Received: 19 August 2016 | Accepted: 25 June 2017

DOI: 10.1111/cdoe.12325

ORIGINAL ARTICLE

Effectiveness of oral health education on oral hygiene and

dental caries in schoolchildren: Systematic review and
meta-analysis

Caroline Stein1 | Nath

alia Maria Lopes Santos1 | Juliana Balbinot Hilgert2 |
Fernando Neves Hugo2

1
Postgraduate Studies Program in Dentistry,
Federal University of Rio Grande do Sul,
Porto Alegre, Brazil
2
Department of Preventive and Social
Dentistry, Federal University of Rio Grande
do Sul, Porto Alegre, Brazil
Correspondence
Fernando Neves Hugo, Faculty of Dentistry,
Federal University of Rio Grande do Sul,
Porto Alegre, Brazil.
Email: fernandoneveshugo@gmail.com
Website: http://www.ufrgs.br/cpos
Funding information
Coordination for the Improvement of Higher
Education Personnel (CAPES)
Abstract
Objectives: The objective of this study was to evaluate the effectiveness of oral
health educational actions in the school context in improving oral hygiene and den-
tal caries in schoolchildren through systematic review and meta-analysis.
Methods: Clinical trials with schoolchildren between 5 and 18 years old were
included. Eligible studies were those which had as outcomes caries, plaque accumula-
tion, gingivitis, toothache or tooth loss and which had been published from 1995 to
2015, in any language. The risk of bias was assessed in specific domains according to
the Cochrane Handbook. A meta-analysis was carried out using fixed-effects models.
Results: A total of 4417 references were found, from which 93 full texts were evalu-
ated and 12 included in this meta-analysis. Five studies showed a reduction in plaque
levels, and two studies with gingivitis as the outcome found no effect. There was not
enough evidence on the effectiveness of the interventions in reducing dental caries.
Conclusions: Traditional oral health educational actions were effective in reducing
plaque, but not gingivitis. There is no long-term evidence in respect of the effective-
ness of these interventions in preventing plaque accumulation, gingivitis and dental
caries in the school environment.

KEYWORDS
adolescent, child, dental health education, meta-analysis, review, schools

1 | INTRODUCTION diseases; health promotion at school should encourage daily tooth-

Oral disorders such as dental caries, periodontal diseases and tooth
loss are critical public health issues around the world, given the fact
that poor oral health has far-reaching effects on overall health and
quality of life. There are challenges to overcome in order to improve
oral health, particularly in developing countries, in which there is an
urgency to globally strength public health programmes by deploying
effective preventive measures against diseases while promoting oral
health.1,2
The World Health Organization in 2003 indicated that the focus
of Oral Health Education (OHE) actions should be on behaviours and
conditions that promote oral health or that reduce the risk of oral
brushing, supervised toothbrushing, use of fluoride, and promotion
of good nutrition, among other strategies.3,4 While reviewing the
evidence on the effectiveness of Dental Health Education (DHE) in
1996, Kay and Locker undertook a systematic review which showed
no evidence to show that DHE was effective against dental caries.
They suggested that further efforts are required to synthesize cur-
rent information about DHE.5 However, that review was published
more than two decades ago, with the most recent evidence having
been included from a study published in 1994. Since its publication,
a large number of intervention studies assessing the effectiveness of
educational measures have been published, and a more contempo-
rary review is required.

