Project Report Smile Around the World 2018 in China

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Table of Contents Executive Summary .................................................................................................................... 3

Introduction................................................................................................................................. 4

Implementation design for China ................................................................................................ 4

Background ............................................................................................................................ 4

Scope of content ..................................................................................................................... 5

Activities ................................................................................................................................. 5

Project methods and materials ................................................................................................... 5

Preparation (February – March 2018) ..................................................................................... 6

Launch ceremony (March 20, 2018) ....................................................................................... 6

SAW project implementation (March – June 2018) ................................................................. 7

Evaluation (July 2018) ............................................................................................................ 9

Evaluation Analysis .................................................................................................................. 10

Results from the children’s questionnaire ............................................................................. 10

Results from the oral health professional questionnaire ........................................................ 12

Results from the teacher questionnaire................................................................................. 13

Conclusion ............................................................................................................................... 15

Acknowledgements .................................................................................................................. 15

References ............................................................................................................................... 15

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Executive Summary FDI rolled-out the first SAW project in India in 2015, and the second was run in 2016 in Brazil, reaching a total 7,500 children and over 200 school teachers from 69 schools. In 2018, partnering with 3M Oral Care, FDI implemented Smile Around the World (SAW) in China by collaborating with the Chinese Stomatological Association (CSA) to increase oral health knowledge and skills among schoolchildren and to improve teaching of oral disease prevention among school teachers and oral health professionals. The programme involved 3,614 children and 90 teachers in five elementary schools and one kindergarten in the provinces of Ningxia, Yunnan and Shaanxi: 1,114 children in Ningxia, 1,500 children in Yunnan, and 1,000 children in Shaanxi.

• Total number of children: 3,614 • Total number of volunteer school teachers: 90 • Total number of volunteer oral health professionals (dentists and dental students):115

List of schools and kindergarten reached:

• Primary School of Yunnan Shifandaxue Fushuxiaoxue, Yunnan Province • Primary School of Tanglai, Ningxia Province • Primary School of Yuehai Yixiao, Ningxia Province • Primary School of Binhe, Ningxia Province • Kindergarten of Daxin, Ningxia Province • Primary School of Fengyinmingde, Shanxi Province

The project provided oral health education materials for children, dentists and teachers, namely posters, booklets, oral health education videos, guidelines for dentists and teachers, and coloured pens for the children. Materials Distributed:

• 35 Posters and 3,020 booklets were available in classrooms and on schools’ bulletin boards • 320 copies of guidelines for oral health professionals and teachers were provided • 3,000 colored pen boxes were provided to children to color-in the booklets

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Introduction FDI World Dental Federation serves as the principal representative body for more than one million dentists worldwide, developing health policy and continuing education programmes, speaking as a unified voice for dentistry in international advocacy and supporting member associations in global oral health promotion activities. As part of its mission, FDI initiated the ‘Smile Around the World (SAW)’ project to deliver oral health education and prevention programmes in partnership with member national dental associations. School-based oral health programmes are the most effective way to reach children, considering the pedagogical environment and the opportunity to reach a large number of children that will benefit from the knowledge provided1. Therefore, SAW aims to raise children’s awareness of oral health in disadvantaged rural and urban communities through engaging cultural and educational programmes in schools.

Implementation design for China

Background The Chinese National Health and Family Planning Commission conducted the 4th National Oral Health Survey in September 20172, which showed that the oral health-related awareness and behaviour of Chinese children has improved to different degrees compared to 10 years ago. However, some challenges remain. The proportion of 5-year-old and 12-year-old children brushing their teeth twice-daily is 24.1% and 31.9% respectively, and the proportion using fluoride toothpaste is 42.1% and 55% respectively. In the same age groups, the proportion of children visiting the dentist for check-ups and preventive care is 40% and 43.2%. It was therefore concluded that more oral health education programmes with higher standards, precision and pertinence are needed to help children build good oral health habits in China. In this regard, FDI and 3M Oral Care partnered to bring the SAW project to China. During the period between March and June 2018, SAW was implemented locally by the Chinese Stomatological Association(CSA) with the support of the 3M China office to increase oral health knowledge and skills among schoolchildren, and to improve the teaching of oral disease prevention to school teachers and oral health professionals. It was also supported by the Disease Control and Prevention Bureau of the National Health Commission, based on the National Children’s Comprehensive Intervention Program in China.

