For example, Walsh (1985) evaluated a school-based program that was implemented among 639 7th and 8th graders in ten San Francisco public middle schools. The study population was 22% Spanish surname, 18% white, 23% black, and 37% Asian, and about evenly split between boys and girls. Dental hygiene students led four, hour-long sessions on dental health and hygiene, with supervised practice in brushing and flossing. At post-test, few differences in behavior were noted, and, although the study author suggested that girls in the experimental group had an increase in the frequency of tooth brushing and flossing, there were problems with the study analysis. Moreover, there was no elapsed time between the end of the program and its evaluation.

A second program was implemented among about 200 6th graders attending a private school in Sao Paulo, Brazil (Axelsson, Buischi, Barbosa, Karlsson, & Prado, 1994; Buischi, Axelsson, Oliveira, Mayer, & Gjermo, 1994). The most intensive program condition consisted of an extensive dental hygiene training program, including educational and behavioral components. An evaluation suggests that the program was associated with greater use of plaque disclosing solution, somewhat greater use of dental floss, and fewer new cavities (Axellson, et al., 1994; Buischi, et al., 1994); however, the analysis did not account for differences between the experimental and control groups at the start of the study. Furthermore, it is unclear whether these results would be applicable to other populations. These studies suggest that combined educational and behavioral approaches may be effective, but, to date, there are no sufficiently compelling findings to fully support this claim. Moreover, the cost-effectiveness of such intensive programs is uncertain. As with other health behaviors, maintenance of dental health behavior change is an essential consideration (Ivanovic & Lekic, 1996). Future studies should include rigorous evaluation of programs designed to promote lasting, positive, dental health behaviors and to alleviate the potential barriers to utilization of professional care.