Oral health is a fundamental component of overall well-being [1], particularly in children. It influences their growth, nutrition, speech development, and self-esteem [2,3]. Despite advancements in dental care, childhood dental caries remain a prevalent global health issue, affecting millions of children worldwide [4]. The rising burden of childhood oral health problems highlights the need for engaging strategies to promote early oral hygiene.

Gamification, the application of game design elements in nongame contexts [5,6], has emerged as an innovative approach to health education, leveraging intrinsic motivation and engagement to encourage behavior change [7-9]. In pediatric oral health management, gamification techniques have been integrated into various digital and nondigital interventions, including mobile apps, interactive video games, augmented reality (AR), and game-based learning tools [10,11].

Several studies have demonstrated the effectiveness of gamified oral health education [8,12,13]. A study found that game-based teaching significantly improved children’s oral hygiene knowledge and behaviors compared to conventional methods [10]. Similarly, another study also reported that gamified interventions such as quizzes and crosswords led to higher engagement and better oral hygiene scores among children compared to traditional educational methods [14]. Moreover, digital interventions such as serious games and apps promote sustained behavior change through real-time feedback and personalized reinforcement [11,15].

Despite evidence supporting gamification in children’s oral health management [16-18], challenges remain in optimizing its design, accessibility, and long-term impact. Future research should develop culturally adaptive and age-appropriate gamified interventions, assess their long-term effectiveness, and integrate them with public health programs.

While previous studies have explored various aspects of gamification in pediatric oral health [10,14], no single review has comprehensively examined gamification as a holistic framework for oral health management, including its role in education, behavior change, engagement, and digital platforms.

A preliminary screening of existing systematic reviews was conducted by the study team via the PROSPERO database and identified 4 potentially relevant reviews. The first one, conducted by Elkin et al [19], assessed the effectiveness of oral hygiene tools but did not specifically address gamification. The second one, authored by Rajeh and Mutairi [20], examined the effectiveness of gamification in improving oral health knowledge, practices, and attitudes among school-aged children; this study is somewhat related to ours but is limited to knowledge, practices, and attitudes, possibly excluding broader aspects of gamification applications. The third review, conducted by Patil and Bhandi [21], focused exclusively on game-based teaching methods for children’s oral health. This review specifically examined game-based teaching methods but appears narrower in scope than our study. Finally, Patil et al [22] systematically analyzed pediatric dentistry mobile apps but did not concentrate on gamification strategies for oral health management. Our review explored gamification as a comprehensive strategy encompassing education, behavioral engagement, and digital interventions. It addresses gaps in the literature by evaluating the effectiveness, challenges, and potential improvements of gamification in children’s oral health management.

This review aimed to evaluate gamification’s application and effectiveness in children’s oral health management by addressing the following research questions: (1) how has gamification been implemented in pediatric oral health management, particularly in the context of education and behavior change? (2) what are the key game design elements used in oral health gamification interventions? (3) how effective are gamified interventions in improving children’s oral health knowledge, behaviors, engagement, and education?

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [23]. It was registered with PROSPERO under registration CRD42025644118.

The eligibility criteria are outlined in Textbox 1.

Inclusion criteria were children and adolescents (aged ≤18 years [24]); interventions using gamification strategies for oral health management; and measurable outcomes related to knowledge, behavior, and adherence to oral hygiene practices. Eligible studies included randomized controlled trials (RCTs), quasi-experimental studies, cohort studies, and systematic reviews. While qualitative studies with measurable outcomes were initially considered for inclusion, the systematic search did not identify any that met the eligibility criteria. Only English-language publications were included.

Exclusion criteria were studies focusing on adults; studies that were not available for download and review; interventions lacking gamification elements; qualitative studies without measurable outcomes, such as development studies; and non–English-language publications.

To ensure comprehensiveness, this review also included relevant systematic, scoping, and other types of reviews. These reviews helped capture both research-based and commercially available apps or games, some of which were not included in previous research.

