Dental Immunisation: Evaluation of a Community-Driven Strategy for Addressing Caries Burden in Indonesian School Children

ABSTRACT

Background

The World Health Organization (WHO) has long emphasized the significance of oral health as a key component of overall health and well-being. Global oral health disparities, often exacerbated by a lack of access to essential dental care, present a challenge that resonates on a worldwide scale.

Aims

This study explores how community-driven strategies can actively support the global oral health goals set forth by the WHO.

Methods

The RE-AIM framework was applied to evaluate a “Dental Immunisation” program in Bali, Indonesia. An evaluation of the Reach, Effectiveness, Adoption, Implementation, and Maintenance of the program was conducted.

Results

Dentists collaborated with local communities to co-create oral health initiatives targeting school children and their families. A total of 210 children from two schools were enrolled in the program, with a mean age of 9.4 years. Collaborative oral health workshops with local staff and families amplified the impact of school-based initiatives with 50 parents and teachers also participating in oral health promotion activities. At baseline, 60% of Grade 1 children presented with carious lesions, averaging 2.3 affected teeth per child. No children had previously received any restorative care. Post-intervention, 150 teeth were restored using ART, with all participants receiving toothbrushes and application of fluoride varnish.

Conclusion

The “Dental Immunisation” program demonstrates a potential paradigm shift in community-based dental care and prevention strategies. By bridging local practices with global objectives, a more interconnected and collaborative approach to tackling oral health disparities may be achieved. Ongoing longitudinal studies will be essential to validate and expand on the findings from this project.

KEYWORDS:

• Dental immunisation
• dental caries
• Indonesia
• children
• atraumatic restorative treatment
• community oral health promotion

Introduction

Oral health disparities persist as an enduring challenge in global public health, disproportionately affecting vulnerable populations across the world. Traditionally, the dental profession has relied on sporadic voluntourism and outreach programs to provide emergency care and bridge the gaps in service delivery. Although, outreach dental programs, deliver crucial care to underserved populations, these programs face significant challenges.^1–3 They often provide a limited range of services due to constraints in funding, equipment, or skilled personnel and struggle with sustainability and continuity of care.^3,4 The temporary nature of some outreach programs can lead to challenges in maintaining high-quality care. There may be a lack of comprehensive patient records, hurried services due to time constraints, or inexperienced volunteers operating outside their comfort zone. Additionally, cultural and language barriers can hinder effective communication, a core component of successful treatment. While addressing urgent dental needs, these programs may also inadvertently discourage the development of local healthcare infrastructure and undercut the value of local dental practitioners. This raises concerns about their long-term impact on community self-sufficiency and the local dental infrastructure. However, with strategic planning and active engagement of local communities, outreach programs can lead to community empowerment, enhance oral health literacy, and bolster local capacity, thereby fostering a more sustainable and impactful approach to healthcare.¹ Several programs across the globe have shown successful outcomes in improving oral health among vulnerable cohorts. Many of these have been integrated into University curricula to enhance student training,^5–7 increase reach of services through mobile clinics^8,9 and build local capacity and community partnerships.¹⁰

Nevertheless, the actions of voluntourism despite being founded on altruistic ideals, have been called into question given their inability to create lasting and sustainable change.¹¹ Therefore, we must pause to reflect on a pivotal question that transcends both borders and local contexts: “Why should dental professionals care about global oral health, and how can they actively contribute to fostering enduring positive change?” The World Health Organization (WHO) oral health agenda, strategy, and action plan underscores the pivotal role of oral health in overall health and well-being, acknowledging that oral diseases are a substantial global burden, impacting millions of individuals and posing a significant economic and social challenge. The WHO’s oral health agenda encapsulates several key principles and objectives:

1. Promotion of Equity: a commitment to reducing oral health inequalities by addressing disparities in access to oral health services and preventive measures among different population groups.

2. Prevention-Centric Approach: Emphasizing prevention as a primary approach to oral health, the WHO advocates for community-based programs that target risk factors, promote good oral hygiene practices, and increase awareness.

3. Integration into Universal Health Coverage: The WHO aligns oral health with the broader goal of achieving universal health coverage, emphasizing the importance of oral health services as an integral component of comprehensive healthcare.

