低龄儿童龋的临床管理专家共识

低龄儿童龋（ECC）影响儿童牙齿、牙列、颅颌面和全身健康发育,是目前世界范围内需要面对和解决的重要儿童公共卫生问题之一。ECC的临床管理应以维护儿童口腔健康为中心,从其致病因素入手,以龋病风险评估为基础,早期预防在先,预防和治疗相结合,医护人员、儿童及其监护人相互配合,周期性地持续进行,从而阻止ECC的发生发展。本共识从ECC的风险评估、早期预防管理、临床治疗及术后管理来阐述ECC的临床管理策略。     

Prevention of early childhood caries

This paper reviews the methods used for the prevention of early childhood caries (ECC). The education of mothers or caregivers to promote healthy dietary habits in infants has been the main strategy used for the prevention of ECC. This review found that education has a modest impact on the development of ECC. While education should be promoted especially in high risk communities and population groups (low-income families and native populations), it should not be the only preventive strategy of ECC. Early screening for signs of caries development, starting from the first year of life, could identify infants and toddlers who are at risk of developing ECC and assist in providing information to parents about how to promote oral health and prevent the development of tooth decay. High risk children include those with early signs of ECC, poor oral hygiene, limited exposure to fluorides, and frequent exposure to sugary snacks and drinks. These children should be targeted with a professional preventive program that includes fluoride varnish application, fluoridated dentifrices, fluoride supplements, sealants, diet counseling, and chlorhexidine. Prevention of ECC also requires addressing the social and economic factors that face many families where ECC is endemic.     

Risk factors for early childhood caries in disadvantaged populations

Early childhood caries is a significant international public health problem. The aim of this paper was to review the current evidence of the risk factors for dental caries in disadvantaged children under 6 years of age. Medline, Cochrane, and PubMed database searches were conducted. Systematic reviews were used where available, or meta‐analyses; randomized, controlled trials; and cohort, case‐control, and cross‐sectional studies (in that order). Studies were restricted to those published in English from 1990 to October 2010. Early childhood caries has a complex etiology with biological, behavioral, and sociodemographic influences. Evidence suggests that young children are most likely to develop caries if Streptococcus mutans is acquired at an early age, although this is influenced by other factors, such as oral hygiene, fluoride, diet, dental visit patterns, socioeconomic status, ethnicity, and health literacy. Etiological pathways should be taken into consideration when designing interventions to prevent dental caries in disadvantaged preschool children.     

The building blocks of precision oral health in early childhood: the ZOE 2.0 study

Improving children's oral health is a long-standing area of priority and sustained efforts by many stakeholders. Despite these efforts, dental caries, particularly early childhood caries (ECC), persists as a clinical and dental public health problem with multilevel consequences. Despite recent successes in the non-restorative management of dental caries, remarkably little has been done in the domain of ECC prevention. There is promise and expectation that meaningful improvements in early childhood oral health and ECC prevention can be made via the advent of precision medicine in the oral health domain. We posit that precision dentistry, including genomic influences, may be best examined in the context of well-characterized communities (versus convenience clinical samples) and the impact of contextual factors including geography and social disadvantage may be explainable via mechanistic (i.e., biological) research. This notion is aligned with the population approach in precision medicine, which calls for the latter to be predictive, preventive, personalized, and participatory. The article highlights research directions that must be developed for precision dentistry and precision dental public health to be realized. In this context, we describe the rationale, activities, and early insights gained from the ZOE 2.0 study – a large-scale, community-based, genetic epidemiologic study of early childhood oral health. We anticipate that this long-term research program will illuminate foundational domains for the advancement of precision dentistry and precision dental public health. Ultimately, this new knowledge can help catalyze the development of effective preventive and therapeutic modalities via actions at the policy, community, family, and person level.     

