This is an update of “Community-based population-level interventions for promoting child oral health. ” Cochrane Database Syst Rev. 2016 Sep 15;9:CD009837.
Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health.
• To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary
• To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.
• To identify interventions that reduce inequality in oral health outcomes.
• To examine the influence of context in the design, delivery and outcomes of interventions.
We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index – Science.
Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.
Data collection and analysis
Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors – four review authors and two research assistants – assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity.
This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.
This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children’s diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.
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Summary of main results
This review includes 38 studies of community-based population-level interventions for promoting child oral health, with a total of 119,789 children. Interventions were generally implemented for less than one year (n = 26), and about half (n = 11) of studies were randomised controlled trials. Investigators tested a variety of oral health promotion strategies: dietary interventions (n = 3), oral health education alone (n = 17), oral health education in combination with a supervised toothbrushing programme (n = 8) and oral health education in combination with a variety of other interventions (n = 10). The broad spectrum of oral health promotion interventions tested and the mixed approaches to intervention dose, delivery and reporting make it difficult to pool outcome data; however, meta-analyses of available data suggest that oral health education alone is the least effective intervention and on its own will not make a difference in caries.
Researchers generally found oral health promotion interventions that included supervised toothbrushing with fluoridated toothpaste to be effective in reducing caries in children, although some investigators found these interventions to be non-effective. Varied effects may be related to the level of supervision provided and the frequency of toothbrushing involved. Interventions that combined oral health education with professional preventive oral care were also effective in reducing dental caries in children. Many studies used a multi-component approach and multi-setting interventions; although interventions were varied in nature (oral health education coupled with interventions such as toothpaste provision, chewing gum, motivational interviewing, professional oral care, training of non-dental professionals, fluoride varnish application and fluoride supplements), most studies in this group reported positive impact. Interventions that focus on diet and reduced sugar consumption also hold promise for reducing caries; additional studies are needed.
Overall completeness and applicability of evidence
The small number of studies that have examined each intervention type limits our ability to draw firm conclusions about effectiveness, although interventions that integrate settings-based oral health education with toothbrushing programmes or professional preventive oral care appear to be most effective. When interventions of this nature are considered, issues of access, cost and appropriateness of care must be explored. However, investigators have rarely reported evidence related to approaches to intervention development and delivery or cost-effectiveness and equity of impact and adverse outcomes, leaving gaps in the evidence base. The stage of childhood when delivery of interventions is most effective for children remains unclear, although interventions that coupled oral health education with toothbrushing programmes including fluoridated toothpaste have been found effective in reducing caries in deciduous teeth, and interventions that comprise oral health education and professional dental care have been effective in reducing caries in children’s permanent teeth. Investigators have not often examined the long-term sustainability of impact, but this is clearly an important consideration, as oral disease is a chronic condition.
Our ability to draw firm conclusions from the evidence reviewed is limited because of the nature of the included studies. In particular, we highlight the following limitations of these studies.
Less than one in five of these studies (18%) were conducted in lower-middle-income or low-income countries.
Included studies were conducted in various regions, but most were undertaken in Asia.
Most studies lasted less than one year.
Close to two-thirds of studies assessed post-intervention follow-up, and the period of follow-up ranged from less than one year to four years. Reported sustainability of impacts varied across studies, and only a few studies looked at long-term sustainability.
Most studies did not include strategies to address diversity and disadvantage, although about one-quarter of studies were implemented solely in highly disadvantaged groups. Although included studies that provided access to education and oral health services addressed disadvantage in some way, evidence related to implementation and acceptability of the intervention, long-term impact and sustainability was generally lacking, as was evidence on whether characteristics of the study population (e.g. socio-economic status (SES), ethnicity, education level) were related to the effectiveness of interventions. These aspects limit our ability to draw conclusions on the applicability and transferability of intervention strategies to other populations and contexts.
Researchers did not widely report stakeholder engagement and involvement in intervention development and implementation, and only a few studies appear to have taken such an approach.
Most studies targeted early (38%) and middle (41%) childhood. Only a few targeted adolescence.
Most studies reported on at least one of the PROGRESS categories at baseline, and the categories most frequently reported were SES, education, gender, race and residence.
Only one-third of studies reported analysis of results by any of the PROGRESS items, and items reported against varied across studies.
Many published reports did not provide a clear description of implementation factors.
Investigators have only rarely collected or reported economic or cost-effectiveness data.
Study findings generally show inconsistency in intervention components tested, in intensity and duration of tested interventions and in reporting of outcomes.
The 38 included studies show substantial variation in intervention strategies and components, age groups of participants, study settings, intervention doses provided, training for implementation and personnel who delivered the interventions, as well as considerable differences in impact and outcome measures and in personnel who collected data. Various moderators such as social environment, parent and teacher involvement and use of dental health services have been identified to influence oral health behaviour change and clinical outcomes. Our review identified that more than half of the interventions tested were developed on the basis of sound theory for health promotion, population health or behaviour change. Although intervention development was not always based on theory, this represents improvement in findings from those of earlier evidence reviews and is a promising development. Despite this fact, only a few studies have investigated how these moderators may have affected intervention outcomes. Further, only a few studies that reported behaviour change outcomes also examined associations of these with clinical outcomes. Researchers must undertake these important analyses to further our understanding of the pathways involved, ranging from oral health promotion to clinical impact. Although several studies have reported on the cost of implementing interventions, we found few economic evaluations of the interventions included in this review, resulting in lack of cost-effectiveness data upon which decision makers can rely.
