Abstract
Objectives
The aim of this work was to assess the oral health outcome of a 2-year comprehensive school oral health programme based on school-health education combined with supervised toothbrushing using 1450-ppm fluoride toothpaste amongst schoolchildren in Palestine.
Methods
A quasi-experimental study (2016–2018) recruited 3939 schoolchildren aged 5 to 6 years from 30 intervention schools (n = 2333) and 31 comparison schools (n = 1606). At baseline and postintervention, mothers and schoolteachers completed World Health Organization (WHO) self-administered questionnaires about oral health of children, oral health behaviour, and family factors. Of the initial participants 75.8 per cent took part in the follow up studies. In addition, 25 calibrated dentists examined dental caries of children according to WHO criteria. Trained teachers provided comprehensive oral health education to children in the classrooms and held regular oral health sessions for mothers. Children brushed their teeth with fluoride-containing toothpaste (1450 ppm fluoride). Student t-test and logistic regression were used in the statistical analysis of changes in dental health and related knowledge, behaviours, and attitudes (P < .05).
Results
In both dentitions, dental caries experience declined over the project. The reduction in Decayed, Missing and Filled permanent Teeth and Decayed, Missing and Filled Surfaces in permanent teeth was 23.3% and 23.2% (P < .001), respectively. The drop in caries experience indices in the Gaza Strip was 8 to 4 times higher than in West Bank, and it reached 47.4% reduction. Mothers and teachers showed improvement in positive knowledge and attitudes towards dental care. Involvement of schoolteachers in oral health in schools and acceptance of dental health education materials significantly enhanced oral health behaviour of children.
Conclusions
The project recommends national implementation of an intervention for the improvement of oral health of schoolchildren and their parents in conflict zones. The project shows the importance of the WHO Health Promoting Schools concept and involving classroom-based health education carried out by schoolteachers. It is suggested to explore the health care system's capacity in hosting effective oral health programme and maintain its efficacy.
Key words: Schoolchildren, School oral health promotion, Oral hygiene behaviour, Dietary habits, Sociobehavioural risk factors, WHO Health Promotion
Introduction
Long-term political instability in Palestine has seriously deteriorated the socioeconomic standard and social well-being of the Palestinian people.1,2 In addition, because of financial limitations, existing health services are unable to meet the population's oral health care needs.3,4
Research carried out in the Palestinian territories has identified substantial social risk factors important to children's health.1,2,5,6 They include constrained economic resources of families, poor health-related quality of life, residing in refugee camps, poor nutrition status,1 the experience of governmental instability,4,7 and severe barriers to accessing health care services.8,9
In 1994, the Ministry of Health and the United Nations Relief and Works Agency (UNRWA) established a School-Health Programme, which provides dental care for schoolchildren enrolled in governmental and private schools in the Gaza Strip (GS) and the West Bank (WB) as well as refugee settings.10
Recently, evaluation indicated a passive School Oral Health programme.11 However, the surveillance data provided by the school health programme reveal a heavy burden of dental caries.12,13 During the past 15 years, the burden of dental caries has been high persistently amongst 6-year-old children, and a considerable increase in the prevalence of disease is now prominent amongst adolescents.12, 13, 14 Recently, 83.4% of Palestinian grade 1 children were reported to experience dental caries in primary teeth, and the average dental caries experience was 11.2 decayed, missing and filled surfaces in primary teeth (dmfs).15
Eight in 10 children aged 12 years were in need of dental care, whilst the corresponding figure was 7 in 10 adolescents aged 16 years.12 The decay components (d/D-components) of the dental caries indices were prominent, indicating that the referral system relevant to dental care of children in primary health clinics remains inadequate to control dental caries. In addition to irregular dental visit practices, infrequent toothbrushing habits, low exposure to fluoridated toothpaste, elevated sugar consumption induce an extraordinary risk of dental caries, although mothers declared a high dental care awareness.15
Hence, the existing school dental health programme does not meet the oral health needs of the child population, and an organised oral disease prevention programme is important for tackling the poor oral health situation of Palestinian children.
