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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 14  |  Issue : 2  |  Page : 100-108

Oral health intervention program among primary school children at El-Qalyubia Governorate


Community Health Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt

Date of Web Publication12-Jan-2018

Correspondence Address:
Eman M Seif El-Nasr
Department of Community Health Nursing, Faculty of Nursing, Cairo University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_15_17

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  Abstract 

Background Oral health is a major public health issue affecting all groups of the population. Poor oral health during childhood is directly associated with poor oral health outcomes during childhood and throughout adulthood.
Aim The aim of this study was to evaluate the effect of an Oral Health Intervention Program among primary school children.
Patients and methods A quasiexperimental study was used to fulfill the aim of the study. This study was conducted at two experimental schools in El-Qaliubiya Governorate. A purposive sample of all students in the fifth grade who fulfilled the inclusion criteria from the two schools was included in the study. Two tools were developed: the oral health structured interviewing questionnaire, which included two parts (personal data and oral health knowledge), and observational checklist for oral hygiene practice.
Results The results revealed that the mean age of the study participants was 10.63±0.63. As regards the causes of tooth decay, 50 and 66%, respectively, recognized the causes before and after the intervention program, and 33 and 63%, respectively, identified the consequences of tooth decay before and after the intervention program. A highly statistically significant difference was found between the study participant’s total knowledge before and that after the intervention program (P<0.000), and a highly statistically significant difference was found between study participant’s practices of oral hygiene before and that after the intervention program (P<0.000).
Conclusion Primary school children represent a high-risk group for oral health problems, and this study indicated that the oral health intervention program was effective in increasing knowledge and practices toward oral health.
Recommendations It is recommended to empower periodic screening for school students to detect oral problems, disseminate the oral health intervention program to parents, school teachers, and nurses for early detection of student’s dental problems, and connect to referral system for care, which is integrated in school insurance program.

Keywords: intervention program, oral health, primary school children


How to cite this article:
Seif El-Nasr EM. Oral health intervention program among primary school children at El-Qalyubia Governorate. Egypt Nurs J 2017;14:100-8

How to cite this URL:
Seif El-Nasr EM. Oral health intervention program among primary school children at El-Qalyubia Governorate. Egypt Nurs J [serial online] 2017 [cited 2018 Jul 23];14:100-8. Available from: http://www.enj.eg.net/text.asp?2017/14/2/100/223092


  Introduction Top


Oral health is a core component of general health and well-being. A healthy mouth enables an individual to speak, eat, and socialize without experiencing active disease, discomfort, or embarrassment (Haque et al., 2016). Oral health is a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, gum disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity, emptying, chewing, smiling, speaking, and psychosocial well-being (Vinay et al., 2013). The World Health Organization (2014) understands the major impact oral health has on the health of an individual and has placed major emphasis on improving oral health in all populations.

Oral health intervention and promotion may be delivered at multiple forums − namely, hospitals, primary healthcare centers, private dental clinics, and school. Nevertheless, schools are perhaps the best place for promoting oral health because approximately one billion children worldwide spend most of their daytime life there (Haque et al., 2016). Schools provide an ideal setting to deliver oral health intervention program in combination with preventive services to achieve oral health promotion. School-based approach has been reported to be more efficient in delivering preventive and curative services compared with community-based approach. The study found that school-aged children who are suffering from poor oral health are 12 times more likely to restrict activity days compared with those are in good oral health. More than 50 million school hours are lost globally because of poor oral health. This can affect student’s class room performance and success later in life [United Nations Intervention, Scientific, and Cultural Organization (UNESCO), 2009).

Poor oral health and untreated infections can have a significant impact on school-aged children. Children have trouble eating and sleeping and can experience speech impairments, have trouble focusing, and have low self-esteem. Moreover, it can greatly reduce a child’s capacity to succeed in the education environment. Teachers observe child who having difficulty attending to tasks or demonstrating the effects of pain, anxiety, fatigue, irritability, depression and withdrawal from normal activities. Children who have a toothache when they take tests are unlikely to score similar to children who are not distracted by pain. When children’s acute oral health problems are treated and they are not experiencing pain, their learning and school attendance records improve (Grossman et al., 2010).

