Preprint:

Please note that this article has not completed peer review.

Effects of Educational Interventions on Oral Hygiene:

A Systematic Review and Meta-Analysis
CURRENT STATUS: UNDER REVIEW

Sakineh Dadipoor
Hormozgan University of Medical Sciences

Mohtasham Ghaffari
Shaheed Beheshti University of Medical Sciences

Abbas Alipour
Mazandaran University of Medical Sciences

Ali Safari-Moradabadi
Shahid Beheshti University of Medical Sciences

[email protected] Author
ORCiD: https://orcid.org/0000-0002-8310-5160

DOI:
10.21203/rs.2.15898/v1
SUBJECT AREAS
Head & Neck Surgery
KEYWORDS
Oral Hygiene, Oral Health, Health Promotion, Intervention, Systematic Review, Meta-
Analysis

1
Abstract
Background: This study assesses the impact of school based educational interventions on oral

hygiene of students conducted worldwide. This is a systematic review and Meta-Analysis. Methods:

Our investigation was conducted in electronic databases including MEDLINE Ovid), Embase Ovid,

Scopus), Web of Science from 2000 to march 2018. The data were extracted based on a standard

data collection form specific to observational studies, and entered into RevMan2014. Twelve studies

of students in this review finally entered the study including five individual RCTs, four cluster-RCTs,

and three quasi-experimental studies. Results: Meta-analyses showed a significant difference in

knowledge (SMD 3.31, 95% CI 2.52 to 4.11; P < 0.001), attitude (SMD 1. 99, 95% CI 0. 43 to 3.54; P <

0.01), behavior (SMD 4.74, 95% CI 3.70 to 5.77; P < 0.001), plaque index (SMD -1. 01, 95% CI -1.50 to

-0. 51; P < 0. 001) and Gingival index (SMD 0.33, 95% CI -0. 36 to 1.02; P = 0.34) for students

receiving educational interventions compared to those receiving usual care . Discussion: The focus

of the present study is the efficacy of all oral health education and promotion interventions, especially

in terms of short-term outcomes. Since long-term and short-term results are of tremendous

importance for oral and dental education programs, it will be possible to make these interventions in

the future with several target groups, including families and teachers.

Introduction
Oral hygiene is a basic component of public health and well-being [1, 2]. “Oral health has
multifaceted nature that provides the ability of speaking, smiling, smelling, tasting, touching, chewing
and swallowing, which helps expressing emotions confidently and prevents the diseases without the
feeling of pain and discomfort” [3]. Poor oral health such as dental caries, periodontal disorders and
missing tooth are important public health issues around the world given the fact that poor
oral hygiene has wide-spreading impacts on overall health and quality of life. Some common
diseases are caused from the direct effect of untreated oral health problems [4]. There is a link
between poor oral health and social-behavioral and environmental factors possibly leading to poor
nutrition, absence from work and school, pain and suffering, and increased healthcare costs [5, 6] .
The statistics show a quarter of the world's population suffers from oral disorders [7, 8]. Tooth decay
is common in about 50 % of the world’s population [9]. The World Health Organization reported in
2015 that most of the adults and schoolchildren experience dental caries and 5%-15% of most
populations are affected by severe periodontitis [10]. Many school based oral health programs, mainly
educational interventions, have been conducted worldwide; however, their impact is not adequately
clear. Considering the cost of these interventions, it is crucial for public health managers, especially in
developing countries, to conduct evidence-based effective preventive measures against diseases
while promoting oral health [11-13]. This review aims to contribute to this aim. In this study, authors
have defined school based oral health-related educational interventions as educational programmers
utilizing different educational methods such as lectures, demonstrations and practical program

2
targeting students individually or in groups in schools. The aim of this study is to evaluate
the effects of school based oral health interventions programs on students’ oral hygiene, knowledge,
attitude, and practice.