Aims
This study aimed to develop and implement a demonstration programme for promotion of oral health amongst primary schoolchildren of representative primary schools in Palestine. The project applied the principles of the World Health Organization (WHO) Health Promoting Schools concept,16 which involves the creation of classroom-based health education to be carried out by schoolteachers coupled with family and community actions. Finally, the objective of the project was to assess the outcome of school-directed oral health intervention.
Material and methods
Study design
The Palestinian Territories comprise 2 areas separated geographically: WB and GS. The WB lies within an area of 5800 km2 west of the River Jordan. The GS is a narrow piece of land lying on the Eastern coast of the Mediterranean Sea. It is a highly populated territory with an area of 360 km2.2,17 The WB and GS contain 16 and 7 governorates, respectively.18
A comparison design was applied based on gender, age, and urbanisation. The primary schools representative for each governorate were randomly assigned into intervention schools (22 primary schools in WB and 8 primary schools in GS) and comparison schools (24 primary schools in WB and 7 primary schools in GS). All children of grade 1 initially aged 5 to 6 years old were invited to participate in the study.
Sampling
Sampling of schools and the estimation of numbers of children followed a comparable intervention carried out in Southern Thailand,19 considering 56% prevalence of decay in deciduous teeth and 90% study power.
The sample size of children in cooperative schools was based on school health and administrative data.20 Hence, at the end of the study, 1575 participants were suggested per group, and to take account of some loss of participants during the study a total sample size of approximately 3500 participants was targeted. At baseline, the final number of children identified was 3939 (2567 children of the WB, 1372 children of the GS). The overall response rate was 84.6% (ie, 84.7% in WB and 84.5% in GS). In all, 54.9% were boys and 45.1% were girls.
Information about fluoride concentration in home supply tap water was achieved from the Palestinian Water Authority and Municipals. The fluoride concentration level in GS home supply water (mean, 1.4 [±1.2]; range, 0.0–9.6) was 6 times higher than that in WB (mean, 0.2 [±0.1]; range, 0.1–0.4).
Project implementation
An explanation letter about the project was sent to parents or caretakers of children; those who accepted the participation of their children were asked to sign a consent form and to complete self-administered questionnaires relevant to child oral health.
The intervention scheme consisted of an enhanced oral hygiene programme, classroom-based health education, and family and community activities. The Ministry of Health provided toothpaste-containing fluoride at the level of 1450-ppm fluoride and toothbrushes to all schoolchildren. Health education materials were prepared in the schools and the primary schoolteachers were responsible of key educational activities.
-
1.
Trained teachers in the intervention schools instructed and daily supervised children's toothbrushing for at least two minutes with pea-size toothpaste (0.25g) and rinsing of the mouth with minimal amount of water after toothbrushing. Toothbrushing commenced when children attended school after their breakfast meal, whilst parents were encouraged to involve in toothbrushing at home.
-
2.
The schoolteachers were asked to provide oral health education for children and their parents.
-
3.
Teachers organised school oral health events and taught parents and children on restricting the intake of sugars and focussing on healthy foods and a healthy environment.
-
4.
Teachers communicated regularly with parents or caretakers about improving children's oral health.
-
5.
Comprehensive capacity-building workshops were organised in the school setting and teachers continuously informed the research team about sustainability of school oral health. Development of an effective referral system for dental care of children in need of dental care was part of the workshop.
Children and parents in the comparison group were not encouraged to modify their oral health behaviour.
Data collection
The intervention was implemented through the scholastic years 2017–2018 and 2018–2019. The study followed WHO principles and the Helsinki committee, and approvals were obtained from ministries of health and education. Informed consent was obtained from the parents. Parents and schoolteachers each completed a self-administered questionnaire on the oral health of children. By the end of project, the research team also invited both groups to answer a follow-up questionnaire for evaluation of oral health and their involvement in school health activities.
Oral health behaviour data of children and parents were collected by use of WHO self-administered questionnaires.21 The questionnaire was formulated in English and then translated into Arabic. Pretests for control of face validity and reliability of the questions took place prior to implement of the intervention project.
