Effectiveness of an Interactive School-Based Oral Health Education Program in Reducing Periodontal Disease Among Palestinian Adolescents: A Double-Blinded Intervention Study
Phase: NA
Conditions: Periodontal Diseases
Sponsor: Al-Quds University

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Study Protocol 
 
Official Title: Effectiveness of an Interactive School-Based Oral Health Education 
Program in Reducing Periodontal Disease Among Palestinian Adolescents: A 
Double-Blind Intervention Study 
NCT Number: Pending 
Document Date: March 1, 2024 
Sponsor: Al-Quds University 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Introduction 
Periodontal disease (PD) is a prevalent and preventable oral health issue that has a 
significant impact on adolescents globally. In Palestine, particularly among school-aged 
youth, the rates of gingivitis and calculus are concerningly high, compounded by limited 
access to preventive oral health initiatives. Adolescents are particularly susceptible to PD 
due to various behavioural, hormonal, and dietary influences. Implementing school-based 
oral health education is a cost-effective and scalable approach to enhance students' 
knowledge, attitudes, and practices regarding oral hygiene.  
 
Primary Aim of this study  
To evaluate the effectiveness of a two-month interactive school-based oral health education 
program in reducing periodontal disease among 15-year-old students in Nablus City, 
Palestine, using clinical indices such as the Community Periodontal Index for Treatment 
Needs (CPITN) and the Simplified Oral Hygiene Index (S-OHI). 
 
Secondary Aims 
To assess the effect of the intervention on students’ oral hygiene practices, including 
brushing frequency, technique, and duration. 
 
To evaluate changes in dietary habits following the intervention, particularly regarding 
breakfast consumption and intake of nutritious foods. 
To examine changes in smoking behaviours, including cigarette and waterpipe use, among 
students exposed to the educational sessions. 
Study design 
A pre-test/post-test experimental design was utilised.  
The study adopted an interactive educational approach to teach oral health self-care. This 
method actively engaged participants through two-way communication, practical 
demonstrations, and hands-on activities. 
 

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Sample techniques and process 
This study employed a multistage sampling technique to ensure a representative sample of 
schools and students from Nablus City. Schools and students were selected using a 
stratified simple random sampling method. This randomness in selection helped create 
comparable groups, thereby reducing potential biases and confounding factors that could 
influence the relationship between the intervention and outcomes.  
 
Table 1. Geographical Distribution and Proportional Sample Allocation of Schools in 
Nablus 
Area 
Total 
Schools 
Proportion 
of Total 
Sample Size 
(Proportional) 
East 
Nablus 
27 
41.5% 
6 
Central 
Nablus 
25 
38.5% 
6 
West 
Nablus 
13 
20.0% 
3 
Total 
65 
100% 
15 
 
To ensure proportional representation, schools were evenly selected from three 
geographical areas of Nablus (East, Central, and West), corresponding to the number of 
schools in each area (Table 1). The Epi Info program was used to calculate the sample size 
based on schools with 9th-grade classes (East = 27, Central = 25, West = 13). A total of 15 
schools were selected: 6 from East Nablus, 6 from Central Nablus, and 3 from West Nablus. 
The final sample included 10 governmental schools and 5 private schools, ensuring 
proportional distribution across the city. 
Schools were eligible for inclusion if they had 9th-grade classes, were feasible for 
participation in the study and data collection and implemented an appropriate consent 

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process for students and their parents. According to the educational directorate’s records 
for 2024, Nablus City had 2832 9th-grade students in governmental schools (males = 1360, 
females = 1472) and 737 students in private schools (males = 434, females = 303). 
The G*Power program was used to estimate the required sample size for the study, 
following the guidelines of Kang (2015, 2020). The effect size was set at dz = 0.5, with an 
alpha error probability (α) of 0.05 and a study power of 90% (1 - β).  
Based on these calculations, 536 students from intervention schools and 410 students from 
control schools were required to obtain accurate and meaningful data.  
 
