, we attempted to assess how psychological theories (health belief model [HBM], theory of planned behaviour [TPB], social cognitive theory [SCT], clinical theories [CT] and other theories [OT]) influence oral health interventions.

METHODS

PubMed, Scopus, Cochrane and Web of Knowledge databases from 2000 to 2017 were searched. We defined psychological theories based on five subgroups: (A) HBM, (B) TPB, (C) SCT, (E) CT and (F) OT.

RESULTS

From the 156 identified studies, 19 studies based on PICO were included. Our findings indicated that the standardized mean difference (SMD) of HBM was 0.37 (95% CI: 0.24, 0.51), which was statistically significant in improving oral health. The SMD of SCT was not significant (0.05 [95% CI: -0.33, 0.44]) in improving oral health. The SMD of TPB was significant (1.66 [95% CI: 1.06, 2.27]) in improving oral health. The SMD of CT (-4.6 [95% CI: -6.49, -2.71]) and OT (2.93 [95% CI: 1.55, 4.32]) revealed significant differences in improving oral health.

CONCLUSION

The current meta-analysis showed that in general, psychological interventions that used OT, CT, HBM and TPB were effective in enhancing oral health status, and interventions that used SCT did not have an effect on improving oral health status. Oral health care providers who work with patients to take methods and improve behaviours that are related to appropriate oral health need to comprehend their applicability and strengths.

Dental caries prevention strategies among children and adolescents with immigrant - or low socioeconomic backgrounds- do they work? A systematic review

BACKGROUND

This systematic review was designed to uncover the most reliable evidence about the effects of caries preventive strategies in children and adolescents of immigrant or low socioeconomic backgrounds.

METHODS

According to pre-determined inclusion and exclusion criteria, relevant articles focusing on underprivileged groups were electronically selected between January1995 and October 2015. The literature search was conducted in five databases; PubMed, Embase, CINAHL, SweMed+ and Cochrane Library. Accepted languages for included articles were English, German and Scandinavian languages. Abstracts and selected articles in full text were read and assessed independently by two review authors. Systematic reviews and meta-analyses were not included. Also articles with topics of water fluoridation and fluoride toothpaste were excluded, this due to all existing evidence of anti-caries effect for disadvantaged groups. The key data about the main characteristics of the study were compiled in tables and a quality grading was performed.

RESULTS

Thirty-seven articles were selected for further evaluation. Supervised toothbrushing for 5-year-old school children was found to be an effective prevention technique for use in underprivileged groups. Also a child/mother approach, targeting nutrition and broad oral health education of mothers showed effectiveness. For older children, a slow-release fluoride device and application of acidulated phosphate fluoride (APF) gel showed to be effective.

CONCLUSION

On the basis of this review, we maintain that in addition to studies of water fluoridation and fluoride toothpaste, there are other preventive intervention studies providing scientific evidence for caries reduction among children and adolescents with immigrant or low socioeconomic backgrounds.

Rationale for the prevention of oral diseases in primary health care: an international collaborative study in oral health education

Ensuring that members of society are healthy and reaching their full potential requires the prevention of oral diseases through the promotion of oral health and well-being. The present article identifies the best policy conditions of effective public health and primary care integration and the actors who promote and sustain these efforts. In this review, arguments and recommendations are provided to introduce an oral health collaborative promotion programme called Live.Learn.Laugh. phase 2, arising from an unique partnership between FDI World Dental Federation, the global company Unilever plc and an international network of National Dental Associations, health-care centres, schools and educators populations.

Effect and process evaluation of a kindergarten-based, family-involved intervention with a randomized cluster design on sedentary behaviour in 4- to 6- year old European preschool children: The ToyBox-study

Background

The aim of the present study evaluated the effect and process of the ToyBox-intervention on proxy-reported sedentary behaviours in 4- to 6-year-old preschoolers from six European countries.

Methods

In total, 2434 preschoolers’ parents/primary caregivers (mean age: 4.7±0.4 years, 52.2% boys) filled out a questionnaire, assessing preschoolers’ sedentary behaviours (TV/DVD/video viewing, computer/video games use and quiet play) on weekdays and weekend days. Multilevel repeated measures analyses were conducted to measure the intervention effects. Additionally, process evaluation data were included to better understand the intervention effects.