There does not appear to be any particular bias associated with the studies that were commercially funded when compared with the others of the same intervention type, however the number of studies is small and definitive conclusions cannot be made (see Table 11).
Quality of the evidence
We graded the evidence as having moderate to very low quality. All studies had some form of limitation regarding risk of bias. Several studies lacked thorough reporting methods and provided insufficient information to permit informed judgement about risk of bias. This review included both randomised and non-randomised controlled trials. Selection bias could present concern in non-randomised studies. A few such studies included in this review attempted to minimise the impact of potential selection bias. Whilst selection bias can be controlled in randomised controlled trials, a few such trials lacked information on randomisation methods and the process of allocation concealment. When sufficient details were lacking, we reported unclear risk for these domains. Similarly, only a few trials reported blinding of participants and personnel. A few reported blinding but failed to explain the blinding process. In studies in which only personnel were blinded, results suggest that lack of participant blinding probably had minimal consequences for outcome assessment. In only a few studies was outcome assessment reportedly conducted by examiners blinded to treatment allocation. Contamination was another important factor in this review. Many studies in this review were cluster-randomised trials, and although a few acknowledged the risk of contamination and its impact on study findings, it is often not possible to avoid contamination when community-based health promotion interventions are implemented. We further downgraded the quality of the evidence as a result of serious imprecision arising from small sample sizes, or from wide confidence intervals around estimated effects.
Potential biases in the review process
We must note certain limitations of this review. Although we conducted a comprehensive search for studies, we were able to include only studies published in some form. It is likely that important studies have been undertaken but remain unpublished in the public domain. Furthermore, studies with positive results favouring treatment were more likely to be published, and this fact could introduce bias into the results. As the result of resource constraints, we did not contact the authors of included studies to request missing data, and this could have resulted in exclusion of specific studies. To be included in this review, studies had to report on one or more of the primary outcomes while presenting baseline and post-intervention measurements, or change scores. Inclusion of studies based only on primary outcomes could have resulted in exclusion of certain types of studies.
Agreements and disagreements with other studies or reviews
This review presents results that are broadly consistent with those of previous reviews on this topic (Cooper 2013; Kay 1998; Marinho 2002; Marinho 2004; Marinho 2013;Tubert-Jeannin 2011), which found insufficient significant, high-quality evidence to measure efficacy of dental interventions for child oral health. This review examined different types of interventions than were studied in previous reviews, as we have examined only community-based interventions implemented outside of a dental clinical setting, while focusing primarily on effects of interventions on dental caries and gingival health of children from birth to 18 years of age. Previous reviews have studied the effects of interventions on child oral health while investigating a specific type of intervention, such as fluoride varnish (Marinho 2004; Marinho 2013) or fluoride supplement (Tubert-Jeannin 2011) and interventions that are not community-based nor delivered in clinical settings. Only one study, Saied-Moallemi 2009, was included in both this review and another review (Cooper 2013). Review authors rated risk of bias of this study equally, with the exception of reporting bias and other bias, both of which were rated as having unclear risk by the authors of this review, and as having high and low risk respectively in Cooper 2013. Similar to previous reviews (Cooper 2013; Kay 1998; Marinho 2004; Marinho 2013; Tubert-Jeannin 2011), we measured primary outcomes of dmfs/DMFS, dmft/DMFT and gingival index. Previous reviews found significant caries-inhibiting effects of interventions utilising fluoride varnish on both primary and permanent teeth (Marinho 2013), and of fluoride supplements on permanent teeth (Tubert-Jeannin 2011). The Kay 1998 review on effectiveness of dental health education interventions did not focus exclusively on interventions for children and identified studies that essentially focused on interventions directed towards individual behaviours.
The findings of this review are largely consistent with the findings of Cooper 2013 and confirm lack of cost-benefit analysis in the included studies. Consistent with the Petersen 2004 review, we identified that the design and evaluation of community oral disease prevention programmes and oral health promotion programmes must be improved to improve the quality of the evidence upon which clinical decisions can be based. Further, we highlight the lack of consistency in community oral disease prevention programmes and health promotion programmes in relation to design, implementation and evaluation. Although we found regular use of theory in intervention development, we noted no consistency in application of these theories in terms of implementation or evaluation.
