essay on health promotion for oral health

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Home > Books > Insights into Various Aspects of Oral Health

Oral Health Promotion: Evidences and Strategies

Reviewed: 19 April 2017 Published: 20 September 2017

DOI: 10.5772/intechopen.69330

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Insights into Various Aspects of Oral Health

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Oral health promotion is for upliftment of oral health of community rather than an individual and has long‐term impact. Since Ottawa Charter for health promotion is implemented, significant advancements have happened in oral health promotion. Under comprehensive health programs, India has been running oral health promotion programs, and these evidences are shared here. Such examples are apt learning and execution to any part of world having similarities. The chapter put forward the strategic view points to consider further oral health promotion aspects and based on the needs. The authors have gathered various examples from national programs implemented in India. The authors discuss how these programs are linked to the Oral health promotion concept. For example, National tobacco control program which currently running across many states in India, how the banning on tobacco products near school premises helped to reduce the incidence is discussed. The worldwide literature and evidences of oral health promotion strategies are explained. The evidences and strategies mentioned can be significant for another region of world. Unless published, many programs remain hidden and are loss of valuable evidences to oral health science.

• oral health
• oral health promotion
• school health
• dental health

Author Information

Vikram r. niranjan *.

• Queen Mary University of London, UK and S.D. Dental College, Parbhani, India

Vikas Kathuria

• Consultant Dentist, Hadi Hospital, Jabriya, Kuwait

Venkatraman J

• Department of Pathology, Mahatma Gandhi Medical college and Research Institute, Puducherry, India

Arpana Salve

• Senior Registrar, Skin & VD Department, Government Medical College & Hospital, Aurangabad, India

*Address all correspondence to: [email protected]

1. Introduction

The twentieth century was noteworthy in dentistry for many epidemiologic advances that occurred in the study of oral diseases and conditions. These combined efforts of optimum personal, social, biological, behavioral and environmental factors contributed to better oral health. Hence, oral health promotion is a planned effort to build public policies, create supportive environments, strengthen community action, develop personal skills or reorient health services pertaining to influence above factors. Following are enlisted examples of effective oral health promotion:

Promotion of healthy eating

Training of relevant oral hygiene methods

Access to preventive oral health services at the earliest

Promotion of topical fluoride application [ 1 ].

Ottawa Charter principles form a sound base for oral health promotion. This suggest that individuals alone are not at risk but the entire population, which needs to be involved in directing action towards the causes of ill health. Importantly, three principles, that is, partnership, participation and protection, are taken into consideration while planning a public health program or intervention. Empowerment than compelling is the key for successful Oral health promotion while achieving good oral health [ 2 ].

The purpose of this article is threefold. First, it reviews the relevance of need of oral health promotion particularly through the public health surveillance of oral disease burden. Second, it puts forward the evidences from the various examples of oral health promotion programs integrated into general health promotion carried across the India. Finally, the authors briefly discuss the strategies for expanding frame of oral health promotion.

2. Oral health promotion through Ottawa Charter

Health promotion programs achieve success through actions that influence the social, physical, economic and political determinants of health. Health promotion irrefutably acknowledges the broader health determinants and focuses on risk reduction via sensitive policies and actions. Ideally, promotion of health in a day‐to‐day life setting having people live, work, learn and play is credible for efficacious and cost‐effective way of improving oral health and indeed the quality of life. Imperatively, actions that address the determinants of health should not be progressed in isolation. Research evidences suggests that isolated activities can have limited impact, particularly over the long term. For this reason, we suggest using the logic model based on Ottawa Charter to develop a comprehensive oral health promotion program, involving a range of interventions.

The Ottawa Charter was developed by the World Health Organization 1 (WHO) as a framework for constructing health promotion programs that address the wider determinants of health. The charter suggests that programs be built around the following five action areas:

Building healthy public policy

Creating supportive environments

Strengthening community action

Developing personal skills

Reorientating health services [ 2 ].

3. Need for oral health promotion

The remarkable improvements in oral health over the past half century reflect the strong science base for prevention of oral diseases that has been developed and applied in the community, in clinical practice and in the home. Yet, despite the remarkable achievements in recent decades, millions of people worldwide have been excluded from the benefits of socioeconomic development and the scientific advances that have improved health care and quality of life. Social and cultural determinants comprising poverty, lack of education, unsupportive traditions, cultures and beliefs increase the relative risk of oral disease and conditions. For instance, lack of safe water and sanitary facilities are the environmental risk factors for both oral and general health. While, access to high sugar containing foods and unhealthy dietary habits may lead to higher risk of dental caries in certain communities. Improvement in availability, accessibility and feasibility of oral health services can definitely cure and control oral diseases. However, strong evidences suggest that limiting the risks to disease is best possible when health services are primary care and prevention oriented. Clinically, oral health status is measured in terms of causal factors, that is, tobacco, sugar, micro‐flora, which have negative impact on quality of life. Emphasizing the risk behavior modifications, such as curbing use of tobacco and alcohol; restraining sugar intake in terms of quantity, intake frequency and nature; proper oral hygiene practices, is equally important incongruent to social and cultural determinants [ 3 ].

The Global Burden of Disease (GBD) 2010 Study produced comparable estimates of the burden of 291 diseases and injuries in 1990, 2005 and 2010. Pertaining to oral health, dental caries, aggressive periodontitis and tooth loss are considered as global burden, which compared from 1990 to 2010. Criteria used were disability adjusted life‐years (DALYs) and years lived with disability (YLDs) metrics to quantify burden. These oral diseases/conditions encroached 3.9 billion. Among all, prevalence of dental caries in permanent teeth was among the highest prevalent condition evaluated for the entire GBD 2010 study (global prevalence of 35% for all ages combined). Among the top 100 ranking as causes of DALYs, oral diseases also secured a ranking after some serious diseases. Oral diseases altogether affected 15 million DALYs globally with the breakdown as 1.9% of all YLDs; 0.6% of all DALYs. Statistical calculations imply that could be average health loss of 224 years per 100,000 populations. While there was reduction observed for other diseases from 1990 to 2010, DALYs due to oral conditions increased by 20.8%. This was due to population overgrowth and aging. DALYs due to aggressive periodontitis and dental caries increased, however due to extensive tooth loss has decreased. While DALYs differed by age groups and regions, those not by genders. The report revealed the challenging scenario of diversified oral health needs across the globe, with alarming needs in developing countries. Further, the burden of oral diseases has unevenly risen in the past 20 years.

As the noted prevalence of oral diseases is very high and has association with disability, it accounted for a substantial number of DALYs. Dental caries without any treatment was the most prevalent condition among all 291 conditions. Moreover, the disability weight in connection with extensive tooth loss (0.073) was marginally neared to those reported for moderate heart failure (0.068) and moderate consequences of stroke (0.074). Oral diseases received ranking of 31st, 34th and 35th of health outcomes causing YLDs in the category of non‐fatal outcomes. Compared to other non‐communicable diseases/conditions, such as maternal conditions, hypertensive heart disease, schizophrenia, hemoglobinopathies and hemolytic anemias, oral diseases/conditions were ranked higher. While oral conditions scored high index for more YLDs than 25 of 28 categories of cancer, shows its significance in terms of affecting individuals equal to lethal diseases. The other organ cancers, such as stomach, liver and trachea, and bronchus and lung cancers ranked higher than oral diseases [ 4 ].

The global burden of oral conditions is shifting from extensive tooth loss toward aggressive periodontitis and untreated dental caries. Tooth loss is a final common pathway when preventive or conservative treatments to alleviate pain fail or are unavailable. The social, economic, political and cultural determinants of health are significant, and it may be argued that better health can be achieved by reducing poverty. Poverty, poor education and inequality not only result in poor oral health but also affect the way in which people think about their oral health. In spite of excellent oral health care, oral diseases are prevalent. This suggests that improving healthcare services merely will not address the issue, oral health promotion is mandatory. Hence, health policymakers should be made aware of these evidences and directs themselves to restructure the policy framework. Health promotion policy acknowledges complimentary measures such as legislation, fiscal measures, taxation and organizational change altogether. These are best example of a coordinated effort towards creating supportive environments and strengthening community action. Ottawa Charter implementation for health promotion through establishing concrete and effective community actions in setting priorities, making decisions, planning strategies leads to achieve better health. Communities facilitate themselves with self‐help, social support, participation and ownership for development and empowerment. They are the best possible existing human and material resources of community and for community.

Oral health promotion through sensitive health policies and actions which already exist in some parts of world can address the global burden of oral diseases, essentially to improve oral health and quality of life.

4. Evidences: country examples from India

Identifying a significant health issue on the basis of prevalence, incidence, severity, cost, or impact on quality of life is preliminary step to design prevention programs. A combination of community, professional and individual strategies is the cost‐effective and creative methods for oral disease prevention. Incorporating public, practitioners and policymakers into strategic development of oral disease prevention and health promotion intervention is necessary. They should be liable to create a healthy setting, limit risk factors, inform target groups, generate knowledge and thus improve behaviors. This section includes a discussion of knowledge and practices of the public and healthcare providers regarding the oral health promotion. The purpose of this discussion is not to outline specific health promotion strategies to enhance knowledge and practices but to indicate the opportunities and needs for both broad‐based and targeted health promotion programs and activities.

4.1. Oral health promotion in health promoting schools (HPS)

Oral health education has been considered as one of the fundamentals in oral health promotion [ 5 , 6 ]. With education, a child receives training and encouragement especially to stimulate development of skills, aptitude formation and creation of values, which lead to act positively in relation to his oral health and other people’s oral health on a daily basis. High caries risk, change in dentition, ability to change bad habits and facilities to learn make oral health promotion for children a priority. The importance of oral health education programs in schools is significantly reported predominantly in the form of positive learning and behavior in children [ 5 – 11 ].

One‐fifth of the world’s population is adolescent, defined by WHO as a person between 10 and 19 years of age. The oral health promotion programs should primarily focus on this age group who become easy victims of excessive consumption of sweets, sugary beverages, tobacco and alcohol. Commonly, their main association is with home, school and community organizations. These three along with oral health professionals can form an effective alliance to control risks to oral diseases and form oral health promotion programs for young people [ 12 ]. Prevalence of dental caries and gingivitis is high in human populations throughout the world, and over 80% of schoolchildren are affected in some parts of the world. Dental erosion due to excessive carbonated beverages consumption is on rise, which was earlier noticed only among the late adulthood. Enamel defects due to malnourishments, dental trauma due to negligence and safety barriers are some of the increasing evidences in children. Moreover, youth became the easy targets of tobacco‐containing products. Eventually and unknowingly, early start of tobacco consumption manifolds risks of oral precancerous lesions and cancer in life ahead [ 8 , 10 , 13 ].

Strong arguments for oral health promotion through schools include the following:

Personal and social education aimed at developing life skills—Pupils and students can be accessed during their formative years, from childhood to adolescence. Students develop lifelong oral health‐related behavior, as well as beliefs and attitudes are being developed.

Schools can provide a supportive environment for promoting oral health. Access to safe water, for example, may allow for general and oral hygiene programs. Also, provision of mouth guards—accessible and affordable sports protection, a safe physical environment and school policy on bullying and violence between students reduce the risk of dental trauma.

The burden of oral disease in children is significant. Most established oral diseases are irreversible, will last for a lifetime and have an impact on quality of life and general health.

School policies on control of risk behaviors, such as intake of sugary foods and drinks, tobacco use and alcohol consumption.

Schools can provide a platform for the provision of oral health care, that is, preventive and curative services [ 14 – 18 ].

Common risk factor approach‐based oral health promotion policies in schools can lead to improvement in oral health and reduce oral health inequality [ 10 , 16 ].

The need to set up oral health promotion programs in schools is evident, and it can easily be integrated into general health promotion, school curricula and activities. One of the proposed examples has been shown in Figure 1 [ 13 ].