30 | © 2017 John Wiley & Sons A/S. wileyonlinelibrary.com/journal/cdoe Community Dent Oral Epidemiol. 2018;46:30–37.
Published by John Wiley & Sons Ltd
STEIN ET AL.
The use of collective actions for oral health education is frequent
and includes lectures using different types of resources such as flip-
charts, video, slide presentation, and other types of actions such as
6
supervised dental brushing and topical fluoride application. About
the effectiveness of the latter, there is already strong evidence,
established by systematic review with meta-analysis, setting the
effectiveness of topical fluoride use on cavity prevention in children
7
and teenagers. For supervised toothbrushing, there is some evi-
dence on its efficacy and cost-effectiveness.8 However, further
studies that follow students for longer periods of time, while incor-
porating economic outcomes, are needed.8
The objective of this study was to evaluate the effectiveness of
oral health educational actions in the school context on improving
oral hygiene and dental caries in schoolchildren through systematic
review and meta-analysis.
2 | METHODS
A systematic review of literature and meta-analysis was performed.
This methodology followed the Cochrane Handbook for systematic
reviews of interventions, version 5.1.0.9 For further details, see the
online Methods. For this review, studies using randomized controlled
trials methodology were included, with randomization at group
(school and/or classroom) or individual level.
Studies in which participants were students with ages ranging
from 5 to 18 years were included. This inclusion disregarded the
dental caries level at the study’s beginning, exposure to fluoride and
current dental treatment. For the purposes of this review, a “school”
is defined as “a space to articulate policies concerning teenagers and
young people, based on the participation of those individuals in that
process: students, families, educational and health professionals.”10
Educational actions interventions on oral health carried out by den-
tal professionals in School Programs were considered. The included
educational interventions on oral health were as follows: supervised
toothbrushing, guidance about toothbrushing, orientation on the main
oral diseases, general orientation on dieting, educational activities,
among others. Studies were included without time restriction. The inter-
vention could have been delivered by dentists, dental hygienists or den-
tal assistants and carried out in the school environment.
The control group was not provided with an educational pro-
gramme on oral health; however, it could have been given an action
that belongs to the school’s curricular framework.
Primary outcomes: dental caries; plaque accumulation; gingivitis.
The clinical effectiveness was defined as some change in caries
experience or some change in the amount of dental plaque and gin-
gival bleeding. Secondary outcomes: dental pain and tooth loss,
before and after the intervention. Articles published from 01/01/
1995 until 09/06/2015 were searched, without any restriction
concerning the publication’s language.
The following bibliographic databases were searched:
MEDLINE/PubMed (01/01/1995-23/04/2015): “Child”[Mesh]
OR “Schools”[Mesh] OR “Adolescent”[Mesh] OR “Child, Preschool”
| 31
[Mesh] AND (“Toothbrushing”[Mesh]) OR “Health Education, Den-
tal”[Mesh] OR “Education”[Mesh] AND (“Oral Health”[Mesh]) OR
(“Dental Plaque”[Mesh] OR “Dental Caries”[Mesh] OR “Gingivi-
tis”[Mesh] OR “Dental Plaque Index”[Mesh] OR “Toothache”[Mesh]
OR “Tooth Injuries”[Mesh] OR “Tooth Loss”[Mesh])). CENTRAL (Cen-
tral Register Cochrane of Controlled Trials) (01/01/1995-13/05/
2015). EMBASE (Excerpta Medica Database) (01/01/1995-09/06/
2015). LILACS (Latin-American and Caribbean Literature on Health
Sciences/Virtual Health Library (BVS)) (01/01/1995-25/04/2015).
The title and the abstract of each study were reviewed and criti-
cally assessed by two independent reviewers. Two reviewers are
dental surgeons (NMLS, CS) and experienced in the field.