4. Collaboration and Capacity Building: International collaboration and capacity-building initiatives are encouraged to strengthen oral health systems, enhance healthcare workforce capabilities, and facilitate knowledge sharing.

This report highlights how a local collaboration with a nonprofit organization veered away from the conventional charity driven approach of care to adopt a more sustainable and globally relevant approach to oral health. It describes a novel “Dental Immunisation” program with the aim to:

1. assess the prevalence and severity of dental caries among school children in Bali, Indonesia and

2. evaluate the reach, effectiveness, adoption, implementation, and planned maintenance of the “Dental Immunisation” program.

Context

Dental caries prevalence among school children poses a considerable public health challenge worldwide, with a particularly pronounced impact in developing countries such as Indonesia. The Indonesian Ministry of Health’s National Oral Health Survey has unveiled alarmingly high rates of dental caries underlined by 90% of children having caries by five years of age with an average dmft of 8.1.^12,13 Studies investigating early childhood caries in Indonesia have identified several risk factors including low maternal education,¹⁴ limited maternal oral health awareness,¹⁵ high consumption of cariogenic foods¹⁶ and irregular tooth brushing during childhood.¹⁵ The pervasive nature of caries across all regions in Indonesia, along with the persistence of these risk factors, underscores the critical need for effective interventions to address this escalating burden. Moreover, in the face of limited resources, it becomes imperative to optimize the use of existing services to achieve the greatest possible impact in managing caries on a community level.

A visiting dentist traveling to Bali had heard that children in the region had a high prevalence and severity of dental caries. The dentist sought to start a pro bono program by providing ad hoc dental services in collaboration with Bali Sehat, a Non-Profit Organization operating in the region. Bali Sehat was founded in 2012 by Australian pensioners Sue and Ray Bishop. The organization has been committed to delivering free medical care to disadvantaged areas, particularly focusing on East-Karangasem. External agencies often hold the locus of control and despite being able to provide much needed services often struggle to create lasting changes in the oral health of vulnerable communities.^2,11 Programs with direct community ownership and the provision of culturally secure care are not only more appropriate but more likely to result in sustainable change.¹⁷

To this end, rather than rely on adhoc voluntourism, local experts in dental public health were consulted in order to empower both schools in the region and the Bali Sehat team to provide a more holistic oral health promotion program. The “Dental Immunization” program, introduced in this study, is a collaborative partnership inspired by medical immunization principles. Immunization is the process whereby a person is made resistant to a disease, in this context the term immunization is used metaphorically to describe comprehensive community-level strategies aimed at providing resistance to dental caries. This usage intends to parallel the preventative essence of traditional immunization, emphasizing a proactive public health approach to dental health. The “Dental Immunization” program encompasses a multi-faceted strategy to address the burden of dental caries on a community level including parental and stakeholder education, caries risk assessment, motivational interviewing, plaque disclosing, supervised school toothbrushing and provision of atraumatic restorative treatment.

Methods

The RE-AIM framework¹⁸ was used to assess the “Dental Immunisation” program’s impact on elementary school children within the Karangasem district of Bali from its inception in December 2022. The RE-AIM dimensions of Reach, Effectiveness, Adoption, Implementation, and Maintenance were operationalized to address specific research questions. As a feasibility study, a convenience sample of two elementary schools in Bali were chosen and invitations to participate were sent to parents of all school children. Caries risk assessment (using the ‘Irene Donut’ system,¹⁹ plaque disclosing (GC Tri Plaque ID Gel™), school toothbrushing and caries control (Atraumatic Restorative Treatment utilizing Fuji IX, GC Corp) were performed in April 2023. The Irene Donut is a tool for assessing and simulating caries risk, based on risk factors validated within the Indonesian population.¹⁹ It methodically guides parents through a series of questions such as whether their child sleeps with a milk bottle or how often their child brushes their teeth (Figure 1). The responses generate a donut-shaped graph depicting the child’s risk of caries. Parents can then identify and commit to modifying certain risk factors, an action that updates the donut graph to reflect these changes (Figure 1). This interactive process adheres to the tenets of self-efficacy and motivational interviewing, offering parents an active role in managing their child’s oral health. Fluoride varnish (MI Varnish GC Corporation, Tokyo, Japan) and in-person plaque disclosing and toothbrushing demonstrations were repeated at 3-monthly intervals. The study was conducted in full accordance with international ethical principles, including the World Medical Association Declaration of Helsinki (2008) and received approval from the Indonesian Ministry of Health

Figure 1. Irene donut system for caries risk assessment and self-managed goal setting. Left: questions guiding parents through caries risk factors right: child’s caries risk shown as a ‘donut’ with the lower thumbnails showing modifiable and non-modifiable risk factors.

