Clin Oral Invest DOI 10.1007/s00784-015-1685-z
ORIGINAL ARTICLE
Evaluation of an interdisciplinary preventive programme for early childhood caries: findings of a regional German birth cohort study Yvonne Wagner 1 & Roswitha Heinrich-Weltzien 1
Received: 21 January 2015 / Accepted: 1 December 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Objectives The aim of this prospective birth cohort study was to evaluate the effect of the interdisciplinary preventive programme (PP) for early childhood caries in 3-year-old children in Germany. Material and methods From July 2009 to October 2010, all parents of newborns (n = 1162) were visited after birth by the communal newborn visiting service of Jena, Thuringia, and advised on general and dental health. In the first year of life, children were invited to a dental examination in Jena University Hospital. Participating children were included in a risk-related recall system with continuous oral care over 3 years. Cariesrisk assessment tool of the AAPD was used for risk categorizing. High-risk children received fluoride varnish biannual. In 2013, the total birth cohort (participants and non-participants) was invited to evaluate the PP. Dental caries was scored using WHO diagnostic criteria expanded to d1-level without radiography. Data were analysed statistically (multivariate logistic regression). Results Seven hundred fifty-five children (mean age 3.26 ± 0.51 years) were examined. Children in the PP (n = 377) showed significantly lower caries prevalence and experience than non-participants (15.6 vs. 37.8 %, 0.9 ± 3.3 d14mfs vs. 2.6 ± 5.2 d1-4mfs). Lack of vitamin D supplements (OR = 1.9, CI 0.99–3.51), familial caries experience (OR = 2.2, CI 1.27–3.73) and visible plaque on teeth Electronic supplementary material The online version of this article (doi:10.1007/s00784-015-1685-z) contains supplementary material, which is available to authorized users. * Yvonne Wagner
[email protected] 1
Department of Preventive Dentistry and Pediatric Dentistry, Jena University Hospital, Bachstr. 18, Jena, Germany
(OR = 6.5, CI 4.41–9.43) were significant risk factors for caries development, whereas regular dental care (OR = 0.5, CI 0.38– 0.79) had a protective effect. Conclusions The PP was an effective interdisciplinary approach for preventing early childhood caries in small children. Clinical relevance Early dental visits with caries-risk-related preventive dental care are necessary to prevent early childhood caries (ECC). Trial registration German Clinical Trials Register DRKS00003438, https://drks-neu.uniklinik-freiburg.de/drks_ web/navigate.do?navigationId=trial.HTML&TRIAL_ID= DRKS00003438 Keywords Infant . Oral health . Risk factors . Vitamin D . Dental care . Fluorides
Introduction Dental caries is a serious oral health problem and affects 5–94 % of 1- to 5-year-old children worldwide [1, 2]. Early childhood caries (ECC) is a rampant caries form of 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 [1]. Any sign of smooth-surface caries in children younger than 3 years of age is known as severe ECC (S-ECC) [1]. ECC may cause immense destruction of primary dentition soon after tooth eruption and affects a child’s health, quality of life and devRelopment [3, 4]. Despite several initiatives to improve oral health in childhood, the reduction of caries prevalence in primary dentition is quite modest and ECC is increasingly typical in groups with low socioeconomic status (SES) [1, 2, 5]. Since dental caries is recognized as a non-communicable disease, a new paradigm for caries management, with a common vision of health
Clin Oral Invest