Clinical Screening 
In this study, the Community Periodontal Index for Treatment Needs (CPITN) was used to 
assess the prevalence of periodontal disease (PD) among 9th-grade students before and 
after the intervention. For adolescents, CPITN scores 0, 1, and 2 are used to assess 
gingivitis: 
 
Score 0: Healthy gingiva 
 
Score 1: Gingival bleeding observed after gentle probing 
 
Score 2: Presence of supra or sub-gingival calculus 
For adults, CPITN includes the following scores for periodontitis: 
 
Score 3: Pathological pockets measuring 4 to 5.99 mm deep 
Score 4: Pathological pockets measuring 6 mm or deeper 
Each sextant of the mouth examined was assigned a code number, with the index teeth 
representing each sextant: 16, 11, 26, 36, 31, and 46 (22). 
 
The Oral Hygiene Index-Simplified (OHI-S) was used to determine the oral hygiene status 
of the subjects. This index consists of two components: debris and calculus, each with a 
possible score range of 0 to 3. The amounts of calculus and debris were assessed by 
examining the facial surfaces of teeth numbers 11, 16, 26, and 31 and the lingual surfaces 
of teeth 36 and 46. The scores for calculus and debris were added together and divided by 
the number of examined surfaces to calculate the OHI-S score for each individual. 
 

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In the pilot phase of the study, the Interclass Correlation Coefficient (ICC) was calculated 
to assess the reliability of the clinical measurements. A total of 20 students were examined 
five times by five data collectors, resulting in ICC values of 0.83 for CPITN and 0.98 for 
OHI-S, indicating high reliability.  
 
Instrument Development 
The questionnaire utilised in this study was adapted from existing literature with 
modifications to align with the study's primary objective. The secondary aim was to 
evaluate the impact of the interactive oral education program on students' oral hygiene 
practices, dietary habits, and smoking behaviours two months after the implementation of 
the educational sessions. Initially, the questionnaire was developed in English and later 
translated into Arabic. To ensure accuracy, the translation was validated through a back-
translation process from Arabic to English before being administered as a pre-test. 
The questionnaire consisted of pretested standardised closed-ended questions that were 
assessed for face and content validity by three experts in the field. It was divided into five 
sections: 
1. Student Background: This section included questions about the type of school 
(governmental or private) and the school system. 
2. Family Background: The questions covered family size, parents' educational and 
occupational status, and the family’s economic status. 
3. Oral Hygiene Practices: This section addresses the frequency and technique of 
tooth brushing. 
4. Dietary Habits: Questions focused on the frequency of breakfast consumption per 
week and the daily intake of nutritious versus non-nutritious foods. 
5. Smoking Behaviours: This section assessed the frequency of cigarette and water 
pipe smoking and the number of cigarettes consumed. 
The questionnaire's internal consistency was also evaluated using Cronbach's alpha, 
yielding a reliability coefficient of 0.967 for the 47 items tested. 
The questionnaire was administered through direct interviews with individual students. All 
participants completed the questionnaire and underwent clinical examinations, resulting in 

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a 100% response rate. The questions in the questionnaire were designed to align with the 
topics covered in the educational program. 
 
Data Collection Processes  
The Al-Quds Committee for Ethical Considerations approved this study (REF.13/24). 
Consent forms were distributed to students, and their approval was sought before data 
collection began. 
The researcher trained five dentists to conduct interviews and dental examinations, 
ensuring the data collection process was standardised and calibrated. Training sessions for 
the data collectors were held every 15 days throughout the research period to maintain 
consistency and accuracy in data collection. 
 
During the baseline phase, all participants were provided with a comprehensive 
explanation of the study. Baseline data were collected in March 2024. The selected 
participants were randomly divided into intervention and control groups, ensuring that both 
groups were matched by age and gender. The control group received one oral educational 
session, while the intervention group participated in six sessions. The educational sessions 
were held every 10 days over two months. 
After two months of interactive education, participants were re-examined and interviewed. 
Follow-up data were collected in the same schools using the same dental examination 
measures and questionnaires used during the baseline phase. 
 
