Prevention of early childhood caries: a public health perspective

This paper proposes strategies for preventing early childhood caries (ECC), preferably for the greatest number of children at the lowest cost. Population-based, public health approaches are more likely to reach the target population groups at risk of developing ECC than individual, private practice-based approaches. Different prevention and early intervention strategies are discussed and the following recommendations are made: 1) Continue to promote community water fluoridation. 2) Evaluate the effectiveness of other public health oriented measures to prevent ECC. 3) Develop a national ECC and rampant caries registry. 4) Link oral health screening and easily implemented, low-cost interventions with immunization schedules and public health nursing activities. 5) Increase opportunities for community-based interventions conducted by dental hygienists. 6) Change insurance reimbursement schedules to provide incentives for dentists to prevent disease. 7) Include dentistry in new child health insurance legislation for children as well as parents of infants and preschool children.     

Biological mechanisms of early childhood caries

The present paper reviews biological issues in early childhood caries (ECC) in light of the current understanding of the field. Despite the general global decline in dental caries in the past decades, ECC has become a significant problem in many developing countries and some minority communities in western industrialized nations. Like other types of caries, ECC is caused by mutans streptococci that ferment dietary carbohydrates to produce acid attacks on susceptible teeth over a period of time. However, while the general etiology of ECC appears similar to that of other types of caries, the predisposing factors are still unclear. The biology of ECC may be modified by several factors unique to young children, related to the implantation of cariogenic bacteria, immaturity of the host defense systems, as well as behavioral patterns associated with feeding and oral hygiene in early childhood.     

Introduction to the Early Childhood Caries Conference: initial description and current understanding

The objective of this paper is to introduce the issues discussed at the Early Childhood Caries Conference, held October 18–19, 1997, in Bethesda, Maryland. Early childhood caries (ECC) is of epidemic proportions in some US minority populations and in many developing countries. However, the inadequate information and research on dental caries in infants and toddlers appears to have fostered acceptance of some incorrect assumptions regarding its etiology and prevention. To reexamine the current knowledge of ECC, leaders in this field have critically reviewed the biological and psychosocial mechanisms, public health implications, prevention, research and policy needs. An additional goal of the conference was to convey the health implications and societal costs of this highly prevalent childhood disease to the public, health care providers and policy-makers.     

Psychosocial and behavioral issues in early childhood caries

Rampant caries in infants and young children has long been recognized as a clinical syndrome referred to by various names, including nursing caries, nursing bottle syndrome, night bottle mouth, and baby bottle tooth decay. The common theme among these terms is the perceived central role of inappropriate use of the baby bottle in the etiology and progression of carious lesions. Use of the baby bottle is not the only, and may not be the most important, factor in caries development. Because of questions about the role of the baby bottle in caries among young children, the Centers for Disease Control and Prevention recently suggested that the term for this clinical syndrome be replaced with early childhood caries (ECC). The purpose of this paper is to evaluate the literature on the influence of psychosocial and behavioral factors in early childhood caries. Prevalence of caries and maxillary anterior decay varies greatly in developed and undeveloped countries and among socioeconomic groups in developed countries. However, relatively little is known about the onset and progression of the disease or the antecedents of ECC, such as high risk behaviors, cultural norms, health beliefs and attitudes, or health care delivery factors. Furthermore, studies that do exist are limited by small and possibly biased samples and a lack of clear case definition. Future research should aim to develop a clear case definition of ECC, differentiate patterns of caries and conduct community-based epidemiological studies in order to obtain accurate estimates of the etiology and epidemiology of ECC in the general population, as well as in high risk groups.     