Methods
Types of studies
Individually randomized controlled trials (RCTs) or cluster-RCTs including quasi- experimental studies

were used to enhance oral hygiene (dental plaque), associated awareness, and attitude, performance

of students using one or more school-based oral health education and/or oral health promotion

interventions programs (the case group in comparison with consistent oral hygiene education (the

control group).

Inclusion criteria were according to the PICOs criteria:

Population: Studies that have evaluated the primary, middle, and high schools in their communities
without paying attention to their oral health conditions;
Intervention: School based educational interventions to improve the level of oral hygiene in students;
Comparison: Studies, which compared the participants in terms of the absence and in the presence of
oral health-educating interventions;
Outcome: Studies that assess the results of oral health and oral health-related awareness, mindset
and behavior: Studies that covered any RCT or quasi-experimental were selected to undergo an oral
hygiene interventions programs;
Types of participants
Male and female students at primary and secondary schools were selected for this study. Most of
them were 6-18 years old.
Types of interventions
Any RCT or quasi-experimental were selected to undergo the oral health interventions
programs versus typical oral health care and education and also quasi-experimental studies as well as
interventions with no educational or oral hygiene promotion components as controls.

Types of outcome measures
Oral health-related awareness, mindset and behavior of students: determined by any tools applied in
the included studies (e.g. questionnaire or interview).
Gingival index measured by Gingival scores.
Dental plaque measured by plaque scores.
DMFT

Search methods to select the studies

This systematic review was based on the search strategy developed for MEDLINE Ovid and Embase
(Pico). The search strategy used a combination of controlled keywords and free-text terms.

Electronic searches

The following electronic databases were searched (2000 to march 2018) (Supplement 1):
MEDLINE Ovid (see Appendix 1).
Embase Ovid) (see Appendix 2).
Scopus (see Appendix 3).

3
Web of Science (see Appendix 4).

When searching the electronic databases, authors placed no restrictions on language of publication.
Data collection and analysis
The search strategy was conducted by two of the review authors (ASM, SD). The first phase was a
search in the titles and abstracts. The second phase was marked by a thorough checking through the
articles in full-text by both authors independently.
Data extraction and management
The data were extracted based on a data collection form specific to observational studies. The
collected data included author’s name, publication year, country, sample size, frequency for each
group, participants, age range, effects, delivery type, language, study design, details of the
intervention, outcome measures, and follow- up. The extracted data were entered in Excel software
2010 in accordance with the above-mentioned categories.
Data extraction was done independently by two review authors (AS, SD) by applying a standard
survey data collection, which was put into Review Manager 5 Software (RevMan 2014). The review
authors were not blinded to authors of included studies. If disagreement occurred, the two review
authors would try to solve it through discussion; otherwise, they would seek consultation with a third
review author and finally those articles that were mutually agreed-upon were selected for inclusion.
Data was extracted based on the fidelity of the intervention implementation. If, information on the
afore-mentioned issues was insufficient, authors gathered additional information through contacting
authors of the primary studies. The Cochrane Collaboration tool was applied to evaluate the risk of
bias.
Evaluation of heterogeneity
Heterogeneity was evaluated statistically by the authors; it was also quantified
among studies included in each analysis using the I² statistic. All studies were analyzed regarding the
interventions and outcomes.
Data synthesis
Studies were categorized based on the intervention programs. For each intervention type, meta-
analyses were performed to be reasonable clinically and methodologically homogeneous; random-
effects models used for all analyses.
Measures of treatment effect
To assess the change of variables, mean difference (MD) was applied and its matching 95%
confidence interval (CI) was used if the same tool was used. Moreover, if the used tools were not
similar, the standardized mean difference was used (SMD).
Results
Results of the search
Two review authors (ASM, SD) screened 309 abstracts for inclusion, and assessed 37 publications in
full text. Finally, 12 Studies had the eligibility criteria. Studies in English and Persian were included in
the study.
Excluded studies
We excluded 25 studies: fifteen had no educational component; six included students; and four
assessed no predefined outcomes (Supplement 2).
Duration of follow-up
Follow-up for two studies was one month [14, 15], and for six studies ranged from one month to three
months [16-21]; for two studies was from three months to six months [22, 23], and a study was
followed up after nine months [24]. In one study, follow-up time was not reported. Authors
categorized studies covering less than three months as short term and more than three months as
long term (Supplement 3).