The first nationwide survey of oral health among Egyptian adults and children conducted by WHO involved different sectors of the society. The study showed that, nearly 70% of examined children had some untreated caries experience; meanwhile, 80% were suffering from some form of periodontal disease, 40% of participants reported that they experienced dental problems at the time of examination but did not seek a dentist for treatment and 20% had never been to a dentist [World Health Organization, Eastern Mediterranean Regional Office (WHO EMRO), 2015).

Branden (2013) revealed that children’s experience and information toward oral health is acquired from different sources, including parents, teachers, and electronic and printed media. Oral hygiene is very important for the prevention of dental problems such as dental cavities, gingivitis, and bad breadth. School health nurses report a range of oral health problems such as dental caries, gingival disease, malocclusion (poor bite), loose teeth, and oral trauma. Arora and Sharma (2012) added that a critical, but often overlooked, impediment to student learning and achievement is poor oral health. Tooth decay is the most prevalent health problem and chronic disease of school-aged children.

School health nurses have an important role in promoting oral health, making every contact count, and giving children, young people and families’ information and support to be able to make healthier choices. The role of the school health nurse includes mouth checks and referrals for any identified oral health concerns as a part of the prep health assessment. These mouth checks are an excellent opportunity to ensure early identification of and intervention in oral disease in school children, and to provide advice and information to parents as regards oral health. Mouth checks are implemented as a result of expressed concerns by parents and/or teachers. School health nurses are in a position to initiate referrals for treatment as required, provide intervention resources about oral health to both parents and teachers within the school and community, deliver some oral health promotion activities within the school environment, and equip parents with up-to-date information about the importance and benefits of fluoride as well as a number of other oral health promotion issues (Clausson, 2008).

Significance of the study

A study carried out to investigate the prevalence of tooth decay in a group of 999 Egyptian children (496 boys and 503 girls) aged from 3 to 6 years at nurseries in El-Kalubia Governorate revealed that the prevalence of tooth decay was high among the children (69.4%). The results of this study showed that the prevalence of tooth decay increases with age (Salah, 2011). Moreover, the study by Farag (2013) in El-Suez Governorate on a total of 442 Egyptian children aged from 5 to 6 years to assess the child’s tooth decay and the effect of implementation of education programs revealed that 75% of the examined children had tooth decay, and a significant positive effect of the oral health intervention program was revealed.

Minimal attention is being paid to primary prevention of dental problems among school children. For appropriate oral health, it is necessary to have adequate knowledge and practice as regards oral health. This study was conducted on students because they are more receptive and can contribute to the transmission of information to other people. Furthermore, their behavior can be modified to prevent various illnesses related to inadequate oral hygiene. The aim of this study was to evaluate the effect of an Oral Health Intervention Program for primary school children.


  Aim Top


The aim of this study was to evaluate the effect of an Oral Health Intervention Program among primary school children.

Hypothesis

  1. Knowledge scores after test will increase compared with scores before test.
  2. Practice scores after test will increase compared with scores before test.



  Patients and methods Top


Design

A quasiexperimental study was used to fulfill the aim of the study.

Setting

El-Qalyubia is one of the provinces of the Arab Republic of Egypt; it is located in the eastern side in the north of Egypt near the top of the Delta, bordered to the south Cairo Governorate. The cities of El-Qalyubia Governorate are Banha, Khanka, Qaha, Qalyub, Shibin El Qanater, Shubra El Kheima, Tukh, El Qanater El Khayreya, Kafr Shukr, Obour City, and Khusus. One city was selected randomly; this city was El Qanater El Khayreya. This city has only two experimental schools, and those schools were Alsayeda khadija Expremental official language school and Hassan Abu Bakr Experimental Languages School (The Ministry of State for Administrative Development, 2014).

Sample

Each school has only two classes in grade 5. A purposive sample of all students in the fifth grade who fulfilled the inclusion criteria from the two schools was included in the study. Each class has about 25–30 students but due to their absences or illness only 100 children completed the study.

Inclusion criteria

  1. Being free from any evidence of systemic diseases.
  2. Being free from any apparent genetic disease.
  3. Being free from dental abnormalities.


Tools for data collection

Two tools were developed by the researcher after extensive review of the related literature: oral health structured interviewing questionnaire, which included two parts (personal data and oral health knowledge), and observational checklist for oral hygiene practice.

Oral health structured interviewing questionnaire

Part I includes personal data: age, sex, and place of residence of school children.