Comparison of allele frequency for HLA-DR and HLA-DQ between patients with ECC and caries-free children

Background: Early childhood caries (ECC) is one of the most common diseases of childhood. The etiology of ECC is multifactorial and both genetic and environmental factors play important roles in the pathogenesis of the disease. Genetic variations in the hosts may contribute to changes in the risk for dental caries. Genetic factors such as human leukocyte antigen (HLA) have recently been suggested as a predisposing factor. Aim: The aim of this study was to look for an association between HLA-DRB1 and HLA-DQB1 with ECC for developing new strategies for the diagnosis as well as the prevention of the disease. Design: In this study, we extracted the genomic DNAs from whole blood samples of 44 patients with ECC and 35 caries-free children by the salting-out method. We amplified the genomic DNA by PCR-SSP and then HLA-typing was performed for all alleles. Results: The results revealed a significant increase in the frequency of HLA-DRB1FNx0104 in the patient group (P = 0.019). The odds ratio for this allele was detected to be 10. The frequency of HLA-DQB1 alleles was not significantly different between the two groups. Conclusion: The above results suggest that HLA-DRB1FNx0104 is associated with the susceptibility to ECC. Thus HLA-DRB1FNx0104 detection as a molecular marker for early diagnosis of ECC may be recommended.     

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。     

Determinants of early childhood caries in low-income African American young children

PURPOSE: The aim of this longitudinal study was to evaluate the association between early childhood caries (ECC) and severe ECC (S-ECC) and social, dietary, and behavioral risk factors. METHODS: A representative sample of low-income 0- to 5-year-old children was selected from Detroit. Children and their caregivers were examined for the presence and severity of dental caries. Trained interviewers administered questionnaires assessing social, dietary, and behavioral factors. RESULTS: A total of 1,021 child and caregiver dyads were examined in wave 1. Of these, 788 (77%) were re-examined in wave 2. ECC and S-ECC were highly prevalent in this cohort By 2 years of age, 7% of the children had ECC without S-ECC (ECC-only) and 27% had S-ECC. The regression model found that age of the child and caregiver, child's gender, and caregivers' fatalistic oral health beliefs were significantly associated with higher odds ratios of developing ECC-only and S-ECC. Consumption of soda beverages was associated with developing S-ECC. Religiosity was protective against ECC-and S-ECC. CONCLUSIONS: Early childhood caries and severe early childhood caries are highly prevalent in low-income African American children. Intake of soda beverages by the children and the caregivers' fatalistic oral health beliefs and religiosity were significant determinants of ECC and S-ECC.     

南京市低龄儿童龋相关危险因素初步研究

目的:研究南京市低龄儿童龋相关危险因素.方法:调查南京市某幼儿园共342例3～5岁儿童口腔健康状况,通过问卷调查收集基线资料,采用横断面研究方法探讨各因素的影响.结果:205例诊断为低龄儿童龋,患龋率为60.0％,其中119例诊断为重度低龄儿童龋,患病率为34.8％.简化软垢指数、菌斑指数、菌斑产酸能力、深点隙裂沟、母...     

Middle ear and respiratory infections in early childhood and their association with early childhood caries

PURPOSE: The purpose of this study was to examine the risk of early childhood caries (ECC) in children who had middle ear infections (MEI) or respiratory tract infections (RTI) during early childhood. METHODS: Medicaid data from Michigan were analyzed for all continuously enrolled children born in 2001 for whom enrollment, medical, and dental claims were filed during 2001-2004. Proportional hazards survival models were used to assess the risk of ECC in children who had MEl or RTI during the first year of life. RESULTS: Included in the study were 29,485 children (51% males and 49% females). By first year of life, 47% and 69% of children had a claim for MEI and RTI, respectively. Children with at least one claim for MEI or RTI were at 29% higher risk for developing ECC compared to those with no claims (P < .001). Hispanic children with 8 or more claims showed 91% greater risk for developing ECC than those with less than 8 claims (P = .01). CONCLUSIONS: The occurrence of middle ear infections or respiratory tract infections during the first year of life is associated with a significantly increased risk for developing early childhood caries during subsequent years. Race and ethnicity are possible predictors for ECC in the studied models.     

