Dental health education : a literature review

A fundamental redesign of health education practices has been necessary but challenging with regard to improving the public’s competence and influencing their decision making. The aim of this study was to review the literature on oral health education and analyze its subjects, methodological strategies and forms of assessment. The following electronic databases were used to search the literature from 2000 to 2011: the Scientific Electronic Library Online (SCIELO), Brazilian Library of Dentistry (BBO), Latin-American and Caribbean Center on Health Sciences Information (LILACS), biomedical journal literature of the National Library of Medicine (MEDLINE/PubMed) and the CAPES Portal. The search was restricted to articles in English and Portuguese. The selected articles (61) were obtained in full and analyzed. The groups that received the most oral health education consisted of those in pre-school and grade school, followed by health professionals and the elderly. Educational leaflets were the most commonly used tool, followed by lectures/verbal instruction/posters and demonstrations using macro models. The questionnaire was the most cited evaluation tool, followed by a combination of clinical examination and questionnaire and clinical examination alone.


Introduction
Health education can contribute to the promotion of health at both the individual and population levels, as it works within newly created concepts and technologies, as well as in the real conditions in which such concepts and technologies are understood and applied [1].Health education is considered an opportunity for experts to use a wide range of experiences and resources promote attitudes and practices that will be beneficial to individuals' wellbeing, family and community.Thus, each person has the social responsibility for their own health and the health of those around them.Health education can also be understood as any opportunity for learning that will lead to voluntary behavioral adaptations that lead to health improvements [2].It comprises actions that allow for the acquisition of knowledge about the health-disease process, including risk and health protection factors, as well as allowing users to change habits and supporting them on their quest for autonomy [3].
Every health action must be understood as an educational action [4].The process of promotion-prevention-curerehabilitation is also a pedagogical process in the sense that both health professionals and patients/communities learn and teach.Such concepts can effectively change the direction and outcomes of health work, transforming subjects into citizens and co-participants in the health construction process.
Thus, to promote health, people must be provided with the tools necessary to identify their aspirations, favorably modify their environments and control the determining factors for their health [5].Whichever aspect is considered, the difficulties of implementing educational practices focused on health promotion and incorporating educational actions into daily academic and professional practice are abundant.
Health education projects are usually part of an approach entailing the transmission of specialized knowledge from experts to the lay population, whose knowledge on how to live is poorly valued and/or ignored in such transmission processes.One assumes that for laymen to learn what they need, they must unlearn a great deal of what had previously been learned in daily life.The education process is often limited to telling patients what they should do, instead of giving them the knowledge to make their own decisions [6,7].Traditionally, health education has been a controlling instrument of a dominant knowledge stance used to make individuals responsible for reducing the risks to their health."Hegemonic" health education has contributed little towards creating comprehensive healthcare and has had little effect on promoting health generally [4,8].Despite recognizing the importance of educational actions, in the health field, one still observes a general emphasis on care centered on the individual and focused on clinical activities, especially those of a curative nature; such a focus overemphasize procedures and techniques as the only option for solving oral health problems [9].
Health education efforts are faced with the challenge of guaranteeing effective learning and the transformation of life attitudes and habits.Experience shows that transmitting information on body functioning and describing disease characteristics, in addition to a set of hygiene habits, are not sufficient to induce individuals to develop a healthy lifestyle.
It is paramount to "educate" on health, taking into account all of the aspects involved in the formation of habits and attitudes that occur in an individual's day-to-day life [10].
Regarding such questions, the present study aimed to review the literature on "oral health education" and analyze its subjects, methodological strategies and forms of assessment.