Seven databases were searched. Multimedia Appendix 1 shows the rationale for inclusion.

The search strategy targeted 3 main concepts: gamification, pediatric populations, and oral health. Boolean operators (AND and OR) were used to refine search queries. Searches were conducted in PubMed, MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, and PsycINFO from January 1, 2014, to February 9, 2025. Detailed information can be found in Multimedia Appendix 2.

The study selection process followed the PRISMA guidelines. Screening was conducted in 3 sequential rounds. First, duplicate records were identified and removed. Second, titles and abstracts were screened based on predefined inclusion and exclusion criteria. Finally, full-text articles were assessed for availability and relevance to the review objectives. Studies that met all eligibility criteria were included in the final synthesis. Screening was conducted independently by 2 reviewers (Jinsong Chen and YY), with discrepancies resolved through discussion or consultation with a third reviewer (WZ). Detailed information was illustrated in a PRISMA flowchart.

Data extraction was conducted using a structured approach based on multiple established guidelines, including the Transparent Reporting of Evaluations With Nonrandomized Designs statement [25], PRISMA guidelines [23], CONSORT (Consolidated Standards of Reporting Trials) 2010 statement [26], and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [27]. Additional tools were used to evaluate specific aspects, such as the Mobile App Rating Scale for app assessment [28] and the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) [29] and revised Cochrane risk-of-bias tool for randomized trials (RoB 2) [30] for risk-of-bias evaluation.

The reviewers used EndNote (Clarivate Analytics) for reference management and duplicate removal, followed by Microsoft Excel for study screening and data extraction. A standardized form was used to collect study details, as well as information on interventions, demographics, outcomes, and risk of bias. Two reviewers (Jinsong Chen and YY) extracted the data independently, resolving discrepancies through discussion or a third reviewer (WFZ). Multimedia Appendix 3 presents the extraction table.

Multiple established tools were used to ensure a comprehensive evaluation. The ROBINS-I tool was applied to assess nonrandomized studies, whereas the RoB 2 tool was used for RCTs [29,30]. In addition, the PRISMA guidelines were followed to enhance the transparency and reliability of the assessment [23]. Other relevant tools, including the STROBE statement for observational studies, were also used [27]. Two reviewers (Jinsong Chen and YY) independently evaluated each study, resolving discrepancies through discussion or a third reviewer (WFZ).

A narrative synthesis approach was used. Due to the heterogeneity in study designs and variations in outcome measures across the studies, a meta-analysis was not feasible. In addition, subgroup analyses could not be conducted as different RCTs used distinct outcome measures, making direct comparisons impractical. The synthesis focused on identifying common themes, evaluating intervention effectiveness, and highlighting methodological strengths and limitations.

The study selection process followed the PRISMA guidelines (Figure 1), resulting in 41 studies.

RCTs were evaluated using the Cochrane RoB 2 tool [7,33], whereas nonrandomized and quasi-experimental studies were assessed using the ROBINS-I tool [43,46]. Systematic and scoping reviews adhered to the PRISMA guidelines [11,55], and observational studies followed the STROBE recommendations [58].

RCTs often faced attrition bias and measurement [12], nonrandomized studies exhibited selection bias and confounding [61], and systematic reviews were susceptible to selection and publication biases [52].

Most studies (39/41, 95%) had a moderate risk of bias, mainly due to self-reported measures, intervention adherence variations, and methodological differences. Some RCTs (10/13, 77%) exhibited low risk in domains such as randomization and blinding [37]; others had inconsistencies in measurement and reporting, affecting reliability. Multimedia Appendix 6 [4,7,10-12,14,16-18,31-41,43-63] shows a summary of the risk of bias.

This synthesis of findings from experimental and nonexperimental studies reveals important trends in the development, evaluation, and effectiveness of gamified interventions in oral health management. The reviewed studies covered a range of intervention types, from serious games [51,56] to mobile health apps [12,59] and AR tools [34]. A notable characteristic of these interventions was their reliance on game elements such as rewards, progress tracking, and interactive learning to enhance user engagement and improve health outcomes.