Figure 1.

Integration of oral health in health‐promoting schools: an example from Denmark.

Using the structures and systems already in place as a competent setting for the installation of vital facilities such as safe water and sanitation can instigate oral health promotion in schools. The HPS strategies are effective, leading to potential long‐term cost savings. For instance, Each key components of an HPS, that is, healthy school environment, school health education, school heath services, nutrition and food services, physical exercise and leisure activities, mental health and well‐being, health promotion for staff and community relationships and collaboration , incorporate equal opportunities oral health promotion as well as general health promotion. While oral health issue is specifically addressed, it can be admixed in general health promotion strategy. It is well illustrated in following examples of school health policies as shown in Table 1 [ 13 ].

Table 1.

Examples of oral health‐related school health policies to be promoted in HPS.

There is an association of socio‐economic, geographic factors and type of schools with school based health promoting activities. On an average, students attending private schools belong to more advantaged backgrounds than their counterparts in public schools. Privately managed schools achieve greater efficiency or academic value‐added than publicly‐managed schools [ 18 ]. According to one study, ten out of eleven participated countries (including India) had the large socio‐economic gap between private and public school pupils except Chile [ 19 ]. Moreover, students going to city/town schools generally belonged to more privileged backgrounds than their counterparts in village schools. All the school headmasters in this study reported that primary school student’s absenteeism rate decreased when the students received support in the form of school uniforms, textbooks, meals and various financial assistance schemes. For example, urban schools tend to have greater resources than those in rural. Also, students in private schools had higher levels of positive behavior than those in public schools, and these results were statistically significant for most countries [ 19 ]. Public and private school differ from each other in many ways as better amenities in school, extra‐curricular activities, outdoor and indoor sports, etc. The private school allots more fees from students for such activities/facilities. Consequently, children from upper and high middle socioeconomic status prefer private schools, while children with low socioeconomic strata attend public schools [ 20 ]. Students gain more attention when the student to teacher ratio is higher. Bruneforth et al. [ 19 ] also reported inferior pupil‐teacher ratios in village schools than in city/town schools in India. The children who do not have adult supervision after school are more vulnerable to indulge them into health hazarding habits like smoking, drugs and substance abuse and behavioral problems. The schools providing self care activities after school were found more effective in reducing the prevalence of smoking among ninth‐grade students in Los Angeles and San Diego Counties [ 21 ]. Smoking and chewing tobacco are systematically associated with socioeconomic markers [ 20 ].

4.2. Healthy food at school: Mid Day Meal Scheme of India

The whole school approach with availability of healthy food in school canteen, tuck shops, instructing parents for healthy food and school staff involved in planning for food and curriculum has amplified student’s knowledge. However, it has not led to change in behavior [ 22 , 23 ].

Providing healthy food in schools can meet the nutritional requirement of students and also guide the parents to deal with healthy diet chart for their children. In UK, campaigns like the ones conducted by famous chef, Jamie Oliver, are one example of actions in this area.

In India, Mid Day Meal Scheme in school started in 1925 from a single city, Madras (now Chennai) and now spread to all States. From April 1st, 2008, the program covers all children studying in Government, Local Body and Government‐aided primary and upper primary schools across the country. The Mid Day Meal Scheme is the world’s largest school feeding program reaching out to 0.84 billion primary students and 0.33 billion upper primary Students, in total about 1.2 billion children in over 9.50 ten thousands schools across the country during 2009–2010 [ 24 ].

Unhealthy eating habits and sedentary lifestyles are closely bound not only to various socioeconomic indicators such as the parent’s education levels, financial resources and professional situations, but also to living in economically deprived areas. This suggests significant contributions of gender, age and religion belief to the eating habit. Therefore, Schools should introduce healthy food policy and activity after consulting with school authority, nutrition expert and parents so as to maintain good eating habits among students [ 25 ].

4.3. National tobacco control program of India

Tobacco consumption either in smoke form or smokeless form has deleterious effect general and oral health. Tobacco abuse is the leading preventable cause of death and disease so far. Long list of diseases caused by tobacco abuse includes different cancers – lung cancer, oral cancer, cardiovascular disease, stroke and chronic lung disease. Pertaining to oral health, it causes aggressive periodontitis, tooth loss, wound healing complications and mainly pre‐cancerous or cancerous lesion leading to disfigurement of face. Risk of oral cancer is 10‐fold in smokers than no‐smokers and 11‐fold risk in smokeless tobacco users than non‐users. One can expect a normal life expectancy with early acknowledgement of tobacco health hazards and culminating tobacco use especially below 35 years. Prevention is the prime key factors, and at initial stage, most of the adverse effects of tobacco are reversible. This fact can be used to motivate tobacco using people to curb the use of tobacco [ 26 ].

India is the second largest consumer and producer of tobacco. India accounts for 10% of the world tobacco area and 9% of the production. 30% of cancer deaths, majority of cardiovascular and lung disorders; 40% of tuberculosis and other related diseases are attributed to tobacco consumption. Over 80% of oral cancers are caused due to tobacco use. As per the WHO Global Report on “Tobacco Attributable Mortality” 2012, 7% of all deaths (for ages 30 and over) in India are attributable to tobacco. Ministry of Health and Family Welfare (MoHFW), Government of India inaugurated The National Tobacco Control Program (NTCP) in 2007–2008, as included in 11th five year plan. The program includes objectives as:

Nationwide awareness regarding tobacco use harms and following tobacco control laws.

Necessary actions for strong implementation of the Tobacco Control Laws.

Effective primordial and primary level prevention strategies are planned under the National Tobacco Control Program (NTCP) .

The prime areas under the NTCP as targets are:

Training of trainers, that is, health and social workers, NGOs, school teachers and enforcement officers.

Information, Education and Communication (IEC) activities.

School Programs.

Monitoring tobacco control laws.

Co‐ordination at village level activities.

Medicinal treatment facility for cessation at district level.

Indian government implemented Cigarette and Other Tobacco Products Act (COTPA; addressing tobacco use in public places, tobacco advertising and sale and packaging regulations) since 2003 with comprehensive action in 2005 following the Framework Convention of Tobacco Control (FCTC). Following laws through the lobbying of anti‐tobacco advocates were successfully established by Indian judiciary.

Section 4: Prohibition of smoking in public places.

Section 5: Prohibition of direct and indirect advertisement, promotion and sponsorship of cigarette and other tobacco products.

Section 6a: Prohibition of sale of cigarette and other tobacco products to a person below the age of 18 years.

Section 6b: Prohibition of sale of tobacco products within a radius of 100 yards of educational institutions.

Section 7: Mandatory depiction of statutory warnings (including pictorial warnings) on tobacco packs.)

Section 7(5): Display of tar and nicotine contents on tobacco packs [ 27 ].

The achievements of this national program are examples of apt implementation. Increase in taxation had led to a reduction in self‐reported tobacco sales and consumption at the short‐term end‐point. The GATS data (2009) indicate that 54.7 and 62.9% are aware of health warnings on cigarette and smokeless tobacco packaging, respectively. Trials of school‐based education interventions demonstrated a positive impact on knowledge, advocacy skills and tobacco use. Teaching about the risks of tobacco use for health professional trainees appeared more widespread, but may have reduced slightly post‐FCTC. Community‐based education interventions and education interventions for adult tobacco users appeared beneficial. Moreover, the secondary outcomes of tobacco control programs observed as cleaner streets and air quality, preservation of forests, increased performance at school/work, reduction in fire hazards, healthy mother and infants and indeed a better quality of life. Tobacco‐use outcomes could be improved by school/community‐based and adult education interventions and cessation assistance that are facilitated by training for health professionals and schoolteachers [ 28 ].

4.4. National fluorosis prevention program

Fluoride is an essential mineral for human health. It widely exists in natural water and in foods such as tea, fish and beer. The twentieth century documented association among reduced level of dental caries with communal fluoridated water consumption. Soon, fluoride has become an effective preventive measure for dental caries. Easy incorporation into toothpaste has improved oral health in some parts of world, particularly in developing countries [ 26 ].

However, the other part of world suffers from excessive fluoride in natural environment. Fluorosis, a public health problem, is caused by excess intake of fluoride through drinking water/food products/industrial emission over a long period. Moderate‐level chronic exposure (above 1.5 mg/liter of water–the WHO guideline value for fluoride in water) is more common. Acute high‐level exposure to fluoride is rare and usually due to accidental contamination of drinking‐water or due to fires or explosions. It results in major health disorders like dental fluorosis, skeletal fluorosis and non‐skeletal fluorosis. The late stages of skeletal and dental fluorosis are permanent and irreversible in nature and are detrimental to the health of an individual and the community, which in turn has adverse effects on growth, development & economy of the country. There is no treatment for severe cases of skeletal fluorosis, only efforts can be made towards reducing the disability which has occurred. However, the disease is easily preventable if diagnosed early and steps are taken to prevent intake of excess fluorosis through provision of safe drinking water, promote nutrition and avoid foods with high fluoride content.

Fluorosis is worldwide in distribution and endemic at least in 25 countries. It has been reported from fluoride belts: one that stretches from Syria through Jordan, Egypt, Libya, Algeria, Sudan and Kenya, and another that stretches from Turkey through Iraq, Iran, Afghanistan, India, northern Thailand and China. There are similar belts in the Americas and Japan. In India, fluorosis is mainly due to excessive fluoride in water except in parts of Gujarat and Uttar Pradesh where industrial fluorosis is also seen. The desirable limit of fluoride as per Bureau of Indian Standards (BIS) is 1 ppm (parts per million or 1 mg per liter). High levels of Fluoride were reported in 230 districts of 20 States of India (after bifurcation of Andhra Pradesh in 2014). The population at risk as per population in habitations with high fluoride is 11.7 million as on 1.4.2014. Rajasthan, Gujarat and Andhra Pradesh are worst affected states. Punjab, Haryana, Madhya Pradesh and Maharashtra are moderately affected states, while Tamil Nadu, West Bengal, Uttar Pradesh, Bihar and Assam are mildly affected states.

Understanding the clinical manifestations of fluorosis

Dental fluorosis : It is categorized into mild, moderate and severe dental fluorosis depending on the extent of staining and pitting on the teeth. In severe dental fluorosis, unaesthetic & brittle enamel is found. Vitamins A and D deficiency or a low protein‐energy diet are also linked to enamel defects. Ingestion of fluoride after 6 years of age will not cause dental fluorosis. The teeth could be chalky white and may have white, yellow, brown or black spots or streaks on the enamel surface. Discoloration is away from the gums and bilaterally symmetrical.

Skeletal fluorosis : The early symptoms of skeletal fluorosis include stiffness and pain in the joints. In severe cases, the bone structure may change and ligaments may calcify, with resulting impairment of muscles and pain. Constriction of vertebral canal and intervertebral foramen exerts pressure on nerves, blood vessels leading to paralysis and pain.

Nonskeletal fluorosis/Effects of fluorosis on soft tissues/systems :

Gastrointestinal symptoms: Abdominal pain, excessive saliva, nausea and vomiting are seen after acute high‐level exposure to fluoride.

Neurological manifestation: Nervousness and depression, tingling sensation in fingers and toes, excessive thirst and tendency to urinate.

Muscular manifestations: Muscle weakness and stiffness, pain in the muscle and loss of muscle power, inability to carry out normal routine activities.

Allergic manifestation: Skin rashes, perivascular inflammation—pinkish red or bluish red spot, round or oval shape on the skin that fade and clear up within 7–10 days.

Effects on fetus: Fluoride can also damage a fetus, if the mother consumes water/food with high concentrations of fluoride during pregnancy/breast feeding. Abortions, still births and children with birth defects are common in endemic areas.