Part II includes oral health knowledge: knowledge about teeth, dietary habits, and oral care. This part has 15 questions. If the answer was ‘yes’ score 1 was given and if the answer was ‘no’ score 0 was given. Students who scored between 1 and 5 were considered to have poor knowledge, those who scored between 6 and 10 were considered as having average knowledge, and those who scored between 11 and 15 were considered to have good knowledge.

Observational checklist for oral hygiene

It includes six steps developed by the researchers guided by The Egyptian Society for Pediatric Dentistry and Children with Special Needs (ESPSN) (2015). The checklist of students who performed it completely was considered ‘done’ and checklist of those who left any step was considered ‘not done’.

Tool validity and reliability

Tools were subjected to a panel of five experts in the field of community health nursing and oral and dental medicine to test the content validity. Modifications were made according to the panel judgment on clarity of sentences and appropriateness of the content.

The tools’ reliability was tested by assessing its internal consistency, and proved high (Cronbach’s α coefficient 0.81 and 0.88). Needed modifications were performed in the form of rephrasing of some items.

Ethical consideration

An approval was obtained from the two school directors, students, and their parents. Each student was informed about the purpose and the importance of the study. The researcher emphasized that participation in the study was entirely voluntary. Anonymity and confidentiality were also assured through coding of the data. Informed verbal consent was obtained from parents of each student. All students were informed that they can withdraw at any time.

Pilot study

A total of 10% of the students were included in the pilot study in order to assess the feasibility and clarity of the tools and to determine the needed time to answer the questions. On the basis of its result minor changes were made. The pilot study revealed that the average length of time needed to complete the structured interview schedule was ∼30–45 min with each student. The pilot study was included in the study as only very limited minor changes were made on the tools.

Procedure

Permission was obtained from the two school directors, students, and their parents. School teachers and school nurses were informed about the nature and purpose of the study. Data were collected through a period of 6 months from October 2015 to the end of March 2016, 2 days/week, from 9.00 a.m. to 12.00 p.m. Data were collected from the students by means of interviewing questionnaires and observation. This study was conducted in three phases: preparation phase, implementation phase, and evaluation phase.

Preparation phase

After reviewing the related literature, the researcher developed the oral health structured interviewing questionnaire that includes personal data, oral health knowledge, and observational checklist for steps of oral hygiene.

Implementation phase

After selecting the students who met the inclusion criteria, the researchers introduced themselves to students, and the purpose and importance of the study were explained. Oral consent was obtained from students before participation in the study. The researcher collected data by distributing questionnaires to students; each question was explained to the students and then answered by them. All children received a toothbrush and a toothpaste tube and then oral hygiene steps were carried out individually and observational checklist was collected by the researcher.

On the basis of the results of the preparation, the oral health intervention program was developed, as well as the time schedules and teaching sessions. An intervention program was designed by the researcher based on actual assessment and in the light of the available research studies and literature. The intervention was developed in a simple Arabic language to cover the relevant knowledge and practical part of the oral health. Different teaching methods such as lectures, discussion, demonstration, and redemonstration were used. Different teaching media were used, such as pamphlets, pictures, posters, tooth model, and real equipment.

The program was implemented in five sessions and in small groups comprising around 10–12 students in each group. Each session was for about half an hour. The first session included knowledge about oral health (definitions and number of temporary and permanent teeth); the second session included importance of oral care and causes of tooth decay; the third session included consequences of tooth decay and diet rich in calcium; the fourth session included oral care (use of toothbrush, use of tooth paste containing fluoride, use of toothbrush two or three times/day, replacement of toothbrush every 3 months, and visit to dentists every 6 months); and the fifth session included demonstration of oral hygiene practices by researcher. These sessions were conducted for two groups every week and according to available times for each group.

Evaluation phase

After 3 months, each child was reinterviewed to assess the child‘s knowledge and practice as regards their oral hygiene. Reassessment of student’s knowledge was carried out and redemonstration of the proper oral hygiene practice technique was carried out using the same tool. This took 15 min and was individualized to ensure accuracy in completion of tools and to brush their teeth in the prescribed manner to assess whether it is correct or incorrect according to the observational checklist for oral hygiene.

