Uptake of a Multilingual Intervention to Promote Toothbrushing in a Safety-Net Health Care System

Dear Editor,

We read with great interest the article by Ahern et al. on the uptake of a multilingual intervention to promote toothbrushing in a safety-net health care system, recently published in The Annals of Family Medicine (1). As a family physician researchers based in Spain, we would like to offer a perspective on how similar approaches could be implemented within our national health care context, particularly in primary care settings that serve low-income and immigrant populations. The practical design and successful uptake of this intervention align with the increasing attention being paid to oral health promotion within global public health agendas (2).

Ahern et al. demonstrate that the distribution of a low-cost dental kit—comprising a toothbrush, fluoridated toothpaste, and educational material—can be effectively embedded into routine well-child visits. In Spain, primary care teams already conduct structured preventive visits with children at various developmental milestones (e.g., 12 months, 2 years, 4 years), often without direct involvement of pediatric dental professionals. While dental care for children is formally included in the portfolio of services of the National Health System, its implementation varies significantly across autonomous communities, and preventive oral health often remains underprioritized (3). Therefore, empowering family physicians and nurses with simple tools and multilingual materials may help address this gap, especially in underserved or multicultural areas.

Spain, like the United States, faces significant inequalities in oral health. Studies have shown that immigrant children in urban areas such as Barcelona exhibit higher rates of untreated caries and poorer access to dental services compared to native-born children (4). These disparities are not limited to access issues but also include lower oral health literacy among parents from migrant backgrounds (5). Ahern et al. address this issue by including written materials in several languages, an approach that has proven effective in other multicultural health systems and could be adapted to our own, where Arabic, Romanian, and Wolof are among the most commonly spoken minority languages (6).

From a cost-effectiveness standpoint, the integration of oral health promotion into primary care workflows offers a promising avenue for sustainable public health interventions. A systematic review by Rochmah et al. (7) analyzed school-based oral health promotion programs and found that such interventions, including supervised toothbrushing and fluoride application, are not only effective in reducing dental caries among children but also cost-effective in the long term. These findings suggest that similar strategies could be adapted within primary care settings to maximize resource utilization and health outcomes.

In Spain, the integration of oral health into primary care is particularly relevant given the decentralized nature of the healthcare system and the existing infrastructure of primary health centers. A scoping review by Harnagea et al. (8) highlighted that integrating oral health services into primary care can improve access to dental care, especially for underserved populations, and enhance the overall efficiency of healthcare delivery. Implementing such integrated models in Spanish primary care centers could address disparities in oral health access and outcomes.

Moreover, the effectiveness of school-based oral health education interventions has been well-documented (9). A systematic review by Akera et al. (10) demonstrated that these programs significantly improve oral hygiene behaviors and reduce the incidence of dental caries among children in low- and middle-income countries. Adapting these educational strategies within primary care settings, particularly for immigrant and low-income populations in Spain, could further enhance their reach and impact.

In our opinion, taking advantage of the existing primary care infrastructure in Spain to incorporate cost-effective oral health promotion strategies, informed by successful school-based programs and integrated care models, holds significant potential for improving oral health outcomes among children, especially those from immigrant and underserved communities.

REFERENCES

1. Ahern J, Pleman B, O’Connor N, Silk H. Uptake of a Multilingual Intervention to Promote Toothbrushing in a Safety-Net Health Care System. Ann Fam Med. 2024 Mar 1;22(2):173–173.

2. Department of Noncommunicable Diseases, Universal Health Coverage/Communicable and Noncommunicable Diseases. Global oral health status report: towards universal health coverage for oral health by 2030 [Internet]. World Health Organization; 2022. 120 p. Available from: https://www.who.int/publications/i/item/9789240061484

3. Portero de la Cruz S, Cebrino J. Oral Health Problems and Utilization of Dental Services among Spanish and Immigrant Children and Adolescents. Int J Environ Res Public Health. 2020 Jan;17(3):738.

4. Veloso Duran A, Framis-de-Mena B, Vázquez Salceda MC, Guinot Jimeno F. Evaluation and Comparison of Oral Health Status between Spanish and Immigrant Children Residing in Barcelona, Spain. Children. 2022 Sep;9(9):1354.

5. Oliván-Gonzalvo G, de la Parte-Serna AC, Oliván-Gonzalvo G, de la Parte-Serna AC. Prevalence of untreated dental caries in Latin American children in the Spanish child protection system. Iberoam J Med. 2020;2(4):261–7.

6. Watt RG, Daly B, Allison P, Macpherson LMD, Venturelli R, Listl S, et al. Ending the neglect of global oral health: time for radical action. The Lancet. 2019 Jul 20;394(10194):261–72.

7. Rochmah TN, Ramadhani A, Bramantoro T, Permata LG, Tun TZ. Systematic review on cost-effectiveness analysis of school-based oral health promotion program. PLOS ONE. 2023 Apr 20;18(4):e0284518.

8. Harnagea H, Couturier Y, Shrivastava R, Girard F, Lamothe L, Bedos CP, et al. Barriers and facilitators in the integration of oral health into primary care: a scoping review. BMJ Open. 2017 Sep 1;7(9):e016078.

9. Das H, Janakiram C, Kumar V, Karuveettil V. Effectiveness of school-based oral health education interventions among schoolchildren. Int Dent J. 2024 Oct 1;74:S409.

10. Akera P, Kennedy SE, Lingam R, Obwolo MJ, Schutte AE, Richmond R. Effectiveness of primary school-based interventions in improving oral health of children in low- and middle-income countries: a systematic review and meta-analysis. BMC Oral Health. 2022 Jun 29;22(1):264.