Into the future: keeping healthy teeth caries free: pediatric CAMBRA protocols

Early childhood caries prevalence has increased significantly in children ages 2-5 years. ECC disproportionately affects lower socioeconomic and minority groups, is a predictor for future decay, but is preventable and manageable. Caries risk assessment systematically derives a patient's caries risk and is important during an infant oral health visit beginning at age 1. Information obtained through a risk assessment can guide a disease management care path tailored to an individual's age and risk to effectively treat and manage one's caries disease process.     

Determinants of early childhood caries (ECC) in a rural Manitoba community: a pilot study

PURPOSE: Preschool oral health is often overlooked as an important aspect of childhood health and well-being. The purposes of this study were to: (1) determine the dental status of 3-year-old children in the community of Carman, Manitoba, Canada; and (2) identify the principal determinants of Early Childhood Caries (ECC) in 2 consecutive years. METHODS: All children and mothers attending a preschool health screening fair were invited to participate. Study procedures included a retrospective interview with parents and dental examination of the child. Statistical analyses included ANOVA, chi-square, and multiple regression. A P value of <.05 denoted significance. RESULTS: A total of 61 children participated (mean age=45.7+/-3.4 months). The prevalence of ECC was 44%, while the mean deft was 2+/-3.3. Increased caries activity and ECC were associated with lower maternal level of education (P<.01). Family size was associated with deft scores (P=.03) while the presence of debris was also associated with ECC (P<.05). CONCLUSIONS: ECC prevalence among these 3-year-olds is less than exhibited among other Canadian preschool children. Factors associated with ECC included debris on the primary teeth and low maternal education. Factors most associated with increased caries activity included low maternal education and increased family size. In addition, parents were able to reliably assess their child's dental health status. Larger epidemiological studies of ECC are needed to better assess prevalence and risk factors. Such data may, therefore, assist in identifying those children at greatest risk for ECC. It may also help in the redirection of scarce resources to effective preventive oral health interventions, as these children have an increased caries burden along the continuum of childhood.     

Comparison of immunological and microbiological characteristics in children and the elderly with or without dental caries

The purpose of this study was to determine the relationships among early childhood caries (ECC), root caries (RC), the quantity of Streptococcus mutans in saliva, and the concentrations of total and specific secretory IgA (sIgA). Saliva samples were collected from 70 children, 3–4 yr of age, with and without ECC, and from 43 adults, ≥60 yr of age, with and without RC. The decayed, missing, and filled teeth (dmft) and decayed, missing, and filled surfaces (dmfs) scores of each child, and the root decayed and filled teeth (RDFT) and root decayed and filled surfaces (RDFS) scores of each elderly subject, were determined. The S. mutans levels, total sIgA, and specific sIgA against two virulence antigens of S. mutans in saliva were analysed using quantitative real‐time PCR (qPCR) and ELISAs. The quantity of S. mutans was significantly higher in caries‐positive subjects within the two populations than in the caries‐free subjects; and a positive correlation was found between the quantity of S. mutans and the dmft, dmfs, RDFT, and RDFS scores. In addition, the salivary total sIgA was significantly higher in children with severe early childhood caries (SECC) and in the elderly subjects with RC. Moreover, although the S. mutans level was significantly higher, the concentrations of specific sIgA against S. mutans antigens were significantly lower in samples from elderly subjects than in samples from children. These results support the concept that S. mutans is positively associated with ECC and RC. Furthermore, the levels of S. mutans‐specific antibodies in saliva are too low to prevent infection with cariogenic bacteria and to inhibit development of ECC and RC.     

Psychosocial factors and early childhood caries among low-income African-American children in Detroit

