Health Education &

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Research in Dental Health Education and Health Promotion: A Review of the

Literature
Louise F. Brown
Health Educ Behav 1994 21: 83
DOI: 10.1177/109019819402100109

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 Research in Dental Health Education and
Health Promotion: A Review of the Literature

Louise F. Brown, MPH, BDSc, MDSc, PhD

This article presents a review of research in dental health education and health pro-
motion. In the period 1982 to 1992, a total of 57 studies evaluating the effectiveness of
interventions to alter individuals behavior related to dental health were identified. Com-
bining the results of these 57 studies with descriptive articles published over the same
period, it appears that dental health education can result in improvements in objective
measures of dental health behaviors and actual oral health measures, but has only limited
success in changing attitudes towards dental issues and achieves only short-term gains in

knowledge. The limited use of theoretical frameworks, poor statistical analyses, the use
of convenient samples and the short postintervention follow-up periods diminish the
contribution of this research to the development of dental health policy and the formation
of strategies to improve the health of communities.

INTRODUCTION

Improvements in oral health have been documented in Western countries

over the last 25 years.-5 National surveys of the prevalence of dental caries
among children in the United States reveal a sharp decline in tooth decay from
1971 to 1987, with a 32% reduction in the mean number of decayed, missing,
and filled permanent tooth surfaces (DMFS index) between 1971 and 1980, and
a further reduction of about 36% between 1980 and 1987.2 By 1987, approxi-

mately 50% of children aged 5 to 17 years were free of dental decay in the
permanent dentition.2 However, a minority of children still suffered unaccept-
ably high levels of dental decay.
Improvements in the oral health of adults have also been documented. 4-6 The
loss of teeth, the dental equivalent of a mortality measure, has declined markedly
since World War II.6 However, the retention of teeth into adult years is often
accompanied by significant morbidity due to the breakdown of existing resto-
rations, active dental caries, and forms of periodontal diseases. Inequalities in
oral health are marked among adults, with people from disadvantaged back-
grounds being significantly more likely to have more untreated dental caries,

Louise F. Brown is with the School of Dental Science, The University of Melbourne,
Parkville, Victoria, Australia.
Address reprint requests to Louise F. Brown, School of Dental Science, the University
of Melbourne, Grattan Street, Parkville, Victoria 3052, Australia.

Health Education Quarterly, Vol. 21(1): 83-102

83 (Spring 1994)
© 1994 by SOPHE. Publishes by John Wiley & Sons, Inc. CCC 0195-8402/94/010083-20

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84

fewer fillings, and more missing teeth.4 The individual consequences of poor
oral health range from suffering pain and discomfort through to functional im-
pairments, which can impact upon social and functional activities of daily life.
The widespread exposure to fluorides, primarily delivered through water
fluoridation and also through fluoride-containing dentrifices, has been implicated
as the major factor in the decline of dental caries in young people.1.9 Burt and
Eklund attribute the improvements in tooth retention to advances in restorative
dentistry (especially the development of the air-turbine dental engine in the late
1950s), increasing affluence and its accompanying improvement in attitudes to-
wards tooth retention, and significant research advances in preventing oral dis-
eases. Further, the advent of water fluoridation may have demonstrated to
individuals and their families that dental caries and subsequent tooth loss were
not inevitable.
A recent review of community water fluoridation highlights the significance
of this approach of dental health promotion.1The alterations in organizational,
economic, and environmental supports necessary to introduce fluoride into a
communitys water supply, and to retain it there over subsequent years, are a
major public health achievement. Water fluoridation is one of the most successful
and cost-effective public health disease prevention programs ever initiated, and
it has the potential to benefit all age groups across all socioeconomic strata.
In contrast to the broad-reaching scope of water fluoridation, other dental
health promotion activities relyon changing individuals behavior. Primary pre-
vention of periodontal diseases rests upon the individual carrying out regular
thorough removal of dental plaque with a toothbrush, supplemented by other
aids such as dental floss, tooth picks, and chlorhexidine mouthrinses. Profes-
sionally provided removal of plaque and calculus is also a method of preventing
periodontal diseases. In the prevention of dental caries, particularly among high
risk individuals or communities, additional supplementation of fluoride, dental
sealants, and the encouragement of healthy diets form a major part of health
promotion and health education activities. This review of the dental health
promotion literature focuses upon the adequacy of research activities to provide
practitioners with substantiated methodologies to conduct dental health pro-
motion.
The body of research in health education and health promotion has expanded
rapidly over the past two decades, and health promotion is recognized increas-
ingly as a way to meet public health objectives and to improve the success of
public health and medical interventions. While ideologically health promotion
and education are seen as fundamental components of approaches to dental
care, questions over the effectiveness of these approaches often are presented
as stumbling blocks to the formulation of clear policy directions. Too often the
result is that these activities receive less support than the treatment-oriented
approaches to dental care. Whether doubts concerning effectiveness arise pri-
marily from an inherent lack of success of dental health promotion activities, or
whether they reflect poor research methodology used to design and evaluate
such interventions needs to be clarified. Consequently, this review will focus on
the research design aspects of dental health promotion rather than addressing
ideological premises or policy issues.

