Effectiveness of a game-based oral health intervention on plaque and gingival scores among schoolchildren: A nonrandomized controlled trial

Abstract

Aim:

This study aimed to evaluate the effectiveness of a game-based oral health education intervention in improving plaque and gingival scores among school children aged 12–15 years in comparison to traditional oral health education methods.

Materials and Methods:

Conducted as a nonrandomized controlled trial over 7 months, the research included eight schools with a total of 162 participants allocated to either the intervention (n = 82) or control (n = 80) group. The intervention group engaged with the game, which integrated oral hygiene principles through visual simulation, while the control group received traditional oral health education using a Dentoform model. Baseline and follow-up clinical data were collected using the plaque index and simplified gingival index. Data compiled were statistically analyzed utilizing SPSS (Statistical Package for the Social Sciences) version 26.0 software.

Results:

Postintervention, the intervention group showed significant improvements in both plaque index (0.89 ± 0.27) and gingival index (1.02 ± 0.23) compared to the control group (1.62 ± 0.30 and 1.72 ± 0.25, respectively; P < 0.001). Within-group improvements in the intervention group were also significant for both indices (P < 0.001 and P = 0.03, respectively). Bivariate analysis revealed that males had significantly higher postintervention scores than females (P = 0.006 for plaque and P = 0.021 for gingival index), and age showed a mild positive correlation (r = 0.21 for plaque and r = 0.18 for gingival index).

Conclusion:

This study highlights the potential of gamified interventions to enhance oral health education and engagement among adolescents, suggesting that such innovative approaches could lead to improved oral hygiene practices.

INTRODUCTION

Oral health is a critical component of overall health and well-being, particularly during adolescence, which is a formative period for establishing lifelong health behaviors. The World Health Organization emphasizes that oral diseases, including dental caries and periodontal disease, are among the most prevalent noncommunicable diseases globally, affecting millions of adolescents. These conditions not only lead to physical health complications but also contribute to significant psychosocial issues, such as low self-esteem and social withdrawal.[1] Adolescence is marked by numerous lifestyle changes, including dietary habits and increased autonomy over personal care practices, which can negatively impact oral hygiene. Effective oral health education during this stage is crucial for preventing long-term health problems and fostering positive health behaviors.

Despite the availability of effective preventive measures, many adolescents lack adequate knowledge and motivation regarding proper oral hygiene practices.[2] Traditional educational approaches, such as lectures and printed materials, often fail to engage young individuals effectively, resulting in limited retention of information and minimal changes in behavior.[3] This inadequacy underscores the necessity for innovative strategies that can promote active participation and enhance learning outcomes.

Emerging electronic and robotic educational models for toothbrushing instruction have demonstrated promising results in improving comprehension, motivation, and plaque control compared with traditional teaching approaches.[4,5]

Gamification, the application of game-design elements in nongame contexts, has emerged as a promising strategy for health education. By harnessing the motivational factors inherent in games, gamification can promote engagement, encourage behavior change, and make learning more enjoyable.[6] The interactive nature of gamified experiences significantly enhances knowledge retention and behavioral intentions, making it an effective method for health promotion among adolescents.[7] The concept has gained traction across various fields, particularly in motivating individuals to adopt healthier behaviors.

“Gum Warrior,” an interactive online game developed by the authors of the present study, integrates storytelling and visual simulations to effectively convey essential oral hygiene principles to adolescents. This innovative approach captures the interest of young users and encourages them to take ownership of their oral health through engaging learning experiences.[8] Research suggests that gamified interventions can lead to improved health outcomes, particularly among adolescents who are typically more responsive to novel educational strategies.[9] Previous studies have also demonstrated the effectiveness of gamification in promoting positive health behaviors in various contexts, such as physical activity, nutrition, and smoking cessation.[10] However, the application of gamification specifically to oral health education remains an underexplored area.

The theoretical framework for gamification in health education is rooted in various psychological and educational theories. The self-determination theory (SDT) asserts that individuals are more motivated to engage in activities when they feel autonomous, competent, and connected to others.[11] Gamification fulfills these needs by offering choices, immediate feedback, and opportunities for social interaction, thereby enhancing motivation and driving behavioral change. In addition, social cognitive theory emphasizes the role of observational learning and modeling in behavior change.[12] Gamification facilitates the demonstration of desired behaviors through engaging narratives and challenges, allowing adolescents to visualize the consequences of their actions in a safe environment. This immersive experience can strengthen self-efficacy, empowering adolescents to adopt healthier behaviors.

