Early predictors of childhood caries among 4-year-old children: a population-based study in north-eastern France

BACKGROUND

Untreated early childhood caries (ECC) can trigger a number of negative consequences, including pain, chewing difficulties, insufficient physical development and low academic performance. Therefore, ECC impacts the oral health-related to quality of life. That is why it is important to assess the ECC prevalence and to determine the associated risk factors.

AIM

The aim of this study was to investigate the relationship between early predictor factors and dental caries among 4-year-old French children, considering the socioeconomic factors, dietary and oral hygiene practices, the access and the follow-up by paediatric dentist.

DESIGN

The study was a cross-sectional observation. A random sample of 4-year-old children was selected among 596 Moselle's public nursery schools in north-eastern France. Data were gathered from clinical dental examinations and a structured questionnaire completed by parents.

RESULTS

In total, 425 subjects with completed questionnaires and clinical examinations were included. The prevalence of ECC and S-ECC (Severe-ECC), including only cavitated lesions, d3mft, were 15.8% and 5.9%, respectively. Multivariable logistic regression modelling identified four main factors associated with a high risk of ECC that were sweet intake (adjusted odds ratio OR_adjusted = 3.43, 95% CI = 1.57-7.53), brushing habits (OR_adjusted = 2.25, 95% CI = 1.23-4.21), childcare arrangement (OR_adjusted = 2.27, 95% CI = 1.23-4.21) and maternal educational level (OR_adjusted = 1.87, 95% CI = 1.06-3.31). These four factors have a cumulative effect. Only 4% of children presented teeth restoration.

CONCLUSIONS

This study highlighted the impact of the family environment on the oral health status of the preschool children. The identification of the risk factors should allow to strengthen preventive measures and initiate oral health education program for children and their family.

Breastfeeding and early childhood caries. Review of the literature, recommendations, and prevention

CONTEXT

Early childhood caries is a chronic disease that affects a child's general state of health. The question of a link between primary tooth caries and breastfeeding has been addressed for many years, with contradictory results. The concomitant decay of primary teeth, effective establishment, or not, of oral hygiene, and alimentary diversification away from breastfeeding are all confounding factors in this topic. The aim of our study was to analyze the links between breastfeeding and the appearance of caries, as described in the scientific literature and in the recommendations of specialist societies.

METHODS

A review of publications written in English and French was carried out, searching for the terms early childhood caries, decay and breastfeeding, focusing on literature reviews and meta-analyses dating from the past 10 years. The PubMed database of the US National Library of Medicine National Institutes of Health (NBCI) was used. Furthermore, a review of specialist dental and pediatric societies was conducted.

RESULTS

Breastfeeding until the age of 1 year is not associated with an increased risk of dental caries, and may even provide protection compared with feeding with formula milk. By contrast, infants who are breastfed beyond the age of 12 months demonstrate an increased risk of caries. However, the results derive from heterogeneous studies that do not always take into account contradictory factors such as eating habits of the mother or infant (feeding during the night, number of meals per day, eating sweet foods etc.), dental hygiene, or the sociocultural context. Moreover, the most recent recommendations of pediatric and dental societies advise breastfeeding until the age of 2 years, suggesting that this be accompanied by toothbrushing and better nutrition by reducing the frequency and consumption of sugary foods, aimed at helping parents choose prolonged breastfeeding.

CONCLUSION

Extended breastfeeding is a protective factor for childhood caries under 1 year of age. Beyond 1 year, it is difficult to conclude between protection and aggravation of caries because of the multiplicity of confounding factors such as dietary patterns, which vary depending on countries and families, and problems of oral hygiene. In practical terms, when breastfeeding continues beyond 1 year, consultation with a dentist is necessary for examination and preventive advice regarding dietary practices (especially sugar intake), oral hygiene, or supplementary fluoride.