Low hemoglobin levels: Fluoride accumulates on the erythrocyte (red blood cells) membrane, which in turn looses calcium content. The membrane which is deficient in calcium content is pliable and is thrown into folds. The shape of erythrocytes is changed. Such RBCs are called echinocytes and found in circulation. The echinocytes undergo phagocytosis (eaten‐up by macrophages) and are eliminated from circulation. This would lead to low hemoglobin levels in patients chronically ill due to fluoride toxicity.

Kidney manifestations: Low volume, dark yellow to red color of urine is seen.

Calcification of ligaments and blood vessel: Forms unique feature of the disease helps in differential diagnosis.

With an aim to prevent and control fluorosis cases, Government of India initiated the National Program for Prevention and Control of Fluorosis (NPPCF) as a new health initiative in 2008–09. During the 11th Plan, 100 districts from 17 States were identified for program implementation. During the 12th 5‐Year Plan period, it is proposed to add another 95 districts for prevention and control of fluorosis. In the 12th Plan, the program has been brought under the Non‐Communicable Disease Flexi‐pool of National Health Mission (NHM).

4.4.1. Goal and objectives

To collect, assess and use the baseline survey data of fluorosis of Ministry of Drinking Water Supply for starting the project.

Comprehensive management of fluorosis in the selected areas.

Capacity building for prevention, diagnosis and management of fluorosis cases.

4.4.2. Strategy

Surveillance of fluorosis in the community and school children.

Capacity building at different level of healthcare delivery system for early detection, management and rehabilitation of fluorosis cases.

Diagnostic facilities in the form of laboratory support and equipment including ion meter to monitor the fluoride content in water and urinary levels at district/hospital/medical college for early detection and confirmation of fluorosis cases.

Health education for prevention and control of fluorosis: (a) Creating awareness about fluorosis disease, drinking water (safe/unsafe), diet editing and diet counseling through interpersonal communication, group discussions, media, posters and wall paintings. (b) Create awareness and skills among the medical as well as paramedical health workers to detect the disease in the community. (c) Provision of safe drinking water, water harvesting (rain water) and other measures in collaboration with Public Health Engineering Department.

Management Efforts are aimed to reduce the fluorosis induced disability and to improve quality of life of affected patients. Medical treatment is mainly supplementation of Vitamins C & D, Calcium, antioxidants and treatment of malnutrition. Treatment of deformity includes physiotherapy, corrective plasters and orthoses (appropriate appliances).

4.4.3. Expected outcome

The expected outcome of the National Program for Prevention & Control of Fluorosis in the districts will be:

Number of fluorosis cases managed and rehabilitated in the program districts.

Capacity for laboratory testing for fluoride in water, urine to be developed.

Trained health sector manpower in Government set up for measuring fluoride in urine and water.

Improve information base for the community and all concerned in the program districts [ 29 ].

Likewise, fluoride is double edge sword, that is, its deficiency and excess both affect the oral health. Hence, science based on effectiveness, safety and benefits should be implemented at different needs at different part of the world.

5. Strategies for oral health promotion

5.1. generation of strategies based on evidences.

WHO aim at building healthy populations involving all communities by combating every possible illness. The organization has recommended strategic framework which focuses and guide on oral health promotion activities/programs.

Reduction in oral disease/condition burden and disability, especially in poor and marginalized populations.

Promoting healthy lifestyles and reducing risk factors to oral health that arise from environmental, economic, social and behavioral causes.

Developing oral health systems that equitably improve oral health outcomes, respond to people’s legitimate demands and are financially fair.

Framing policies in oral health, based on integration of oral health into national and community health programs, and promoting oral health as an effective dimension for development policy of society [ 7 ].

Program goals are broad statements on the overall purpose of a program. For instance, “to eliminate racial disparities in oral cancer survival rates,” “to improve the oral health of nursing home residents” or “ to improve the oral health of country’s children under 5 years. Program objectives are more specific statements of desired endpoints of program.

Objectives of oral health programs should meet SMART criteria:

Specific —they should describe an observable action, behavior or achievement.

Measurable —they are systems, methods or procedures to track to record the action upon which objective is focused.

Achievable —the objective is realistic, based on current environment and resources.

Relevant —the objective is important to the program and is under the control of program.

Time based —there are clearly defined deadlines for achieving the objective [ 3 ].

Designing an oral health promotion program: step by step can be studied as shown in Figure 2 [ 1 ]:

Best practices in oral health promotion and prevention can take various forms, be it education, health promotion, integrating oral health promotion into general health promotion programs, policy changes which promote better oral health, the provision of care services, or programs specifically designed at addressing oral health inequalities. It is interesting to learn how oral health promotion and practices are implemented in through various interventions applying the Ottawa Charter guidelines.

Figure 2.

A step‐by‐step design of an oral health promotion program (based on Ministry of Health, New Zealand, 2006).

5.1.1. Building healthy public policy

Establishing healthy policies is integral in improving oral health. Based on the needs, evidences and situation analysis, National Government, health ministry, local governments, organizations, communities, schools, primary healthcare settings and local stakeholders forms or reforms the healthy policy. Health promotion advocates hold key responsibility to convey appropriate health needs of the population.

Examples of interventions that build healthy public policy

Campaigning to extend the coverage of optimal water fluoridation or water de‐fluoridation based on needs.

Supporting early childhood centers and school boards in developing healthy food and nutrition policies.

Working on policy options that eliminate the advertising of harmful food and beverages to children.

Working with organizations to promote injury prevention policies, for example, mouth‐guards in sport or safe play equipment.

Industrial approach to limit the marketing of carbonated & sugar‐containing drinks to children.

Working to study and develop standards for marketed harmful products to children.

Developing and implementing smoke free environment policies.

5.1.2. Creating supportive environments

Making the healthy choice easy choice is the aim of health promotion. This can be achieved by creating supportive social, physical, biological and cultural environments. These determinants of health directly and indirectly affect the oral health with or without general health consequences. Hence, the needs of local population should be considered in order to design and implementation of health promotion actions. Health promotion practitioners play a lead role in creating supportive environments along with public health units, government agencies, health organizations, NGOs, professional Dental Association, industry organizations and print and digital media.

Interventions that harness creating healthy supportive environments for oral health

Provision of fluoridated toothpastes at subsidized cost that low income group can also avail.

Reforming supermarket’s marketing policies for instance replacing sugary products like chocolates.

Encouragement for usage of smoke‐free environment advertisements and sponsorship for oral health promotion.

Media coverage of healthy food choices which enhance oral health.

Oral health awareness and promotion through social marketing campaigns.

Promoting safe water supply at all the public events.

5.1.3. Strengthening community action

Communities are a powerful force for achieving actions for any health promotion program where the key success factors are: partnership, participation and engagement . Encompassing all the communities for united efforts to understand their own oral health needs and ascertain to improve the oral health outcomes of their community. These health promotion programs may differ with age, society, culture and environment. Among the five actions themes of Ottawa Charter, community action is unique as concentrate on how particular health actions to be carried out. It eventually may turn out to be effective examples to be followed. Important factor for communities to have equitable access to resources to support the control they must have over their own health and development. Hence, strengthening community action is about providing and facilitating access to sufficient and appropriate resources.

Examples of interventions that strengthen community action for oral health

Engaging the community to support water fluoridation/de‐fluoridation and encourage safe water supply.

Engaging communities to participate in school oral health programs through leadership activities.

Empowering communities for healthy eating programs that enhance oral health.

Specific target‐oriented oral health improvement programs based on community cultures.

Community and school collaboration for establishing playgrounds with safe play equipment, barricades for children safety.

5.1.4. Developing personal skills

Personal skills can help individual to take control of his own health. Empowering people with appropriate knowledge and skills to improve and maintain their oral health is essential. Oral health literacy is the way that provides information, education and skills for oral health improvement. Such things help increases the resources available to people to exercise more control over their own health and environments. Health promotion programs needs to be updated that go collateral with changing environment and culture. Hence, continuum for health education, particularly for oral health, throughout life is necessary. Here, comes the role of oral health professionals who forms the bridge between health promotion advocates and health promotion program communities. At community level or at individual level, they create support system to ingress healthy personal skills to improve and maintain oral health. Oral health professionals fulfill this role of trainer by providing information, resources and training.

Interventions that help developing personal skills

Oral health promotion though guided tooth brushing using fluoridated toothpaste as self‐care habits.

Smoking cessation actions under the guidance of Oral health professionals.

Nutritional and dietary education programs which include oral health message.

Encouraging sports authorities for safe environment at sports events such as making sportsmen to put on mouth guards compulsory when required.

5.1.5. Reorientating health services

Health services carry the burden of all diseases by providing three tier cares. With advancing burden of new diseases and population explosion challenges, reorientation of health services is inevitable. The global burden of oral diseases had led to integrate oral health into general health. Indeed, it is giving a new direction for oral health services and recognizing that oral health is not merely a biomedical process. Health services should be reformed such that they not only treat the diseases but also find suitable solutions for health promotion. Strengthening of health services to analyze needs, to understand the socioeconomic determinants of health of the population is required. Such reformation which reduces oral health inequalities and improves oral health‐related quality of life is all about reorienting health services. While prime focus is on primary healthcare services, prevention, allocation, access and cost‐beneficial health services are obligatory to achieve this.

Interventions for reorientating health services

Establishing community‐led oral healthcare providers.

Extensive collaboration with NGOs and social services for oral health promotion, so the curative burden from Government is reduced.

Linking general health services and children oral health care under primary health centers.

Training the trainers, that is, training all health professionals about preventive and social components of oral health promotion.

Facilitating and building knowledge for diagnosing early caries detection programs by primary healthcare professionals.

Health care led healthy policies supporting access to oral health care.

Provision of professional fluoride lack and excess treatment facilities delivered by primary healthcare professionals and community [ 1 ].

Oral health should be an important agenda on the country’s health policy. The above international policy examples envision the challenges and opportunities for better identification, prioritization and integration of oral health services. Collaborative planning and organization may accelerate the process to arrest the global burden of oral diseases and pioneer the oral health promotion. Relevant international developments suggest that some other health promotion frameworks exists that are parallel to Ottawa Charter framework. Although their principles are same, the implementation may differ according to the needs and socio‐cultural environment of the region. One can develop or reform a different model based on above evidences for oral health promotion programs at their region.

5.2. Country examples for oral health promotion program

Investment in simple preventive programs is cost‐effective for prevention of oral diseases and promotion of good oral health which is already proven in Europe. Twenty eight examples of good practice are presented from across Europe as shown in Figure 3 . These cover all areas of oral health promotion across the life course and include programs aimed at pregnant mothers, children and adolescents, the elderly and disadvantaged groups. To solve the problem of poor oral health in other parts of world a thorough evaluation of existing successful policies and programs, identification of evidence‐based interventions can be learned from these programs.

Figure 3.

Examples of good practices in oral health promotion programs existing across the Europe.

These programs outline a number of successful initiatives that can help prevent oral diseases, which reduce the social burden and in turn reduce existing inequalities. This is done with various measures, for instance: prevention programs in communities; limiting social, economic, cultural and environmental risk factors for non‐communicable diseases, oral hygiene promotion, oral health literacy and an appropriate access to oral health care [ 30 ].

6. Conclusion

Gradient shift to rural population to urban area, issues of migrants, urbanization, socio, cultural and environmental changes alienate health promotion. Isolated intervention may not be successful at such circumstances. Oral health promotion actions with different approaches can only improve. Health for all is certainly efficient way than the target specific behaviors. It is evident that an effective and sustainable intervention combines health, society and individual through organization, policy and laws to create healthy living conditions which promotes better quality lifestyle.

