Journal of Investigative and Clinical Dentistry (2011), 2, 223–228

REVIEW ARTICLE Community Dentistry

Risk factors for early childhood caries in disadvantaged populations Amit Arora1, Eli Schwarz2 & Anthony Stevenson Blinkhorn1 1 Department of Population Oral Health, Faculty of Dentistry, The University of Sydney, Sydney, NSW, Australia 2 Department of Community Dentistry, School of Dentistry, Oregon Health and Science University, Portland, OR, USA

Keywords dental caries, disadvantaged population, early childhood caries, preschool children, risk factor. Correspondence Dr Amit Arora, Population Oral Health, Faculty of Dentistry, The University of Sydney, 1 Mons Road, Westmead, NSW 2145, Australia. Tel: +61-2-8821-4371 Fax: +61-2-8821-4366 Email: [email protected] Received 27 February 2011; accepted 26 March 2011.

Abstract 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.

doi: 10.1111/j.2041-1626.2011.00070.x

Introduction Primary (baby) teeth serve multiple roles, such as chewing food, preserving space for permanent teeth, development of speech, and an attractive smile, which is linked to selfesteem. Despite improvements in oral health, dental caries is identified as one of the most prevalent chronic diseases of early childhood.1–3 Dental caries is a bacteria-mediated transmissible disease of multifactorial etiology, characterized by the demineralization and destruction of tooth enamel, dentine, and ultimately infection of the pulp. The onset of dental caries has five necessary components: cariogenic bacteria (predominantly mutans streptococci), fermentable carbohydrates (the substrate), susceptible teeth (the host), lack of fluoride, and time for the disease to develop. Although the literature on the etiology of dental caries is extensive, little is known about the development of dental caries in early childhood.4 This point is highlighted by the fact that researchers have struggled to clearly define dental caries in preschool children. It has been referred to by many different names,5 ª 2011 Blackwell Publishing Asia Pty Ltd

and this has led to problems in comparing the international epidemiological data on caries prevalence.6 In 1999, a US Government-sponsored workshop addressed this issue, and defined early childhood caries (ECC) as the presence of one or more decayed, missing (due to caries), or filled surfaces on any primary tooth in children up to 71 months of age.7 ECC is a rapidly-progressing, debilitating disease, and is characterized by childhood distress, repeat prescriptions of antibiotics, severe pain, sepsis, and sleep loss.3 The longterm consequences of ECC might include reduced growth, nutritional and sleep problems, as well as the potential to disrupt family life.8 Many dental services are faced with preschool children with dental pain who are difficult to treat, and clinical care under general anesthetic is often the only practical option for pain relief and for dealing with carious teeth.3 ECC is an international public health problem.1–3 In 1996, 39% of Australian 6-year-old children had dental caries,9,10 and since that time, the caries experience in Australian children in all states and territories has increased.10,11 The 2002 Child Dental Health Survey of 223

Dental caries in preschool children

Australia reported that 45% of 5 year olds had one or more decayed or missing teeth, and 10% of those children examined were found to have more than seven decayed teeth.12 The problem is not unique to Australia. In the UK, successive national child dental health surveys have shown little change in caries prevalence in 5-year-old children over the last 20 years.13 Data from the USA tell a similar story; from 1988 to 1994, and from 1999 to 2002, there was no change in the prevalence of dental caries among children aged 2–11 years.14 Caries rates in industrialized countries are higher among the more socially disadvantaged,15–17 particularly for children who are refugees or migrants, or whose parents are refugees or migrants from a non-English-speaking background.18 The prevalence of ECC in developing countries and disadvantaged populations within developed countries can be as high as 70%.6 This can arise from socioeconomic disadvantage, social exclusion, sociocultural differences in oral health beliefs and practices, and low health literacy.19–22 The high levels of dental disease are important in dispelling the myth that oral health problems are largely solved, and that future investments in dental care and health promotion are not warranted. However, there is little agreement as to the most effective interventions to prevent ECC. Fisher-Owens et al.23 proposed a model with individual-, family-, and communitylevel influences on the oral health of young children, which incorporates five key domains, namely: genetic and biological factors, the social environment, the physical environment, health behaviors, and dental/medical care. However, these domains should be used with care, as there is considerable overlap of the physical environment and dental/medical care with the other three domains. The objective of this review is to investigate the current evidence base in relation to the etiology of dental caries in disadvantaged children under the age of 6 years, in order to provide an evidence base to inform health service personnel planning interventions to control the problem. Methods This review was undertaken to delineate the mechanisms involved in the etiopathogenesis of ECC, so that effective future preventive programs could be developed for disadvantaged communities. The following databases were searched: Cochrane Central Register of Controlled Trials (CENTRAL), Medline (Ovid), and PubMed. Sensitive search strategies were developed using a combination of free text and controlled vocabulary, with the assistance of a highly-experienced librarian to identify the best-available evidence. Systematic reviews were used where available, and in their absence, meta-analyses; randomized, controlled trials; cohort studies; case-control studies; and 224