Some interventions were complex interventions, which involved more than one active component. All
educational interventions covered theoretical or practical education sessions, or both, on oral health
for students as one of the key intervention components, while the number of intervention components
was different significantly among studies.

4

Authors categorized the interventions into two groups: educational intervention based on the
theoretical and usual (Table 1).

Table-1: Characteristics of studies Based on the to the variables studied

Author Year country Participant Sample Sample size in each gro

size Ig1 Ig2 Ig3

Andarkhora et al. 2018 Iran Primary school 90 45 - -

Chandrashekar et al. 2014 India Middle school 141 36 35 36

Ganapathi et al 2015 India Middle school 200 40 40 40

Haleem et al. 2012 Pakistan Primary school 200 40 40 40

D'Cruz and Aradhya 2013 Indian Middle school 568 141 143 -

Hassani et al. 2016 Iran Middle school 80 40 - -

Khudanov et al. 2018 Uzbekista High School 86 42 - -

n

Sadana et al. 2017 Indian Middle school 200 50 50 50

Mohamadkhah et al. 2013 Iran Middle school 300 100 100 -

Vangipuram et al. 2016 India Middle school 450 150 150 -

Yazdani et al. 2009 Iran High School 388 135 130 -

Yang et al. 2009 Taiwanes High School 135 67 - -

e

Author effects Ti Oral health-related Outcome

me
poi Gingival index knowledge attitude behavior
nt

Andarkhora et al. Short-term 4w - ü ü ü

Chandrashekar et al. Short-term 3m ü - - -

Ganapathi et al Short-term 8w - ü - -

Haleem et al. Long-term 6m - ü - ü

D'Cruz and Aradhya Long-term 9m ü ü - ü

5
 Hassani et al. Short-term 1m - ü ü ü

Khudanov et al. Short-term 2m - ü ü ü

Sadana et al. Short-term 1.5 - ü - -

m

Mohamadkhah et al. Short-term 3m - ü ü ü

Vangipuram et al. Long-term 6m ü ü - ü

Yazdani et al. Short-term 3m ü - - -

Yang et al. - N - ü ü ü
/R

Included studies
We included five individual RCTs [17-19, 23, 24], four cluster-RCTs [16, 21, 22, 25], and three Quasi-
experimental [14, 15, 20] with 2838 students as participants(Table 2).
Table 2: The main findings of studies reviewed

Author Study Design Model of delivery group

Andarkhora et al. Quasi- Film, lecture Ig1: lecture

experimental

Ig2: Multi Media

Control group
Chandrashekar et al. Cluster- RCTS Brochure, demonstration Ig1: DHE by a qualified Dentist + using
the model the
audio-visual aids

Ig2: DHE by the
trained school teachers

Ig3: DHE by the trained school teachers
+ oral hygiene aids (tooth brush and
tooth
paste)

Control group

Ganapathi et al RCTS Audio record, pamphlets Ig1: Audio record

Ig2: Pamphlets

6
 Ig3: Tooth models

Ig4: Multisensory

Control group

Haleem et al. Booklet supplemented, Ig1: Dentist-led

Cluster- RCTS session
Ig2: Teacher-led

Ig3: Peer-led

Ig4: Self-learning

Control group

D'Cruz and Aradhya RCTS Pamphlets, demonstration Ig1: A lecture using a PowerPoint
the model presentation

