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Closing the Gap With School-Based Dental Care

School-based supervised toothbrushing programs may be key to addressing oral health disparities among children worldwide.

Dental caries is prevalent worldwide, affecting 60% to 90% of children, with varying severity.1 Across the globe, an estimated 621 million children experience decay by age 6.2 In developing countries, the rising incidence of dental caries is largely attributed to increased sugar consumption and inadequate exposure to fluoride, which remains a critical issue in addressing oral health disparities. Factors, such as socioeconomic status, access to dental care, and diet, significantly influence this trend, particularly as sugary food consumption becomes more widespread in these regions. Efforts to improve fluoride exposure and oral health education are key to mitigate this growing issue.3 Underprivileged communities are particularly vulnerable to oral diseases in both developed and developing countries.4

Overall, social inequalities in oral health are complex and multifactorial; addressing them requires a comprehensive and multidisciplinary approach that considers social, economic, and environmental factors, as well as individual behaviors and attitudes. Social inequalities in oral health refer to the disparities in oral health outcomes and access to dental care services among different social groups.5 One of the most effective ways to reduce caries in high-risk populations is to expand access to oral healthcare.

Dental caries is not evenly distributed across the world. The mean number of decayed, missing, or filled teeth (dmft) in children is high in North and South America, Europe, and some parts of Asia.5 In contrast, Sub-Saharan Africa has a lower dmft index, with scores as low as 0.14 reported in Nigeria and 0.3 in Ghana.6

Oral diseases in children are concentrated in underprivileged communities, regardless of whether they are in developed or developing parts of the world.7 For instance, in England, there is a clear North-South geographical divide in the dental health of children, with those living in Northern England presenting with poorer oral health than those living in Southern England. Caries incidence is particularly high among children from low-income households.8

Research shows that establishing and maintaining good toothbrushing habits in childhood have long-term benefits in reducing caries risk.9 Children with dental caries experience pain, lack of sleep, difficulties speaking and eating, and lost school time, which can adversely affect their general health, quality of life, academic performance, and attendance record.10 A systematic review discovered that children with one or more decaying teeth are more prone to display low academic performance and poor attendance compared to those without evident caries. Conversely, children with good oral health can eat, speak, and interact without any discomfort, pain, or embarrassment. 11

In the United States, public health measures, such as the promotion of fluoride toothpaste and the widespread implementation of community water fluoridation, have significantly reduced the prevalence of dental caries in children and the population as a whole. Community water fluoridation, which involves adjusting the fluoride levels in public water supplies, has been a key preventive measure since its introduction. It has contributed to a marked decline in tooth decay, being recognized by the United States Centers for Disease Control and Prevention as one of the top public health achievements of the 20th century. By 2020, more than 72% of the US population using public water systems had access to fluoridated water, a strategy that continues to benefit both children and adults by reducing caries by approximately 25%.12,13

The combined use of fluoride toothpaste and community water fluoridation enhances dental health across socioeconomic groups, offering an effective, cost-saving method for caries prevention. Both initiatives are endorsed by major health organizations including the American Dental Association and the World Health Organization. However, the recommended fluoride concentration in water was adjusted in 2015 to 0.7 mg/​L to optimize benefits while minimizing potential risks such as dental fluorosis.13

The use of fluoride toothpaste is one of the most effective caries-preventive methods, reducing decay rates by 24%.14 Regular twice-daily toothbrushing with a fluoride toothpaste is recommended for individuals of all ages to maintain good oral health and prevent tooth decay and periodontal diseases.14 However, data from the National Health and Nutrition Examination Survey for 2015-2016 reveals that the prevalence of dental caries (both treated and untreated) in children ages 12 to `19 was 43.1%, with untreated caries affecting 13.0% of this population.15

Among preschool-aged children (ages 2 to 5), the prevalence of total dental caries was 17.7%, and untreated caries was 8.8%.15 These figures represent a slight decline in total caries prevalence compared to earlier years. However, while the overall trend shows a decrease since 2011-2012, there was a fluctuation in the untreated caries rate, which increased between 2011 and 2014 before decreasing again in 2015-2016.15

Research suggests that while dental education programs provided by dentists and dental hygienists in schools can increase awareness, their effectiveness in significantly preventing dental caries is limited.16 Studies show that while school-based oral health programs improve access to care and provide services, such as screenings, fluoride varnish, and sealants, the educational component alone may not be sufficient for long-term prevention of caries.17 Other interventions, such as direct preventive services (eg, fluoride applications, sealants), are often more effective in reducing caries rates, especially in high-risk populations.18

Oral Health Education in Schools

Schools play a critical role in addressing oral health inequities because they have a broad reach across many demographics. Schools are essential platforms for shaping children’s health-related beliefs, attitudes, and behaviors by providing not only education, but also access to preventive care, such as dental screenings, fluoride treatments, and sealant programs. These interventions help to mitigate disparities in oral health, particularly for children from low-income families or racial/​ethnic minority groups, who often experience greater barriers to accessing dental care.

