Playful and game-based oral health education for children in Latin America

INTRODUCTION

Dental caries remains a frequent condition among children in Latin America. A regional systematic review that pooled studies published in the new century estimated that more than half of the children in Latin America and the Caribbean were affected, with prevalence higher outside Brazil than in Brazil.(1) A regional consensus later described persistent inequalities, a high burden of untreated decay and outdated or absent estimates in several countries.(2,3) Community strategies against caries in the region have centred on fluoride and sealants, while documented interventions that restrict sugar consumption, including educational ones, were scarce.(4)

Teaching oral hygiene is the entry point of most school and clinic programs, and many use games, puppets, stories or comics to hold the attention of children. A review of school-based programs found that traditional education reduced plaque but not gingivitis, and that long-term evidence was missing.(5) Systematic reviews of game-based teaching reported better knowledge and plaque scores than conventional lessons.(6,7) A review of playful interventions aimed at health literacy in children aged 6 to 12 years, in turn, found mostly low methodological quality and no evidence of retention over time.(8) Studies from Latin America appear largely in Spanish and Portuguese, in regional journals and university repositories. No systematic review of this type centred on the region was identified in the searches for this work, and it remains unclear what the region has tested and what its results show.

The objective of this review was to determine whether playful and game-based oral health education improves oral hygiene knowledge, plaque or gingival indices in Latin American children compared with conventional education or no intervention. Four questions organize the work. P1: which playful strategies, populations and settings have been evaluated in Latin America? P2: what changes in oral health knowledge have been reported? P3: what changes in plaque, oral hygiene and gingival indices have been reported? P4: how reliable is the evidence, given the designs and the risk of bias of the studies?

METHODS

RESULTS

Twenty-four studies from seven countries, mostly uncontrolled before-after designs

The searches identified 3,563 records, of which 945 duplicates were removed and 2,618 were screened (Figure 1). Screening excluded 2,524 records, and 94 reports were sought for retrieval; 14 could not be retrieved because the full text and an informative abstract were both unavailable. The remaining 80 reports were assessed, 56 were excluded and 24 studies were included.

The reasons for exclusion at full-text assessment corresponded to the absence of a documented playful component in 26 reports, the absence of a measured outcome in 24 reports, a population outside the scope in 4 reports, the absence of a baseline or comparator in 1 report and an issue dated before 2013 in 1 report. The 4 reports in the population group comprised two reports of one parent-directed program in Peru, whose dramatizations were delivered to caregivers, one study of teachers and one study with participants aged 6 to 32 years that could not be separated.

The included studies (Table 1) were published from 2013 to 2025, 12 of them in 2013 to 2018 and 12 in 2019 to 2025. Brazil contributed 12 studies, Peru 4, Colombia 3, Cuba 2, and Mexico, Venezuela and Nicaragua 1 each. Nineteen reports were published in Spanish or Portuguese, some with English versions. Sample sizes ranged from 14 to 479 participants, with a median of 50 among the 23 studies that reported a size, and 7 studies enrolled preschool children. Four studies were conducted with children with hearing impairment or intellectual disability.