Ig2: lecture, a demonstration of the tooth

brushing method

Control group

Hassani et al. Quasi- Booklet, CD, session I g

experimental

Control group

Khudanov et al. RCTS Lesson, lecture, messages, I g

demonstrational models

Control group

Sadana et al. RCTS Audio record, pamphlets Ig1: verbal communication

Ig2: verbal communication and self-

educational pamphlets

Ig3: audiovisual aids and verbal

communication

Control group

Mohamadkhah et al. Quasi- Film, lecture Ig1: film Group

experimental

Ig2: lecture Group

7
 Control group

Vangipuram et al. RCTS Power point presentation, Ig1: peer Group

chalk and talk presentation,
using charts, posters, Ig2: dentist Group
booklets and tooth
brushing demonstration Control group
models
Yazdani et al. Cluster- RCTS Leaflet, Videotape Ig1: Leaflet Group

Ig2: Videotape Group

Control group

Yang et al. Cluster- RCTS lectures, role-playing, small Intervention group

group discussion and group
contests Control group

Outcomes assessed1: K (knowledge), A (Attitude), B (behavior), PI (Plaque index), GI (Gingival Index),

DMFT (decayed, missed, filled permanent tooth).





Measured outcomes
Oral health-related knowledge
Based on the results, ten studies reported oral health-related knowledge of students [14, 15, 17-20,
22, 24, 25]; all studies Oral health-related knowledge assessed by self-administered questionnaires.
Data of twelve studies on students’ awareness were combined in the current study. Moreover,
ten studies at high and unclear risk of bias including 2309 members of students were combined in a
meta-analysis. Compared to students with no education, students receiving educational interventions
were significantly different in terms of knowledge (SMD 3.31, 95% CI 2.52 to 4.11; P < 0.001)
(Figure 1).
Oral health-related attitude
Oral health-related attitude of students was evaluated by six studies [14, 15, 18, 20]. Self-
administered questionnaires were applied with Likert scale. Self-administered questionnaires were
applied with Likert scale. Six studies including 1141 members of students were combined in a meta-
analysis by the authors. In contrast to students with no education, students receiving educational
interventions differed significantly in terms of the attitude (SMD 1.99, 95% CI 0. 43 to 3.54; P <
0.001) (Figure 2).
Oral health-related behavior
Oral health-related behavior of students was evaluated by eight studies [14, 15, 18, 20, 22, 24]. Eight
studies including1909 members of students were combined in a meta-analysis by the authors.
Contrary to students with no education, students receiving educational interventions were different
significantly in terms of the attitude (SMD 4.74, 95% CI 3.70 to 5.77; P < 0.001) (Figure 3).
Dental plaque index
We meta-analyzed six studies [16-19, 21-24] and involving 1947 students. In comparison with
students with no education, students receiving educational interventions were significantly different
in terms of the dental plaque scores (SMD -1.01, 95% CI -1.50 to -0. 51; P < 0.001) (Figure 4).
Gingival index
Authors meta-analyzed four studies [16, 21, 23, 24] and involving 1541 students. Contrary to
students with no education, students receiving educational interventions were considerably different
in terms of gingival scores (SMD 0. 33, 95% CI -0. 36 to 1. 02; P = 0.34) (Supplement 4).

8


Overall risk of bias
None of the studies reported low risk of bias. A high risk of bias in assessment of risk of bias was
observed in eight studies [14, 15, 17, 20-24]. The other four studies were at unclear risk of bias [16,
18, 19, 24, 25] (Supplement 5).
Discussion
The studies suggested positive effects of OHE on oral health-related knowledge in short term.
Compared to those without education, students receiving educational interventions were significantly
different in knowledge. Therefore the effectiveness of oral health education- related program could
lead to increase of knowledge, attitude and behavior. According to the results by Kay and Locker, it
was possible to enhance knowledge by dental health education [26]. Nevertheless, Pieper et al.
argued that tooth decay could be decreased by preventive services even with no change in
knowledge and health behavior [27]. On the other hand, one of the ways to increase knowledge and
attitudes can be engaging other groups in educational interventions. Naker reported that the
education when more effective on the students that involvement of other groups, such as parents, as
teachers [28].
Systematic review shows that OHE in a range of sample sizes efficiently enhanced oral health-related

behavior. Studies were more effective when OHE aimed school student and when important others

were included. A significant progression in oral health-related behavior was observed by Alsada et al.,

Kowash et al.,Vachirarojpisan et al. and Rong et al. Besides, all the above-mentioned studies covered

important others like care givers and mothers of children in the intervention of the target groups that

affected the practice of the target group efficiently [29-32].