and the involvement of health and non-health sectors, should be developed [6]. By prioritizing infants, the Global Caries Initiative places oral health within maternal and child health programmes using new multi-sectoral and collaborative approaches together with strengthening the role of dentists to eradicate ECC in children younger than 3 years of age [7]. New preventive approaches should focus on pregnant women and mothers of infants by involving gynaecologists, midwives, paediatricians and nurses as well as trained nonprofessionals to improve health awareness and to give dietary guidance [6, 7]. In this context, a regional programme in the German federal state of Thuringia was carried out focussed on a new pathway taking a holistic interdisciplinary approach for the prevention of ECC, based on cooperation between the Department of Preventive and Pediatric Dentistry (DPD), Jena University Hospital, and the communal newborn visiting service (CNVS) of the Youth Welfare Office of the city of Jena. The purpose of this cooperation was to ensure access to all families for general and oral health promotion in young children. The evidence-based strategies used for the prevention of ECC included maternal counselling, daily brushing with fluoridated toothpaste, the 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 [8–12]. Early identification of a child’s level of risk of the development of dental caries and the implementation of appropriate preventive measures are critical to avoid caries
onset [13, 14]. Recent studies have shown the success of these preventive approaches as a foundation for effective oral health promotion [15, 16]. Qualified staff (midwives, social workers and nurses) of CNVS visit all parents of newborn children (about 1000 children per year) shortly after birth and counsel them on general and oral health using brief motivational interviewing and anticipatory guidance approaches. Dental care, including caries-risk-related continuous dental visits up to the age of 3 to 4 years of age, should be provided by a dentist in the dental practice of the DPD. The purpose of the present study was to evaluate the effect of the interdisciplinary preventive programme (PP) for ECC in 3- to 4-year-old Thuringian children in Germany. The study hypothesis was that children who participate in the PP have a lower caries prevalence and caries experience than children who did not participate (the control group).
Materials and methods The Ethics Committee of Jena University Hospital approved this prospective cohort study (2759-02/10; German Clinical Trials Register DRKS00003438). This study was conducted with the informed consent of all caregivers and in full accordance with the ethical requirements of the World Medical Association Declaration of Helsinki (2008). This investigation complied with the recommendations of the Strengthening the
Timeline 2009
Communal newborn visiting service (CNVS) 1162 children born and visited
Control group (CG) 650 (55.9%) children 342 children - family dentist 308 children - no interest
Prevention group (PG) 512 (44.1%) children
Drop-out rate 135 (26.4%) children 67 children - schedule difficulties 12 children - relocation 56 children - without stating reasons
Drop-out rate 272 (41.8%) children 76 children - relocation 196 children - without stating reasons
Follow-up 377 (73.6%) children Continuous dental care
2013
Final examination 755 (65.0%) children
Fig. 1 Patient flow chart of the total birth cohort for the 3-year interdisciplinary preventive programme
Clin Oral Invest Table 1 Caries prevalence (%), caries experience (dmfs/dmft) and care index (%) of the prevention (PG) and control group (CG) after 3 years running of the preventive programme (PP)
Total
PG
CG
p value
Caries prevalence at d1–4 level (%) Caries prevalence at d3–4 level (%) d1-4mfs (x ± SD) d3-4mfs (x ± SD)
755 26.9 8.6 1.7 ± 4.4 0.8 ± 3.5
377 15.6 1.3 0.9 ± 3.3 0.3 ± 2.1
378 37.8 17.2 2.6 ± 5.2 1.4 ± 4.4
0.001 0.001 0.001 0.001
d1-4mft (x ± SD) d3-4mft (x ± SD)
1.2 ± 2.5 0.4 ± 1.4
0.5 ± 1.4 0.1 ± 0.7
1.9 ± 3.0 0.6 ± 1.8
0.001 0.001
Care index (%)
50.0
100.0
0.0
0.001
Children (n)