Beyond motivational theories, game-based learning also draws on several cognitive processes that are important for behavior change. Interactive games require players to interpret visual information, make quick decisions, sustain attention, and respond to feedback in real time. These features engage visuospatial skills, executive functioning, and reward-based learning mechanisms, which are known to strengthen understanding and memory.[13] Evidence from neurocognitive and educational research suggests that serious games can improve working memory, procedural learning, and problem-solving abilities, making them particularly suitable for adolescent health education. By stimulating these cognitive processes, gamified oral health education may support deeper learning and encourage students to translate knowledge into everyday oral hygiene practices.[14]

Focusing on adolescents for oral health education is particularly important due to the unique challenges this group faces. Adolescents often experience a decline in parental supervision regarding oral hygiene, which can lead to neglect of proper practices.[15] In addition, peer influence can significantly affect their attitudes and behaviors toward oral health. Therefore, addressing the needs and preferences of adolescents through innovative educational strategies is crucial for fostering positive oral health behaviors. Several studies have highlighted the importance of tailored interventions for adolescents. For instance, research has shown that adolescents respond better to interactive and engaging educational materials compared to traditional methods.[16] This suggests that gamified approaches could be particularly effective in reaching this demographic, addressing their specific needs and preferences.

“Gum Warrior” is designed to engage adolescents by integrating key oral hygiene principles through visual simulations. The game employs a narrative framework that allows players to embark on a journey, where they encounter various scenarios related to oral health. Its engaging format not only enhances knowledge but also encourages students to apply what they learn in their daily lives.[17] The intervention includes high scores and achievements, which are recorded and shared among participants to foster a sense of competition and community. This competitive element can further motivate adolescents to improve their performance and engage more deeply with the material, reinforcing positive behaviors.[18] Additionally, the use of visual feedback through a two-tone disclosing agent allows students to see the impact of their oral hygiene practices, thereby enhancing their understanding and encouraging self-reflection.[19] Therefore, this present study aimed to evaluate the effectiveness of a game-based oral health education intervention in improving plaque and gingival scores among schoolchildren aged 12–15 years in comparison to traditional oral health education methods.

MATERIALS AND METHODS

The present study was designed as a clustered nonrandomized controlled trial conducted within school settings. This study was conducted and reported in accordance with the Transparent Reporting of Evaluations with Nonrandomized Designs Statement guidelines for transparent reporting of nonrandomized evaluations. Allocation occurred at the classroom level to avoid contamination between students receiving different educational approaches within the same class. Random allocation of individual students was not feasible because the intervention had to be implemented within existing classroom structures and school schedules, and school authorities required that students within the same class receive the same type of educational activity. Participants were then allocated to intervention and control groups based on preexisting class divisions and logistical feasibility. The study was conducted over a period of 7 months, from August 2024 to February 2025. To ensure geographical representation, the region was divided into four blocks – North, South, East, and West – and approximately two schools from each block were selected through a lottery-based random selection process. Data of the schools were taken from the district education officer’s office with proper permission. A total of eight schools (both government and private) were included in the study. Within each participating school, students aged 12–15 years were allocated into either the intervention or control group based on timetable feasibility and administrative permission. Thus, the unit of assignment was the class, while the unit of analysis was the individual student.

Ethical approval for the study was obtained from the Institutional Ethics Committee. Sample size calculation was based on the results of a pilot study with a moderate effect size of 0.5, with 80% statistical power and a significance level of 0.05. As per the results obtained from the pilot study, the interventional group showed significantly improved plaque and gingival scores, which, upon calculation, revealed a minimum inclusion of 60 participants per group (G*Power Software, version 3.1.9.7 [Heinrich-Heine-Universität Düsseldorf (University of Düsseldorf), German]).[20] To accommodate potential attrition (estimated at 10%–15%), the sample was increased, resulting in a total of 162 participants divided equally into both groups.

As the study followed a nonrandomized design, participants were not randomly assigned to the intervention and control groups. Instead, group allocation was based on preexisting school or class divisions, logistical feasibility, and administrative permissions. Consequently, the number of students in each group was influenced by natural variations in class sizes, student availability, and willingness to participate on the days of intervention or data collection. These real-world factors led to a slight discrepancy in group sizes (82 in the intervention group and 80 in the control group), which was within acceptable limits and did not significantly affect the statistical validity of the study.