The methods used to apply the selection criteria were the follow-
ing: (i) integration of the searched outcomes in the bibliographic refer-
ence EndNoteWeb software to delete duplicate entries; (ii)
examination of titles and abstracts to delete clearly irrelevant articles;
(iii) recovery of the full text of potentially relevant articles; (iv) binding
and gathering of multiple articles of the very same study; (v) examina-
tion of the articles’ full text to verify the degree of compliance that the
studies had with the eligibility criteria; (vi) establishing connection with
researchers, if necessary, to clarify the study’s eligibility; (vii) deciding
about the study’s inclusion and proceeding with data gathering.
When disagreements between researchers arose, the eligibility
criteria or the codification schemes for data gathering were reviewed
by a third reviewer (FNH) experienced in the content of the review,
to take the final decision on the articles’ inclusion or exclusion.
Data gathering was carried out using a verification list of items
that were considered for data extraction. The main items of this list
were as follows: study definition, risk of bias assessment, total length
of the study, unit of randomization, unit of analysis, participants’
characteristics, interventions, outcomes, results and other items.
The risk of bias was assessed in five specific domains: selection
of participants; allocation sequence concealment; blinding of partici-
pants and evaluators; incomplete outcome data; and selective out-
come reporting. This was done through the assignment to “low risk
of bias,” “high risk of bias” or “unclear risk of bias” rulings.9
Measures for continuous data were assessed as follows: mean
change in Plaque Index (before and after the intervention) and stan-
dard deviations; and mean change in gingivitis (before and after the
intervention) and standard deviations.
The unit of the analysis from the studies was every conglomerate
(class or school) and/or the individual (student) of each study
included in this review. The estimates of effect and their standard
errors, deriving from the analysis of group-randomized trials, were
explored in a meta-analysis using the generic inverse variance
method on Review Manager 5.3.
We sought to identify the variability among the studies, in partic-
ipants, interventions, outcomes and planning, and risk of bias. The
chi-square test was used to assess whether the observed differences
were homogenous or heterogeneous. The statistic test used to quan-
tify the inconsistence between studies was the I². It was interpreted
in accordance with the Cochrane Handbook for Systematic Reviews
of Interventions.9
32 | STEIN
Data synthesis was carried out using a descriptive synthesis, with
a summary of the characteristics of each included study. For quanti-
tative synthesis, a summary of the combined estimate related to the
intervention effect was calculated as a mean of the differences of
the effects of intervention in individual studies.
The meta-analysis of the continuous outcomes used the fixed-
effect method, which provides exactly the same answers when
heterogeneity does not exist. To calculate the standard error and the
standard deviation of the mean differences for the outcomes of
interest, the Comprehensive Meta-Analysis Software was used, and
then, mean differences and their standard deviations were analysed
using Review Manager 5.3. software.
FIGURE 1 Review flow diagram in selection of studies, 2015
ET AL.
3 | RESULTS
The studies selected during the search process, assessed by eligibil-
ity, included in the review and excluded given the proper reasons,
are presented in Figure 1, using a flow diagram. For further details,
see the online Results.
The characteristics of the studies can be found in Table 1, which
depicts the included studies’ the general characteristics. Among the
12 included studies, six were randomized by school,11–16 two by
classroom17,18 and four by individuals.19–22
The age of the participants ranged from 6 to 15 years old
throughout the interventions’ conducting period. 3932 participants
 STEIN