Objectives: This study sought to advance knowledge of the social determinants of oral health, by examining how several specific maternal health beliefs, behaviors, and psychosocial factors relate to young children's early childhood caries (ECC) status in a lower‐income African–American population. Methods: Data were collected by the Detroit Dental Health Project (NIDCR grant), a population‐based study of 1021 African–American families with at least one child under 6 years of age and living in 39 low‐income Census tracts in Detroit, Michigan. Analyses were limited to 719 children aged 1–5 years and their biological mothers, and conducted in SUDAAN to account for the complex sampling design. Survey data included health belief scales on mothers’ self‐efficacy, feelings of fatalism, knowledge about appropriate bottle use and children's oral hygiene needs, brushing habits, psychosocial measures of depressive symptoms (CES‐D), parenting stress, and availability of instrumental social support. The child's age, dental insurance status, dental visit history, and 1‐week brushing frequency were also included in the model. Children's ECC status, based on a dental examination, was the main outcome. The dental team used the International Caries Detection and Assessment System (ICDAS) criteria for caries detection. Each child was classified as either caries‐free or having ECC or severe ECC (S‐ECC) based on the case definition of ECC proposed by an expert panel for research purposes with preschool‐aged children. Results: The dental team followed a specific examination protocol and established reliable and consistent ratings of ECC based on the ICDAS criteria. The inter‐rater reliability kappa was 0.83 overall, and the intra‐rater reliability kappa was 0.74 overall. One‐third of the children had ECC, and 20% had severe ECC. Age of the child and lower parenting stress scores were each positively associated with ECC, while higher education and income were protective. Maternal oral health fatalism and knowledge of children's hygiene needs were associated with ECC among preschool‐aged children. ECC was higher among younger children who had past restorative care. Conclusions: These findings call attention to the high prevalence of ECC in this population and the need to consider psychosocial as well as traditional risk factors in developing interventions to reduce oral health disparities.     

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.     

Prevalence of early childhood caries among First Nations children, District of Manitoulin, Ontario

Background. Epidemiological studies of Aboriginal communities in Canada and Native American populations in the United States have reported that early childhood caries (ECC) is highly prevalent. The purpose of this study was to determine the prevalence of ECC and dental caries in the First Nations population of 3‐ and 5‐year‐old children in the District of Manitoulin, Ontario to assist in developing effective dental health promotion strategies. Methods. All 3‐ and 5‐year‐old children in elementary schools and day‐care centres in seven First Nation communities were eligible for the survey examination. Three‐year‐old children at home and 5‐year‐old children attending school off‐reserve in six of the communities were also eligible for epidemiological survey examination of oral health status including caries, gingival and soft tissue conditions. Cases of ECC were defined as children with caries or restorations on two or more primary maxillary incisors or canines or those having a total decayed, missing, filled primary teeth (dmft) score of 4 or greater. Results. A total of 87 children (59% 5 years old, 54% females) were examined. Seventy‐four per cent of children had one or more carious lesions. Forty‐five cases of ECC were found, a prevalence of 52%. The mean dmft score for cases was 7·5 (95% CI 6·5–8·4) and 0·8 (95% CI 0·5–1·1) for non‐cases (P < 0·001). Boys in both age groups were more likely to be affected by ECC than girls. Conclusion. Our results indicate that dental caries and ECC are highly prevalent in this population, with ECC cases having 6.7 more dmft than non‐cases.     

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.     

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早期婴幼儿龋是发生在婴幼儿期的与饮食密切相关的多因素作用下的慢性感染性传播性疾病。变形链球菌是在龋齿的始动和进展中的重要致病微生物。早期婴幼儿龋是一个严重的公众健康问题,它不仅累及牙齿,而且会导致多方面的健康影响。早期婴幼儿龋的防治不但需要来自口腔医疗机构和儿童口腔专科医生的关注,而且需要公众健康机构和决策者的重视。本文将对早期婴幼儿龋的病因、患病率、临床表现和危害、综合防治等问题进行讨论。     

早期婴幼儿龋

提要：早期婴幼儿龋是发生在婴幼儿期的与饮食密切相关的多因素作用下的慢性感染性传播性疾病。变形链球菌是在龋齿的始动和进展中的重要致病微生物。早期婴幼儿龋是一个严重的公众健康问题,它不仅累及牙齿,而且会导致多方面的健康影响。早期婴幼儿龋的防治不但需要来自口腔医疗机构和儿童口腔专科医生的关注,而且需要公众健康机构和决策者的重视。本文将对早期婴幼儿龋的病因、患病率、临床表现和危害、综合防治等问题进行讨论。     

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.