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European Journal of Translational Myology logoLink to European Journal of Translational Myology
. 2023 Mar 24;33(1):11158. doi: 10.4081/ejtm.2023.11158

The importance of promoting oral health in schools: a pilot study

Sabina Saccomanno 1, Martina De Luca 2, Stefano Saran 3,, Maria Teresa Petricca 4, Elena Caramaschi 5, Rodolfo Francesco Mastrapasqua 6, Giuseppe Messina 7, Gianni Gallusi 1
PMCID: PMC10141745  PMID: 36994533

Abstract

Promotion of oral health has an essential role in the maintenance of teeth in adults. However, health education must start from an early age, in order to monitor the child's growth and prevent pathologies. Schools are in charge of the overall education of children and of guidance to parents but could also be engaged in the promotion of oral health, supported and counseled by pediatricians and dentists. The purpose of this pilot study is to evaluate whether school age children could be taught, successfully, basic oral sciences and dental hygiene, by a professional, during school hours. In this pilot study, an anonymized test was administered to 45 children of age between 8 and 10, both before and after an interactive lecture on oral health, to assess the effectiveness of the lesson and acquisition by the children of knowledge on oral health. After the presentation, the majority of the children were able to answer correctly to the questionnaire that was given to them (test, retest) which was related to dental anatomy and pathology (number of teeth, cavities, halitosis), and dental hygiene tools and practices (brushes, floss, mouth wash, tongue scrapers). The children seemed to be receptive to learning while in school, and a specific educational session of dental hygiene and oral health seems to be the right approach to ensure children can identify dental hygiene tools and use them appropriately.

Key Words: Caries, epidemiology, pediatric dentistry, prevention, questionnaire, primary school, malocclusion, tooth

Ethical Publication Statement

We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

Oral health is closely related to general health and the well-being of our body and it’s not just tooth health. Being able to improve oral health could have great benefits for the organism,1-5 in the prevention of pathologies and in the improvement of quality life for individuals.6,7 Therefore, oral health promotion is fundamental, starting from childhood because poor oral health impacts both the children’s lives and their families’s as well.8,9 The World Health Organization (WHO) had promulgated several goals for oral health to be achieved by 2020. However, among these goals there is a forecast that is too optimistic and does not coincide with the current reality: that 95% of 5-6 year old subjects may be exempt from caries, when this goal, in reality, differs from recent surveys.8 Suffice to say that tooth decay (dental caries) is the most prevalent and chronic disease affecting infants and children. Therefore, prevention programs have the objective to provide training and information for parents and caregivers, which makes it possible to identify and intercept all potentially harmful factors to the child's development at an early stage. In fact, early childhood cavities is one of the most severe forms of dental disorder affecting children younger than 3 years. Though dental caries is preventable, the burden of disease is very high. This is because of lack of preventive oral health education. Scientific literature reveals that poor knowledge and attitudes among the caregivers are the major reasons for poor oral health status among children.10 Tooth decay is also the most common reason for 5–9-year-old British children admission to the hospital (Health and Social Care Information Centre (HSCIC), 2015).11 Early Childhood Caries (ECC) prevalence in Italy, in 2019, was 8.2% overall, 2.9% in 0–23-month-old children, 6.2% in 24–47-month-old children and 14.7% in 48–71-month-old children (p for trend<0.001).4 The carious process starts when S. mutans, the principal bacterial component implicated in the initiation of dental caries, colonizes the oral cavity of infants/children following the eruption of primary teeth. Colonization of S. mutans in infants takes place through their mothers around 2 years of age; especially during the first 26 months, which is the window of infectivity. In a study reported by Alaluusua and Renkonen, children who harbored S. mutans at age 2 had a significantly higher decayed, missing or filled teeth surface (DMFS) score than those children who acquired this bacterium at age 4 (DMFS 10.6 vs 3.4).12 A child’s degree of colonization of cariogenic bacteria is dictated by the mother’s S. mutans level at the time of transmission, suggesting that mother/caregiver’s oral health status has a direct influence on child’s oral health.