Reporting of Observational studies in Epidemiology (STROBE) statement guidelines. Preventive programme Since 2009, CNVS qualified staff (midwives, social workers and nurses) have visited and counselled all parents of newborn children (about 1000 children per year) between the 1st and 4th week after birth. The CNVS staff were trained and educated by the DPD in pedagogics and didactics to enable them to perform the PP. The training of the staff involved a workshop comprising 2 days of background learning of ECC (epidemiology, treatment, prevention). An evaluation of the training programme was undertaken, which consisted of a knowledge-based questionnaire. The staff were further assisted and supported by the DPD with yearly 1-day follow-up meetings for programme refinement and development and by mutual shadowing during the courses. Mothers were counselled on general and oral health using brief motivational interviewing and anticipatory guidance approaches (covering the importance of breastfeeding, use of baby bottles and pacifiers, healthy diet, importance of screening examinations by a paediatrician and caries development and its prevention). It was advised that tooth brushing should be started when the first tooth erupts and should be undertaken once a day after meals with an age appropriate toothbrush and a smear layer of fluoride toothpaste (500 ppm F) [12]. From the child’s 2nd birthday, teeth should be brushed twice a day after meals with a pea-sized amount of fluoride toothpaste [12]. Parents should establish a dental home with regular dental care. Every family received a folder with brief information material in their native language, and a toothbrush, toothpaste and a pacifier for the child were provided as incentives. In the child’s first year of life, the families were invited by CNVS to a dental examination of the child in the DPD. Families who followed the invitation were included as participants of the PP with caries-risk-related continuous dental care in the dental practice of the DPD up to the age of 3 to 4 years; these were classed as the participating group (PG). Families who did not appear for the dental examination were included in the
control group (CG). All the examinations were conducted by the same qualified dentist (YW) in the dental practice of the DPD. The dentist was trained and guided by an experienced clinician (RHW). The caries-risk assessment tool (CAT) for infants, children and adolescents of the American Academy of Pediatric Dentistry (AAPD) was used for the caries-risk categorizing of the children, and this was re-evaluated at each dental appointment [17]. Children who had initial caries lesions (d1-lesion), cavities and/or developmental defects of enamel were included in the high-caries-risk group. Children at increased caries risk were reappointed every 3 months, and children with low or moderate caries risk every 6 months to receive dental care in the dental practice of the DPD [14, 17]. High-risk children received fluoride varnish application biannually (Fluoridin N5, VOCO GmbH, Cuxhaven, Germany). The cariogenic microflora (level of mutans streptococci, lactobacilli) as a risk factor was not recorded due to the associated higher costs.
Dental examination In 2013, all the parents of children (total n = 1162, PP n = 512, CG = 650) born in Jena, Germany, between July 2009 and Table 2 Caries experience (d1–4mfs) in the prevention (PG) and control group (CG) regarding the socioeconomic status Socioeconomic status Low Children (n = 755) 64 PG (n = 377) 35 CG (n = 378) 29 Total d1–4mfs (mean ± SD) 4.4 ± PG 1.5 ± CG 7.9 ± Total d3–4mfs (mean ± SD) 2.7 ± PG 0.3 ± CG 5.6 ±
7.8 5.3 8.9 6.1 0.6 8.1
ANOVA
Middle
High
491 228 263 1.6 ± 0.7 ± 2.4 ± 0.7 ± 0.1 ± 1.2 ±
200 114 86 1.0 ± 0.5 ± 1.3 ± 0.3 ± 0.1 ± 0.5 ±
4.1 3.1 4.8 3.0 0.7 4.0
p value
3.1 1.4 3.2 1.8 0.6 2.7
0.001 0.302 0.001 0.001 0.221 0.001
Male Female Yes No Low Middle/high Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Gender
Migration background
Socioeconomic status
Single parent
Mother/primary caregiver has active caries
Familial early childhood caries burden
Preterm birth
General disease/special health care needs
Medication
Systemic antibiotic medication
No use of vitamin D supplements
Child has >3 between-meal sugar-containing snacks/beverages per day
Child is put to bed with a bottle containing natural or added sugar
Child’s teeth were brushed daily with fluoridated toothpaste
Child receives topical fluoride from health professional
Child has dental home/regular dental care
Child has enamel defects
Child has plaque on teeth
Variables
25.3 74.7
4.1 95.9
64.1 35.9
