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Primary school-based behavioural interventions for preventing caries

  1. Anna M Cooper1,*,
  2. Lucy A O'Malley2,
  3. Sarah N Elison1,
  4. Rosemary Armstrong3,
  5. Girvan Burnside4,
  6. Pauline Adair1,
  7. Lindsey Dugdill1,
  8. Cynthia Pine5

Editorial Group: Cochrane Oral Health Group

Published Online: 31 MAY 2013

Assessed as up-to-date: 18 OCT 2012

DOI: 10.1002/14651858.CD009378.pub2


How to Cite

Cooper AM, O'Malley LA, Elison SN, Armstrong R, Burnside G, Adair P, Dugdill L, Pine C. Primary school-based behavioural interventions for preventing caries. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009378. DOI: 10.1002/14651858.CD009378.pub2.

Author Information

  1. 1

    University of Salford, Directorate of Psychology and Public Health, School of Health Sciences, Salford, Greater Manchester, UK

  2. 2

    The University of Manchester, School of Dentistry, Manchester, Greater Manchester, UK

  3. 3

    School of Health Sciences, University of Salford, World Health Organization Collaborating Centre for Research on Oral Health in Deprived Communities, Salford, Greater Manchester, UK

  4. 4

    University of Liverpool, Department of Biostatistics, Institute of Translational Medicine, Faculty of Health and Life Sciences, Liverpool, UK

  5. 5

    Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, UK

*Anna M Cooper, Directorate of Psychology and Public Health, School of Health Sciences, University of Salford, Allerton Building, Frederick Road Campus, Salford, Greater Manchester, M6 6PU, UK. a.m.cooper@salford.ac.uk.

Publication History

  1. Publication Status: New
  2. Published Online: 31 MAY 2013

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

 
Summary of findings for the main comparison.

Behavioural intervention compared with control for prevention of caries in children

Patient or population: Children aged 4 to 12 years

Settings: Primary school

Intervention: Behavioural intervention (both oral hygiene and dietary components)

Comparison: No intervention or delayed intervention

OutcomesRelative effect
(95% confidence interval (CI))
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Caries - DMFS (prevented fraction (PF))

Follow-up: 15 months
PF = 0.65 (95% CI 0.12 to 1.18)60 participants (1 RCT)⊕⊕⊝⊝
low1
Small study of children at high risk of caries

Plaque indices

Follow-up: 3 to 15 months
All 3 RCTs showed a reduction in plaque in the intervention group compared to control group827 participants (3 RCTs)⊕⊕⊝⊝
low2
Data not suitable for meta-analysis

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Quality of the evidence was downgraded for risk of bias (unclear allocation concealment) and imprecision.
2 Quality of the evidence was downgraded for risk of bias (1 trial unclear and 2 trials high risk of bias) and inconsistency (heterogeneity due to differences in design, intervention and outcome measurement).

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Description of the condition

Oral diseases are common in many societies globally, with dental caries being the most prevalent chronic disease among children (Gussy 2006). Dental caries is present in low-income, middle-income and high-income countries; between 60% and 90% of children in industrialised countries are affected (Petersen 2005). The US Surgeon General report on oral health (Surgeon General 2000) states that oral health problems are five times more likely to occur in children than asthma and seven times more than hay fever. Dental caries is a debilitating condition that can cause a child to suffer a significant degree of pain (Edelstein 2000) and if left untreated the disease may lead to further complications including sepsis (Pine 2006). Severe untreated caries has also been found to have links to general health and well being, affecting young children's body weight and growth (Sheiham 2006). Additionally, good oral health is important in terms of the psychosocial factors which relate to quality of life (Sheiham 2005) and optimum social functioning (Exley 2009) including self expression and communication. The mouth is a highly visible facial feature in most cultures (Goffman 1990). Discoloured and missing teeth have negative connotations in modern culture, being predominantly associated with unhygienic and undesirable lifestyles (Exley 2009) and with severe deprivation (Gibson 2008). Additionally, children who experience dental pain may lose time at school (Jackson 2011) and have difficulties sleeping, eating and playing (Casamassimo 2009). Being prevented from taking part in these and other normal recreational social activities with family and friends may have a detrimental effect on the child's social development and overall well being.

Brought about by dietary factors (such as frequent consumption of sugar) and exacerbated by inadequate oral hygiene routines (lack of brushing with fluoride toothpaste), caries is virtually completely preventable (Edelstein 2006). The impact of dental caries can be extensive and enduring for the child, sometimes impacting on their adult life (Nunn 2006) and potentially, future generations (Amin 2009).

Improving and promoting oral health has become common practice worldwide, both at local and population levels. Oral health is influenced by a myriad of interconnected variables, including socioeconomic status (SES) (Reisine 2001), ethnicity (Shiboski 2003) and attitudes (Blinkhorn 2001) which potentially have a cumulative effect and appear to be most profound in materially and socially deprived populations.

Rates of caries among children in many parts of the world have improved dramatically since the introduction of fluoridated toothpastes in the 1970s (Mullen 2005). Yet while child dental health has improved overall in recent years the gap between the most and least deprived children continues to widen (Armfield 2009; Watt 1999; Watt 2007), suggesting that relative poverty is a moderating factor in terms of rates of dental caries. Children from disadvantaged communities and some ethnic minorities have the highest rates of dental caries. This is particularly significant in light of observed increases in ethnic minorities among some communities and in the interest of halting and reversing the magnification of disparities throughout low SES groups (Pine 2004a).

 

Description of the intervention

Improving and promoting oral health has become common practice worldwide both at local and population levels. Establishing good routines in childhood is vital for optimum oral health as these behaviours, once established, can endure throughout adulthood (Aunger 2007) and provide lifelong protection against caries (Ramos-Gomez 2002). Intervention studies related to child oral health have aimed to reduce childhood caries by encouraging children to establish and maintain effective oral health routines (e.g. Worthington 2001). Behaviour change interventions have utilised a number of evidence-based behavioural change techniques (Michie 2008) including: goal setting, goal review, monitoring specified behaviours, coping planning/strategies, instruction, behavioural rehearsal, homework tasks and reinforcement. The experience of distressing dental treatment in childhood can result in dental fears and phobias which can progress into adulthood (Brukiene 2006). Dental anxiety is a commonly cited reason for adults refusing to attend routine oral health checks with a dentist. Non-attendance can have a detrimental effect on oral health status (Eitner 2006) and may result in an increased number of patients requiring significant treatment. The cost of treating these patients creates a significant financial burden on the health services, both in terms of the cost of the treatment itself and in dealing with anxious patients. Oral health interventions early on in life could potentially save costs and avoid anxiety among patients later in life.

Patterns of behaviour conducive to positive dental outcomes are not always achieved in the home and this may be attributed to a variety of interconnected variables including SES (Shaw 2009) and cultural factors. For this reason and in the interest of reducing dental health inequalities, it remains necessary to provide effective interventions at the population level.

Primary schools, because of their inclusive nature, provide a suitable environment for dental health behavioural interventions (Kwan 2005). Interventions for preventing caries, which take place in primary schools, are potentially too late to prevent early childhood caries (ECC), particularly in its initial stages. However, targeting interventions at children earlier will reduce the effectiveness of interventions; that is to say, children develop the motor control necessary for effective toothbrushing more fully when they are primary school aged. Additionally children are unlikely to have sufficient control over routines in the home whilst they are very young. It is therefore inappropriate to target interventions for preventing caries (or ECC) at preschool age children (as opposed to targeting their parents).

Behaviours and routines are developed and become established during childhood, and as a result they become more difficult to alter in adulthood due to formed habits and automatic behaviour. Between the ages of 5 and 8 years children progress developmentally in many areas. To facilitate habitual tooth cleaning it is important to ensure the behaviour is established by the end of this life stage. Oral health programmes may be especially relevant at primary school level, particularly for children in their eighth year of life as this is considered to be a latency phase in which the child is more open to absorbing information about how to care for their body (Graham 2005).

Although brushing at home twice a day is optimum, many children do not do this. School-based interventions not only offer children supervised brushing once a day, they also offer training in a skill that may not be being taught in the home. Although an artificial setting, which may not reproduce individual behavioural triggers for incorporating toothbrushing into a personal morning and evening hygiene routine at home, school-based interventions facilitate the teaching of toothbrushing as a skill. Additionally, there is potential for translating these behaviours into the home environment on a twice daily basis. In spite of the increase in the number of school-based oral health programmes in recent years, the majority of school-based oral health interventions have not produced sustained behavioural change. A systematic review of oral health interventions (Kay 1996; Kay 1998) and a subsequent review by Watt 2001 found there to be an improvement in oral health knowledge but not in the related attitudes, beliefs and behaviours.

Parental habits impact on child behaviour, particularly through modelling actions. However, a parent's perception of their own ability to deliver the behaviour of regular toothbrushing (self efficacy) can also significantly impact on child dental health (Pine 2004b). Primary school-based interventions rarely target both child and parent behaviour, or parental self efficacy. It remains crucial to the development of effective primary school-based interventions that specific cultural components around self efficacy are identified so that they can be further refined if necessary and replicated in future interventions.

 

How the intervention might work

Primary school-based interventions aiming to improve child oral health may disseminate education and information around developing skills for toothbrushing and managing the consumption of cariogenic foods and drinks. In addition they can provide support to parents and family to facilitate both behaviours occurring at home. This may be achieved through task-specific behavioural rehearsal and reinforcement and through the application of other documented behaviour change techniques (BCTs). The overall outcome may be to increase child and parental self efficacy for oral health behaviours.

 

Why it is important to do this review

In many countries, primary schools have a recognised duty to deliver health education of which oral health education and the associated behavioural skills are often components. The purpose of this systematic review is to effectively evaluate research on behavioural interventions delivered in primary schools and to provide an understanding of the components and mechanisms of successful interventions which produce lasting behaviour change concerning toothbrushing and controlling the consumption of cariogenic foods and drinks.

Research has repeatedly found significant associations between SES and caries prevalence. The burden of oral ill-health is such that it remains crucial to provide every child and their family with the knowledge and behavioural skills necessary to maintain a healthy dental lifestyle in the long term.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

To assess the clinical effects, in terms of caries prevention, 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).

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Randomised controlled trials (RCTs) where randomisation occurs at the level of the group (cluster by school and/or class) or individual children were included. All other studies were excluded during the screening process or at the point of data extraction.

 

Types of participants

Children within the age range of 4 to 12 years at the start of the study and attending a primary/elementary/infant or junior school in any country were included. Inclusion was irrespective of dental caries level at the start of the study, fluoride exposure, both topical (e.g. toothpaste, tablets, milk) and via water (both naturally occurring and added), current dental treatment and attendance levels, and nationality. Studies not predominantly taking place in a school setting were also excluded due to the focus of the current review. The review included studies regardless of whether teaching staff or peers were included in the delivery of the intervention.

For the purposes of this review, a 'school' is defined as a place delivering curricular primary education, to children aged between 4 and 12 years. Primary school encompassed the terms: junior, elementary, infant, kindergarten, community and nursery within the specified age range.

 

Types of interventions

 

Test or intervention group

Behavioural interventions (including education and/or skills and/or behaviour change) taking place in a school setting around oral health and/or hygiene and frequency of cariogenic food and drink consumption. Studies were included with or without a follow-up period after the completion of the intervention.

Interventions for inclusion in this review were required to:

  • have a focus around toothbrushing and cariogenic foods;
  • use schools as the focal site for intervention delivery;
  • contain skills, instructions and educational components.

The intervention may be delivered by teachers, dental health professionals, peers, or other educators and must be delivered principally in the school the children are attending. Elements of the intervention may also occur in the home and in clinical settings. Delivery of intervention components can be written, verbal, web-based or through electronic devices (e.g. video games).

The aim of the intervention must be to improve child oral health. Studies utilising one or more behaviour change techniques (BCTs) were included in the review. Behavioural interventions were coded using the Coding Manual to Identify Behaviour Change Techniques in Behaviour Change Intervention Descriptions, detailed by Abraham 2008. This provided a pre-validated method to code specific BCTs in interventions. Examples of BCTs that may be included are: reinforcement (brushing charts), modelling (facilitator demonstration of correct brushing technique) and prompts and cues (visual reminders in appropriate settings).

 

Control group

The control group should receive usual curriculum-based health education programmes; these may be defined as standard health information and education offered as part of the school curriculum and independent of the study intervention (non-intervention control). Control groups may also be waiting list control groups.

 

Exclusion criteria

Studies were excluded where:

  • the intervention was a change at the level of the school environment - such as change in foods and drinks available in schools;
  • the intervention was within a nursery school but targeting only children aged 3 to 5 years old.