Results

Positive intervention effects were found for computer/video games use. In the total sample, the intervention group showed a smaller increase in computer/video games use on weekdays (ß = -3.40, p = 0.06; intervention: +5.48 min/day, control: +8.89 min/day) and on weekend days (ß = -5.97, p = 0.05; intervention: +9.46 min/day, control: +15.43 min/day) from baseline to follow-up, compared to the control group. Country-specific analyses showed similar effects in Belgium and Bulgaria, while no significant intervention effects were found in the other countries. Process evaluation data showed relatively low teachers’ and low parents’ process evaluation scores for the sedentary behaviour component of the intervention (mean: 15.6/24, range: 2.5–23.5 and mean: 8.7/17, range: 0–17, respectively). Higher parents’ process evaluation scores were related to a larger intervention effect, but higher teachers’ process evaluation scores were not.

Conclusions

The ToyBox-intervention had a small, positive effect on European preschoolers’ computer/video games use on both weekdays and weekend days, but not on TV/DVD/video viewing or quiet play. The lack of larger effects can possibly be due to the fact that parents were only passively involved in the intervention and to the fact that the intervention was too demanding for the teachers. Future interventions targeting preschoolers' behaviours should involve parents more actively in both the development and the implementation of the intervention and, when involving schools, less demanding activities for teachers should be developed.

Trial registration

clinicaltrials.gov NCT02116296

Prevalence of dental caries and toothbrushing habits among preschool children in Khartoum State, Sudan

BACKGROUND

Dental caries in preschool children remains a major dental public health problem and affects significant numbers of children in developed and developing countries. The incidence is increasing in developing countries, such as Sudan, because of lifestyle changes, absence of oral health-preventive services and inadequate access to oral health care.

OBJECTIVES

This study assessed the prevalence of dental caries and toothbrushing habits among 3- to 5-year-old preschool children in Khartoum State, Sudan, and described the correlation between the mean decayed, missing and filled tooth (dmft) score for primary teeth with toothbrushing and sugar consumption.

MATERIALS AND METHODS

The subjects were 553 preschool children with their mothers/guardians, selected by random sampling from the kindergartens of the seven localities of Khartoum State, Sudan. Data were obtained through clinical examination using a modified World Health Organization (WHO) examination data-capture sheet and through structured administered interviews with mothers/guardians.

RESULTS

The prevalence of dental caries was 52.4%, with a mean dmft score of 2.3. There was an increase in the dmft scores with increasing age. The frequency of children who brushed their teeth regularly at least once a day was high (83.4%), lower dmft scores were associated with starting toothbrushing earlier in life and with increased frequency of brushing per day. Eating sugar-containing food was significantly associated with dmft score.

CONCLUSIONS

The prevalence of dental caries was found to be high among 3- to 5-year-old preschool children, and caries experience increased with age. This was mostly associated with sugar consumption and therefore calls for educational interventions to control sugar intake. The toothbrushing habit is well established in Khartoum State, Sudan, as a large number of children were found to be brushing their teeth regularly. No significant association was found between feeding habits and dmft score.

Drilling Deeper into tooth brushing skills: Is proactive interference an under-recognized factor in oral hygiene behavior change?

Proper tooth brushing is a seemingly simple motor activity that can promote oral health. Applying health theories, such as the Information-Motivation-Behavioral Skills (IMB) model, Motivational Interviewing (MI) and Integrated Health Coaching (IHC), may help optimize tooth brushing technique in those with suboptimal skills. Some motor activities, including tooth brushing, may over time become rote and unconscious actions, such that an existing habit can inhibit new learning, i.e., exert proactive interference on learning the new skill. Proactive interference may impede the acquisition of new tooth brushing skills; thus, in this report, we: (1) Review how the habit of tooth brushing is formed; (2) Postulate how proactive interference could impede the establishment of proper tooth brushing retraining; (3) Discuss the merits of this hypothesis; and (4) Provide guidance for future work in this topic within the context of an approach to behavior change that integrates IMB, MI and IHC methodology.