The integration of oral health programs within schools has proven effective in promoting equity by delivering care directly where children spend a significant portion of their time.20 Programs that offer on-site dental services have been shown to improve both oral health outcomes and general health, as children with untreated dental issues are more likely to miss school and face difficulties in learning and social interaction due to pain and discomfort. Moreover, schools serve as a platform for comprehensive health education, empowering students and their families to adopt healthier practices that extend beyond the classroom and into the home environment.7, 21

Supervised Toothbrushing Program

Supervised toothbrushing programs in schools have proven to be effective in preventing dental caries by ensuring children receive adequate fluoride exposure and by reinforcing positive oral health behaviors.22 These programs not only provide additional fluoride to developing teeth but also promote long-term self-care habits. Research shows that these interventions, particularly when implemented consistently, can significantly reduce caries in children by improving both preventive care and daily oral hygiene practices.22

In 2019, a quasi-experimental study conducted in Northland, New Zealand, evaluated the effectiveness of a supervised school toothbrushing program on children aged 10 to 13. The study found that children who participated in the program had significantly lower caries prevalence compared to those who did not participate.23 Specifically, children in the toothbrushing group experienced a 7.3% caries incidence, whereas the control group, which did not receive supervision, had a much higher incidence at 71.5%.23 The results clearly demonstrated that supervised toothbrushing with fluoride toothpaste can significantly reduce dental caries among children, especially in populations with high dental disease levels. At baseline, all participants received routine dental examinations, including bitewing radiographs and caries assessment using the International Caries Detection and Assessment System. The results showed that children who participated in the supervised toothbrushing program had a significantly lower prevalence of dental caries compared to those who did not participate.23

Similarly, a randomized controlled trial in Northwest London compared caries incidence between primary school children who received teacher-supervised toothbrushing with a fluoride toothpaste at 1,450 ppm once a day at school and a nonintervention group.24 The study concluded that the intervention group had a statistically significant lower caries incidence compared to the control group (2.60 vs 2.92; 10.9%; p-value < 0.001). These findings suggest that implementing preventive measures in schools can help improve oral health.

Additionally, children are more likely to remember what their teachers say about toothbrushing and oral health. This may be because teachers have a better understanding of how to design and deliver sessions to children as well as the opportunity to reinforce the knowledge and skills regularly.

Successful school-based toothbrushing programs depend on factors such as integration with other health programs, involvement of nonteaching staff, and active participation from peer leaders and health promoters. Additionally, incorporating oral health into the curriculum, especially in schools where teachers have more autonomy, can lead to enthusiastic teaching and greater acceptance of such programs. Peer support plays an important role by boosting motivation and engagement, and involving classmates in supervising toothbrushing can reduce the burden on staff.

To create sustainable improvements in oral health, policies should focus on improving the nutritional quality of school meals and engaging alternative health providers. These efforts would ensure that all children, particularly those from disadvantaged backgrounds, have the resources to maintain good oral health and overall well-being.24,25

Toothpaste is a highly effective way to provide fluoride directly to the tooth surface, as it coats the enamel during brushing, helping to prevent tooth decay. However, several factors related to toothbrushing can influence its effectiveness, including the frequency of brushing, the amount of toothpaste used, the duration of brushing, and whether brushing is supervised, especially in young children.

Supervised brushing ensures adequate fluoride exposure while promoting good brushing techniques, which can improve overall dental health.24 Research indicates that the fluoride concentration in toothpaste plays a critical role in preventing dental caries. Higher fluoride concentrations, such as 1,450 to 1,500 ppm, are more effective at reducing dental caries compared to lower concentrations.24

Adult supervision during children’s toothbrushing ensures proper use of fluoride toothpaste, maximizing its benefits. Supervised brushing not only increases fluoride exposure but may also teach children how to brush more effectively, leading to long-term improvements in their oral health behaviors. This regular supervision could encourage children to brush more frequently, especially during school-based programs, and may even trigger a Hawthorne effect, in which children improve their brushing habits simply because they are being observed.25

Conclusion

Addressing dental caries, particularly in children, requires multifaceted approaches that target the underlying social, economic, and behavioral determinants of oral health. Although toothpaste and water fluoridation remain essential preventive tools in reducing caries prevalence, supervised toothbrushing programs in schools offer additional benefits, particularly in underprivileged communities. These programs not only enhance fluoride exposure but also foster lifelong oral hygiene habits. However, for sustainable improvements, it is vital to integrate oral health education within broader health-promotion strategies, engage nonteaching staff, and leverage peer support to reduce the burden on school personnel. Policies that prioritize improved nutrition in schools and address social inequities in healthcare access will help ensure that all children, regardless of socioeconomic background, can achieve optimal oral health.

References

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From Dimensions of Dental Hygiene. October/November 2024; 22(6):20-25.

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