A. Arora et al.

cross-sectional studies were used, in that order. The studies were restricted to those published in English that reported on children under the age of 6 years, and were published from 1990 to October 2010. No specific hand searching was undertaken. The findings of the literature are presented under three headings: biological issues, behavioral issues, and sociodemographic influences in ECC. Biological issues in ECC Streptococcus mutans (SM) and lactobacilli are the predominant microorganisms in the development of ECC.4,8,24–27 SM has been associated with the development of early carious lesions,24–26 and lactobacillus has been associated with the progression of lesions into the dentine.27 The cariogenic bacteria can: (a) transport sugars and convert them to acid (acidogenic); (b) produce extracellular and intracellular polysaccharides that contribute to the plaque matrix and enable the bacteria to adhere to one another and to the tooth surface, probably via specific receptors; and (c) thrive at a low pH.28,29 The age at which the child is infected with SM is important in determining the caries risk of the child.4,30 Historically, it was believed that mutans streptococci required a non-shedding surface for colonization, and it was hypothesized that they were unable to colonize a predentate infant,31 as researchers did not find SM until the primary teeth erupted.32 In addition, it has become evident that the ‘‘window of infectivity’’ for the colonization of SM is between the age of 19 and 31 months.33 However, research from the USA raises doubt on the accuracy of the ‘‘window of infectivity’’, as SM has been detected in toddlers under the age of 19 months.34 In addition, recent research from Australia supports these findings that predentate infants can be colonized with SM.35,36 The factors associated with early colonization were sweetened fluids taken to bed, frequent sugary snacks, sharing foods with adults, and maternal SM levels.35 A recent systematic review that investigated the relationship between SM and ECC concluded that SM is a strong risk indicator for ECC,37 and data from longitudinal studies are now emerging, showing that SM is the key determinant of ECC.35 The main defense against SM-induced dental caries is the fluoride from toothpaste or water and saliva. Fluoride encourages remineralization of damaged enamel and interferes with the bacterial metabolism. Saliva reduces dental caries by buffering plaque acids, the presence of immunoglobulins, and increased flow rates when eating.4,38 In addition, it is a reservoir for calcium and phosphate minerals, which aid in the remineralization of the enamel.38 Upon eruption, teeth have immature enamel and are most susceptible to dental decay.39 However, with time, ª 2011 Blackwell Publishing Asia Pty Ltd

A. Arora et al.

the tooth enamel matures after incorporating minerals from the mouth, including fluoride.39 Many studies have also found an association between developmental defects of teeth, such as enamel hypoplasia, and dental caries.40–43 Behavioral issues in ECC Dental caries is related to family norms of behavior, especially a child’s feeding habits, toothbrushing frequency, exposure to fluoride, and dental visits. Feeding habits There is a wealth of evidence that demonstrates a relationship between fermentable carbohydrates in the diet and dental caries.44 The relationship between sugar consumption and caries experience is largely dependent on the frequency of sugar consumption.45 A systematic review concluded that the relationship between sugar consumption and dental caries is not as strong as it was in the prefluoride era; however, the restriction of sugar consumption has an important role in caries prevention, especially in young children with immature enamel.46 Although non-milk extrinsic sugars differ very little in their acidogenic potential, sucrose is the most common product in most food and drinks, and it is readily fermented by SM.45 A systematic review on ECC has shown that the manner and form in which sugar is taken, and the frequency of consumption, are more important than the absolute amount of sugar consumed.30 Drinks, such as fruit juices and carbonated drinks, are an increasingly important source of sucrose in the diet of young children,47 and their consumption is associated with dental caries in the primary dentition.48,49 There is some debate as to whether infant formula or bovine milk in bottles and breast milk given frequently to young children contribute to the development of ECC. The proposed relationship is based on the fact that the lactose in milk is available for fermentation by SM. Compared to bovine milk, breast milk has a lower mineral content, higher concentration of lactose, and lower protein content, but these differences are insignificant in terms of its effect on oral health.5 Although prolonged or on-demand breast-feeding has been suggested as an etiological factor for dental caries,50 there is limited published evidence to support this supposition.51 However, many researchers have reported an association between ECC and prolonged/night-time bottle-feeding.52–55 These studies examined bottle use in children aged 12–24 months, and suggest that continued bottle use after a child’s first birthday is associated with ECC, but factors, such as duration of the habit and the content in the bottle, are crucially important. ª 2011 Blackwell Publishing Asia Pty Ltd