The total number of invited 6-year-old schoolchildren (grade 1) was 3939, and 92.4% of the students finalised the intervention (n = 3640 schoolchildren). Reasons for loss to follow-up were absence on the day of oral examination or moving to other schools. Only the collaborative intervention schools and their matching comparison schools in the same governorates were included in the data analyses (n = 2984 schoolchildren), which composes 75.8% of participating schoolchildren at baseline.
At baseline and after the project, 25 trained school dentists examined dental caries and gingival health of children. For the protection of objectivity, the dental examiners were not members of the school health promotion team. Dentists reexamined the oral health conditions at the end of programme activities. WHO criteria21 were used in recording of dental caries at tooth and tooth surface levels. Calibration trials were undertaken prior to baseline and postprogramme examinations. During the survey, double examinations of approximately 10% of the children were performed in order to assess intra- and inter-examiner variability in the use of diagnostic criteria. The kappa scores for intra- and inter-examiner consistency in the diagnosis of caries were 0.9 and 0.9, respectively.
Statistical Package for the Social Sciences IBM SPSS Statistics 22 was used for data entry. Primary clinical outcome is the difference in Decayed, Missing and Filled permanent Teeth (DMFT) and Decayed, Missing and Filled Surfaces in permanent teeth (DMFS) measurements between intervention and comparison groups. The differences in baseline and 24-month examinations between the 2 principal groups were compared using 2-tailed t tests (P values < .05). Frequency distributions were computed for univariate and bivariate analysis of answers to questionnaires, and the statistical evaluation of proportions were performed by chi-square test. Moreover, sociodemographic characteristics and dental services use were applied as independent variables. Independent-samples t test (P values < .05) was used to test whether the implemented intervention would change the levels of oral health knowledge, attitude, and behaviour of children and parents. A scale with scores ranging from 0 (“never”) to 5 (“several times a day”) has been used to measure the frequency of the child's consumption of sweets and/or sugary drinks.
Results
The declines in caries experience of permanent teeth (DMFT and DMFS) over the 2-year project are illustrated in Table 1. After 24 months, the decreases in caries incidence amongst children in intervention schools were 23.3% and 23.2%, respectively, when compared with comparison schools. This reduction in caries indices was 8 to 4 times higher in GS compared to WB (47.4%, 45.9% and 6.3%, 10.3%, respectively). Most of the drop in caries indices occurred in the decayed component.
Table 1.