Together with parents, who are primarily responsible for growth and education of a child,13 primary guidance and medical assistance is given by the pediatrician.14 This important figure of reference for childhood accompanies the entire growth of the child, by preventing, diagnosing, and treating childhood diseases, to ensure adequate psychophysical development of the little patient.1 Pediatric dentists can be the ones to support parents and dentists identify and fill in the gaps in the mother/parents’s knowledge about health and oral hygiene. And yet, despite the significant progress in terms of oral hygiene, known since last century, caries remains one of the most prevalent diseases in the world.15

Recent Italian research demonstrates a strong association between the prevalence of ECC and bad habits assumed by parents.4,16 Moreover, a 2014 study showed how the level of education of parents and their socio-economic conditions greatly affect the education that children receive on oral health, and their consequent state of health; in fact, children of parents with a higher educational background tend to implement better oral hygiene). Educating children in schools now will make more informed parents in the future and this was the underlining philosophy behind this pilot study. Because studies indicate over and over again that the parents cannot convey to their children what they themselves do not know, it makes sense for the school system to step in a fill the knowledge gap. The collaboration between specialists, such as pediatric dentists, and the school seems to benefit all parties: schools offer much needed information to children already primed to learn, clinicians get the opportunity to disseminate important preventative instructions, children learn in a fun atmosphere, and parents are left with only the task of supervising the children’s oral and dental care. It is important to have highly interactive sessions, in which the instructors show children various methods, techniques and tools for oral hygiene aimed at keeping at bay pathogenic oral bacteria. Oral health education programs have been conducted in schools in many countries because these interventions are effective in increasing oral health knowledge, attitudes, and dental hygiene among children. Early childhood is an important period, an indicator of the oral health of the growing patient: in fact, children between 6 to 7 years of age can acquire efficient oral hygiene habits,17 and that’s the age in which almost all children worldwide are already in school. According to the results of De Sousa Né YG et al.,18 a plan for supervising school brushing could be effective in preventing tooth decay. In fact, schoolchildren demonstrated a significant improvement in tooth brushing skills when practical demonstration has been provided followed by supervision during oral hygiene maneuvers. Once the school-age children learn proper oral hygiene, a support for families is needed to direct them towards early interventions,18-22 so that parents will be able to prevent their children’s oral health problems, thus also reducing the economic burden of care.9

The aim of this pilot study was to assess the feasibility of an interactive session in schools to promote oral health by testing the children’s awareness of oral care tools and techniques, and general knowledge about the teeth and the mouth.

Materials and Methods

The study was conducted at the S. Antonio Primary and Infant School in Rome. All procedures were in accordance with the Helsinki Declaration and informed consent was obtained from parents of all students to be included in the study. The chosen sample consisted of a total of 45 children aged between 8 and 10 years, all Italian speaking. The written test was previously shown to a sample of 5 children, not from the school, for field testing, to ensure that the questions were understandable. The questionnaire of 12 questions (in Italian) was then submitted to the children to be answered in 5 minutes.

The questions are listed below:

  • Age

  • Gender

  • Do you know how many basic tastes are there?

  • Do you know many deciduous teeth are there?

  • Do you know how many permanent teeth are there?

  • What does it mean diphyodont?

  • Do you know what teeth look like?

  • How many main parts are in a tooth?

  • Do you know what tooth decay is?

  • Do you know what foods give you halitosis?

  • Do you know what are the tools for teeth cleaning?

  • How many teeth cleaning tools do you know?

After carrying out the questionnaire, a lesson was held regarding the topics that were mentioned in the previous questionnaire. The title of the lesson was "Let's get to know our mouths”. The explanation was accompanied by the support of a powerpoint presentation composed of 50 slides structured with many images to facilitate the understanding of the topic. Questions were encouraged to increase interactivity and promote learning. Following the lesson, the questionnaire was re-submitted to assess the effectiveness of the children's learning. The children were reassured that they would not receive a score on the tests and the results would be anonymous. The anonymized questionnaires were then uploaded on to Google form. At the end of the lesson, the children were also asked to draw what they had learned from the lesson and the drawings demonstrated correct learning by them (Figure 1).

Fig 1.

Fig 1.

Some of the children's drawings after the lesson, depicting discussed topics.

Statistical analysis: Age was expressed as mean+SD, dichothomic answers were expressed as absolute (percentage), while for multiple choice were considered the proportion of correct answers; these variables were confronted using Fisher exact test for dichothomic variables. The number of known hygiene tools were confronted using Kolgomorov-Smirnov test for paired samples. Significance was set at p < 0.05. All the statistical procedures were performed with the Statistical Package for the Social Sciences (SPSS 25.0, SPSS Inc., Chicago, USA”.