Teeth Tales: a community-based child oral health promotion trial with migrant families in Australia

OBJECTIVES

The Teeth Tales trial aimed to establish a model for child oral health promotion for culturally diverse communities in Australia.

DESIGN

An exploratory trial implementing a community-based child oral health promotion intervention for Australian families from migrant backgrounds. Mixed method, longitudinal evaluation.

SETTING

The intervention was based in Moreland, a culturally diverse locality in Melbourne, Australia.

PARTICIPANTS

Families with 1-4-year-old children, self-identified as being from Iraqi, Lebanese or Pakistani backgrounds residing in Melbourne. Participants residing close to the intervention site were allocated to intervention.

INTERVENTION

The intervention was conducted over 5 months and comprised community oral health education sessions led by peer educators and follow-up health messages.

OUTCOME MEASURES

This paper reports on the intervention impacts, process evaluation and descriptive analysis of health, knowledge and behavioural changes 18 months after baseline data collection.

RESULTS

Significant differences in the Debris Index (OR=0.44 (0.22 to 0.88)) and the Modified Gingival Index (OR=0.34 (0.19 to 0.61)) indicated increased tooth brushing and/or improved toothbrushing technique in the intervention group. An increased proportion of intervention parents, compared to those in the comparison group reported that they had been shown how to brush their child's teeth (OR=2.65 (1.49 to 4.69)). Process evaluation results highlighted the problems with recruitment and retention of the study sample (275 complete case families). The child dental screening encouraged involvement in the study, as did linking attendance with other community/cultural activities.

CONCLUSIONS

The Teeth Tales intervention was promising in terms of improving oral hygiene and parent knowledge of tooth brushing technique. Adaptations to delivery of the intervention are required to increase uptake and likely impact. A future cluster randomised controlled trial would provide strongest evidence of effectiveness if appropriate to the community, cultural and economic context.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12611000532909).

Challenges in designing, conducting, and reporting oral health behavioral intervention studies in primary school age children: methodological issues

Often within oral health, clinical outcome measures dominate trial design rather than behavioral outcome measures, and often there is a reliance on proxy self-reporting of children's behavior with no corroboration through triangulation of measures. The complexity of the interventions involved in oral health intervention is often overlooked in trial design, and more flexible pragmatic designs that take account of the research context may be more appropriate. Some of the limitations in oral health behavioral intervention studies (trials) in primary school age children were reported in a recently published Cochrane review. This paper aims to critically discuss the findings of a recent Cochrane review in terms of the methodological implications that arise for future design, development, measurement, and reporting of oral health trials in primary school age children. Key components of the UK Medical Research Council's framework for the design and evaluation of complex interventions are discussed in relation to using taxonomies of behavior change. This paper is not designed to be a definitive guide but aims to bring learning from other areas of public health and health promotion into dental public health. Ultimately, the aim is to aid the design of more successful interventions that produce long-term behavioral changes in children in relation to toothbrushing and nighttime sugar snacking.

Parents' reasons for brushing or not brushing their child's teeth: a qualitative study

BACKGROUND

Despite recent improvements in oral health, dental caries remains a significant source of morbidity for young children. Research has shown that regular toothbrushing with fluoride toothpaste reduces the risk of dental caries, but the factors that influence parental decisions about whether or not to brush their infant children's teeth at home are poorly understood.

AIM

To develop an in-depth understanding of the issues that parents face from socio-economically deprived areas when trying to brush their young children's teeth at home.

DESIGN

Fifteen parents of children aged 3-6 years took part in semi-structured telephone interviews, discussing factors relating to brushing their child's teeth at home. Thematic analysis was used to develop three themes.

RESULTS

Parents discussed the difficulty of brushing their children's teeth in the evening, due to changing day-to-day routines, and the subsequent difficulty of forming a toothbrushing habit. Motivating factors for brushing children's teeth were largely short term. Satisfaction with brushing frequency was influenced more by perceptions of how often other parents brushed children's teeth than by the 'twice a day' norm or health outcomes.