Baseline and follow-up clinical data were recorded using the plaque index (Loe and Silness, 1964 original version, simplified version)[21] and the simplified gingival index.[22] A two-tone disclosing agent (Apha-Plac, Dental Products of India) was used both for plaque assessment and as a motivational tool, highlighting new plaque (pink) and old plaque (blue). This visual feedback allowed students to understand their oral hygiene status and promoted better engagement. Recognizing the inherent subjectivity in scoring the plaque index, a single standardized and calibrated examiner recorded all clinical findings to minimize inter-examiner variability and ensure consistency. However, the gingival index was recorded by three standardized examiners after the plaque scores were recorded first. The scores of the indices were recorded in a validated pro forma, filled by four duly trained recording clerks (Bachelor of Dental Surgery interns).

Due to the nature of the educational intervention, blinding of participants and educators was not feasible. However, outcome assessment was partially blinded. The examiner recording the plaque index was unaware of group allocation. Gingival index recording was performed by calibrated examiners who were not involved in delivering the intervention. Data analysts were blinded to group identity using coded datasets.

Follow-up clinical assessment for plaque and gingival indices was conducted 7 months after the intervention to evaluate sustained changes in oral hygiene status. The 7-month follow-up period was selected to allow sufficient time for the adoption of improved oral hygiene behaviors and for measurable clinical changes in plaque and gingival indices to occur. In addition, this duration aligned with the academic calendar of the participating schools, enabling completion of baseline and follow-up assessments within the same academic session while minimizing loss to follow-up.

The inclusion criteria consisted of school-going adolescents aged 12–15 years, willing to participate, and whose parents provided written informed consent, 1 day before the day of examination. Exclusion criteria included students with systemic illnesses, special healthcare needs, ongoing orthodontic treatment, or those who had undergone professional oral prophylaxis in the previous 3 months, absence on the day of conducting the examinations, and absence of any index teeth in either plaque or the gingival index.

The intervention group (n = 82) received oral health education through an interactive online game called “Gum Warrior.” The game was developed using GDevelop 5, an open-source visual game engine, and was reviewed and validated by two independent dental professionals who were not involved in the study. The reliability of the content was found to be acceptable, with a Cronbach’s alpha (α) of 0.79.[23] Students were first introduced to the game using laptops and projectors, after which each participant played the game individually under supervision from the research team to ensure proper participation. The minimum duration of gameplay was around 5 min, but students were free to continue playing for as long as they wished. The game was introduced only once during the study, and students did not have access to it afterward on personal devices. While players’ scores were recorded and shared to encourage motivation and engagement, these scores were used only for reinforcement and were not included in the statistical analysis. The game conveyed essential oral hygiene concepts through age-appropriate challenges and engaging visual simulations. The game followed a score-based gameplay format designed to reinforce correct oral hygiene practices. Participants progressed through different interactive scenarios related to daily oral health behaviors. During gameplay, students were required to make choices such as selecting the correct brushing technique, identifying plaque-retentive areas, and choosing healthy dietary habits for maintaining oral health. Each correct response earned points, while incorrect responses prompted corrective feedback within the game before allowing progression to the next stage. The cumulative score reflected the participant’s performance throughout the game and served as a motivational element to encourage engagement and learning. At the end of the gameplay session, scores were displayed to the participants to create a sense of achievement and friendly competition among students. In contrast, the control group (n = 80) received a single standardized oral health education session. This consisted of a demonstration of proper brushing techniques and oral hygiene instructions using a Dentoform model, delivered through direct counseling. Both interventions were designed to be of roughly comparable duration to avoid major differences in exposure time. Both interventions were delivered as a single standardized session to evaluate the independent effect of the educational modality itself. Multiple reinforcement sessions were intentionally avoided to minimize additional behavioral reinforcement that could confound the comparative effectiveness between the gamified and traditional methods. The overall study protocol is illustrated in Figure 1, while the screenshots of the game are depicted in Figure 2a and b.

Figure 1.

Participant flow diagram according to the Transparent Reporting of Evaluations with Nonrandomized Designs guidelines

Figure 2.