Response to Horowitz: Research issues in early childhood caries

Interest in early childhood caries (ECC) remains strong internationally, yet a name remains elusive. Baby bottle tooth decay (BBTD) was widely recognized by non-dental health professionals — a factor to consider in choosing a more appropriate name. Due to limits in historic data, progress against the disease remains difficult to determine. As reflected by Dr Horowitz's list of recommendations, a focused agenda is not at hand on research leading to specific interventions. We also struggle to develop a specific set of interventions suitable for public health settings. In the absence of research-based effective interventions, I hope we do not withdraw from efforts to reduce ECC.     

Early childhood caries: nomenclature and case definition

A fruitless debate so far has continued to find an ideal name for early childhood caries (ECC), one which could encompass all its risk factors and express the possible seriousness and rampant nature of the problem. It should be simultaneously comprehensible to the dental profession, medical personnel and the general public. However, it is hard to find an example of a multifactorial disease where the name alone indicates its etiology, signs, symptoms, and prevention. It is time for us as a dental profession to accept the responsibility to educate ourselves, our medical colleagues and the public about ECC, and stop hoping that a perfect name for ECC will do the job for us. A similar situation exists regarding the case definition of ECC. To find a single definition of ECC based on number of lesions, teeth involved and age of the affected children is an unrealistic goal. Therefore, a classification of ECC and a case definition for each type is proposed.     

Advances in the microbial etiology and pathogenesis of early childhood caries

Early childhood caries (ECC) is one of the most prevalent infectious diseases affecting children worldwide. ECC is an aggressive form of dental caries, which, left untreated, can result in rapid and extensive cavitation in teeth (rampant caries) that is painful and costly to treat. Furthermore, it affects mostly children from impoverished backgrounds, and so constitutes a major challenge in public health. The disease is a prime example of the consequences arising from complex, dynamic interactions between microorganisms, host, and diet, leading to the establishment of highly pathogenic (cariogenic) biofilms. To date, there are no effective methods to identify those at risk of developing ECC or to control the disease in affected children. Recent advances in deep‐sequencing technologies, novel imaging methods, and (meta)proteomics–metabolomics approaches provide an unparalleled potential to reveal new insights to illuminate our current understanding about the etiology and pathogenesis of the disease. In this concise review, we provide a broader perspective about the etiology and pathogenesis of ECC based on previous and current knowledge on biofilm matrix, microbial diversity, and host–microbe interactions, which could have direct implications for developing new approaches for improved risk assessment and prevention of this devastating and costly childhood health condition.     

Early childhood caries in northern Philippines

OBJECTIVES: To determine prevalence and severity of early childhood caries (ECC) among children in northern Philippines. Further, to describe and determine the impact of child-rearing practices and dental visits on caries status. METHODS: Cross-sectional survey of 993 children aged 2-6 years. Caries was diagnosed based on WHO recommendations. Additional behavioral information was obtained from 452 children aged 3-6 years. RESULTS: Caries prevalence and mean dmft (+/-SD) by age were as follows: 2 years = 59% (4.2 +/- 5.3); 3 years = 85% (7.4 +/- 5.5); 4 years = 90% (8.8 +/- 5.6); 5 years = 94% (9.8 +/- 5.5); and 6 years = 92% (10.1 +/- 5.5). Caries rates mirrored those of developing countries with untreated lesions dominating all ages. Mixed breast and bottle feeding was the norm. Almost half were weaned at more than 2 years old. Majority had toothbrushing practices, but mostly without parental assistance. Toothbrushing was initiated at an average age of 2 years. Only a small proportion had a dental visit, mostly for emergency reasons. Among 3-4-year-old children, a significant increase in caries levels were noted for those who started brushing at a later age, had frequent snacks, and had a dental visit for emergency reasons. For children aged 5-6 years, those who went for emergency visits also had significantly more caries. Results indicated an urgent need to (i) increase awareness that ECC is a public health problem in these areas, (ii) advocate use of fluoride as a public health measure, and (iii) increase access to preventive dental services for preschool children.     