Reach and Feasibility

The reach of the program was gauged by quantifying the number, proportion, and representativeness of individuals and families engaged with the program. Participant recruitment was examined in terms of its comprehensiveness and inclusivity within the elementary schools. The demographic characteristics of participants was also assessed to ensure a diverse and representative sample of children by age and gender. In the “Dental Immunisation” program, feasibility was prospectively assessed using a multifaceted criterion prioritizing community engagement, scalability, capacity building, methodological robustness, and compliance with ethical and regulatory standards. Community engagement and cultural relevance were ensured through collaborative partnerships with Bali Sehat and local dental health experts, coupled with active participation from parents and school authorities, to meet the community’s unique cultural and oral health needs. Scalability and efficient resource utilization were addressed by integrating the program into existing school infrastructures and adopting cost-effective dental health strategies, such as the ‘Irene Donut’ system and ART. Capacity building and sustainability were facilitated by training local dental professionals and embedding oral health practices into the school routine. The program’s adaptability and impact were systematically evaluated using the RE-AIM framework, ensuring a methodologically robust approach that could respond dynamically to evolving community needs. Furthermore, adherence to ethical standards and securing local regulatory approvals, particularly from the Indonesian Ministry of Health, were paramount to ensure the program’s ethical soundness and community acceptance.

Effectiveness

To understand the current dental health landscape, identify potential areas of intervention, and inform the suitability and relevance of the program a baseline survey oral health survey was conducted in December 2022. A simplified version of the World Health Organization’s oral health basic survey was used.²⁰ This approach ensures that the program is appropriately targeted and aligns with community needs. A formal pre- and post-intervention and outcome evaluation will be conducted after completion of the program in 2024. Children were examined within the school setting using a battery powered mouth mirror-light and a blunt-ended probe by trained general dentists. DMFT/dmft scores were calculated and categorized by school grades and decay levels (D1: carious lesion in enamel, D2: carious lesion in dentin and D3: carious lesion in pulp). The determination of D1 (caries lesion in enamel) and D2 (caries lesion in dentine) was conducted through visual observation with a headlamp and consideration of associated symptoms as no radiographs were able to be taken in the field. Additional measures included H: stained pit and fissure system, W: white spot lesion, R: carious root stump, A: abscess, and P: existing fissure sealant.

A team briefing and formal calibration was completed the day before the program was implemented. The calibration process was carried out with the participation of six practitioners, including one local practitioner. The dentists were trained and calibrated by using both intra-oral photos and real patients for diagnosis with good inter-examiner reliability (Cohen Kappa = 0.9). Calibration included the application of tri plaque, caries diagnosis, performing fillings, administering LSTR treatment, and applying MI varnish with guided case discussions.

Adoption

Adoption was measured by quantifying the number, proportion, and representativeness of students and families who actively embraced the program’s interventions. The utilization of parental education sessions, plaque disclosing, caries risk assessment, motivational interviewing, and various preventive measures such as fissure sealants, fluoride varnish, and ART were assessed to determine the extent to which these strategies were adopted. As the focus of this program was school children, we recognized that parents play a pivotal role as the primary decision-makers for their children. Therefore, parents must grasp the importance of oral health and understand the oral health status of their children. Thorough this program, parents were provided with instructions on assessing caries risk using the Irene donut examination. After understanding the risk, they were guided on how to manage and mitigate risk by choosing appropriate measures including changing modifiable risk factors (Figure 1). These activities took place on the first day, with the anticipation that if parents comprehend the information, they would also encourage and support their children throughout the process. Additionally, parents were encouraged to actively volunteer to continue oral health activities when participating in the children’s brushing sessions at school.

Implementation

The implementation centered on the execution of program activities and strategies. The ‘Irene Donut’ system and the integration of planned interventions into school-based screenings were analyzed to assess how well these strategies were carried out. This will be described using a logic model.