Mean dental caries experience in the permanent and primary dentitions of children in collaborative schools of Palestine.
| Cooperative schools |
Mean dental caries experience at baseline |
Difference from baseline and follow-up after 24 mo |
% reduction compared to control | P value | ||
|---|---|---|---|---|---|---|
| Comparison | Intervention | Comparison | Intervention | |||
| All schools | n = 1713 | n = 1271 | n = 1713 | n = 1271 | ||
| DMFT | 0.3 (1.0) | 0.3 (1.0) | 0.9 (1.2) | 0.6 (1.0) | 23.3 | <.001 |
| DT | 0.2 (0.6) | 0.2 (0.6) | 0.9 (1.2) | 0.6 (1.0) | 25.9 | <.001 |
| DMFS | 0.3 (1.0) | 0.3 (1.0) | 1.1 (2,0) | 0.8 (1.8) | 23.2 | <.001 |
| DS | 0.3 (1.0) | 0.3 (1.0) | 1.1 (2,0) | 0.8 (1.8) | 24.1 | <.001 |
| Gaza Strip schools | n = 730 | n = 432 | n = 730 | n = 432 | ||
| DMFT | 0.3 (1.0) | 0.2 (0.7) | 1.0 (1.2) | 0.5 (1.0) | 47.4 | <.001 |
| DT | 0.2 (0.7) | 0.2 (0.6) | 0.9 (1.2) | 0.5 (1.0) | 44.7 | <.001 |
| DMFS | 0.3v(1.0) | 0.2 (0.7) | 1.1 (1.7) | 0.6 (1.4) | 45.9 | <.001 |
| DS | 0.3 (0.9) | 0.2 (0.7) | 1.1 (1.7) | 0.6 (1.4) | 45.0 | <.001 |
| West Bank schools | n = 983 | n = 839 | n = 983 | n = 839 | ||
| DMFT | 0.2 (1.1) | 0.3 (1.1) | 0.8 (1.1) | 0.7 (1.0) | 6.3 | <.05 |
| DT | 0.2 (0.5) | 0.2 (0.6) | 0.8 (1.1) | 0.7 (1.0) | 11.4 | <.05 |
| DMFS | 0.2 (1.1) | 0.3 (1.1) | 1.1 (2.1) | 0.9 (1.9) | 10.3 | |
| DS | 0.2 (1.1) | 0.3 (1.1) | 1.1 (2.1) | 0.9 (1.9) | 11.2 | |
| All schools | n = 1713 | n = 1271 | n = 1713 | n = 1271 | ||
| dmft | 5.7 (4.3) | 5.7 (4.5) | 5.6 (3.6) | 4.9 (3.6) | 13.1 | <.001 |
| dt | 5.2 (4.0) | 5.2 (4.2) | 4.7 (3.1) | 4.2 (3.3) | 10.1 | <.0001 |
| mt | 0.4 (0.9) | 0.4 (0.9) | 0.7 (1.2) | 0.5 (1.0) | 33.8 | <.001 |
| dmfs | 11.9 (11.8) | 11.5 (11.7) | 14.1 (11.6) | 12.4 (11.4) | 15.0 | <.001 |
| ds | 10.3 (10.7) | 10.0 (10.6) | 10.2 (9.2) | 9.4 (9.5) | 9.6 | <.03 |
| ms | 1.4 (3.4) | 1.2 (3.6) | 3.4 (5.6) | 2.4 (4.9) | 32.7 | <.001 |
| Gaza Strip schools | n = 730 | n = 432 | n = 730 | n = 432 | ||
| dmft | 5.7 (4.3) | 5.5 (4.6) | 5.5 (3.7) | 4.1 (3.6) | 30.1 | <.001 |
| dt | 5.1 (3.9) | 4.9 (4.2) | 4,5 (3.2) | 3.4 (3.2) | 29.0 | <.001 |
| mt | 0.5 (1.0) | 0.4 (1.0) | 0.9 (1.3) | 0.5 (1.0) | 50.6 | <.001 |
| dmfs | 12.8 (12.4) | 12.0 (12.5) | 14.3 (11.8) | 10.6 (11.2) | 31.6 | <.001 |
| ds | 10.7 (10.9) | 10.1 (11.2) | 9.6 (9.1) | 7.7 (9.3) | 26.2 | <.001 |
| ms | 1.8 (3.8) | 1.5 (4.1) | 3.9 (5.8) | 2.2 (4.7) | 49.0 | <.001 |
| West Bank schools | n = 983 | n = 839 | n = 983 | n = 839 | ||
| dmft | 5.8 (4.4) | 5.8 (4.5) | 5.6 (3.5) | 5.3 (3.5) | 4.3 | |
| dt | 5.4 (4.1) | 5.4 (4.2) | 4.8 (3.1) | 4.6 (3.3) | 3.1 | |
| mt | 0.3 (0.8) | 0.3 (0.8) | 0.6 (1.1) | 0.5 (1.0) | 13.3 | <.05 |
| dmfs | 11.1 (11.3) | 11.2 (11.2) | 14.0 (11.4) | 13.3 (11.4) | 4.5 | |
| ds | 9.9 (10.5) | 9.9 (10.3) | 10.6 (9.3) | 10.4 (9.5) | 1.9 | |
| ms | 1.1 (3.1) | 1.1 (3.2) | 3.0 (5.4) | 2.5 (5.0) | 16.3 | <.05 |
DMFS, decayed, missing and filled surfaces; DMFT, decayed , missing and fiilled teeth.
