Community-based oral health promotion interventions

The review found that adding family-based interventions to school-based interventions may reduce the onset of smoking by 4-25%.

Caries and periodontal disease are two of the commonest chronic non-communicable diseases globally. Oral Diseases remain a significant public health challenge in high income countries are a growing problem in low- and middle-income countries, they are also amongst the most costly health problems to treat. Consequently the prevention of oral disease and promotion of oral health by implementing effective public health measures is important.

The aim of this review was to evaluate and assess the effectiveness of oral health interventions targeting children in community settings.

Methods

Searches were conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINHAL, Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science (ISI), Database of Abstracts of Reviews of Effects (DARE), Social Science Citation Index (ISI), PsycINFO , ProQuest Dissertations & Theses, ScienceDirect, Conference Proceedings Citation Index – Science , Web of Science, Sociological Abstracts and SCOPUS databases from 1996. These searches were supplemented by searches in a number of relevent journals conference proceedings, newsletters, government reports, policy documents and dissertations sources.

Randomised or quasi-randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after studies (CBAs) and interrupted time series (ITSs) with a minimum of three points before and after the intervention for examination of intervention effects with no minimum duration of intervention or follow-up period were considered. The primary outcomes were measurements of caries or periodontal disease by an oral health clinician or trained examiners. Two reviewers independently screened studies, extracted data and assessed of risk of bias of included studies using Cochrane methodology. Mean differences with 95% confidence intervals were calculated for continuous data and where data permitted fixed-effect meta-analysis was used to summarise results.

Results

38 studies involving a total of 119,789 children were included.
1 national study contributed 99,071 children (80% of total)
A range of strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing) were delivery in a variety of settings.
Interventions were usually implemented for less than one year (n=26) and were classified as
Dietary interventions (n = 3),
Oral health education (OHE) alone (n = 17),
OHE combined with supervised toothbrushing with fluoridated toothpaste (n = 8)
OHE combined with other interventions (n = 10).
11 of the 38 studies were RCTs and overall the evidence was graded as moderate to very low quality.
Meta-analyses of some interventions were possible;

	Outcome	No of studies	Mean difference (95% confidence interval)	Quality of evidence
OHE alone	DMFT	2	-0.12 (0.11 to 0.36)	low
	dmft	3	-0.3 (-1.11 to 0.52)	low
	DMFS	1	-0.01 (-0.24 to 0.22)	very low
OHE + supervised toothbrushing with fluoridated toothpaste	dmfs	3	-1.59 (-2.67 to -0.52)	low
	dmft	2	-0.97 (-1.06 to -0.89)	low
	DMFS	2	-0.02 (-0.13 to 0.10)	low
	DMFT	3	-0.02 (-0.11 to 0.07)	moderate

Meta-analyses of 2 studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence).
Data were inadequate for meta-analyses on gingival health, although positive impact was reported.

Conclusions

The authors concluded: –

This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children’s diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Comments

This Cochrane review has taken as a start point for this review the 1998 review by Kay and Locker and has employed an extensive and wide ranging search strategy including a broad range of relevant study designs. As the authors note a majority of the interventions ( 26) were implemented for less than a year which may not be long enough to demonstrate an effect as typically cares reduction trials have a 2-year duration. However, a majority of studies using oral health promotion interventions that included supervised toothbrushing with fluoridated toothpaste were effective in reducing caries. IT was also noted that both the diversity of interventions and settings mean that it remains unclear which approach is best suited to promote oral health across a range of contexts. The need for researchers to apply scientific rigour and quality standards to the design, implementation, delivery and reporting of future intervention studies cannot be over emphasised in order to bring a stronger evidence-base to this area of activity.

Primary paper

de Silva AM, Hegde S, Akudo Nwagbara B, Calache H, Gussy MG, Nasser M, Morrice HR, Riggs E, Leong PM, Meyenn LK, Yousefi-Nooraie R. Community-based population-level interventions for promoting child oral health. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD009837. DOI: 10.1002/14651858.CD009837.pub2.