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 85

Definitions of health education and health promotion are varied, with health
promotion generally encompassing a broader perspective than health education.
Definitions of health education include:

Any combination of learning experiences designed to facilitate voluntary ad-

aptations of behavior conducive to health.&dquo;
The process of assisting individuals, acting separately or collectively, to make
informed decisions about matters affecting their personal health and that of
others. ~~

Health promotion underscores the broader social structural context of health

behavior more clearly than health education. Health promotion has been defined
as:

Health education and related organizational, economic and environmental sup-

ports conducive to health. 15
A combination of health education and health advocacy. 16
The distinction between health education and health promotion is blurred,
with the terms often being used interchangeably by the public and professions.
Positive changes in health behavior are the ultimate aim of both; and, given the
overlapping and closely linked nature of these terms, this review examines both
health promotion and health education research in dentistry. The review ex-
amines :

1. The types of health education and health promotion activities reported in

the dental literature.
2. The effectiveness of health education and health promotion activities in
dentistry.
3. The extent to which educational and intervention activities are based on

currently accepted theories of health behavior.

METHODS

systematic review of the health promotion and health education literature

A
was conducted. Articles were identified through Medline, printed indices cov-
ering the period 1982 to 1992, and from reference lists at the end of the reviewed
articles. Articles selected were from refereed journals in the English language.
For assessment of effectiveness, the articles must have presented an evaluation
of an intervention designed to influence health-related behavior; however, a
further selection of articles presenting descriptions of interventions, associations
between health education and other outcomes, and policy issues related to health
promotion or education were also reviewed.
The research methodology employed by evaluative studies under review was
examined and classified by experimental design and by level of outcome. The
following categories were used to define the research experimental design:
1. Pre-post intervention measures; controlled study design.
2. Pre-post intervention measures; nonequivalent control groups.

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86

3. Pre-post intervention measures; no control groups.

4. Cross-sectional; or post-intervention measures only, with no control
groups.
The
highest level of outcome measured in a study was categorized along the
hierarchy:
1. Change in oral health measures
2. Objective measure of behavior change
3. Self-reported behavior change
4. Change in knowledge or attitudes
5. Awareness of program

Further evaluative criteria included:

1. The focus of the intervention

2. The age of the target population
3. Types of media used in the intervention
4. The maximum length of duration of follow-up
5. The degree of effectiveness of the intervention
6. Use of theoretical models in the development of the intervention

RESULTS

Study Designs
A total of 57 articles presenting an evaluation of dental health education or
promotion interventions were identified. 17-71 An additional 35 articles of a de-
scriptive or policy focus were also reviewed. 74-101
Table 1 presents a cross-tabulation of study design by level of outcome.. The
majority of studies reflected quasi-experimental designs, with pre and post-

Table 1. Distribution of Evaluative Health Education and Health Promotion Literature

in Dentistry Published between 1982-1992dd

~
Cross-tabulation of highest level of outcome measured by study design. (Italic numbers
refer to references as cited at end of article).