 

Types of outcome measures

 

Primary outcomes

  1. Changes in caries increment measured by the difference in decayed, missing and filled teeth (dmft/DMFT).
  2. Changes in caries increment on tooth surfaces (dmfs/DMFS).
  3. Changes in plaque scores for permanent and deciduous teeth over the course of the intervention and the follow-up period.

Primary outcomes for both permanent and deciduous teeth were considered if they measured change from baseline for the same cohort of children. For the purposes of this review, clinical effectiveness is defined as either a change in caries experience (decayed, missing or filled teeth - dmft/DMFT) and/or a change in the amount of dental plaque.

 

Secondary outcomes

  1. Frequency of toothbrushing: measured using reported data correlated with clinical measures.
  2. Frequency of cariogenic food and drink consumption: reported behaviour.
  3. Behavioural outcomes: reported and/or other measures (e.g. data tracking toothbrushes and collecting food wrappers).
  4. Changes in dental attendance (i.e. frequency of dental check-ups, increase in dental attendance) during the period of the intervention.
  5. Adverse events were recorded using data extraction forms if they were reported. These were considered by the review team.

 

Search methods for identification of studies

For the identification of studies included or considered for this review, detailed search strategies were developed for each database searched. These were based on the search strategy for MEDLINE but revised appropriately for each database to take account the differences in controlled vocabulary and syntax rules. No restriction on the language of publication was applied to the inclusion criteria.

The search strategy combined the subject search with the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying reports of randomised controlled trials as published in box 6.4.c in the Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0 (updated March 2011) (Higgins 2011). 

 

Electronic searches

The following databases were searched:

 

Searching other resources

In addition to conducting systematic searches of electronic databases, handsearches of appropriate journals were conducted where these have not already been searched as part of the Cochrane Journal Handsearching Programme. The following journals have all been identified as those in which trials in the field are likely to be reported:

  • Acta Odontologica Scandinavica (2004 to October 2012)
  • ASDC Journal of Dentistry for Children (2004 to October 2012)
  • British Dental Journal (2006 to October 2012)
  • Caries Research (2004 to October 2012)
  • Community Dental Health (2003 to October 2012)
  • Community Dentistry and Oral Epidemiology (2003 to October 2012)
  • Journal of the American Dental Association (2005 to October 2012)
  • Journal of Dental Research (2005 to October 2012)
  • Journal of Public Health Dentistry (2004 to October 2012)
  • Swedish Dental Journal (2002 to October 2012)
  • International Journal of Paediatric Dentistry (2000 to October 2012).

 

Data collection and analysis

 

Selection of studies

Citations retrieved were screened for relevance by five review authors independently on titles, keywords and abstracts. For studies where there was insufficient evidence in the title, keywords or abstracts, or the review team did not agree on the inclusion/exclusion of the report, the full study/paper was obtained. References screened as relevant for the review were obtained in full and assessed for inclusion in the review. If disagreement arose, other review authors were consulted to resolve this; such occurrences were documented.

All included studies were subject to a cited reference search aimed at identifying any related publications.

 

Data extraction and management

Four review authors extracted data for all included studies. The review authors worked in pairs and any discrepancies arising were discussed by the team. Prior to use, the data extraction form was piloted on a sample of articles to allow for any necessary modifications. Following Cochrane guidelines, details of why studies failed to meet the review criteria were documented and are presented in the Characteristics of excluded studies table.

For each included study we recorded the following data.

  1. Study identification code.
  2. Number of reports on study.
  3. Year study commenced and finished.
  4. Trial funding, number of sites on which the study has been conducted.
  5. Method: study design, type of randomisation, duration of study.
  6. Participants: recruitment, inclusion/exclusion, demographic characteristics, baseline fluoride exposure and dental health data (dmft, dmfs).
  7. Intervention: description of the programme including intervention facilitator, specific BCTs and components utilised as outlined in the Taxonomy of Behavioural Change Techniques Used in Interventions (Abraham 2008). Information on specific theoretical health models that had been reported to inform the intervention design was also recorded.
  8. Control group(s): number of points of contact with researchers and details.
  9. Outcome measures and outcome data collection time points as reported.
  10. Adverse effects.
  11. Analysis details.
  12. Rates of attrition.
  13. Follow-ups, including time intervals.
  14. Risk of bias.
  15. Risk of bias specific to cluster randomised trials: recruitment bias, baseline imbalance, loss of cluster, incorrect analyses and comparability with individual randomised trials.

 

Assessment of risk of bias in included studies

The recommended method for assessing the risk of bias in studies included in Cochrane reviews, set out in chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) was applied.

This is a two-part tool, addressing seven specific domains (namely sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective outcome reporting and 'other bias'). Each domain includes one or more specific entries in a risk of bias table. Within each entry, the first part of the tool involves describing what was reported to have happened in the study. The second part of the tool involves assigning a judgement relating to the risk of bias for that entry. This is achieved by assigning a judgement of 'Low risk' of bias, 'High risk' of bias, or 'Unclear risk' of bias. The risk of bias assessment was undertaken independently and in duplicate by four review authors in total as part of the data extraction process. Where a consensus was not reached, methods experts within the group were consulted.

After taking into account the additional information provided by the authors of the trials, studies were grouped into the following categories.

  • Low risk of bias (plausible bias unlikely to seriously alter the results) for all key domains.
  • Unclear risk of bias (plausible bias that raises some doubt about the results) if one or more key domains were assessed as unclear.
  • High risk of bias (plausible bias that seriously weakens confidence in the results) if one or more key domains were assessed to be at high risk of bias.

A risk of bias table (Characteristics of included studies) was completed for each included study and the results are presented graphically (Figure 1; Figure 2).

 FigureFigure 1. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

 

Measures of treatment effect

Dichotomous data were not reported. Although Zanin 2007 reported on prevalence rates, caries increment was calculated.

In dealing with caries increment data, the mean difference and standardised mean difference were calculated and taken as the summary statistic. If multiple studies reporting a variety of measures (dmft, dmfs etc.) had been included in this review, the prevented fraction (i.e. mean caries increment in the treatment group subtracted from that of the control group and divided by the mean increment in the control group) would have been calculated. Use of prevented fraction allows for a more reliable examination of heterogeneity between trials.

 

Unit of analysis issues

The review included cluster randomised controlled trials, where schools or classes are the unit subject to randomisation. Where appropriate, intra-cluster correlation coefficients (ICC) were used to estimate variability between and within clusters as detailed in section 16.3 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Methods of analysis and reporting were reviewed for appropriateness by a review author expert in these methods (Girvan Burnside (GB)).

 

Dealing with missing data

If data were unavailable and clarification required (e.g. study characteristics and numerical outcome data), corresponding authors of studies were contacted directly in order to obtain missing information.

Where authors could not be contacted, missing standard deviations were estimated using intention-to-treat (ITT) analyses when primary outcome data or participant attrition data are missing.

 

Assessment of heterogeneity

Where there was poor overlap of confidence intervals of the individual studies, assessments of heterogeneity were carried out using the Chi2 test and the I2 statistic. The I2 statistic was interpreted according to the guide provided in section 9.5 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011), the magnitude and direction of effects and alongside the P value of the Chi2 test. Sources of heterogeneity were explored where the I2 statistic exceeds 25%. If there was unexplained heterogeneity, a meta-analysis was not conducted.

 

Assessment of reporting biases

The impact of reporting bias was minimised by undertaking comprehensive searches of multiple sources (including trial registries), increasing efforts to identify unpublished material and including non-English language publications. Efforts were also made to identify outcome reporting bias in studies by recording all outcomes, planned and reported, and noting where there were missing outcomes. Where evidence of missing outcomes was found, attempts were made to obtain any available data direct from the study authors.

 

Data synthesis

For the primary outcome variable, the treatment effect was assessed by calculating the relative effect as indicted by the prevented fraction (PF): the mean caries increment in controls minus mean caries increment in the intervention group, divided by the mean caries increment in controls. For the included study, the 95% confidence interval of the PF was calculated.

Each included study was summarised and described according to participant and intervention characteristics and outcomes.

 

Subgroup analysis and investigation of heterogeneity

Subgroup analyses were planned on the basis of:

  1. age: 4 to 7 years and 8 to 12 years (best practice advice on child age associated competencies for effective toothbrushing; i.e. it is advised that parents undertake or supervise toothbrushing for children under 7 years);
  2. number of BCTs applied as denoted in the Taxonomy of Behavioural Change Techniques Used in Interventions (Abraham 2008);
  3. frequency and duration of exposure to the intervention; and
  4. gender.

A test to determine the interaction between the subgroup estimates was planned.

 

Sensitivity analysis

Sensitivity analysis was planned on:

  1. risk of bias assessment;
  2. random-effects modelling;
  3. ICCs estimates where these values were missing in studies.

Only studies at low risk of bias were included in the final analysis.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Description of studies

Further descriptions of the studies can be found in the Characteristics of included studies tables. The following section summarising key aspects of the studies.

 

Results of the search

The processing of the references identified through electronic searches, handsearches and citation tracking is described in Figure 3.
After de-duplication of the results from electronic searching there were 1518 records. A further 8326 records were identified through handsearching and citation tracking (total 9844). Based on the screening of the title and abstracts (Sarah Elison (SE), Lucy O'Malley (LO), Pauline Adair (PA), Rosemary Armstrong (RA), Anna Cooper (AC)), 9680 records were discarded as irrelevant to this review. Articles were rejected on initial screening if the review author could determine from the title and abstract the article did not meet the inclusion criteria. The review authors assessed full-text copies of 84 articles (SE, LO, PA, RA, AC). Two review authors (Lindsey Dugdill (LD), AC) independently double screened all citations once the initial screening had been completed. Sixty-four references were discarded as not relevant. Subsequently, 20 articles were indicated as having potentially met the inclusion criteria and were subjected to full data extraction. During this phase, 16 articles were deemed not to have the distinct elements of the intervention that targeted cariogenic food (in addition to toothbrushing) or the study, upon further examination, was found not to be an RCT. In one case, a study was deemed to be so poorly reported that it could not be included in this review.

 FigureFigure 3. Review flow diagram.

 

Included studies

 

Characteristics of the trial design and setting

Two studies were cluster randomised at the level of the school (Saied-Moallemi 2009; Worthington 2001); with the remaining two trials randomised at the level of the individual (Petrecca 1994; Zanin 2007). One study was conducted in South America (Brazil) Zanin 2007, two in Europe, Petrecca 1994 in Italy and Worthington 2001 in the UK and one in Asia, Saied-Moallemi 2009 in Tehran.

Sample size: In total 2302 children participated in the four studies, of these 1529 children were subject to behavioural interventions and 773 children acted as controls. Sample sizes ranged from 30 (Zanin 2007) to over 400 per group (Petrecca 1994). For a more detailed breakdown of sample size per study please refer to the Characteristics of included studies tables. Two studies reported that power calculations were conducted to inform the sample size (Saied-Moallemi 2009; Zanin 2007), the remaining two studies did not report how the sample size was arrived at.

Of the included studies, two did not state the source of trial funding, the study by Saied-Moallemi 2009 was supported by the Iran Centre for Dental Research and the other study by the National Sugar Bureau (Worthington 2001).

 

Characteristics of the participants

 
4 to 7 year olds (baseline)

One study was conducted with children aged 4 to 7 years (Zanin 2007). The intervention reported by Zanin 2007, taught an age-appropriate modified toothbrushing technique to the children. This was done through instruction and demonstration. The technique took into account the limited motor control of children at this age and aimed to improve the children's plaque removal ability. Supervised brushing sessions took place every 3 months. In addition, the intervention involved educational elements which covered dental hygiene and consumption of cariogenic food and drink.

 
8 to 12 year olds (baseline)

Two studies were conducted with children aged 8 to 12 years (Saied-Moallemi 2009; Worthington 2001). They were both delivered and monitored by dental professionals, with one involving teachers alongside dental professionals (Saied-Moallemi 2009). Both linked the school programme to the home with varying levels of parental involvement.

 
Age at baseline unclear

Petrecca 1994 only reported that children at baseline were within primary school age and specified at baseline they were in primary school years one to three. Based on the current Italian school system, this may indicate that the children were aged between 6 and 9 years at baseline, however it is important to note that this cannot be confirmed. Attempts to make contact with the authors were unsuccessful. The intervention was aimed at children and teachers; diagrams and plastic models were used to explain caries to the children and to teach them oral (including dietary) hygiene. Children were asked every 30 days if they were following the oral (and dietary) hygiene regimen. Teachers were involved in the delivery of the intervention. A second intervention group had the same educational programme plus daily fluoride tablets (1 mg).

The number of boys and girls within each group was not outlined in two studies (Petrecca 1994; Zanin 2007). One study randomised eight boys and eight girls schools separately to include two schools of each gender within each of the four clusters (Saied-Moallemi 2009 ). The remaining study (Worthington 2001) had an overall equal number of girls and boys in intervention and control groups (based on information from Hill 1999).