52.2 47.8
94.2 5.8
2.3 97.7
2.3 97.7
7.9 92.1
29.0 71.0
11.9 88.1
6.0 94.0
3.9 96.1
11.0 89.0
1.9 98.1
0.8 99.2
8.5 91.5
5.3 94.7
51.0 49.0
(191) (564)
(31) (724)
(484) (271)
(381) (374)
(711) (44)
(17) (738)
(17) (738)
(60) (695)
(219) (536)
(90) (665)
(45) (710)
(29) (726)
(83) (672)
(14) (741)
(6) (749)
(64) (691)
(40) (715)
(385) (370)
58.6 16.0
19.4 26.9
21.9 35.4
18.4 35.3
25.0 29.5
41.2 26.4
29.4 26.7
48.3 24.9
37.9 22.2
28.9 26.6
24.4 27.0
24.1 26.9
54.2 23.4
42.9 26.5
16.7 26.8
37.5 25.8
35.0 26.3
26.0 27.6
%
%
(112) (90)
(6) (195)
(106) (96)
(70) (132)
(189) (13)
(7) (195)
(5) (197)
(29) (173)
(83) (119)
(26) (177)
(11) (192)
(7) (195)
(45) (157)
(6) (196)
(1) (201)
(24) (178)
(14) (188)
(100) (102)
(n)
Yes (n = 202)
(n = 755) (n)
Caries
All children
41.4 84.0
80.6 73.1
78.1 64.6
81.6 64.7
75.0 70.5
58.8 73.6
70.6 73.3
51.7 75.1
62.1 77.8
71.1 73.4
75.6 73.0
75.9 73.1
45.8 76.6
57.1 73.5
83.3 73.2
62.5 74.2
65.0 73.7
74.0 72.4
%
(79) (474)
(25) (529)
(378) (175)
(311) (242)
(522) (31)
(10) (543)
(12) (541)
(31) (522)
(136) (417)
(64) (488)
(34) (518)
(22) (531)
(38) (515)
(8) (545)
(5) (548)
(40) (513)
(26) (527)
(285) (268)
(n)
No (n = 553)
7.45
0.65
0.51
0.41
0.84
1.94
1.14
2.82
2.15
1.06
0.77
0.87
3.88
2.08
0.54
1.73
1.51
1.08
OR
5.17–10.74
0.26–1.60
0.37–0.71
0.29–0.58
0.43–1.64
0.73–5.18
0.40–3.28
1.65–4.81
1.53–3.03
0.65–1.73
0.38–1.58
0.36–2.06
2.43–6.19
0.71–6.08
0.06–4.69
1.01–2.94
0.77–2.95
0.78–1.49
95 % CI
0.001
0.646
0.001
0.001
0.600
0.183
0.805
0.001
0.001
0.822
0.472
0.742
0.001
0.220
0.491
0.043
0.228
0.636
p value
Table 3 Description of independent variables for all the children and the children with caries experience. Chi-square test or Fisher exact test were used with caries experience (d1–4 level) in children as the dependent variable
Clin Oral Invest
Clin Oral Invest
October 2010 were invited by the CNVS to a final dental examination in the DPD. All the examinations were conducted using a dental light, mirror and sterile gauze for teeth cleaning and drying. Caries experience was assessed by the dmfs index at the d1-level and scored according to WHO standard criteria [18]. No radiographs were taken. In addition to the parent interview in CAT, the factors single parent, preterm birth, familial ECC burden, general disease (cardiovascular, metabolic or kidney disease), medication, systemic antibiotic medication and the use of vitamin D supplements were recorded [1, 2, 13, 14, 17, 19–24]. To determine the caries burden of the family, the mother/ caregiver was asked if the siblings have caries, fillings or other restorations, or if they had received dental treatment under general anaesthesia. For cases with missing values, the factor was considered as Bno familial ECC burden^. To determine the caries burden of the mother/caregiver, families were asked if they have consulted a dentist within the last 24 months, and what was the reason for the visit, or if they currently have dental problems, such as caries or dental pain. Restorative or surgical therapy due to caries, including fillings, crowns, a dental prosthesis or tooth removal, was interpreted as treatment. Dental problems, such as caries or dental pain, were interpreted as untreated active caries. For cases with missing values, the factor was considered as Bmother/caregiver has no active caries^. The SES of the families was assessed by using the Brandenburg social index [25]. The index was computed for each child based on the education and employment status of their parents, and children were allocated to lower, middle or higher SES groups [25]. For cases with missing values for one parent, the value of the other parent part was double weighted, analogous for single parents [25]. The care index used for the evaluation of dental care describes the proportion of filled and extracted teeth of the d3-4mft index. All the records were performed by the same calibrated dentist (YW). The dentist was trained and calibrated in accordance with the recommended methodology for basic oral health surveys by an experienced epidemiologist (RHW) [18]. The intra-rater reliability was almost perfect (κ = 0.89).