T A B L E 1 General characteristics of the included studies

ET AL.

Duration N Intervention N Control Age of Who applied the

Reference (year) of study group group Intervention1 participants Outcomes assessed2 intervention
Ivanovic 1996 6 mo 80 (Group I) 80 OHE, OHI and TD (Group I) 11-14 y PI and GI Silness & Dental Hygienist
Loe
80 (Group II) OHE, OHI, TD ad ST (Group II)
Esteves 1998 6 mo 25 (Group II) 25 (Group I) OHE (Group II) 7-9 y PI O’Leary Dentist
25 (Group III) OHE, OHI, TD and ST (Group
III)
25 (Group IV) OHE, OHI, TD and ST and
dietary (Group IV)
Worthington 2001 4 mo 146 135 OHE, OHI and TD 10 y PI Silness & Lo
€e Dental Hygienist
Rodrigues 2003 1 mo 20 (Group I) 20 OHE and OHI (Group I e II) 7-9 y PI O’Leary Dentist
20 (Group II) OHE, OHI and TD (Group III)
20 (Group III)
Al-Jundi 20063 4y 411 397 OHE, OHI, TD and ST 6-11 y DMFT and dmfs Dental Hygienist
and research
assistant
Zanin 20073 15 mo 30 30 OHE, OHI, TD and ST 6y PI, GI, dmf and Dentist
DMFS
de Farias 20093 1 mo 195 93 OHE, OHI and TD 7-15 y PI, GI and DMFT Dentist
Anttonen 20113 9 mo 140 220 (Control I OHE, OHI and ST 13-14 y demineralization and Dental Hygienist
and dietary remineralization in
intervention) molars
340 (Control II)
3
Yekaninejad 2012 3 mo 129 123 OHE 11-12 y CPI Dentist
Haleem 20123 2y 303 334 OHE, OHI and TD 10-11 y PI and GI Dentist
D’Cruz 2013 9 mo 141 (intervention I) 284 OHE (Group I) 13-15 y PI and GI Dentist
143 (intervention II) OHE, OHI and TD (Group II)
Chandrashekar 2014 6 mo 36 35 OHE 15 y PI, G and DMFS Dentist
1
Interventions: OHE (Oral Health Education: activities with lectures, albums, slides, leaflets, counselling, games, drawings, theatre, dieting guidance); OHI (Oral Health Instruction); TD (Tooth brushing demon-
stration); ST (supervised tooth brushing).
2
Outcomes assessed: PI (Plaque index), GI (Gingival Index), DMFS (decayed, missed, filled permanent tooth surface); dmfs (decayed, missed, filled primary tooth surface); DMFT (decayed, missed, filled per-
manent tooth); CPI (Community Periodontal Index).
3
Al-Jundi 2006, Anttonen 2011, de Farias 2009, ²Esteves 1998 (Group IV), Haleem 2012; Yakaninejad 2012 e Zanin 2007, they were not included in the meta-analysis.
|
33
34 | STEIN
F I G U R E 2 Summary of the risk of bias: + (low risk of bias); ?
(unclear risk of bias); - (high risk of bias) [Colour figure can be
viewed at wileyonlinelibrary.com]
were part of the studies’ analyses, with 1864 of those included in
intervention groups and 2068 in control groups.
Significant methodological variability was found among the inter-
ventions performed in the included studies. Thus, the interventions
described by the studies were categorized as follows: (i) Oral Health
Education (OHE): activities with lectures, albums, slides, leaflets,
counselling, games, drawings, theatre, dieting guidance; (ii) Oral
Health Instruction (OHI) reported as additional delivery of information
directed particularly to toothbrushing methods; (iii) Tooth brushing
demonstration (TD) with macro models or dental dummies; (iv) Super-
vised Tooth brushing (ST): the intervention study period ranged from
1 month17 to 4 years.19 Therefore, all interventions selected for this
review are considered traditional oral health education activities.
The presentation of the assessments of the risk of bias was done
based on Figure 2, using Review Manager 5.3 software. First, studies
with groups that got any sort of OHE intervention vs controls con-
cerning the Loe and Silness and O’Leary’s plaque indices outcomes
11,14,18,20,22
were analysed. In the cumulative analysis of five studies
with both indices, there was a significant difference in the change of
the Plaque Index favouring intervention groups, which showed a
ET AL.
reduction in mean plaque levels (MD 0.36, IC 95%: 0.59 a 0.13)
(Figure 3, Comparison 1).
In comparison 2, studies in which there were groups who got
some activity of OHE, OHI and TD were included, vs control groups,
concerning plaque outcome (Loe & Silness PI). In this fixed-effects
model analysis,14,20 there was a significant difference in the change
of the plaque index favouring intervention groups, which showed a
better oral hygiene (MD 0.42, IC 95% 0.69 a 0.15) (Figure 3,
Comparison 2).
In comparison 3, studies in which there were intervention groups
that got any intervention on OHE vs control groups related to gin-
givitis outcome (Loe & Silness). In this fixed-effects model analysis,