Since the students spend most of their time at school, schools can provide an important
and effective context for improving oral and dental health. Aljanakh et al. reported the role of
the school in promoting the oral health behavior of students [33].
It seems that teachers can succeed in upgrading their students’ knowledge, which can be attributed
to students' trust in the material transferred by teachers. Sukhabogi et al. reported that a teacher
with an adequate knowledge of oral hygiene could play an important role in oral health
education of students [34].
The results of meta-analysis show that in contrast to students with no education, students receiving
educational interventions were significantly different. The results of the meta-analysis indicated that
the educational program in the intervention group were able to improve the students' positive
attitude towards health behaviors. Effective education and raising awareness can be one of the
reasons for positive attitudes among students. On the other hand, improving attitude can lead to
health behavior. Studies have shown that there is a positive relationship between positive
attitude and frequent tooth brushing of students [35-37]. Moreover, the positive
attitude of educational staff can lead to a positive attitude in students. A study showed that teachers
who have a positive attitude towards oral hygiene of students can be a positive role model, and vice
versa, teachers with a negative attitude would have an unfavorable effect on students' health
behaviors [34]. The role of health education and promoting health in promoting oral hygiene is
crucial. Educational interventions will be more effective when they are based on theories. According
to the studies recommendations, the oral health knowledge, attitude, and behavior were improved by
oral health education based on theories and it is possible to use them to develop theoretical structure
of the interventions [38-41].
The results of gingivitis outcome in meta-analysis showed that there was difference between
the experimental and control groups indicating that oral health intervention had effect on gingivitis
reduction. The results showed that majority of the studies had a short-term follow-up period.

9
Therefore, there is a need to assess long-term studies, which can evaluate the effects of the
education practices on those outcomes, especially because the goal of the education actions in
the settings such as school is to prevent oral disorder and expand healthy behaviors and practices.
Compared to students with no education, students receiving educational interventions were
significantly different in terms of dental plaque scores. These review showed the impact of OHE on
plaque levels on short term. The systematic review of Prabhu and John showed that oral health
educational interventions and consequently improvements in individuals’ knowledge, attitude, and
oral health-related practice were effective in improving oral health indexes status such
as reduction in dental plaque, gingival bleeding, and significant decline in dental caries [42]. Teachers
are also trained in many countries and are used as a powerful tool for reducing dental plaque and
improving oral hygiene among students (Petersen & Kwan, 2004). Therefore, health education and
health promotion should be an essential element in educating teachers and other educational staff.
Because the role of teachers in this field is very significant and valuable, they can affect thousands of
students and families [33].
Most of the studies reported data on short-term effects (three or six months). Seemingly, follow-up
period was sensible for outcome like plaque and gingivitis. Nonetheless, it should be emphasized that
it was no adequate for other outcomes like knowledge and attitude. It is possible that constant
impressions on knowledge and attitudes for school are required to pave the way for behavioral
changes in oral health care. Thus, outcomes should be measured in future studies in the longer term.
Our comprehensive search strategy confirmed that publication bias is not seemly. Studies selection
and data extraction, and analyses were done independently by two review authors. In
addition, disagreements, if necessary, were resolved through consensus or consultation with a third
review author.
Conclusions
Results of the present study shows that majority of included education programs included singular or
short- term program interventions, and the evaluation of the outcomes were done in the short term.
Two classes of interventions (education of oral health promoting behavior and prevention services)
have positive effects on oral and dental health. Meanwhile, the strategies of teaching students and
involving parents and school staff in training have a greater impact on improving oral health and
increasing knowledge, improving the attitude and behavior of students, and continuing community-
based education, using programs Modular training and combination techniques, the use of behavior
change models and theories, follow up and provision of preventive services can be the best way of
designing and planning interventions to improve oral health in students. In addition, majority of the
studies investigated short-term impacts: thus, further intervention studies are required
to differentiate the efficacy of the oral health-related educational intervention programs for students,
especially in terms of students’ oral health-related quality of life and oral hygiene.
Declarations
Ethics approval and consent to participate
The study has been approved by the Ethics Committee of the School of Public Health & Neuroscience
Research Centre in Shahid Beheshti University of Medical Sciences; Approval ID:
IR.SBMU.PHNS.REC.1397.051 : Approval Date:2019-01-15).