Table 4 Multivariate logistic regression analysis of associations between caries experience in children and low socioeconomic status, familial early childhood caries burden, systemic antibiotic medication, no use of vitamin D supplements, child receives topical fluoride from health professional, child has regular dental care and child has plaque on teeth. Backward stepwise elimination was used
Statistical analysis Data were recorded in Excel files and transferred to the Statistical Package for Social Sciences (SPSS version 20) for analysis (IBM Corporation, Armonk, NY, USA). The data were analysed using the t test (for comparison of two groups) and one-way ANOVA (for comparison of three groups). The chi-square test (Pearson) or Fisher exact test was used to determine if there was a relationship between the independent variable (mother/caregiver with caries, low SES, ethnicity, diet, single parent, preterm birth, familial ECC burden, general disease, medication, use of vitamin D supplements, etc.) and the outcome variable of caries experience before the multivariate analysis was conducted. Variables that showed significant associations were included in the multivariate logistic regression analysis. A backward stepwise elimination was used in the logistic regression. A further calculation was conducted to determine if there was a relationship between the independent variable (mother/caregiver with caries, low SES, ethnicity, diet, single parent, preterm birth, familial ECC burden, general disease, medication, use of vitamin D supplements, etc.) and the variable participation in the preventive programme. A p value ≤0.05 was used to indicate statistically significant differences.
Results Seven hundred fifty-five children (PP, n = 377; CG, n = 378) with a mean age of 3.26 ± 0.51 years could be examined. Forty-nine percent of the children were female and 5.3 % had a migration background. Figure 1 demonstrates the patient flow chart of the total birth cohort for the 3-year interdisciplinary preventive programme. ECC was present in 26.8 % (n = 202) of the children and S-ECC was recorded in 16.3 % (n = 123). The data of caries prevalence, caries experience and the care index are shown in Table 1. Children in the PG had significantly lower caries prevalence and experience at the d1–4 and d3–4 level than children in the CG. No dental decay in the CG was treated. The SES composition of both
Variable Familial early childhood caries burden No use of vitamin D supplements Child has regular dental care Child has plaque on teeth
Yes No (ref) Yes No (ref) Yes No (ref) Yes No (ref)
OR
95 % CI
p value
2.2
1.25–3.80
0.005
2.2
1.15–4.20
0.054
0.5
0.36–0.77
0.001
6.5
4.35–9.55
0.001
Male Female Yes No Low Middle/high Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Gender
Migration background
Socioeconomic status
Single parent
Mother/primary caregiver has active caries
Familial early childhood caries burden
Preterm birth
General disease/special health care needs
Medication
Systemic antibiotic medication
No use of vitamin D supplements
Child has >3 between-meal sugar-containing snacks/beverages per day
Child is put to bed with a bottle containing natural or added sugar
Child’s teeth were brushed daily with fluoridated toothpaste
Child receives topical fluoride from health professional
Child has dental home/regular dental care
Child has enamel defects
Child has plaque on teeth
Variables
25.3 74.7
4.1 95.9
64.1 35.9
52.2 47.8
94.2 5.8
2.3 97.7
2.3 97.7
7.9 92.1
29.0 71.0
11.9 88.1
6.0 94.0
3.9 96.1
11.0 89.0
1.9 98.1
0.8 99.2
8.5 91.5
5.3 94.7
(191) (564)
(31) (724)
(484) (271)
(381) (374)
(711) (44)
(17) (738)
(17) (738)
(60) (695)
(219) (536)
(90) (665)
(45) (710)
(29) (726)
(83) (672)
(14) (741)
(6) (749)
(64) (691)
(40) (715)
5.4 44.4
2.6 47.2
49.9 0.0
47.9 2.0
47.5 2.4
1.3 48.5
1.7 48.1
2.1 47.7
10.1 18.8
6.8 43.1
3.6 46.3
2.1 47.7
2.0 47.9
0.7 49.2
0.7 49.2
4.6 45.2
3.0 46.8
26.1 23.7
(41) (336)
(20) (357)
(377) (0)
(361) (16)
(358) (19)
(10) (367)
(13) (364)
(16) (361)
(77) (300)
(51) (326)
(27) (350)
(16) (360)
(15) (362)
(5) (372)
(5) (372)
(35) (342)
(23) (354)
(197) (180)
(n)
%
(385) (370)
(n)
% 51.0 49.0
Yes (n = 377)