One study (Petrecca 1994) excluded children who were either unable to follow the instructions provided or had not taken their fluoride tablets. All children within the research area were given the opportunity to participate in the intervention reported by Worthington 2001. This was facilitated by the design with only those with positive consent being sampled for a clinical examination. One study (Zanin 2007) reported that children were excluded from the study at baseline if they were showing signs of severe fluorosis, hypoplasia, or systemic alteration. Children were also excluded from this study if they had fixed braces. One study did not report any exclusion criteria (Saied-Moallemi 2009).

 

Characteristics of the interventions

In all cases, interventions took the form of educational programmes, broken down into a series of classroom-based lessons. Lessons were designed to fit into the UK national curriculum in one study (Worthington 2001). Details of the design of the interventions of the remaining studies were not reported. All interventions included toothbrushing instruction and skill lessons and information on the use of fluoride toothpaste. Supervised toothbrushing practice sessions with the children were carried out in two of the interventions (Worthington 2001; Zanin 2007). Although all interventions included dietary elements (as per inclusion criteria), the strength of this component varied across the interventions. Information around dietary effects was provided through group discussion (Worthington 2001) or lessons (Zanin 2007), or via instruction (Petrecca 1994) and in one study was provided only through leaflets or worksheets (Saied-Moallemi 2009). In all studies, it appeared that the dietary elements came secondary to dental hygiene in terms of the strength of delivery.

General dental health information and more detailed information around the behaviour health link was included in all interventions. Interventions were delivered by specifically trained dental nurses (Worthington 2001) and by school health counsellors and teachers (Saied-Moallemi 2009). For the remaining studies, it is unclear who delivered the interventions. Disclosing tablets were used as part of the interventions in one study as part of a classroom activity (Worthington 2001).

Structures for transition of the intervention into the home were absent in two of the studies (Petrecca 1994; Zanin 2007). Saied-Moallemi 2009 described one intervention arm that provided parents with leaflets and materials (e.g. brushing charts and worksheets) used in the school with the aim of getting the parents to replicate the intervention at home (these children did not receive an intervention in school). The remaining intervention arm in this study included a combination of home and school elements, each intended to reinforce the other. One study encouraged a link to the home with the provision of oral health related home work tasks (along the same theme as the work in schools) lasting around 1 hour. Parents or grandparents were required to complete these with the children (Worthington 2001).

In three of the studies, control groups were non-intervention controls; no preventive treatment or instruction was provided (Petrecca 1994; Saied-Moallemi 2009; Worthington 2001). However in one of these studies half the control schools became active at 4 months (Worthington 2001). In the remaining study (Zanin 2007) treatment, including fillings and extractions, was provided as well as an annual supervised toothbrushing session.

Of the included trials, two did not report that pilot work had been carried out prior to the development of the intervention (Saied-Moallemi 2009; Zanin 2007). One study conducted pilot work on a population previously examined by the authors (Petrecca 1994) and the remaining study piloted the intervention with children and teachers to test measures, delivery and materials prior to the RCT (Worthington 2001).

In the included studies post-intervention outcome measures were reported at 3 months (Saied-Moallemi 2009), 6 months (Zanin 2007) and 1 year after the intervention (Petrecca 1994). Worthington 2001 employed a cross-over design and as such reported post-intervention outcome measures at 4 months within phase one and after 3 months for phase two. Only one of the included studies reported having an additional follow-up time point (Petrecca 1994).

 

Excluded studies

The search and screening process is summarised in Figure 3. Studies not included in this review (and the reason for exclusion) can be found in the Characteristics of excluded studies table. The most common reason for exclusion was study design. Studies were also excluded where behavioural interventions were provided along side clinical interventions such as sealants or varnish making it impossible to determine the effect of the behavioural intervention alone. Additionally, a substantial number of studies were excluded on the basis that the intervention did not contain the two key components described in the inclusion criteria (oral hygiene and diet) for this review. Most commonly, interventions tended to be based around oral hygiene only.

 

Risk of bias in included studies

Quality assessment was conducted using The Cochrane Collaboration's 'risk of bias' tool on all included studies. This assesses each study on seven domains: sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessors, incomplete outcome data, selective outcome reporting and any other bias. Across the domains relating to selection, performance and detection bias, the majority of trials scored low or unclear. Selective reporting bias was deemed to be highest risk of bias, being scored as high for half of the included studies (Figure 1 and Figure 2). Overall the risk of bias was assessed as unclear in Zanin 2007, and high in the remaining three studies.

 

Allocation

 

Random sequence generation

One of the studies reported that a "lottery" was the method of randomisation (Zanin 2007) and for another included study, details were provided by personal communication (Worthington 2001) confirming that randomisation was achieved by way of a computer generated schedule. Both of these studies were assessed as low risk of bias for this domain. The remaining two studies were assessed at unclear risk of bias here.

 

Allocation concealment

It was unclear who conducted the "lottery" in the study reported by Zanin 2007, so allocation concealment was assessed as unclear. Personal communication confirmed that allocation to intervention and control groups was undertaken by the statistician and concealed from the dental nurse who conducted the intervention in the other study (Worthington 2001). The remaining two studies reported no information about allocation concealment and were assessed at unclear risk of bias. Within these, two of the studies were cluster randomised controlled trials (Saied-Moallemi 2009; Worthington 2001) with the unit of allocation being the school.

 

Blinding

 

Participants and personnel

Blinding of deliverers and participants in behavioural interventions is problematic and this has been acknowledged in other Cochrane reviews of behavioural interventions (e.g. Waters 2011). Some of the included studies in this review had attempted to minimise the level of information given to children, however it was not always possible to blind the delivery of the intervention for obvious reasons.

Two studies reported that participants were not aware of the treatment group they were allocated to (Saied-Moallemi 2009; Zanin 2007). Two were cluster randomised hence it was assumed that the risk of performance bias was reduced (Saied-Moallemi 2009; Worthington 2001).

 

Outcome assessors

Three studies were judged to be of low risk of performance bias (Saied-Moallemi 2009; Worthington 2001; Zanin 2007). Lack of information in the remaining study (Petrecca 1994) meant it was not possible to ascertain the level of bias (Petrecca 1994); this was judged to be unclear.

Of the studies that were judged to have low risk of performance bias, three were also judged to have low risk of detection bias, having reported on blinding (Saied-Moallemi 2009; Worthington 2001; Zanin 2007). For the remaining study (Petrecca 1994) it was not possible to determine the detection bias due to insufficient reporting.

 

Incomplete outcome data

Three studies included in the review were judged to be of low risk of attrition bias (Saied-Moallemi 2009; Worthington 2001; Zanin 2007). Low levels of participant drop-out were reported across these studies meant that attrition was unlikely to impact upon the outcomes of interest.

The study described by Petrecca 1994 was judged to be of high risk of attrition bias as some children were taken out of the sample after the initial phase for not adequately following the oral hygiene and nutrition components of the intervention. Rates of attrition were different in each group over the 2 years of this trial.

 

Selective reporting

Half of the included studies in this review were judged to have low risk of reporting bias (Worthington 2001; Zanin 2007). However, it is important to note that study protocols could not be obtained; it was clear from the papers that all pre-specified and expected outcomes were reported.

One study was judged to have high risk of reporting bias (Petrecca 1994) because only point estimates with no estimates of variance were reported, meaning that data could not be interpreted accurately.

 

Other potential sources of bias

Although the study reported by Worthington 2001 was judged to be of low risk of bias for all other domains, bias may have been introduced regarding the outcome data for plaque. Plaque was measured using a subsample of 10 children in each school, selected based on parental consent. It is possible that the children whose parents did not give consent may have had different mean plaque scores to the subsample measured. It was established through communication with the author that the funder of this study (National Sugar Bureau) had no influence over the data reported.

 

Effects of interventions

See:  Summary of findings for the main comparison

See  Summary of findings for the main comparison.

 

Primary outcomes

 

Changes in caries increment measured by the difference in decayed, missing and filled teeth (dmft/DMFT)

One study reported DMFT (Petrecca 1994). While it is unclear as to the precise age of the children in this study, concern about measurement arose from a sentence in the methods section of this paper:
"The WHO advises using the same criteria for milk teeth as for permanent dentition, using DMFT but taking into account that teeth lost through caries can be identified only up to the age of 8, since up to that age the absence of a milk molar cannot be due to changeover".

From the DMFT data reported in this study we calculated an estimate of prevented fraction of 0.49 over 2 years, but no standard deviations or standard errors were presented in the paper. Three attempts in total were made to contact the authors of this study for clarification, unfortunately these were unsuccessful. Due to the uncertainty over the measure, this study has not been included in the analysis.

 

Changes in caries increment on tooth surfaces (dmfs/DMFS)

One study reported on dmfs/DMFS (Zanin 2007). Data presented allowed for the calculation of caries increment, but not standard deviations. This study has been included in the analysis, with estimated standard deviations (SDs) calculated using the regression equation derived by Marinho 2009 in the review of Topical fluorides for preventing dental caries in children and adolescents. This equation was based on a regression analysis of 179 treatment arms. The equation is log (SD caries increment) = 0.64 + 0.55 log (mean caries increment).

This study showed evidence of a reduction in caries increment measured by the difference in decayed missing and filled surfaces (preventive fraction (PF) 0.65, 95% confidence interval (CI) 0.12 to 1.18, 1 RCT, 60 participants) ( Analysis 1.1).

 

Changes in plaque scores for permanent and deciduous teeth over the course of the intervention and the follow-up period

Three studies reported plaque outcome data. All plaque indices were based on variations of the Silness and Löe index, with results reported either as post-treatment plaque score, or change in plaque score from baseline. While the indices differ, they aim to measure a similar outcome and so standardised mean difference (SMD) was used to measure treatment effect.

One study (Zanin 2007) only reported median plaque index (PI). The median PI at the end of the study (15 months) was reported as 0.93 in the control group and 0.60 in the intervention group, with a Mann-Whitney test reported as significant (P < 0.05). No means were reported, so we were unable to include this outcome in the analysis.

Saied-Moallemi 2009 reported change in plaque index between pre- and post-intervention examinations. This study had three intervention groups, all of which were judged to meet the inclusion criteria for this review, so the data from these three groups have been combined for analysis here. The study was cluster randomised, with four clusters per group (so 12 clusters in the combined intervention group). No intra-cluster correlation coefficient (ICC) was reported, although the authors did recognise the cluster design in the analysis of additional outcomes (using generalised estimating equations) the plaque analysis did not adjust for clustering. For the purposes of this review, the ICC has been assumed to be 0.05 (Higgins 2011). After adjustment for clustering, there was a significant difference in change in plaque score, with the intervention groups showing better oral hygiene (SMD -0.34, 95% CI -0.67 to -0.01, cluster adjusted effective sample size 186).

The remaining study, Worthington 2001, was cluster randomised and analysed using generalised estimating equations to allow for the clustering in the analysis. ICC values were also included in the paper, allowing the SMD to be appropriately adjusted for the clustering, by amending the effective sample size. This study presented outcomes at 4 and 7 months, but after the 4-month examination, the groups were re-configured, so data from the 4-month examination have been included here. After adjustment for clustering, there was a significant difference in plaque score, with the intervention group showing a reduction in plaque (SMD -0.64, 95% CI -0.90 to -0.38, cluster adjusted effective sample size 233).

When the Saied-Moallemi 2009; Worthington 2001 were combined in a meta-analysis, there was substantial heterogeneity (I2 = 0.50) likely to be due to differences in study design and in the details of the interventions, so meta-analysis has not been presented ( Analysis 1.2).

 

Secondary outcomes: Non-clinical

Of the four included studies, three (Petrecca 1994; Saied-Moallemi 2009; Zanin 2007) did not measure any secondary outcomes. A variety of non-clinical measures have been reported in one study (Worthington 2001). These measures relied on self report. The data are described below. There is at present no single reliable method for recording toothbrushing or sugar snacking behaviours.

 

Children's frequency of toothbrushing

Worthington 2001 reported on children's brushing frequency. Almost all children (99%) at baseline reported twice daily brushing prior to the start of the study, and this level was maintained across all groups throughout the intervention. However, in the baseline focus groups, 'most' children reported that they did not brush their teeth more than once a day.

 

Children's frequency of cariogenic food and drink consumption

Worthington 2001 reported few children had problems identifying foods containing sugar with only 15% of the intervention and 19% of control participants reporting they routinely consumed sugary snacks when they arrived home from school. However, snack consumption prior to bedtime was reported by approximately a third of participants at baseline, with this figure showing a non-significant decline across the study period.