Availability of data and materials
The datasets used and analyzed during the current study are available from the corresponding author
on reasonable request.

Consent for publication
Not applicable.
Competing interests
The authors have no conflicts of interest.

Funding
This study is sponsored by Shahid Beheshti University of Medical Sciences in Tehran. The funding

10
agencies had no role in the design of study, data collection and analysis, or presentation of the
results.

Authors’ contributions
MGH, SD, and ASM designed the study. ASM, AA and SD wrote the first draft. All authors contributed
to writing, revising, and approved the final manuscript.
Acknowledgments
The authors would like to thank the research deputy of Shahid Beheshti University of Medical Sciences
for their financial support.
References
1. Haque SE, Rahman M, Itsuko K, Mutahara M, Kayako S, Tsutsumi A, Islam MJ, Mostofa

MG: Effect of a school-based oral health education in preventing untreated

dental caries and increasing knowledge, attitude, and practices among

adolescents in Bangladesh. BMC Oral Health 2016, 16(1).

2. Ghaffari M, Rakhshanderou S, Safari‐Moradabadi A, Torabi S: Oral and dental

health care during pregnancy: Evaluating a theory‐driven intervention. Oral

Dis 2018, 24(8):1606-1614.

3. Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ: A new definition

for oral health developed by the FDI World Dental Federation opens the door

to a universal definition of oral health. J Public Health Dent 2017, 77(1):3-5.

4. Falahi A: Determinants of dental health behaviors among Iranian students. Int

J Health Promot Educ 2015, 3(1):15-24.

5. Murphey C: Oral health experiences of pregnant and parenting adolescent

women: a qualitative descriptive study. Int J Nurs Stud 2013, 50(6):768-775.

6. Wang T-F, Huang C-M, Chou C, Yu S: Effect of oral health education programs for

caregivers on oral hygiene of the elderly: A systemic review and meta-

analysis. Int J Nurs Stud 2015, 52(6):1090-1096.

7. Beaglehole R: The oral health atlas: mapping a neglected global health issue:

FDI World Dental Federation; 2009.

8. Ghaffari M, Rakhshanderou S, Ramezankhani A, Buunk‐Werkhoven Y, Noroozi M,

11
 Armoon B: Are educating and promoting interventions effective in oral

health?: A systematic review. Int J Dent Hyg 2018, 16(1):48-58.

9. Balasubramanian M, Brennan D, Fox C, Hewett S: Oral health challenges. In., edn.:

FDI World Dental Federation; 2015.

10. Bracksley-O’Grady SA, Dickson-Swift VA, Anderson KS, Gussy MG: Health promotion

training in dental and oral health degrees: a scoping review. J Dent Educ 2015,

79(5):584-591.

11. Marcenes W, Kassebaum NJ, Bernabé E, Flaxman A, Naghavi M, Lopez A, Murray CJ:

Global burden of oral conditions in 1990-2010: a systematic analysis. J Dent

Res 2013, 92(7):592-597.

12. Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C: The global burden

of oral diseases and risks to oral health. Bull World Health Organ 2005, 83:661-

669.

