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 Table of Contents  
Year : 2022  |  Volume : 17  |  Issue : 3  |  Page : 568-574

Effectiveness of three different types of oral health promotion programs among schoolchildren in Sakaka, Saudi Arabia: A cluster randomized controlled trial

Department of Preventive Dentistry, College of Dentistry, Jouf University, Sakakah, Saudi Arabia

Date of Submission02-Jul-2020
Date of Decision03-Nov-2020
Date of Acceptance21-Nov-2020
Date of Web Publication2-Nov-2022

Correspondence Address:
Dr. Sakaka Vundavalli
Department of Preventive Dentistry, College of Dentistry, Jouf University, Sakakah, Aljouf
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_247_20

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Background: Untreated component of dental caries in Saudi Arabia is alarming even though the accessibility of dental services is at free of cost to all Saudi nationals. Aim/Objective: The aim of the present study is to assess the efficiency among three different types of school-based oral health promotion programs in Sakaka children. Materials and Methods: A cluster randomized controlled trail included 765 schoolchildren. Three different models of school-based oral health promotion programs were tested in this study. Outcome measures were evaluated after 12-month follow-up, which include difference in prevalence and mean number of untreated dental caries, annual dental service utilization rates, and difference in mean oral health-promoting behavior between baseline and at the end of the program. Results: Seven hundred and two children were available for outcome measurement. There is reduction in both prevalence and mean number of untreated dental caries in all the three groups but significant reduction observed in Model-3 group of children. Similarly, improvement in dental visit patterns was also observed more in Model-3 group compared with other two groups. Conclusion: Health education including teachers with 6-monthly reinforcement, screening, and referral to specific treatment facility with follow-up reminders was found to be an effective model.

Keywords: Health education, oral health, school dental program

How to cite this article:
Vundavalli S, Baig MN. Effectiveness of three different types of oral health promotion programs among schoolchildren in Sakaka, Saudi Arabia: A cluster randomized controlled trial. J Datta Meghe Inst Med Sci Univ 2022;17:568-74

How to cite this URL:
Vundavalli S, Baig MN. Effectiveness of three different types of oral health promotion programs among schoolchildren in Sakaka, Saudi Arabia: A cluster randomized controlled trial. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Feb 4];17:568-74. Available from: http://www.journaldmims.com/text.asp?2022/17/3/568/360199

  Introduction Top

Oral health is an inseparable component of general health and overall well-being. Optimum oral health is an essential element required for proper nutrition and growth in children.[1] Dental caries is one of the risk factors for poor oral health-related quality of life in children and young adolescents. Dental caries prevalence in Saudi Arabia is 80% in deciduous dentition and 70% in permanent dentition, and untreated component is alarming despite the accessibility of dental services at free of cost for all Saudi nationals.[2] 64.6% of children among 12 years of age never visited a dentist in their life time, and most of them have symptomatic dental visits.[3] Poor oral health-related knowledge is found to be one of the contributing factors for underutilization of dental services, and a lack of public demand for preventive dental health services may lead to high caries burden.[4] Considering the consequences of untreated dental caries and magnitude of the problem, the prevention of dental caries and oral health promotion is an unequivocal choice.[5] To this end, community-based preventive programs to improve oral health-related knowledge of children and their parents and specific caries preventive initiatives such as topical fluorides and pit and fissure sealants are a need of an hour.[6] School-based oral health program has been used in various countries as one of the measures in the prevention of dental caries in children. School-based screening and referral are intended to motivate the children and their parents to effective utilization of dental services, but there is a conflicting evidence about the long-term impact of school-based screening on children.[7] Among the researchers reported on the impact of school-based screening on children, one of the high-quality studies reported by Milsom et al. tested three different types of referral systems, and it was concluded that there were no significant differences in caries incidence in both dentitions or in the proportions of children attending a dentist after screening between the control and intervention groups.[8] These findings suggest that simple screening and referral is highly unpredictable in seeking dental care even though free services are available. Some additional factors may influence dental services utilization[7] and there is a gap in identifying such additional factors and knowledge about such factors are vital to design an ideal school-based intervention for dental caries prevention in Saudi Arabia.

In December 2018, the College of Dentistry of Jouf University decided to implement an oral health promotion program for schoolchildren in Sakaka City, Al Jouf, KSA. Various models of oral health promotions were implemented. This study attempts to identify the factors which positively influence the success of school-based oral health promotion programs for a country like Saudi Arabia for school dental health policy development. Hence, the aim of this study is to evaluate the effectiveness of three different models of school-based oral health promotion programs.

  Materials and Methods Top


This was a cluster randomized controlled trial.

