Effect of game-based teaching on the oral health of children: a systematic review of randomised control trials

2.1 Search strategy

The inclusion criteria for selecting studies in the PICOS framework was:

Population (P): studies involving children aged 4 to 12 years were considered.

Intervention (I): studies that employed game-based teaching interventions for oral health education were included. This encompassed serious games, interactive games or other forms of digital or non-digital games used as an educational tool.

Comparison (C): inclusion: studies that examined the effectiveness of game-based teaching compared to alternative interventions, conventional teaching methods or control conditions.

Outcome (O): studies assessing oral health-related outcomes such as oral health knowledge, oral hygiene behaviors and plaque scores.

Study Design (S): randomized controlled trials.

Multiple electronic databases, including PubMed, Embase and Web of Science, were searched using a combination of keywords and Medical Subject Headings (MeSH) terms. The search strategy combined terms related to oral health, children, game-based teaching, serious games, interactive games and education. Boolean operators (AND, OR) were used to combine the search terms effectively. No filters or date restrictions were placed with only English language publications considered for inclusion.

To ensure the inclusiveness of the search, additional sources were explored, including conference proceedings, and grey literature databases. Two reviewers (SGP and FWL) independently assessed the search results to identify relevant articles. The reviewers were not blinded to the author names or affiliations. Non-relevant articles and duplicates were excluded. In the initial screening, titles and abstracts were reviewed to determine their relevance to the research question and the predefined inclusion criteria. The full texts of potentially relevant articles were then assessed in the second screening phase to determine their eligibility for final inclusion. The reference lists of relevant articles were manually searched for any additional studies that may be included. Discrepancies between reviewers were resolved by a third author (SB) through consensus. The search strategy is shown in Supplementary Table 1.

2.2 Data extraction

Two reviewers (KHA and MDB) independently conducted the data extraction process using a customized template, which was subsequently verified by a third author (GI). Information from the selected studies was extracted, including study characteristics (e.g., author, publication year), study design, participant characteristics, intervention details (e.g., type of game-based teaching, duration), outcome measures and key findings.

2.3 Quality assessment

The risk of bias assessment was performed by two authors (MC and GM) independently using relevant guidelines from the Cochrane Handbook for Systematic Reviews [29]. Randomised trials were assessed using the Revised Cochrane Risk of Bias Tool (RoB-2) to evaluate their methodological quality and potential biases across five domains: randomization process, deviations from intended interventions, missing outcome data, measurement of outcomes and selection of reported results. For each domain, specific signaling questions were applied to determine the risk of bias. Based on the answers to the signaling questions, a judgment of low, high or some concerns regarding the risk of bias for each domain was assigned.

2.4 Quality of evidence for outcomes in summary of findings table

The evaluation of the evidence quality for each outcome presented in the Summary of Findings section followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. A single author (MDB) conducted the application of the GRADE system, and subsequent discussions were held with the other two authors (MC and SB) to achieve a consensus on the evidence quality for each outcome. The assessment involved considering five domains for potential downgrading of evidence quality: Risk of Bias, Inconsistency of results, Indirectness of evidence, Imprecision of results and Publication Bias. The certainty of the evidence was graded as high, moderate, low or very low.

Evidence from randomized trials was initially classified as high quality for each outcome. It was downgraded by one level for concerns related to study limitations or outcome inconsistencies, and by an additional level for concerns regarding indirectness, imprecision or publication bias.

3.1 Characteristics of the selected studies

A majority of the studies were conducted in Asia (India [30, 32, 34, 36] Jordan [31] and Iran [33]) and one study conducted in the UK [35]. The summary of the characteristics of the selected trials is shown in Table 1.

3.2 Population

The majority of the included studies focused on pre-teen children, specifically within the age range of 7 to 12 years [30, 32, 33, 34, 35, 36]. However, one study expanded the age range to include pre-schoolers aged 4 years and children up to 10 years old [31]. Additionally, two studies specifically targeted children between the ages of 8 and 12 years [32, 33] while three other studies included children aged 7 to 10 years, 7 to 12 years, and 12 years old, respectively [30, 34, 36]. Aljafari et al. [35] recruited participants within a similar age range of 6 to 8 year olds.

3.3 Intervention

The interventions used in the included studies varied in their methods including the use of board games, word games and videogames but shared a common focus on game-based teaching for improving the oral health of children.