WHO is considered as an accountable and reliable organization which provide necessary technical and policy support. Their evidence based guidance enable countries to integrate oral health promotion programs into the general health promotion. The organization has different expertise at Collaboration Centers across globe that is resourceful for oral health promotion guidance. However, most of the developed and developing countries utilize own resources and develop their own action program for health promotion. It is based upon local experiences and strengths, active communities to contribute participation facilitate community empowerment by creating sustainable supporting environment. WHO has given a vision to oral health promotion programs, that is, “think globally—act locally.” To conclude the chapter, an oral health promotion program should focus on following aspects:

Recognition of health determinants, capacity building for designing and implementing interventions to promote oral health.

Community led and based oral health promotion programs, having equal opportunity for marginalized segments of population.

Planning, monitoring and evaluation strategies to be implemented strictly for national oral health promotion activities/programs.

Methods and methodological development to analyze the processes and outcomes of national oral health promotion interventions.

Collaboration with strong of networks and alliances that strengthen local, national and international activities for oral health promotion. Every experience, whether success or failure should be counted and shared to acknowledge the cost‐effective and cost‐beneficial experience that yield to improve oral health quality of life.

Oral health promotion is one practice that involves strategic planning, integrative activities, evidence‐based concepts, evaluation, policy making and other related multifactor. Knowledge generation for oral health promotion through evidence‐based concepts is the goal of this chapter.

Abbreviations

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• WHO = World Health Organization.

© 2017 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Oral Health Promotion

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Promotion of oral health

Oral health promotion is any combination of oral health education and legal, fiscal, economic, environmental, organizational and technical interventions designed to facilitate the achievement of oral health and the prevention of disease. Oral health promotion directs multi-sectoral actions to the determinants of health in order to ensure that the environment is conducive to health. A key concern is the achievement of equity in health. Methods are community involvement, multi-sectoral working, empowerment, advocacy and mediation.

Basic Characteristics

The consumption of sugars in processed food and drinks is the major cause of dental caries . Smoking and oral hygiene are the major influences related to periodontal health. Further factors are the optimal exposure to fluoride and the appropriate use of good-quality dental care. Excess alcohol consumption predisposes for oral cancer. Dental and facial trauma are influenced by traffic...

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Asthana S, Halliday J (2006) What works in tackling health inequalities? The Policy Press, Bristol, pp 569–598

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Leadership, regulatory approaches and policy to re-orientate health services towards health promotion

Affiliations.

• 1 Dental Health Services Victoria, Level 1, 720 Swanston Street, Carlton, Victoria, 3053, Australia.
• 2 Melbourne Dental School, University of Melbourne, Level 1, 720 Swanston Street, Carlton, Victoria, 3053, Australia.
• 3 Victorian Department of Health, 50 Lonsdale Street, Melbourne, Victoria, 3000, Australia.
• 4 Melbourne School of Population & Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 207 Bouverie Street, Carlton, Victoria, 3053, Australia.
• 5 Institute for Health Transformation, Deakin Health Economics, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
• 6 Health Economics Group, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences. Monash University, Level 4, 553 St Kilda Road, Melbourne, Victoria, 3004, Australia.
• PMID: 38809234
• PMCID: PMC11135209
• DOI: 10.1093/heapro/daae050

Globally, oral conditions remain the most prevalent of all non-communicable diseases. Among the broad range of target goals and recommendations for action by the World Health Organization's Global Oral Health Strategy, we call out three specific actions that provide an enabling environment to improve population oral health including: (i) enabling population oral health reform through leadership, (ii) enabling innovative oral health workforce models, (iii) enabling universal health coverage that includes oral health. The aim of the article is to outline how leadership, regulatory approaches and policy in Australia can strengthen health promotion practice and can inform global efforts to tackle the complex wicked problems associated with population oral health. Examples in Australia show that effective leadership, regulatory approaches and well-designed policies can address the growing burden of non-communicable diseases, and are made possible through public health advocacy, collaboration and research.

Keywords: health policy; health promotion; leadership; public health practice; regulation.

© The Author(s) 2024. Published by Oxford University Press.

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Half the world is affected by oral disease – here’s how we can tackle this unmet healthcare need

Oral diseases are linked to a wide range of health issues, including diabetes, stroke, dementia, heart disease and more. Image:  Unsplash/Shedrack Salami

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• Oral diseases affect 1 billion more people than many other major diseases combined.
• An estimated $710 billion a year is spent on oral treatment costs and productivity losses.
• Healthcare systems need to invest in oral health and it’s disproportionately affecting the world’s most vulnerable people, says a new report from the World Economic Forum.

Almost half the world’s population is affected by oral diseases, and the number of cases is growing faster than the population. There are around a billion more cases of oral disease globally than cases of mental disorders, cardiovascular disease, diabetes, chronic respiratory diseases, and all cancers combined, according to the latest data from the World Health Organization (WHO).

Oral disease puts people at greater risk of other diseases with links to diabetes, stroke and respiratory conditions. And it costs an estimated $710 billion a year in direct treatment costs and productivity losses.

But despite this, oral health remains a neglected global challenge – and it’s disproportionately affecting the world’s most vulnerable people.

Have you read?

How poor oral health impacts health equity , poor dental health costs employers $54 billion a year. here’s how to fix it, a world health day lesson: oral health is key to overall health and wellbeing.

To tackle these challenges, the World Economic Forum launched the Oral Health Affinity Group (OHAG) in 2023 under the Forum’s Global Health Equity Network – a group of more than 50 companies committed to advancing health equity to create stronger and more productive societies.

A new report by the group, titled 'The Economic Rationale for a Global Commitment to Invest in Oral Health', explores the economic rationale for investing in oral health and why healthcare systems need to consider the mouth alongside the rest of the body.

Why is the oral health need unmet?

There are multiple reasons for this high level of unmet oral health needs. In part, it is policy-related: dental care is often not treated as an essential healthcare need in the same way as other physical health complaints.

Most healthcare services – including those where care is mainly publicly funded – tend to treat oral health separately from rest-of-the-body health. Dental care is typically seen as a discretionary, privately financed healthcare service. This, in turn, leads to affordability issues.

Why is good oral health important?

Oral diseases are linked to a wide range of health issues, including diabetes, stroke, dementia, and heart disease, as well as mental health and pregnancy outcomes. So better oral health, in turn, reduces health spending elsewhere and affects health outcomes.

However, by treating dental care as a separate issue from rest-of-body care – often in entirely different locations—the connection between oral health and health more broadly is often underappreciated.

The impact of poor oral health also extends beyond the healthcare system. It leads to lost school days and working time and impacts productivity. This impact is more pronounced for low-income, vulnerable populations, meaning improving the oral healthcare system can also help close health equity gaps.

What can we do about the oral health issue?

The OHAG report recommends several strategies to start tackling the problem. This includes actions by governments to create policies which help make dental services more affordable, such as integrating oral care within public health insurance programmes and universal health coverage policies.

Governments also have a role to play in improving oral health literacy, partnering with other organizations to advocate for better oral health.

The Global Health and Strategic Outlook 2023 highlighted that there will be an estimated shortage of 10 million healthcare workers worldwide by 2030.

The World Economic Forum’s Centre for Health and Healthcare works with governments and businesses to build more resilient, efficient and equitable healthcare systems that embrace new technologies.

Learn more about our impact:

• Global vaccine delivery: Our contribution to COVAX resulted in the delivery of over 1 billion COVID-19 vaccines and our efforts in launching Gavi, the Vaccine Alliance, has helped save more than 13 million lives over the past 20 years .
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• Mental health policy: In partnership with Deloitte, we developed a comprehensive toolkit to assist lawmakers in crafting effective policies related to technology for mental health .
• Global Coalition for Value in Healthcare: We are fostering a sustainable and equitable healthcare industry by launching innovative healthcare hubs to address ineffective spending on global health . In the Netherlands, for example, it has provided care for more than 3,000 patients with type 1 diabetes and enrolled 69 healthcare providers who supported 50,000 mothers in Sub-Saharan Africa.
• UHC2030 Private Sector Constituency : This collaboration with 30 diverse stakeholders plays a crucial role in advocating for universal health coverage and emphasizing the private sector's potential to contribute to achieving this ambitious goal.

Want to know more about our centre’s impact or get involved? Contact us .

The private sector, meanwhile, can have a positive impact on oral health by ensuring affordable access to fluoride toothpaste, oral hygiene products, and other products beneficial to oral health. It can also promote research and development into alternatives to products that are bad for oral health, such as sugary foods and drinks.

Companies should ensure that employer-provided insurance programmes include oral healthcare services.

The report also highlights the importance of civil society and how philanthropic investment in oral health activities can support health systems and improve the evidence base for oral health policy.

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Knowledge of the health personnel involved in the fluoride varnish therapy programs of primary schools in Tehran, Iran

• Mohammad Reza Khami 1 , 2 ,
• Ali Haghparast Ghomsheh 1 ,
• Hossein Hessari 1 , 2 &
• Mohsen Shati 3 , 4  

BMC Oral Health volume  24 , Article number:  649 ( 2024 ) Cite this article

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Introduction

The World Health Organization (WHO) places great importance on oral health promotion programs in schools, given that approximately one billion people worldwide are students. This demographic not only includes the students themselves, but also extends to school staff, their families, and the broader community, all of whom are interconnected. The objectives of this study were firstly to assess the knowledge of health personnel conducting fluoride varnish treatment (FVT) in schools, and secondly to solicit their views on the effectiveness of their training methods.

Data was collected from health personnel involved in FVT in schools, supervised by medical universities in Tehran province, using a questionnaire. The questionnaire was divided into four sections: demographic information, methods of receiving FVT training, respondents’ knowledge regarding FVT, and opinions about the effectiveness of FVT training methods. The questionnaire was distributed via social media, phone conversations, and email. The collected data was analyzed using Mann-Whitney in SPSS Version 26. A regression model was also fitted to the data.

The present study included 403 participants. Among various educational methods, it was found that participation in previous workshops ( P  = 0.001) and FVT workshops ( P  = 0.013) was significantly correlated with a higher FVT knowledge score. Additionally, participation in previous oral health promotion programs was significantly associated with a higher knowledge score ( P  < 0.05). Therefore, a history of participating in previous health promotion programs significantly contributed to the participants’ knowledge.

Participation in previous oral health programs was found to be significantly correlated with a higher knowledge score. The effectiveness of training programs can be attributed to participation in previous workshops and FVT workshops. This study provided insights into potential strategies for enhancing personnel training in national oral health programs.

Peer Review reports

Over 530 million children suffer from dental caries globally, with the vast majority being students or preschoolers [ 1 , 2 ]. Overlooking the issue of dental caries can lead to an increase in living expenses, particularly the cost of treatment, and can place financial strain on a country’s insurance and public health funds. Dental caries and the ensuing toothache can considerably affect a child’s quality of life [ 3 ]. Research indicates that six-year-old Iranian children, who are of school age, typically have more than four decayed teeth [ 4 ].The incidence of caries in these children has risen to an average of four and a half per child [ 5 ]. According to a 2012 report from Iran’s Ministry of Health and Medical Education (MOHME), the average Decayed, Missing, and Filled Teeth (DMFT) score was 5.6for Iranian children. Of this, 3.3, or approximately 59.3%, was attributed to the decayed component. The average caries score for Iranian children was 5.16, with an onset rate of 86% in this age group. The same report indicated that the mean DMF score for 12-year-old Iranian children was 3.29, with a caries prevalence of 75% [ 6 ].

Schools are often viewed as crucial platforms for health promotion due to their educated and readily accessible populations. The WHO places significant emphasis on oral health promotion programs in schools, as approximately one billion people worldwide are students. This group, in addition to being a substantial demographic in itself, also has strong ties with school staff, their families, and the wider community [ 4 ]. Indeed, the educational potential among school children is substantial. Consequently, the WHO has identified school students as a key target group for oral health programs [ 3 , 7 ].