The effectiveness of digital-based interventions was generally positive, with 38% (9/24) of the experimental studies reporting improvements in oral health knowledge and behaviors [12,59]. For instance, in the gamified app group in one study, plaque control was superior (P<.05) compared to the conventional method group [12]. These interventions also showed improved engagement metrics, with higher participation rates especially when game elements such as badges and rewards were incorporated [45,61]. For example, 72.4% of children in the gamified app group in one study engaged regularly compared to 48.3% in the nongamified intervention group [12].

In nonexperimental studies, gamified interventions such as mobile health apps [57,60] demonstrated significant improvements in parental engagement and awareness of oral health practices, which translated into better brushing habits and increased preventive dental visits. The game elements used, such as quizzes and interactive feedback, were particularly effective in driving sustained engagement and behavior changes [51].

However, most studies (39/41, 95%) exhibited moderate risk of bias, including self-reported data and potential selection biases [4,56]. The theoretical frameworks used, such as behavioral reinforcement and the theory of planned behavior, were consistent with improvements in both engagement and effectiveness [44,60]. Despite the variability in study designs, gamified interventions consistently demonstrated promise in improving oral health outcomes, especially when complemented with engaging, interactive features.

The studies in this review explored the effectiveness of gamified interventions in oral health education and management. The experimental studies consistently showed that gamified interventions significantly improved oral health behaviors and engagement [10,12]. For example, the gamified mobile health app group in one study showed superior plaque control (P<.05) compared to the nongamified control group, and higher engagement rates were observed in interventions incorporating rewards and progress tracking [12]. These results align with those of previous research that emphasizes the positive impact of digital gamification in health interventions [11,52], which underscores the role of gamification in improving health knowledge and motivation, especially among children.

However, the nonexperimental studies further expanded the understanding of the role of gamification, particularly with regard to long-term engagement and user satisfaction. For instance, mobile health apps [57,60] showed improvements in parental engagement with educational content, which led to better oral health practices and dietary choices. These studies point to the growing importance of gamification in motivating not only children but also parents in managing oral health [59]. This supports the current research, which highlights gamified apps as particularly effective in both enhancing knowledge and encouraging behavior change.

While both experimental and nonexperimental studies showed promising results, the limitations of many of the reviewed studies, such as lack of controlled trials and small sample sizes, remain an issue, which is consistent with findings from previous reviews [11,56].

First, there was significant heterogeneity across the studies in terms of intervention types, outcome measures, and populations, making direct comparisons challenging [60]. Different gamified elements were used across the studies, making it difficult to pinpoint which specific features were most effective [16]. In addition, many studies (22/41, 54%) relied on self-reported data, which introduced potential biases related to participant recall and response [12,44]. Furthermore, while the PROSPERO registration proposed including qualitative studies, the final synthesis was limited to quantitative designs as the systematic search did not identify any qualitative studies that met the eligibility criteria. Finally, several studies (10/41, 24%) lacked long-term follow-up as most focused on short-term outcomes [32,33]. These limitations highlight the need for future studies to adopt more standardized designs, integrate educational frameworks into gamification strategies, and include multistakeholder collaboration to ensure that gamified children oral health tools are practically effective. Long-term follow-up and mixed methods approaches are also recommended to provide a more comprehensive understanding of user experiences and effectiveness.

This systematic review synthesized the findings from 41 studies on the use of gamification in children’s oral health management. Gamified interventions, particularly those incorporating digital technologies such as mobile apps and AR, showed significant improvements in children’s oral health knowledge, brushing behaviors, and plaque control. The effectiveness of these interventions was notably enhanced when gamification elements such as rewards, progress tracking, and interactive feedback were used. In addition, the theoretical frameworks used, including behavior change models and game-based learning principles, played a crucial role in fostering engagement and improving health outcomes.