This review of studies published from January 1996 to April 2014 reveals testing of a range of interventions for promoting child oral health. We found little evidence that oral health education alone can make a difference in the level of tooth decay, although some studies have reported improvement in gum health, oral hygiene behaviours and oral cleanliness. Oral health promotion interventions combined with supervised toothbrushing with fluoridated toothpaste were generally found to be effective in reducing caries in children’s deciduous teeth. Interventions consisting of oral health education provided in an educational setting combined with professional preventive oral care in a dental clinic were effective in reducing caries in children’s permanent teeth. We found many studies that examined multi-component and multi-setting interventions. Although these interventions were varied in nature (oral health education coupled with interventions such as toothpaste provision, sugarless chewing gum, motivational interviewing, professional oral care, training of non-dental professionals, fluoride varnish application and fluoride supplements), most studies in this group reported positive impact. Interventions focused on diet and reduced sugar consumption also hold promise for reducing caries, but further research of this nature is needed. In addition, strong links between children’s settings and community-based dental services are required to ensure that children receive the treatment or preventive services needed, as early as possible. In some studies, access to professional oral care was standard across the study population, and this was not tested as part of the intervention. In other studies, professional oral health care was included in the intervention programme, and investigators delivered a range of services in community or clinical settings.
Interventions included in this review were diverse and were delivered in a range of childhood settings including education, community, health care and home. It remains unclear which intervention approach is best suited to promote child oral health across a range of community contexts because of the small number of studies that have tested each intervention type. Although most of the interventions included in this review were delivered in educational settings, studies did not broadly report on the nature and extent of engagement with students, caregivers or oral health service providers. More work is needed to assist care providers in recognising the multiple influences of broader determinants linked to clinical oral health outcomes, for example, oral health knowledge, behaviours and practices, and healthcare systems including psychosocial environments. Further, the authors of this review could not determine who is best placed to deliver oral health promotion interventions. We suggest that the ability to integrate intervention strategies and specific activities (such as oral hygiene practices, fluoride varnish application, curriculum-based teaching and policy) into current activities within specific settings and services may be dependent on the level of engagement, consultation and ownership of the programme implemented. Less reliance on dental professionals and researchers to deliver interventions and increased reliance on cross-sector multi-disciplinary teams should be tested if we are to progress to cost-effective and sustainable solutions for promoting child oral health. Activities underpinned by theory, such as the health promoting school approach, community capacity building and community engagement, in addition to known oral health promotion frameworks, would reveal best practice. Further, integration of oral health promotion interventions with approaches to improvement in other non-communicable diseases (e.g. smoking, cancer) is needed, as is implementation of interventions that address the broader social determinants of child oral health.
Oral health education in isolation was not effective in reducing caries; the quality of evidence was low or very low.
Integrating oral health education with supervised toothbrushing with fluoridated toothpaste or professional oral care practices can improve dmft and dmfs, but effects on DMFT and DMFS were smaller.
Strong links between children’s settings and community-based dental services are important for oral health promotion.
Community context and the influence of broader determinants are important considerations.
Stakeholder engagement and collaboration are important, given that interventions are implemented in a variety of child and community settings.
Researchers could strengthen the evidence base by applying scientific rigour and quality standards to the design, implementation, delivery and reporting of future intervention studies. Further, researchers must undertake analysis that expands our understanding of determinants, moderators and pathways involved in promoting oral health in children, while exploring relationships between and across multiple levels of influence that we know exist in relation to oral disease development and prevention. To enable this, investigators must provide data collected and reported according to factors such as age, gender, socio-economic status and geographical location.
Cost-effectiveness data are critical for policy makers, planners and public health service providers and have not been provided in oral health promotion intervention studies of the nature included in this review. Researchers must measure and report the ability to sustain both oral health promotion strategies implemented within specific settings and the impact of such interventions. In addition, we were unable to locate adequate evidence related to adverse or unintended consequences of interventions. Future intervention studies should attempt to answer important questions related to cost-effectiveness, long-term sustainability and adverse outcomes. Questions related to equitable impact of interventions also need urgent attention, given the large disparities in oral disease observed across many communities.
It is imperative that effective interventions are described in a manner that allows them to be replicated or at least assessed for suitability of use in other contexts. Available information must enable adaptations performed to suit community needs, without losing effective components of the interventions. Clear articulation of the following details of intervention studies is important to allow this.
Process of intervention development (including stakeholder engagement, theoretical frameworks and community context).
Intervention (and components) delivered (including by whom, resources and support needed to achieve effective implementation and intensity and frequency of delivery).
Implementation duration (recognising that no end date of implementation for a policy intervention may be known).
Sample recruitment, allocation and blinding.
Researchers have tested a range of oral health promotion interventions, but available evidence on effectiveness of oral health promotion interventions for clinical oral health outcomes is generally limited and is not of high quality.
Investigators found that oral health education in isolation was not effective in reducing caries.
The most promising intervention approaches seem to include improving access to fluoride in its various forms or reducing sugar consumption, although evidence is limited.
Future interventions would be improved by involvement of a variety of stakeholders in intervention development and implementation, and should be underpinned by theory while addressing the broader determinants of child oral health.
Testing is needed for oral health promotion interventions that adopt a common risk factor approach, and oral health promotion must be integrated with approaches designed to improve other non-communicable disease.
Most interventions tested were provided for one year or less; this limitation of the interventions reviewed does not allow determination of long-term impact.
The evidence base would be strengthened by application of scientific rigour and quality standards to the design, implementation, delivery and reporting of future intervention studies.
Cost-effectiveness data are critical for policy makers, planners and public health service providers and are currently insufficient.
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