Effectiveness of supervised tooth brushing programs is widely described in the literature: it improves children’s tooth brushing knowledge and behavior and influences parents’ attitudes towards oral health [8, 12, 13]. Regular use of fluoridated toothpaste in tooth brushing programs improves dental health and reduces inequalities and the burden of dental disease [14].
Currently, supervised tooth brushing is an important part of leading national oral health improvement programs in different countries [15, 16]. Numerous studies have shown improvement in dental health of 5-year-olds attending nurseries which implement tooth brushing programs [17, 18]
Yet, “evidence of low certainty” for caries reduction in children was found in a Cochrane library review of community-based oral health interventions (2016). This paper has shown some beneficial effect of supervised tooth brushing with fluoridated toothpaste on dmft and dmfs [19].
In our study, we found a difference in prevalence proportion of caries, in the d and f component as well as in dmft. The differences are statistically significant in PP and d component and treated (f/dmft) and untreated fraction of affected teeth (d/dmft) between children who participated in supervised tooth brushing program in the last 2 years in the kindergartens, comparing to those who did not.
Children from the Arab group, who participated in the supervised tooth brushing program, had less decayed teeth, and much more filled teeth compared to non-participants. These findings show a difference in uptake of dental services within the Arab group, with significantly higher treatment coverage of the tooth brushing group. Even though access to dental treatment has improved dramatically since dental care for children was included into the basket of services of the NHIL, patterns of services uptake are influenced by several factors and differ within the communities. Higher service uptake might have influenced the dmft index in the tooth brushing group, by raised f and m components. However, significantly lower percentage of decayed teeth at age 5 in this group is an important finding, indicating the level of active disease.
Between 2014 and 2016, 600 ppm fluoride toothpaste was used in the kindergarten program. Low fluoride toothpaste (500–900 ppm fluoride) for children aged 2 to 6 years was recommended by national fluoride guidelines established in 2007. These guidelines were issued when about 70% of all water supplies were fluoridated. This policy was implemented in order to prevent dental fluorosis and provide adequate level of prevention from multiple sources of fluoride. Since 2014, when water fluoridation was ceased, much effort has been invested by the professionals, organizations and authorities, to renew fluoridation of water supplies in Israel. The renewal of water fluoridation is highly important because since 2018 most of the drinking water is desalinated water with no microelements in it. In June 2015, the decision to restore fluoridation of drinking water was made by the Ministry of Health, in accordance with the professional opinion of the Ministry’s experts as well as medical associations outside the Ministry. Accordingly, the low fluoride toothpaste policy was left unchanged. However, it has taken longer than expected to restore water fluoridation and the effort is still ongoing, resulting in water supplies in the country lacking adequate fluoride levels for over 5 years.
In 2021 the MoH expert committee advised to update the National Guidelines for Fluoride use in children, according to professional bodies recommendations [20,21,22] and considering high ECC morbidity. Accordingly, the guidelines were revised and 1000 ppm F toothpastes were recommended for children bellow the age of six. It may be assumed that use of 1000 ppm F Toothpaste in the STB program will endorse the caries reduction effect.
In our study, we found very high caries prevalence among 5-year-olds in both Jewish and Arab Bedouin groups as compared to previous studies conducted in Israel in this age group [4, 5]. Only in one study group (Jewish tooth brushing group), was the caries prevalence less than half (48%). Three other groups of children – Jewish non-participants (PP 69%), Arab non-participants (PP 75%), and Arab participants (PP 83%) - had very high caries prevalence levels.
The anticipated decline in caries levels due to the free of charge preventive dental treatment in basket of dental services of NHIL has not yet occurred. The tooth brushing group of children had better dental health indicators and lower untreated disease, as mentioned above.
Limitations of the study
dmft index itself is not a sensitive enough index in order to reflect the complexity of oral health status nor severity changes in it.
