Schools Could Fix the Oral Health Crisis, but a Landmark Review Shows We Are Barely Trying

Tooth decay is the most common chronic disease of childhood, and it quietly sabotages the very thing schools exist to protect: a child’s ability to learn. Painful cavities, infections, and missing teeth interfere with eating, sleeping, speaking, and concentrating, eroding quality of life long before adulthood begins. Yet a new scoping review published in PLOS Global Public Health suggests that when schools design health programs for their pupils, the mouth is too often left out of the picture. The study, led by Nikita Surani, Nathalia Carolina Fernandes Fagundes, Harmanpreet Kaur, Rebecca Gokiert, Arnaldo Perez-Garcia, and Maryam Amin, systematically mapped how oral health promotion has been woven into primary school health programs around the world, and its findings reveal both genuine promise and striking blind spots.

The research team followed the well-established Arksey and O’Malley framework for scoping reviews and adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews, known as PRISMA-ScR, to ensure transparent and reproducible reporting. For data extraction they referred to the JBI Manual for Evidence Synthesis, a widely respected methodological guide. A systematic search was performed across six databases with no restrictions on publication dates or geographic locations, a deliberately broad strategy designed to capture every corner of four decades of school-based oral health scholarship. The final pool comprised 31 articles published between 1981 and 2025, a corpus spanning the rise of modern health-promoting schools and the emergence of contemporary global oral health policy.

The first red flag in the data is geographic. More than 70 percent of the included studies were concentrated exclusively in high-income and upper-middle-income regions, leaving the low-income countries where the burden of untreated dental caries is often heaviest dramatically underrepresented in the evidence base. This skew matters because the conditions that shape children’s oral health, from sugar availability and water fluoridation to access to dental care and health literacy, vary enormously across economic settings. Programs designed and validated in affluent school systems may simply not transfer to communities facing different constraints, and the review’s authors argue that the current literature offers policymakers in much of the world very little to work with.

Methodologically, the field leans heavily on numbers. Quantitative methods were reported in twenty-one of the thirty-one studies, while qualitative and mixed approaches that could illuminate why programs succeed or stall were comparatively rare. All of the included studies reported programs targeting children themselves, which is unsurprising for school-based work, but only 12 involved parents or guardians, and even then mostly as passive recipients of information rather than as active partners. Given that family routines around meals, snacks, and bedtime brushing are decisive for young children’s dental health, the marginal role assigned to caregivers represents a significant structural weakness in how these interventions have been conceived.

Inside the classroom, the most common delivery agents were teachers, identified in 25 of the studies. This makes practical sense: teachers have sustained daily contact with pupils, understand the curriculum, and can embed health messages into ordinary school life without the recurring cost of external dental professionals. The review found that classroom education was the dominant strategy for promoting oral health, followed by engagement of interest holders, the stakeholders with a vested interest in children’s wellbeing, and structured toothbrushing programs. Across these approaches, the emphasis fell on student skill-building and empowerment, alongside teacher involvement, reflecting a pedagogical shift from lecturing children about cavities toward equipping them with the habits and confidence to manage their own health.

The review also examined which risk factors the programs chose to target, and here the picture becomes lopsided. Unhealthy diet and poor hygiene were the frequently addressed common risk factors, identified in 18 and 11 studies respectively. These are sensible priorities, since frequent sugar consumption and inadequate plaque removal are the proximate drivers of dental caries and gum disease. But the broader common risk factor approach to oral health, which links the mouth to the rest of the body through shared determinants, was only partially realized. Tobacco use, stress, and injury were largely overlooked across the corpus, even though all three shape oral health trajectories and are increasingly addressed in school health programs dealing with cancer prevention, mental wellbeing, and physical safety. The omission suggests that oral health is still being treated as a siloed topic rather than as an integral strand of a unified health agenda.

On the positive side, 27 of the studies reported activity-based learning to promote general health, indicating that schools already possess the pedagogical machinery that oral health promotion could plug into. Games, experiments, demonstrations, and hands-on projects appear well suited to teaching children why sugary drinks erode enamel or how to brush effectively, and they align with the skill-building and empowerment orientation that characterized the strongest programs. Structured toothbrushing, a simple intervention with strong evidence behind it in several national programs, emerged as the most concrete oral-health-specific activity, while interest holder engagement, bringing together teachers, families, and communities, was the second most common mechanism for embedding oral health beyond a single classroom lesson.

Perhaps the most technically damning finding is theoretical. None of the 31 studies applied integration-specific or implementation science frameworks or models. In other words, researchers rarely articulated a theory of how oral health activities become a durable, institutionalized component of a school’s health program rather than a one-off campaign that evaporates when funding or enthusiasm fades. Implementation science offers exactly the tools needed to study adoption, fidelity, scalability, and sustainability, from mapping barriers and facilitators to testing strategies for embedding new practices into existing systems. Their complete absence from this literature means the field has been accumulating activity without accumulating transferable knowledge about how to make integration stick.

The outcome measurements tell a similar story of imbalance. Twenty-six studies assessed child-level oral health outcomes, such as changes in children’s knowledge, behaviors, or clinical indicators. By contrast, only seven reported changes in knowledge, attitudes, and practices among educators and parents, the adults whose sustained behavior ultimately shapes the child’s environment, and ten reported program-related outcomes such as reach, feasibility, or institutional uptake. This hierarchy of measurement reflects a narrow causal model: if children learn, the assumption goes, health will follow. A more sophisticated view recognizes that school programs operate within families, staffrooms, and policy environments, and that measuring only the child misses most of the system that determines whether gains endure.

The review’s synthesis is cautiously optimistic but demanding. Structured programs that engage children, target risk factors related to hygiene and diet, combine interest holder engagement with curriculum integration, and involve teachers hold genuine promise for improving oral health at scale. But the authors conclude that the field needs theoretically informed, comprehensive, policy-focused, multi-level, multi-risk factor approaches to support sustainable integration of oral health into school health programs. In practical terms, that means designing interventions grounded in explicit frameworks, measuring outcomes across children, educators, families, and institutions, addressing the full spectrum of shared risk factors from sugar to tobacco to injury, and treating oral health not as an optional extra but as a core strand of the health-promoting school. With more than 70 percent of existing evidence coming from wealthier nations and no study yet applying implementation science, the roadmap for the next four decades of research is, in effect, being written now, and the children whose teeth and learning depend on it cannot afford another generation of fragmented, theory-free pilot projects.

Subject of Research: Integration of oral health promotion into primary school health programs

Article Title: Integration of oral health promotion in primary school health programs: A scoping review

Article References: Integration of oral health promotion in primary school health programs: A scoping review. (n.d.). https://doi.org/10.1371/journal.pgph.0007390

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0007390

Keywords: oral health, school health programs, scoping review, children's health, public health, health promotion, dental caries, health equity, implementation science, primary schools, risk factors, global health