Source of data

This research is a part of on-going school oral health promotion program for schoolchildren of Sakaka, which was initiated in 2018. Schoolchildren who are native residents of Sakaka (both urban and rural) were selected for this study. Participants were selected using cluster sampling method. In the initial phase, three schools from the list of schools listed in the Ministry of Education were by simple random (lottery) method and all the children in the selected schools were included in this study based on the inclusion and exclusion criteria.

Inclusion criteria

  • Children aged between 7 and 12 years who are attending the selected schools
  • Children who gave oral consent and also got written consent for the participation from their parents/legal guardian
  • Only Saudi nationals were included in this study.

Exclusion criteria

  • Children who are medically compromised/any medical condition which may adversely affect outcome variables
  • Foreign nationals were not included in original sample; however, they received similar intervention like Saudi children
  • Children who failed to give/get consent to participate in this study.

Sample size

Sample size was calculated based on the prevalence of untreated dental caries (83%) reported in a previous study by Gudipaneni[5] in Sakaka children. Considering 95% confidence interval and 80% power, 690 children (230 individuals per arm) were sufficient to detect clinically significant difference of 10% with design effect of two. Therefore, the total sample size was adjusted to 765 expecting the fact that there are 10% chances of attrition and it was divided as 255 children per school from three selected schools.

Randomization and blinding

Randomization was done at the school level, i.e., each school among the three selected schools from the list of schools was randomly assigned into any of the three intervention groups by simple random method (lottery method by a statistician). Only single blinding of outcome evaluators was done. Blinding of participants and their parents is not feasible in this study due to nature of intervention in which parents were provided complete information about interventions as a part of obtaining informed consent.


All participants and their parents were fully informed about the objectives and methodology of the study. Initial examinations were done to all the children in three selected schools to establish baseline data. All the children present in the school irrespective of their participation in this research received oral health promotion initiatives. It was chosen to avoid bias due to effect modification and social desirability by the study participants. The following interventions were done.

Conventional (Model-1)

Health education, screening, and referral (information form in which parents were informed about child's dental problem and advising them to take their child for dental treatment).

Modified conventional (Model-2)

  • Dental health education using pamphlets, models, audio-visual aids, etc., and reinforcement of health education
  • Screening and referral to a specific dental treatment facility, Dental Clinic Center, College of Dentistry, Sakaka, KSA, where all dental treatments were provided at free of cost to all patients on all working days.

Modified conventional + two additional measures (model-3)

  • Dental health education using pamphlets, models, audio-visual aids, etc., and 6 monthly reinforcement of health education
  • Additional measure-1: Health education for school teachers to promote healthy breakfast habits in children during school hours
  • Additional measure-2: Screening and referral to specific dental care facility with follow up reminders by sending text message (short message service [SMS]) to their parent's mobile telephone.


No additional risks for the study participants are anticipated.

Outcome measures

Primary endpoint measures

  • Difference in the prevalence of untreated dental caries (DT >0 for permanent dentition and dt >0 for deciduous dentition) between baseline and at the end of the program
  • Difference in the mean number of active dental carious teeth (DT and dt) and the mean of treated caries (FT and ft) between baseline and at the end of the program
  • Difference in the annual dental visit rates between baseline and at the end of the program.

Secondary endpoint measures

Difference in the oral health-related behaviors such as brushing, use of fluoride tooth paste, mouth rinsing, frequent fruit consumption, and infrequent sugar consumption between baseline and at the end of the program.[9] All oral health-related behaviors are coded as 0 or 1; 0 for unfavorable oral health behaviors and 1 for favorable behavior, and an aggregate was created by summing up all oral health-related behaviors which ranged from 0 to 5.

Data collection

Information about dental caries was collected using the World Health Organization's (WHO) diagnostic criteria.[10] Oral health-related knowledge and practices were collected using the WHO's Oral Health Questionnaire for children-2013[10] which included 14 items. Questionnaire was translated to Arabic, and corrected item-total correlation (CITC) and Cronbach's alpha were used to assess the internal reliability of the construct. The CITC value of Arabic questionnaire was 0.46 (CITC >0.30 was considered good)[11] and Cronbach's alpha score for this questionnaire was 0.88. It was a self-administered questionnaire and children were asked to fill with the help of parents.

Eight dental investigators were used for initial data collection and another set of eight investigators acted as endpoint evaluators. Both sets of investigators were trained and inter- and intra-examiner calibrations will be done before the beginning of data collections. The Kappa values for inter- and intra-examiner reliability in assessing dental caries for all investigators were in the range of 0.86–0.92.

Data management

All relevant data collected during the study were entered in a case record sheet by the investigator as soon as the information was collected. Anonymity was maintained by not recording the name of the participant, and each participant has a serial number and so privacy of each participant was maintained. Neither the names of the school nor name of the participants were retrieved from main data; thus, confidentiality was maintained.