Response to Weinstein: Public health issues in early childhood caries

Dr Weinstein's thoughtful overview of public health issues in early childhood caries (ECC) provides an excellent basis for further exploration. For public health to focus on a given problem several factors must be addressed: the disease must be widespread; the etiology or the prevention of the disease or condition must be known; this knowledge is not being applied; and resources for interventions must be available. Currently, appropriate data are not available for ECC and the problem is exacerbated because there is no case definition for the disease. Therefore it is difficult to make public health policy to address this disease. With the knowledge of case definition, prevalence, and efficacy of treatment, we are more likely to engender interest and funding for ECC. Studies in other countries have demonstrated that children who are malnourished, have low birth-weight or both, likely will have hypomineralized primary teeth and thus at risk of ECC. Low birth-weight infants (less than 2500 g) currently constitute over 7% of all US births. The impact of low birth-weight on oral health is not known. Weinstein favors the use of operator-applied preventive agents, yet little evidence is available on the safety and effectiveness of these agents among infants and young children. Further, they are unlikely to be cost-effective and they require frequent appointments, which is often difficult for poor families to manage. Community interventions hold the greatest promise for preventing ECC because larger numbers of people can be reached than in private practice clinical settings.     

Pattern and severity of early childhood caries

OBJECTIVES: The aim of this study was to investigate the association between selected social and behavioural variables and the pattern and severity of early childhood caries (ECC) within a community child population. METHODS: A cross-sectional sample of 2515 children aged 4-5 years were examined in a preschool setting using decayed, missing, filled teeth/surface (dmft/dmfs) indices and a self-administered questionnaire was used to obtain information regarding social, demographic, birth, infant feeding, oral and general health attitudes. Children with caries (847) were divided into anterior or posterior caries pattern groups and severe (dmfs score > or =6) or non-severe (dmfs score <6) caries groups. The data were analysed using a chi-square test and modelled using a logistic regression procedure. RESULTS: Significant variables associated with anterior ECC pattern were ethnicity other than Caucasian (OR = 2.1, 95% CI = 1.4-3.1), sipping from the bottle during the day (OR = 1.9, 95% CI = 1.3-2.7), male gender (OR = 1.6, 95% CI = 1.2-2.2) and sleeping with a bottle at night (OR = 1.5, 95% CI = 1.1-2.2). Significant variables associated with severe ECC form were sipping from the bottle during the day (OR = 2, 95% CI = 1.4-2.8), maternal age at birth < or =24 years (OR = 1.8, 95% CI = 1.3-2.7), ethnicity other than Caucasian (OR = 1.6, 95% CI = 1.1-2.5) and sleeping with a bottle at night (OR = 1.5, 95% CI = 1.1-2.2). CONCLUSIONS: Infant bottle-feeding habits (either allowing a child to sip from a bottle during the day or put to sleep at night) and ethnicity other than Caucasian were significant determinants for both anterior caries pattern and severity of ECC in 4-5-year-old Australian children.     

A randomized trial of the effectiveness of home visits in preventing early childhood caries

OBJECTIVES: Assess the effectiveness of home visits for advising mothers about breast feeding and weaning on early childhood caries (ECC) at the age of 12 months. METHODS: A randomized field trial was conducted in mothers who gave birth within the public health system in the Brazilian city of Sao Leopoldo (intervention group = 200; controls = 300). The intervention group received the advice 10 days after the child's birth, monthly up to 6 months, at 8, 10 and 12 months, based on the 'Ten Steps for Healthy Feeding', a Brazilian national health policy for primary care, based on WHO guidelines. Both groups had research assessment at 6 and 12 months, with dental caries investigated in this last assessment; 122 children were lost in the 1-year follow-up; 378 were assessed for caries: two predentulous children were excluded from the analysis. Mann-Whitney U was used to test if the average number of decayed surfaces (DS; white spots and cavities) differed between the intervention and control groups, and logistic regression to estimate the effects of the intervention on the odds of ECC. Chi-square test was used to test for differences between the intervention and control groups in the distribution of feeding behaviours tackled by the dietary intervention. RESULTS: 10.2% of the children in the intervention group and 18.3% of the controls had caries. The odds of caries was 48% lower for the intervention group, adjusted for number of teeth (OR = 0.52, 95% CI = 0.27-0.97). Mean DS were lower for the intervention group (0.37) when compared with the control group (0.63), (Mann-Whitney U, P = 0.03). The intervention group had significantly longer duration of exclusive breast feeding (P = 0.000), later introduction of sugar (P = 0.005), and smaller probability of ever having eaten biscuits (P = 0.000), honey (P = 0.003), soft drinks (P = 0.02), fromage-frais (P = 0.001), chocolate and sweets (P = 0.001). CONCLUSIONS: ECC is a public health problem in that population. The home visits for dietary advice appear to help reducing dental caries in infants. Greater efforts are needed to tackle cariogenic dietary behaviours even further, as a relevant proportion of children of the intervention group were shown to present with dental caries. Further studies should examine the effect of the intervention in the longer term.     