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Scope of content • The programme targeted children, teachers and oral health professionals in three provinces

in China • It provided standard oral health educational courses by distributing SAW booklets and

posters, including: o guidelines for teachers on how to carry out oral health classes and activities o guidelines for dentists for reference and how to train teachers to demonstrate correct

teeth brushing technique • Project managers encouraged school staff to implement oral health education in schools

permanently • Project managers informed parents of the activity in writing and asked them to sign the

informed consent form before activities began

Activities • Launch ceremony • Provide standard oral health education • Give oral health education courses • Demonstrate oral care skills

Project methods and materials The project team (FDI, 3M and CSA) rolled out the project within a 6-month including preparation, implementation and evaluation.

Preparation (Feb - March)•Adaptation of educational material

messages for local needs and translation

•Translation of guidelines•Agreement of timeline

Implementation (March -June)• Launch ceremony (March 20) • Project managers communicated

closely with schools and oral health professionals to ensure the project implementation on site

• Promotion and communication

Evaluation (July)• Analysis of collected data• Discussion of feedback and the

final project report

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Preparation (February – March 2018) • Design of oral health education materials: FDI provided protocol documents including

booklets, guidelines for dentists and teachers, and videos • CSA translated the SAW 7-steps into Chinese • 3M China produced the animation video1 • Weekly tele-conferences were held during the preparation period, and regular calls were held

for monitoring and support during the implementation period

Launch ceremony (March 20, 2018) On World Oral Health Day, March 20th, SAW was launched in Kunming, Yunnan, China2:

• 500 people, including children, participated in the launch ceremony • Prior to the opening ceremony, 300 children sang songs about teeth-brushing. • 3M China donated free prevention products (e.g. White Varnish fluoride treatment and

Sealant) to CSA and Yunnan Dental Hospital at the ceremony, which can be used for children’s dental care

• Around 60 postgraduate and undergraduate students from the Dental School of Kunming Medical University held interactive classes on oral self-care with children in grade 1 and grade 2 (age 6 – 12)

• Over 60 Chinese oral health professionals attended the ceremony and were divided into 10 groups to enter the classroom and interact with students by telling them about oral self-care

• FDI president elect Dr. Seeberger, CSA and 3M executives were interviewed by five main Chinese media outlets.

1 https://www.fdiworlddental.org/smile-around-the-world 2 Video clip of Launch event https://www.fdiworlddental.org/smile-around-the-world

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SAW project implementation (March – June 2018) The programme involved 3,614 children and 90 teachers in elementary schools3 in the provinces of Ningxia, Yunnan and Shaanxi: 1,114 children in Ningxia, 1,500 children in Yunnan, and 1,000 children in Shaanxi.

The project provided oral health education materials for children, dentists and teachers, namely posters, booklets, oral health education videos, guidelines for dentists and teachers, and coloured pens for the children.

Educational messages The SAW booklet includes an educational approach for children and parents, together with the demonstration of oral care skills by oral health professionals onsite. SAW encourages children to follow seven steps for healthy teeth:

1. Brush your teeth twice a day 2. Use a toothbrush, fluoride toothpaste, and clean water 3. Eat your meal and don’t snack 4. Visit your dentist 5. Don’t suck your thumb 6. Mind your teeth 7. Keep away from tobacco and alcohol

SAW encourages parents to practice six ways to protect their children’s oral health:

1. Make sure they brush twice a day with a fluoride toothpaste

2. Help young infants brush their teeth, gently brush very young infant’s teeth for them

3. Give them healthy meals, don’t let them snack between meals

4. Mind their teeth, and take them for a dental check-up once a year

5. Stop them sucking their thumb, as it’s bad for the teeth 6. Warn them about the threat to the teeth from alcohol and tobacco use

3 List of schools and kindergarten reached:

• Primary School of Yunnan Shifandaxue Fushuxiaoxue, Yunnan Province • Primary School of Tanglai, Ningxia Province • Primary School of Yuehai Yixiao, Ningxia Province • Primary School of Binhe, Ningxia Province • Kindergarten of Daxin, Ningxia Province • Primary School of Fengyinmingde, Shanxi Province

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Give oral health education courses All participating schools and classes gave at least one course on oral health, referencing the key points from the dentist and teacher guidelines, “7 Steps to Healthy Teeth” electronic posters, and CSA PowerPoint presentation. The course aimed to help children develop good oral health habits and basic oral care knowledge and skills. Every province also developed their own way of providing the oral health education, such as through school health classes, themed class meetings, etc.