two studies11,12 presented data on gingivitis indices at the beginning
and at the end of the study. There was no significant difference in
the change in gingivitis between the groups (MD 0.07, IC 95%
0.32 a 0.19) (Figure 3, Comparison 3).
The studies of de Farias17 and Zanin21 also had the plaque index
and gingivitis outcomes in their analysis, but their data for the out-
comes of interest were presented in charts, which prevented their
inclusion in the meta-analysis.
The study of Haleem13 presented results for Plaque Index and
gingivitis based on a dichotomous scale for the outcomes of inter-
est. It was not possible to include it in the meta-analysis. This
study concluded that the interventions had a rather modest effect
on plaque and gingivitis. The study of Yekaninejad15 assessed the
effect of OHE on oral hygiene measured using the Community
Periodontal Index (CPI), and there was no improvement in the gin-
gival health of the intervention group. The results for gingivitis
were presented in estimates from the multilevel ordinal logistic
regression model, which precluded its inclusion in the meta-
analysis.
For the dental caries and tooth loss outcomes, four stud-
11,17,19,21
ies presented results using the DMFT, DMFS and dmfs
indices to evaluate the effectiveness of the OHE sessions. Al-
Jundi,19 in a 4-year study, found that caries status of the children in
the intervention group, which comprised supervised daily tooth-
brushing using fluoridated toothpaste, was better than that of the
control group and concluded that this preventive programme was
successful in controlling dental caries. In the study of Chan-
drashekar,11 for the DMFS outcome, and in the study of Zanin,21
with the DMFS and dmfs outcomes, significant changes between the
groups were not found. According to de Farias,17 the DMFS index
showed a significant association with the Gingival bleeding index at
the end of the study.
Anttonen16 assessed the effect of the actions of OHE on the
monitoring of demineralization and remineralization of tooth sur-
faces, based on mean laser fluorescence values and concluded that
the 1-year OHE was resulted in favourable changes in dietary habits
and a decrease in the laser fluorescence values of molars. The results
of the study were presented in graphs and the type of measurement
for caries condition, precluded its inclusion in the meta-analysis.
Studies with tooth pain as outcomes were not found.
STEIN ET AL.
FIGURE 3 The effectiveness of oral health educational actions [Colour figure can be viewed at wileyonlinelibrary.com]
4 | DISCUSSION
For the plaque outcome, five studies11,14,18,20,22 were included in
the meta-analysis and showed significant differences in the change
of the plaque index (Loe & Silness and O’Leary) favouring interven-
tion groups. Although limited, the studies suggest positive effect of
OHE on plaque levels on short term. On the other hand, the stud-
ies of Esteves22 and Rodrigues,18 encompassing O’Leary’s Plaque
Index, did not find significant difference between the groups, which
can be explained by the small number of participants in the study
groups.
For the gingivitis outcome in meta-analysis, the studies of Chan-
11 12
drashekar and D’Cruz showed that there was no difference
between the groups and revealed that oral health education had no
effect on gingivitis reduction. These studies varied their intervention
time from 6 months to 2 years, with participants aged from 10 to
15 years old. The prevention of oral diseases is an important
| 35
objective of oral health education and evidence to support decision
would be of relevance for oral care providers and stakeholders.
There were only four studies assessing caries as the outcome
included in this review.11,17,19,21 In general, their findings are conflic-
tive, with three not showing differences between intervention and
control groups and a larger, longer one showing differences in favour
of oral health education.
For such matter, we need to make further progresses in the
development and systematic assessment of such actions throughout
longer periods of time. Besides that, the short follow-up time to
carry out analysis of effectiveness on dental caries must be taken as
a limitation of the assessed primary studies, because the latency per-
iod of caries (and tooth loss, consequently), is longer than the fol-