13. Stein C, Santos NML, Hilgert JB, Hugo FN: Effectiveness of oral health education

on oral hygiene and dental caries in schoolchildren: Systematic review and

meta‐analysis. Community Dent Oral Epidemiol 2018, 46(1):30-37.

14. Andarkhora F, Bohrani M, Goodarzi A: Comparison of the Effect of Lecture and

Multimedia Screening on Oral Health Behavior of Students in Tehran. MCS

2018, 4(3):213-220.

15. Hassani L, Aghamolaei T, Ghanbarnejad A, Madani A, Alizadeh A, Safari Moradabadi

A: The effect of educational intervention based on BASNEF model on the

students' oral health. J Res Health 2016.

16. Chandrashekar BR, Suma S, Sukhabogi JR, Manjunath BC, Kallury A: Oral health

promotion among rural school children through teachers: an interventional

study. Indian J Public Health 2014, 58(4):235-240.

12
17. Ganapathi AK, Namineni S, Vaakavaaka PH, Vavamsilatha K, Das R, Devi M, Akkaloori

A, Kumbakonam A: Effectiveness of various sensory input methods in dental

health education among blind children- a comparative study. J Clin Diagn Res

2015, 9(10):ZC75-ZC78.

18. Khudanov B, Jung HI, Kahharova D, Lee JW, Hamidov I, Lee ES, Kim BI: Effect of an

oral health education program based on the use of quantitative light-

induced fluorescence technology in Uzbekistan adolescents. Photodiagnosis

Photodyn Ther 2018, 21:379-384.

19. Sadana G, Gupta T, Aggarwal N, Rai HK, Bhargava A, Walia S: Evaluation of the

Impact of Oral Health Education on Oral Hygiene Knowledge and Plaque

Control of School-going Children in the City of Amritsar. Journal of

International Society of Preventive & Community Dentistry 2017, 7(5):259-263.

20. Mohamadkhah F, Shokravi FA, Faghihzadeh S, Ghaffarifar S: The effect of digital

media programs on the oral health promotion in the health office: A quasi-

experimental study. Shiraz E Med J 2013, 14(1).

21. Yazdani R, Vehkalahti MM, Nouri M, Murtomaa H: School-based education to

improve oral cleanliness and gingival health in adolescents in Tehran, Iran.

Int J Paediatr Dent 2009, 19(4):274-281.

22. Haleem A, Siddiqui MI, Khan AA: School-based strategies for oral health

education of adolescents--a cluster randomized controlled trial. BMC Oral

Health 2012, 12:54.

23. Vangipuram S, Jha A, Raju R, Bashyam M: Effectiveness of peer group and

conventional method (Dentist) of oral health education programme among

12-15 year old school children - A randomized controlled trial. J Clin Diagn Res

2016, 10(5):ZC125-ZC129.

13
24. D'Cruz AM, Aradhya S: Impact of oral health education on oral hygiene

knowledge, practices, plaque control and gingival health of 13- to 15-year-

old school children in Bangalore city. Int J Dent Hyg 2013, 11(2):126-133.

25. Yang YH, Sue RL, Warnakulasuriya S, Dasanayake AP: Promoting better oral

health practices among aboriginal Taiwanese adolescents: A school based

oral health education intervention program. J Health Care Poor Underserved

2009, 20(4 SUPPL.):41-50.

26. Kay E, Locker D: Is dental health education effective? A systematic review of

current evidence. Community Dent Oral Epidemiol 1996, 24(4):231-235.

27. Pieper K, Weber K, Margraf-Stiksrud J, Stein S, Heinzel-Gutenbrunner M, Jablonski-

Momeni A: Evaluation of an intensified preventive programme aimed at 12-

year-olds with increased caries risk. J Public Health 2012, 20(2):151-157.

28. Nakre PD, Harikiran A: Effectiveness of oral health education programs: A

systematic review. Journal of International Society of Preventive & Community

Dentistry 2013, 3(2):103.