Safety evaluation and reporting of adverse events

An adverse event is defined as any untoward medical/dental occurrence in a patient that does not necessarily have a causal relationship with the trial intervention and that occurs between inclusion of the patient and final evaluation.

Ethical approval

Ethical approval for the study protocol was obtained from the Local Committee of Bioethics (LCBE), Jouf University, with reference number 02-07/41.

Good clinical practice

All the procedures mentioned in this trial protocol, relating to the conduct, outcome assessment, and documentation of this trial, are designed to ensure that the trial abide by LCBE and Helsinki's declaration.

Confidentiality of the data

Confidentiality was maintained and participants' information was not be disclosed without their/parents' consent.

Statistical analysis

Data were analyzed with Statistical Software for Social Sciences, IBM SPSS Version 20 (Armonk, NY, USA, IBM Corp.) and Mplus 7.4 and R X64 3.5.1 (psych package). First, the normality of the data (mean scores, before and after intervention) was evaluated using the Kolmogorov–Smirnov test. Statistical analysis included Donner and Klar's cluster-specific method[12] as randomization was done at school level rather than individual participant level. Percentage of untreated dental caries, mean number of decayed teeth, percentage of children visited dentist, etc., were calculated at school level calculating the average of all participant scores in each school. Dependent samples “t” test/paired “t” test was used to compare the mean number of untreated decayed teeth. One-way ANOVA with Tukey's HSD was used to compare intergroup differences. Chi-square test was used to analyze oral health habits and dental visit patterns. A P ≤ 0.05 was considered as statistically significant for all analyses.

  Results Top

Enrolment and retention

Seven hundred and sixty-five children from three different schools were included at the beginning of the trail, and at the end of the year, 702 children were retained for outcome assessment. Among the dropouts, there were no withdrawals and dropouts are due to children transferring from participating school to other schools [Figure 1].
Figure 1: Flow diagram showing the flow of participants at each stage of trial

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Demographic features

All the participating children were male; among these, 240 (34.1%) belong to the age group of 7–9 years, while 462 (65.9%) belong to the age group of 10–12 years and the mean age of the children is 10.8 years. Parents' education status was also included in the data and only 4% of fathers and 6.4% of the mothers did not have formal education [Table 1].
Table 1: Participant characteristics

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Dental caries

[Table 2] represents the prevalence of untreated dental caries in both primary and permanent dentitions across the three groups of children. There is some amount reduction in the prevalence of untreated caries in all the three groups, significant differences are found in Group 2 and Group 3 for permanent dentition and for deciduous dentition, and only Group 3 has significant reduction in untreated caries level.
Table 2: Prevalence (percentage) of untreated caries in the primary and permanent dentitions at baseline and outcome examinations

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Mean number of untreated decayed teeth (DT/dt) was compared between baseline and outcome values [Table 3]. Among the intervention groups, only Group 3 has statistically significant reduction in the mean number of untreated carious teeth in both deciduous and permanent dentitions.
Table 3: Mean number of untreated and treated carious teeth in the primary and permanent dentitions at baseline and outcome examinations

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Dental visit patterns

Difference in the annual dental visit patterns at the beginning and end of the program is presented in [Table 4]. Statistically significant improvement in dental visit patterns is observed in both Group 2 and Group 3. Among these two groups, group 3 has more improvement than group 2.
Table 4: Dental visit patterns

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Oral health behavior

Mean oral health-promoting behavior scores is presented in [Table 5], and among the intervention groups, a significant rise in the mean oral health promoting score was observed in Group 3, whereas some improvements are observed in other two groups also, which is not statistically significant.
Table 5: Mean health-promoting behavior

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  Discussion Top

No consistent national-level school-based oral health promotion programs were established in Saudi Arabia, and certain isolated studies reported either effectiveness on dental health education program on the improvement of oral health knowledge or factors affecting dental visit. A recent study conducted in Riyadh about effectiveness of health education program on improvement in oral health knowledge and self-reported oral health behavior among primary schoolchildren showed that school-based health education was effective in improving children's knowledge and self-reported oral health behavior after 6 weeks.[13] The outcome evaluation was just after 6 weeks of health education; therefore, the long-term effects of such educational programs without reinforcement were ascribable. Another cross-sectional study reported about the factors influencing dental visit among the 6–12-year-old children in Eastern province of the KSA, in which the presence of pain is a major influencing factor in seeking dental care.[14] One of the major lacunae in these studies was cross-sectional in nature and lack of control groups for comparison. In contrast, the present study is a cluster randomized controlled trail and was followed up 12 months later. Moreover, one of the intervention strategies (Model-3) used in this study was in agreement with the WHO Health Promoting Schools Project concept in which school teachers play an important role in health promotion.[15] Strict adherence to the principles in conducting randomized controlled clinical trials was followed in this study in terms of allocation, blinding of examiners, calibrations, and minimizing social desirability effect modification. All the children present in the selected school irrespective of their participation in the study or not got similar initiatives such as sample population. Thus, the field experience gained from this trail might help in designing school-based oral health promotion programs across the country.