 

Change in oral health knowledge and skills

Worthington 2001 reported changes in oral health knowledge and skills following the intervention. Changes were apparent in both the intervention and control groups at the 4-month follow-up (phase one); however, this improvement was greater among the intervention group (34% increase) compared to the control group (15% increase). In phase two, post-intervention measures showed that the new intervention group had a 10% improvement in knowledge and skill and previous increases found in the intervention and control groups were sustained.

No other behavioural outcomes were measured by the four included studies.

 

Changes in dental attendance

Worthington 2001 found no change in reported dental visits over the course of the programmes, with 97% of children at baseline reporting visiting the dentist every 2 years. When asked in the focus groups however, most children reported being unsure how often dental visits are recommended.

 

Adverse events

No study reported any adverse events.

 

Other analyses

Subgroup and sensitivity analyses were planned, however these were not conducted due to insufficient studies.

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Summary of main results

This review includes four studies of primary school-based behavioural interventions aimed at preventing dental caries in children 4 to 12 years of age. Studies were generally less than 2 years in length and there is very limited evidence from these randomised controlled trials (RCTs) on the efficacy of the interventions for dental health. Lack of uniformity in describing the interventions and measuring and reporting outcome variables made accurate pooling of evidence difficult. Only one small study, with 60 participants (Zanin 2007), reported a caries outcome, and showed that the children in the intervention group developed fewer new caries over the study period. Although no meta-analysis was performed for plaque outcomes, three studies reporting plaque (Saied-Moallemi 2009; Worthington 2001; Zanin 2007) reported statistically significant reductions in plaque in the intervention groups. This provides some limited evidence that these interventions reduce plaque outcomes over the short term. Short term improvements in plaque scores may arguably not be considered a 'true health outcome' and do not provide useful information on long term effects of these interventions.

In summary the key learning from this review in terms of the efficacy of primary school-based behavioural interventions on clinical and behavioural outcomes is very limited. The included studies were multifarious in terms of intervention design and clinical and behavioural outcomes. Consequently it is difficult to give any clear evidence-based recommendations as to the best intervention designs with respect to oral health behaviour change.

 

Overall completeness and applicability of evidence

This is the first Cochrane review that has examined the use of behaviour change techniques (BCTs) in dental clinical trials. Behaviour change science has progressed rapidly over the last decade and has been applied within various areas of public health research including attempts to change multiple behaviours (e.g. diet and physical activity in obesity interventions) (Michie 2012).

Interventions were subject to high levels of heterogeneity and ways of measuring caries and plaque outcomes varied. Meta-analysis could not be conducted on caries outcomes as data from only one study were eligible. Nor could a meta-analysis be conducted on plaque outcomes as we judged heterogeneity to be too high. Additionally, subgroup analysis could not be conducted due to the low number of included studies.

The studies included in this review provide a limited means for answering questions around how best to prevent caries through primary school-based behavioural interventions. The interventions themselves were not described in detail within published reports, however it is recognised that publication limitations may apply.

Several BCTs could be identified in the included studies; these are recorded in Additional  Table 1 (theoretical basis of these BCTs is provided in Appendix 12). These were predominantly around.

  1. Instruction - in most cases referred to promoting toothbrushing or demonstration of brushing but also changing sugar consumption.
  2. Demonstration of toothbrushing - which varied from using models (Petrecca 1994) to supervision of the children's technique on a regular basis, in Saied-Moallemi 2009 by health counsellors. In the intervention reported by Zanin 2007, it was unclear who supervised the brushing sessions and whether they were trained to do so.

In the case of the intervention described by Zanin 2007, the aetiology of caries was explained in order to provide children with the link between behaviour and consequences. In the intervention described by Worthington 2001, general behaviours were described as resulting in particular dental outcomes. In all cases messages were disseminated either through leaflets or through lessons. One study reported that the interventions involved some form of active learning, such as group discussion (Worthington 2001).

The data presented by Zanin 2007 indicate a large effect on caries as a result of the intervention. It is important to note that the intervention included an age specific toothbrushing technique and toothbrushing was practiced at regular supervised intervals. The evaluation period did not extend beyond the length of the intervention and as such we cannot be certain of the long term impact of this intervention on health behaviours.

Many of these interventions targeted knowledge. It is recognized that knowledge increase or indeed instruction will not necessarily lead to sustained behavioural change (Freeman 2009; Kay 1996; Kay 1998; Stillman-Lowe 2008). The integration of relevant behavioural components may be important in terms of behavioural outcomes. Such components may benefit from inter-professional delivery or expertise in the integration of the intervention by an appropriately trained team (Watson 2011).

 

Quality of the evidence

Based on the evidence gathered by this review (four studies incorporating a total of 2302 children at baseline), it cannot be determined that primary school-based behavioural interventions are effective at promoting behaviours related to caries prevention.

Methodologically, there were inconsistencies in the use of the terms 'post-intervention' and 'follow-up' to describe outcome measurement. No study reported considerations related to exit strategies upon completion of supported intervention delivery hence we cannot make any judgements about the sustainability of interventions.

The interventions reported in this review primarily focused on the toothbrushing component, with the cariogenic dietary component carrying much less weight. Only two of the studies reported that a power calculation had been conducted to determine sample size. There was considerable variation in terms of who delivered the interventions (including variation in the training received). No study reported delivery by dietary professionals. The variation in the responsibility for delivery, reinforcement and maintenance of interventions is likely to impact upon the fidelity and hence efficacy of the interventions. Studies reported frequent supervised toothbrushing sessions and in some interventions parents were encouraged to take an active role in supervising their child's toothbrushing (active reinforcement) however, this intensity of intervention was not replicated for the cariogenic food/drink components.

Based on the evidence for school behavioural interventions for preventing caries presented by the studies included in this review, there are significant knowledge gaps. None of the studies included a cost-benefit analysis, additionally there was limited analysis of the impact of deprivation. Little can therefore be said about the potential financial implications of providing behavioural interventions in a primary school setting. Further research is also required around the impact of deprivation on behavioural interventions targeting primary school children. Child oral health related quality of life and overall health status are not reported as outcome measures or explanatory variables in any of the included studies.

While some studies have reported behavioural measures alongside clinical outcomes, none have attempted to link the various types of evidence to understand the effects of the interventions in a holistic sense. Complex behavioural interventions require process evaluations to explore, in greater depth, how and why they work or do not. Such evaluations "would improve the science of many randomised controlled trials" (Oakley 2006).

None of the interventions were underpinned by theory. Pilot work to inform intervention design appeared limited, a noteworthy finding in consideration of the recent guidance from the MRC 2000 updated to MRC 2008, NICE 2007 and Intervention Mapping Approaches (Bartholomew 2011) which stress the importance of pre-testing interventions. Difficulties were encountered in obtaining full intervention manuals (although some intervention materials were provided via contact with authors). This was a limiting factor in understanding the more specific components of the interventions. This also has implications for the repeatability and therefore the reliability of these studies.

A major finding from this review is the lack of consistency in the design of interventions in terms of their intensity and optimum length. Indeed, some studies did not report these parameters. We are not yet at a stage of understanding in oral health research to be able to draw conclusions about the key components needed for effective behavioural interventions for caries prevention in primary school aged children. It may be beneficial to draw on the advances currently being made in the field of behavioural science, largely driven by health psychology. Additionally, the social determinants of health is a key area for all research seeking to reduce disparities in health across socioeconomic strata.

 

Potential biases in the review process

The number of databases searched electronically and journals handsearched was comprehensive. Through the initial title and abstract screening and the full secondary screening, it is felt that all relevant studies have been included in the review. During the review process, we had greater success in contacting authors of more recent studies. This lead to clarification of studies for the purposes of study screening as well as data extraction. Through contact with authors, some intervention materials were also obtained meaning that we gained a more thorough understanding of these interventions.

 

Agreements and disagreements with other studies or reviews

This review partially supports reviews which have examined oral health education interventions (Kay 1996; Kay 1998; Watt 2001) in finding short term improvements in the oral health knowledge of children and adults. A recent review conducted by Harris 2012 around chairside interventions for dietary behaviour change found that the reporting of interventions was greatly varied, with "no studies concerned with dietary change aimed at preventing tooth erosion". The primary focus of the interventions was fruit, vegetable and alcohol consumption. Additionally only one study included by Harris 2012 included a cost analysis for the intervention. Cost benefit analysis is highlighted within this review as important and under-researched in this field.

A review examining interventions aimed at preventing childhood obesity (Waters 2011) also highlighted the difficulty in determining which component of the intervention was most beneficial, although key areas to promote were identified. Waters 2011 concludes that there is a need to strengthen study and evaluation design as well as the reporting of procedures and intervention implementation. Waters 2011 similarly refers to the need to understand the longer term impacts and the cost of interventions.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

 

Implications for practice

Based on this review there is limited evidence that primary school-based behavioural interventions that promote twice daily toothbrushing and reduce snacking on sugary foods can prevent caries by improving children's oral hygiene. There is some evidence to suggest that these interventions may have a positive impact upon children's knowledge and on plaque removal.

Recognition of the social determinants of health and the pivotal role of the home environment are likely to be key aspects enhancing design and delivery of future interventions (active involvement of parents was found to impact intervention effectiveness in this review) helping to ensure strong links with the home. The results presented within this review suggest that the home is an important influence on clinical outcomes (plaque) in these types of intervention. Through the inclusion of an 'active' home component, the efficacy of primary school-based behavioural interventions may be increased. However, due to the small number of included studies, it is not possible to determine the extent of this impact. This is an area recommended for further research.

A greater emphasis should be placed on embedding healthy morning and bedtime routines, focusing on relevant environmental cues within the home. Future intervention design should target development of behavioural transition moving from knowledge acquisition to the adoption of habitual behaviour (i.e. knowledge, skill development, reinforcement and practice behaviours in a relevant setting). As yet it is unclear which BCTs are the most effective for dental health related behaviours. Attention must be paid to theoretical detail regarding behaviour change; failure to do so may limit the potential of interventions to bring about sustained health improvement.

This review highlighted that the dietary component of combined oral health behavioural interventions is less developed and tends to come secondary to oral hygiene. There appears to be a lack of integration between dietary and hygiene messages. Only one study had a more active approach to diet and nutrition. Future practice should ensure a balance between these components. Inter-professional working may help facilitate such practice.

From a sustainability and cost perspective, programmes should be designed to be integrated into current oral health strategies and school curricula using models such as 'train the trainer'. Such models do not rely on specialist staff and can thus be implemented in future years following the end of the evaluated intervention. The interventions in this review were predominantly delivered by teachers however, it was not reported how these teachers were trained.

 
Implications for research

This review highlights that there are questions still to be answered around how to effectively change the behaviour of primary school children and their families to reduce dental caries. In terms of expanding the evidence base, future studies should seek to demonstrate the rigorous standards in the design, implementation, delivery and reporting of these interventions thus aiding subsequent systematic reviews in this area. This should result in a more comprehensive interpretation of the specific behavioural components of interventions. As with intervention components, the same weight should be applied to the measurement and reporting of clinical and behavioural outcomes. Within this review the primary aim of the interventions was to change behaviour; however the focus of measurement was based on clinical outcomes that detect the results of lack of behaviour targeted (e.g. poor gingival health and high plaque levels). Only one study reported behaviour measures (Worthington 2001) being collected as part of the study.

New clinical trials conducted in primary schools aimed at reducing caries should include.

  • Outcomes that allow assessment of dental caries effect (start age 5 to 6 years to allow effect estimates for first permanent molar teeth) as well as behaviour change.
  • Cost effectiveness measures.
  • Recognised staged approach to designing and evaluating complex interventions such as the Medical Research Council (MRC) guidelines for complex intervention.
  • Theory-based interventions and incorporate BCTs; reporting of interventions should detail their length.
  • Multi-disciplinary teams in addition to dental expertise including health psychologists, dieticians and health economists.
  • Sample sizes sufficiently powered to measure clinical and behavioural outcomes appropriately.
  • A significant period of follow-up (e.g. 2 to 3 years) in order to measure long term impact on caries outcomes.
  • Data reported according to potentially relevant factors such as age, gender and socio-economic status allowing for subgroup analysis.

In addition to the Consolidated Standards of Reporting Trials (CONSORT) (CONSORT 2010), reporting should detail.

  • Intervention length, intensity and frequency as well as specific components.
  • Intervention deliver(s) and information about the setting.
  • Statistically, future trials should report mean and standard deviations for each outcome, as well as number of participants at each time point in order to improve the opportunity for meta-analyses to be performed in future systematic reviews.

Increasingly there is an awareness of the publication of intervention manuals in behavioural research. Journals such as Addiction now publish such materials online to supplement study reports. This could make for a more comprehensive evaluation of behavioural interventions in future systematic reviews.

For all but incomplete outcome data, selective reporting and blinding of participants studies were most commonly assessed to have an unclear risk of bias due to limited reported information. In addition to problems highlighted around the reporting of interventions, there is also an ongoing need to address the reporting of randomisation methods and the details of participant blinding.