The WHO has formulated a comprehensive plan for healthy schools. This plan is grounded in objectives, such as fostering a healthy school environment, promoting health education, providing health services within schools, offering food and nutrition services, encouraging sports and recreational activities, prioritizing well-being and mental health, ensuring employee health, and facilitating communication and collaboration with the broader community [ 3 ]. It can also lead to a reduction in inequality at the school level and ultimately in the society.

A variety of oral and dental health promotion programs have been implemented in Iran. In 1998, a tripartite agreement focusing on education, prevention, and treatment was signed between the MOHME and the Ministry of Education for school students aged 6–12 years. Subsequent to this, additional programs were initiated. For instance, one of the oral health promotion programs coordinated with child-related organizations to implement a plan aimed at improving the oral health of kindergarten teachers. Concurrently, preschool students underwent examinations and received fluoride varnish treatments (FVTs) [ 8 , 9 ]. In 2014, a plan was initiated to utilize a mobile dental unit for delivering oral health promotion services to schools. The Student Oral Health Improvement Plan was designed around several key services: issuance of dental birth certificates, fluoride therapy, health education, and the provision of necessary treatments, including referrals when required [ 10 ].

In 2015, the most recent initiative, which was a new agreement for primary school oral health promotion, was signed between the MOHME and the Ministry of Education. It was named the Primary School Oral Health Promotion Program (PSOHPP), targeting children under 14 years of age. According to this program, services are provided free of charge for rural and less privileged areas, while in urban areas, parents cover 30% of the cost. Additionally, children receive free oral examinations. If a child is diagnosed with dental issues during these examinations, they are referred to government-funded dental centers, such as dental schools or clinics contracted by the Ministry of Education for treatment. During these student examinations, the examiner also spends a few minutes on oral health education [ 11 ]. Another component of this program is the administration of FVT twice a year.

The addition of FVT to caregiver counseling has proven effective in reducing the incidence of early childhood caries [ 12 ]. This approach has been implemented in school-based oral health programs globally [ 13 ]. The FVT is typically administered by a trained health professional who is knowledgeable about the procedure. A diverse group of these professionals, ranging from community health workers in rural areas to dental hygienists and dentists in urban locales, are employed by the MOHME to carry out FVT in the PSOHPP program. However, the majority of this personnel comprises non-dental professionals who have been specifically trained to administer FVT as part of this program. On the other hand, the success of the FVT program is highly dependent to the knowledge of its operators [ 14 ], as essential considerations should be taken into account when performing the procedure [ 15 ]. Evidently, evaluating the knowledge of these professionals and its correlation with their training methods can provide valuable insights for enhancing this program and informing future initiatives.

In Iran, the universities of medical sciences, which are supervised by the MOHME, are tasked with providing healthcare services to the populations under their jurisdiction. Tehran, with a population exceeding nine million, is served by three main universities of medical sciences. Each of these universities covers distinct geographical areas within the city.

Despite the eight-year operation of the PSOHPP, there is, to the best of our knowledge, no comprehensive evaluation of the program, including an assessment of the involved personnel’s knowledge. Therefore, the aim of this study was firstly to examine the knowledge of health personnel who administered FVT in Tehran schools, and secondly to solicit their views on the effectiveness of their training methods.

The present study was approved by the Ethics Committee of the School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran(Code: IR.TUMS.DENTISTRY.REC.1400.138). Due to the ethical considerations from one of the three medical universities in Tehran (Iran University of Medical Sciences), our study was conducted in the remaining two universities (Tehran University of Medical Sciences and Shahid Beheshti University of Medical Sciences), which collectively serve populations of 3,160,817 [ 16 ] and 5,745,828 [ 17 ], respectively, according to the latest statistics available. Of these populations, around 11.5% have been in the age range of 6–14 years, and were candidate for FVT at the beginning of PSOHPP [ 18 ]. In these two universities 434 professionals were involved in FVT in Tehran schools.

The target population of our study consisted of health personnel who were involved in administering FVT in schools, under the supervision of medical universities in Tehran province. The primary instrument for this research was a researcher-made questionnaire (See Appendix 1). This data collection tool was divided into four sections:

Demographic and background information : This section collected information on age, gender, level of education, and history of participation in previous oral health promotion programs.

Methods of receiving FVT training : In this section, the participants were asked about the FVT training methods they had participated in. All methods applied to the FVT service providers were listed as a checklist, and the participants could select as many options as applicable. The options were: FVT workshop, Professional development courses, Pamphlets and posters, Booklets, CD.

Knowledge of the respondents regarding FVT : This section covered the nine steps required for a successful FVT checklist from a previously validated questionnaire [ 19 ]. The respondents were asked to rate their agreement with the importance of each step on a scale of 0–5, resulting in a possible score range of 0–45.

Opinions about the effectiveness of FVT training methods : In this section, the participants were asked to identify which FVT training methods they found to be more effective than others. The options were the same as those for “Methods of receiving FVT training” section, mentioned above.

The questionnaire was in Farsi language. In order to include all available options for the questions and to validate the check lists, the questionnaire and its items were discussed in three separate group discussions, one with the experts of Oral Health Bureau (MOHME), and two with dental officers of the two universities. Necessary amendments were done according to the experts’ opinion [ 20 ].

Data collection

The contact list of service providers, including their phone numbers, was procured from the health vice-chancellors of medical sciences universities. A link to the online questionnaire was distributed among these individuals via SMS or the WhatsApp social network. If the questionnaire remained incomplete after two weeks, a reminder was sent to the participants. The reminder process was repeated after one week.

The data collection started in January 2022, and lasted for six weeks.

Statistical analysis

To describe the data, frequency, median, mean, and standard deviation (SD) were calculated. Given the lack of normality in the data, non-parametric methods, such as Mann-Whitney was employed for data analysis. A regression model was fitted to the data to explore the relationships of the independent variables to the participants’ knowledge of FVT. The gathered data was processed using SPSS Version 26.

Out of the 434 links distributed, a total of 403 participants (representing 93% of the recipients) took part in the study. The average age of the participants was 36.1 years, and they had an average of 5.93 years of work experience. Of these participants, 30 (7.44%) were men, and 375 were women. In terms of educational attainment, 223 (55.3%) of the 403 participants held a bachelor’s degree or higher. Regarding the employment status, 119 (29.5%) participants had permanent contracts, while 284 (70.5%) were temporarily hired for this program. Additionally, 255 (63.3%) respondents had previously participated in oral health promotion programs.

Table  1 presents the frequency of participants reporting scores of 4 and 5 for each knowledge statement. “The importance of keeping oral fluids away from dental surfaces for a while after FVT” statement ranked the highest, followed by “The importance of isolating teeth from oral fluids for FVT”. “The importance of giving instructions after FVT” received the lowest ranking.

Table  2 presents the average knowledge scores of the participants based on their background characteristics. A significant increase in the mean knowledge score was observed with advancing age ( P  < 0.05). Furthermore, participants who had previously engaged in oral health programs demonstrated a higher mean knowledge score compared to those without such experience ( P  = 0.001).

Table  3 describes the average knowledge scores of the participants, categorized by the methods through which they received FVT training (all of the participants had received education on VFT via at least one of the training methods). Participation in FVT workshops ( P  = 0.013) was significantly related to a higher FVT knowledge score.

Based on the findings, no significant relationship was found between the opinions of the respondents regarding the effectiveness of various educational methods and their knowledge regarding FVT (Table  4 ).

Table  5 presents the regression model based on variables that exhibited a significant correlation with the knowledge score in prior tests. Notably, participation in earlier oral health promotion programs (before FVT) was significantly linked to a higher knowledge score ( P  < 0.05). This suggests that the knowledge score was independent of age and associated with the history of participation in previous health promotion programs. The knowledge score of individuals who attended previous FV Training workshops was nearly one unit greater than the score of those who did not participate in these workshops.

The objective of this study was to assess the knowledge of health personnel conducting FVT in schools of Iran and to determine its determinants. The results revealed that the overall knowledge of the participants was good. The significant presence of healthcare workers (“Behvarzes” in the Iranian medical system) in this study can be attributed to their status as the primary health workforce in the country’s rural areas, where they perform oral health tasks, such as oral examinations, FVT, and referrals [ 21 ]. Over 90% of the participants acknowledged the importance of executing the necessary steps for FVT, with the exception of two items related to tooth isolation; approximately 20% of the participants did not fully agree with these two items. It is worth noting that isolation is a critical step in FVT [ 22 ]; therefore, future programs should place more emphasis on it.

In the bivariate analysis, individuals of higher ages and those with prior experience in oral health programs reported significantly better knowledge. However, in the regression model, after adjusting for variables, only the correlation with previous experience remained significant, suggesting that the age-related difference is likely a reflection of experience. This underscores the importance of experience, indicating that these individuals will gain more knowledge if they continue with this program or participate in future health promotion programs. Involvement in previous oral health promotion programs provides insight about effectiveness of strategies, challenges, and the ways to improve outcomes [ 23 , 24 ]. This insight increases the motivation to continue involvement in oral health programs, which, in turn, improves the success of these programs. For example, according to a study in the US, pediatricians reported “personal experience implementing oral health into their practice” as one of the main factors enabling their success in a new oral health initiative. This experience provided more interest and motivation for them to actively participate in the new program [ 24 ].

Among the various training methods, the FVT workshop was identified as the most effective. This observation aligns with the findings of previous studies involving non-health professionals, where it was found that training workshops enhanced the oral health knowledge of school teachers [ 25 , 26 ]. Although interactive workshops could improve knowledge and participant satisfaction, combining interactive workshops with other teaching methods may be more successful [ 27 ].

Based on our findings, among the various educational methods and materials, CDs were reported to be the least utilized. Conversely, booklets were identified as the most frequently used training method. Generally, booklets are more accessible [ 28 ] and can be read without the need for a computer. Furthermore, a study in Iran showed that combination of booklet, pamphlet and Continuing Medical Education (CME) could significantly improve oral health knowledge for primary care physicians [ 29 ]. CME is the professional development courses specifically designed for those in the medical field [ 30 ].

Professional development courses are routinely offered to healthcare professionals to enhance the necessary skills for their profession; some of these courses require mandatory participation. Furthermore, these professionals can expedite their career progression by attending these courses. This is why professional development courses were ranked as the second most popular training method by the participants. These courses offer valuable capabilities for oral health promotion programs [ 29 ] and should be given greater consideration in future programs. Moreover, online platforms exist for these courses, enhancing their accessibility and popularity. Given the advancements in distance and digital education systems and the increased ease of access to these platforms, particularly in the wake of the corona virus pandemic, these methods could be incorporated into future programs. This could include hosting webinars or online classes and utilizing digital education tools and content, with a particular emphasis on leveraging artificial intelligence. On the other hand concerns exist about online CME, including technological limitations and lack of sufficient engagement of the participants [ 31 ].

One of the strengths of this study was its census-style approach, which ensured a satisfactory sample size of participants. However, our inability to directly observe FVT in schools due to the COVID-19 pandemic could have led to invalid results. The cross-sectional design of the study can be seen as another limitation. Our questionnaire was mainly in the format of checklist, extracted partly from a previously validated questionnaire [ 19 ]. We had no complex variable to go through routine validation process. However, we used experts’ opinion to validate checklist [ 20 ]. The authors suggest conducting separate studies to compare the success or potential failure of PSOHPP, as well as to gauge the satisfaction levels of project stakeholders in different regions of the country.

According to the findings of this study, participation in previous oral health programs was significantly linked to a higher knowledge score. Moreover, engagement in prior workshops and FVT workshops can be viewed as an effective training method, both for the continuation of the current program and for future initiatives. This study could provide insights into how to enhance personnel training in national oral health programs.

Data availability

All data are available upon request. For more information please contact to correspondence email at: [email protected].

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Acknowledgements

The authors would like to extend their acknowledgements to all study participants and study team members for their time and energy spent on this project. The author wish to acknowledge Dr. Reza Emrani for his useful and constructive recommendations on this project.