CONCLUSION

Results are discussed in relation to research and theories from the psychology and behavioural economics literature, and comparisons are drawn with assumptions inherent in more traditional oral health promotion messages.

Primary school-based behavioural interventions for preventing caries

BACKGROUND

Dental caries is one of the most common global childhood diseases and is, for the most part, entirely preventable. Good oral health is dependent on the establishment of the key behaviours of toothbrushing with fluoride toothpaste and controlling sugar snacking. Primary schools provide a potential setting in which these behavioural interventions can support children to develop independent and habitual healthy behaviours.

OBJECTIVES

To assess the clinical effects of school-based interventions aimed at changing behaviour related to toothbrushing habits and the frequency of consumption of cariogenic food and drink in children (4 to 12 year olds) for caries prevention.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 18 October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4), MEDLINE via OVID (1948 to 18 October 2012), EMBASE via OVID (1980 to 18 October 2012), CINAHL via EBSCO (1981 to 18 October 2012) and PsycINFO via OVID (1950 to 18 October 2012). Ongoing trials were searched for using Current Controlled Trials (to 18 October 2012) and ClinicalTrials.gov (to 18 October 2012). Conference proceedings were searched for using ZETOC (1993 to 18 October 2012) and Web of Science (1990 to 18 October 2012). We searched for thesis abstracts using the Proquest Dissertations and Theses database (1950 to 18 October 2012). There were no restrictions regarding language or date of publication. Non-English language papers were included and translated in full by native speakers.

SELECTION CRITERIA

Randomised controlled trials of behavioural interventions in primary schools (children aged 4 to 12 years at baseline) were selected. Included studies had to include behavioural interventions addressing both toothbrushing and consumption of cariogenic foods or drinks and have a primary school as a focus for delivery of the intervention.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently extracted data related to methods, participants, intervention design including behaviour change techniques (BCTs) utilised, outcome measures and risk of bias. Relevant statistical information was assessed by a statistician subsequently. All included studies contact authors were emailed for copies of intervention materials. Additionally, three attempts were made to contact study authors to clarify missing information.

MAIN RESULTS

We included four studies involving 2302 children. One study was at unclear risk of bias and three were at high risk of bias. Included studies reported heterogeneity in both the intervention design and outcome measures used; this made statistical comparison difficult. Additionally this review is limited by poor reporting of intervention procedure and design. Several BCTs were identified in the trials: these included information around the consequences of twice daily brushing and controlling sugar snacking; information on consequences of adverse behaviour and instruction and demonstration regarding skill development of relevant oral health behaviours.Only one included study reported the primary outcome of development of caries. This small study at unclear risk of bias showed a prevented fraction of 0.65 (95% confidence interval (CI) 0.12 to 1.18) in the intervention group. However, as this is based on a single study, this finding should be interpreted with caution.Although no meta-analysis was performed with respect to plaque outcomes (due to differences in plaque reporting between studies), the three studies which reported plaque outcomes all found a statistically significant reduction in plaque in the intervention groups with respect to plaque outcomes. Two of these trials involved an 'active' home component where parents were given tasks relating to the school oral health programme (games and homework) to complete with their children. Secondary outcome measures from one study reported that the intervention had a positive impact upon children's oral health knowledge.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence for the efficacy of primary school-based behavioural interventions for reducing caries. There is limited evidence for the effectiveness of these interventions on plaque outcomes and on children's oral health knowledge acquisition. None of the included interventions were reported as being based on or derived from behavioural theory. There is a need for further high quality research to utilise theory in the design and evaluation of interventions for changing oral health related behaviours in children and their parents.

Examining antecedents of caregivers' access to early childhood developmental screening: implications for campaigns promoting use of services in Appalachian Ohio

Although developmental delays are common in the United States, only about one third of developmental delays are identified before a child enters school. As challenging as use of developmental screening is on a national basis, the Appalachian region faces extreme lack of screening, diagnosis, and treatment for developmental delay. Local health care providers attribute this lack to poor parent understanding and have called for communication interventions to educate caregivers. This investigation sought to understand the antecedents of Appalachian caregivers' intentions to access developmental screening and services for their children as formative research for a communication-based intervention. The investigation was grounded by the health belief model. Surveys completed by 366 caregivers were used to model antecedents to behavioral intention. Perceived severity, perceived benefits, and self-efficacy were found to be the strongest predictors of intention to access developmental screening. Implications for a communication-based intervention are provided.