Within the measurement of behavioural outcomes, and to a lesser extent, clinical outcomes, there is a lack of standardization around best measures. Future research should look at the need to develop a common core indicator set of behaviour measurements for use in dental public health intervention studies.

Key points

  • The evidence of effectiveness of primary school-based behavioural interventions on clinical and behavioural oral health outcomes is limited.
  • All the included studies contained behavioural interventions which lacked a theoretical basis. They also exhibited limited BCTs; those identified tended to relate to information giving rather than support.
  • Future delivery of effective oral health interventions may benefit from increased collaboration between relevant dental and dietary professionals to ensure programmes focus on both toothbrushing and dietary practice in an integrated way. Programmes must address the issue of the school-home interface so that parental involvement is developed as a mechanism to enable future sustainability of children's oral health habits.
  • Reporting of dental public health trials needs considerable improvement focusing on design, process, impact and outcome of trials, including cost benefit and cost effectiveness.
  • Future trials are needed to test the impact of better designed and longer-term oral health behavioural interventions which are designed to sustain behaviour change and should include measures of cost benefit and cost effectiveness.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

We would like to thank the Cochrane Oral Health Group for the support with the review especially Anne Littlewood for her help in designing and running the search strategy. Val Featherstone was involved in examining search results to support the team. Thank you to www.sel-uk.com for translating Petrecca 1994 from Italian to English and to Abir Abdel Rahmen for kindly organising the translation of intervention materials pertaining to the study by Saied-Moallemi 2009. Finally the team would like to thank Louise Robinson and Lucy Fish for their support with the administration of the review.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
Download statistical data

 
Comparison 1. Behavioural intervention versus control

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 DMFS (prevented fraction)160Prevented Fraction (Random, 95% CI)0.65 [0.12, 1.18]

 2 Plaque2Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Change in plaque index (3-4 months)
2419Std. Mean Difference (IV, Random, 95% CI)-0.51 [-0.80, -0.21]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Appendix 1. Cochrane Oral Health Group's Trials Register search strategy

((cavit* or caries or carious or decay* or lesion* or deminerali* or reminerali* or plaque or DMF or "oral hygiene index") AND (mouthwash* or "mouth wash*" or mouth-wash* or dentifrice* or "oral health" or "oral hygiene" or "oral care" or "mouth care" or "dental care" or "teeth care" or toothbrush* or tooth-brush* or "tooth brush*" or toothpaste* or tooth-paste* or "tooth paste*" or mouthrinse* or mouth-rinse* or "mouth rinse*" or clean* or "sugar intake" or sweet* or candy or candies or gum* or snack* or diet* or food* or drink or beverage*) AND (educat* or instruct* or advice or advis* or teach* or train* or promot* or demonstrat* or supervis*) and (school* or child*))

 

Appendix 2. The Cochrane Central Register of Controlled Trials (CENTRAL) search strategy

#1 ((teeth near/5 cavit*) or (teeth near/5 caries) or (teeth near/5 carious) or (teeth near/5 decay*) or (teeth near/5 lesion*) or (teeth near/5 deminerali*) or (teeth near/5 reminerali*))
#2 ((tooth near/5 cavit*) or (tooth near/5 caries) or (tooth near/5 carious) or (tooth near/5 decay*) or (tooth near/5 lesion*) or (tooth near/5 deminerali*) or (tooth near/5 reminerali*))
#3 ((dental near/5 cavit*) or (dental near/5 caries) or (dental near/5 carious) or (dental near/5 decay*) or (dental near/5 lesion*) or (dental near/5 deminerali*) or (dental near/5 reminerali*))
#4 ((enamel near/5 cavit*) or (enamel near/5 caries) or (enamel near/5 carious) or (enamel near/5 decay*) or (enamel near/5 lesion*) or (enamel near/5 deminerali*) or (enamel near/5 reminerali*))
#5 ((dentin near/5 cavit*) or (dentin near/5 caries) or (dentin near/5 carious) or (dentin near/5 decay*) or (dentin near/5 lesion*) or (dentin near/5 deminerali*) or (dentin near/5 reminerali*))
#6 ((pulp* near/5 cavit*) or (pulp* near/5 caries) or (pulp* near/5 carious) or (pulp* near/5 decay*) or (pulp* near/5 lesion*) or (pulp* near/5 deminerali*) or (pulp* near/5 reminerali*))
#7 MeSH descriptor Tooth Demineralization explode all trees
#8 MeSH descriptor Dental Plaque this term only
#9 MeSH descriptor Dental Health Surveys explode all trees
#10 ("DMF Index" or "Dental Plaque Index" or "Oral Hygiene Index")
#11 (plaque and (teeth or tooth or dental or oral))
#12 (#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11)
#13 MeSH descriptor Oral Health explode all trees
#14 MeSH descriptor Oral hygiene explode all trees
#15 MeSH descriptor Mouthwashes this term only
#16 MeSH descriptor Dentifrices explode all trees
#17 ((mouth near/6 care) or (oral near/6 care) or (dental near/6 care) or (teeth near/6 care))
#18 ((plaque near/3 control) or (plaque near/3 remov*))
#19 (toothbrush* or tooth-brush* or "tooth brush*" or toothpaste* or tooth-paste* or "tooth paste*" or dentifrice*)
#20 ((tooth near/3 clean*) or (teeth near/3 clean*) or (interdental near/3 clean*))
#21 (mouthwash* or mouthrinse* or "mouth wash*" or "mouth rinse*" or mouth-wash* or mouth-rinse*)
#22 ("sugar intake" or sweet* or candy or candies or gum*)
#23 (snack* or diet* or food* or drink* or beverage*)
#24 ((mouth near/6 health) or (oral near/6 health) or (dental near/6 health) or (teeth near/6 health))
#25 ((mouth near/6 hygien*) or (oral near/6 hygien*) or (dental near/6 hygien*) or (teeth near/6 hygien*))
#26 (#13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25)
#27 MeSH descriptor Health education, dental this term only
#28 MeSH descriptor Health promotion this term only
#29 ((dental or oral or mouth or teeth) and (instruct* or advice or advis* or educat* or teach* or train* or promot*))
#30 ((demonstrat* or supervis*) and (toothbrush* or "tooth brush*" or tooth-brush* or floss* or "interdental clean*" or mouthrinse* or mouthwash* or "mouth rinse*" or "mouth wash*" or mouth-rinse* or mouth-wash*))
#31 (#27 or #28 or #29 or #30)
#32 MeSH descriptor Schools this term only
#33 (school* and (primary or elementary or junior or infant*))
#34 "4-11 year* old*"
#35 child*
#36 (#32 or #33 or #34 or #35)
#37 (#12 and #26 and #31 and #36)

 

Appendix 3. MEDLINE via OVID search strategy

1.         (teeth adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.               
2.         (tooth adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                               
3.         (dental adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                          
4.         (enamel adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                                   
5.         (dentin adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                          
6.         (pulp$ adj5 (cavit$ or caries or carious or decay$ or lesion$)).mp.  
7.         exp TOOTH DEMINERALIZATION/                                    
8.         Dental plaque/                                    
9.         exp Dental Health Surveys/                           
10.       ("DMF Index" or "dental plaque index" or "oral hygiene index").mp.
11.       (plaque and (teeth or tooth or dental or oral)).mp.
12.       or/1-11                                    
13.       exp Oral Health/                                 
14.       exp Oral Hygiene/                              
15.       Mouthwashes/                                    
16.       Dentifrices/                             
17.       ((mouth adj6 care) or (oral adj6 care) or (dental adj6 care) or (teeth adj6 care)).mp.          
18.       ((plaque adj3 control) or (plaque adj3 remov$)).mp.
19.       (toothbrush$ or "tooth brush$" or tooth-brush$ or (toothpaste$ or tooth-paste$ or "tooth paste$") or dentifric$).mp.                           
20.       ((tooth or teeth or interdental) adj3 clean$).mp.                                
21.       (mouthwash$ or mouthrinse$ or "mouth wash$" or "mouth rinse$" or "mouth-wash$" or "mouth-rinse$").mp.                                    
22.       ("sugar intake" or sweet$ or candy or candies or gum$).mp.                       
23.       (snack$ or diet$ or food$ or drink$ or beverage$).mp.
24.       ((mouth adj6 health) or (oral adj6 health) or (dental adj6 health) or (teeth adj6 health)).mp.                                  
25.       ((mouth adj6 hygien$) or (oral adj6 hygien$) or (dental adj6 hygien$) or (teeth adj6 hygien$)).mp.                                   
26.       or/13-25                                  
27.       Health education, dental/                               
28.       Health promotion/                              
29.       ((dental or oral or mouth or teeth) and (instruct$ or advice or advis$ or educat$ or teach$ or train$ or promot$)).mp.
30.       ((demonstrat$ or supervis$) and (toothbrush$ or "tooth brush$" or tooth-brush$ or floss$ or "interdental clean$" or mouthrinse$ or mouthwash$ or "mouth rinse$" or "mouth wash$" or mouth-rinse$ or mouth-wash$)).mp.
31.       or/27-30                                  
32.       Schools/                                 
33.       (school$ and (primary or elementary or junior or infant)).mp.                      
34.       Child/                          
35.       ("school age child$" or "school-age child$" or "4-11 year$ old$").mp           
36.       child$.mp.                            
37.       or/32-36                                  
38.       12 and 26 and 31 and 37

The above subject search was linked to the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials in MEDLINE: sensitivity maximising version (2008 revision) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of the Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 [updated March 2011] (Higgins 2011).

1. randomized controlled trial.pt.
2. controlled clinical trial.pt.
3. randomized.ab.
4. placebo.ab.
5. drug therapy.fs.
6. randomly.ab.
7. trial.ab.
8. groups.ab.
9. or/1-8
10. exp animals/ not humans.sh.
11. 9 not 10

 

Appendix 4. EMBASE via OVID search strategy

1.         (teeth adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.       
2.         (tooth adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                           
3.         (dental adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                          
4.         (enamel adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                                   
5.         (dentin adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                          
6.         (pulp$ adj5 (cavit$ or caries or carious or decay$ or lesion$)).mp.  
7.         Dental caries/                         
8.         Tooth plaque/                         
9.         ("DMF Index" or "dental plaque index" or "oral hygiene index").mp.
10.       (plaque and (teeth or tooth or dental or oral)).mp.
11.       or/1-10                                    
12.       exp Mouth hygiene/                           
13.       Mouthwash/                           
14.       Toothpaste/                            
15.       ((mouth adj6 care) or (oral adj6 care) or (dental adj6 care) or (teeth adj6 care)).mp.                                  
16.       ((plaque adj3 control) or (plaque adj3 remov$)).mp.
17.       (toothbrush$ or "tooth brush$" or tooth-brush$ or (toothpaste$ or tooth-paste$ or "tooth paste$") or dentifric$).mp.                         
18.       ((tooth or teeth or interdental) adj3 clean$).mp.                                
19.       (mouthwash$ or mouthrinse$ or "mouth wash$" or "mouth rinse$" or "mouth-wash$" or "mouth-rinse$").mp.                                    
20.       ("sugar intake" or sweet$ or candy or candies or gum$).mp.                       
21.       (snack$ or diet$ or food$ or drink$ or beverage$).mp.                                
22.       ((mouth adj6 health) or (oral adj6 health) or (dental adj6 health) or (teeth adj6 health)).mp.                                    
23.       ((mouth adj6 hygien$) or (oral adj6 hygien$) or (dental adj6 hygien$) or (teeth adj6 hygien$)).mp.                                    
24.       or/12-23                                  
25.       Dental health education/                                
26.       Health promotion/                              
27.       ((dental or oral or mouth or teeth) and (instruct$ or advice or advis$ or educat$ or teach$ or train$ or promot$)).mp.
28.       ((demonstrat$ or supervis$) and (toothbrush$ or "tooth brush$" or tooth-brush$ or floss$ or "interdental clean$" or mouthrinse$ or mouthwash$ or "mouth rinse$" or "mouth wash$" or mouth-rinse$ or mouth-wash$)).mp.   
29.       or/25-28                                  
30.       School/                                   
31.       (school$ and (primary or elementary or junior or infant)).mp.                      
32.       exp Child/                               
33.       ("school age child$" or "school-age child$" or "4-11 year$ old$").mp.
34.     child$.mp.                              
35.       or/30-34                                  
36.       11 and 24 and 29 and 35

The above subject search was linked to the Cochrane Oral Health Group filter for EMBASE via OVID:

1. random$.ti,ab.
2. factorial$.ti,ab.
3. (crossover$ or cross over$ or cross-over$).ti,ab.
4. placebo$.ti,ab.
5. (doubl$ adj blind$).ti,ab.
6. (singl$ adj blind$).ti,ab.
7. assign$.ti,ab.
8. allocat$.ti,ab.
9. volunteer$.ti,ab.
10. CROSSOVER PROCEDURE.sh.
11. DOUBLE-BLIND PROCEDURE.sh.
12. RANDOMIZED CONTROLLED TRIAL.sh.
13. SINGLE BLIND PROCEDURE.sh.
14. or/1-13
15. ANIMAL/ or NONHUMAN/ or ANIMAL EXPERIMENT/
16. HUMAN/
17. 16 and 15
18. 15 not 17
19. 14 not 18

 

Appendix 5. CINAHL via EBSCO search strategy

S1        (teeth N5 (cavit* or caries or carious or decay* or lesion* or deminerali* or reminerali*))  
S2        (tooth N5 (cavit* or caries or carious or decay* or lesion* or deminerali* or reminerali*))  
S3        (dental N5 (cavit* or caries or carious or decay* or lesion* or deminerali* or reminerali*))  
S4        (enamel N5 (cavit* or caries or carious or decay* or lesion* or deminerali* or reminerali*))  
S5        (dentin N5 (cavit* or caries or carious or decay* or lesion* or deminerali* or reminerali*))  
S6        (pulp* N5 (cavit* or caries or carious or decay* or lesion*))  
S7        MH "Tooth Demineralization+"
S8        MH "Dental Plaque"  
S9        ("DMF Index" or "dental plaque index" or "dental health survey*" or "oral hygiene index")  
S10      (plaque and (teeth or tooth or dental or oral))  
S11      S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10  
S12      MH "Oral Health+"  
S13      MH "Oral Hygiene+"
S14      MH "Mouthwashes"  
S15      MH "Dentifrices" 
S16      ((mouth N6 care) or (oral N6 care) or (dental N6 care) or (teeth N6 care))
S17      ((plaque N3 control*) or (plaque N3 remov*))    
S18      ((toothbrush* or "tooth brush*" or tooth-brush* or toothpaste* or "tooth paste*" or tooth-paste* or dentifrice*))  
S19      ((tooth or teeth or interdental) N3 clean*) 
S20      (mouthwash* or mouthrinse* or "mouth wash*" or "mouth rinse*" or mouth-wash* or mouth-rinse*)  
S21      ("sugar intake" or sweet* or candy or candies or gum*)  
S22      (snack* or diet* or food* or drink* or beverage*)
S23      ((mouth N6 health) or (oral N6 health) or (dental N6 health) or (teeth N6 health))  
S24      ((mouth N6 hygien*) or (oral N6 hygien*) or (dental N6 hygien*) or (teeth N6 hygien*))  
S25      S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22 or S23 or S24 
S26      MH "Dental health education"  
S27      MH "Health Promotion"  
S28      ((dental or oral or mouth or teeth) and (instruct* or advice or advis* or educat* or teach* or train* or promot*))  
S29      ((demonstrat* or supervis*) and (toothbrush* or "tooth brush*" or tooth-brush* or floss* or "interdental clean*" or mouthrinse* or mouthwash* or "mouth rinse*" or "mouth wash*" or mouth-rinse* or mouth-wash*))
S30      S26 or S27 or S28 or S29  
S31      MH "Schools"  
S32      (school* and (primary or elementary or junior or infant))  
S33      MH "Child+"  
S34      child*  
S35      S31 or S32 or S33 or S34  
S36      S11 and S25 and S30 and S35     

The above subject search was linked to the Cochrane Oral Health Group filter for identifying RCTs in CINAHL via EBSCO:

S1        MH Random Assignment or MH Single-blind Studies or MH Double-blind Studies or MH Triple-blind Studies or MH Crossover design or MH Factorial Design  
S2        TI ("multicentre study" or "multicenter study" or "multi-centre study" or "multi-center study") or AB ("multicentre study" or "multicenter study" or "multi-centre study" or "multi-center study") or SU ("multicentre study" or "multicenter study" or "multi-centre study" or "multi-center study")   
S3        TI random* or AB random*  
S4        AB "latin square" or TI "latin square" 
S5        TI (crossover or cross-over) or AB (crossover or cross-over) or SU (crossover or cross-over)  
S6        MH Placebos  
S7        AB (singl* or doubl* or trebl* or tripl*) or TI (singl* or doubl* or trebl* or tripl*)
S8        TI blind* or AB mask* or AB blind* or TI mask*  
S9        S7 and S8
S10      TI Placebo* or AB Placebo* or SU Placebo*  
S11      MH Clinical Trials 
S12      TI (Clinical AND Trial) or AB (Clinical AND Trial) or SU (Clinical AND Trial) 
S13      S1 or S2 or S3 or S4 or S5 or S6 or S9 or S10 or S11 or S12  

 

Appendix 6. PsycINFO via OVID search strategy

1.         (teeth adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                   
2.         (tooth adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                           
3.         (dental adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                          
4.         (enamel adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                                   
5.         (dentin adj5 (cavit$ or caries or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                          
6.         (pulp$ adj5 (cavit$ or caries or carious or decay$ or lesion$)).mp.  
7.         ("DMF Index" or "dental plaque index" or "oral hygiene index").mp.
8.         (plaque and (teeth or tooth or dental or oral)).mp.
9.         ((mouth adj6 care) or (oral adj6 care) or (dental adj6 care) or (teeth adj6 care)).mp.                                  
10.       ((plaque adj3 control) or (plaque adj3 remov$)).mp.
11.       (toothbrush$ or "tooth brush$" or tooth-brush$ or (toothpaste$ or tooth-paste$ or "tooth paste$") or dentifric$).mp.                        
12.       ((tooth or teeth or interdental) adj3 clean$).mp.                                
13.       (mouthwash$ or mouthrinse$ or "mouth wash$" or "mouth rinse$" or "mouth-wash$" or "mouth-rinse$").mp.                                    
14.       ("sugar intake" or sweet$ or candy or candies or gum$).mp.                       
15.       (snack$ or diet$ or food$ or drink$ or beverage$).mp.
16.       ((mouth adj6 health) or (oral adj6 health) or (dental adj6 health) or (teeth adj6 health)).mp.                                    
17.       ((mouth adj6 hygien$) or (oral adj6 hygien$) or (dental adj6 hygien$) or (teeth adj6 hygien$)).mp.                                    
18.       Health promotion/                              
19.       ((dental or oral or mouth or teeth) and (instruct$ or advice or advis$ or educat$ or teach$ or train$ or promot$)).mp.
20.       ((demonstrat$ or supervis$) and (toothbrush$ or "tooth brush$" or tooth-brush$ or floss$ or "interdental clean$" or mouthrinse$ or mouthwash$ or "mouth rinse$" or "mouth wash$" or mouth-rinse$ or mouth-wash$)).mp.
21.       (school$ and (primary or elementary or junior or infant)).mp.                      
22.       ("school age child$" or "school-age child$" or "4-11 year$ old$").mp.
23.     child$.mp.                              
24.       or/1-8                          
25.       or/9-17                                    
26.       or/18-20                                  
27.       or/21-23                                  
28.       24 and 25 and 26 and 27       

 

Appendix 7. Current Controlled Trials search strategy

(school* AND behavi* AND prevent* AND (caries or carious or "tooth decay"))

 

Appendix 8. ClinicalTrials.gov search strategy

(school AND prevent* AND (caries or carious or "tooth decay"))

 

Appendix 9. ZETOC search strategy

(Search limited to Conference Proceedings)

(school* and prevent* and caries)
(school* and prevent* and carious)
(school* and prevent* and “tooth decay”)

 

Appendix 10. Web of Science search strategy

(Search limited to Conference Proceedings)

#1        TS=((teeth or tooth or dental or enamel or dentin or pulp*) AND (cavit* or caries or carious or decay* or lesion* or deminerali* or reminerali*))
#2        TS=("DMF Index" or "dental plaque index" or "dental health survey*" or "oral hygiene index")
#3        TS=(plaque and (teeth or tooth or dental or oral))
#4        #1 or #2 or #3
#5        TS=(toothbrush* or "tooth brush*" or tooth-brush* or toothpaste* or tooth-paste* or "tooth paste*" or interdental or mouthwash* or mouthrinse* or mouth-wash* or mouth-rinse* or "mouth wash*" or "mouth rinse*")
#6        TS=("sugar intake" or sweet* or candy or candies or snack* or diet* or food* or drink* or beverage* or gum*)
#7        TS=((oral or mouth or dental or teeth) AND (hygien* or health or care))
#8        TS="plaque control"
#9        TS=(plaque and remov*)
#10      TS=(school* or child*)
# 11     #5 or #6 or #7 or #8 or #9
# 12     #4 and #10 and #11
# 13     TS=((dental or oral or mouth or teeth) AND (instruct* or advice or advis* or educat* or teach* or train* or promot*))
# 14     TS=((demonstrat* or supervis*) AND (toothbrush* or "tooth brush*" or tooth-brush* or floss* or "interdental clean*" or mouthrinse* or mouthwash* or "mouth rinse*" or "mouth wash*" or mouth-rinse* or mouth-wash*))
# 15     #13 or #14
# 16     #12 and #15

 

Appendix 11. Dissertations and Theses via Proquest search strategy

ab(caries or carious or "tooth decay" or cavit*) AND ab(school* or child*) AND ab(prevent*) AND ab(random* or trial* or control* or placebo*)

 

Appendix 12. Explanation of the Taxonomy of Health Behaviour Change Techniques from Abraham & Michie (2008)


Theoretical frameworkDefinition

1Information-Motivation-Behavioural Skills Theory (Fisher 1994)This model of behaviour puts forward that change is most likely to occur if individuals have been provided with relevant, effective information, are sufficiently motivated and have social support. Additionally individuals must have the skill to perform the desired behaviour as well as high self efficacy for the task.

2Theory of Reasoned Action (Fishbein 1975)This theory assumes that most socially relevant behaviours are under volitional control, that they are the result of choices made by the individual enacting them. Therefore the intention to enact the behaviour is both the immediate determinant and the single best predictor of that behaviour. Intention to perform the behaviour is influenced by attitudes towards the action. This will include the person's positive or negative beliefs and evaluations of the outcome of the behaviour. Intention is also influenced by subjective norms including the perceived expectations of important others such as family, friends and work colleagues. Behavioural intention results in action.

3Theory of Planned Behaviour (Ajzen 1991)The theory of planned behaviour is an extension of the theory of reasoned action. This theory, in addition to the constructs of reasoned action, allows for the impact of past behaviour and also for the individual not always being in control of their behaviour.

The notion of behavioural control is included in this theory. Knowledge of the relevant skills and experience, emotions, past track record and external circumstances are important. Behavioural control is assumed to have a direct influence of intention.

4Social Cognitive Theory (Bandura 1986)A comprehensive theory of behaviour change, social cognitive theory puts forward a multi-faceted causal structure of motivation and behaviour. It proposes a reciprocal interaction between the individual, the environment and behaviour. Knowledge of health risks, benefits of change social influences and perceived barriers are important components in addition to self influences. Self efficacy is a key component of this theory. This theory proposes that behaviour change can occur if people perceive that they have control over the outcome, that there are few external barriers and people are confident in their ability to enact the behaviour.

5Control Theory (Glasser 1985)Control theory is a theory of motivation which states that behaviour is not a response to external stimuli but that it occurs in response to what the individual most wants at that particular time. Glasser puts forward that all behaviour are a reaction to 1 of 5 internal needs, 1. Survival, 2. The need to belong, 3. In pursuit of power and importance, 4. In pursuit of freedom and independence and 5. To have fun.  Interventions guided by this theory stress positive reinforcement and punishment. Developing an environment in which individuals feel safe will reduce negative responses to behaviour change which may be triggered by perceived threats to survival.

6Operant Conditioning (Skinner 1953)A behaviourist theory, operant conditioning puts forward that an individual's behaviour is based on reinforcement and incentives. The process describes how behaviours are acquired and maintained. Behaviour is learned, reinforcement and punishment are key constructs, the consequences of a behaviour once preformed will affect the likelihood of that behaviour being enacted again.

7Social Comparison Theory (Festinger 1954)Social comparison theory posits that individuals look to external sources in order to check and align their behaviour. These sources may be other people or may be environmental. The comparisons people make between themselves and external sources may affect their emotions, motivation and subsequently their behaviour. Comparisons can be 'upward' or 'downward'. 'Upward' comparisons occur when the comparison behaviour (or behavioural outcome) of the external source is more optimal and 'downward' comparisons occur when the external source is less optimal than the individual making the comparison. Upward comparisons tend to elicit greater motivation for change however if the gap between the comparisons is very large, without additional support, the individual may be discouraged from change (Martin 2010).