The main clinical outcome measure used in this study was the prevalence of untreated dental caries and mean number of untreated dental caries in children. The mean DMFT/dmft scores, the standard measure of dental caries experience was not used as the outcome variable due to the fact that 12 months is an insufficient period to measure new increment of caries. The prevalence of untreated dental caries in the deciduous dentition at the beginning of the program was 71.2%, 74.6%, and 72.3% respectively which is similar to study conducted in Aljouf region by Gudipaneni et al. in which the prevalence was reported to be 73.2%.[5] The prevalence of untreated caries among permanent dentition in this study at the baseline was 56.3%, 47.2%, and 51.4%, which is less compared to study reported by Baskaradoss et al.[16] However, there are some reductions in all the three groups at the end of the program but greater reduction happened in Model-3 participants from 51.4% to 36.4%. Statistically significant reduction in both prevalence of untreated caries and mean number of untreated carious teeth in the deciduous dentition was observed again in Model-3 participants. Reduction in untreated caries in Model-3 children can be attributed to improvement in oral health behavior scores and dental service utilization rates. Another most important noticeable change observed during the follow-up visit in the Model-3 school was active involvement of teachers and their motivation leads to banning of junk food and sweetened beverages in school canteen and children are encouraged to consume fruits, egg, milk, etc., as a breakfast in schools. Various studies reported in the past that active involvement of school teachers will improve success of school-based oral health programs; a cluster randomized trail conducted in China by Tai et al.[15] reported that, among the oral health promotion interventions in the trail, that intervention which involved school teachers yielded more positive results and teachers played a vital role in reinforcing oral health knowledge; while another study conducted in India also highlighted that dental health education to schoolchildren by teachers were more effective than dentist's dental health education.[17]

In the present study, again, the improvement in dental visits is observed in all the three models, but statistically significant rise in dental visits was observed only in Model-3 which can be attributed to follow-up reminders SMS's sent to parents and referral to specific treatment facility in which appointments were easily available compared to traditional dental care system. In this study, increase in dental visit patterns [Table 4] at the end of the program not only reflected in terms of percentage improvement in annual dental visits but also reflected in terms of filled component (FT/ft) of caries measurement [Table 3]. However, there is overall improvement in dental visits in all the three groups, the highest percentage of annual dental visits pattern among the three groups was just 53.3%(for group 3) which is still less compared to previous study reported by AlHumaid et al. from Eastern province of KSA, in which 61.7% of 6–12-year-old children visited dentist in the last one year.[14] Moreover, dental care in the KSA is provided free of charge for all the citizens through public healthcare system.[18] However, this does not seem to promote dental visits among participant children and lengthy appointment duration may be one of the major hurdles in seeking dental care as reported in previous studies.[14],[19] Identifying behavioral, cultural, and sociodemographic barriers from nonvisitors and motivating factors from those who regularly visit the dentist might help in developing a successful strategy.[4],[20]

In the pursuit of oral health behaviors, our oral health promotion programs were mainly focused on regular oral health behaviors such as brushing their teeth at least twice a day, mouth rinsing, frequent fruit consumption, infrequent sugar consumption, and using fluoride toothpaste. Among the intervention groups, the statistically significant improvement in oral health behavior scores was observed in Model-3 participants.

For young children, primary school has great potential for influencing oral health behavior. Children spend a considerable amount of time in school and can be reached at a life stage when their health habits are still being formed.[21] The implementation of a school-based oral health program might have many benefits because of its potential to reach all children, both in the continuity of instructions and the provision of preventive measures. This study did have a few limitations. First, oral health behavior information was collected by means of self-administered questionnaires completed by children with parents guidance under the no supervision of dentists. Only male children were included in this study and female children are not accessible due to cultural barriers.

  Conclusion Top

Based on the study results, it can be concluded that health education involving teachers along with dentists, screening and referral to specific treatment facility, and parental reminders about taking their children's dental visits were found to be successful strategy for school-based oral health promotion in Saudi schoolchildren. Although this intervention brought some positive oral health behaviors, future clinical studies are still needed to assess the long-term effectiveness of these school-based oral health promotion programs in both male and female children.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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