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 87

interventionmeasures and inclusion of nonequivalent or equivalent control

groups.Objective measures of the outcome of the intervention, either through

measures reflecting behavior change or actual changes in measures of dental
disease, dominated the studies.
Figure 1 displays a breakdown of the focus of the intervention by the type
of study design. Oral hygiene measures and periodontally related issues were
the focus of the majority of interventions, with lower numbers addressing be-
haviors related to preventing dental caries, and the remainder primarily being

Figure 1. Focus of intervention by study design.

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88

targeted towards increasing dental attendance among nonattenders. Primary

school children and adults were the age groups targeted by the majority of
interventions (Fig. 2). The sampling of children was usually school based, and
sometimes reflected the use of previously obtained epidemiological data iden-
tifying particular areas of need. Sampling of adult participants in interventions
was rarely random or representative-dental students,43 army recruits,20 factory

workers,1247 and patients of a particular dental practice40 formed convenient

study groups.

Figure 2. Age of target group by study design.

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 89

The breakdown of the types of communication media used to effect the

educational interventions by the study design is shown m Figure 3. One-to-one
instruction was commonly evaluated using controlled or nonequivalent con-
trolled study designs, whereas cross-sectional techniques were used to evaluate
mass-media and classroom styles of education.
Figure 4 displays the distribution of studies by reported length of follow-up.
Although the majority of studies reported more than the immediate outcome
of the intervention, the length of follow-up was usually less than 6 months,

Figure 3. Intervention media by study design

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90

except for evaluations using a cross-sectional approach which were able to make
some assessment of the effect of interventions by comparing samples of people
exposed to the intervention at some time in the past to samples of unexposed
people. The lack of adequate pre-intervention measures, coupled with the ab-
sence of measures of confounding factors that could also account for observed

differences, often weakened the capacity to draw conclusions regarding the

effectiveness of these interventions.

Figure 4. Length of follow-up by study design.

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 91

Measures of Effectiveness of the Interventions

The results of the 14 studies that employed pre-post-intervention measures

in a controlled study design were examined to gain some quantitative measure
of effectiveness of the health education intervention. The percentage change
measured in the control group was subtracted from the percentage change ex-
perienced in the test groups. The ranges of effectiveness measured across various
outcome levels are presented in Table 2. Averaging the percent effectiveness
across each outcome revealed that an increase in knowledge in the test groups,
20.1 % more than control groups, was the largest overall measured effect of the
interventions. Objective measures of plaque control, that is, plaque indices and
bleeding indices, showed an average improvement of 17.8% and 12.5%, re-
spectively. One study did find a 52.6% improvement in plaque control and 44.5%
reduction in gingival bleeding after a 3.5-year post-intervention follow-up. This
study, reported by Schou in 1985,22 evaluated the long-term effect of an inter-
vention based on a theoretical approach of using active-involvement principles
in the design and implementation of the program. The teaching was conducted
among unskilled workers, and used pre-existing peer group structures. Further,
it let participants set their own goals and needs, excluded traditional dentist-
patient barriers, and employed repeated sessions. It is interesting to note that
these behavioral changes occurred without measurable increases in knowledge
and attitudes of the participants.
Other outcome measures showed little change when compared with control
subjects. The health measures, change in the percentage of teeth with peri-
odontal pocketing or decay-free teeth, both averaged near zero. Pre-intervention
measures of attitude also showed little change when measured at some interval

post-intervention. Only one study in this group of 14 examined the outcome of

dental attendance, and found that sending an application form to insured non-
attenders stimulated an application for dental visit in 47.4% of insured nonat-
tending young adults in The Netherlands within an 11-day period. 28
Measures of effectiveness of interventions in the remaining 43 evaluative
studies were often marred by inadequate study designs. The overwhelming fea-

Table 2. Range of Effectiveness of Health Education and Health Promotion Studies in

Dentistry, as Reported in the 14 Studies Published Between 1982 and 1992 that Employed
Pre-Post-Intervention Measures in a Controlled Study Design

