Toothbrushing Program in Saudi Arabia "TOPS"- A Cluster Randomized Controlled Trial in Kindergartens, Riyadh

Background Studies confirmed caries and socio-economic factors association. Caries prevalence in children was related to parental factors, such as parents' socio-economic status, behaviors, and their attitudes to oral health. Several studies examined the prevalence of dental caries and associated social risk factors among preschool children in Riyadh, Saudi Arabia. Al-Meedani and Al-Dlaigan in 2016, found that among the total of 388 children examined in Riyadh, 69% had dental caries. There was no statistically significant difference between boys and girls in caries prevalence. There was a significant association between caries prevalence and parental educational level. Children of mothers with postgraduate degrees had higher caries prevalence of 57% while children of mothers with bachelor's degrees and high school level or below had caries prevalence of 66% and 78% respectively. The children of non-working parents had higher caries prevalence compared to those with working parents. The children from larger family size had higher caries prevalence as compared to those from smaller family size.

Another study by Wyne (2008) reported an overall caries prevalence of 74.8% among preschool children who had a mean age of 4.7 years in Riyadh. Similarly, Al-Malik et al (2003) found that 73% of two- to five-year-old children in Saudi Arabia were diagnosed with caries4. Another cross-sectional study by AlMarshad et al 2021, included Saudi preschoolers aged 36-71 months where a total of 383 children were examined. Early childhood caries (ECC) prevalence was 72.6%. Children from schools in northern Riyadh and those of fathers in professional jobs were less likely to have ECC. Children with a nocturnal feeding history and poor oral hygiene were more likely to have ECC.

Oral health improvement programms in education settings such as kindergartens and schools are particularly important because they have shown to be effective and can have the potential of a wide reach across the population during the crucial early years of childhood. Some studies have found that a programme of supervised daily toothbrushing in school can be effective in caries reduction particularly in high-risk populations, it can reduce caries increment in a population experiencing high levels of dental disease. In addition, school-based supervised toothbrushing programme can improve oral hygiene including decreasing levels of plaque, gingival bleeding, and gingivitis. There have been fewer randomized controlled trials of supervised toothbrushing programme particularly in areas with high caries or where other oral health improvement program or initiatives are in place such as water fluoridation.

In a trial including 2228 two to four year-old children attending kindergartens in two counties in northern Hesse, German were randomly allocated to participate in daily tooth brushing with 500 ppm fluoride toothpaste, which was supervised by specially trained dental nurses. The caries increment of the test group was 24% lower than the increment of the control group, and high increment values were observed in the control group twice as often as in the test group. Another trial in England recruited a total of 517 children (mean age 5.63 years) which children in the intervention group brushed once a day at school. For children in the intervention group, the overall caries increment (2.60) was significantly less than for children in the non-intervention group (2.92). In Kaunas city of Lithuania a sample of 411 three years old children were selected to participate in the prevention programme. For test group, supervised toothbrushing was prescribed, and for the control group, children did not undergo any of the procedures. The prevalence of dental caries varied between 39.7% and 90.8%, the reduction in test group was 45.4%. In another clinical trial in Tayside, that was to determine the reduction in two-year caries increment that can be achieved by daily supervised toothbrushing on schooldays, combined with recommended daily home use, compared to a control group involving no intervention. A sample of 534 children, mean age 5.3, in schools in deprived areas were recruited and significant reductions of 32% at D (1) and 56% at D (3) were found. In a study in Jordan, has a similar cultural and community background to Saudi Arabia, caries status of children in the supervised daily tooth brushing group over four years was better than that of the control group. The difference was statistically significant with estimates of relative risk values also showed that children in the control group are 3.1 and 6.4 times at higher risk of having dental caries than those in the study group for age group 12 and six respectively .

Although, there were no enough studies undertaken in background of water fluoridation or in the Saudi population, many international good studies for long follow-up periods had recommended to apply the supervised toothbrushing programme especially in communities with a high prevalence of caries, such as the Saudi community.