Study	Country	Design	Participants	Playful strategy	Comparator
Stürmer Badalotti et al.(20)	Brazil	BA	41 children, 4 to 6 years	Story-based meetings with a children series	Baseline
García Rupaya and González Chávez (a)(13)	Peru	NRCT	224 children, 3 to 5 years	Participatory and ludic program Sonrisa feliz	Expository program
Torres Gárriz et al.(21)	Cuba	BA	40 children, 7 to 11 years, intellectual disability	Games and puppets	Baseline
Gutiérrez Ilave et al. (a)(14)	Peru	NRCT	Children, 8 to 9 years, n NR	Rule game DENTOPLAY	Expository teaching
Evaristo-Chiyong et al. (a)(15)	Peru	BA	28 children, 7 to 9 years	Ludic strategy	Baseline
Da Cruz et al.(22)	Brazil	BA	64 children, 9 to 12 years	Lecture followed by educational games	Baseline
Oliveira et al.(23)	Brazil	BA	72 children, 5 to 12 years, rural	Hero characters, theatre and games	Baseline
Barreto et al.(24)	Brazil	RCT	38 children, 3 to 5 years	Puppet theatre and interactive play	No activity
Sigaud et al.(25)	Brazil	BA	44 children, 3 to 5 years	Three playful sessions on toothbrushing	Baseline
De Araujo et al. (a)(16)	Brazil	RCT	14 children, 7 to 8 years	Ludic activities plus hygiene instruction	Hygiene instruction
Caetano Araújo et al.(26)	Brazil	NRCT	183 children, 5 to 6 years	Recreational activities, lectures and supervised brushing	No program
Aguiar et al. (a)(17)	Brazil	BA	29 students, 11 to 17 years	Card game Jogo SB	Baseline
Ávila-Curiel et al.(27)	Mexico	BA	25 children, 6 to 11 years, hearing impairment	Lottery game, letter soup and colouring	Baseline
Alzamora De La Rosa et al.(28)	Colombia	NRCT	50 children, 6 to 10 years	Comic book	Lecture and demonstration
Rincón Cadavid et al.(29)	Colombia	BA	31 analysed of 41 children, 6 to 18 years, hearing impairment	Puppets, word games and ludic roulette	Baseline
Leal Rodríguez et al.(30)	Venezuela	BA	60 children, 8 to 11 years	Didactic games and participatory techniques	Baseline
Díaz Garavito et al.(31)	Colombia	BA	479 children examined in two surveys, mean age 3 years	Ludic activities with fluoride varnish	Earlier survey
Martins et al.(32)	Brazil	BA	173 children, 6 to 11 years	Theatre and stories with lectures	Baseline
Ramón Leiva et al.(33)	Cuba	BA	26 children, intellectual disability	Games, songs and a story	Baseline
Genaro et al.(34)	Brazil	BA	300 children, 9 to 12 years	Immersive virtual reality and an educational book with games	Baseline
Ladera-Castañeda et al.(35)	Peru	BA	132 children, 3 to 5 years	Puppet theatre, 10 sessions	Baseline
Haad Ruiz da Silva et al.(36)	Brazil	BA	50 children, 6 to 12 years	Playful comic book with a hygiene kit	Baseline
Castro Sánchez and Vanegas Sáenz (37)	Nicaragua	BA	174 children, mean age 9.7 years	Word searches, crosswords and riddles among other techniques	Baseline
Fontes dos Reis et al.(38)	Brazil	BA	177 children, 4th and 5th grade	Digital board game	Baseline

Note: n = number of participants; RCT = randomized controlled trial; NRCT = non-randomized controlled trial; BA = uncontrolled before-after; NR = not reported in the abstract; (a) data from the abstract only.

The children were 3 to 5 years old in 4 studies, 4 to 6 years old in 1 study, and 5 to 6 years old in 1 study, whereas the others enrolled school-age children from 5 to 12 years, and 2 studies extended to adolescents up to 17 or 18 years. The samples were drawn from public nursery schools and schools, from special schools in 4 studies, from a football school in Colombia,(28) from a rural school in Brazil(23) and from a pediatric dental clinic in the Brazilian Amazon.(36) Boys formed 92% of the Colombian football school sample.

With respect to design, 2 studies were randomized, 4 were non-randomized and controlled, and 18 were uncontrolled before-after studies. Regarding the playful format, 9 studies were based on games of different types, 6 on puppets, theatre, stories or character-led activities, 6 on general ludic or recreational activities, 2 on comics and 1 on virtual reality. In most studies, the playful element was one component of a program that also included lectures, demonstrations or supervised toothbrushing, and only 6 studies had a comparison arm, which was conventional teaching in 4 and no activity or program in 2.

The programs differed widely in length and intensity. The Peruvian puppet theatre study delivered 10 sessions of 30 minutes over 4 months, with a short question and answer period at the end of each performance.(35) The Mexican program for children with hearing impairment consisted of 3 sessions of about 120 minutes, in which a lottery game with 45 dental pictures was combined with a presentation in Mexican Sign Language.(27) The Brazilian randomized pilot trial used a single activity of 60 minutes with puppets and interactive play.(24)

A Peruvian comparison of two teaching methods in children aged 8 to 9 years used 8 weekly sessions of 45 minutes with the same content in both arms.(14) In Colombia, a program with 48 activities was delivered over about 10 months in groups of about 23 children, weekly and lasting 3 hours.(31) The Cuban programs for children with intellectual disability combined games, songs, a story and puppets over several sessions.(21,33)

Where the delivery agents were reported, they were university-based. First-year dental students delivered the activities in Nicaragua,(37) a university extension team in the Brazilian rural project,(23) and a dental school program team in the Brazilian nursery school comparison.(26) The Brazilian nursery school study of playful sessions was led by a school of nursing.(25) Teachers and parents attended the sessions in the Peruvian puppet study.(35)

Two studies used digital technology. A digital board game was applied in 5 public schools in Rio de Janeiro state,(38) and an immersive virtual reality journey of 8 minutes through a model of the mouth was followed by an educational book with games.(34) Among the non-digital games, a card game with 69 cards was played in groups of 2 to 4 adolescents in the Amazon region.(17)

The review identified 24 studies from 7 countries.