(n = 755)
19.9 30.2
1.5 48.7
14.2 35.9
2.7 47.5
46.8 3.3
0.9 49.2
0.5 49.6
5.8 44.3
18.8 31.3
5.2 45.0
2.4 47.7
1.7 48.5
9.0 41.1
1.2 48.9
0.1 50.0
3.8 46.3
2.3 47.9
24.8 25.4
%
No (n = 378)
Participation in preventive programme
All children
(150) (228)
(11) (367)
(107) (271)
(20) (358)
(353) (25)
(7) (371)
(4) (374)
(44) (334)
(142) (236)
(39) (339)
(18) (360)
(13) (366)
(68) (310)
(9) (369)
(1) (377)
(29) (349)
(17) (361)
(188) (190)
(n)
5.38
0.53
4.51
0.01
0.71
0.69
0.3
2.96
2.38
0.73
0.65
0.80
5.28
1.81
0.20
0.81
0.72
1.13
OR
3.66–7.89
0.25–1.13
3.82–5.34
0.01–0.02
0.38–1.32
0.26–1.83
0.10–0.92
1.64–5.35
1.71–3.29
0.47–1.14
0.35–1.20
0.38–1.69
2.96–9.42
0.60–5.45
0.02–1.69
0.48–1.35
0.38–1.37
0.85–1.50
95 % CI
0.001
0.102
0.001
0.001
0.280
0.475
0.029
0.001
0.001
0.179
0.170
0.576
0.001
0.420
0.123
0.436
0.334
0.401
p-value
Table 5 Description of independent variables for all the children and the children who participated in the preventive programme. Chi-square test or Fisher exact test was used with participation in preventive programme as the dependent variable
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Clin Oral Invest
groups was similar and the impact of SES on caries experience was significant (Table 2). The average number of dental visits in the PG was 4.5 ± 2.3 compared to 0.3 ± 0.4 in the CG. All the children in the PG had received fluoride varnish application, with an average number of 1.8 ± 1.8 applications, whereas in the CG, 5.3 % of the children were treated once by fluoride varnish. The descriptions of the independent variables for all the children and for the children with caries experience are presented in Table 3. Statistically significant associations were found for caries experience in children with a low SES (OR = 1.7) and familial ECC burden (OR = 3.9). A higher caries risk was also present in children receiving systemic antibiotic medication (OR = 2.2) and in children with no use of vitamin D supplements (OR = 2.8), whereas children receiving professional fluoride varnish application (OR = 0.4) and with regular dental care (OR = 0.5) were at lower caries risk. Children with visible plaque on their teeth revealed the highest caries risk (OR = 7.5). The results of the final multivariate logistic regression analysis (Table 4) demonstrate associations between caries experience in children and low SES, familial ECC burden, systemic antibiotic medication, no use of vitamin D supplements, professional fluoride varnish application, regular oral care and visible plaque on teeth. Children who did not receive vitamin D supplements had a 1.9 times higher probability of having caries experience at the age of 3 years than children who received vitamin D. Children with familial ECC burden had a 2.2 times higher probability of having caries experience than children without familial caries. Children with visible plaque on their teeth had a 6.5 times higher probability of having caries experience than children with clean teeth. Children who had a dental home and received regular dental care had a 0.5 times lower probability of having caries experience than children without regular dental care. The descriptions of
the independent variables for all the children and for the children who participated in the PP are presented in Table 5. The resulting statistical associations are similar to the findings in Table 3, with the exception of the variable low SES. There was no statistical significant association found between participation in the PP and children having a low SES. However, a new statistically significant association was found between participation in the PP and a child having >3 between-meals sugarcontaining snacks/beverages per day. The results of the final multivariate logistic regression analysis (Table 6) demonstrate associations between participation in the PP and the variables: familial ECC burden, systemic antibiotic medication, no use of vitamin D supplements, a child having >3 between-meal sugar-containing snacks/beverages per day, professional fluoride varnish application, regular oral care and visible plaque on teeth. The findings are consistent with the presented results in Table 3.