In the studies using word games, Yogesh et al. [25] used a connect the dots game with a “Bright Smile” anagram, where each alphabet represented an oral hygiene instruction. The children connected the dots between the alphabets and read out the corresponding instructions, aiming to promote a happy and healthy smile. Flashcards with pictures and oral hygiene instructions were also used in this intervention. Kashyap et al. [36] used crosswords and puzzles with a PowerPoint presentation to educate children about oral health. The crossword consisted of 15 questions related to tooth functions, dental caries, dental plaque, etc., and scores were assigned based on correct answers. Malik et al. [34] utilized crosswords and puzzles along with a PowerPoint presentation as their intervention method, although additional details regarding the game procedure were not provided in the article.

In the studies using board games, snake and ladder was employed by two studies. Nourian et al. [33] employed a snake and ladder game enhanced with question cards and a dental model to improve the practical skills of children. The training package included a game sheet, a manual, a dental model with a toothbrush, an educational brochure for parents, a CD containing educational clips, question cards with answers, game pieces and a dice. An instructive session was conducted for both children and parents, and the game was played in the waiting room under the guidance of a healthcare provider acting as a facilitator. Following completion of the game, children were encouraged to continue practicing at home with their parents [33].

Sharma et al. [37] incorporated a storybook method alongside the game-based approach. The game involved a snake and ladder board, where players moved their coins based on the dice roll and either climbed up ladders (representing oral hygiene do’s) or slid down snakes (representing oral hygiene don’ts). Flashcards were used to reinforce the do’s and don’ts. Additionally, dental storybooks with cartoon characters were utilized to illustrate various oral hygiene maintenance modalities [34].

Aljafari et al. [31] used videogames as an intervention. A video game with oral health content on a touch tablet was provided along with a DVD copy for home use. The video game focused on the importance of toothbrushing twice daily, reducing sugar frequency, following the “Eatwell Plate” guidelines, regular dental visits, and the application of fluoride varnish and fissure sealants for high caries risk children [35].

3.4 Duration

All the studies tested the effect of educational intervention after spacing it out from the initial teaching session, with the minimum being 1 week [30, 31, 33, 35] and maximum being 6 months [36] after the intervention. All the studies with the exception of the study by Nourian et al. [33] recalled the patients till 3 months interval for follow up [30, 31, 32, 34, 35] while Nourian et al.[33] followed up the patients till 1 month post intervention.

3.5 Standardization/calibration

Regarding standardization and calibration, Aljafari et al. [31, 35] appointed a dental nurse-educator for participant allocation and measurements and ensured examiner calibration through a pilot process. Malik et al. [34] utilized trained and calibrated examiners, and Nourian et al. [33] employed blinded experts for scoring. Sharma et al. [37] involved undergraduate dental students supervised by investigators. Kashyap et al. [36] evaluated questionnaire reliability and had a trained examiner record scores.

3.6 Methodology used to assess outcome

Various assessment methodologies were employed across the included studies with the most common being the Oral Hygiene Index-Simplified (OHI-S) [33, 34, 36] and Debris Index-simplified (DI-S) [30, 33, 34, 36]. Malik et al. [34] utilized AlphaPlac Two Tone and the Quigley-Hein index modification for plaque index assessment, along with a close-ended questionnaire for oral health knowledge. Aljafari et al. [31, 35] used a range of methods including visual analog scale, Pictorial Dietary Quiz, Children’s Dietary Questionnaire, Toothbrushing & snacks selection scores, and parental questionnaires.

3.7 Quality assessment

In terms of the overall risk of bias, there were significant concerns regarding the risk of bias in a majority of studies. None of the studies examined were high-quality studies defined as studies with low risk of bias across all domains. Four out of seven studies showed some concerns [30, 31, 33, 35] while three studies were assessed to have a high risk of bias [32, 36, 37]. The higher ratings were due to insufficiencies occurring in multiple domains including deviation from intervention, and measurement of outcome. Poor reporting across most studies led to concerns regarding reliability and validity that are reflected in the higher ratings. A summary of the risk of bias assessment is shown in Fig. 2. The summary of findings for outcome specific ratings is shown in Table 2.

Fig. 2.Summary of risk of bias assessment.

