Early Childhood Caries (ECC) is a rampant caries form of the primary dentition and is defined as the presence of one or more decayed, missing or filled tooth surfaces in any primary tooth in a child under the age of 6. Children suffer from dental pain, difficulties with eating, speaking and socializing. In addition, children with ECC are considered to have tooth developmental disorders, eruption problems and a high caries risk in the permanent dentition. Any sign of smooth-surface caries in children younger than 3 years of age is known as severe ECC (S-ECC).
Despite several initiatives to improve oral health in childhood, reduction of caries prevalence in primary dentition is quite modest and ECC is increasing typically in groups with a low socioeconomic status (SES). Since dental caries is recognized as non-communicable disease a new paradigm for caries management with a common vision of health and the involvement of health and non-health-sectors should be developed. By prioritising infants, the Global Caries Initiative places oral health within maternal and child health programs using new multi-sectorial and collaborative approaches together with strengthening the role of dentists to eliminate ECC in children younger than 3 years. New preventive approaches should focus on pregnant women and mothers of infants by involving gynaecologists, midwives, paediatricians and nurses as well as trained non-professionals to improve health awareness and to give dietary guidance.
A regional program in the German state of Thuringia follows this inter-sectorial approach by involving the department of Preventive and Paediatric Dentistry (DPD) of the Jena University Hospital and the communal new-born visiting service (CNVS) of the Youth Welfare Office of the city of Jena. The purpose of this cooperation was access to all families for general and oral health promotion in young children. In this program different evidence-based strategies for ECC prevention are used, such as: maternal counselling, daily brushing with fluoridated toothpaste, establishment of a dental home by 12 months of age, inclusion of the children in a caries risk related recall system with continuous dental care, and fluoride varnish application. Early identification of the child's risk level for the development of dental caries and the implementation of appropriate preventive measures are effective to avoid the onset of caries.
This study was based on data from a regional birth cohort study in Germany. The collaboration between the DPD as health actor and the CNVS of the Youth Welfare Office as non-health-actor was a new inter-sectorial approach to prevent ECC. Counselling of the parents by the CNVS at time of birth was the first step to promote their awareness for healthy diet, good oral hygiene and regular paediatric and dental visits. The study showed that more than half of the non-participants could be motivated to consult their family dentist after counselling by the CNVS. Another great advantage of the inter-sectorial approach was the access to all families, independent of their SES or ethnicity.
Despite the benefits, the study revealed that for a sustainable influence on oral health, counselling by CNVS has to be continued with constant anticipatory guidance and continuous dental care. Educational information alone is relatively ineffective in changing behaviours. This study showed that children with regular dental care had a lower caries experience at the age of 3. Parents have to be aware of ECC and its risk factors. The inclusion of the children in a caries-risk related recall system is helpful to make parents understand the importance of oral health care and regular tooth brushing. In this study visible plaque on teeth was highly related to the caries experience of the children. Therefore, daily tooth brushing with a fluoride toothpaste is essential for the prevention of dental caries in children. A further advantage of our approach was that the dentist was able to recognize first signs of caries and applied appropriate interventions to prevent caries progression according to the individual caries risk. Thus, children with a higher caries-probability were recalled every 3-month and biannually received fluoride varnish application. It could be demonstrated that fluoride varnish application had a protective effect on caries development. The efficacy of fluoride varnish has been reliably proven in scientific studies and several health programs include fluoride varnish application already in the first three years of life.
Another outstanding result of this study was that not using vitamin D supplements could be identified as a risk factor for caries development. Until now, only a few studies examined the influence of vitamin D on caries development and found that vitamin D seems to reduce the risk of dental caries due to its effects on calcium metabolism and on calcification of the teeth. The evaluation demonstrated that the PP was an effective inter-sectorial approach for improving oral health in preschool children. The collaboration with CNVS, as a non-health-actor is a promising new approach in Germany to support a healthy start of children and to equalize health inequalities.
The program received the Wrigley prophylaxis award for its work .
Acknowledgements:
We thank the communal new-born visiting service (CNVS) of the Youth Welfare Office Jena, Germany for the excellent cooperation. The study received financial and material support by MAM Baby AG, Wollerau, Switzerland, VOCO GmbH, Cuxhaven, Germany, MAM Babyartikel GmbH, Vienna, Austria, Procter & Gamble International Operations S.A., Petit-Lancy, Switzerland, Wrigley GmbH, Munich, Germany and the German Society of Oral and Maxillofacial Surgery (DGZMK), Germany.