Results

Our sample was composed of children of mean age 9.64+1.73, 17 girls (37.8%) and 28 boys (62.2%) with a M:F ratio of 1.64. Comparing pre-test and post-test regarding the knowledge of basic tastes (sweet, salty, bitter, acidic and umami or fat) there was an improvement, from 30/45 (66.6%) correct answers versus 45/45 (100%), p<0.01 (Table 1). The correct answers regarding the number of deciduous teeth went from 2/45(4.4%) to 44/45 (95.6%) p<0.01. Regarding the number of permanent teeth, the pre-test answers varied wildly from 12 to 32, with only 5/45 (11.1%) children giving the correct answer at the pre-test versus 44/45 (97.8%) p<0.01 at post-test. At the beginning, 20/45 (44.4%) children were confident about knowing the teeth structure (how the teeth look like), while all of them answered positively at the post-test (p<0.05); 41/45 knew what teeth decay is, while all of them answered positively at post-test (results non-significant). The question “Do you know what diphyodont means?” was devised to verify if the children were answering truthfully. In fact, being diphyodont a difficult term, children were not expected to know its meaning, and therefore tick the "NO" box as an answer to the question. Only 2 (4.4%) children reported being familiar with the concept of diphyodont at pre-test compared with 37/45 (82.2%) at post-test (p<0.05). Regarding the identification of teeth structures (crown, roots, enamel, dentin, and pulp) at pre-test, 5/45(11.1%) children identified two parts, 20/45(44.4%) three, 3/45(6.7%) four, and 17(37.8%) did not respond, while at post-test 37/45(82.2%) answered two, 4/45 (8.9%) three and 4/45 (8.9%) four. In terms of what foods caused halitosis, 33/45(73.3%) children already were able to name some foods (such as onion, garlic, or fish) versus 44/45 (95.6%) at post-test (non-significant). The term halitosis was chosen in the test over the expression bad breath because the children are familiar with it due to TV advertisments using the word halitosis. A large number of children, 41/45(91.1%), knew which teeth cleaning tools are used (such as toothbrush, toothpaste, floss or toothpick), while all of them were aware of them at the post-test (non-significant). In terms of how many teeth cleaning tools did they know, at the pre-test 9/45(20.0%) knew one tool, 17/45 (37.8%) answered two, 15/45(33.3%) answered three, while 4/45 (8.9%) did not respond. At the post-test, 2/45 children answered two and the other 43/45(95.5%) answered three (p<0.05).

Discussion

Oral health education is an important step in the education of the child. Initially it was thought that only biological and dietary determinants were responsible for oral health in children, but in 2007 a new, more complex framework of interaction between different factors was proposed to include the determinants related to the social and physical environment, and last but not least, to the behaviors that influence health. Precisely for this reason, parents have a very important role, but pediatricians and pediatric dentists should not be underestimated. Schools have the task of supporting these figures in the child's growth path, promoting projects aimed at deepening and improving children's knowledge of oral health. It is also necessary to periodically strengthen educational programs as it is very important to maintain the motivation of children and that of their parents.23 The study shows that 40.9% of parents were unaware of the hygiene situation of their child's mouth. In addition to oral hygiene, the degree of awareness was related to the level of employment and education of the parents, as well as the socio-economic condition of the family unit. However, opinions are not always in agreement: a study on Colorado caregivers, who looked after children up to 6 years of age, shows how, despite a certain degree of understanding of odontostomatological problems by the adult, children did not always adopt positive behaviors towards one's oral hygiene. Therefore, leaving the task of oral education only to parents might not be fair or feasible.24 It also emerged that children and / or caregivers were not aware of the qualitative characteristics of the toothbrush, of the most suitable manual techniques for the age of the little patient, of the use of plaque-detecting tablets, at the time necessary to brush the teeth and finally to the use or abuse of fluoride toothpaste.25 In the last decade, means of transmission of knowledge and information have multiplied exponentially, with the advent of social media such as Facebook, Twitter, Instagram or TikTok, which are easy and quick to use as the information can be transmitted via videos within a few seconds. However, often these media give the opportunity to share information which may be fact-checked, verified and correct, or not, which could be a problem for those patients who do not consider the dentist as an authoritative source of information for their oral health and that of the child. Getting information prevalently from “Dr. Google” is not affecting only the medical profession but the dental professions as well. Unfortunately, there is still a lot of confusion and disagreement on dental and oral hygiene practices even among pracitioners.19 This type of disagreement on prevention rules, especially in the first 3 years of life leads to further confusion among parents.14 Precisely, for this reason it is important to emphasize once again the importance of the disclosure of the Italian Ministerial Guidelines aimed at oral hygiene in developmental age (2017).27 This large gap between reccommendations from different professionals, once again underlines the importance of transmitting clear and comprehensive information and leaves the door open to a more standardize set of instructions provided directly by the schools. In 2020 Menegaz demonstrated how after practicing targeted educational programs in a Brazilian school, positive effects were found on behaviors related to the oral health of children and the knowledge of caregivers, improving the use of fluoride toothpaste in the right amount based on the 'age.11 In a 2021 study, Andrew L., et al., reports how the lack of oral hygiene care in children not only reflects a lack of knowledge of the professional guidelines, but it is also the result of personal barriers or external constraints such as the emotional reactions of children that cannot be controlled (aversion of having a toothbrush or tooth paste in the mouth), or the manual skills required for proper oral hygiene are not exercised and reinforced.28 Other external constraints can be a hectic lifestyle, with strict deadlines and schedules that take away needed time for personal care. Oral health education is an important step in the child's education. Parents are the first figures responsible for this task, along with the pediatrician and the dentist, as they are the enforcers of the rules and the supervisors of the implementation of oral and dental hygiene daily. The schools have the task of supporting parents and professionals, in promoting projects aimed at improving the knowledge of children about oral health, by including it into their curriculum. The present pilot study led to some interesting results, as it made it possible to evaluate the effectiveness of communicating principles of oral and dental health to primary school children. In fact, the lesson including the explanation and the visual support of the slides showed an immediate improvement in the children's knowledge compared to the pre-test, at least for the short-term results. We did not investigate the information retention in a longer interval of time between education and post-test. However, the understanding of the concepts taught in session was confirmed by the drawings that the children made after the lesson, a method previously used in other studies.5 A limitation of this pilot study, which can be addressed in a later version, was asking the children how many dental hygiene tools they knew about, without giving them the chance to identify them immediately, and the lack of images on the pre-test, which make understanding much easier. Building on the method applied in this work, further studies should investigate: the long-term retention of dental hygiene concepts by children of same age range; expand the study to include a greater age range; assess whether learning could be equally effective in very young children, for example from the age of 6 instead of 8; the feasibility of oral health training in the whole school system. and the gap of knowledge between parents and children. In conclusion, considering the results obtained, this pilot study underlines the usefulness of oral health education programs in young children. Children were able to listen and interact during a one-hour lesson and demonstrate that they learned the principles of basic oral and dental hygiene, documented by pre- and post-test in the form of a questionnaire.The school is the right a place for education, not just for science in general but most importantly for personal health. For this reason, it is appropriate and necessary to educate children at school on how to prevent dental and oral issues, which will bring benefits not only for the well-being of children but also reduce or eliminate any future economic costs to the parents.