Dental caries in preschool children

Toothbrushing and exposure to fluoride It is well established that toothbrushing is included in the primary socialization process, and most parents want to make sure their child’s teeth are brushed at least once a day. While toothbrushing is an important habit to encourage, its key influence on caries is to introduce fluoride from toothpaste onto the enamel surfaces. Fluoride is a highly-effective agent that remineralizes early lesions and acts to strengthen the surface dental enamel by forming fluorapatite. Brushing without fluoride will not prevent the majority of carious lesions. However, Reisine and Psoter56 suggest that it is difficult to distinguish whether the effect of toothbrushing is a measure of fluoride application or whether it is the result of the mechanical removal of plaque. Featherstone57 states that the caries process is a delicate balance between demineralization and remineralization, and in the mouth there is a ‘‘see-sawing’’ between these two phenomena. Children not exposed to fluoridated water and not using fluoride toothpaste are more likely to have dental caries.58–62 There is convincing evidence that brushing with a fluoride toothpaste is the most significant factor in the decline of dental caries in many developed countries since the 1970s.58,62–65 Studies have reported that the onset of caries is more likely when the children start brushing at a later age.58,66 Furthermore, there is sufficient evidence to show children who brushed their teeth less frequently are more likely to have ECC.23,24,30,42,58 A systematic review by Harris et al.30 suggests that brushing less than once per day, no parental supervision of toothbrushing, not brushing at bed time, and not using fluoride toothpaste are the main risk factors for ECC. Apart from brushing with a fluoride toothpaste, there is well-established evidence that children living in areas without fluoridation of public water supplies have a higher prevalence of ECC.67 Dental visits Dental care is one of the most unmet health needs of young children in the USA, which makes disadvantaged populations at greater risk of poor oral health.68 Although it is recommended that children should have their first dental visit by 12 months of age,69 data from the USA indicate that only approximately 9% of 3–4 year olds are taken to a dental professional.70 In Australia, less than 40% of children aged 3–4 years are taken to a dental professional.71 Data from Australia show that young children with private health insurance were more likely to have a dental visit, and disadvantaged children have less frequent dental visits.71 The lack of dental visits might be due to the costs involved. Despite the fact that dental visits before the age of 3 years is low, contact with general medical practitioners and child family health nurses is 225

Dental caries in preschool children

A. Arora et al.

high. Dental professionals should work with other primary health-care providers and screen early signs of dental decay and provide anticipatory advice to reduce the incidence of ECC.

outcomes in general and oral health.76 Clinicians need to be aware of the major impact health literacy makes on all aspects of health care, particularly when giving preventive advice or information.

Sociodemographic influences in ECC


Three major sociodemographic factors have been associated with the risk of ECC: socioeconomic status (SES), ethnicity, and health literacy. SES is usually a composite of the level of education, family income, and occupation.72 One of the limitations, from a public health research perspective, is the lack of consensus on how to define SES.56 Despite this academic disagreement, social disadvantage is a strong predictor for dental caries.22,30,56,73 Sheiham and Watt74 argue that the main cause of inequalities in oral health are due to differences in patterns of consumption of non-milk extrinsic sugars and the daily use of fluoride toothpastes. In addition, children raised in ethnic minority communities are at an increased risk of ECC,30 but it is difficult to separate cultural influences of ethnicity from the parameters suggested by Sheiham and Watt.74 Literacy can be defined as ‘‘the ability to understand and employ printed information in daily activities in order to achieve one’s goals and develop one’s knowledge potential’’.75 Health professionals, in general, tend to overestimate the reading skills of patients. For example, a recent survey75 showed that approximately 20% of Americans and 17% of Canadians have difficulty reading simple English prose. More recently, it was reported that individuals with lower levels of health literacy have poor

