School dental screening programmes for improving oral health of children

What was the aim of this review?

Oral health means the condition of the mouth, throat, teeth and gums. The aim of this Cochrane Review was to find out if school dental screening improves oral health of children; and if it does, which screening method works best. We found eight relevant studies to answer this question. This is the second update of a review that was published in December 2017 and first updated in August 2019.

Key message

There is not enough evidence to draw conclusions about whether traditional school dental screening can improve dental attendance (can lead to children visiting the dentist more often). Moreover, it is not clear if improvement in dental attendance leads to better oral health. We still need high-quality studies that measure the impact of screening on oral health over longer periods of time.

What did this review study?

Oral diseases, especially tooth decay (called 'dental caries' by dentists), affect children worldwide. If untreated, oral health can deteriorate and negatively impact children's general well-being. It also has a financial cost for families and society as a whole.

School dental screening involves a dental professional examining children's mouths and teeth at school and letting parents know about their child's oral condition and treatment needs. It aims to identify oral health concerns at an early stage and prompt parents to seek treatment where required. Whether this actually improves children's oral health is the question we wanted to answer in this review.

What were the main results of this review?

Our updated search identified one new study to be included since the last version of the review was published. In total, the review includes eight studies that presented results for 21,290 children. Four studies took place in the UK, two in India, one in the USA and one in Saudi Arabia. The children were 4 to 15 years old. Studies looked at the oral health and dental attendance of children who were screened in school compared to children who did not have screening. Some studies also compared different ways of screening and different forms of follow-up (e.g. advice letter or referral).

We do not know whether traditional school dental screening improves dental attendance. Studies looking at screening based on specific criteria (e.g. targeted at children not registered with a dentist) suggested it may be slightly more effective than no screening for improving attendance at the dentist. There may be no difference between criteria-based screening and universal screening for improving dental attendance, but we are very unsure about the results.

A personalised or specific referral letter to parents may improve dental attendance more than a non-specific letter, but we are very unsure about the results.

Screening with added motivation (health education and offer of free treatment) may improve dental attendance compared to screening alone, but we are very unsure about the results.

One study comparing different referral letters (with more or less information about dental diseases) found that neither was better than the other for improving dental treatment in children.

A specific referral letter did not encourage more parents to take their children to the dentist when compared to a letter with generic advice to visit the dentist.

The eight studies followed up children for 3 to 11 months after they received screening. Therefore, we do not know the effects of screening over a longer period of time.

None of the studies checked whether there were any negative effects of screening programmes or how much they cost.

How up to date is the review?

We searched for published studies up to 15 October 2021.

Authors' conclusions: 

The evidence is insufficient to draw conclusions about whether there is a role for school dental screening in improving dental attendance. 

We are uncertain whether traditional screening is better than no screening (very low-certainty evidence). Criteria-based screening may improve dental attendance when compared to no screening (low-certainty evidence). However, when compared to traditional screening, there is no evidence of a difference in dental attendance (very low-certainty evidence).

For children requiring treatment, personalised or specific referral letters may improve dental attendance when compared to non-specific referral letters (very low-certainty evidence). Screening supplemented with motivation (oral health education and offer of free treatment) may improve dental attendance in comparison to screening alone (very low-certainty evidence). We are uncertain whether a referral letter based on the 'common-sense model of self-regulation' is better than a standard referral letter (very low-certainty evidence) or whether specific referral to a dental treatment facility is better than a generic advice letter to visit the dentist (very low-certainty evidence).

The trials included in this review evaluated effects of school dental screening in the short term. None of them evaluated its effectiveness for improving oral health or addressed possible adverse effects or costs.

Read the full abstract...

In school dental screening, a dental health professional visually inspects children’s oral cavities in a school setting and provides information for parents on their child's current oral health status and treatment needs. Screening at school aims to identify potential problems before symptomatic disease presentation, hence prompting preventive and therapeutic oral health care for the children. This review evaluates the effectiveness of school dental screening for improving oral health status. It is the second update of a review originally published in December 2017 and first updated in August 2019.


To assess the effectiveness of school dental screening programmes on overall oral health status and use of dental services.

Search strategy: 

An information specialist searched four bibliographic databases up to 15 October 2021 and used additional search methods to identify published, unpublished and ongoing studies.

Selection criteria: 

We included randomised controlled trials (RCTs; cluster- or individually randomised) that evaluated school dental screening compared with no intervention, or that compared two different types of screening.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane.

Main results: 

The previous version of this review included seven RCTs, and our updated search identified one additional trial. Therefore, this update included eight trials (six cluster-RCTs) with 21,290 children aged 4 to 15 years. Four trials were conducted in the UK, two in India, one in the USA and one in Saudi Arabia. We rated two trials at low risk of bias, three at high risk of bias and three at unclear risk of bias. 

No trials had long-term follow-up to ascertain the lasting effects of school dental screening. The trials assessed outcomes at 3 to 11 months of follow-up.

No trials reported the proportion of children with treated or untreated oral diseases other than caries. Neither did they report on cost-effectiveness or adverse events.

Four trials evaluated traditional screening versus no screening. We performed a meta-analysis for the outcome 'dental attendance' and found an inconclusive result with high heterogeneity. The heterogeneity was partly due to study design (three cluster-RCTs and one individually randomised trial). Due to this inconsistency, and unclear risk of bias, we downgraded the evidence to very low certainty, and we are unable to draw conclusions about this comparison.

Two cluster-RCTs (both four-arm trials) evaluated criteria-based screening versus no screening, suggesting a possible small benefit (pooled risk ratio (RR) 1.07, 95% confidence interval (CI) 0.99 to 1.16; low-certainty evidence). There was no evidence of a difference when comparing criteria-based screening to traditional screening (RR 1.01, 95% CI 0.94 to 1.08; very low-certainty evidence).

One trial compared a specific (personalised) referral letter to a non-specific letter. Results favoured the specific referral letter for increasing attendance at general dentist services (RR 1.39, 95% CI 1.09 to 1.77; very low-certainty evidence) and attendance at specialist orthodontist services (RR 1.90, 95% CI 1.18 to 3.06; very low-certainty evidence).

One trial compared screening supplemented with motivation to screening alone. Dental attendance was more likely after screening supplemented with motivation (RR 3.08, 95% CI 2.57 to 3.71; very low-certainty evidence).

One trial compared referral to a specific dental treatment facility with advice to attend a dentist. There was no evidence of a difference in dental attendance between these two referrals (RR 0.91, 95% CI 0.34 to 2.47; very low-certainty evidence).

Only one trial reported the proportion of children with treated dental caries. This trial evaluated a post-screening referral letter based on the common-sense model of self-regulation (a theoretical framework that explains how people understand and respond to threats to their health), with or without a dental information guide, compared to a standard referral letter. The findings were inconclusive. Due to high risk of bias, indirectness and imprecision, we assessed the evidence as very low certainty.