Figures are shown at baseline and caries increment after 24 months for teeth (DMFT and dmft) and tooth surfaces (DMFS and dmfs). Standard deviation in parentheses and statistical significance between comparison and intervention groups are indicated.
The differences in caries experience of deciduous teeth (decayed, missing and filled primary teeth (dmft) and dmfs) are illustrated in Table 1. Generally, the reduction in dmft and dmfs was lower than the DMFT and DMFS. The intervention group showed 33.8% and 32.7% reduction in the missing components (missing primary teeth (mt) and missing surfaces in primary teeth (ms)), respectively. Furthermore, the decrease in the dental caries variables was 4 times higher in GS schools compared to WB schools.
In the intervention group, fewer children avoided smiling and laughing because of teeth than in the comparison group or they missed classes occasionally or for whole days because of toothache or discomfort of teeth (30.8% and 24.6%, respectively; Table 2). Parents’ dissatisfaction about the appearance of their children's teeth were equal, and two-thirds of the parents in both groups indicated that their children were in need of oral hygiene instruction.
Table 2.
Percentages of Palestinian parents who reported that their child had oral health problems or claiming that children were in need of treatment after 24 months of programme (initially 7 years old).
| Comparison schools |
Intervention schools |
|||
|---|---|---|---|---|
| Baseline | Follow-up | Baseline | Follow-up | |
| n = 1713 | n = 1713 | n = 1271 | n = 1271 | |
| % | % | % | % | |
| Often experience toothache or feeling of discomfort on account of teeth | 27.5 | 27.5 | 24.8 | 26.5 |
| Avoid smiling and laughing because of teeth | 15.1 | 18.2 | 13.5 | 14.9 |
| Miss classes occasionally or for whole days because of toothache or discomfort of teeth | 18.3 | 30.8 | 17.0 | 24.6 |
| Not satisfied by appearance of teeth of child | 23.6 | 27.5 | 14.1 | 25.7 |
| Need for instruction in proper oral hygiene | 65.2 | 67.8 | 66.1 | 69.1 |
| Need for dental fillings | 52.0 | 47.1 | 43.8 | 44.1 |
| Tooth extraction | 43.4 | 47.3 | 43.1 | 47.0 |
About 40% of children in both study groups saw a dentist once or twice a year; pain/troubles with teeth or gums were the main reason for visiting the dentist (Table 3). Notably, the majority of children did show up for dental visits with their mother. After follow-up, three-quarters of the intervention group received an oral examination. Tooth-cleaning aids were used less often by the same group compared to comparison group.
Table 3.
Percentage of Palestinian schoolchildren (initially 7 years old) with certain dental visiting behaviours and performing oral hygiene habits after 24 months of the programme.
| Comparison schools |
Intervention schools |
|||
|---|---|---|---|---|
| Baseline | Follow-up | Baseline | Follow-up | |
| n = 1713 | n = 1713 | n = 1271 | n = 1271 | |
| No. of dental visits during the past 12 mo | % | % | % | % |
| 1 | 25.6 | 25.6 | 22.5 | 24.9* |
| 2 | 14.4 | 17.9 | 13.7 | 18.6* |
| 3 | 7.4 | 10.2 | 6.9 | 8.7* |
| 4 | 3.3 | 5.4 | 3.6 | 3.8* |
| >4 | 8.9 | 6.9 | 8.1 | 6.8* |