29. Rong WS, Bian JY, Wang WJ, De Wang J: Effectiveness of an oral health education

and caries prevention program in kindergartens in China. Community Dent Oral

Epidemiol 2003, 31(6):412-416.

30. Vachirarojpisan T, Shinada K, Kawaguchi Y: The process and outcome of a

programme for preventing early childhood caries in Thailand. Community Dent

Health 2005, 22(4):253-259.

31. Alsada LH, Sigal MJ, Limeback H, Fiege J, Kulkarni GV: Development and testing of

an audio-visual aid for improving infant oral health through primary

caregiver education. J Can Dent Assoc 2005, 71(4):241.

32. Kowash M, Pinfield A, Smith J, Curzon M: Dental health education: effectiveness

14
 on oral health of a long-term health education programme for mothers with

young children. Br Dent J 2000, 188(4):201.

33. Aljanakh M, Siddiqui AA, Mirza AJ: Teachers’ knowledge about oral health and

their interest in oral health education in Hail, Saudi Arabia. Int J Health Sci

2016, 10(1):87.

34. Sukhabogi JR, Shekar BC, Hameed IA: Knowledge, attitude and practices related

to oral health among English and Telugu medium school teachers in two

districts of Andhra Pradesh, India: a comparative study. J Indian Assoc Public

Health Dent 2014, 12(4):306.

35. Asgari I, Tabatabaei Fakhar M: Attitude toward Tooth Brushing and the Validity

of the Questionnaire Based on Self-efficacy in Brushing in the 13-15 Years

Adolescents in Isfahan, Iran. J Mas Den Sch 2018, 42(4):329-339.

36. Åstrøm AN: Changes in oral health related knowledge, attitudes and

behaviours following school based oral health education and atraumatic

restorative treatment in rural Tanzania. Nor Epidemiol 2012, 22(1).

37. Al Subait AA, Alousaimi M, Geeverghese A, Ali A, El Metwally A: Oral health

knowledge, attitude and behavior among students of age 10–18 years old

attending Jenadriyah festival Riyadh; a cross-sectional study. Saudi J Dent Res

2016, 7(1):45-50.

38. Solhi M, Zadeh DS, Seraj B, Zadeh SF: The application of the health belief model

in oral health education. Iran J Public Health 2010, 39(4):114.

39. Yekaninejad MS, Eshraghian MR, Nourijelyani K, Mohammad K, Foroushani AR, Zayeri

F, Pakpour AH, Moscowchi A, Tarashi M: Effect of a school‐based oral health‐

education program on I ranian children: results from a group randomized

trial. Eur J Oral Sci 2012, 120(5):429-437.

15
40. Pakpour AH, Yekaninejad MS, Sniehotta FF, Updegraff JA, Dombrowski SU: The

effectiveness of gain-versus loss-framed health messages in improving oral

health in Iranian secondary schools: a cluster-randomized controlled trial.

Ann Behav Med 2013, 47(3):376-387.

41. Blake H, Dawett B, Leighton P, Rose-Brady L, Deery C: school-based educational

intervention to improve children’s oral health–related knowledge. Health

Promot Pract 2015, 16(4):571-582.

42. Prabhu S, John J: Oral health education for improving oral health status of

school children—a systematic review. IOSR J Dent Med Sci 2015, 14(2):101-106.

Figures

Figure 1

Comparison Educational intervention versus usual care, Outcome Oral health-related

knowledge.

16
 Figure 2

Comparison Educational intervention versus usual care, Outcome Oral health-related

attitude.

Figure 3

Comparison Educational intervention versus usual care, Outcome Oral health-related

behavior.

17
 Figure 4

Comparison Educational intervention versus usual care, Outcome plaque index.

Supplementary Files
This is a list of supplementary files associated with this preprint. Click to download.

Supplementary 1.docx
Supplementary 5.docx
Supplementary 4.docx
Supplementary 2.docx
Supplementary 3.docx

18