8Social support theoriesSocial support is a broad concept. Different theories relate to the ways in which social support has been defined. In a review of the literature on social support theories, Hupcey 1998, found there to be 5 categories of theoretical definitions: 1. Type of social support, 2. Recipients perceptions of support, 3. Intentions or behaviours of the providers, 4. Reciprocal support and 5. Social networks. Social support may include emotional support, support with the specific task targeted for change or with overcoming barriers to change as well as support around providing relevant information or tools. The basic premise of theories in this area is that individuals who are supported in the above mentioned ways will be more likely to change their behaviour than individuals who are not.

9Relapse Prevention Therapy (Marlatt 1998)This theory stresses the maintenance of behaviour change, identifying potential steps to prevent relapse. Relapse prevention theory states that relapse is most likely to occur if an individual has low self efficacy, insufficient coping skills. Interventions developed around this theory should prepare individuals for setbacks, these components include, 1. Anticipation of high risk situations, 2. Avoidance of these situations, 3. Working on improving coping responses to these situations, 4. Correctly attributing the cause of the setback and 5. Reframing reactions to the setback.

10Stress Theories (Lazarus 1966)Stress theory relates to how an individual copes with a situation. Upon being confronted with an outside stressor, the individual first assesses the significance of the stressor, then their perceived ability to cope with the stressor. These appraisals direct behaviour in the given stressful situation.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Co-ordinating the review: Anna Cooper (AC).
Developing search strategy and undertaking search for trials: Anne Littlewood (Trials Search Co-ordinator and Feedback Editor, Cochrane Oral Health Group), Lindsey Dugdill (LD) and AC.
Retrieving trials: AC, Lucy O'Malley (LO) and Sarah Elison (SE).
Examining search results and retrieved papers against inclusion criteria: AC, LO, SE, Rosemary Armstrong (RA), LD, Pauline Adair (PA).
Data extraction: PA, LD, AC, LO.
Contacting trial authors for necessary additional information: AC with support from Lucy Fish.
Data management and input into RevMan: LO, AC and Girvan Burnside (GB).
Analysis and interpretation of data: GB.
Writing the review: AC, LO, SE, LD and GB.
Plain language summary: RA.
Editing the review: LD, RA, Cynthia Pine (CP) and PA.
Providing advice on the review: CP, LD and (PA).

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

None of the identified review authors have any financial or commercial interest that would present a conflict for this review.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Internal sources

  • No sources of support supplied

 

External sources

  • Cochrane Oral Health Group Global Alliance, UK.
    All reviews in the Cochrane Oral Health Group are supported by Global Alliance member organisations (British Orthodontic Society, UK; British Society of Paediatric Dentistry, UK; Canadian Dental Hygienists Association, Canada; National Center for Dental Hygiene Research & Practice, USA and New York University College of Dentisry, USA) providing funding for the editorial process (http://ohg.cochrane.org/).
  • National Institute for Health Research (NIHR), UK.
    CRG funding acknowledgement:
    The NIHR is the largest single funder of the Cochrane Oral Health Group.
    Disclaimer:
    The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

There were insufficient data to allow planned subgroup analyses to be performed in this review.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
Petrecca 1994 {published data only}
  • Petrecca S, D'Arcangelo C, Esposito P, Di Marco N. A 2-year evaluation of different methods of dental caries prophylaxis in a sample school-aged population. Minerva Stomatologica 1994;43(1-2):23-8.
Saied-Moallemi 2009 {published and unpublished data}
Worthington 2001 {published and unpublished data}
  • Hill K. An assessment of a dental health education programme. MSc Thesis 1999; Vol. The University of Manchester.
  • Worthington HV, Hill KB, Mooney J, Hamilton FA, Blinkhorn AS. A cluster randomized controlled trial of a dental health education program for 10-year-old children. Journal of Public Health Dentistry 2001;61(1):22-7.
Zanin 2007 {published data only}
  • Zanin L, Meneghim MC, Assaf AV, Cortellazzi KL, Pereira AC. Evaluation of an educational program for children with high risk of caries. Journal of Clinical Pediatric Dentistry 2007;31(4):246-50.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
Agerbaek 1979 {published data only}
Al-Jundi 2006 {published data only}
Anaise 1976 {published data only}
  • Anaise JZ, Zilkah E. The effectiveness of a dental education program on oral cleanliness for school children of 11 to 14 years old. Israel Journal of Dental Medicine 1976;25(4):23-7.
Andruskeviciene 2008 {published data only}
  • Andruskeviciene V, Milciuviene S, Bendoraitiene E, Saldunaite K, Vasiliauskiene I, Slabsinskiene E, et al. Oral health status and effectiveness of caries prevention programme in kindergartens in Kaunas city (Lithuania). Oral Health & Preventive Dentistry 2008;6(4):343-8.
Bagramian 1976 {published data only}
  • Bagramian RA, Graves RC, Bhat M. A combined approach to preventing dental caries in schoolchildren: caries reductions after one year. Journal of the American Dental Association 1976;93(5):1014-9.
Bagramian 1978 {published data only}
Bagramian 1982 {published data only}
Belloso 1999 {published data only}
  • Belloso N, Hernández N, Rivera L, Morón A. Effectiveness educational programs for school dental health. Experimental trial. Acta Científica Venezolana 1999;50(1):42-7.
Bentley 1983 {published data only}
  • Bentley JM, Cormier P, Oler J. The rural dental health program: the effect of a school-based, dental health education program on children's utilization of dental services. American Journal of Public Health 1983;73(5):500-5.
Bordoni 2005 {published data only}
  • Bordoni N, Squassi A, Bellagamba H, Galarza M. Efficiency of a schoolchildren program for oral care. Acta Odontológica Latinoamericana 2005;18(2):75-81.
Bretz 2004 {published data only}
  • Bretz W. School children with a high caries experience benefit from supervised tooth brushing equally with 500 ppm and 1450 ppm sodium fluoride toothpastes after a 9-month study period. Journal of Evidence-Based Dental Practice 2004;4(2):138-9.
Buischi 1994 {published data only}
Culler 2011 {published data only}
  • Culler CS. An outcomes evaluation of a comprehensive school-based oral health program. Dissertation Abstracts International: Section B: The Sciences and Engineering 2011;71(7-B):4148.
Curnow 2000 {published data only}
  • Curnow M, Pine CM, Burnside G, Nicholson J, Chesters R, Huntington E. A clinical trial of the efficacy of supervised school toothbrushing in high caries risk children. Caries Research 2000;34(4):349 (Abs No 120).
Curnow 2002 {published data only}
  • Curnow MMT, Pine CM, Burnside G, Nicholson JA, Chesters RK, Huntington E. A randomized controlled trial of the efficacy of supervised toothbrushing in high-caries-risk children. Caries Research 2002;36(4):294-300.
Davies 2002 {published data only}
  • Davies GM, Worthington HV, Ellwood RP, Bentley EM. A randomised controlled trial of the effectiveness of providing free fluoride toothpaste during the pre-school years on reducing caries in 5-6-year old children. Journal of Dental Research 2002;81(Spec Iss A):A385 (Abs No 3103).
Davies 2002a {published data only}
  • Davies GM, Worthington HV, Ellwood RP, Bentley EM, Blinkhorn AS, Taylor GO, et al. A randomised controlled trial of the effectiveness of providing free fluoride toothpaste from the age of 12 months on reducing caries in 5-6 year old children. Community Dental Health 2002;19(3):131-6.
de Farias 2009 {published data only}
Ekstrand 2000 {published data only}
  • Ekstrand KR, Kuzmina IN, Kuzmina E, Christiansen ME. Two and a half-year outcome of caries-preventive programs offered to groups of children in the Solntsevsky district of Moscow. Caries Research 2000;34(1):8-19.
Ellwood 2004 {published data only}
Englander 1979 {published data only}
Esfahanizadeh 2011 {published data only}
  • Esfahanizadeh N. Dental health education programme for 6-year-olds: a cluster randomised controlled trial. European Journal of Paediatric Dentistry 2011;12(3):167-70.
Feldens 2010 {published data only}
Fernández 1988 {published data only}
  • Fernández Parra A. Development of dental hygiene skills in children by means of procedures of behavioral intervention. Avances en Psicología Clínica Latinoamericana 1988;6:77-94.
Fernández 1988a {published data only}
  • Fernández Parra A, Gil Roales-Nieto J. Health education and behavioral intervention in the development of dental hygiene habits (toothbrushing) in the elementary school.. Análisis y Modificación de Conducta 1988;14(41):383-99.
Ferrazzano 2008 {published data only}
  • Ferrazzano GF, Cantile T, Sangianantoni G, Ingenito A. Effectiveness of a motivation method on the oral hygiene of children. European Journal of Paediatric Dentistry 2008;9(4):183-7.
Fischman 1977 {published data only}
  • Fischman SL, English JA, Albino JE, Bissell GD, Greenberg JS, Juliano DB, et al. A comprehensive caries control program--design and evaluation of the clinical trial. Journal of Dental Research 1977;56(Spec Iss):C99-103.
Frencken 2001 {published data only}
  • Frencken JE, Borsum-Andersson K, Makoni F, Moyana F, Mwashaenyi S, Mulder J. Effectiveness of an oral health education programme in primary schools in Zimbabwe after 3.5 years. Community Dentistry and Oral Epidemiology 2001;29(4):253-9.
Graehn 1984 {published data only}
  • Graehn G, Toutenburg H. Health education program for pre-school children. 2. Effect on caries morbidity. Stomatologie der DDR 1984;34(5):293-7.
Graves 1975 {published data only}
  • Graves RC, McNeal DR, Haefner DP, Ware BG. A comparison of the effectiveness of the "Toothkeeper" and a traditional dental health education program. Journal of Public Health Dentistry 1975;35(2):85-90.
Grimoud 2005 {published data only}
Grocholewicz 1999 {published data only}
  • Grocholewicz K. The effect of selected prophylactic-educational programs on oral hygiene, periodontium and caries in school children during a 4-year observation. Annales Academiae Medicae Stetinensis 1999;45:265-83.
Harrison 2007 {published data only}
  • Harrison R, Benton T, Everson-Stewart S, Weinstein P. Effect of motivational interviewing on rates of early childhood caries: a randomized trial. Pediatric Dentistry 2007;29(1):16-22.
Hartono 2002 {published data only}
Hebbal 2011 {published data only}
  • Hebbal M,  Ankola AV, Vadavi D, Patel K. Evaluation of knowledge and plaque scores in school children before and after health education. Dental Research Journal 2011;8(4):189-96.
Hietasalo 2009 {published data only}
Hochstetter 2007 {published data only}
  • Hochstetter AS, Lombardo MJ, D'eramo L, Piovano S, Bordoni N. Effectiveness of a preventive educational programme on the oral health of preschool children. Promotion et Education 2007;14(3):155-8.
Holm 1990a {published data only}
Horowitz 1976 {published data only}
  • Horowitz AM, Suomi JD, Peterson JK, Voglesong RH, Mathews BL. Effects of supervised daily dental plaque removal by children: first-year results. Journal of Public Health Dentistry 1976;36(3):193-200.
Horowitz 1977 {published data only}
Huang 1996 {published data only}
  • Huang ST, Chen HS, Yu GW, Tsuang SY. The patterns of dental caries of preschool children in Kaohsiung City Taiwan. Kaohsiung Journal of Medical Sciences 1996;12(7):417-22.
Jackson 2005 {published data only}
  • Jackson RJ, Newman HN, Smart GJ, Stokes E, Hogan JI, Brown C, et al. The effects of a supervised toothbrushing programme on the caries increment of primary school children, initially aged 5-6 years. Caries Research 2005;39(2):108-15.
Julien 1994 {published data only}
  • Julien MG. The effect of behaviour modification techniques on oral hygiene and gingival health of 10-year-old Canadian children. International Journal of Paediatric Dentistry 1994;4(1):3-11.
Kakudate 2009 {published data only}
  • Kakudate N, Morita M, Sugai M, Kawanami M. Systematic cognitive behavioral approach for oral hygiene instruction: a short-term study. Patient Education and Counseling 2009;74(2):191-6.
Kerebel 1985a {published data only}
Klimek 1987 {published data only}
  • Klimek J, Prinz H, Hellwig E. Effect of a preventive program on plaque, gingivitis and caries in school children after 3 years. Deutsche Zahnarztliche Zeitschrift 1987;42(2):146-50.
Kramer 1990 {published data only}
  • Kramer N, Kunzelmann KH, Hickel R. Middle course between group and individual preventive programs. Deutsche Zahnarztliche Zeitschrift 1990;45(11):706-9.
Lena 2001 {published data only}
  • Lena PB, Looi LL, Normala MR, Vijayamanohar K. Effectiveness of supervised daily tooth-brushing amongst primary school children in Pahang. International Dental Journal 2001;51(5):374.
Martinez 2004 {published data only}
  • Martinez BM, Sanchez-Balmisa C, Parga MX. Behavioral intervention in dental health: A preliminary result of a school program. Análisis y Modificación de Conducta 2004;30(129):51-69.
Mazzocchi 1997 {published data only}
Milejczak 2011 {published data only}
  • Milejczak CB. The impact of school-based oral hygiene education on the oral-health-related quality of life. Dissertation Abstracts International: Section B: The Sciences and Engineering 2011;72(4-B):2061.
Moorhead 1991 {published data only}
  • Moorhead JE, Conti AJ, Marks RG, Cancro LP. The effect of supervised brushing on caries inhibition in school age children. The Journal of Clinical Dentistry 1991;2(4):97-102.
Morgan 1998a {published data only}
  • Morgan MV, Campain AC, Adams GG, Crowley SJ, Wright FA. The efficacy and effectiveness of a primary preventive dental programme in non-fluoridated areas of Victoria, Australia. Community Dental Health 1998;15(4):263-71.
Nyandindi 1996 {published data only}
  • Nyandindi U, Milén A, Palin-Palokas T, Robison V. Impact of oral health education on primary school children before and after teachers' training in Tanzania. Health Promotion International 1996;11(3):193-201.
Peng 2004 {published data only}
  • Peng B, Petersen PE, Bian Z, Tai B, Jiang H. Can school-based oral health education and a sugar-free chewing gum program improve oral health? Results from a two-year study in PR China. Acta Odontologica Scandinavica 2004;62(6):328-32.
Peterson 1979 {published data only}
Pine 2000 {published data only}
  • Pine CM, McGoldrick PM, Burnside G, Curnow MM, Chesters RK, Nicholson J, et al. An intervention programme to establish regular toothbrushing: understanding parents' beliefs and motivating children. International Dental Journal 2000;50(S6_Part1):312-23.
Pine 2007 {published data only}
Pujol 1996 {published data only}
  • Pujol MT, Betlla E, Coma C, Cena B, González M, Fernández MA. Evaluation of a 4-year dental hygiene preventive program of the Les Planes health district in Sant Joan Despi (Barcelona). Atención Primaria 1996;17(8):523-6.
Roberts-Thomson 2010 {published data only}
  • Roberts-Thomson KF, Slade GD, Bailie RS, Endean C, Simmons B, Leach AJ, et al. A comprehensive approach to health promotion for the reduction of dental caries in remote Indigenous Australian children: a clustered randomised controlled trial. International Dental Journal 2010;60(3 Suppl 2):245-9.
Rodrigues 2003 {published data only}
  • Rodrigues JA, dos Santos PA, Garcia PP, Corona SA, Loffredo LC. Evaluation of motivation methods used to obtain appropriate oral hygiene levels in schoolchildren. International Journal of Dental Hygiene 2003;1(4):227-32.
Rodrigues 2009 {published data only}
  • Rodrigues JA, dos Santos PA, Baseggio W, Corona SA, Palma-Dibb RG, Garcia PP. Oral hygiene indirect instruction and periodic reinforcements: effects on index plaque in schoolchildren. Journal of Clinical Pediatric Dentistry 2009;34(1):31-4.
Sagheri 2009 {published data only}
  • Sagheri D, Wassmer G, Hahn P, McLoughlin J. Dental caries experience of schoolchildren of two different oral health care delivery systems. International Dental Journal 2009;59(3):161-7.
Schinder 1992 {published data only}
  • Schinder EOM, Rosenberg M, Zangwill L. Educational approach to modifying dental habits in pre-school children [Ensayo educacional de modificación de los hábitos dentales en niños de edad preescolar]. Revista Asociación Odontológica Argentina 1992;80(4):225-30.
Schwarz 1998 {published data only}
Secades 1995 {published data only}
  • Secades Villa R, Fernandez Rodriguez C. Efficiency of corrective feedback and contingency management in establishing dental hygiene in children. Análisis y Modificación de Conducta 1995;21(77):397-417.
Segal 1967 {published data only}
  • Segal AH, Stiff RH, George WA, Picozzi A. Cariostatic effect of a stannous fluoride-containing dentifrice on children: two-year report of a supervised toothbrushing study. Journal of Oral Therapeutics and Pharmacology 1967;4(3):175-80.
Stadtler 1981 {published data only}
  • Stadtler P. Medical-educational effect of supervised oral hygiene exercises. Results after a year. Osterreichische Zeitschrift fur Stomatologie 1981;78(6):228-34.
Stadtler 1982 {published data only}
  • Stadtler P. Results of a 3-year clinical, experimental double-blind study with weekly supervised brushing with a sodium fluoride gel. Osterreichische Zeitschrift fur Stomatologie 1982;79(3):83-99.
Suomi 1980 {published data only}
Tagliaferro 2011 {published data only}
  • Tagliaferro EP, Pardi V, Ambrosano GM, Meneghim Mde C, da Silva SR, Pereira AC. Occlusal caries prevention in high and low risk schoolchildren. A clinical trial. American Journal of Dentistry 2011;24(2):109-14.
Tai 2009 {published data only}
Tapias 2001 {published data only}
  • Tapias MA, De Miguel G, Jimenez-Garcia R, Gonzalez A, Dominguez V. Incidence of caries in an infant population in Mostoles, Madrid. Evaluation of a preventive program after 7.5 years of follow-up. International Journal of Paediatric Dentistry 2001;11(6):440-6.
Toassi 2002 {published data only}
Tolvanen 2009 {published data only}
Tolvanen 2010a {published data only}
Vanobbergen 2004 {published data only}
van Palenstein 1997 {published data only}
  • van Palenstein Helderman WH, Munck L, Mushendwa S, van't Hof MA, Mrema FG. Effect evaluation of an oral health education programme in primary schools in Tanzania. Community Dentistry and Oral Epidemiology 1997;25(4):296-300.
Wierzbicka 2002 {published data only}
  • Wierzbicka M, Petersen PE, Szatko F, Dybizbanska E, Kalo I. Changing oral health status and oral health behaviour of schoolchildren in Poland. Community Dental Health 2002;19(4):243-50.
Yamaguchi 1997 {published data only}
  • Yamaguchi N, Saito T, Oho T, Sumi Y, Yamashita Y, Koga T. Influence of the discontinuation of a school-based, supervised fluoride mouthrinsing programme on the prevalence of dental caries. Community Dental Health 1997;14(4):258-61.