Demonstration of oral care skills Dentists and teachers used the teeth model to demonstrate proper toothbrushing technique and examined children to measure visible plaque index. Students practiced toothbrushing in groups and checked each other’s results using the “Healthy Smile Happy Smile” booklet, which includes colouring activities.

Interaction with parents As homework, children were asked to read the six points from the “Healthy Smile Happy Smile” booklets to their parents (a consent form was signed by parents).

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Other educational material Animated videos were also shared with children during the project implementation to explain the messages easily and clearly. The following videos were used whenever possible:

• FDI Mouth Patrol animated video series • 3M Animation (in Chinese)

Evaluation (July 2018) To evaluate the impact of the project, two separate questionnaires were designed for children, teachers and oral health professionals. Selected participants completed the questionnaire beginning the SAW project and one week after participating in the educational activities.

Data collection A total of 3,614 children aged between six and 12 (1,114 in Ningxia, 1,500 in Yunnan, and 1,000 in Shaanxi) participated in the SAW project together with 90 teachers and 115 oral health professionals (dentists and dental students). CSA sampled 1,940 children, 104 teachers, and 31 oral health professionals to be observed and evaluated. Every province completed the Oral Health Education Activity Registration Form, the project summary, and data entry for two questionnaires (before the start of the programmes and one week after implementation). They submitted the registration form, summary, photos (at least five), videos and database to CSA by mid-July 2018. Then, CSA reported the data collection result to FDI at the end of July 2018.

Questionnaires for children The questionnaires were completed by selected group (1,940 out of 3,614) among those who participated in the SAW programmes and they were designed to assess the oral health knowledge and behaviour of children. The three core questions were to evaluate children’s brushing-frequency behaviour (Table 1) and knowledge about oral health and nutrition (Table 2). There was also a separate survey to ask how children perceived the booklet with simple questions.

Questionnaires for oral health professionals and teachers The questions asked about the accessibility of the project (Q1, Q2, Q3), quality of materials, educational methods and demonstration in classes (Q4, Q5, Q6), and overall satisfaction level (Q7, Q8, Q9).

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Evaluation Analysis Children, teachers and oral health professionals (dentists, school doctors and dental students) involved in this activity completed the questionnaires within one week of the project implementation. All data were collected on time and showed positive impacts.

Results from the children’s questionnaire A total of 1,940 children completed the questionnaire, which was composed of 11 questions.

Brushing-frequency behaviour After the oral health education programmes, there is a statistically significant difference in children brushing teeth more frequently, using fluoride toothpaste and brushing their teeth at better times compared to before the intervention. 83.3% of children said they brush their teeth twice and more after participating in the SAW programmes. This demonstrates that many children are committed to change their oral care behavior after participating in the SAW project and learning how to prevent oral disease and underlines the effectiveness of such a programme Table 1: Brushing-frequency behavior

BEFORE AFTER

Q1. How many times do you brush your teeth?

Not every day 120（6.2%） 80（4.1%） Once 443（22.8%） 228（11.8%） twice and more 1343（69.2%） 1616（83.3%） None 29（1.5%） 16（0.8%）

Q4. Do you use fluoride toothpaste?

Every day 556（28.7%） 999（51.5%） Sometimes 494（25.5%） 459（23.7%） Seldom 363（18.7%） 291（15.0%） Don’t know 521（26.9%） 190（9.8%）

Q5. When you brush teeth, does it bleed?

Sometimes 722（37.2%） 755（38.9%） Usually 113（5.8%） 110（5.7%） Never 1051（54.2%） 1040（53.6%） Don’t remember 44（2.3%） 35（1.8%）

Q10.When do you brush your teeth every day?

Before breakfast 1602（82.6%） 1542（79.5%） after breakfast 296（15.3%） 424（21.9%） after lunch 391（20.2%） 516（26.6%） at night, and eat after brushing teeth

101（5.2%） 116（6.0%）

at night, and never eat after brushing teeth

1309（67.5%） 1389（71.6%）

other time 92（4.7%） 74（3.8%） never brush teeth 15（0.8%） 8（0.4%）

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Knowledge about oral health and nutrition SAW made a great impact on children’s knowledge about oral health. After the programme, 99.1% of children believed that it is very important to brush their teeth every day and 95.5% expressed that it is necessary to check their teeth regularly. Also 61.9% children recognized bleeding while brushing teeth is a sign of gum inflammation following the intervention. Table 2: Knowledge about oral health and nutrition

BEFORE AFTER

Q2. Do you think it’s important to brush teeth every day?