The present study was granted by Tehran university of medical science as a PhD thesis.

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Mental Health Research Center (MHRC), School of Behavioral Sciences and Mental Health, Tehran Institute of Psychiatry, Iran University of Medical Sciences, Tehran, Iran

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Conceptualization: A.H. Collecting data and Formal analysis: M.SH. Writing - original draft preparation: MR.KH. Writing - review and editing: H.H, A.H.

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Correspondence to Ali Haghparast Ghomsheh .

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The study was approved by the institutional ethics committee of Tehran university of medical science (NO: IR.TUMS.DENTISTRY.REC.1400.138) and complied with the declaration of Helsinki and good clinical practice guidelines.

In the beginning the questionnaire we explain to the participants that: “Completing the questionnaire by you as is considered as you are inform consent to participate in this study”.

The people who had received fluoride varnish therapy service in PSOHPP were school pupils in the age group of 7 to 14 years, and before providing the service, written consent had been obtained from their parents or legal guardians.

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Khami, M., Haghparast Ghomsheh, A., Hessari, H. et al. Knowledge of the health personnel involved in the fluoride varnish therapy programs of primary schools in Tehran, Iran. BMC Oral Health 24 , 649 (2024). https://doi.org/10.1186/s12903-024-04390-8

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Oral health community engagement programs for rural communities: A scoping review

Hlulani alloy nghayo.

1 Faculty of Dentistry, Department of Community Oral Health, University of the Western Cape, Cape Town, South Africa

2 Faculty of Science, Department of Sport, Rehabilitation and Dental Sciences, Tshwane University of Technology, Pretoria, South Africa

Celeste Ellouise Palanyandi

3 Faculty of Dentistry, Department of Prosthodontics, University of the Western Cape, Cape Town, South Africa

Khabiso Jemima Ramphoma

Ronel maart, associated data.

All relevant data are within the manuscript and its Supporting Information files.

This scoping review aims to identify the available literature on oral health community engagement programs that have been developed to guide oral health care in rural communities and to summarize their outcomes. This review was conducted using the 5-stage scoping review framework outlined by Arksey and O’Malley. We conducted a literature search with defined eligibility criteria through electronic databases such as Science Direct, PubMed, ProQuest, Scopus, EBSCOhost, and Wiley Online; other well-established online scientific health and dental organizations such as the WHO, the Fédération Dentaire Internationale of the World Dental Federation, the American Dental Association, and the South African Dental Association; and grey literature spanning the time interval from January 2012 to August 2023. The charted data were classified, analysed, and reported using descriptive and thematic analyses. A total of 19 records were included in the final review. These records were classified into four categories of interventions: community-based, school-based, integrated dental-based, and non-dental volunteer oral health programs. The findings imply that there is a growing appreciation for the significance of qualitative data in enhancing oral healthcare interventions and outcomes. Furthermore, the study showed that oral health strategies were successful in shaping the understanding and perception of oral health among children and mothers/caregivers, and in improving the oral health and quality of life of edentulous older adults and children living in rural communities.

Introduction

The Global Burden of Disease (GBD) study has shown that the prevalence of common oral diseases remains a significant global health issue [ 1 ], affecting an estimated 3.5 billion people worldwide and having a major impact on health, well-being, health care systems, and economies, as well as the increasing burden of Non-Communicable Diseases [ 2 ]. Moreover, the global burden of untreated oral diseases, the continued absence of universal health coverage, the cost of basic oral health care for significant portions of the global population, and the escalation of disparities indicate that oral health has not been regarded as a public health priority [ 3 , 4 ].

In developing countries, access to suitable oral healthcare interventions is commonly absent [ 5 ]. As a result, disadvantaged communities are still disproportionately affected by oral diseases and are more likely to face barriers in accessing and utilizing oral health care services [ 6 ]. Despite significant progress in the prevention and treatment of oral diseases, as well as overall improvements in oral health in recent years, disparities persist, and there is a definite common discrepancy in oral health that reflects that of general health. [ 7 ]. This has resulted in significant disparities in global oral health.

Although developing countries are confronted with prevalent challenges such as lack of oral health awareness, limited access to professional dental care services, inadequate transportation options, perceived lack of need for dental care, and obstacles associated with language and culture [ 8 – 10 ], a lack of dental professionals is the primary cause of severely reduced accessibility to oral health services and poor oral health status, not only in developing countries but worldwide [ 4 , 11 – 13 ].

To address this, the World Health Organization has launched oral healthcare programs, particularly for disadvantaged countries, which include oral health education and the integration of health education with other oral health practices, such as preventive, restorative, and emergency dental care. These programs aim to enhance oral health services within member countries with a particular focus on the most disadvantaged communities [ 5 ]. The goal is to ensure equal access to information and resources for high-quality oral health care, provide specialized knowledge for executing clinical trials, and create cost-effective alternatives to increase the availability of oral health services [ 14 ].

Several global studies have shown that implementing community-based initiatives for oral health promotion can improve community engagement, leading to the development and improvement of knowledge, attitudes, and behaviours related to oral health. These initiatives have also proven effective in involving communities in promoting long-term oral health [ 15 – 18 ]. Furthermore, the active and meaningful engagement of communities and civil society are essential components of any comprehensive strategy or initiative aimed at achieving oral health objectives and targets included in the Sustainable Development Goals (SDG 3 –good health and well-being, SDG 4 –quality education, SDG 10 –reduced inequality, and SDG 17 –partnerships to achieve the goal) [ 19 ].

Implementing mandatory community-based programs for oral health promotion and prevention is crucial. Early detection and treatment of oral diseases can prevent their progression and improve overall health. It is imperative to develop initiatives that cater to underprivileged communities. These initiatives have the potential to contribute significantly to achieving Sustainable Development Goals and ensuring Universal Health Coverage for all. Therefore, this scoping review aims to identify oral health community engagement programs that guide oral health care in rural communities and to provide an overview of their outcomes.

Materials and methods

This study used the methodological framework for scoping reviews defined by Arksey and O’Malley [ 20 ]. The aim of conducting a scoping review is to comprehensively examine and identify the fundamental ideas and themes related to a particular research subject along with the primary sources and various forms of evidence that exist. The scoping review was guided by five stages: identification of the research question, identification of relevant studies, study selection, data charting, and collating, summarizing, and reporting the results. The sixth stage was optional and was excluded upon consensus among the four reviewers (HAN, CEP, KJR, and RM).

Identification of the research question

The process of conducting this scoping review was guided by a specific research question that informed the selection of relevant literature. The research question formulated for this scoping review was as follows: What are the oral health community engagement programs that guide oral health care in rural communities ?

Identification of relevant studies

To identify appropriate studies, Arksey and O’Malley argued that it is necessary to define a search plan based on the location, type, or parameters of the study [ 20 ]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) [ 21 ] were used to conduct a comprehensive literature review. Using Boolean operators, the key terms and Medical Subject Headings were combined, and an example of a search string ( S1 Table ) constructed and used in this manner was as follows:—(Oral OR dental) AND (health) AND (rural OR remote) AND (communities OR settings OR areas) AND (engagement OR participation OR outreach OR programs) AND (programs OR programmes OR strategies OR initiatives). The following databases were used to search for all relevant and published journal articles: Science Direct, PubMed, ProQuest, Scopus, EBSCOhost, and Wiley Online. Google Scholar was also used to maximise the search. A health science librarian was consulted to guide the search strategies. Furthermore, Google Scholar and other well-established online scientific health and dental organizations such as the WHO, the Fédération Dentaire Internationale of the World Dental Federation (FDI), the American Dental Association (ADA), and the South African Dental Association (SADA) were used to search for grey literature.

Study selection

Two independent reviewers (HAN, and CEP) screened the titles and abstracts of each article and identified articles for full review. EndNote reference manager was used to eliminate duplicate articles. Any uncertainties and disagreements were discussed and resolved by consensus.

Inclusion criteria

Peer-reviewed journal articles published in English between January 2012 and August 2023 were included as part of the inclusion criteria for this scoping review. Articles referring to Oral Health Community Engagement Programs for Rural Communities were eligible for inclusion. In addition, established online scientific health and dental organizations, including ADA, FDI, SADA, and WHO, were searched for grey literature, and academic dissertations were also considered.

Exclusion criteria

Non-English and non-peer-reviewed journal articles published before 2012 were excluded. In addition, editorials, commentaries, and reviews were excluded, along with all articles that did not reference Oral Health Community Engagement Programs for Rural Communities.

Data charting

One reviewer (HAN) charted all the data from the included articles based on (a) Bibliographic details: Author (s) , Year , Country ; (b) Study aim; (c) Study design; (d) Participant demographics of rural communities; (e) Type of oral health community engagement programs; (f) Duration of oral health community engagement programs/strategies (g) Outcome measures and (h) Key Findings/results. Thereafter, the other reviewer (CEP) extensively analysed the extracted data to validate its accuracy. Any disagreements and rectifications were agreed upon by consensus.

Collating, summarizing, and reporting the results

Based on the charted data, two reviewers (HAN and CEP) developed categories and subcategories for programs related to oral health community engagement in rural communities. The other two reviewers (KJR and RM) reviewed and verified the categories to ensure consistency and authenticity. The charted data were then grouped, analysed, and reported through descriptive and thematic analyses.

Ethical considerations

This scoping review formed part of the research project, which was approved by the Biomedical Science Research Ethics Committee of the University of the Western Cape (BMREC) (reference number: BM23/6/16). Informed consent was not obtained for this study because no participants were involved.

Characteristics of the included publications

Of the 750 articles found through online databases and manual searches, 100 duplicates were eliminated. Of the remaining 650 articles, 575 were excluded due to irrelevance. A total of 75 articles were screened and 19 were selected for full-text review. These 19 articles were later deemed eligible for the scoping review based on the established inclusion criteria ( Fig 1 ) . The published research articles identified and included in this scoping review are summarized in Table 1 .

The majority (n = 11) of the 19 studies included in this scoping review were conducted in developing countries, while only (n = 8) were conducted in developed countries ( Table 2 ) . That is, four studies were conducted in Australia and India, respectively, while three were conducted in the USA. Canada, El Salvador, Nepal, Pakistan, Sri Lanka, Taiwan, Tanzania, and Uganda each produced one. The definition of rural community is complicated and has multiple connotations, such as farms, ranches, villages, small towns, open spaces, and low population density, which researchers and policymakers have used inconsistently [ 37 ]. However, for this scoping review, rural communities have been defined as disadvantaged and vulnerable settings owing to their low socioeconomic status, limited access to transportation, scarce availability of quality oral health care, insufficient number of oral health care providers, and limited access to oral health education, all of which led to high rates of non-communicable diseases and poor general health [ 38 , 39 ].

The majority (n = 13) of the studies employed a quantitative research approach, while (n = 4) of the studies were qualitative, and only (n = 2) employed a mixed-method approach. Most of the included articles sampled primary school children (n = 6), whereas (n = 4) of the articles used community members (adults), dental personnel, and non-dental personnel as study participants. Overall, (n = 1) of the studies used community members (patients) as study targets.

Identification of oral health community engagement programs

Based on the findings of this scoping review, oral health community engagement programs were grouped into four distinct intervention categories that have been successfully implemented in diverse rural communities. The initial category elucidates the community-based dental interventions [ 15 , 22 – 27 ]. The subsequent category delineates the school-based dental interventions implemented in the primary school setting [ 17 , 18 , 28 – 30 ]. The third category emphasizes the importance of integrated dental-based interventions [ 25 , 28 , 32 , 35 ]. The fourth category characterises the auxiliary care community-based interventions [ 16 , 35 , 36 ]. The summary of categories of oral health community engagement interventions and their programs are outlined and depicted in Table 3 .