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92

ture of the 20 studies that used nonequivalent controls, that is, comparing the
effectiveness of one type of intervention with another, was the lack of demon-
strated differences between modalities on the outcomes measured. Although
the post-intervention measures increased over pre-intervention to levels com-
parable to percentages reported for the controlled studies, all studies accepted
the null hypothesis that each type of intervention tested within a study was
equally effective. For example, Baab and Weinstein in 198636 concluded that a
self-inspection plaque index was as effective as traditional one-to-one oral hy-
giene instruction in controlling plaque accumulation. Moltzer and Hoogstraten 41
compared three methods of dental health instruction on dental knowledge, at-
titudes, behavior, and fear, and accepted that the additional use of video and
group discussion as well as oral hygiene instruction was of no extra benefit
compared with oral hygiene instruction alone. Sample sizes for the different
interventions rarely exceeded 20 in this group of studies. In no study was there
a calculation of the power of the statistical analysis to determine whether the

sample size used was sufficient to demonstrate that the observed difference could
reach significance at a predetermined alpha level. In fact, the acceptance of the
null hypotheses in these studies seemed to violate all fundamental principles
that researchers use to help determine when no-difference findings warrant
tentative acceptance of the null hypothesis.&dquo;19 Further, the overwhelming ma-
jority of studies usedt tests to compare the post-intervention scores, without
accounting for the covariation introduced by variations in pretest measures, and
hence not eliminating the effects of regression towards the mean as an explan-
atory factor accounting for some of the observed changes.
In spite of often poor analytical methodologies, the studies do tend to reach
a degree of consensus regarding the effectiveness of health promotion and health
education interventions in dentistry, although it is difficult to draw sound con-
clusions regarding the relative effectiveness of the different types of media uti-
lized. The following summary combines the results of these studies as well as
drawing upon the descriptive studies in an attempt to elucidate the effects of
health promotion and health education in dentistry.

Effects on Awareness, Knowledge, and Attitudes

Reported awareness of programs is usually high, with over 80% of commu-

nitiesbeing aware of mass media campaigns and their overall message.&dquo; How-
ever, descriptive studies have found that people will usually cite the dental office
as being their primary source of information about preventive dental behaviors.&dquo;
This finding holds across most dental health issues except water fluoridation,
where the mass media is cited as the main source of information. Isman88 reported
that only about 20% of the public cite the dentist as the main source of infor-
mation of fluoridation.
Studies examining knowledge generally have failed to find a lasting effect of
focused dental health education interventions, despite short-term gains in knowl-
edge. Descriptive studies point to a lack of clarity of some of the knowledge
components of health-directed messages,91 and Frazier85 identified a lack of

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 93

consensus between researchers and practitioners regarding current preventive

approaches as a major barrier to more effective promotion of caries prevention.
In spite of the widespread practice of toothbrushing in Western societies, the
public still appears to be confused over whether this activity is related primarily
to the prevention of caries or to the prevention of periodontal diseases. This
was documented by Gift in 1988,86 and by Russell et al. in 1989.69 This latter

study used a cross-sectional design to compare the knowledge and reported oral
hygiene practices of sixth-grade schoolchildren who had participated in the
4-year National Preventive Dentistry Demonstration Program with a group of
nonparticipants. Generally, students were unable to discriminate among meth-
ods appropriate for preventing dental caries and periodontal diseases, and it was
recommended that education regarding the purpose and value of preventive
regimens should be consistent with, and an integral part of, the delivery of such
services. Bader et al. 75 reported that regularly attending patients of general
practice dentists were generally knowledgeable about the prevention and treat-
ment of periodontal diseases; however, over one third of the sample were un-
aware that bleeding gums were a sign of disease.
Attitudes towards dental health appear to be fairly resistant to measurable
change. Descriptive studies have shown that peoples dental health behavior can
be strongly influenced by their attitudes to aspects of dental care and dental
disease.94.107 And yet, the intervention studies reported in the last 10 years have
had little success in changing cognitive, affective, or behavioral components of
attitudes. However, Holund in 19904y reported the effectiveness of a nutrition
education program that had been designed to create positive attitude changes
among adolescents. After a 2-month follow-up, there were some significant
affective gains, particularly among female participants. The program, &dquo;Learning
by Teaching,&dquo; succeeded in raising the adolescents receptiveness and respon-
siveness to messages about healthy foods as a means of health promotion.