low-up period of the studies included in this review. This way, there
is a need to develop long-term studies which can assess the effec-
tiveness of the education actions on those outcomes, particularly
because the goal of the education interventions in the school
36 | STEIN
environment is to prevent oral diseases and to develop healthier
behaviours and practices.
The last systematic review about the effectiveness of educational
actions on the oral health of schoolchildren was published more than
two decades ago. Since then, a considerable amount of papers on
the subject has been published. Oral health education programmes
continue to be developed and implemented in school settings, mean-
ing that the critical assessment and summarization of that evidence
is important to provide clinicians, stakeholders and decision makers
with needed information about the cost-effectiveness of education
based oral health programmes. This is in agreement with the current
23
definition of oral health that was recently published by the FDI.
The several forms of delivery of OHE presented in the studies
only varied in regard to the deployed educational objects; however,
the methods, as they were developed, were based mainly on infor-
mation transfer. The development of evidence-based protocols that
allow the delivery of sound and effective OHE actions is needed
mainly in primary healthcare settings and in school environments. It
is strategic to carry out prevention and health promotion actions
that are consistent and produce a positive impact on oral health sta-
tus. It is important to review OHE methods, organizing them accord-
ing to children’s development period, while also acknowledging a
more active engagement hailing from school communities and fami-
lies, because there is a complexity when it comes to being apt to
motivate oneself while promoting changes in persons’ health beha-
viours.24
As this study only selected interventions carried out by oral
health professionals and, considering that throughout the selection
process, studies in which interventions were applied by others such
as teachers and students’ parents were found, there is a need to also
systematically assess the effectiveness of those interventions. In a
critical review study on educational programmes for schools, Pau-
leto25 concluded that education remains strongly based on knowl-
edge transfer practices and that it is necessary to rethink it by using
education methods that are focused on problematization.
In a previous systematic review about the effectiveness of Oral
Health Education actions, Kay5 found that there was a rather small
positive effect, however momentary, in the plaque index and not a
single perceptible effect about the cavity increase. The present
review included papers published after 1994 and showed similar
results in respect to plaque accumulation. Furthermore, results in
respect to caries were conflictive and no study included important
outcomes such as tooth loos or evaluated the cost-effectiveness of
OHE interventions.
The general applicability of the evidence of the present review
is limited, taking into consideration that OHE only contributed to
a small reduction over a short period of time in plaque accumula-
tion. Furthermore, oral and psychosocial characteristics are known
to vary widely between children in the age range considered in
the present systematic review. This is a limitation of this study,
and results must be interpreted taking such into account. Sub-
group analyses could have been carried out to overcome it; how-
ever, this was precluded due to the small number of individual
ET AL.
studies with similar outcomes included. The study’s relevance is
mainly related to the need to assess the effectiveness of educa-
tional actions on oral health carried out in school programmes,
given the fact that, according to individual studies and other sys-
tematic reviews, a conclusive outcome about their effectiveness is
yet to be established, even though they remain as priority actions
in many countries.
In conclusion, traditional oral health education was effective in
reducing plaque accumulation over a short period. This reduction
was of small magnitude. OHE was not effective for gingivitis while
for caries the findings were conflicting. There is no long-term evi-
dence on the effectiveness of these interventions in preventing pla-
que accumulation, gingivitis and dental caries in schoolchildren. This