(a) Starting screen of the game;[23] (b) Screenshot of the gameplay[23]

Participation was entirely voluntary, and data confidentiality was strictly maintained; all data were stored securely and accessed only by the primary investigator. Data analysis was performed using SPSS (Statistical Package for the Social Sciences: IBM, New York, USA version 26.0).[24] Normality of the data was assessed using the Shapiro–Wilk test, and since the data followed a normal distribution, parametric tests were applied. Paired t-tests were used for intra-group comparisons of mean plaque and gingival index scores (pre- and postintervention), while independent t-tests were applied for inter-group comparisons. Chi-square tests were used to evaluate changes in categorical outcomes such as the distribution of good, fair, and poor oral hygiene scores. Binary logistic regression was employed to examine the association of age and gender with oral hygiene outcomes. In addition, bivariate analysis using Pearson’s correlation (for age) and independent t-tests (for gender) was performed to explore their influence on postintervention plaque and gingival index scores. P < 0.05 was considered statistically significant.

RESULTS

A total of 162 students participated in the study, with 82 in the intervention group and 80 in the control group. The mean age was comparable between the groups: 13.22 ± 1.1 years for the intervention group and 13.14 ± 1.0 years for the control group [Table 1]. Males comprised 54.9% and 53.8% of the intervention and control groups, respectively. It was observed that gender and age distributions were almost similar across both the groups.

Table 1.

Demographic characteristics of study participants (percentages rounded off to the nearest decimal)

Groups	Mean age (years)±SD	Males (%)	Females (%)
Intervention (n=82)	13.22±1.1	45 (54.9)	37 (45.1)
Control (n=80)	13.14±1.0	43 (53.8)	37 (46.2)
Overall	13.18±1.05	88 (54.3)	74 (45.7)

SD – Standard deviation; n – Number

In the intervention group, the proportion of students with good plaque scores increased from 35.4% at baseline to 52.4% after the intervention. Those with poor scores reduced significantly from 15.8% to 3.7%, indicating a marked improvement following the gamified education (P = 0.02). Similarly, gingival scores improved, with students showing good gingival health increasing from 37.8% to 63.4% and poor scores dropping from 14.7% to 3.7% (P = 0.04). In the control group, plaque scores also improved modestly. Good scores increased slightly from 41.3% to 43.75%, and poor scores reduced from 19.8% to 7.5% (P = 0.04). However, the change in gingival scores was not statistically significant (P = 0.09), with good scores increasing from 38.7% to 46.2% and poor scores dropping to 0% [Table 2].

Table 2.

Plaque index and gingival index scores (pre- and postintervention)

Pre- and postplaque and gingival scores
	PI			GI
	Pre, n (%)	Post, n (%)	P	Pre, n (%)	Post, n (%)	P
Intervention (n=82)
Good	29 (35.4)	43 (52.4)	0.02*	31 (37.8)	52 (63.4)	0.04*
Fair	40 (48.8)	36 (43.9)		39 (47.5)	27 (32.9)
Poor	13 (15.8)	3 (3.7)		12 (14.7)	3 (3.7)
Control (n=80)
Good	33 (41.3)	35 (43.75)	0.04*	31 (38.7)	37 (46.2)	0.09*
Fair	31 (38.9)	39 (48.75)		35 (43.7)	43 (53.8)
Poor	16 (19.8)	6 (7.5)		14 (17.6)	0

*Statistically significant P value. Percentages rounded off to the nearest decimal; n – Number; PI – Plaque index; GI – Gingival index; P – Probability value

At baseline, mean plaque and gingival index scores were similar between the intervention and control groups. Postintervention, the intervention group showed a statistically significant improvement in both plaque and gingival index scores (P < 0.001 and P = 0.03, respectively). The control group exhibited only a modest improvement in plaque scores (P = 0.04), while the change in gingival scores was not statistically significant (P = 0.08). These findings suggest the superior effectiveness of the gamified intervention in improving oral hygiene outcomes [Table 3].

Table 3.

Mean plaque and gingival index scores (pre- and postintervention)

Group	PI (pre), mean±SD	PI (post), mean±SD	P	GI (pre), mean±SD	GI (post), mean±SD	P
Intervention	1.72±0.34	0.89±0.27	<0.001*	1.85±0.29	1.02±0.23	0.03*
Control	1.75±0.31	1.62±0.30	0.04*	1.87±0.27	1.72±0.25	0.08
Overall	1.73±0.33	1.26±0.39	-	1.86±0.28	1.37±0.32	-

*Statistically significant P value. Percentages rounded off to the nearest decimal. SD: Standard deviation; P: Probability value; PI – Plaque index; GI – Gingival index

Postintervention comparisons revealed significantly lower mean plaque and gingival index scores in the intervention group compared to the control group. The mean plaque index in the intervention group was 0.89 ± 0.27, while in the control group, it was 1.62 ± 0.30 (P < 0.001). Similarly, the mean gingival index was 1.02 ± 0.23 in the intervention group and 1.72 ± 0.25 in the control group (P < 0.001). These differences were statistically significant, indicating that the game-based oral health education was more effective in improving oral hygiene outcomes than the conventional method [Table 4].