Research issues in early childhood caries

Research 3 needed to establish what nomenclature and case definition for early childhood caries (ECC) are most relevant to health care professionals and to the public. Profiles or indexes for predicting the prevalence of ECC in communities should be developed on the basis of the socioeconomic factors, immigrant status and ethnic/racial backgrounds of populations. Future research should target risk factors of ECC, particularly prenatal and perinatal histories, nutritional status and microbiologic factors. Determining the relation of malnutrition of infants and young children, low birthweight, complicated pregnancies and traumatic births with the development of enamel linear hypoplasia deserves research attention. Factors that affect how and when infants and young children are colonized by mutans streptococci also need further study. The evaluation of chemotherapeutic preventive agents will likely yield more fruitful interventions for prevention than trying to change behaviors. Research in young children to prevent ECC, however, has particular ethical considerations. Withholding treatments or administering placebos to vulnerable subjects is not acceptable. Consequently, future clinical research likely will determine the relative rather than the absolute effectiveness of preventive regimens; the former requires large sample sizes and may necessitate multi-center studies. Human studies may be hampered by problems of recruitment, compliance and transiency of subjects. Because federal support for research on dental caries has declined in recent years, a special initiative that focuses specifically on ECC may be necessary to obtain adequate funding for research on the disease.     

维生素D水平与低龄儿童龋风险的相关性分析

目的探讨维生素D水平与低龄儿童龋(early childhood caries,ECC)发生风险的相关性分析,为ECC儿童的一级预防提供依据。方法收集389名6~48月龄儿童的月龄、喂养方式、口腔健康行为等资料,记录龋、失、补指数(decayed?missing?filled teeth,dmft),分为ECC组(n=146)和无龋组(n=243),采集指尖末梢血检测维生素D体内活性形式--25?羟维生素D[25(OH)D],采集牙菌斑行龋活跃性检验检测龋态(Cariostat)值,Logistic回归分析25(OH)D等龋相关因素与ECC发生风险的相关性。结果25(OH)D缺乏、不足、正常的儿童的患龋率差异无统计学意义(c2=2.320,P=0.313)。dmft与25(OH)D水平之间无相关(dmft=1~3,r<0.001,P>0.05;dmft>3,r=0.009,P>0.05)。而月龄(OR=1.082,95%CI:1.045~1.121,P<0.001)、出生后6个月内母乳喂养(OR=2.789,95%CI:1.581~4.921,P<0.001)、吃夜奶或含乳头睡(OR=4.187,95%CI:1.938~9.048,P<0.001)、1.5~3.0的高Cariostat值(OR=4.173,95%CI:2.014~8.646,P<0.001)是ECC的风险因素。结论25(OH)D水平与6~48月龄儿童龋无相关性,而月龄、出生后6个月内母乳喂养、吃夜奶或含乳头睡、高龋活跃性(Cariostat值1.5~3.0)是ECC的风险因素,提倡母乳喂养的同时,应为幼儿树立良好的喂养习惯及口腔卫生习惯。     

Parental knowledge, beliefs and behaviours for oral health of toddlers residing in rural Victoria