Maintenance

Maintenance focuses on the sustainability and enduring impact of the program with view toward its continued implementation, resource allocation, and community engagement beyond the study period.

Results

Participant Demographics and Reach

A total of 210 children were enrolled across the two schools in this study. Table 1 shows the demographic distribution according to grade, gender and the mean age distribution. The student population was relatively evenly distributed across gender and the six grades, with Grade 3 having the highest enrollment (22%) and Grade 1 the lowest (10%).

Table 1. Demographic characteristics of children in this study.

Grade	Number (%)	Male (n, %)	Female (n, %)	Mean Age
Grade 1	22 (10%)	11 (50%)	11 (50%)	6.1
Grade 2	36 (17%)	22 (61%)	14 (39%)	8
Grade 3	46 (22%)	23 (50%)	23 (50%)	8.5
Grade 4	32 (15%)	15 (47%)	17 (53%)	10
Grade 5	36 (17%)	21 (58%)	15 (42%)	10.9
Grade 6	38 (18%)	23 (61%)	15 (39%)	11.9
Total	210 (100%)	Male: 115 (55%)	Female: 95 (45%)	9.4

Baseline Dental Health Landscape

Table 2 shows the oral health status of children in this study across all grades. 60% of children in Grade 1 presented with carious lesions with an average of 2.3 teeth being affected per child. However, 5% of children in this group had more than seven carious lesions. Moreover, almost every child in grade one presented with a carious root stump.

Table 2. Baseline dental status of children.

	Status of the primary dentition - Mean number of teeth affected per child per grade
Grade	Sound	Pit and Fissure Staining	Incipient Lesion	Enamel Caries	Dentine Caries	Caries into the Pulp	Carious Root Stump	dft
Grade 1	11.8	0.5	0	0.6	0.2	0.4	1.1	2.3
Grade 2	9.8	0.1	0	0.3	0.1	0.1	0.7	1.3
Grade 3	8.3	0.2	0	0.2	0.2	0.3	0.5	1.2
Grade 4	2.8	0	0	0	0	0	0.7	0.8
Grade 5	1.3	0.1	0	0.2	0.1	0.1	0.3	0.7
Grade 6	0	0	0	0	0	0	0.2	0.3
Total	5.4	0.1	0	0.2	0.1	0.2	0.5	1.0

Across all grades essentially no children had received previous restorative care.

Across all age groups 5% of permanent teeth had caries with children in Grade 6 accounting for the majority of this burden (13%).

Program Adoption and Utilization

The collaboration with Bali Sehat, local schools, and Indonesian experts in dental public health was not only a strategic choice but also a reflection of the alignment with the global oral health vision set forth by the World Health Organization (WHO). The success of public health initiatives is often predicated upon their integration with local communities, a principle firmly advocated by the WHO in its global oral health strategy. This strategy emphasizes the significance of community and cultural validation in oral health endeavors, an aspect that was integral to the Dental Immunisation program. Following this and to ensure a holistic approach, the headmasters from both schools, parents and children all participated in the program (Figure 2). A parent and teacher meeting was held with 50 people in attendance including headmasters from both schools and parents of children from grades 1–3. The focus of the session was to educate parents about oral health and its relation to systemic health and performance at school, while also introducing Bali Sehat as the referral pathway for children in need. Activities included an interactive PowerPoint presentation, introduction to the Irene donut caries risk assessment, plaque disclosing application by parents and teachers (Figure 3). The day concluded with a shared commitment and responsibility agreed upon by the school, parents and Bali Sehat to improve the oral health of children.

Figure 2. Parent educational session.

Figure 3. Parents applying plaque disclosing solution.

Implementation Analysis

Formal implementation of the program included i) dental screening of children and triaging to identify level of need ii) plaque disclosing completed by both staff and parents on their children iii) supervised school toothbrushing following plaque disclosing iv) triaging children with carious lesions to receive fissure sealants, atraumatic restorative treatment (ART), lesion sterilization and tissue repair (LSTR) and/or application of fluoride varnish depending on their level of need. LSTR is a non-instrumentation endodontic treatment and was used to manage lesions beyond the scope of ART. In these situations, the pulp chamber was accessed and a triple antibiotic mixture in a propylene glycol was used for the disinfection of pulpal and periapical lesions.²¹ In total 210 children participated all of them receiving toothbrushes and application of MI varnish. A total of 150 teeth were restored using ART within the school setting as seen in Figure 4.

