https://orcid.org/0000-0003-2079-7929
Figures
Abstract
Objective
To explore the interventions for change in oral health behaviour that are effective in improving oral health behaviours in 8 to 18-year-old children during oral health promotion.
Methods
The Joanna Briggs Institute framework of evidence synthesis for conducting a scoping review was implemented for the methodology. Included studies related to the objective, measured clinical or non-clinical outcomes, were in English, 2011–2023, and were experimental, observational or reviews. PUBMED, Science-Direct, Scopus and Sabinet were systematically searched with predetermined search strings. Studies were selected by appraisal of the title, abstract and full text. Data were extracted using a standardised template and the key questions were addressed via a qualitative analysis.
Results
Searches yielded 407 articles from electronic databases. Of these, 290 articles were excluded, and 47 full-text studies were assessed for eligibility, with 23 studies and two systematic reviews finalised for inclusion. In addition, a PEARL search was conducted from the reference lists of other studies. Most studies (91.3%) focused on educating children directly; 8.7% indirectly influenced parents, guardians, and teachers. Interventions focused largely on traditional oral health education presented in diverse forms and via different platforms. Studies differentiated clinical outcomes (indices) from non-clinical outcomes (knowledge, behaviour). All included RCTs were of different quality regarding selection, performance and detection bias. But all studies indicated a low risk of bias in attrition and Reporting bias. Seventeen of the 25 studies (68%) were not based on any behaviour change theory.
Conclusions
Oral health interventions based on motivational interviewing and the social cognitive theory have been shown to be to be effective. Interventions could also include practical tooth brushing activities, gamification, audio-visual components, as well as reinforcement and repetition in the longer term. Future oral health promotion in children should be designed to include these elements. There is a need for higher quality studies in this field, with future research being urged to provide detailed intervention descriptions and incorporate longer follow-up periods.
Citation: Peerbhay F, Mash R, Khan S (2025) Effectiveness of oral health promotion in children and adolescents through behaviour change interventions: A scoping review. PLoS ONE 20(1): e0316702. https://doi.org/10.1371/journal.pone.0316702
Editor: César Félix Cayo-Rojas, Universidad Privada San Juan Bautista, PERU
Received: April 5, 2024; Accepted: December 16, 2024; Published: January 10, 2025
Copyright: © 2025 Peerbhay et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the article and its Supporting Information files.
Funding: FP received funding from the University of the Western Cape through the University Capacity Development Grant (UCDG), specifically under the Developing the Research Scholar Programme (Grant No. UCDG/2021-2023). The programme's page can be accessed at https://www.uwc.ac.za/news-and-announcements/news/university-capacity-development-grant-ucdg-developing-the-research-scholar-programme. The funders had no role in the study's design, data collection and analysis, decision to publish, or the preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Globally, oral diseases continue to present a public health challenge, with the greatest burden of disease in lower socio-economic communities [1, 2]. Oral diseases are one of the most prevalent conditions in low- and middle-income countries [1, 3, 4], with untreated dental caries of deciduous teeth affecting approximately 514 million children [1]. The global prevalence of untreated dental caries in permanent teeth is 29%, affecting more than 2 billion individuals [1].
The risk factors that contribute to dental caries include poor oral hygiene practices, cariogenic diets, limited exposure to fluoride, lack of access to oral healthcare and oral health promotion (OHP), and patients’ low socio-economic status [4, 5]. Oral health promotion interventions that address these risk factors assist in improving oral health and consequently reduce the levels of oral disease [5, 6]. Oral health promotion is a structured effort to achieve oral health goals by creating supportive policies, environments, and community engagement while also enhancing personal skills and adapting health service [6].
Oral health interventions (OHIs) are classified into three types, and they can assist individuals achieve good oral health [4]:
- a) Individual OHIs refer to oral hygiene practices such as tooth brushing with a fluoride toothpaste and dietary changes [4].
- b) Community oral health education (OHE) and water fluoridation fall into the category of community OHIs.
- c) Professional OHIs refer to early identification and appropriate management of oral disease, dietary counselling, and professional fluoride application [4, 5, 7].