Effects on Oral Hygiene, Periodontal Diseases, and Dental Caries

Self-reported positive behavior changes in the practice of plaque control ap-

pear to be more common among females. For example, in 1985 Walsh 41 found
that classroom dental health education resulted in an increased level of self-
reported brushing and flossing by adolescent girls. When objective measures of
behavior change are used, however, this gender difference diminishes. It appears
that one-to-one instruction, repeated contacts, and participant involvement are
important elements of interventions that have achieved at least short-term pos-
itive changes in plaque and bleeding scores. Beyond observing gingival bleeding,
very few studies examined periodontal health outcomes. These include reduction
in periodontal pocket depths, prevention of loss of periodontal attachment, as
well as reductions in the symptoms of periodontal diseases such as mobility of
teeth, bad breath, and discomfort. Stiefel et al .24 reported that significant re-
duction in gingivitis, calculus, and pocket depths could be achieved only with
the addition of professionally provided biweekly toothcleaning to an oral hygiene
instruction regimen among a group of disabled persons. Hetland et a1.32 found

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94

that the addition of oral hygiene instruction to a professionally provided tooth-

cleaning regimen produced significant reductions in the proportion of teeth with
at least one pocket, over a 6-month follow-up.
The effects of educational-based interventions on dental caries were equiv-
ocal. Holt et a1.19 used a cross-sectional study design to evaluate the dental
health of 5-year-olds whose mothers were given dental health education at home
at an early stage in the childs life. A total of 314 mothers were visited at home
by a dental health educator on three occasions in the first 6 months following
the birth of their child. Mothers were given advice about dental health for their
children and were offered a free supply of fluoride supplement drops. After 5
years, significantly more children had used fluoride supplements over their life-
time, and also these children experienced less caries and lower levels of gingivitis.
Truin et al. 64 reported reductions in caries in a time-series analysis that partly
attributed the reductions to the effects of a 9-year dental health campaign fea-
turing dietary and oral hygiene instruction.
The difficulty of assessing the long-term effects of behavioral interventions
on the incidence of caries is that any improvement must take place in an envi-
ronment of widespread multiple fluoride exposure. Any additional benefits are
likely to be marginal, and issues regarding the cost-effectiveness of intensive
programs must be considered. Dental sealants provide both a primary and sec-
ondary level preventive intervention in the prevention of decay. Properly applied
dental sealants are not only highly efficient in preventing the commencement
of dental decay, but also can arrest early active caries.106 Weintraubs 106 1989
review of dental sealants found them to be effective in reducing pit and fissure
caries by up to nearly 50% and that their use was slightly more effective in
fluoridated areas. Sealant programs, conducted with a framework that targets
high risk communities, individuals, and teeth within the individual, must continue
to play a role in public dental health activities. In spite of this documentation
of their effectiveness, the use of dental sealants still remains limited in the United
States. Studies exploring reasons for this conclude that the use of sealants remains
largely provider driven, with the publics role in instigating the use of sealants
being marginal. 102

Use of Theoretical Models

The final objective of this review was to examine the use of theoretical models
in the development of dental health interventions. Of the 57 evaluative studies
reviewed, a total of 12, that is, 21%, reported basing part of the educational or
intervention activities on aspects of currently accepted theories of health be-
havior. Partial adoption of notions contained in the theories was more common
than use of a complete model. The most complete use of a model was reported
by Knazan2 in 1986, who based a dental health promotion program for a Ca-
nadian well-elderly population on elements of the PRECEDE model, which is
a diagnostic approach to health education planning. This model starts with an
overall behavioral outcome, and works backwards in diagnosing what actions
and interventions are necessary to achieve this outcome. The author attributed
the significant improvements in oral health of the subjects to the slower paced,

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 95

individualized, multisessioned instructional format. Similarly, use of other

models has usually been incorporated into a setting of repeated contacts, using
a variety of educational media and self-involvement of the participants to effect

change. Many other studies used similar principles of learning, without reference
to a particular theoretical model.