Figure 4. Caries management and atraumatic restorative treatment.

Maintenance and Sustainability

The program is still ongoing with monthly activities prescheduled for both schools including application of fluoride varnish at 3-monthly intervals. Plaque disclosing, toothbrushing demonstration and distribution of oral hygiene kits will continue on a monthly basis to reinforce the dental messages. Supervised school toothbrushing has now been embedded into the school schedule and continues to be monitored by the Bali Sehat team (Figure 5). In the initial year, the funding for this program was provided by Bali Sehat foundation and external donors. However, for the continuation of the program, the schools have agreed to contribute half of the budget, shared by the school and parents. This signifies empowerment and will contribute to the sustainability of the activity. A logic model mapping the inputs, activities, outputs and impact of this program is shown below:

Figure 5. Supervised school toothbrushing.

Discussion

The success of public health initiatives are often predicated upon their integration with local communities.^17,22 The collaboration in this study with Bali Sehat, local schools and Indonesian experts in dental public health underscores the importance of community and cultural validation in service delivery. In evaluating participation metrics, the engagement rates among parents in dental education sessions indicated more than just passive acceptance; they reflected a profound alignment with and ownership of the initiative’s objectives. This observation is in line with the WHO’s emphasis on the sustainability of health interventions when they are co-owned by the community.²³ The WHO recognizes that a community’s vested interest ensures adaptability and resilience, even in the face of potential external challenges such as resource fluctuations or leadership transitions.

The design and final implementation of this program also prompts a reflection on the role of external volunteers. While well-intentioned, a top-down approach in underserved regions can sometimes mask the pivotal role of local involvement. Although providing dental services in areas of unmet need is important, in order to facilitate sustainable change building capacity is more critical.¹¹ This implies the necessity of upskilling local individuals and fostering a co-creation ethos. Such an approach not only amplifies the program’s immediate efficacy but anchors it deeply within the community’s existing infrastructure and value systems.

In the context of the WHO’s global oral health agenda, the Dental immunization program takes on added significance as it aligns with the preventive tenets of immunization. Conceptualizing dental caries management through the lens of immunization is transformative in the promotion of oral health. The “Dental Immunisation” program, as introduced in this study, aligns itself with the preventive tenets of immunization and situates it within a broader health narrative mirroring the WHO’s approach to integrate oral health into overall healthcare. The program began by laying a foundational phase that revolved around educating parents and stakeholders to foster widespread awareness and ownership this resonates with the WHO’s commitment to promoting oral health awareness and preventive measures. This was evident in the program’s holistic approach where headmasters from both schools, parents, and children all participated actively. Mirroring immunization protocols, the program then progressed to phases of assessment and tailored intervention with the use of plaque disclosing being strategically integrated, serving as an analogous procedure to controlled antigen exposure.²⁴ Dental screenings served as the primary diagnostic tool, identifying children’s specific needs. The finding that 60% of children in Grade 1 presented with carious lesions, with an average of 2.3 teeth affected per child, echoes the disparities in oral health seen across the region.¹³ Disturbingly, almost no children had received previous restorative care and carious root stumps were ubiquitous among children at grade 1, reinforcing the severity of disease and the need for early intervention by extrapolating basic principles used in immunization.²⁴

Given the limited access to specialized dental equipment, ART and placement of fissure sealants were the main interventions used, these functioned as the program’s “immunisation agents.” As highlighted in the results 150 teeth were restored using ART, this achievement is amplified by the absence of prior restorative care among this population. These techniques have been used successfully in similar situations in Indonesia.²⁵ A unique component of this program was the execution of monthly evaluations. Much like the boosters in standard immunization regimens, this iterative approach allowed for the consistent monitoring of the children’s dental health and fine-tuning of interventions as required.