Oral health interventions whether on an individual, community or professional level, are essentially all directed towards prompting a change in oral health behaviour to improve the patients’ oral health [8]. The primary behaviours that contribute to improving oral health include tooth brushing with a fluoridated toothpaste and reducing the consumption of sugary foods and drinks [4, 7]. Since dental health behaviour becomes established around the age of 15 years, it is prudent that OHP be instituted in early school grades among children and adolescents [9].
Oral health promotion to prevent dental caries in school-aged children should include the following (A-grade evidence) recommendations [10]. Children should brush their teeth twice a day with a fluoridated toothpaste, have fluoride varnish applied professionally at intervals of three to six months if at high risk, have resin-based fissure sealants placed on permanent teeth, and limit their daily consumption of sugar-containing foods and drinks [4, 10, 11].
Creating behaviour change interventions is more effective when based on a theoretical foundation [12]. This approach targets the root causes of behaviour and helps advance theoretical frameworks in various contexts, demographics, and behaviours [12]. In order for behaviour change interventions to be effective, they need to “target a determinant that predicts behaviour; be able to change that determinant; be translated into a practical application in a way that preserves the parameters for effectiveness and fits with the target population, culture, and context” [[13] p.303].
One type of health behaviour intervention is health education [14]. Health education can be defined as “the communication of information concerning the underlying social, economic and environmental conditions impacting on health, as well as individual risk factors and risk behaviours, and use of the health care system” [[14] p.12]. An OHI that is provided in an educational context and that combines OHE and preventative oral care can reduce caries in children’s permanent teeth [14, 15]. Traditional OHE that focuses on the provision of information in schools, including primary schools, remains the primary focus of OHP programmes, even though it yields a relatively low level of effectiveness in the long term [12, 16, 17]. Traditional OHE does in fact improve oral health literacy, yet it is not an effective approach when used in isolation [18]. Although traditional OHE improves oral health knowledge (OHK) in the short term, it unfortunately only contributes to a transient improvement in oral health behaviour [19]. The effect that traditional OHE has on clinical outcomes such as plaque levels appears to be conflicting [16, 17]. Several studies, however, confirm that OHE does not produce any long-term sustained effects on oral health [12, 16, 17]. Hence, there is a need to consider alternative approaches [17].
In addition, the design of OHIs for school-aged children has lagged far behind behavioural science theory [20]. The OHP approaches that were found to be effective in both adults and adolescents were based on psychological behaviour change models [21, 22]. Therefore, there is a need to explore alternative approaches to modifying oral health behaviour in children in order to address their current high prevalence of dental caries [20].
Few systematic reviews have been published on OHIs [23–25]. The findings of these systematic reviews are conflicting [23–25]. Two of the systematic reviews reported that there is moderate evidence that behavioural interventions are effective in promoting oral health in the short term, but the studies were of poor quality with a high heterogeneity [23, 24]. The systematic review conducted in primary schools reported that there was limited evidence on the effectiveness of OHIs [25]. There is a need for more high-quality studies to be conducted using theory when developing interventions aimed at altering oral-health-related behaviours in children and their parents [25]. Most of the studies in the systematic reviews were focused on OHIs in adolescents but there is a scarcity of information on the evidence of OHIs in pre-adolescents [25].
The aim of this scoping review (ScR) was to explore the types of interventions that are effective in improving oral health behaviours in 8- to 18-year-old children.
Methods
Study design
This ScR was based on the steps described in the Joanna Briggs Institute (JBI) framework of evidence synthesis [26] and the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) [27–29].
Review questions
The main research question was as follows:
Which interventions for changing oral health behaviour are effective in improving the oral health behaviours in 8- to 18-year-old children during oral health promotion.
The review also addressed the following sub-questions:
- What types of interventions for changing oral health behaviour are used during oral health promotion?
- Which of these interventions are effective in changing oral health behaviour or the outcomes?
- Which behaviour change or psychological theories underlie effective interventions for modifying oral health behaviour in children (8–18 years)?
Identification of relevant studies
Eligibility criteria.
The inclusion and exclusion criteria were as follows:
- Study population: Children aged 8–18 years. Independent tooth brushing is recommended in children from 8-years-old onwards as this is when hand-eye coordination becomes more established [30]. Studies of children with special needs were excluded.