Oral hygiene and dental caries in 5- to 6-year-old children in Ajman, United Arab Emirates

OBJECTIVE

To investigate the association between oral hygiene and dental caries in young children in the Emirate of Ajman, United Arab Emirates.

METHODS

A one-stage cluster sample was used to randomly select children. Clinical examinations were conducted by a single examiner. Parents completed questionnaires seeking information on child and family characteristics, dietary habits and oral hygiene practices.

RESULTS

The total number of children sampled was 1297. Dental examination and questionnaire data were obtained for 1036 (79.9%). Frequency of eating per day and snack consumption level were both significantly associated with plaque score. Children who brushed their teeth more often had lower plaque scores. The observed association between mean plaque score and mean decayed, missing, filled teeth suggests that children with high plaque scores are more likely to experience caries.

CONCLUSIONS

Brushing with fluoride toothpaste was under-utilized in Ajman. Tooth brushing therefore needs better promotion and reinforcement.

Effect of a school-based oral health-education program on Iranian children: results from a group randomized trial

Parents and school staff play important roles in promoting children's oral health. Our study goals were to investigate whether an intervention targeting parents and school staff can improve the oral-health behavior and oral-health status of schoolchildren. Three-hundred and ninety-two schoolchildren in six schools in Tehran participated in a group randomized trial from September 2010 to March 2011. Schools were randomly allocated into three groups: comprehensive, student, and control. Intervention in the comprehensive group consisted of strategies to encourage children, their parents, and school staff to increase the frequency of toothbrushing and flossing. In the student group, the intervention targeted only children. The control group received no intervention. The primary outcome was change in oral-health behaviors (brushing and flossing), while the secondary outcomes were changes in oral hygiene and Community Periodontal indices and in Health Belief Model components. Multilevel modeling was employed for data analyses. Students who were in the comprehensive intervention group brushed and flossed significantly more frequently compared with those in the student intervention group. Although students' gingival health improved significantly in the comprehensive intervention group, such significant improvement was not seen in the student group. In conclusion, promising results are seen when the oral-health education targets both school and home settings.

Analysis of a unique global public-private partnership to promote oral health

Partnerships for health promotion are between two or more partners to work co-operatively towards a set of shared health outcomes; few public-private partnerships in oral health promotion have been established.

AIM

To undertake a detailed analysis of a unique global public-private partnership to promote oral health between a global company, Unilever and the Féderation Dentaire International (FDI), a membership organisation representing more than one million dentists worldwide.

METHODS

Qualitative and quantitative, including: collating and analysing a wide range of partnership documents (n =164); reviewing film and pictorial records; undertaking structured interviews (n=34) with people who had a critical role in establishing and delivering the aims of the partnership, and external experts; and site visits to selected global projects active at the time of the evaluation.

RESULTS

Over 1 million people have been reached directly through their engagement with 39 projects in 36 countries; an oral health message about the benefits of twice daily tooth brushing has appeared with the authority of the FDI logo on billions of packs of Unilever Oral Care's toothpastes worldwide; many individual members of National Dental Associations have participated in health promotion activities within their communities for the first time; some organisational challenges during the development and delivery of the partnership were recognised by both partners.

CONCLUSIONS

The first phase of this unique global partnership has been successful in making major progress towards achieving its goals; lessons learned have ensured that the next phase of the partnership has significant potential to contribute to improving oral health globally.

Early childhood caries

Dental caries is one of the most common childhood diseases, and people continue to be susceptible to it throughout their lives. Although dental caries can be arrested and potentially even reversed in its early stages, it is often not self-limiting and progresses without proper care until the tooth is destroyed. Early childhood caries (ECC) is often complicated by inappropriate feeding practices and heavy infection with mutans streptococci. Such children should be targeted with a professional preventive program that includes oral hygiene instructions for mothers or caregivers, along with fluoride and diet counseling. However, these strategies alone are not sufficient to prevent dental caries in high-risk children; prevention of ECC also requires addressing the socioeconomic factors that face many families in which ECC is endemic. The aim of this paper is to systematically review information about ECC and to describe why many children are suffering from dental caries.