BACKGROUND: Little is known about the oral health of children under the age of four years. The determinants of early childhood caries (ECC) in this young age group are also not well understood despite a growing recognition that early interventions may deliver the greatest benefits. The aim of this study was to examine the oral health-related knowledge, attitudes and reported behaviours of parents of children aged 12-24 months living in rural areas of Victoria, Australia. METHODS: A robust theoretical model was utilized to identify oral health-related behaviours and their antecedent and reinforcing conditions within the context of this specific population group. Two hundred and ninety-four parent/child dyads were recruited through their maternal and child health nurses as part of a larger intervention trial. Parents completed a self-report questionnaire. RESULTS: Knowledge regarding risk and protective factors amongst parents was variable and sometimes at odds with contemporary evidence. Knowledge of the role of early infection with S. mutans was very low, with high levels of behaviours that may promote early transmission reported. Tooth cleaning was reported by most parents at least sometimes, however a large proportion lacked confidence and this was significantly related to the frequency of the cleaning. Parents were confused about the fluoride status of their water supplies. Most parents believed fluoride toothpaste reduced the risk of ECC but did not know whether it should be used with toddlers. CONCLUSIONS: The results of this study have implications for efforts to prevent dental decay in this very young age group. Health care professionals other than dentists need support to provide information and promote confidence with regard to optimal fluoride exposure. Attention should also be given to the contribution of early contact with particular bacteria in oral health education and promotion programmes.     

A longitudinal study of dental caries risk among very young low SES children

Abstract – Objectives: Early childhood caries (ECC) is a challenging public health problem in the United States and elsewhere; however, there is limited information concerning risk factors in very young children. The purpose of this study was to assess baseline risk factors for 18‐month caries prevalence as part of a longitudinal study of high‐risk children. Methods: About 212 children, 6–24 months of age were recruited from a rural community in Iowa. Subjects were enrolled in the WIC program, which provides nutritional support for low‐income families with children. Dental examinations using d1, d2–3 criteria were conducted at baseline and after 18 months. Caries prevalence was determined at the frank decay level (d2–3 or filled surfaces), as well as at the noncavitated level (d1), and combined (d1, d2–3 or f surfaces). Risk factor data were collected at baseline and after 9‐ and 18‐ months. These data included beverage consumption data, presence of visible plaque, and use of fluoride toothpaste for children as well as mutans streptococci (MS) levels of mothers and children and family sociodemographic factors. Results: About 128 children (60%) remained in the study after 18 months. Among these children, prevalence of d1,d2–3/f level caries increased from 9% to 77%, while d2–3/f level caries increased from 2% to 20%. Logistic regression models for baseline predictors of d2–3f caries at the 18‐month follow‐up found the presence of MS in children (OR = 4.4; 95% CI: 1.4, 13.9) and sugar‐sweetened beverages (OR = 3.0; 95% CI: 1.1, 8.6) to be the only significant risk factors. Sociodemographic factors and the use of fluoride toothpaste were not significant in these models. Conclusions: Results suggest that early colonization by MS and consumption of sugar‐sweetened beverages are significant predictors of ECC in high‐risk populations.     

Public health issues in early childhood caries

Early childhood caries (ECC) is primarily a disease of poor, minority population children who generally have limited access to dental services. Public health dental clinics have not made the prevention and control of ECC a priority, and the services provided have not controlled ECC. New training and early screening are recommended. Additionally, repeated accessing of mothers and children through prenatal and postnatal medical visits is recommended. At such visits behavioral and chemotherapeutic strategies need to be utilized. Examples from a demonstration project in the Commonwealth of Northern Marianas are presented.     

Preventing early childhood caries: lessons from the field

Early childhood caries (ECC) is a significant public health concern affecting millions of high-risk families with young children. The purpose of this article is to present the proceedings from a May 2005 national forum, convened in Washington, DC, by the Maternal and Child Health Bureau of the Health Resources and Services Administration, which brought together representatives of 14 ECC programs from around the United States to share experiences and help inform future efforts to prevent and reduce ECC. Conclusions drawn from the presentations representing public, private, and academic sectors include: (1) oral health is an integral part of overall health and impacts quality of life and health outcomes; (2) oral health should be integrated into broader child health and development systems; (3) dental caries should be addressed through a chronic disease management model; (4) comprehensive approaches incorporating multiple strategies that involve families, clinicians, and child services providers in ECC prevention and reduction efforts should be employed. Lessons learned from existing ECC programs-summaries of which are included in the article-provide valuable insight into a number of core principles for preventing ECC. Findings from this workshop constitute a knowledge base that can help improve and strengthen ECC programs.     