- Nature of the intervention: Changing oral health behaviour.
- Outcome variables: Oral health outcomes such as dental caries, plaque, gingivitis, and periodontitis. Secondary oral health outcomes were oral-health-related behaviour, oral-health-related quality of life, health beliefs and attitudes, and self-perceived oral health.
- Time period: 2011–2023.
- Cultural and linguistic range: English.
- Types of study design: These included randomised controlled trials and other experimental studies, observational studies, qualitative studies, and systematic and ScRs.
Information sources.
Relevant published studies were identified using a carefully structured search strategy in the following electronic databases: PUBMED, Science-Direct, Scopus, and Sabinet. These databases are some of the most commonly used in Dentistry, and Sabinet was added to include publications in South Africa and Africa. Only articles published during the time period 2011–2023 were included in the study. In addition, a PEARL search was also performed by examining the reference lists of other studies.
Search terms.
The search string was created using keywords and Medical Subject Headings (MeSH), and terms were combined using Boolean operators as shown below. This search string was then used to search within the specific databases.
- [[“Dental Care for Children” [Mesh] OR (Oral AND Health AND children)] AND [(“Health Promotion” [Mesh] OR “Risk Reduction Behaviour” [Mesh]) OR Health behaviour].
The search string was modified slightly for the search engine requirements of each database, and the number of articles that was retrieved was recorded.
Selection of studies.
The researchers (FP and SK) used a three-step screening approach. Initially, the titles were screened, then abstracts were evaluated, and thereafter, full-text articles were assessed independently for inclusion, guided by a study eligibility form created for this purpose. Any disagreements were resolved by discussion between the two reviewers. If agreement was still not reached, a third reviewer (RM) adjudicated the discussion. The reviewers recorded the number of included and excluded articles and the reasons for exclusion.
Extraction of data.
Data was extracted independently by each reviewer (FP and SK) and collated in tabular form using Excel spreadsheets. Data extraction was completed using a form developed by the reviewers, and the data from each full-text article was extracted in a standardised manner and summarised in a template. The fields of extracted information included the author, country, study design, participant demographics, intervention, psychological theory/framework, outcomes, and conclusion.
Data analysis.
The characteristics of the included studies were analysed descriptively using frequencies and percentages for categorical data. The extracted data that addressed the review questions was interpreted qualitatively, and the findings were synthesised in a narrative review. A risk of bias (RoB) assessment was also conducted for any clinical trials. This assessment evaluated randomisation processes, allocation concealment, blinding, completeness of outcome data, reporting of all outcomes, and any other sources of bias. In the RoB assessment, studies were categorised to indicate a low, high, or unclear RoB [29].
Results
The results for this study are presented in three specific sections:
- Search results
- Types and effectiveness of OHIs used during OHP with children
- Psychological theories underpinning effective OHIs in children
Search results
The searches identified 407 articles (Fig 1), and following the three-step screening process, 25 studies were included in the review. The details of the included studies are presented in Table 1 and their characteristics are summarised in Table 2.
Table 2 presents a summary of the characteristics of the included studies. Most studies were conducted in schools (84%). In most of the studies (91.3%), the interventions were directly conducted with children and adolescents and indirectly with those who had an influence on oral health behaviour such as parents, guardians, and teachers (8.7%).
One study that resulted in improving the children’s OHK used a card game as the medium to deliver oral-health-related information to schoolchildren [35], while another study directed at improving the oral-health-related knowledge and behaviours of mothers used mobile phones to deliver text messages to these mothers for repetition and reinforcement [44].
The clinical outcome measures refer to outcomes in which a clinical index was used to measure the outcome, while the non-clinical outcome refers to outcomes such as knowledge and self-reported behaviour.
A RoB assessment (Fig 2) of the twelve randomised control trials (RCTs) was conducted to assess the quality of these studies. The other types of study designs were quasi-experimental, before-and-after experimental (paired and unpaired), and observational cross-sectional analytical (Table 2). Most of the articles included in this review were published between 2016 and 2022(Table 2) and were conducted primarily in Asia (65.2%), followed by Europe (21.7%).