Table 4.

Intergroup comparison of postintervention plaque and gingival scores

Index	Intervention group (mean±SD)	Control group (mean±SD)	P
PI	0.89±0.27	1.62±0.30	<0.001*
GI	1.02±0.23	1.72±0.25	<0.001*

*Statistically significant P value. Percentages rounded off to the nearest decimal. SD: Standard deviation; P: Probability value; PI – Plaque index; GI – Gingival index

Binary logistic regression analysis was performed to evaluate the association of age and gender with oral hygiene outcomes. The analysis revealed that age was not significantly associated with improved oral hygiene status, with an odds ratio (OR) of 1.10 (95% confidence interval [CI]: 0.95–1.28; P = 0.200). Similarly, gender did not show a significant influence, with males having an OR of 0.87 (95% CI: 0.51–1.48; P = 0.610). These findings suggest that neither age nor gender had a statistically significant impact on the postintervention oral hygiene scores [Table 5].

Table 5.

Association of age and gender with oral hygiene outcomes (logistic regression)

Variables	OR	95% CI	P
Age	1.10	0.95–1.28	0.200
Gender (Male)	0.87	0.51–1.48	0.610

Percentages rounded off to the nearest decimal. OR – Odds ratio; CI – Confidence interval; P – Probability value

Bivariate analysis revealed a statistically significant association between gender and postintervention oral hygiene scores. Males showed significantly higher plaque (t = 2.78, P = 0.006) and gingival scores (t = 2.34, P = 0.021) compared to females. Age also demonstrated a mild but statistically significant correlation with plaque index (r = 0.21, P = 0.032) and gingival index (r = 0.18, P = 0.046) [Table 6]. These findings suggest that both age and gender may influence postintervention oral hygiene outcomes.

Table 6.

Bivariate analysis of age and gender with oral hygiene outcomes

Variables	Outcome variable	Test used	P
Age	PI (post)	Pearson’s r=0.21	0.032*
Age	GI (post)	Pearson’s r=0.18	0.046*
Gender (male/female)	PI (post)	Independent t-test (t=2.78)	0.006*
Gender (male/female)	GI (post)	Independent t-test (t=2.34)	0.021*

*Statistically significant P value. Percentages rounded off to the nearest decimal. r – Pearson’s correlation coefficient; P – Probability value; PI – Plaque index; GI – Gingival index; t – Statistic test

DISCUSSION

The demographic characteristics of participants were similar across both the groups, with mean ages of 13.22 years in the intervention group and 13.14 years in the control group. Gender distribution was also comparable, with males comprising 54.9% in the intervention group and 53.8% in the control group. This demographic similarity is important, as it helps minimize confounding variables that could obscure the true effect of the intervention. Previous studies by Al-Ansari JM et al.[25] and Sanadhya et al.[26] reported that age and gender can significantly influence oral health outcomes. However, in contrast, the present study found that these demographic factors did not significantly affect the effectiveness of the gamified intervention.

Postintervention scores in the current study demonstrated a substantial improvement in both plaque and gingival index scores among participants in the intervention group. The proportion of students with good plaque scores increased markedly from 35.4% to 52.4%, while the proportion with poor scores declined significantly from 15.8% to 3.7%. Similarly, gingival health improved, with good gingival scores rising from 37.8% to 63.4%. These findings align with previous research by Deterding et al.[7] and Hamari et al.,[27] which highlight the efficacy of gamification in enhancing engagement and motivation in health-related behaviors, ultimately leading to improved clinical outcomes.

In contrast, the control group exhibited only modest changes. It was observed that in the intervention group, good plaque scores rose slightly from 41.3% to 43.75%, while changes in gingival scores were not statistically significant (P = 0.09). This suggests that although traditional educational methods may yield some improvement, gamified interventions are markedly more effective in promoting meaningful behavior change and improved oral health outcomes. The superior effectiveness of the gamified intervention may be attributed to several behavioral and educational mechanisms. Gamification integrates elements such as interactive challenges, visual feedback, rewards, and competition, which can significantly enhance motivation and engagement among adolescents. These features promote active participation rather than passive learning, thereby improving knowledge retention and encouraging the practical application of oral hygiene practices. Furthermore, the use of visual simulations and immediate feedback allows students to better understand the consequences of their oral hygiene behaviors. Such interactive learning environments are known to enhance intrinsic motivation, consistent with principles of SDT and social cognitive theory, which emphasize autonomy, competence, and observational learning in behavior change. These results support earlier findings that gamification can lead to higher motivation levels and sustained behavioral change compared to conventional approaches.[28]