Children's understanding of and motivations for toothbrushing: a qualitative study

OBJECTIVE

To explore children's understanding of why they do or do not brush their teeth and their motivations for toothbrushing.

METHODS

Individual semi-structured interviews were conducted with 66 children aged 6-7 years and 10-11 years in four purposively selected primary schools in Cardiff, UK. Data were analysed using a constructive process of Thematic Content Analysis and techniques of open and selective coding.

RESULTS

While a routine activity, toothbrushing was prompted rather than monitored by parents and easily fell by the wayside because of tiredness, excitement or distraction. Rationalizations for toothbrushing were poorly formed in the children's accounts and related to 'doom scenarios' such as teeth falling out, or to issues of personal grooming and cleanliness rather than caries prevention. Electric (powered) toothbrushes were popular and had engaged the children's interest. Social and domestic circumstances, such as when children stayed with different parents at different times, impacted on toothbrushing routines.

CONCLUSION

This study has revealed information that is of value in directing oral health education messages, oral health promotion programmes and has identified issues that potentially affect compliance with toothbrushing that merit further investigation.

Interrelation between obesity, oral health and life-style factors among Turkish school children

Obesity, dental caries and periodontal diseases are among major public health concerns which may affect children's growth and development. This study seeks any clustering between obesity, oral health and life-style factors among school children in Istanbul, Turkey. A cross-sectional study of children, 10- to 12-year-olds, from a public and a private school was undertaken with questionnaires for children and their mothers and child oral health data, in Istanbul (n = 611). DMFS (number of decayed, missing and filled surfaces of permanent teeth), CPI (Community Periodontal Index), body mass index (BMI) and life-style factors (tooth-brushing frequency, milk consumption at breakfast and bedtimes on school nights) of children were examined. Data analysis included factor analysis, Student's t test and Chi-square tests by cross-tabulation. Public school children were more dentally diseased but less obese than were those in private school (P < 0.001). They more frequently had calculus (62%) and reported non-recommended tooth-brushing (68%) than did those in private school (37%, 56%; P < 0.05). Principal component analysis revealed that DMFS, CPI and BMI shared the same cluster among all children. A need exists for addressing obesity, oral health and nutrition jointly in health promotion strategies to improve children's well-being and empower good life-style factors.

School-based intervention to promote preadolescents' gingival health: a community trial

OBJECTIVES

Evaluation of the effectiveness of a school-based oral health promotion intervention on preadolescents' gingival health.

METHODS

A community trial designed for a 3-month intervention study in a representative sample of 9-year-olds (n = 457) in 16 schools in Tehran, Iran. The schools were randomly assigned to three intervention groups and one control group, each group comprising two boys' and two girls' schools. The first group of children (n = 115) received intervention via class work, solving a set of puzzles containing oral health messages, under supervision of their health counsellor. The second group (n = 114), intervention via parents, included an oral health education leaflet and a brushing diary for supervising the child's tooth-brushing; the third group (n = 111) received a combination of both these interventions. The control group (n = 117) had no intervention. Effects of the intervention were assessed as changes in dental plaque and gingival bleeding. Improvements in gingival health were recorded when half of the index teeth with plaque at baseline became clean (acceptable oral hygiene) or when all index teeth with bleeding at baseline became healthy (healthy gingiva). Statistical analysis included chi square, anova, t-test, Number Needed to Treat (NNT) and generalized estimating equations (GEE).

RESULTS

At baseline, none of the children were free of plaque and all except for three boys had bleeding. After the trial, acceptable oral hygiene was more frequent in the parental-aid (P < 0.001) and the combined groups (P < 0.05), and healthy gingiva in both groups (P < 0.001) in comparison with the control group. Outcomes in the class-work group did not differ from those in the control group. The GEE models confirmed a strong intervention effect on healthy gingiva in both groups where parents were involved: parental-aid group (OR = 7.7, 95% CI: 2.2-27.7) and combined group (OR = 6.6, 95% CI: 2.0-22.1). In all intervention groups more girls than boys achieved healthy gingiva (OR = 2.5-2.6). Parents' education showed no impact on the outcome.