Intervention Description  
The oral education program in this study focused on (PD). It aimed to equip participants 
with the knowledge and skills to understand, manage, and prevent complications associated 
with periodontal conditions. The program was adapted from previous studies, with 
modifications made to suit the specific objectives of this research. 
The educational content was based on the standard guidelines set by the World Health 
Organization. The oral education sessions lasted between 30 and 45 minutes and employed 
an interactive approach, incorporating various audio-visual aids such as dental forms, 

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models, charts, posters, and plaster models (Table 2). These materials were designed to 
engage participants actively, fostering a deeper understanding of oral health practices 
 
Table (2): Educational Sessions Program 
Session 
No. 
Session Title 
Duration & 
Group Size 
Learning 
Objectives & 
Content 
Teaching 
Methods 
Instructional 
Tools 
Evaluation 
Strategy 
1 
Anatomy & 
Physiology of the 
Oral Cavity and 
Clinical 
Presentation of 
Periodontal 
Disease 
45–60 
minutes, 
30–35 
participants 
Objectives: 
Identify the major 
anatomical 
structures of the 
oral cavity; 
Explain the normal 
function of 
periodontal tissues 
Content: Overview 
of teeth, gingiva, 
periodontal 
ligament, alveolar 
bone; Signs and 
clinical 
presentation of 
periodontal disease 
(PD) 
Interactive 
lecture & 
Q&A 
Smartboard, 
photographs, 
PowerPoint, 
dental models 
Prepare a brief 
report on a 
family 
member’s oral 
condition 
2 
Prevention and 
Treatment of 
Periodontal 
Disease 
45–60 
minutes, 
30–35 
participants 
Objectives: 
Describe primary 
preventive 
measures against 
PD; Compare non-
surgical treatment 
options 
Group 
discussion 
& live 
demonstrati
on under 
supervision 
Whiteboard & 
markers, 
photographs, 
PowerPoint 
Compile a list 
of barriers to 
effective oral 
hygiene 

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Content: Oral 
hygiene 
techniques: 
brushing, flossing, 
mouthwash; 
Professional 
measures: scaling, 
polishing, fluoride 
application 
3 
Maintenance and 
Follow-Up of 
Preventive 
Measures 
45–60 
minutes, 
30–35 
participants 
Objectives: 
Outline a 
maintenance 
schedule for 
periodontal health; 
Apply problem-
solving strategies 
to common 
barriers 
Content: Recall 
intervals and re-
evaluation 
protocols; 
Strategies for 
overcoming 
patient-identified 
maintenance 
barriers 
Brainstormi
ng & group 
discussion 
Photos, 
preventive 
devices 
(toothbrush, floss, 
mouthwash), 
posters, puzzles 
Develop a list 
of solutions to 
overcome 
identified 
barriers 
4 
Daily Preventive 
Practices 
45–60 
minutes, 
30–35 
participants 
Objectives: 
Practice correct 
brushing and 
interproximal 
cleaning 
techniques; 
Live 
demonstrati
on under 
supervision 
Whiteboard, 
PowerPoint, tooth 
models, 
preventive 
Create a 
resource list for 
daily oral-health 
information 

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Reinforce daily 
oral-care routines 
Content: Live 
demonstrations of 
toothbrush and 
floss use; Hands-
on practice with 
models and peer 
feedback 
& mini-
lecture 
devices (brush, 
floss, mouthwash) 
5 
Smoking and Its 
Harmful Effects 
on Periodontal 
Tissues 
45–60 
minutes, 
30–35 
participants 
Objectives: 
Explain how 
tobacco smoking 
damages 
periodontal tissues; 
List short- and 
long-term oral 
health effects of 
smoking 
Content: Chemical 
effects of nicotine 
and tar; 
Epidemiology of 
PD in smokers vs. 
non-smokers 
Live 
demonstrati
on under 
supervision 
& lecture 
Colorful 
PowerPoint slides 
with photos 
Compile a 
resource list on 
the oral-health 
impacts of 
smoking 
6 
Nutrition and Its 
Impact on 
Supportive 
Periodontal 
Tissues 
45–60 
minutes, 
30–35 
participants 
Objectives: 
Analyze how 
different foods 
affect periodontal 
health; 
Recommend 
dietary 
adjustments to 
support 
Group 
discussion 
& live 
demonstrati
on 
Colorful 
PowerPoint slides 
with photos 
Prepare a list of 
dietary 
guidelines and 
resources on 
nutrition and 
oral health 

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periodontal tissues 
Content: Role of 
sugars, acids, and 
antioxidants; 
Nutritional 
guidelines and 
examples of tooth-
friendly diets