Statistical analysis

Data entry was performed and data were coded, scored, tabulated, and analyzed using Statistical Package for the Social Sciences (SPSS) windows statistical package for social science, version 21. It included the test of significance given in standard statistical books. Collected data were summarized and tabulated using descriptive statistics. Frequency and percentage were used for numerical data, as well as mean and standard deviation. For analysis of nonquantitative data, the χ2-test was used. In addition, correlation coefficient was used to describe association between variables in the same group. P-value less than 0.05 was considered significant and less than 0.001 considered as highly significant.


  Results Top


The study results were presented in four main parts: (i) description of the study participants; (ii) description of knowledge about oral health and total knowledge score; (iii) description of oral hygiene practices and total practices score; and (iv) correlation between variables.

The results revealed that only 7% of the study participants were 12 years of age; 50% of participants were between 11 and 12 years of age with a mean age of 10.63±0.630 years ([Figure 1]). As regards sex, more than half (52%) were boys and 48% were girls. As regards study participant’s place of residence, 51% were from rural area and 49% from urban area.
Figure 1 Distribution of the students as regards their age

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As regards student’s knowledge about oral health, around a quarter (14%) of the students identified the correct number of temporary teeth before oral health intervention program, whereas 45% identified it after the program. As regards the number of permanent teeth, 63 and 90% identified it before and after the intervention program, respectively. [Table 1] clarifies that 48% of the study participants recognized the importance of teeth before the intervention program, which increased to 66% after the program. As regards the causes and consequences of tooth decay, 50 and 66% of students and 33 and 63% of students recognize all causes and consequences before and after the intervention program, respectively.
Table 1 Distribution of the students as regards their oral health knowledge before and after the intervention program (N=100)

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As regards the types of food rich in calcium, [Table 1] reveals that the number of students who consumed diet rich calcium increased after the intervention program; 27% of them had the habit of drinking milk before the intervention program and 34% developed the habit after the program. An overall 55 and 68% consumed dairy products before and after the intervention program, respectively. As for eating vegetables and fruits, 40% of study participants before the program and 68% after the oral health intervention program consumed vegetables and fruits.

The results also revealed that 73 and 89%, respectively, used tooth paste containing fluoride before and after the intervention program, and 71% of the study participants used toothbrush two or three times/day before the intervention program compared with 92% after the intervention program. As regards the dentists visit, 17 and 49% of the study participants visited dentists every 6 months before and after the intervention program, respectively ([Table 1]). [Table 2] reveals a highly statistically significant difference between the study participant’s total knowledge before and that after oral health intervention program (P<0.000).
Table 2 Total knowledge before and after the oral health intervention program (N=100)

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As regards the steps of the oral hygiene practices, the results revealed that 21 and 58%, respectively, followed the steps completely before and after the intervention program. Study participants who cleaned their outer teeth in circular motion increased from 55% before the intervention program to 74% after the intervention program. However, 62% cleaned inner teeth before program and 81% after it. Only 40% cleaned their digestive surfaces in circular motion before the intervention program, whereas 66% followed this procedure after the intervention program. Above half (54%) of the students cleaned their inner teeth from low to high before the intervention program compared with 70% after the intervention program ([Table 3]). As regards oral hygiene practices, [Table 4] clarifies that a highly statistically significant difference was found between that before and that after oral health intervention program (P<0.000).
Table 3 Distribution of oral hygiene as done by school age children before and after intervention program (N=100)

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Table 4 Total oral hygiene practices as done by school age children before and after the oral health intervention (N=100)

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[Table 5] reveals that no statistically significant difference was found between age, sex, and place of residence with total knowledge and practice before and after oral health intervention program. [Table 6] clarifies that statistically significant differences were found between knowledge of the study participants before and that after applying the oral health intervention programs in relation to knowledge about the importance of teeth (t=2.33, P=0.02), causes of tooth decay (t=4.36, P=0.000), and consequences of tooth decay (t=1.96, P=0.05).
Table 5 Correlation between age, sex and place of residence with total knowledge and practice before and after the oral health intervention program

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Table 6 Comparison between items of oral health knowledge before and after the intervention program

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  Discussion Top


Childhood is a critical period in the development of a healthy child. The consequences of poor oral health in children reach beyond dental problems, with oral health being associated with overall systematic health as well as one’s quality of life. Poor oral health can have a negative impact on a child’s ability to eat, sleep, and socialize and can affect the individual’s ability to learn (Bach and Manton, 2014).