Table 6 Multivariate logistic regression analysis of associations between participation in preventive programme and familial early childhood caries burden, systemic antibiotic medication, no use of vitamin D supplements, child has >3 between-meal sugar-containing
snacks/beverages per day, receives topical fluoride from health professional, child has regular dental care and child has plaque on teeth. Backward stepwise elimination was used
Variable Familial early childhood caries burden No use of vitamin D supplements Child has regular dental care Child has plaque on teeth
Yes No (ref) Yes No (ref) Yes No (ref) Yes No (ref)
Discussion The study shows that the 3-year-old children who participated in the PP with anticipatory guidance and continuous dental care since birth had a significantly lower caries prevalence and caries experience than their peers who did not participate. The main results are that children with visible plaque on their teeth, children with familial caries burden and children who had not received vitamin D supplements had a higher probability of having caries than other children, whereas regular dental care revealed a caries protective effect. This study is based on data from a regional birth cohort study in Germany. It could be shown that the interdisciplinary PP was effective for the prevention of ECC and the study hypothesis could be confirmed. The combination of early maternal counselling and continuous risk-orientated dental care is an ideal approach for achieving a sustainable influence on a
OR
95 % CI
p value
2.2
1.27–3.73
0.005
1.9
0.99–3.51
0.054
0.5
0.38–0.79
0.001
6.5
4.41–9.43
0.001
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child’s dental health. Counselling of the parents by the CNVS shortly after the time of birth is the first step to promote their awareness of the importance of a healthy diet, good oral hygiene and regular paediatric and dental visits. Parents need to be aware of ECC and its risk factors. The collaboration between the DPD as the health actor and the CNVS of the Youth Welfare Office as a non-health-actor is a new interdisciplinary approach for the prevention of ECC [6, 7]. Working across sectors and alongside the implementation of general and oral health preventive measures in other programmes, such as the CNVS focussing on the early detection of child neglect and child abuse, is a promising tool for holistic health promotion [6, 7, 26]. Another great advantage of the interdisciplinary approach is the access to all families independent of their SES or ethnicity. Lower-income groups usually have a lower response rate to health promotion and preventive programmes, so the CNVS was a good fit to reach more families [26]. The present study shows that more than half of the non-participants could be motivated to consult their family dentist after counselling by CNVS. Despite the benefits, the study reveals that, for a sustainable influence on dental health, counselling by CNVS has to be continued, with constant anticipatory guidance and continuous dental care, and that educational information alone is relatively ineffective in changing behaviours [27]. The inclusion of the children in a caries-riskrelated recall system is helpful so that parents recognize the importance of regular dental health care. Daily tooth brushing with fluoride toothpaste is essential for preventing dental caries in children [8, 10, 11]. In this study, visible plaque on teeth was highly related to the caries experience in the children. Therefore, it is necessary that the parents start teeth brushing in their child when the first tooth erupts, and then continue to assist and supervise them. Recent studies revealed that children who were late to start teeth brushing and children who did not receive a regular second brush by the parents were significantly more affected by dental decay [20, 28]. A further advantage of continuous dental care is that the clinician is able to recognize the first signs of caries and can then apply appropriate preventive interventions, such as a fluoride varnish application. It could be demonstrated that fluoride varnish application has a protective effect on caries development. The efficacy of fluoride varnish has been reliably proven in several scientific studies, and several health programmes already include the application of fluoride varnish in the first 3 years of a child’s life [8–12]. In addition, regular and periodic dental care allows an ongoing re-evaluation regarding the individual caries risk, diet and oral hygiene counselling, as well as plaque removal [14, 17]. Therefore, it is recommended that children at a high risk for caries should have more frequent dental examinations than just 6 months intervals [14, 17]. The present findings show that children with familial ECC burden have a higher