Important 1881（97.0%） 1922（99.1%） Not important 26（1.3%） 7（0.4%） Don’t know 26（1.3%） 11（0.6%）

Q3. How do you brush your teeth?

Transverse brushing 820（42.3%） 443（22.8%） Vertical brushing 669（34.5%） 1011（52.1%） Circle brushing 388（20.0%） 452（23.3%） Don’t know 56（2.9%） 34（1.8%）

Q6. What does it mean if it bleeds when you brush your teeth?

It’s normal 252（13.5%） 196（10.1%） Gum inflammation 821（42.3%） 1200（61.9%） I brush too hard 593（30.6%） 393（20.3%） Don’t know 259（13.4%） 149（7.7%）

Q7. What’s the effect of pit and fissure sealing?

To prevent decay 1082（55.8%） 1390（70.6%） To prevent periodontal disease

167（8.6%） 131（6.8%）

To prevent other dental diseases

214（11.0%） 179（9.2%）

Don’t know 470（24.2%） 258（13.3%）

Q8. Do you think it is necessary to check teeth regularly?

Yes, it is necessary 1778（91.6%） 1852（95.5%） No, it’s not necessary 91（4.7%） 58（3.0%） Don’t know 64（3.3%） 27（1.4%）

Q9. Do you eat snacks between main meals? Yes, I do 108（5.6%） 96（4.9%） No, I don’t 1281（65.5%） 1472（75.9%） Sometimes 553（28.5%） 369（19.0%）

Q11. Which kind of foods are not good for teeth?

Vegetable 106（5.5%） 59（3.0%） Fruit 93（4.8%） 88（4.5%） Candy and cookies 1656（85.4%） 1738（89.6%） Carbonated beverages 1594（82.2%） 1639（84.5%）

Students’ acceptance for oral health education materials More than 90% of children liked the SAW booklet and 80% said the contents are easy to understand. This shows the SAW messages were well received by the majority of children, leading to improved oral health behaviours.

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Table 3: Students’ acceptance of oral health education materials Acceptance

Q1. Did you receive the “Healthy smile happy smile” booklet?

Yes, I do No, I haven’t I forget 1908（98.4%） 20（1.0%） 12（0.6%）

Q2. Do you like this booklet Yes, I like it Just so so No, I don’t like it 1727（89.0%） 156（8.0%） 49（2.5%）

Q3. Is it easy to understand the contents of this booklet?

Yes, it is easy to understand Just so so No, it’s hard to

understand 1544（79.6%） 304（15.7%） 83（4.3%）

Results from the oral health professional questionnaire Every province worked with oral health professionals, including school doctors, volunteer dentists and dental students, to train school teachers and provide dental check-ups for children. They also demonstrated oral care skills in the classrooms. In total, 115 oral health professionals participated and 31 completed the questionnaire, giving positive feedback on SAW teaching materials and its accessibility to children. Almost everyone agreed the objectives of the project were clearly defined and appreciated the drawing activities designed to engage the children. According to the oral health professionals, through the online and offline educational materials, children easily understood the SAW messages. Table 4: Accessibility of the project

Strongly agree Agree Disagree Strongly disagree

Q1. The objectives of the project were clearly defined 29（93.5%） 2（6.5%） 0（0） 0（0） Q2. The drawing activities were engaging for the

children and facilitated the educational process 29（93.5%） 2（6.5%） 0（0） 0（0）

Q3. The educational sessions for the children were easy to understand 30（96.8%） 1（3.2%） 0（0） 0（0）

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All respondents appreciated the educational programmes and agreed with the methods, in particular the manner in which the oral health educational programmes were conducted in the classrooms. table 5: Quality of materials, educational methods and demonstration in classes

Strongly agree Agree Disagree Strongly disagree

Q4. The project materials (booklets, posters, etc.) were adapted to the children 29（93.5%） 2（6.5%） 0（0） 0（0）

Q5. The educational methods used by trainers were satisfactory 29（93.5%） 2（6.5%） 0（0） 0（0）

Not useful Useful Very Useful Q6. How would you describe the oral health

education program conducted in the classrooms?