Statistical analysis further confirmed the effectiveness of the gamified approach: improvements in both plaque and gingival index scores were statistically significant in the intervention group (P < 0.001 and P = 0.03, respectively). In contrast, the control group’s change in gingival index scores remained nonsignificant (P = 0.08). These results underscore the superior impact of gamified education and reinforce its value as a potent tool for improving oral hygiene. Prior research supports this conclusion, showing that gamified interventions can enhance knowledge retention and skill acquisition in health education settings.[29]

The intergroup comparisons further underscored the effectiveness of the gamified intervention. The mean plaque index in the intervention group was significantly lower (0.89 ± 0.27) than that in the control group (1.62 ± 0.30), with P < 0.001. Similarly, the mean gingival index in the intervention group was markedly lower (1.02 ± 0.23) compared to the control group (1.72 ± 0.25). These statistically significant differences indicate that the gamified approach not only improves individual oral hygiene scores but also contributes to overall better oral health among adolescents. These findings support the growing body of evidence suggesting that interactive and engaging educational strategies – such as gamification – can enhance health-related outcomes by fostering motivation and sustained behavioral change. The results are consistent with prior research, including that of Li M et al.,[30] which highlights the potential of gamified health education in improving learning retention and behavioral adoption in school-based interventions.

Binary logistic regression analyses indicated that neither age nor gender significantly influenced postintervention oral hygiene scores. The ORs for age and gender were 1.10 (P = 0.200) and 0.87 (P = 0.610), respectively. This lack of significant association suggests that the effectiveness of the gamified intervention transcends demographic differences, making it a universally applicable approach for improving oral health among adolescents. This finding is particularly important, as it suggests that gamified interventions can be designed to effectively engage a diverse audience, regardless of age or gender, which is crucial in public health education.[31]

The bivariate analysis revealed a statistically significant correlation between gender and postintervention oral hygiene scores. Males demonstrated significantly higher plaque (t = 2.78, P = 0.006) and gingival scores (t = 2.34, P = 0.021) compared to females. In addition, age showed a mild but statistically significant correlation with plaque index (r = 0.21, P = 0.032) and gingival index (r = 0.18, P = 0.046). These findings suggest that while gamification benefits all participants, younger males may require additional strategies to enhance their engagement and health outcomes. This aligns with literature indicating that gender differences can influence health behaviors, and tailored approaches may be necessary to maximize effectiveness.[32]

Implications for future research

The results of this study underscore the potential of gamified interventions in health education. Future research should explore the long-term effects of gamification on oral health behaviors and outcomes, as well as the feasibility of implementing such interventions in broader settings, such as schools or community health programs. Investigating the specific elements of gamification that contribute to its effectiveness would also be valuable, allowing for the refinement of educational strategies.[33] Moreover, studies could assess the scalability of such interventions, examining how they can be integrated into existing health education frameworks.

Limitations

Despite the valuable findings, the present study has several limitations. The nonrandomized allocation of participants at the class level may have introduced selection bias and residual confounding despite comparable baseline characteristics between the groups. Because the intervention was delivered within existing school settings, blinding of participants was not feasible, which may have resulted in performance bias. The clustered nature of the data was not adjusted using multilevel modeling, which may slightly influence the precision of the estimates. In addition, the intervention consisted of a single educational session without reinforcement, which may underestimate the full potential of repeated gamified learning exposure. Behavioral outcomes such as brushing frequency and dietary practices were not directly measured, limiting insight into the behavioral pathways underlying the observed clinical improvements. Finally, the 7-month follow-up period may not fully capture the long-term sustainability of the improvements in oral hygiene outcomes.

CONCLUSION

This study highlights the effectiveness of a gamified educational intervention in improving oral hygiene outcomes among adolescents. The significant improvements in plaque and gingival scores among the intervention group demonstrate the potential of gamification as a tool in health education. As oral health continues to be a critical public health issue, incorporating innovative strategies like gamification could play a vital role in engaging young individuals and promoting healthier behaviors. By fostering a more interactive and engaging learning environment, gamified interventions can enhance knowledge retention, encourage positive health behaviors, and ultimately improve health outcomes.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.