Table 1.

Correct and positive answers were expressed as frequency (percentage) while the two questions with no correct answers are plotted with proportion and percentage for all answers.

Initial test (pre-test) Final test (post-test) Significance
Do you know how many basic tastes are there? 30/45 (66.6%) 45/45 (100%) p<0.01
Do you know how many deciduous teeth are there? 2/46 (4.4%) 44/45 (95.6%) p<0.01
Do you know how many permanent teeth are there? 5/45 (11.1%) 44/45 (97.8%) p<0.01
What does it mean diphyodont? 2 (4.4%) 37/45 (82.2%) p<0.01
Do you know what your teeth look like? 20/45 (44.4%) 45/45 (100%) p<0.05
How many main parts are in a tooth? Two: 20/45 (44.4%) Three: 20/45 (44.4%) Four: 3/45 (6.7%) No answer: 17 (37.8%) Two: 37/45 (82.2%) Three: 4/45 (8.9%) Four: 4/45 (8.9%) No answer: 0
Do you know what tooth decay is? 41/45 (91.1%) 45/45 (100%) N.S
Do you know what foods give you halitosis? 33/45 (73.3%) 44/45 (95.6%) p<0.05
Do you know what are the tools for cleaning teeth? 41/45 (91.1%) 45/45 (100%) N.S
How many teeth cleaning tools do you know? One: 9/45 (20.0%) Two: 17/45 (37.8%) Three: 15/45 (33.3%) No answer: 4/45 (8.9%) Two: 2/45 (4.4%) Three: 43/45 (95.5%) P<0.05

N.S. stands for not significant.

Acknowledgments

We would like to thank Marilina Capitanio, teacher at S.Antonio School, Primary and Infant School inRome, for the organization of the study. Thanks to allthe students who participated. A special thanks to theLD and LG for the drawings.

List of acronyms

DMFS

decayed, missing or filled teeth surface

ECC

Early Childhood Caries

HSCIC

Health and Social Care Information Centre

SD

standard deviation

WHO

World Health Organization

Funding Statement

Funding The authors received no specific funding for this work.

Contributor Information

Sabina Saccomanno, Email: sabinasaccomanno@hotmail.it.

Martina De Luca, Email: martina.deluca04@icatt.it.

Maria Teresa Petricca, Email: mariateresa.petricca@studenti.unich.it.

Elena Caramaschi, Email: caramaschi.elena@gmail.com.

Rodolfo Francesco Mastrapasqua, Email: rfmastrapasqua@aslto3.piemonte.it.

Giuseppe Messina, Email: giuseppe.messina17@unipa.it.

Gianni Gallusi, Email: gianni.gallusi@gmail.com.

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