CONCLUSIONS

When a school-based oral health intervention involves parents it may result in a significant improvement in the gingival health of preadolescents with poor gingival health at baseline.

Determinants of oral health behaviour among Iranian dentists

AIM

To study the oral health behaviour of Iranian dentists.

DESIGN

A cross-sectional study.

SETTING

Two annual dental meetings in Tehran, Iran.

PARTICIPANTS

1,033 dentists responded, 980 were eligible for this study.

METHOD

Data were collected using a self-administered questionnaire which covered dentists' oral self-care, dental attendance, and smoking. Recommended oral self-care (ROSC) included tooth brushing > 1/day, eating sugary snacks < daily, and regularly using fluoride toothpaste. Knowledge of preventive dental care was assessed by nine Likert-scale statements. Dentist's gender, age, and professional reading were recorded. Statistical evaluation was by the Chi-square test and logistic regression.

RESULTS

In total, 59% of respondents reported brushing their teeth at least 2/day, 59% consumed sugary snacks < daily, 74% used fluoride toothpaste regularly, and 76% were non-smokers. Of all, 27% followed ROSC. Women reported desirable behaviours more frequently than did the men (p < 0.01). Female gender (OR 1.4-2.3), being a non-smoker (OR 1.3-1.5), and wider professional reading (OR = 1.2) were the major factors that contributed to dentists' desirable oral health behaviour.

CONCLUSIONS

That only a small number of Iranian dentists follow the ROSC calls for more attention to behavioural contributions to oral diseases and its consequences with general and oral health, regarding both dental curriculum and continuing education.

Caries Prevalence Four Years after the End of a Randomised Controlled Trial

This study measured dental caries in children after cessation of a 30-month randomised clinical trial in which the intervention group received supervised toothbrushing once a day at school with 1,000 ppm fluoride toothpaste and a home support package encouraging twice-daily toothbrushing. The non-intervention group did not brush at school or receive the home support package. Children were aged 5 years at baseline and were examined every 6 months during the trial, then at 6, 18, 30 and 54 months after the end of the trial. Significantly less caries developed in first permanent molars of intervention children at the end of the trial. Of the 428 children who were examined at the end of the trial 329 (77%) were examined 54 months later when the children were aged 12 years on average. The intervention group still had less caries (D3FS caries increment 1.62) than the non-intervention children (D3FS caries increment 2.65, p < 0.05). Prolonged benefits have been found for intervention children principally in less caries in first permanent molars. Further follow-up at an age when the second molars and premolars have all erupted will help determine whether this benefit is due to a long-term behavioural change or a prolonged biological effect.

Prevention-oriented practice of Iranian senior dental students

OBJECTIVES

To investigate self-reported preventive practice of Iranian senior dental students in dental caries management.

SUBJECTS AND METHODS

To obtain an estimated sample size of 250 subjects, seven state dental schools were selected based on a stratified random sampling approach. All the senior dental students (n = 327) were asked to voluntarily fill in a self-administered pre-tested questionnaire during the spring term in 2005. In the questionnaire two hypothetical patient cases (a high-risk and a low-risk patient) were presented and the students were asked to express their conceptions on a five-point Likert scale about including each of nine given alternatives in the patients' treatment plans. The respondents' self-reported oral self-care (OSC), preventive knowledge, attitude towards prevention and self-perceived competency in giving preventive care were also assessed. Chi-squared test and logistic regression model served for statistical analyses.

RESULTS

A total of 270 students filled in the questionnaire (response rate = 82%). Acquiring high scores of preventive practice as assessed by patient cases was found to be more frequent among those reporting recommended OSC (P = 0.007) and those with higher attitude scores (P < 0.001). Also, those reporting being competent in giving preventive care had higher scores of preventive practice compared with the others (P = 0.02). In the regression model, recommended OSC (P = 0.05, OR = 1.9) and positive attitudes towards preventive dentistry (P = 0.001, OR = 3.3) showed significant association with acquiring highest scores of preventive practice.

