Using oral hygiene education in schools to tackle child tooth decay: a mixed methods study with children and teachers in England

Figures & data

Table 1. Randomisation of classes per school.

Year Group	Gloucestershire	Greater London
3	Control	Control
4	Intervention	Intervention
5	Intervention	Control
6	Control	Intervention

Figure 1. Data collection process.

Table 2. Oral hygiene baseline knowledge for all students (n = 121).

Question	Correct (n)	Correct (%)
3: Can you protect your teeth from tooth decay? Correct answer: YES	63	52
4: Can tooth decay make your teeth hurt? Correct answer: YES	58	48
5: Which of the following foods and drink contain sugar?
a) Fruit Juices Correct answer: YES	80	66
b) Cornflakes Correct answer: YES	50	41
c) Biscuits Correct answer: YES	96	79
d) Milk Correct answer: YES	15	12
e) Fizzy Drinks Correct answer: YES	114	94
f) Smoothies Correct answer: YES	72	60
6: Tick which drinks you think could be bad for your teeth?
a) Fruit Juices Correct answer: YES	50	41
b) Water Correct answer: NO	120	99
c) Fizzy drinks with sugar Correct answer: YES	116	96
d) Milk Correct answer: NO	116	96
e) Diet fizzy drinks Correct answer: YES	92	76
7: How often should you brush your teeth? Correct answer: Twice a day	99	82
8: When is the most important time of day to brush your teeth? Correct answer: Just before bedtime	38	31
9: Is it better for your teeth to have toothpaste with Fluoride in it? Correct answer: YES	48	40
10: After brushing your teeth what should you do with the toothpaste in your mouth? Correct answer: Spit it out but do not rinse	38	31

Key: <50% correct responses 50–75% correct responses >75% correct responses.

Table 3. Student demographics.

		Total Frequency n (%)	Intervention Frequency n (%)	Control Frequency n (%)
Site	Gloucestershire	64 (52.9)	32 (55.2)	32 (50.8)
	Greater London	57 (47.1)	26 (44.8)	31 (49.2)
	Total	121 (100)	58 (100)	63 (100)
Gender	Male	51 (42.5)	24 (42.1)	27 (42.9)
	Female	69 (57.5)	33 (57.9)	36 (57.1)
	Total	120* (100)	57 (100)	63 (100)
Year Group	3	40 (33.1)	0 (0.00)	40 (63.5)
	4	21 (17.4)	21 (36.2)	0 (0.00)
	5	36 (29.8)	21 (36.2)	15 (23.8)
	6	24 (19.8)	16 (27.6)	8 (12.7)
	Total	121 (100)	58 (100)	63 (100)
Average age		8.7 years old	9.2 years old	8.3 years old

*One case did not declare gender.

Table 4. Intervention group baseline knowledge, post-intervention knowledge and knowledge change (n = 58).

Question	Correct before n (%)	Correct after n (%)	Change in responses (%)	p value
3: Can you protect your teeth from tooth decay? Correct answer: YES Covered in: Introduction and Activity 2	29 (51.8)	49 (84.5)	32.7	0.000*
4: Can tooth decay make your teeth hurt? Correct answer: YES Covered in: Introduction and Activity 2	28 (49.1)	50 (87.7)	38.6	0.000*
5: Which of the following foods and drink contain sugar? Covered in: Activity 1A and Activity 1B (dependent on diet diaries and common soft drinks brought in)
a) Fruit Juices Correct answer: YES	38 (65.5)	53 (91.4)	25.9	0.000*
b) Cornflakes Correct answer: YES	25 (43.1)	38 (65.5)	22.4	0.004*
c) Biscuits Correct answer: YES	47 (81.0)	53 (91.4)	12.7	0.109
d) Milk Correct answer: YES	6 (10.3)	30 (51.7)	41.4	0.000*
e) Fizzy Drinks Correct answer: YES	57 (98.3)	58 (100)	1.7	1.000
f) Smoothies Correct answer: YES	33 (56.9)	52 (89.7)	32.8	0.000*
6: Tick which drinks you think could be bad for your teeth? Covered in: Activity 1A and Activity 1B (dependent on diet diaries and common soft drinks brought in)
a) Fruit Juices Correct answer: YES	22 (37.9)	49 (84.5)	46.6	0.000*
b) Water Correct answer: NO	58 (100)	58 (100)	0	N/A
c) Fizzy drinks with sugar Correct answer: YES	55 (94.8)	57 (98.3)	3.5	0.500
d) Milk Correct answer: NO	56 (96.6)	41 (70.7)	−25.9	0.000*
e) Diet fizzy drinks Correct answer: YES	43 (74.1)	36 (62.1)	−12.0	0.143
7: How often should you brush your teeth? Correct answer: Twice a day Covered in: Introduction and Activity 2	47 (82.5)	53 (93)	10.5	0.125
8: When is the most important time of day to brush your teeth? Correct answer: Just before bedtime Covered in: Introduction and Activity 2	16 (53.3)	35 (87.5)	34.2	0.035*
9: Is it better for your teeth to have toothpaste with Fluoride in it? Correct answer: YES Covered in: Introduction and Activity 2	29 (50.0)	51 (87.9)	37.9	0.000*
10: After brushing your teeth what should you do with the toothpaste in your mouth? Correct answer: Spit it out but do not rinse Covered in: Introduction and Activity 2	16 (28.1)	55 (96.5)	68.4	0.000*

Key: <50% correct responses 50–75% correct responses >75% correct responses.

Figure 2. Baseline and post intervention student knowledge (intervention group n = 58).