Methods
A literature review was conducted using the following Brazilian and international databases: Scientific Electronic Library Online (SCIELO), Brazilian Dental Library (Biblioteca Brasileira de Odontologia -BBO), Latin-American and Caribbean Health Sciences Literature (Literatura Latino-Americana e do Caribe em Ciências da Saúde -LILACS), biomedical journal literature of the National Library of Medicine (MEDLINE/PubMed) and the Coordination of Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior -CAPES) Portal.The search started with the identification of controlled indexing terms in the BIREME (Biblioteca Regional de Medicina/Regional Library of Medicine) database (Descritores em Ciências da Saúde/ Health Sciences Indexing Terms), taking into consideration the keywords most often cited in the reference literature.The inclusion criteria were as follows: publication in English or Portuguese, description and/or assessment of "oral health education" methods.Literature review-type papers or those that did not conform to these criteria were excluded.
An initial search was performed using the search terms "dental health education" and "oral health promotion" plus the Boolean operator [AND] in the MEDLINE/PubMed and CAPES databases.Six-hundred eighty-nine articles were found.After limiting the search by time period (2000 to 2011), 452 papers remained.Selection was then performed by title and abstract according to the pre-established criteria; subsequently, 77 studies remained.These articles were obtained in full and analyzed.After reading and excluding duplicates, as well as those that did not conform to the inclusion criteria, a final selection comprising 34 papers was obtained.
In the SCIELO database, a search was performed using only the indexing term "oral health education" because when the term "oral health promotion" was included, no results were found.This search yielded 8 papers accessed via CAPES and 27 papers obtained directly from the SCIELO database.Five papers were selected from the above search, of which 1 was a duplicate from the PubMed search, leaving a total of 4 papers.
The next stage was to search for papers with the terms "educação em saúde bucal"/"oral health education" in the title in the BBO, LILACS and Wiley Online Library databases.Limiting the time period to 2000-2011 initially yielded 19, 28 and 31 papers in these respective databases, and 17, 25 and 25 were selected.After obtaining and reading the full articles, excluding duplicates and those that did not conform to the inclusion criteria, 5 papers were selected from BBO (all were duplicated in LILACS), 9 articles from LILACS (1 of which was duplicated in SCIELO) and 19 from Wiley (4 of which were duplicated in PubMed).
From the final selection of publications, accounting for all databases accessed and excluding duplicates, a total of 61 papers were obtained and analyzed (Table 1).

Results and Discussion
The selected articles allowed for the demarcation of the theme "oral health education" into different contexts, which were analyzed according to the study population, the educational method used and the forms of assessment of the educational practices performed (Table 2).
Schools were the places most often used for educational activities, as they represent a social environment in which the children are in a favorable age group to receive knowledge, acquire habits and strengthen pre-learned preventative care to help them to improve their health, self-esteem, behavior and life skills [72,73].
Another group that was highly represented in oral health education activities was the elderly.This group has been receiving special attention in recent years because the population of Brazil, as in other countries, is aging.Data from the Brazilian Ministry of Health show that more than 3 million (15%) elderly Brazilians need full upper and lower dentures and that 4 million (23%) need partial dentures in one of the arches [74].The need for curative treatment in the elderly, related mainly to edentulism, tooth loss, abrasion/ erosion and periodontal disease, remains a reality and, therefore, must be prioritized.
In a much lower number of papers, adolescents were also studied in both school and extracurricular environments.Adolescents have unique attitudes and characteristics, as well as distinct needs, and adolescence is often considered a period of increased risk of dental caries as a result of incomplete plaque control and decreased attention to tooth brushing.An educational proposal to reduce the incidence of caries and periodontal disease in this group must take into consideration the need to work with the stimulation and reinforcement components of oral health implementation because these components can be more easily visualized [28].
Silveira Filho et al. [22] showed that caries indices tend to increase in adolescents.The lack of oral health education activities at middle schools, teenage truancy and inadequate guidance of this group may contribute to an increase in caries during adolescence.The authors highlighted the need to pursue new knowledge and to develop different practices targeting adolescents, using new technology and health education methods.
Pregnant women were also the subjects of oral health education activities.During pregnancy, health education is an important strategy to promote oral health, including oral health actions specified by the Women's Healthcare Program (Programa de Atenção à Saúde da Mulher), according to the current National Oral Health Policy (Política Nacional de Saúde Bucal) Guidelines [2].
The scarce participation of teachers in oral health education activities was also highlighted [24,31,63,64].According to Sá and Vasconcelos [73], teachers are the best promoters of educational actions because they are familiar with methods of educating and motivating school children and, therefore, should be trained to do so.Studies that assessed elementary school teachers showed that the majority did not have enough specific knowledge to engage in an oral health education initiative with their students.Therefore, the adoption of new strategies and continuous training in a multidisciplinary effort involving dental surgeons and elementary school teachers should be encouraged [75].