probability of having caries. Inequalities in oral health among children from families with a low educational achievement, low SES, migration background, children of single parents and children with familial ECC burden have been reported in numerous studies worldwide [5, 20, 21, 29]. This study also reveals that the SES is an influencing variable. Nevertheless, it could be demonstrated that the PP has a positive effect on the dental health of 3-year-olds with a low SES. Although participating children with a low SES have a higher caries experience than children with a middle or high SES, the differences between the children of the low-, middle- and high-SES groups are not statistically significant. The present study shows that the interdisciplinary PP with early maternal counselling and continuous risk-orientated dental care is able to compensate the disparities regarding the caries experience. Another outstanding result of this study is that Bno use of vitamin D supplements^ could be identified as a risk factor for caries development. Until now, only a few studies have examined the influence of vitamin D on caries development and they found that vitamin D seems to reduce the risk of dental caries due to its effects on calcium metabolism and on the calcification of teeth [22, 30]. It has also been found that a high proportion of children aged 1–5 years with dental caries are deficient in vitamin D [31]. A meta-analysis suggested that receiving vitamin D supplements in early life was associated with a 47 to 54 % reduced risk of caries [22]. Lower vitamin D serum concentrations were even associated with a higher probability for molar-incisor hypomineralization and cariesrelated restorations [32]. According to the present findings, the current caries risk assessment forms, including the CAT of the AAPD, may need to be extended to include a factor relating to the use of vitamin D supplements. There are a few limitations of the study to note. This was a regional conducted survey in a medium-sized and well-situated city in Germany. It can be expected that in socially deprived areas of Germany, the caries prevalence and experience could be higher; however, this would strengthen the need for action and not change the study findings. Attempts were made to compensate for the lack of randomization of the birth cohort by carrying out an analysis of the non-participants (n = 650) regarding their SES and ethnicity, and this showed no differences (data not shown). To reduce the source of potential bias, all data of the participating children were recorded longitudinally, starting at the time of birth up to the age of 3 to 4 years, and the CAT was re-evaluated at each dental appointment. Nevertheless, it has to be mentioned that the association between the use of vitamin D supplements and caries development was made on the basis of the parent interview and not verified by taking blood samples. With respect to this remarkable finding and the limited number of studies and data, further studies should investigate the role of vitamin D and caries development.
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The evaluation demonstrated that the PP was an effective interdisciplinary approach for the prevention of ECC in preschool children. The collaboration with the CNVS, as a nonhealth actor, is a promising new approach in Germany to support a healthy start in life for children and to equalize health inequalities. In future, dentists should be challenged to incorporate infant oral health care into their practices [1, 6, 10, 13]. Early dental visits with caries-risk-related regular oral care and fluoride varnish application are necessary to prevent caries. Acknowledgments We thank the communal newborn visiting service (CNVS) of the Youth Welfare Office Jena, Germany, for the excellent cooperation. The study received financial and material support by Bamed 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. The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript. Both authors are responsible for reported research (concept and design, data analysis and interpretation, drafting and revising of the manuscript). Compliance with ethical standards The Ethics Committee of Jena University Hospital approved this prospective cohort study (2759-02/ 10; German Clinical Trials Register DRKS00003438). This study was conducted with the informed consent of all caregivers and in full accordance with the ethical requirements of the World Medical Association Declaration of Helsinki (2008). This investigation complied with the recommendations of the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement guidelines. Conflict of interest The authors declare that they have no competing interests.
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