The healthcare system and the provision of oral healthcare in EU Member States: France

The French oral health system is based on the provision of dental treatment and is organised around a fee-per-item model. The system is funded by a complex mix of public and complementary health insurance schemes. The system is successful in that it provides access to affordable dental treatment to the majority of the French population. However, France had the highest health expenditure as a share of gross domestic product (GDP) of all European Union countries in 2008 and rising oral health inequalities may be exacerbated by the manner in which oral health care is provided and funded. In addition, there is no organised national strategy for the prevention of oral diseases or for oral health promotion.

WITHDRAWN: Community-based population-level interventions for promoting child oral health

BACKGROUND

Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health.

OBJECTIVES

Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions.

SEARCH METHODS

We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science.

SELECTION CRITERIA

Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity.

MAIN RESULTS

This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.

AUTHORS' CONCLUSIONS

This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Community-based population-level interventions for promoting child oral health

BACKGROUND

Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health.

OBJECTIVES

Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions.

SEARCH METHODS

We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science.

SELECTION CRITERIA

Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity.

MAIN RESULTS

This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.

AUTHORS' CONCLUSIONS

This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Effectiveness of oral health education in children - a systematic review of current evidence (2005-2011)

BACKGROUND

So that resources and manpower are allocated in a way of most benefit to the population, systematic review of available evidence on the effectiveness of programmes and interventions is required.

OBJECTIVES

To assess the quality of evidence presented in studies carried out to investigate the effectiveness of oral health education in children.

METHODS

The MEDLINE (PubMed) bibliographic database was searched for English-language articles published from 2005 to 2011. Fifty-five articles were identified by the literature search, and the relevance of each article was determined by examining the title and the abstract. Sixteen original research studies met the inclusion criteria. These articles were read in full and scored independently by two reviewers, with scoring based on predetermined criteria. Articles scoring less than 10 were excluded from the study. For each paper that achieved a validity score of more than 10 (n = 11), data concerning the objectives of the intervention, the types and numbers of participants and the outcomes were extracted from the article. Considering the absence of homogeneity among the articles (as a result of variation in the age of subjects, type of intervention and outcome measures) quantitative analysis was not conducted. The publications were grouped based on their outcome measures: (i) plaque and gingival health; (ii) caries incidence; (iii) knowledge, attitude and oral health-related behaviour; and (iv) toothbrushing skills.

RESULTS

The results of this analysis suggest that further efforts are required to synthesise, systematically, current information about dental health education, along with the maintenance of rigorous scientific standards in research.

Addressing children's oral health inequalities: caries experience before and after the implementation of an oral health promotion program

OBJECTIVE

(1) To evaluate the dental status of 5-year-old children in Clermont-Ferrand (France) in 2009; (2) To measure changes in children's dental status between 2003 and 2009; and (3) To estimate the impact of an Oral Health Promotion (OHP) program implemented in nine schools since 2005.

MATERIALS AND METHODS

All 5-year-olds attending public schools in deprived areas (n = 15) and six randomly selected other schools in Clermont-Ferrand were invited to participate. Dental status was recorded using d(3)mft, as in 2003. Parents responded to questions about their child's oral hygiene and provided socio-demographic information.

RESULTS

Of children invited, 478 (77%) were examined. Mean dmft was 1.18 (SD 2.61); 27.6% had at least one tooth affected. Caries experience varied significantly with deprivation status, oral hygiene and household SES indicators. The only difference observed between 2003 and 2009 was an increase in the 'f' component (p < 0.001). Dental status had slightly deteriorated in areas characterized in 2003 by low caries levels (p=0.07). In deprived areas, mean dmft increased in schools without the OHP program (p = 0.04). Changes between 2003 and 2009 were studied at school level using Multiple Factorial Analysis; it tended to improve in four schools, which had the OHP program. Household indicators of SES changed little. Oral hygiene levels varied differently from one school to another.

CONCLUSIONS

Caries experience was high, with large inequalities between children. No major differences were observed between 2003 and 2009. The OHP program has done little to reduce disparities in oral health, even if dental status improved in four schools.