Additional references

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
Abraham 2008
Ajzen 1991
Amin 2009
Armfield 2009
Aunger 2007
Bandura 1986
  • Bandura, A. Social Foundations of Thought and Action: a Social Cognitive Theory. London: Prentice-Hall, 1986.
Bartholomew 2011
  • Bartholomew LK,  Parcel GS,  Kok G,  Gottlieb NH,  Fernandez ME . Planning Health Promotion Programs: An Intervention Mapping Approach. 3rd Edition. San Francisco: Jossey-Bass, 2011.
Blinkhorn 2001
Brukiene 2006
  • Brukiene V, Aleksejuniene J, Balciuniene I. Is dental treatment experience related to dental anxiety? A cross-sectional study in Lithuanian adolescents. Stomatologija 2006;8(4):108-15.
Casamassimo 2009
  • Casamassimo PS, Thikkurissy S, Edelstein BL, Maiorini E. Beyond the dmft: the human and economic cost of early childhood caries. Journal of the American Dental Association 2009;140(6):650-7.
CONSORT 2010
  • Schulz KF, Altman DG, Moher D, CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. PLoS Medicine 2010;7(3):e1000251.
Edelstein 2000
Edelstein 2006
  • Edelstein BL. The dental caries pandemic and disparities problem. BMC Oral Health 2006;6 Suppl 1:S2.
Eitner 2006
Exley 2009
Festinger 1954
  • Festinger L. A Theory of Social Comparison Processes. Indianapolis: Bobbs-Merrill, 1954.
Fishbein 1975
  • Fishbein M, Ajzen I. Belief, Attitude, Intention and Behavior: an Introduction to Theory and Research. London: Addison-Wesley, 1975.
Fisher 1994
  • Fisher J, Fisher W, Malloy T. Empirical tests of an information-motivation-behavioral skills model of AIDS-preventive behavior with gay men and heterosexual university students. Health Psychology 1994;13:238-50.
Freeman 2009
  • Freeman R,  Ismail A. Assessing patients' health behaviours. Essential steps for motivating patients to adopt and maintain behaviours conducive to oral health. Monographs in Oral Science 2009;21:113-27.
Gibson 2008
  • Gibson B. Cultural history of the mouth and teeth. Cultural Encyclopaedia of the Body. Westport: Greenwood Press, 2008.
Glasser 1985
  • Glasser W. Control Theory: A New Explanation of How We Control Our Lives. London: Harper and Row, 1985.
Goffman 1990
  • Goffman E. Stigma - Notes on the Management of Spoiled Identity. London: Penguin Books, 1990.
Graham 2005
Gussy 2006
Harris 2012
Higgins 2011
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
Hupcey 1998
Jackson 2011
  • Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children's schools attendance and performance. American Journal of Public Health 2011;101(10):1900-6.
Kay 1996
Kay 1998
  • Kay EJ, Locker D. A systematic review of the effectiveness of health promotion aimed at improving oral health. Community Dental Health 1998;15(3):132-44.
Kwan 2005
  • Kwan SY, Petersen PE, Pine C, Borutta A. Health-promoting schools: an opportunity for oral health promotion. Bulletin of the World Health Organization 2005;83(9):677-85.
Lazarus 1966
  • Lazarus R. Psychological Stress and the Coping Process. New York: McGraw-Hill, 1966.
Marlatt 1998
  • Marlatt G, George A, William H. Relapse prevention and the maintenance of optimal health. In: Shumaker SA, Schron EB, Ockene JK, McBee WL editor(s). The Handbook of Health Behavior Change. 2nd Edition. New York: Springer Publishing, 1998:33-58.
Martin 2010
  • Martin L, Haskard-Zolnierek K, Dimatteo M. Health Behaviour Change and Treatment Adherence: Evidence Based Guideline of Improving Health Care. New York: Oxford University Press, 2010.
Michie 2008
Michie 2012
  • Michie S, Johnston M. Theories and techniques of behaviour change: Developing a cumulative science of behaviour change. Health Psychology Review 2012;6(1):1-6.
MRC 2000
  • Medical Research Council. A Framework for the Development and Evaluation of RCTs for Complex Interventions to Improve Health. Medical Research Council. London, 2000.
MRC 2008
  • Medical Research Council. Developing and Evaluating Complex Interventions: New Guidance. Medical Research Council. London, 2008.
Mullen 2005
NICE 2007
  • National Institute for Health and Care Excellence (NICE). Behaviour Change at Population, Community and Individual Levels. Public Health Guidance 6 2007.
Nunn 2006
Oakley 2006
Petersen 2005
  • Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bulletin of the World Health Organization 2005;83(9):661-9.
Pine 2004a
  • Pine C, Adair PM, Nicoll AD, Burnside G, Petersen PE, Beighton D, et al. International comparisons of health inequalities in childhood dental caries. Community Dental Health 2004;21(1 Suppl):121-30.
Pine 2004b
  • Pine C, Adair PM, Petersen PE, Douglass C, Burnside G, Nicoll AD, et al. Developing explanatory models of health inequalities in childhood dental caries. Community Dental Health 2004;21(1 Suppl):86-95.
Pine 2006
  • Pine C, Harris RV, Burnside G, Merrett MC. An investigation of the relationship between untreated decayed teeth and dental sepsis in 5-year-old children. British Dental Journal 2006;200(1):45-7.
Ramos-Gomez 2002
  • Ramos-Gomez F, Jue B, Bonta CY. Implementing an infant oral care program. Journal of the California Dental Association 2002;30(10):752-61.
Reisine 2001
  • Reisine ST, Psoter W. Socioeconomic status and selected behavioral determinants as risk factors for dental caries. Journal of Dental Education 2001;65(10):1009-16.
Shaw 2009
Sheiham 2005
Sheiham 2006
Shiboski 2003
Skinner 1953
  • Skinner B. Science and Human Behaviour. Oxford, England: Macmillan, 1953.
Stillman-Lowe 2008
  • Stillman-Lowe C. Oral health education: What lessons have we learned?. Oral Health Report 2008;2:9-13.
Surgeon General 2000
  • U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research. Oral Health in America: a Report of the Surgeon General. Office of the Surgeon General 2000; Vol. NIH Publication Number 00-4713.
Waters 2011
Watson 2011
  • Watson PM,  Dugdill L,  Pickering K,  Bostock S,  Hargreaves J,  Staniford L,  et al. A whole family approach to childhood obesity management (GOALS): Relationship between adult and child BMI change. Annals of Human Biology 2011;38(4):445-52.
Watt 1999
Watt 2001
Watt 2007