To sustain the activities and program, Bali Sehat has a local team that supervises and executes the activities every month. In addition to the intervention school, baseline oral health surveys were also conducted at other schools without any other interventions. The purpose of this is to compare the results and assess the impact of nonintervention in schools. With ongoing reviews and analysis, it is anticipated that the oral health status among the intervention schools will continue to improve seeing a reduction in urgent dental treatment and increased preventive treatments. Furthermore, it is anticipated that other schools will also express interest in participating in the program, potentially leading to a new project for Bali Sehat.

The strengths of the current study include robust community engagement and the systematic implementation of the “Dental Immunisation” concept that has been successfully used in other regions of Indonesia.¹⁹ However, as a feasibility study it is limited by a focus on only two schools which limits the broad applicability of the findings. While this feasibility study’s short-term outcomes are promising, the WHO’s global oral health agenda reminds us of the need for long-term evaluation to ensure the continued success of interventions and community engagement. In reflecting on the outcomes and context of this study, dental professionals may wonder, ‘why should I be invested in global oral health, and how can I make a meaningful impact?’. The role of dental professionals extends beyond performing operative treatments. As content experts, dentists can participate in the co-creation and design of community-based initiatives, while ensuring that these endeavors are informed by context experts within the local communities. This approach not only heightens a program’s immediate impact but firmly embeds it within the existing community infrastructure and value systems. More importantly actively engaging in the transfer of knowledge and skills to local healthcare workers, can enhance the community’s capacity for self-sustained oral health initiatives. Advocating for oral health within their professional circles can raise awareness and mobilize support for global oral health efforts. Staying updated about global oral health trends and best practices is essential for informed decision-making and the implementation of evidence-based interventions. By aligning their efforts with the WHO global oral health agenda, dentists can play a pivotal role in reducing oral health disparities and enhancing the well-being of communities worldwide. This multifaceted approach ensures that their involvement is both meaningful and impactful, addressing the risks associated with poorly structured voluntourism and adhoc outreach work.

Conclusion

This study underscores the significant influence of community involvement in pediatric oral health outcomes. Utilizing an innovative “Dental Immunisation” framework, the study explores how structured, community-centric preventive measures have strong potential to address dental caries on a community level while aligning with the WHO global oral health agenda. The baseline data in this study highlights the pronounced need for such interventions, given almost half of all school children present with dental caries. By placing the community at the forefront of such health initiatives, there is an inherent promise of sustainability and adaptability. The challenge for future research lies in scaling and replicating such endeavors while maintaining the essence of community participation. As we navigate the intricate landscape of global oral health in alignment with the WHO agenda, it becomes paramount to underscore the pivotal role of community engagement and evidence-based interventions. These key elements should serve as the cornerstone of our strategies, ensuring enduring, evidence-driven improvements in oral health outcomes on a global scale.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Irene Adyatmaka

Irene Adyatmaka, born in Papua, graduated in dentistry in 1995 and excelled in dental public health and now manages services for over 10,000 students from 1996 to 2011. She pioneered the Atraumatic Restorative Treatment (ART) approach in Indonesia, completing 2,000+ restorations, and collaborated with WHO’s Prof. Douglas Bratthall on translating the Cariogram into Indonesian. Her research with Mediteam Sweden focused on Carisolv, and she oversaw oral health in 22 government schools. She earned a record-breaking Ph.D. in dental public health within 22 months, receiving cum laude honors and setting an Indonesian record. As a senior researcher at Universitas Indonesia, she developed a nationally adopted school oral health program, UKGS Innovative. Her co-authored book with Dr. Bruce Donoff, “Dental Immunization,” showcases her expertise. Dr. Adyatmaka is also a lecturer in research methodology and GC Indonesia’s Country Manager.

Jilen Patel

Jilen Patel, is a specialist paediatric dentist, senior lecturer at the University of Western Australia and a consultant at Perth Children’s Hospital. For over a decade, Jilen has been involved with providing volunteer dental services to remote Aboriginal communities and has been involved in adapting models of dental care to address areas of unmet need among vulnerable communities. Jilen’s research interests include dental public health and cariology, and he is the clinical lead for the West Australian Early Childhood Dental Program a state-wide initiative aiming to provide universal access to dental care to children under four years of age. His PhD created an evidence-based quality improvement framework for dental care to Indigenous communities and studied the impact of volunteer services to remote communities. He was recently awarded the Australian Dental Association’s outstanding young dentist award for his contributions to the profession.