Scientific Article

A German Preventive Program follows an inter-sectorial approach to fight Early Childhood Caries

Dr. Yvonne Wagner


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 a 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 prioritizing 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 gynecologists, pediatricians 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 Pediatric 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.

About the Preventive Program (PP)

Since 2009 qualified staff (midwives, social workers, nurses) of the communal new-born visiting service visit all parents of newborns (about 1000 children per year) between the 1st and 4th week after birth. Mothers are counselled on general and oral health. Tooth brushing should be started as soon as the first tooth erupts once a day after dinner with an age-appropriate toothbrush and a smear layer of fluoride toothpaste (+500 ppm F). From the 2nd birthday on, the teeth should be brushed in the morning and in the evening after meals with a pea-sized amount of fluoride toothpaste. Parents should establish a dental home with regular dental care. Every family received a folder with brief information material in their native language as well as a tooth brush, toothpaste and a pacifier for the child. 
In the baby’s first year of life the CNVS invited the families to a dental examination in the DPD. Families who followed the invitation were included as participants of the PP with caries risk related continuous oral care up to the age of 3 to 4 years. Families who did not appear were included in the control group (CG). These groups were also used for the medical study.
The Caries-risk Assessment Tool (CAT) for infants, children and adolescents of the American Academy of Pediatric Dentistry (AAPD) was used to categorize the caries risk of the children and was re-evaluated at each dental appointment. Children who had initial caries lesions (d1-lesion), cavities and/or developmental defects of enamel were included in the high caries risk group. Children with an increased caries risk were reappointed every three months and children with low or moderate caries risk every six months. High-risk children biannually received fluoride varnish application (Fluoridin N5, VOCO GmbH, Cuxhaven, Germany).

The Dental Examination

In 2013, all parents of children (total n=1162, PP n=512, CG=650) born in Jena between July 2009 and October 2010 were invited by the CNVS to a final dental examination in the DPD.
Caries was assessed using dmfs index at d1-level and categorized according to WHO standard criteria. No radiographs were taken. All records were performed by one calibrated dentist. 
755 children (PP: n=377, CG: n=378) with a mean age of 3.26 ± 0.51 years were examined (49.0% female; 5.3% migration background). ECC was present in 26.8% (n=202) of the children and S-ECC was recorded in 16.3% (n=123). Children in the PP had significantly lower caries prevalence (1.3%) than children in the CG (17.2%). Caries prevalence (d1-level) was 15.6% in the PP compared to 37.8% in the CG group. No dental decay in the CG was treated. The average number of dental visits in the PP was 4.5 ± 2.3 compared to 0.3 ± 0.4 in the CG.

The Results

The study showed that 3-year-old children who participated in the PP with anticipatory guidance and continuous oral care from birth on had a significantly better oral health than their peers who did not participate. The main results were that children with visible plaque on teeth, children with a familial caries burden, and children who had not received vitamin D supplements had a higher risk of having caries than other children, whereas regular dental care showed a protective effect against 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 pediatric 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 behaviors. 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.

Dr. Yvonne Wagner

Pediatric Dentist

Dr. Yvonne Wagner is an experienced German specialist. Her work has been published in journals around the world. Dr. Wagner provides education for midwives, dentists and physicians, as well as training courses for families.