DISCUSSION

Does playful education improve oral hygiene knowledge, plaque or gingival indices in Latin American children? The studies point in the same direction. They do not, however, allow a quantified answer. Playful and game-based formats were associated with better knowledge and lower plaque in most reports, and in all 6 controlled comparisons they were equal or better than conventional teaching, yet 18 of the 24 studies had no comparator and none followed the same children beyond 6 months.

The first question concerns what the region has tested (P1), and the answer is a small and uneven set of studies. Brazil and Peru supplied 16 of the 24 studies, while Argentina, Chile, Ecuador, Uruguay and Central America other than Nicaragua contributed none. The formats used, namely games, puppets, storytelling and comics, are the same as those described in reviews of other regions.(7,8) The programs were short. Several were delivered in schools by university students or health professionals. The scarcity of educational interventions against caries documented for the region fits this picture,(4) and it is plausible that the work is driven by university outreach projects rather than by funded trials, which would explain the small samples and the weak designs. Four of the 24 studies involved children with hearing impairment or intellectual disability, which shows that playful formats are being adapted to children who are difficult to reach with lectures.

The second question concerns the changes in knowledge (P2), and knowledge was usually higher after playful teaching. The 13 improvements agree with a systematic review of 7 randomized trials, which found better knowledge after game-based teaching than after traditional teaching,(6) and with trials from India in which a crossword and quiz format, a board game and a dice game combined with lectures gave higher knowledge between 1 and 6 months.(39-41) In a board game trial with preschool children, gains persisted at 3 months in both age groups taught with the game, whereas the youngest children taught with slides returned to their baseline.(42) Conversely, a computer game was as effective as one-to-one education for children at high caries risk, and not better,(43) and a meta-analysis of e-learning found no advantage over conventional education.(44) The Latin American controlled studies, in which the playful arm exceeded the conventional one, resemble the first group of results, but the differences were measured with different instruments and in small samples, so their size cannot be compared across studies. The 2 null results suggest where effects may fail. In the Colombian program, the knowledge reported by parents was assessed in two separate surveys and fluoride varnish was applied at the same time. In the virtual reality program in Brazil, knowledge of oral hygiene did not change while self-reported behaviours did. A possible reading is that immersive formats move behaviour more than knowledge, but a single study cannot confirm it.

As for the third question, plaque, hygiene and gingival indices (P3), 14 of 15 studies reported improvement, and the controlled ones reported lower plaque with the playful arm. This matches the reductions in plaque scores found in trials of game-based education outside the region,(6,45) including adults with intellectual disability, and a pooled analysis in which theory-based programs reduced plaque.(46) It also matches the observation that traditional school education reduces plaque,(5) so the studies do not show that the playful element adds to the effect of supervised toothbrushing or lectures that accompanied many programs. Gingival evidence is the weak point. Only 2 studies measured it; one showed no significant change and the other, a pilot trial of 38 children, showed no bleeding in the playful arm and an increase in the control arm. The school-based review found no effect of traditional education on gingivitis,(5) whereas a review of programs in low and middle income countries reported improved gingival health,(47) so the question remains open for playful formats in the region.

Plaque is a short-term marker, and improvements seen from 3 weeks to 6 months can reflect the motivation generated by the activity and by supervised brushing. The Peruvian puppet study showed no significant plaque reduction in rural children, and the Brazilian story-based program in preschool children did not reduce plaque or bleeding significantly. These results indicate that the effect is not universal and may depend on dose, age and the support of the school routine, although the studies do not allow these factors to be separated.

The fourth question, the reliability of the evidence (P4), has a direct answer: it is low. Sixteen studies were rated critical for confounding because they compared children with themselves before and after an activity, and 5 were not assessable because the full text could not be obtained. Reviews of gamification in children's oral health and of playful health literacy reported moderate risk of bias in 39 of 41 studies and low methodological quality, respectively,(7,8) so the Latin American literature is not an outlier, although its share of uncontrolled designs is high. Mobile applications and augmented reality are prominent formats in the gamification literature,(7) and few applications focus on oral hygiene education.(48) In this review only 2 studies used a digital game or virtual reality and none used an application with a comparator, so the regional evidence does not yet support claims about digital tools.