An overall interpretation of the quality of the twelve RCTs is shown in Fig 2. None of the studies was completely free of the possibility of bias.
Three studies had only one of the seven methodological items assessed as an unclear risk of bias. Of these 3 studies, 1 was not clear about allocation impacting on selection bias and the other 2 were unclear about blinding. Five studies had three of the seven items identified as problematic, and in one study, two items indicated a high risk of bias. Three studies had four of the seven items identified as having an unclear or high risk of bias. Also in one study, high risk of bias was reported for selection, performance, and detection bias, making it a poor-quality RCT. This indicates that in many cases, important methodological issues were not adequately reported, and thus the potential risk of bias must be considered when interpreting the findings.
In terms of this specific methodological issue, six trials provided detailed information on random sequence generation methods using the lottery method, a computerised processer, a table of random numbers, or computer-generated numbers [36, 37, 40, 41, 46, 50, 51]. However, for other RCTs, the sequence generation was unclear [34, 42, 44, 47, 54]. Only two RCTs indicated the method of allocation concealment and thus have low risk of bias [50, 51].
Regarding blinding, four studies were deemed to have a low RoB by blinding participants and personnel [40, 41, 47, 50]. One study did not blind the participants, personnel nor the assessor [54]. Another study blinded only the assessor [53]. Only one study achieved a low RoB by also blinding the assessors [36]. All studies had a low risk of bias in terms of presentation of outcome data and selective reporting, and no other sources of bias were detected.
Types of oral health interventions used during oral health promotion with children.
Of the 23 individual studies, nine involved traditional OHE with face-to-face education, delivered via lectures (using PowerPoint or ‘chalk and talk’ methods) or videos (Tables 1 and 2). Three studies reported that OHE was delivered by alternative methods such as a computer program, SMS communication via mobile phone, or a card game (Tables 1 and 2). Nine studies included face-to-face OHE and a tooth brushing activity. Two studies reported using motivational interviewing (MI) (Tables 1 and 2). Of those that used OHE, information booklets were provided after the presentation. The people responsible for delivering the OHI varied and included dentists, dental hygienists, dental nurses, health education specialists, teachers, parents, or peers.
Effectiveness of oral health interventions.
Effectiveness was measured through parameters such as the Plaque Index, Gingival Index, and Dental Caries Index (Decayed Missing and Filled Teeth [DMFT]) (Table 1) [33, 34, 38, 40, 47, 49, 50, 52–54]. Effective interventions included OHE with practical tooth-brushing activities, games, and audio-visual aids [31, 33, 36, 40, 42, 47, 51–54]. Motivational interviewing also proved to be an effective intervention [34, 50]. Moreover, the OHIs that used repetition and reinforcement after the initial intervention similarly improved outcomes [37].
Psychological theories underpinning effective oral health interventions.
Only eight studies reported that the OHI was based on some form of a theoretical/conceptual framework or behaviour change theory (Table 1). A summary of the main characteristics of the frameworks or theories is presented in Table 3. The theories include the health belief model, the social cognitive theory (SCT), and the theory of planned behaviour. Table 3 does not contain MI since MI is a counselling strategy that was developed pragmatically and is based on practical experience rather than a psychological theory [55]. According to the RCTs with a low RoB, MI and the SCT and SCT combined with the HBM underlie effective interventions for modifying oral health behaviour in children [36, 50, 51].
Discussion
Summary of key findings
The OHIs used in 91% of the studies made use of traditional OHE where the primary difference between the studies was related to the medium used to deliver OHE and if a toothbrushing activity was included. Two studies reported using a different approach, namely MI [34, 50]. Approximately 39% of the studies only evaluated OHK (Table 2). Although these studies revealed an improvement in OHK, firm conclusions regarding effectiveness could not be reached. The studies that evaluated clinical outcomes suggest that employing OHE that is more participatory and engaging (e.g. with tooth-brushing activities, games, or audio-visual materials) together with MI is effective. Many of these clinical trials, however, had an unclear RoB and lacked long-term follow-up. According to two robust RCTs with a low RoB, MI and the SCT underlie successful interventions for improving oral health behaviour in children and could be considered to inform future OHIs. The included studies also imply that it is not necessary for a dentist to provide OHE, and this can be effectively done by [59] teachers or even peers [36]. Repetition and reinforcement of OHP has also been shown to improve adherence to behaviour change [37].