Category 1: Community-based oral health community engagement interventions

This category encompasses articles on community-based oral health programs implemented to guide oral health care through the adoption of participatory community-based approaches. These articles mainly involve the integration of community members into oral health programs while also addressing social and environmental factors that act as substantial barriers to accessing optimal oral health. The two studies included in this scoping review were conducted in rural communities in Canada and El Salvador and aimed to enhance community and caregiver knowledge and awareness, improve early childhood oral health [ 6 ], and assess the impact of oral health education and fluoride on reducing early childhood caries [ 8 ] in a 5-year community-based early childhood oral health intervention program. Both studies concluded that the program was successful in improving caregivers’ understanding of and attitudes toward early childhood oral health, and it led to a significant reduction in early childhood caries.

In an ongoing oral health education program, Sajid et al . (2020) [ 13 ] found a significant association between higher education and better oral health status for dental caries and periodontal disease in a rural Pakistani community. In addition, improvement in knowledge and perception of oral health was observed among individuals within the community. However, the authors concluded that community-related factors, including family, teachers, and dental health personnel of school-based programs, have a positive impact on oral health and should be integrated into oral health education programs to enhance the knowledge and perception of oral health.

Similarly, Australian remote Aboriginal adults were engaged in an ongoing community-based Yarning Program where their perceptions and attitudes towards oral health were investigated to better understand existing prevention and education strategies and inform future ones. Consequently, remote Aboriginal adults indicated that existing school-based oral health promotion and community-driven initiatives have put restrictions on the sale of sugary food and drinks, and these initiatives were seen as positive strategies for improving oral health. However, the availability of the Internet and fixed community stores were perceived as creating new challenges and shifting priorities for those living in remote communities [ 18 ].

Huang et al . (2020) conducted a study in a rural community in Taiwan, in which 136 community-dwelling adults with metabolic syndrome were recruited from two rural townships. These individuals were invited to participate in an 18-month community-based oral hygiene program. This study aimed to investigate the efficacy of a comprehensive oral hygiene intervention coupled with telephone health counselling among individuals residing in rural communities who were diagnosed with metabolic syndrome. The program demonstrated efficacy in enhancing awareness and mitigating Cardiometabolic risks, along with notable improvements in oral hygiene and health-related behaviours. However, the authors concluded that there was a deficiency in the implementation of a comprehensive dental examination before and after the program [ 24 ].

A four-week public-funded oral rehabilitation program, specifically known as the public-funded denture program, was introduced in a prospective pre-post comparison study conducted in India. The program primarily targeted edentulous senior citizens aged ≥ 60 years. Although the observed effectiveness in enhancing oral health quality of life among the edentulous elderly is worth acknowledging, the authors concluded that it would be significant to further investigate the favourable aspects of the natural settings, a significant sample size, and long-term reliability of the tools used to measure oral health-related quality of life (OHRQoL) before generalizing the findings to different contexts [ 15 ].

The prevalence of tooth loss among Black individuals in the USA has been noted. To understand whether a usual source of health care helps mitigate racial differences in complete tooth loss and recent dental visits among urban and rural older adults, Caldwell and colleagues evaluated the Primary Care for the Oral Health program. The target population consisted of adults aged ≥ 50 years. Access to primary health care was found to be associated with improved oral health outcomes, but the authors concluded that it did not completely close the gap between Whites and Blacks in rural communities. However, the inclusion of the US region and tract-level poverty improved the description of how living in a rural area may contribute to racial differences in oral health status. To comprehend variations in dental health in later stages of life as well as differences in fluoride exposure, the authors recommended that future research should explore the childhood experiences of rural White and Black adults [ 10 ].

Category 2: School-based oral health community engagement interventions

Schools can play a significant role in promoting children’s oral health and overall wellbeing. By implementing school-based oral health programs, schools can extend the reach of oral health education, preventive measures, and services to children within school-age groups. Therefore, this category included articles that utilized such programs to offer guidance and support for oral health care. Two interventional studies were conducted on primary school children to evaluate a 6-month school-based program. Both studies showed that the program was effective in enhancing tooth brushing, knowledge, and attitudes, as well as in reducing the oral hygiene index-simplified, plaque index, and gingival index scores. These studies were conducted in Tanzania [ 1 ] and India [ 2 ] and implemented the Atraumatic Restorative Treatment (ART)/Oral Health Education (OHE) program and the Teacher-Dentist Dental Health Education (DHE) program, respectively. However, in the Tanzanian study [ 1 ], the short-term intervention program did not result in a decrease in sugar consumption, indicating that behavioural change is a gradual process that requires time, whereas an Indian study [ 2 ] indicated that the effectiveness of Dental Health Education was higher when conducted regularly by trained teachers than when conducted by qualified dentists. This suggests that after receiving brief training, teachers can also perform periodic screenings for visible build-up of plaque and calculus in children.

In contrast, another interventional study was conducted in India to implement and evaluate community participatory oral health promotion and prevention programs in school children as well as to conduct knowledge, attitude, and practice surveys among health workers and schoolteachers on oral health in a 16-month Participatory Oral Health Promotion and Prevention Program. The results of the study showed significant improvements in filled surface lesions of both the primary and permanent dentition, as well as in the bleeding sextants. The authors concluded that empowering the local community to provide oral health education and basic preventive treatment would bridge the oral health inequality gap between urban and rural communities, particularly among schoolteachers who can effectively impart oral health education to school children on a long-term basis [ 23 ].

Surprisingly, the 3-month program conducted in schools that focused on preventing tooth decay through teaching proper oral hygiene and supervised toothbrushing successfully increased oral health knowledge and cultivated positive oral hygiene practices among school children. However, the authors noted that despite being the shortest program, the most positive results were obtained when they included additional activities. These activities included assessing the nutritional status and hidden sugar in each child’s diet using a 3-day diet diary and conducting frequent oral examinations to motivate children to improve their brushing technique [ 3 ].

Despite significant technological advancements in dentistry, the lack of a sufficient dental workforce remains a significant obstacle for underprivileged communities to access dental and oral healthcare services. In 2016, the USA implemented the TeleHealth Network Grant Program in schools, in a study conducted by Ward et al . (2022). Despite the findings indicating that the method allowed traveling clinicians to successfully carry out almost all (97%) of the necessary treatment within their professional boundaries, it significantly decreased the necessity for a physical visit to a dentist (52%). The need for dental hygienists in schools and the use of telehealth technology to collaborate with dental professionals can improve access to oral healthcare services for children in rural communities. In addition, the authors suggested that dental hygienists could utilize teledentistry to perform oral health screenings in schools, thereby effectively identifying school children who have a higher risk of dental caries. This method may be beneficial in the prevention and management of oral diseases [ 20 ].

Category 3: Integrated dental-based oral health community engagement interventions

Studies have shown that communities with access to oral health professionals experience improved oral health [ 40 , 41 ]. These professionals are trained to create personalized oral health plans and take preventive measures to enhance the oral health of communities [ 42 ]. Furthermore, their participation is crucial for improving referral pathways and implementing programs for oral health management [ 40 ]. Therefore, this category included articles that underpinned integrated dental-based oral health community engagement programs. For example, Dental assistants were trained to apply fluoride varnish to Aboriginal primary school children to mitigate disparities in access to oral healthcare services. Skinner et al . (2020) investigated the feasibility of using such personnel in a 12-month Aboriginal Dental Assistant Scholarship Program and a Fluoride Varnish Program. Their study found that dental assistants were effective in safely applying fluoride varnish to primary school children, with no reported adverse reactions. Additionally, no complaints were received from students, parents, guardians, schoolteachers, or principals regarding participation in or conduct of the study [ 14 ].

Similarly, in Australia, during the 3-year integrated partnership between the Oral Health Therapy Graduate Year Program and the Dalang Project, which promoted oral health service delivery and promotion, Skinner et al . (2021) investigated the interest of graduates working in rural communities following their participation in the collaborative project. Although the project was successful in improving oral health services for Aboriginal children and provided a positive experience for oral health therapists, many graduates continued to work in rural, remote, and regional locations after completing the program [ 16 ].

A community health center (CHC) in Washington, USA, introduced a medical-dental integration program (MDI) for children. The program allowed medical and dental providers to examine children during the same visit at a paediatric medical clinic or women, infants, and children program location in a rural community. The main aim of the program was to increase access to oral health care and to mitigate childhood caries. Consequently, Pawloski et al . (2022) evaluated the acceptability, feasibility, and success of an MDI integration strategy in a CHC setting and determined that it was acceptable and feasible owing to the collaborative approach that included the involvement of service providers, leadership alignment, and support, consistent and clear communication, and employment of a registered dental hygienist as the oral health provider [ 19 ].

In Australia, the Kimberley Dental Team (KDT) was founded as a non-profit and volunteer organization in 2009. Their objective was to deliver dental care and education to Aboriginal children and their families residing in the Kimberley area. Despite the initiative being in place for a long period, the Aboriginal population in the Kimberley region continues to face challenges in obtaining oral health services, experiencing inadequate nutrition, and a lack of government assistance. These obstacles persist despite the advantages of education and access to appropriate culturally sensitive care, which were previously believed to contribute to better oral health outcomes [ 5 ].

Category 4: Non-dental-based oral health community engagement interventions

Proper allocation of skilled and motivated healthcare workers in a timely and suitable manner is crucial for ensuring efficient healthcare services and improving health outcomes [ 43 ]. While non-dental personnel can provide temporary relief from symptoms and refer individuals to oral health professionals [ 44 ], their involvement in communities can result in the sharing of oral health knowledge and influence decision-making [ 45 ]. As a result, this scoping review included articles on oral health programs that guide oral health care through non-dental personnel. For instance, the study conducted by Fernando et al . (2015) demonstrated that the enhancement in the oral health of preschool children was statistically significant and was attributed to the intervention aimed at educating mothers and caregivers of preschool children. This finding suggests that non-dental personnel can effectively deliver oral health education to improve the oral health of children. This experimental study was conducted in Sri Lanka to evaluate a 6-month Non-Dental Personnel Program [ 4 ].

Similarly, regarding the community health worker program, Erchick et al . (2020) conducted a prospective cohort study that evaluated the validity of periodontal examinations conducted by auxiliary nurse midwives in a rural home setting in Nepal. Although the study found that the overestimation was minor and unlikely to have an impact on population-based estimates of important indicators of oral health status, it was recommended that certain basic oral health services be transferred from dentists and other highly trained professionals to auxiliary nurse midwives or community health workers. These conclusions were drawn after auxiliary nurse midwives tended to report higher periodontal probing depth scores relative to dentists [ 11 ].

In the WHO health-promoting school framework in Uganda, Akera et al . (2022) concluded that oral health promotion in primary school children requires the support of teachers, parents, health workers, and community leaders. Regular training is necessary for teachers to improve their skills and to provide dental services. Local, district, and national resources are necessary to support oral health promotion in school children [ 17 ].

The purpose of this scoping review was to identify oral health community engagement programs that guide oral health care in rural communities and to provide an overview of their outcomes. To achieve this, we employed a systematic approach to identify records bearing oral health community engagement programs, which were then categorized into four main intervention groups: community-based, school-based, integrated dental-based, and non-dental volunteer-based strategies. The eligible records that we obtained originated from both developed [ 15 , 25 , 27 , 30 – 34 ] and developing countries [ 16 – 18 , 22 – 24 , 26 , 28 , 29 , 35 , 36 ]. Overall, the results of this scoping review confirmed that oral health community engagement programs were effective in enhancing the knowledge and perception of oral health among children and mothers/caregivers; improving oral health and quality of life of edentulous older adults and children; expanding access to and incorporating oral healthcare services provided by dental personnel; and improving oral health outcomes through the involvement of community health workers and teachers among rural residents. Despite these achievements, the current scoping review highlighted a persistent and significant gap in the literature regarding the implementation, evaluation, and impact of oral health community engagement programs in rural communities. This gap pertains to individuals’ need for shared responsibilities and an understanding of oral health community engagement programs as well as their content.