| Pain/troubles with teeth or gums reason of last dental visit | 40.1 | 40.6 | 43.4 | 42.4 |
| Treatment at last dental visit | ||||
| Provision of fillings | 45.2 | 46.0 | 37.4 | 43.4 |
| Removal of calculus | 8.2 | 15.1 | 6.6 | 10.8* |
| Tooth extraction | 44.4 | 59.7 | 42.4 | 57.9 |
| Examination of teeth | 76.4 | 79.2 | 76.3 | 75.2* |
| Treatment of gums | 20.5 | 25.5 | 19.0 | 21.6 |
| X-ray | 10.4 | 15.6 | 10.9 | 14.0 |
| Fluoride application | 8.9 | 13.1 | 6.4 | 11.9 |
| Instruction in care of teeth | 65.2 | 67.8 | 66.1 | 69.1 |
| At last visit to the dentist, who went with the child? | ||||
| Mother | 56.7 | 60.3 | 60.6 | 57.9* |
| Father | 27.9 | 24.5 | 23.4 | 28.8* |
| Both parents | 2.2 | 2.6 | 1.1 | 1.5* |
| Other adults like brother/sister | 13.2 | 12.6 | 14.9 | 11.8* |
| How often do you brush the teeth of your child at home? (Note) | ||||
| Once a day | 33.1 | 29.2 | 32.1 | 39.0** |
| 2 or more times a day | 18.7 | 28.8 | 21.3 | 35.2** |
| Use of toothpaste containing fluoride | 59.6 | 56.8 | 61.5 | 72.5** |
| Use of tooth-cleaning aids | ||||
| Wooden toothpicks | 44.5 | 46.6 | 43.6 | 38.4** |
| Plastic toothpicks | 8.4 | 15.8 | 8.7 | 6.9** |
| Thread (dental floss) | 10.8 | 17.8 | 9.4 | 9.3** |
| Charcoal | 4.5 | 9.8 | 3.8 | 1.8** |
| Chewstick/miswak | 25.0 | 24.5 | 26.6 | 21.1** |
| Scores of sweets and sugary drink consumption | ||||
| Sweets consumption | 10.6 (6.7) | 10.8 (6.5) | 12.0 (6.2) | 11.2 (6.9) |
| Sugary drink consumption | 8.5 (5.5) | 8.5 (5.2) | 9.4 (4.9) | 8.7 (5.1) |
| Sweets and sugary drink consumption | 19.1 (11.7) | 19.4 (11.2) | 21.4 (10.5) | 19.9 (11.0) |
P < .05.
P < .0001.
Note. All schoolchildren in intervention schools brushed their teeth whilst in school under trained schoolteacher supervision.
By the end of the study, the percentage of children practicing toothbrushing at home once a day or 2 or more times a day was relatively higher in the intervention group compared with the comparison group (74.2% and 58.0%, respectively). Around three-quarters of the children in the intervention group used toothpaste containing fluoride (72.5%), which was significantly higher than for children in the comparison group (56.8%). Finally, consumption of sweets and sugary drinks was almost similar for the 2 groups.
Parents were the main source of information on oral health care for 76.9% of schoolchildren, whilst the teachers’ contribution to oral health care facts increased to 43.3% in the intervention group by the end of the study (Figure).
Fig.
Source of knowledge for oral health care for 5- to 7-year-old schoolchildren at baseline and after 24 months.
Table 4 indicates high perceptions and positive attitudes of Palestinian mothers towards child dental status and dental care needs. Likewise, the study showed favourable scores on attitude items amongst mothers of children in the intervention group. Remarkably, the fear of going to the dentist because of possible pain existed in 60% of Palestinian mothers.
Table 4.
Percentages of Palestinian mothers and schoolteachers who agreed on certain attitude items related to oral health of schoolchildren after 24 months of programme.