A wide range of risk factors are associated with ECC in children from disadvantaged backgrounds. However, the strength of association is highly variable. Although caries is classed as an infectious disease caused by SM, the absolute link to ECC is one of conjecture. The influence of other factors clearly modifies how the dental hard tissues react to the acidic byproducts produced by SM. The key points to address are behavioural and cultural issues, which will influence family behaviors in such a way as to encourage or reduce the risk of ECC. The importance of a child’s family environment is evident from the work of Milsom et al.,77 who reported that a young child with one carious lesion is five times more likely to develop more carious lesions than a child who is caries free. This finding highlights the importance of population prevention programs to maintain a healthy oral environment as the teeth erupt.

References 1 United States Department of Health and Human Services. Oral Health in America – A Report of the Surgeon General. Rockville: US Department of Health and Human Services, 2000. 2 Stecksen-Blicks C, Sunnegardh K, Borssen E. Caries experience and background factors in 4-year-old children: time trends 1967–2002. Caries Res 2004; 38: 149–55. 3 Arora A, Scott JA, Bhole S et al. Early childhood feeding practices and dental caries in preschool children: a multi-centre birth cohort study. BMC Public Health 2011; 11: 28.


Acknowledgments We are grateful to Mr Jeremy Cullis for his assistance in developing the search strategies. Dr Amit Arora was supported by the Oral Health Foundation and University of Sydney International Research Scholarship to conduct this review.

4 Seow WK. Biological mechanisms of early childhood caries. Community Dent Oral Epidemiol 1998; 26: 8–27. 5 Huntington NL, Kim IJ, Hughes CV. Caries-risk factors for Hispanic children affected by early childhood caries. Pediatr Dent 2002; 24: 536–42. 6 Milnes AR. Description and epidemiology of nursing caries. J Public Health Dent 1996; 56: 38–50. 7 Drury TF, Horowitz AM, Ismail AI et al. Diagnosing and reporting early childhood caries for research purposes. A report of a workshop sponsored by the National Institute of Dental and Craniofacial Research, the Health Resources and Services Administration, and the Health

Care Financing Administration. J Public Health Dent 1999; 59: 192–7. 8 Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Community Dent Oral Epidemiol 1998; 26: 32–44. 9 Armfield JM, Roberts-Thomson KF, Spencer AJ. The Child Dental Health Survey, Australia 1996. AIHW Cat. No. DEN 47. Adelaide: The University of Adelaide (AIHW Dental Statistics and Research Unit Series No. 20), 1999. 10 Armfield JM, Robert-Thomson KF, Spencer AJ. The Child Dental Health Survey, Australia, 1999: Trends across the 1990s. AIHW Cat. No. DEN 95. Adelaide: The University of Adelaide (AIHW Dental Statistics and Research Series No. 27), 2003.

