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Table 1 Characteristics of included studies

From: Barriers and enablers in the implementation and sustainability of toothbrushing programs in early childhood settings and primary schools: a systematic review

Author, year, (country)

Study aims

Study setting and methods




Funding source



Dimitropoulos et al. (Australia) [30]

Possible challenges and barriers in continuation of school tooth brushing program

Primary schools; Focus groups

School staff and oral health aide

School staff level

-Positive attitude, acceptability, and adaptability

Organisational level

-Local school staff and oral health aides infection control training,

-Classroom-based toothbrushing activities,

-Authoritative school staff,

-Strong local school leadership,

-Peer support

-Flexibility of program implementation timings

Children level

-Program acceptability and children acceptance of lunchtime tooth brushing

Organisational level

-Whole school toothbrushing activity


-In-cooperation of the program in school daily routine (initial concern)

Children level

-Older age children program acceptability issues,

-Resistance of early morning toothbrushing

-Mishandling of toothpaste

-One school did not consent for focus groups

-Teacher’s response influenced by program supportive environment

-Increased local community participation (community collaborative implementation approach)

Not given

Yusuf et al. (England) [31]

Identifying barriers and enablers in fluoride varnish and toothbrushing programs implementation

Primary School; semi-structured interviews

Health champions (volunteers), general dental practitioners, and school staff

Children level

-Children’s participation in toothbrushing activities (79.2%)

Schools level

-Adaptation of various parental consent approaches

-Improve parents program engagement with the assistance of health champions (program Somali community volunteers’)

-Program protocol development aimed at schools for facilitation of implementation

-Program implementation flexible timelines

-Adequate sharing of information among school staff

-Program information translation in Arabic and Somali languages for parents


-Acceptability of health-promoting schools and by volunteers (Health Champions) and the dental team


-Some schools struggle with the return of the consent forms from parents

-Program communication issues with schools were highlighted by school staff

-Inadequate transfer of information from head staff to the school staff

School staff

-Frustrated due to internal organizational factors, time, and space issues

-It was a pilot study and results cannot be generalised to a wider population

Not specified

Glaser-Ammann et al. (Switzerland) [32]

Parents knowledge and attitude towards school dental health programs

Early childhood setting, questionnaire-based surveys

Parents-children’s dyads

Parents level

-72% of parents accepted the importance of school dental programs in preschools

-72% attended the prophylaxis programs

-One fourth (25%) of the parents reported the dental health instructor as the best teacher for children toothbrushing learning skills

-One fifth (20%) believe school dental instructor is also the right person to teach a healthy diet

-Parents of children who were caries-free were more intended to participate in school dental programs (p = 0.11)

-The statistically non-significant association was observed between parents' attendance in school dental health program and their educational level (p = 0.11), country of origin (p = 0.07), and their income (p = 0.07)

Children level

-60% believes that their child has benefitted from the program and now brush their teeth better

-Just 36% reported that their child consumed healthy mid-morning snacks after the school dental health programs

Parents level

-Parents assumed that the kindergarten teacher’s role in teaching toothbrushing skills is not important

-Study design limits the study statistical analysis to be considered explorative, and regression analysis and Bonferroni corrections were performed

Not given

Woodall et al. (UK) [33]

Toothbrushing intervention effectiveness and process issues related to its coordination and delivery

Early childhood setting; case studies, interviews, surveys

Parents, children, school staff, oral health promotors

School staff level

-Acceptability of the program


-Role of teaching support workers as the main contact point of program co-ordination with oral health promoters,

-Linking toothbrushing intervention with school educational curriculum,

-Training of school staff,

-Provision of adequate information to parents along with children's weekly oral hygiene updates

Parental level

-Program acceptability and participation

Children level

-Engagement and acceptability of program,

-Ripple effect

School staff level

-Increased workload,

-School committed staff frequent turnover,

-Role of teacher’s as pseudo-parent

Parents factor

-Lack of engagement and participation,

-Lack of awareness,

Toothbrushes storage and hygiene issues (initial concern)

-Participants sample size issue in each of the data gathering approach

-Survey didn’t include all schools

-Sample size of case studies was not representative of the school population

-Limited number of students participated in drawing activities due to lack of parental consent

Not given

Natapav et al. (Israel) [34]

Factors associated with continuation of supervised toothbrushing program

Early childhood setting; telephonic surveys

School Teachers

School staff level

-Teachers’ positive attitudes (70%)

-Program acceptability (96%)

--Willingness to teach toothbrushing skills (85%) and enjoying teaching toothbrushing skills (20%)

-Correlation between Teachers' willingness for the continuation of the program with their belief in program success (r = 0.73), acceptance of their role of teaching toothbrushing skills to children (r = 0.53), and enjoying teaching toothbrushing (r = 0.59)

-Statistically significant (p ≤ 0.05) association between teachers’ positive attitude towards the program sustainability and conduction of toothbrushing activities daily or several times a week

Children level

-84% of teachers reported that children like to learn toothbrushing skills

School staff level

-Teachers anticipated more barriers were associated with their unwillingness for the program continuation (r =  − 0.34)

-Thirty percent  of teachers think its parent's role to train children in toothbrushing skills

-Statistically significant (p ≤ 0.05) association was observed in teachers’ anticipated barriers of program sustainability and frequency of conduction of toothbrushing activities once a week or less

Not reported

Ministry of Health (MOH)

Nyandindi et al. (Tanzania) [35]

Assessment of teachers'-led factors in the oral health educational programs activities

Primary schools, surveys and interviews, teachers’ oral examination and practical exercises


Teacher’s level

-85% of teachers acknowledge the importance of health sessions in enhancing their personal hygiene

Teacher’s factors

-Teachers ranked health lessons in schools moderately important after reading, writing, and mathematics subjects

-Twenty-four percent  of teachers had taught about diet in the class, without mentioning the association between tooth decay and diet

-Most of the teachers prefer to teach toothbrushing theoretically and perceive it a parent’s responsibility to teach their kids toothbrushing skills

-Teachers claimed that the association between diet and tooth decay is not part of the health lesson curriculum of grade one class

-Teachers complained of insufficient material and time to teach health lessons in the overly packed class of children (mean [SD]: 65 +/− 27 students)

-Eleven percent of teachers perceived the need for further training in oral health education

-Only 26% of teachers had skills of making wooden toothbrush

Organisational level

-School administration rarely inquired about the health lessons conducted in schools

Not given

Not given