An evaluation of NHANES III estimates of early childhood caries

OBJECTIVES: The purposes of this study were to estimate and evaluate the prevalence for the United States of early childhood caries (ECC) among children 12 to 23 months of age. METHODS: The 1988-94 National Health and Nutrition Examination Survey (NHANES III) public-use data set was analyzed using SUDAAN. Two ECC case definitions were used. Definition #1 was restricted to the caries score called by the examiner. Definition #2 liberally included children identified by definition #1 and those possibly having questionable caries scores. RESULTS: The NHANES III six-year prevalence estimates of caries in the maxillary anterior incisors of children 12 to 23 months of age were 1.0 percent for definition #1 and 1.7 percent for definition #2. Mexican-American and economically disadvantaged children were disproportionally represented with ECC. CONCLUSIONS: The prevalence of ECC among children 12 to 23 months of age is barely detectable at the national level. Alternative study designs and improved case definitions are needed for further advances in ECC.     

Incidence of early childhood caries: A systematic review and meta‐analysis

The aim was to systemically review the incidence of early childhood caries (ECC). The addressed focused question was “What is the reported incidence of ECC?” Indexed databases were searched using various key words. Five studies were included and processed for data extraction. All studies were prospective and two studies were randomized clinical trials. The number of participants ranged between 96 and 1275 children. Two studies reported the mean age of children, that ranged between 1.8 and 2.5 years (range 0.5 to 5 years). In three studies, the follow‐up duration was 2 years, and in two studies the participants were followed‐up till 3 and 5 years, respectively. Results from all studies reported that the incidence of ECC was significantly higher among children with caries at baseline compared with caries‐free children. In conclusion, the incidence of ECC is significantly higher in children with a previous history of dental caries.     

A 2-year community-randomized controlled trial of fluoride varnish to prevent early childhood caries in Aboriginal children

Abstract – Objective: To measure the effectiveness of fluoride varnish (FV) (Duraflor^®, 5% sodium fluoride, Pharmascience Inc., Montréal, QC, Canada) and caregiver counseling in preventing early childhood caries (ECC) in Aboriginal children in a 2‐year community‐randomized controlled trial. Methods: Twenty First Nations communities in the Sioux Lookout Zone (SLZ), Northwest Ontario, Canada were randomized to two study groups. All caregivers received oral health counseling, while children in one group received FV twice per year and the controls received no varnish. A total of 1275, 6 months to 5‐year‐old children from the SLZ communities were enrolled. In addition, a convenience sample of 150 primarily non‐Aboriginal children of the same age were recruited from the neighboring community of Thunder Bay and used as comparisons. Longitudinal examinations for the dmft/s indices were conducted by calibrated hygienists in 2003, 2004 and 2005. Results: Aboriginal children living in the SLZ or in Thunder Bay had significantly higher caries prevalence and severity than non‐Aboriginal children in Thunder Bay. FV treatment conferred an 18% reduction in the 2‐year mean ‘net’ dmfs increment for Aboriginal children and a 25% reduction for all children, using cluster analysis to adjust for the intra‐cluster correlation among children in the same community. Adjusted odds ratio for caries incidence was 1.96 times higher in the controls than in the FV group (95% CI = 1.08–3.56; P = 0.027). For those caries‐free at baseline, the number (of children) needed to treat (NNT) equaled 7.4. Conclusions: Findings support the use of FV at least twice per year, in conjunction with caregiver counseling, to prevent ECC, reduce caries increment and oral health inequalities between young Aboriginal and non‐Aboriginal children.