Discussion of key findings.
Although traditional OHE contributes to an increase in OHK, this improvement is temporary and does not necessarily translate into improving clinical oral health outcomes and having a positive impact on the individual’s oral health status [22, 25].
Many of the studies measured OHK, and oral health behaviour was self-reported. Although the studies demonstrated that knowledge was acquired, this did not necessarily reflect a change in behaviour, particularly where no clinical outcomes were measured [59]. An improvement in oral health literacy may improve oral health outcomes [60, 61]. However, this association cannot be assumed, and it is preferable for clinical outcomes to be measured to confirm this. Fourteen studies in this ScR reported on clinical oral health outcomes. Another review concluded that there is a relationship between clinical oral health status and oral health-related quality of life (OHRQoL) [60].
In this review, school-based interventions were dominant despite evidence that the efficacy of primary school-based behavioural interventions is limited [28, 62]. The OHIs at primary schools mainly focused on the provision of traditional OHE and tooth-brushing demonstrations, and except for two RCTs that provided a detailed description of the OHI, reporting of the OHIs in the remaining studies was poor (Table 1) [36, 37]. There was a lack of standardisation in how the OHIs were reported and in fact, none of the OHIs utilised reporting guidelines for a behaviour change intervention. In addition, OHIs delivered in schools were poorly reported, making it difficult to identify the active components that were associated with the outcomes [20]. This highlights the need for OHIs to be reported using a comprehensive and standardised approach in order to allow for comparisons in systematic reviews and meta-analyses [50]. In addition, the heterogeneity of the studies and the poor reporting made a meta-analysis difficult [23]. Furthermore, important statistical values such as odds ratios and relative risk ratios (OR and RRR) were not available [23].
Although traditional OHE in schoolchildren reduces the levels of plaque in the short-term, there was a lack of long-term evidence regarding the effectiveness of school-based interventions in reducing plaque accumulation, gingivitis, and dental caries [28]. A systematic review of the OHIs included in this ScR concluded that the positive impact of the intervention on dental visits, attitudes, brushing, and flossing was demonstrated in the three-month follow-up after the intervention [23].
The use of digital media and games is reported as having some value and is gaining popularity in delivering oral health-related messages [63]. Digital media has a powerful impact on promoting good oral health across all age groups. Its widespread use in everyday life offers an excellent opportunity to influence oral health behaviours through OHE and OHP [63].
Theoretical frameworks.
Theory-based approaches to health behaviour modification have been beneficial in other fields of medicine and could be used for OHP [64]. Other studies confirm that OHP underpinned by a psychological or behavioural theory is effective [14, 35, 36, 47].
A previous review of the effectiveness of school-based interventions concluded that none of the studies were underpinned by a psychological theory [25]. Another study explored the effectiveness of psychological interventions on the oral health of adolescents and adults and found no significant differences in gingivitis or plaque presence when comparing different interventions for periodontal disease [65]. However, one analysis showed a small but statistically significant difference in favour of psychological interventions for the Plaque Index [64]. Psychological interventions also had statistically significant benefits in terms of oral health behaviour and self-efficacy in tooth brushing, although the clinical significance of these findings is uncertain. Overall, the certainty of the evidence was considered low [65].
There is a need to apply psychological theory-based interventions not only to studies in adults with periodontitis but also to studies in adolescents with poor oral health [65]. Until October 2012, there was a lack of theory underpinning the OHIs [25, 26]. However, since 2012, an increasing number of OHIs are reported to be underpinned by a psychological theory [24, 34, 37, 39, 43, 47, 51, 53, 64, 66].
There is limited evidence for the effectiveness of OHIs in reducing tooth decay and plaque levels [25]. Furthermore, the interventions do not appear to be grounded in behavioural theory [25]. Additional high-quality research that incorporates behavioural theory is needed to improve interventions for changing oral health behaviours in children and parents [25].