may be due to the variability of OHE methods deployed in the
individual studies.
ACKNOWLEDGEMENTS
This study was funded in part by the Coordination for the Improve-
ment of Higher Education Personnel (CAPES).
REFERENCES
1. Marcenes W, Kassebaum NJ, Bernabe
E, et al. Global burden of oral
conditions in 1990-2010: a systematic analysis. J Dent Res.
2013;92:592-597.
2. 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.
3. Kwan SY, Petersen PE, Pine CM, Borutta A. Health-promoting
schools: an opportunity for oral health promotion. Bull World Health
Organ. 2005;83:677-685.
4. WHO. Information Series on School Health. Oral Health Promotion:
An Essential Element of a Health-Promoting School. Geneva: World
Health Organization; 2003.
5. Kay E, Locker D. Is dental health education effective? A systematic
review of current evidence. Community Dent Oral Epidemiol.
1996;24:231-235.
6. Brazil. Department of Primary Care, Brazilian Ministry of Health.
Instruction - Health at School Program. Brazil: Ministry of Health;
2011:1-27.
7. Marinho VC, Worthington HV, Walsh T, Chong LY. Fluoride gels for
preventing dental caries in children and adolescents. Cochrane Data-
base Syst Rev 2015;(6):CD002280.
8. Fraz~ao P. Cost-effectiveness of conventional and modified super-
vised toothbrushing in preventing caries in permanent molars among
5-year-old children. Cad Saude Publica. 2012;28:281-290.
9. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic
Reviews of Interventions Version 5.1.0. The Cochrane Collaboration;
2011. www.cochrane-handbook.org. Accessed 14th May, 2014.
10. Brazil. Department of Primary Care, Brazilian Ministry of Health.
Guidelines for implementation of the Health and Prevention in
Schools. Brazil: Ministry of Health; 2006:1-24.
11. 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:
235-240.
12. 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. Indian J Public
Health. 2013;11:126-133.
STEIN ET AL.
13. Haleem A, Siddiqui MI, Khan AA. School-based strategies for oral
health education of adolescents-a cluster randomized controlled trial.
BMC Oral Health. 2012;54:1-12.
14. Worthington HV, Hill KB, Mooney J, Hamilton FA, Blinkhorn AS. A
cluster randomized controlled trial of a dental health education pro-
gram for 10-year-old children. J Public Health Dent. 2001;61:22-27.
15. Yekaninejad MS, Eshraghian MR, Nourijelyani K, et al. Effect of a
school-based oral health-education program on Iranian children: results
from a group randomized trial. Eur J Oral Sci. 2012;120:429-437.
16. Anttonen V, Sepp€a L, Niinimaa A, Hausen H. Dietary and oral
hygiene intervention in secondary school pupils. Int J Paediatr Dent.
2011;22:81-88.
17. de Farias IA, de Araujo Souza GC, Ferreira MA. A health education
program for Brazilian public schoolchildren: the effects on dental
health practice and oral health awareness. J Public Health Dent.
2009;69:225-230.
18. Rodrigues JA, dos Santos PA, Garcia PP, Corona SA, Loffredo LC.
Evaluation of motivation methods used to obtain appropriate oral
hygiene levels in schoolchildren. Int J Dent Hyg. 2003;4:227-232.
19. Al-Jundi SH, Hammad M, Alwaeli H. The efficacy of a school-based car-
ies preventive program: a 4-year study. Int J Dent Hyg. 2006;4:30-34.
20. Ivanovic M, Lekic P. Transient effect of a short-term educational
programme without prophylaxis on control of plaque and gingival
inflammation in school children. J Clin Periodontol. 1996;23:750-757.
21. Zanin L, Meneghim MC, Assaf AV, Cortellazzi KL, Pereira AC. Evalu-
ation of an educational program for children with high risk of caries.
J Clin Pediatr Dent. 2007;31:246-250.
| 37
22. Esteves GV, Navarro RS, Oliveira Ju
nior WTd, Youssef MN. Estudo
cl
ınico do comportamento de escolares mediante escovac߀ao supervi-
sionada, controle da dieta e motivac߀ao para prevenc߀ao da c
arie e
doencßa periodontal. Rev Pos-Grad. 1998;5:211-218.
23. 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 Am Dent Assoc. 2016;147:915-917.
24. Mialhe FL, Silva CMC, Cunha RB, Possobon RF. Health education.
In: Pereira AC, Handbook of Collective Health. Nova Odessa:
Napole~ ao; 2009:441-485.
25. Pauleto ARC, Pereira MLT, Cyrino EG. Oral health: a critical review
about educative programmes for students. Cien Saude Colet.
2004;9:121-130.
How to cite this article: 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;46:30–37. https://doi.org/10.1111/cdoe.12325