3.8 Effect of intervention

The systematic review found that game-based teaching is an effective tool for promoting oral health among children, particularly in the pre-teen and preschool age groups. The included studies consistently demonstrated positive outcomes in terms of improved oral health knowledge, oral hygiene scores, and reductions in debris and plaque scores. Game-based interventions were found to be more engaging and effective compared to conventional teaching methods, such as verbal instructions or educational posters. The use of self-made dental story books also showed promise in promoting oral health [34].

The results of Yogesh et al. [25], Nourian et al. [33], and Kashyap et al. [36] collectively demonstrate the positive impact of game-based teaching on oral health outcomes.

Yogesh et al. [25] found that both the experimental and control groups experienced a significant reduction in debris index scores after three months. However, the game-based teaching group showed a highly significant difference, indicating that game-based teaching was particularly effective in reducing debris. Moreover, the game-based teaching group exhibited significant improvement in knowledge scores compared to the control group, highlighting the educational benefits of this approach [30].

Similarly, Nourian et al. [33] observed statistically significant improvements in OHI-S and DI-S scores in the experimental group at one week and one-month follow-up. This suggests that game-based teaching contributed to enhanced oral hygiene and reduced debris among the participants [33].

Malik et al. [34] and Kashyap et al. [36] findings showed a trend with the game-based group showed higher knowledge scores and better oral hygiene scores, along with significant reductions in debris and plaque scores at follow-up compared to the control group. These results emphasize the sustained effectiveness of game-based teaching in improving oral health knowledge and oral health index scores over an extended period.

Aljafari et al. [31, 35] reported that the game-based teaching method of oral health education was comparable to the conventional method of verbal oral education instructions. Both parents and children expressed satisfaction with both methods. Immediate post-education assessments showed significant improvements in the recognition of unhealthy foods in both groups. Three months of follow-up indicated improvements in diet, including reduced intake of sweetened drinks and non-core foods, with no significant differences between the two groups. Toothbrushing frequency remained consistent, but there were no changes in snack selection in both education methods [31, 35].

4.1 Overall completeness and applicability

It is important to note that the studies included in the review were conducted on a socially viable group of children with access to education, video games and schools. Therefore, the generalizability of these findings to children from diverse socioeconomic backgrounds or with limited access to educational resources should be considered with caution. It would be useful to know about the effectiveness of these interventions in other age groups and determine whether duration and permanence of change is a key issue. Some measures used relied on self-reporting, which introduces the potential for response bias.

Another limitation pertains to the relatively short follow-up period of three months in most studies. This duration may not allow for the full maturation of dental health messages and the assessment of long-term effects. Much longer follow-ups are required to demonstrate that the benefits of intervention are maintained and to assess the size of the benefit. The included trials had considerable heterogeneity related to the type of interventions. Substantial variations in the type (digital vs. non-digital games) and length of intervention were noted. Also different is the fact that some interventions were carried out with parents present, whilst in other studies independent practice was encouraged. The limited sample sizes undermine our confidence in the ability of these studies to fully address the primary objective of this review. These shortcomings may diminish the robustness of findings with small study effects.

4.2 Quality of the evidence

The body of evidence identified in this study does not allow for a robust conclusion regarding the assessment of the effectiveness of game-based teaching of oral health on school-age children. Reporting guidelines laid down in Consolidated Standards of Reporting Trials (CONSORT) or similar standards were not followed in a majority of studies. This leads to inadequate reporting on procedures that minimize selection, performance and attrition bias. Reports frequently omitted details regarding allocation concealment, randomization and lack of blinding making it challenging to fully assess the sources of bias within the studies. We accounted for this in the GRADE approach by downgrading the evidence level by two levels for serious risk of bias. The quality of evidence therefore was low, i.e., we are uncertain of the estimate of the effect.

A key strength of this review is its comprehensive and rigorous search strategy, which involved multiple databases and multiple independent authors. We examined only randomized trials, considered the gold standard in research design, which enhances the validity of the review’s conclusions. However, this review is not without its limitations—specifically the small number of studies available which restricts the scope and depth of the analysis and may limit the generalizability of the findings to broader populations. We also included papers published in the English language. Despite these limitations, the review provides valuable insights into the effectiveness of game-based teaching approaches in improving oral health among children, highlighting the need for further well-designed and adequately reported studies to strengthen the evidence base in this area.