Methodological strategies in oral health education literature
Regarding the proposed methodological strategies, 6/61 (9.8%) papers did not describe the educational methods used.Of the 55 papers that described their educational methods, educational leaflets (written guidance) were the most common resource, followed by lectures/verbal instruction (spoken guidance), posters and demonstrations using macro models.
In most of the studies analyzed, these methodological resources were linked to "traditional" health education practices, without knowing the needs of their target population.Few studies took into account the preexisting knowledge of the groups about the subject in question.In addition, questions on oral health were generally isolated from the context of general health, seeking to modify behavior and lifestyle and focusing on guidelines of oral hygiene skills, changes to "inadequate" eating habits and encouragement of regular dental check-ups.
It is important to understand that talking about oral health education practices is not sufficient nor does it guarantee the quality of health promotion and disease prevention strategies.Models based on unidirectional, dogmatic and authoritarian communication practices focusing on information transmission should be replaced by models in which discussion and reflection are enhanced by effective communication and problematization of oral health themes, building strategies based on population-wide experiences [76].

Assessment tools in oral health education literature
Five (8.2%) of the selected papers did not report whether an educational activity/program assessment actually occurred or how it was performed.Of the 56 papers that described an assessment method, questionnaires were most commonly used, followed by a combination of clinical examination and questionnaire and clinical examination alone.Few studies used an approach centered on the analysis of an individual's subjective situation, such as interviews and focus groups.
A questionnaire used to assess oral health education activities may provide information regarding knowledge and habits [29].However, the questionnaire may not provide actual information regarding improvement of an individual's health condition.Vanobbergen et al. [23] used a questionnaire and clinical examination to assess a school-based oral health education program, which consisted of yearly 1-hour educational sessions.After 6 years, the authors assessed the program and its outcomes based on the responses to the questionnaires and found improvements in the reported eating habits and adequate use of fluoride toothpaste.However, no significant reduction in the prevalence of dental caries was observed.

Advancements and challenges in oral health education
Despite the recognition of the importance of health education in healthcare practices, its application and significance are still limited, often failing to make sense to the target groups or improve their health and quality of life [1].
Our review of the literature on oral health education revealed few studies that described the methods used and/ or the way in which the educational actions developed were assessed, and they generally used traditional educational practices, i.e., focusing on school children (pre-school and grade-school ages) and teaching with leaflets, lectures and posters, without much attention to the groups' pre-existing knowledge.
Effective health education does not occur in a manner that is abstract, punitive, isolated and disjointed from the reality and the needs of the population.It must involve training health professionals with regard to the development of practices and consent among the subjects, based on a recognition and respect of their autonomy, individuality and degree of trust of their teachers.It is necessary to overcome the limited model of information transmission that aims solely at behavioral changes and to move towards a cooperative procedural health education model that is open to dialogue and allows people to make their own decisions about their daily life habits and attitudes.This translates into the establishment of a relationship based on trust and empathy between the health professional/team and the individual, encouraging questions, information and listening.

Conclusions
This literature review aimed to identify trends in both the Brazilian and international literature from 2000 to 2011 on oral health education and analyzed the subjects, methodological strategies and forms of assessment.In the 61 papers analyzed, we found the following: • pre-school and grade-school children, followed by health professionals and the elderly, were the groups that most often participated in educational activities/ programs; • educational leaflets were the most commonly used method of instruction, followed by lectures/verbal instruction, posters and demonstrations using macro models; • of the assessment modalities described, the questionnaire was the most prevalent, followed by the combination of questionnaire and clinical examination and clinical examination alone.
It is important to rethink the educational aspects that remain challenging for health/oral health promotion so that new models of education and intervention can be developed that will maximize the autonomy and self-respect of individuals and populations.

Table 1 .
Number of papers selected from each database.

Table 2 .
Selected papers on oral health education.