The results of the current study indicated that the mean age of the study participants was 10.63±0.630 years, but no statistically significant correlation was found between study participant’s age and the total knowledge and total practice before and after the intervention program. This is in agreement with the finding of Abu-Elenen et al. (2015), who conducted a study in general primary schools in Port-Said city to evaluate the effect of an oral care educational program on the knowledge, practice, and self-efficacy among school age children and found that there were no significant differences between total knowledge and practice with age of children.

The results revealed no statistically significant correlation between sex and place of residence with total knowledge and total practice before and after the oral health intervention program. The same results were found in the study by Imran et al. (2015) to determine the knowledge and practice of oral health among higher secondary school students and revealed no significant difference for knowledge and practice among male and female students.

The results concluded that the majority of the study participants were using tooth paste containing fluoride after the intervention program, and most of them used toothbrush twice or thrice times/day and recognized the importance of visiting the dentists every 6 months after the intervention program. In agreement with the study results, a study carried out at El-Ismailia Governorate among preschool children revealed a significant increase in the children’s normal diet and tooth brushing, and a decrease in the prevalence of children who consumed sugar after health education program (Yehia, 2013).

In agreement with the study results, Haque et al. (2016), who assessed the effectiveness of a school-based oral health intervention program for adolescents in Bangladesh, found a significant number of students who visited the dentists for any type of dental diseases and for annual routine check-up after the program. Moreover, oral health education program clarified the importance of using of fluoridated tooth paste for prevention of dental caries, increasing the frequency of cleaning teeth at least three times after each meal and increasing the frequency of changing the tooth brush after the oral health intervention program. This would indicate the importance of teaching the students because they are still growing, and learning would be very easy for them to acquire knowledge and apply it.

The present study indicated that there were statistically significant improvements in the children’s oral health knowledge before and that after intervention program about the importance of teeth, causes of tooth decay, and consequences of tooth decay. These results are very logic because they were giving the program and there is an increase in their knowledge, which reflect the need of those children for effective teaching program about oral health. These results were supported by researchers Shenoy and Sequeira (2013), Ahn and Yi (2010), and Abu-Elenen et al. (2015), who showed that the application of oral health programs for children is effective for improving dental health knowledge and practice. These results may be attributed to the application of oral hygiene practice by attractive methods for children.

A highly statistically significant difference was found between the study participant’s total knowledge before and that after the intervention program. The same results was found by Haque et al. (2016), who found a significant difference in almost all indicators of knowledge variable before and after the program. Overall, a significant improvement (P<0.001) was observed as regards participants’ self-reported high knowledge score at follow-up compared with baseline (75.9 vs. 19.3%).

The present study revealed that before oral health intervention program more that a quarter of students performed all steps of brushing teeth but after program the percentage improved to more than half. These findings could be attributed to the oral care practice of students observed and the children having good knowledge about oral care after program. The results of the study of Abu-Elenen et al. (2015) to evaluate the effect of an oral care educational program on the knowledge, practice, and self-efficacy among school-aged children is in agreement with the results of the present study, as 21.2% of students performed the recommended practice of brushing teeth twice daily, but after program the percentage improved to 27.6 and 32.5% immediately and at follow-up, respectively.

As regards oral hygiene practices, the results revealed an increase in the number of the study participants who followed all steps of the intervention program. Moreover, a highly statistically significant difference was found between the total practice scores of oral hygiene practice before and that after the intervention program (P<0.000). Similarly, the study by Haque et al. (2016) revealed a significant improvement in oral health practices among the studied participants and change to healthy practice occurred after giving adequate information, motivation, and practices done by the participants. A tooth model was used to help the students visualize the proper way of brushing with fluoridated tooth paste. The study also showed an improvement in the skills of the participants as increasing the frequency of rinsing mouth after meal, and cleaning tongue regularly during brushing or after meal.


  Conclusion Top


In summary, this study concluded that oral health intervention program has a positive impact on children’s knowledge and practices toward oral health.

Recommendations

The findings of the present study proved the following:
  1. Further oral intervention programs on regular basis with the involvement of parents and teachers are needed in order to maintain the children in a state of good oral health.
  2. Further confirmatory research is suggested to reinforce dental checkup to prevent dental problems among children periodically.
  3. Periodic screening for school students for early detection of dental decay and referred to health insurance services.
  4. Parents of school children should be encouraged to have a role in early detection and prevention of their children’s dental problems.


Further research is required on a larger sample of school children in Egyptian community.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
  References Top

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