0（0） 7（22.6%） 24（77.4%）

FDI is pleased to see that the majority of people were satisfied to participate in the programme and reported how much children appreciated it. Table 6: Overall satisfaction level

≤6 7 8 9 10 Q7. What is your satisfaction level with

your participation in the programs? * 0（0） 0（0） 1（3.2%） 3（9.7%） 27(87.1%）

Q8. What is your satisfaction level with the participation of the children in the programs?

0（0） 0（0） 1（3.2%） 2（6.5%） 28（90.3%）

Strongly agree Agree Disagree Strongly

disagree

Q9. The objectives of the education program were reached 23( 74.2%） 8（25.8%） 0（0） 0（0）

* 0-10 represents satisfaction, 0=not satisfy, 10=very satisfy, ≤6 represents 0-6

Results from the teacher questionnaire Every province selected school teacher to complete the survey after the event. In total, 104 completed the questionnaire. Every teacher agreed that the objectives of the project were clearly defined and appreciated the drawing activities designed to engage the children. Like oral health professionals, teachers expressed that children easily understood the SAW messages. Table 7: Accessibility of the project

Strongly agree Agree Disagree Strongly disagree

Q1. The objectives of the project were clearly defined 80（76.9%） 24（23.1%） 0（0） 0（0）

Q2. The drawing activities were engaging for the children and facilitated the educational process

69（66.3%） 35（33.7%） 0（0） 0（0）

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Q3. The educational sessions for the children were easy to understand 72（69.2%） 32（30.8%） 0（0） 0（0）

All respondents appreciated the educational materials and agreed with the methods used by the trainers. Teachers were less supportive of the oral health education program than oral health professionals however. it will be further studied in the next SAW programme by including a comments section to ask for an elaboration if answering ‘not useful’. Table 8: Quality of materials, educational methods and demonstration in classes

Strongly agree

Agree Disagree Strongly disagree

Q4. The project materials (booklets, posters, etc.) were adapted to the children 76（73.1%） 28（26.9%） 0（0） 0（0）

Q5. The educational methods used by trainers were satisfactory 70（67.3%） 34（32.7%） 0（0） 0（0）

Not useful Useful Very Useful

Q6. How would you describe the oral health education program conducted in the classrooms? 20（19.2%） 23（22.1%） 60（57.7%）

The majority of teachers were happy to participate in the programme and observed children being well engaged in the programme. Almost every teacher agreed the objectives of the programme were well achieved. Table 9: Overall satisfaction level

≤6 7 8 9 10 Q7. What is your satisfaction level with your

participation in the programs? * 4（3.8%） 4（3.8%） 13（12.5%） 2（1.9%） 81（77.9%）

Q8. What is your satisfaction level with the participation of the children in the programs?

3（2.9%） 7（6.7%） 10（9.6%） 2（1.9%） 82（78.8%）

Strongly agree Agree Disagree Strongly

disagree

Q9. The objectives of the education program were reached

73（70.2%） 29（27.9%） 2（1.9%） 0（0）

* 0-10 represents satisfaction, 0=not satisfy, 10=very satisfy, ≤6 represents 0-6

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Conclusion Smile Around the World in China made a significant change in children’s oral health behavior and knowledge. The programme involved oral health professionals, teachers and parents who will enable the ongoing encouragement of children to take care of their oral health afterwards. It also created opportunities for local authorities, ministries and media to work together and spread the important message of oral health to the public. Chinese health authorities and hospitals showed great interest and supported the activities throughout the SAW project implementation. Major Chinese media outlets were also present and released continued news around it. FDI strongly believes that good oral hygiene learned at an early age will help good oral health through their life-course. The success of SAW in China confirms the value of such programmes and demonstrates the importance of rolling-out as many similar initiatives as possible around the world Please visit FDI website4 to see the video of SAW in China and to learn more about Smile Around the World.

Acknowledgements FDI would like to thank 3M for its support to the Smile Around the World project in China and the Chinese Stomatological Association who led the roll-out of the project. Special acknowledgements to Ms Cherry Lu from 3M, Dr Liu Yi, Ms Xuenan Liu, Mrs Alice Yilan Jiang from CSA and Mrs Tina Hong Kaiser from FDI.

References 1. Melo P et al. The effectiveness of the Brush Day and Night programme in improving children’s

toothbrushing knowledge and behaviour. Int Dent J; 68: 7–16. 2. Zhou X et al. Oral health in China: from vision to action. Int J Oral Sci 2018; 10: 1.

4 Video clip of SAW https://www.fdiworlddental.org/smile-around-the-world