| Comparison schools |
Intervention schools |
|||
|---|---|---|---|---|
| Baseline | Follow-up | Baseline | Follow-up | |
| n = 1713 | n = 1713 | n = 1271 | n = 1271 | |
| Mothers | % | % | % | % |
| Tooth decay can make me look bad | 91.1 | 85.9 | 92.4 | 91.2** |
| Keeping natural teeth is not that important | 4.9 | 5.8 | 5.0 | 5.5** |
| False teeth will be less of a bother than natural teeth | 19.8 | 18.5 | 20.2 | 22.1* |
| I'm afraid of going to the dentist because of possible pain | 64.2 | 60.6 | 68.2 | 60.9 |
| Regular visits to the dentist keep away dental problems | 93.5 | 86.2 | 94.0 | 92.6** |
| Brushing my teeth can prevent tooth decay | 97.3 | 91.0 | 98.0 | 97.4** |
| Brushing my teeth will keep me from having trouble with my gums | 93.5 | 80.0 | 93.2 | 98.4** |
| Eating and drinking sweet things does not cause tooth decay | 12.7 | 13.5 | 13.1 | 9.9** |
| Using fluoride is a good way of preventing tooth decay | 71.2 | 70.3 | 74.1 | 79.5** |
| Children younger than 10 years old need help from adults in tooth cleaning | 88.2 | 89.9 | 89.5 | 98.4** |
| Parents should restrict children's consumption of sweets and sweetened drinks | 95.3 | 94.3 | 95.3 | 96.7 |
| Schoolteachers | n=28 | n=28 | n=25 | n=25 |
| Fluoride protects the teeth against decay | 78.6 | 87.5 | 84.0 | 100 |
| Toothbrushing prevents tooth decay | 92.9 | 100 | 95.8 | 100 |
| Toothbrushing prevents bleeding from gums | 85.7 | 82.4 | 64.0* | 93.8 |
| Improper consumption of sugar causes teeth to decay | 96.4 | 100 | 95.8 | 100 |
| Children younger than 10 years old need help from adults in tooth cleaning | 92.9 | 87.5 | 92.8 | 93.8 |
| Schoolteachers should teach children about diet and sugar | 100 | 100 | 96.0 | 100 |
| Schoolteachers should teach children about the causes of decay and bleeding gums | 92.9 | 88.2 | 100.0 | 100 |
| Schoolteachers should teach children about fluoride and caries | 92.9 | 88.2 | 91.7 | 100 |
| Schoolteachers should teach children how to take care of their teeth | 100 | 100 | 96.0 | 100 |
| Did you tell your children from your class about teeth and oral health during this school year? | 74.1 | 64.1 | 61.3 | 100* |
| Do you have sufficient material for teaching about oral health? | 75 | 70.5 | 56.5 | 100* |
P < .05.
P < .0001.
In both study groups, schoolteachers often declared that they should teach children about causes of decay and bleeding gums, diet and sugars, fluoride and caries, and how to take care of their teeth.
All teachers in the intervention group provided instructions to classes about teeth and oral health during the school year, and they claimed to have sufficient material to teach about oral health.
Discussion
Palestine has suffered from long-lasting political unrest for decades. The implementation difficulties observed in this study mostly relate to bureaucratic governmental procedures and political unrest. The field control of the project was better in the GS due to enhanced access to schools because there were no Israeli checkpoints. These checkpoints in the WB area hugely delayed programme undertakings. Meanwhile, the principal investigator was continuously in contact with the participating schools in the WB and supervised the fieldwork activities and review virtually. It is worth noting that the Ministry of Health in Palestine was unable to support the entrance of the project principal investigator in regular travels from the GS to WB areas. These borders persist under Israeli occupation control. Such obstacles emphasise the necessity of effective collaboration with the WHO and UNICEF to facilitate movements of researchers in occupied regions and to ensure implementation of national health promotion projects appropriately.
Nevertheless, this is the first national oral health promotion study in Palestine; the project followed the principles of the WHO Health Promoting Schools concept16 and involved representative governmental primary schools from all governorates.
At baseline and postintervention stages, both mothers and schoolteachers completed the WHO robust questionnaires to assess children's oral health behaviour and knowledge and attitudes towards child dental care. In order to ensure reliability of the clinical data, calibrated dentists performed oral examinations of schoolchildren according to WHO criteria.21 The proportion of mothers who finished tertiary schools was higher than the proportion of the fathers. Compared with the Palestinian Central Bureau of Statistics data, the sample of this study provided a good match with the educational level for Palestinian population.22
The 2-year school oral health programme led to a significant reduction in dental caries experience of permanent teeth in intervention schools as compared with the reference schools. The reduction in DMFT and DMFS in the GS zone was 8 to 4 times higher compared with the figures of the WB. In both regions, most of the reduction in caries occurred in the decayed component (Decayed Teeth (DT) and Decayed Surfeces (DS)) of permanent teeth. This outcome reflects the programme interest of activating schoolchildren towards healthy dental lifestyles and intensive oral hygiene. The parallel reduction of caries experience, mostly in dt and ds in deciduous teeth, prolongs the life-span of these teeth in the oral cavity until normal exfoliation. Consequently, this may have contributed to a better quality of life owing to the effective chewing of foods and a better, more healthy smile.