This ScR identified eight publications that reported OHIs with a theoretical and/or conceptual framework. There was, however, a lack of detail regarding how the theoretical framework informed the intervention and, in some studies, it appeared as if the theory informed the questionnaires rather than the design of the intervention [39, 47]. None of the studies with an underlying psychological theory included in this ScR reported using a reporting guideline for the behaviour change intervention [36, 37, 39, 43, 47, 50].
Four RCTs in this ScR reported using psychological theories [36, 45, 51, 53]. The two publications of Haleem et al. demonstrated different objectives [36, 37]. However, the psychological theories used by Haleem et al. in their 2012 and 2016 articles were conflicting as the one article reported using the SCT [36] and the second cited the use of the social learning theory [37]. Following a personal communication, the first author, Haleem, confirmed that there was an error in the article published in 2016 and mentioned that it was in fact, the SCT and not the SLT that was used in the article published in 2016 (personal communication, Haleem, 2016, 5 December 2022). Although the study reported using the constructs of the SCT by including interactive group activities, details of how this theory informed the rest of the intervention were not clear [37].
A practical counselling strategy for behaviour change reported on in recent times is MI [34, 50]. Motivational interviewing is a person-centred collaborative form of counselling that involves using an individual’s intrinsic motivation to encourage the person to participate actively in changing their behaviour [67]. Motivational interviewing focuses on exploring and resolving ambivalence in addition to eliciting change talk [67]. There is an overlap between the concepts of MI and the self-determination theory, where these two counselling perspectives can be considered as being complementary [55]. The effectiveness of MI in healthcare is connected to self-determination [55]. The emphasis of autonomy support and goal-directedness between MI and the self-determination theory are however different [55].
Two studies were reviewed that used MI; in the first study [34], MI was directed at parents and in the second study [50], at adolescents. The first MI study included in this ScR reported that a single MI session positively contributed to changing the oral health behaviour of parents when compared with traditional OHE [34]. However, the study did not provide exact details of the MI intervention except to say that “a 30 min counselling session using a modified and translated protocol” was used [[34] p.193]. Further investigation revealed that the protocol was based on earlier work by Weinstein [unpublished] and incorporated the original principles of MI (personal communication, Weinstein, 11 October 2023).
The second MI study with a low RoB reported on a detailed MI intervention with positive results [50]. This MI study was a single-blinded RCT that investigated the effectiveness of MI in improving the oral health of adolescents [50]. The study provided a detailed description of the MI intervention and tested the fidelity of the MI intervention using the Motivational Interviewing Treatment Index tool [50]. The study also measured behavioural, clinical, and self-reported outcomes and found that the MI intervention was more effective than traditional OHE in improving adolescents’ oral health behaviours and preventing dental caries [50].
Limitations
The limitation of the ScR was that it was restricted to articles published in English and thus may have missed useful evidence in other languages. In addition, grey literature such as conference proceedings and unpublished theses and studies was not sought. Furthermore, the search was limited to specific databases, and relevant studies might have been contained in other databases.
Implications
The findings of this ScR can inform the design of future OHIs in children. Key points to consider include the following:
- A person-centred approach such as MI
- Social cognitive theory and/or health belief model
- A practical tooth-brushing activity such as demonstration and/or supervised tooth brushing
- The use of games and audio-visual aids
- Repetition and reinforcement through the medium of either text messages or telephone calls to improve patient compliance
Overall, there is a need for additional high-quality studies to be conducted that provide a detailed description of the behaviour change intervention, including behaviour change reinforcements. Furthermore, future studies should focus on longer-term follow-ups and the quality control of the intervention.
Conclusions
Most of the OHIs investigated in this ScR primarily focused on using traditional OHE in various forms and delivery methods. While these interventions led to short-term improvements in OHK, their effectiveness in changing oral health behaviour and clinical outcomes remains inconclusive. The quality of reporting and standardisation of OHIs in schools was often poor, making it challenging to identify active components associated with positive outcomes.
Successful approaches incorporate motivational interviewing (MI), social cognitive theory, health belief model, practical tooth brushing techniques, gamification, and audio-visual methods. Additionally, strategies benefit from consistent reinforcement and repetition.
This review emphasizes the need for higher quality studies on oral health interventions for children. Future research should include more detailed descriptions of interventions and longer follow-up periods.
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