Table 5. Questions from teacher baseline questionnaire.

Number	Question
1	What do you think causes teeth to decay?
2	How do you think you can prevent tooth decay?
3	What do you think causes gums to bleed?
4	How do you think you can prevent bleeding gums?
5	Which of the following items can harm your natural teeth?
6	Think of children from your class; what state would you say their teeth are in today?
7	How much treatment do you think children from your class needs now?
8	Please indicate a proper answer to the following statements?
9	From where have you received your information on teeth and care of teeth?
10	Did you tell your children from your class about teeth and oral health during this school year? If YES a. What exactly did you tell children in your classroom? b. How many lessons did you give on teeth/oral health?
11	How many lessons on teeth did you give for children in 4th class during the last 3 years? a. What educational methods have you used?
12	What is your opinion of the educational materials on teeth and oral health designed for the school?
13	Did you participate in the workshop for schoolteachers on oral health?
14	Were you satisfied or dissatisfied with the programme of the workshop?
15	Do you feel that you have sufficient knowledge to teach children about teeth and care of teeth?
16	How often do you instruct children of your classes in tooth cleaning?
17	How often have you arranged meetings on oral health for parents of your classes?
18	Are you satisfied or dissatisfied being involved in oral health education for children?
19	How much support has you received from dentists to arrange oral health education at school?

Table 6. Thematic findings and quotes from teacher focus groups.

Theme	Main findings	Quote
Teachers’ knowledge and attitudes towards oral health	Teachers expressed that oral health is a priority and should be taught regularly in schools, not just in Year 4 where it currently sits in the National Curriculum. Teachers felt that educating children is important to prevent tooth decay; schools and parents both have a role to play in education. Teachers felt that they had a responsibility to make sure children were healthy, including reducing tooth decay. Most teachers agreed that reading the e-Bug teaching resources in advance of the lesson delivery improved or refreshed their knowledge around the topic.	‘Oral hygiene is a really high priority, I think it should be taught in every year group’ (London FG) ‘Tooth decay is preventable; it’s a lack of education [in schools] and parent involvement with the children’ (Glos FG) ‘I do think it’s our [teachers] responsibility to make sure the children are healthy… [including tooth decay] oh absolutely’ (London FG) ‘I think the teacher pack helped [my knowledge] or if it didn’t add to it, it certainly refreshed it’ (London FG)
Access to materials and advance preparation	Teachers expressed ease accessing the lesson through the e-Bug website. Teachers described photocopying the resources for the students in advance of the lesson and purchasing the drinks bottles and sugar for the activity; some teachers were unprepared for the lesson, needing to purchase this equipment on the morning of the lesson.	‘I looked on the e-Bug website, downloaded the PowerPoint, downloaded the resources easily and printed the resources’ (Glos FG) ‘I just thought it was you know the PowerPoint and it was just good to go and we would just do the lesson and everything was there, then it said you should have been saving up the drinks bottles, so yeah I could have been doing that’ (London FG)
Lesson timings	All teachers thought the e-Bug lesson contained too much for a 1 hour lesson, and that it would have been better if a longer duration was allocated to the lesson. Teachers commented on not having time to complete all the activities in the module.	The lesson was more of a ‘sequence of lessons’ with ‘several different objectives which would work really nicely as a whole unit’. (London FG) ‘I think at least an afternoon, a whole afternoon, and I’ll be honest we didn’t even do the things with the food diaries’ (London FG)
Linking to the National curriculum	The lesson links to the Key Stage 2 National Curriculum in England for both Science and PSHE. Oral hygiene is mainly covered in Science but it is only covered in Year 4 (8–9 years old). PSHE teaching is not assessed as formally as Science, meaning schools place a greater focus on topics covered in the science curriculum. Despite this teachers suggested that oral hygiene fits in to PSHE Food and Fitness lessons and also Healthy Eating weeks. Teacher time and resources are stretched, and all teachers agreed that they prioritise those topics that are in the tested national curriculum, as they are held accountable for this with school leaders, inspection and governing bodies. The lesson linked in with the Maths curriculum, due to the food labelling activity, in which children look at labels on food or drinks and determine how much sugar is in the product.	‘Oral hygiene gets covered in the science curriculum and in PSHE’ (Glos FG) ‘I think the curriculum covers types of teeth, functions of teeth in humans and animals and that side of it, and oral health as a life skill is almost an underlying life skill… it’s a side objective rather than a focus’(Glos FG) ‘We’ve got a PSHE focus in Food and Fitness including sugary foods and drinks but not particularly dental aspects’ (London FG) ‘The demands on us and just trying to get through the curriculum, if it is not put in the curriculum we are going to have to prioritise everything else, because we’re accountable for everything else’ (London FG) ‘It’s brilliant, I would have loved to spend a lot longer on it and done it as part of my maths, you know because it’s real life skills’ (London FG)
Lesson activities	Teachers enjoyed the interactivity of the lesson and in particular the food labelling activity, describing it as visual and practical. Teachers commented that some children felt shy and self-conscious about discussing their diaries in class. Teachers needed to support children to complete the diet and brushing diaries, particularly the younger children, which contributed to the low return rate.	‘I liked the visual practical… I think it made them realise and see how much sugar…It was good there was lots to do so it’s physical, it’s not sitting around watching’(Glos FG) ‘Children were feeling quite self-conscious about sharing [diaries] with the whole class’ (London FG) ‘In year three we supported the children a lot. In year six we expect them to do a little bit more themselves. There wasn’t much time in class [to complete the diaries] and your return rate was much lower” (Glos FG)