It is important to highlight that there was a scarcity of literature available on oral health community engagement programs in this scoping review. While the majority of the records included in this scoping review were quantitative studies, mixed-method, and qualitative studies were also included. This observation may indicate a growing recognition of the value of qualitative data in enhancing oral healthcare interventions and outcomes [ 46 ], especially concerning oral health community engagement programs in rural communities.

Although the overall findings of this scoping review revealed oral healthcare improvements in various rural communities, the findings also suggested that developing countries face a substantial burden of oral diseases [ 16 – 18 , 22 – 24 , 26 , 28 , 29 , 35 , 36 ]. Furthermore, the inclusion of studies evaluating oral health strategies in rural communities of developed countries provided evidence of persistent discrepancies in oral healthcare accessibility and a shortage of oral healthcare professionals, confirming that this burden is of global significance [ 15 , 25 , 27 , 30 – 34 ]. The results of the scoping review also indicated that the methods used to evaluate the effectiveness of the oral health community engagement programs implemented in rural communities of both developing and developed countries were inconsistent ( Table 2 ). Therefore, these findings were inconclusive, as it was discovered that all the intervention studies were only conducted in rural communities of developing countries and had used a variety of methods to measure or compare the effectiveness of oral health strategies [ 16 – 18 , 23 , 24 , 28 , 29 ], but none of the intervention studies were conducted in developed countries. These findings are supported by the report, which suggested that in developing countries, oral health services are predominantly focused on the delivery of emergency care and targeted interventions within the various populations [ 47 ].

The current study also found that, out of the 11 oral health community engagement programs implemented to guide oral health care in rural communities of developing countries, Dental Health Education was the only strategy implemented in such settings [ 22 ]. Furthermore, in Africa, only two oral health strategies have been implemented and evaluated, both of which were implemented in the eastern part of the continent and were focused on promoting oral health in primary schools [ 18 , 36 ]. These findings suggest a significant inadequacy and deficiency in the provision of oral health education in developing countries. Similarly, the majority of oral health community engagement programs were implemented in Asia [ 16 , 17 , 23 , 24 , 26 , 28 , 29 , 35 ], where the continent stands out as the only one that has successfully implemented a diverse range of oral health strategies to guide oral health care for various populations, such as children, mothers/caregivers, pregnant women, edentulous individuals, teachers, and geriatric patients. However, the implementation of these strategies may be driven by the objective of mitigating the complex issue of approximately 900 million cases of untreated dental caries, severe periodontal disease, and edentulism prevalent throughout the continent [ 48 ].

In contrast, the results of this scoping review revealed that integrated dental-based oral health community engagement programs were only implemented in rural communities of developed countries and were successful in expanding access to and incorporating oral healthcare services provided by dental personnel [ 25 , 28 , 32 , 35 ]. Although disparities in access to oral health care have been demonstrated to be universal challenges, rural communities in developed countries have better access to oral healthcare services than those in developing countries. These findings may be attributed to the availability of a variety of dental personnel with different skill mixes integrated into oral health strategies to provide oral health services in these settings, such as dental assistants, oral health therapist graduates, dentists, and medical practitioners [ 25 , 28 , 32 , 35 ]. This finding further confirms a significant shortage of available and effective oral health community engagement programs that consist of integrated dental personnel to provide oral healthcare services in rural communities in developing countries.

This scoping review also revealed that diverse oral health community engagement programs, specifically aimed at improving the oral health of children in primary schools, were successful, as most children showed improved toothbrushing techniques, improved oral health knowledge, positive attitudes, and reduced prevalence of dental caries [ 15 – 18 , 22 , 28 – 30 , 36 ]. Although the teachers were integrated and able to successfully incorporate oral health promotion into primary school oral health programs, various obstacles may hinder the long-term viability of this approach. These obstacles may include limited time, excessive workloads, the absence of an accountable person for the program, food stalls and vendors, gaps in the curriculum, lack of cooperation, and scarce resources [ 49 ]. Furthermore, the integration of the TeleHealth Network Grant Program in a rural school in a developed country proved successful in bridging the gap between the rural community’s primary school children and access to oral health care [ 36 ]. Nevertheless, the likelihood of this technology being successful in rural communities may be limited due to the significant influence of poor infrastructure and inadequate services such as electricity and telecommunications on the provision of services [ 43 ].

In response to the WHO’s recommendations to improve access to healthcare workers in rural communities [ 43 ], three community engagement programs for oral health were implemented with a focus on non-dental personnel to provide oral health services in rural communities. This scoping review found that deploying non-dental personnel was an economically viable strategy, as it leads to significant cost savings by utilizing local resources. However, concerns have been raised, and they include poor sustainability of oral health strategies and the lack of government support for resource allocation for oral health promotion and continuous training for oral health education among these personnel [ 16 , 35 , 36 ]. Furthermore, improving the attraction, recruitment, and retention of the workforce regardless of their level of economic development is part of the WHO’s strategies to increase the number of community healthcare workers in rural communities [ 43 ]. However, according to the results of this scoping review, no community healthcare workers were integrated into any of the oral health community engagement programs implemented in the rural communities of developed countries to guide oral health care ( Table 2 ). This finding may be in accordance with the finding that healthcare facilities in developed countries are potentially furnished with cutting-edge technical equipment and reinforced by sufficient oral health professionals specializing in diverse domains, thereby facilitating collaborative efforts aimed at ensuring optimal patient outcomes [ 47 ].

The current comprehensive scoping review yielded substantial evidence demonstrating the effectiveness of community-based oral health programs in guiding and enhancing the knowledge and perception of oral health among children and mothers/caregivers and improving oral health and quality of life of children and edentulous older adults ( Table 3 ) [ 15 , 23 – 27 ]. Although the objective of these programs was to enhance access to oral healthcare services for all rural communities in developed and developing countries, the general members (patients) of these communities were given lower priority and only received limited benefits from these programs. That is, of the seven community-based programs implemented, only one oral health strategy was designed to address the oral health needs of general members (patients) [ 31 ]. Based on this finding, it is evident that existing oral health strategies only target specific populations and neglect the general public.

Strengths and limitations

To the best of our knowledge, this is the first comprehensive scoping review to identify and provide detailed information on community-based oral health promotion and prevention programs/strategies in rural communities. We ensured the rigorous application of eligibility criteria by including only peer-reviewed articles. This review captured the perspectives of various stakeholders, such as schoolteachers, parents/caregivers, children, community health workers, and volunteers. After consulting with a health science librarian, we conducted a thorough search of seven databases and chased citations of previously published articles and eligible studies without any restrictions on publication type or region, which ensured the capture of all relevant literature and minimized the risk of selection bias. The limitations of this scoping review are grounded in the inclusion and exclusion criteria. In particular, the criterion that all records be written in English may have introduced bias by excluding relevant records in other languages. In addition, other materials, such as abstracts, dissertations, and white papers, which may have provided relevant information, were omitted in this scoping review. The interpretation of the concept of the "rural community" is inconsistent and can be expressed in various ways. Consequently, some records obtained may relate to the concept but were not labelled as such by the authors. Therefore, these records were not included in the final analysis of the scoping review.

Recommendations

This scoping review suggests that it is advisable for oral health community engagement programs, both in the present and in the future, to prioritize integrated dental-based strategies. This approach should also include the use of Dental Assistants to ensure the optimization of oral health education-based strategies. By doing so, the emphasis would shift away from curative-oriented strategies and instead be inclusive of all rural residents rather than exclusively targeting specific populations.

This scoping review describes oral health community engagement programs for guiding oral health care for rural communities. The results suggest that there is an increasing understanding of the importance of qualitative data in improving oral healthcare interventions and outcomes. The results also indicate that oral health strategies were effective in guiding the knowledge and perception of oral health among children and mothers/caregivers and in improving the oral health and quality of life of children and edentulous older adults in rural communities. However, rural communities are still heavily burdened by oral diseases, owing to unequal access to dental care and a shortage of oral health professionals. The existing oral health community engagement programs for engaging with these communities have used inconsistent methods to assess their effectiveness. This study also found a significant gap in the provision of oral healthcare services in these communities, owing to the absence of programs that integrated dental personnel as well as a lack of sustainability and government support for resources to promote oral health.

Supporting information

Acknowledgments.

We extend our sincere gratitude to Prof. Saadika Khan and Prof. Nicolette Roman of the University of the Western Cape for their valuable contributions in providing guidance, expertise, and extensive knowledge in the academic realm of review studies, particularly in conducting scoping reviews. We would also like to express our gratitude to Ms. Reneda Basson for her invaluable contribution to language editing of this work.

Funding Statement

The author(s) received no specific funding for this work.

Data Availability

Benevis Supports Senator Todd Pillion’s Promotion of Children’s Oral Health Improvement in Western Virginia

Abingdon, VA, June 05, 2024 (GLOBE NEWSWIRE) -- Benevis, a leading dental healthcare and orthodontics delivery organization committed to providing quality care to underserved communities, and its 100-plus dental offices in 13 states and the District of Columbia, is thrilled to announce a donation of 1,000 toothbrushes to kindergarten students in Western Virginia. This generous initiative, conducted in partnership with State Senator Todd Pillion and Henry Schein, underscores the state’s commitment to enhancing oral health among young children. 

As a pediatric dentist, Senator Pillion has firsthand knowledge of the challenges faced by children in the region due to inadequate dental care. His advocacy for better oral health practices is instrumental in this partnership. The toothbrush donation took place before the kids embarked on their summer vacation, ensuring they had the necessary tools to maintain good oral hygiene. 

"In every child’s life, good oral health plays a pivotal role in overall wellness. We are proud to support Senator Pillion’s effort to educate and provide our young children with the essential means for a healthy start," said Bryan Carey, CEO at Benevis. "By fostering early dental care habits, we are paving the way for a brighter, healthier future for the next generation.” 

The toothbrushes were distributed by the Senator's team, who also provided essential oral health education to the children. “This initiative not only highlights the importance of dental care from an early age but also fosters a community spirit by bringing together local leaders and organizations for a common cause,” said Senator Todd Pillion. “A smile is a window into a person’s world, and we want to equip our students with the tools and information required to form healthy habits early on that translate throughout the next stages of their lives and set them up for success.” 

Previously, in 2019, Benevis supported Senator Pillion, then a member of the House of Delegates, with a donation of toothbrushes, significantly impacting the oral health of the youth in his constituency. This year’s initiative reached 1,000 children in two counties in the Abingdon area. 

Benevis is proud to be recognized as a partner in this critical health initiative and remains committed to supporting community health efforts across the region. Since 2002, Benevis has treated 5 million children and adults, including 82% who are enrolled in Medicaid and Children’s Health Insurance Program (CHIP), at more than 100 locally branded dental offices in underserved communities. The company is dedicated to supporting a network of like-minded, community-focused dentists who prioritize patient health to make a national impact. In addition to providing compassionate care, clinical teams prioritize educating children and families about daily brushing, flossing, and the importance of good nutrition for a healthy smile and improved oral health. 

For more information about this initiative, please contact Senator Pillion’s office at (276) 220-1209. 

About Benevis   Benevis is a leading dental healthcare delivery organization for practices focused on delivering life-changing oral care and orthodontics to underserved communities. Through comprehensive care and operational services that expand access to dentistry, Benevis has a 20-year history of providing the highest quality care to approximately 5 million children and adults. Its network reaches more than 100 locally branded dental offices across the U.S. that deliver treatment through 1.4 million visits each year. Benevis also advocates for programs and legislation that ensure all families have access to the oral healthcare they need and deserve. For more information, visit Benevis.com.