A plausible mechanism for the pattern observed is engagement. The gamification review reported higher participation and better adherence to hygiene routines in gamified interventions,(7) and the review of playful health literacy interventions found that games, drama and theatre were the formats most often used to increase health knowledge.(8) In the Latin American studies, the reports describe attentive and participative children, but only a few measured engagement, so the mechanism remains an interpretation and not a finding.

Pooled estimates outside the region give a scale of reference. Theory-based programs for children and adolescents raised knowledge with a standardized mean difference of 1.09,(46) and the pooled analysis of school-based education in low and middle income countries also found gains in knowledge, behaviour and oral hygiene.(47) The regional studies cannot be placed on that scale, because most did not report dispersion and the instruments were not common. Reading a pooled estimate into them would give a false precision.

For policy in the region, the consensus on caries emphasizes inequalities and the need for population-wide strategies that are affordable.(2,4) Several programs were applied by university teams in public schools, so playful teaching could complement that approach. The present evidence supports using it to engage children in the school setting, and does not support presenting it as a stand-alone caries prevention strategy.

Four studies in children with hearing impairment or intellectual disability reported better hygiene indices after programs that adapted their content, using Mexican Sign Language, puppets, songs or simple games.(21,27,29,33) All four were uncontrolled and small, with between 25 and 41 children, so they offer a signal and not evidence, but they show that the format can be adapted to communication needs that conventional lectures do not meet well.

Age and context may modify the effect. The Brazilian study of theatre and stories found the largest improvement in the youngest children,(32) the Peruvian puppet study found no significant change in rural children,(35) and a board game trial outside the region found that retention differed by age and by teaching method.(42) These observations suggest that a program should be adjusted to the age of the children and to the school routine, and that trials should report effects separately by age group, by sex and by urban or rural setting.

This review adds two points to the international literature. First, it shows that playful formats have been tested in at least seven Latin American countries, in public schools and special schools, with results that point in the same direction as the trials from other regions. Second, it shows where the regional evidence differs from that literature: the proportion of uncontrolled designs is high, the instruments are not harmonized, and the follow-up is short. Both points are relevant for anyone planning a program or a trial in the region, because they indicate which designs would add information and which would repeat what is already known.

For practice, playful formats seem a low-risk way to teach toothbrushing and diet to children, and the available data do not show harm, but they do not justify replacing supervised toothbrushing and fluoride-based strategies. For research, the next studies should use randomized or controlled designs with masked examiners, a common plaque index, gingival outcomes and follow-up of at least 12 months, and they should report playful components in enough detail to be replicated. Studies in countries not represented here, and in digital formats, are the main gap.

The strengths of the review are its regional scope, the search in three languages with country filters, and the explicit description of what was and was not obtained. Nineteen of the 24 included reports were published in Spanish or Portuguese, and many appeared in journals and repositories that international reviews of game-based teaching do not search, which suggests that the regional literature has been underrepresented in earlier syntheses.(6,7) The use of a common set of outcomes allowed each study to be placed on the same questions, even when the instruments differed.

The instruments are a further obstacle to synthesis. The studies used at least four plaque or hygiene indices, knowledge tests with different numbers of items, and several reported categories rather than means, which prevents the calculation of standardized effects. A consensus set of outcomes for school-based oral health education, as proposed in reviews of theory-based programs,(46) would make the regional studies comparable and would allow a future meta-analysis.

Finally, the comparators deserve attention. Where a conventional arm existed, it consisted of lectures, demonstrations or expository teaching, which are themselves a weak standard because their effect on plaque is small and short.(5) A trial in which the playful arm was compared with an equally intensive conventional arm, delivered by the same person for the same time, would show whether the format or the extra attention explains the difference. Only 2 of the 6 controlled studies stated that the content and the number of sessions were the same in both arms,(13,14) and the others do not report whether contact time was matched.

CONCLUSIONS

The studies that evaluated playful education in Latin American children came from a few countries and were mostly uncontrolled before-after designs with small samples and short follow-up.

Oral health knowledge was higher after playful and game-based teaching in most of the studies that measured it, and the controlled studies favoured the playful arm.

Plaque and hygiene indices improved in nearly all studies, whereas gingival outcomes were measured too rarely to allow a conclusion.

The evidence is of very low certainty because of confounding, small samples and missing full texts, so the magnitude and the duration of the effect remain unknown.

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