The high effectiveness of the intervention in reducing dental caries incidence in the GS compared with WB can be attributed to fluoride concentration in home-supply tap water. Therefore, the use of further fluoride topical application (eg, fluoride varnish) alongside daily toothbrushing in areas of low fluoride level in tap water may be relevant.23
Globally, systematic evaluation of school oral health interventions seldom takes place in low-income countries.24 Thus, comparing the present findings with those of other studies is somewhat restricted. In Jordanian schoolchildren25 who received school-based intensive oral hygiene instruction sessions and supervised daily toothbrushing using fluoridated toothpaste, the decline in dental caries was similar to the current results. The studies confirm the importance of such supervised procedures for dental caries control in schoolchildren.25 The caries prevention outcome was also observed in 2 similar WHO school oral health promotion programmes that were implemented in primary schools in Thailand19 and China.26 In Thailand, a 2-year school health education programme combined with thoroughly supervised toothbrushing achieved a significant reduction in dental caries of permanent teeth.19 In China, a school-based oral health education programme targeted 6-year-old schoolchildren and their mothers; in addition, schoolteachers were involved in supervised toothbrushing on a daily basis. This study found a decline in dental caries experience in primary teeth after the intervention.26
In both study groups, the proportions of children who experienced toothache or felt discomfort on account of teeth were high compared to their proportion at baseline. Such extraordinary proportions in Palestine may relate to the unavailability of dental treatment, to the ongoing socioeconomic worsening, and to the adverse effect on health services and restrictions in care use.
There is a direct negative impact of toothache on children's oral health–related quality of life.27,28 Furthermore, the proportion of mothers expressing dissatisfaction about appearance of their children's teeth was substantial due to a high need for tooth extraction and dental fillings. Thus, incorporation of dental treatment into oral health promotion directed towards young schoolchildren is important.
The intervention activities did not significantly promote the frequency of dental visits, and this could be attributed to the poor economic status of Palestinian families. Importantly, providing toothbrushes and fluoridated toothpaste free of charge to schoolchildren ensured better oral hygiene habits of schoolchildren in the intervention group. It is worth noting that no differences in the consumption of sweets and sugary drinks were observed between intervention and comparison groups. This could be affected by the lack of initiatives by the Ministries of Health and Education as regards the content of meals offered from school canteens and particularly limited efforts reducing children's access to unhealthy sugars (eg, sweets and crisps) in schools.
The present intervention study has shown that mothers remain the main source of information for oral health care in relation to children. However, empowering schoolteachers with education material on dental care facilitated their active contribution to communication on preventive care.
In the intervention group, all the schoolteachers taught classes about teeth and oral health during the project years, whilst contribution of schoolteachers in comparison schools to oral health education was diminished. Mothers and schoolteachers subsequently reported advanced levels of dental knowledge and attitudes towards children's dental status. This is in agreement with similar WHO school oral health programmes implemented across low-income countries.26
Conclusions
The school health intervention was effective in preventing up to 47.4% of dental caries incidence. However, the effectiveness varied between different geographic parts in Palestine because of differences in tap water fluoride concentration level, field control, system administration procedures, and political unrest. Community support by international health associations may possibly facilitate oral health programme implementation in political distressed regions. In addition, this study confirmed the experience of empowering parents, schoolteachers, and the community at large in disease prevention of poor settings. Finally, effective results in dental caries prevention is particularly possible when disease prevention programmes involve providing toothbrushes free of charge and fluoridated toothpaste.
Conflict of interest
None disclosed.
Acknowledgements
Sincere thanks to the Borrow Foundation for having provided valuable funds for the project. Genuine thanks to the Ministry of Health and Ministry of Education in the State of Palestine for their significant help and contribution in implementing and running the projects.
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