CONCLUSION

To improve their preventive practice in the future, more emphasis should be placed on the dental students' own oral health behaviour and attitudes related to it.

Clinical trials in dental primary care: what research methods have been used to produce reliable evidence?

OBJECTIVE

To identify controlled clinical trials done exclusively in dental primary care and to classify the research according to design. Details of any procedures used to recruit general dental practitioners and any special organisational arrangements were also collected.

DESIGN

A scoping literature review.

SETTING

Dental primary care defined as general dental practice, community and school dental settings.

PARTICIPANTS

Published randomised controlled trials using randomised or quasi randomised approaches and controlled clinical trials were considered for inclusion in the review. Reports were excluded if they did not describe either a randomised controlled trial or a controlled trial. Studies were excluded if the setting was not primary dental care or the intervention was for non-dental conditions. Conference abstracts without a full report and trials published in a language other than English were also excluded.

MAIN OUTCOMES

Experimental and quasi-experimental designs, clinical areas and different kinds of strategies used to recruit dentists, any organisational arrangements made to support research in dental primary care.

RESULTS

The search of the Cochrane Oral Health Group Controlled Trials Register found 174 articles. Forty-three randomised controlled trials met the inclusion criteria. Trials to evaluate the effects of interventions for types of anaesthesia, periodontal diseases, smoking cessation techniques, dental materials, organisational aspects of dental care, patient anxiety, post extraction healing rates, antibiotics were identified. All were done in general dental practice. Trials in school and community settings were also included.

CONCLUSIONS

Practice-based research needs to be encouraged to provide dental primary care with relevant evidence upon which effective treatment can be based. This review shows there are few trials done in dental primary care to inform clinical practice, most of which have been reported since 1997. The range of trial designs shows that this method of evaluation can be used to evaluate dental primary care interventions and this is promising for those with an interest in improving dental patient outcomes. More research on how to recruit dentists into clinical trial research must be done.

An advocacy project to fluoridate toothpastes in Nepal

AIMS

To describe a recent health promotion project undertaken by the United Mission to Nepal Oral Health Programme (UMN OHP) to increase the availability and consumption of affordable, fluoridated toothpaste in Nepal.

METHOD

The process of advocating for the fluoridation of toothpastes in Nepal is based on Tearfund's advocacy cycle.

RESULTS

The project achieved health promotion outcomes including healthy corporate and public policies and organisational practice and intermediate outcomes such as increased availability and consumption of affordable fluoridated toothpaste. Prior to implementation of the advocacy project in 1997, availability and consumption of fluoridated toothpaste was negligible. By March 2002 total market share of fluoridated toothpaste was approximately 90%. This represents an annual tonnage of 900 tons of fluoridated toothpaste.

CONCLUSIONS

The health promotion activity of advocacy for the fluoridation of toothpastes in Nepal achieved measurable gains in health promotion outcomes and intermediate outcomes. Gains in health and social outcomes will take longer to evaluate but based on epidemiological evidence and the experience of other countries increased availability of affordable fluoridated toothpaste will have a significant and ongoing impact on the oral health of the people of Nepal.

Patient compliance with oral hygiene regimens: a behavioural self-regulation analysis with implications for technology

Achieving optimal oral health through preventive efforts is a hallmark of the dental profession. A primary goal of a preventively-oriented dental practice is to encourage patients to practice appropriate oral self-care behaviours. When patients are asked to follow an oral self-care regimen, they are being given a target or goal (for example, brush twice a day) and their task is to control or regulate their behaviour to achieve that objective. Unfortunately, patients often fail to meet the expectations set forth by the clinical recommendation. This review examines the problem of poor patient compliance with oral hygiene regimens by applying the general principles that govern the self-regulation of behaviour. The component parts of a behavioural self-regulation model are reviewed in the context of oral self-care. Research in the area of toothbrushing behaviour is reviewed and methods for providing patients with feedback about their degree of compliance are discussed.