DISCUSSION

To summarize the current state of research in health promotion and health

education in dentistry, much of the equivocacy over the effectiveness of inter-
ventions and programs arises from the research methodology employed. The
limited use of theoretical models, often without clearly stated hypotheses to be
tested, limits many of the interventions to testing traditional types of dental
health education, such as oral hygiene instruction. These approaches often ignore
the individuals own schema of health-related issues, through which the patient
will filter the information. The work by Croucher, 83 demonstrating what he refers
to as &dquo;the Performance Gap,&dquo; clearly demonstrates the gulf that exists between
this traditional approach and what patients perceive as being of some value in
effecting behavioral change.
The generalizability of the studies is diminished by the use of small convenient
samples and with limited follow-up periods. In contrast to community-based
programs in the medical field, for example, cardiovascular focused prevention
110.111
programs that make extensive use of epidemiological data in planning, very
little use of epidemiological data on the prevalence of dental disease, and as-
sociated risk factors was documented in the dental literature. Finally, the use
of poorly controlled study designs, with inadequate sample sizes and often in-
appropriate use of statistical techniques, resulted in the blind acceptance of no-
difference results that were more likely to have resulted from Type 2 error.
A number of issues warrant attention in the development of further health
promotion research in dentistry. Health promotion messages need to be clarified
not only by the researchers, but also by the dental profession, other health-
related professions, and by marketing companies. Often messages need fine-
tuning to keep in touch with the latest research. An example of this can be
illustrated through issues raised by recent surveys documenting high prevalence
of dental fluorosis in certain communities. &dquo;2 Dental fluorosis exhibits as pitting
and staining of the enamel of teeth in individuals who have been exposed to
above-optimal levels of fluoride at a young age. The issues regarding education
to prevent fluorosis, although still promoting the widespread support of water
fluoridation and fluoride toothpastes, are an example of how sensitive a balance
health promotion messages have to reach.
There is a need to distinguish between whether the research is evaluating the
efficacy or the effectiveness of the particular dental health intervention, and to
113
employ the appropriate research methodology to address the issues. In effec-
tiveness trials, where external factors beyond the control of the researchers may
intervene and substantially reduce the capacity for conducting rigorous statistical
analyses, wider integration of qualitative, quantitative, and process data 114
can

provide results that are useful for the development of future programs.

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96

Finally, wider use of theoretical models of health behavior, both in descriptive

types of analyses and in the planning and evaluation of interventions, will lead
to more insight into the between awareness, knowledge, and atti-
relationship
tudes, and health behavior. Although the use of theory in the dental health
education and health promotion literature published over the last 10 years has
been very limited, it does appear that the studies that employed a theoretical
framework not only achieved positive behavioral and health outcomes, but were
also able to identify factors related to the observed changes. Given the social
context of many dental health behaviors, 83 it is surprising that social learning
theories 11 and concepts of self-efficacy 11 have not been used in the recent dental
literature. Stage theories, such as those proposed by Prochaska and Di-
Clemente, &dquo; and relapse theories&dquo; have not been integrated into dental health
education and health promotion interventions to any extent. The &dquo;empty vessel&dquo;
approach to dental health education still appears to be the predominant frame-
work for constructing interventions.

IMPLICATIONS FOR THE HEALTH PRACTITIONER

Although this review has focused predominantly on research aspects of dental

health promotion and health education, the messages to the health practitioner
are clear. The practice of dentistry has suffered by its isolation from others

working in the health field. Not only do dental researchers need to integrate
their activities with health education researchers, but structural changes to the
practice of dentistry to enable a multidisciplinary approach to the effective de-
livery of dental health promotion and education are needed. The recent article
by Hochbaum et all states:
Any profession that is not based on sound and continuously evolving theories
that yield new understanding of its problems and yields new methods, is bound
to stagnate and fall behind in the face of changing challenges.

It appears that the delivery of dental health education and health promotion
needs to avoid this stagnation. Researchers and practitioners need to position
themselves to give more positive contributions to the development of dental
health policy and to guide the practice of dental health education and health
promotion at the community and individual patient level.

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