ª 2011 Blackwell Publishing Asia Pty Ltd

A. Arora et al.

11 Armfield JM, Spencer AJ. Quarter of a century of change: caries experience in Australian children, 1977– 2002. Aust Dent J 2002; 53: 151–9. 12 Armfield JM, Slade GD, Spencer AJ. Water fluoridation and children’s oral health. The Child Dental Health Survey, Australia, 2002. AIHW Cat. No. DEN 170. Adelaide: The University of Adelaide (AIHW Dental Statistics and Research Series No. 36), 2007. 13 Lader D, Chadwick B, Chestnutt I et al. Children’s Dental Health in the United Kingdom, 2003. London: Office for National Statistics, 2004. 14 Beltran-Aguilar ED, Barker LK, Canto MT et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism and enamel fluorosis – United States, 1988–1994 and 1999–2002. MMWR Surveill Summ 2005; 54: 1–43. 15 Watt RG. From victim blaming to upstream action: tackling the social determinants of oral health inequalities. Community Dent Oral Epidemiol 2007; 35: 1–11. 16 Edelstein BL. The dental caries pandemic and disparities problem. BMC Oral Health 2006; 6: S2. 17 Petersen PE. World Health Organization global policy for improvement of oral health – World Health Assembly 2007. Int Dent J 2008; 58: 115–21. 18 Davidson N, Skull S, Calache H et al. Holes a plenty: oral health status a major issue for newly arrived refugees in Australia. Aust Dent J 2006; 51: 306–11. 19 Department of Health. Modernising NHS dentistry: implementing the NHS Plan. London: Department of Health, 2000. 20 Edelstein BL. Solving the problem of early childhood caries: a challenge for us all. Arch Pediatr Adolesc Med 2009; 163: 667–8. 21 Institute of Medicine. Health Literacy: a prescription to end confusion. Washington DC: National Academic Press, 2004. 22 Gussy MG, Waters EG, Walsh O et al. Early childhood caries:

ª 2011 Blackwell Publishing Asia Pty Ltd

Dental caries in preschool children












Current evidence for aetiology and prevention. J Paediatr Child Health 2006; 42: 37–43. Fisher-Owens SA, Gansky S, Platt LJ et al. Influences on Children’s Oral Health: a conceptual model. Pediatr 2007; 120: e510–20. Grindefjord M, Dahllo¨f G, Nilsson B et al. Prediction of dental caries in 1-year-old children. Caries Res 1995; 29: 343–8. Grindefjord M, Dahllo¨f G, Nilsson B et al. Stepwise prediction of dental caries in children up to 3.5 years of age. Caries Res 1996; 30: 256–66. Thibodeau EA, O’Sullivan DM. Salivary mutans streptococci and caries development in the primary and mixed dentitions of children. Community Dent Oral Epidemiol 1999; 27: 406–12. Aaltonen AS, Tenovuo J. Association between mother–infant salivary contacts and caries resistance in children: a cohort study. Pediatr Dent 1994; 16: 110–6. Fejerskov O, Kidd EAM. Dental caries: the disease and its clinical management. Oxford: Blackwell, 2003. Aas JA, Paster BJ, Stokes LN et al. Defining the normal bacterial flora of the oral cavity. J Clin Microbiol 2005; 43: 5721–32. Harris R, Nicoll AD, Adair PM et al. Risk factors for dental caries in young children: A systematic review of the literature. Community Dent Health 2004; 21: 71–85. Catalanotto FA, Shklair IL, Keene HJ. Prevalence and localization of Streptococcus mutans in infants and children. J Am Dent Assoc 1975; 91: 606–9. Berkowitz RJ, Turner J, Green P. Maternal salivary levels of Streptococcus mutans and primary oral infection in infants. Arch Oral Biol 1981; 26: 147–9. Caulfield PW, Cutter GR, Dasanayake AP. Initial acquisition of mutans streptococci by infants: evidence for a discrete window of infectivity. J Dent Res 1993; 72: 37–45.

34 Mohan A, Morse DE, O’Sullivan DM et al. The relationship between bottle usage/content, age and number of teeth with mutans streptococci colonization in 6-24-month-old children. Community Dent Oral Epidemiol 1998; 26: 12–20. 35 Wan AK, Seow WK, Purdie DM et al. A longitudinal study of Streptococcus mutans colonization in infants after tooth eruption. J Dent Res 2003; 82: 504–8. 36 Wan AK, Seow WK, Purdie DM et al. Oral colonization of Streptococcus mutans in six-month-old predentate infants. J Dent Res 2001; 80: 2060–5. 37 Parisotto TM, Steiner-Oliveira C, Silva CM et al. Early childhood caries and mutans streptococci: a systematic review. Oral Health Prev Dent 2010; 8: 59–70. 38 Hicks J, Garcia-Godoy F, Flaitz CJ. Biological factors in dental caries: role of saliva and dental plaque in the dynamic process of demineralization and remineralization (Part 1). Clin Pediatr Dent 2003; 28: 47–52. 39 Simmer JP, Hu JC. Dental enamel formation and its impact on clinical dentistry. J Dent Educ 2001; 65: 896–905. 40 Lai PY, Seow WK, Tudehope DI et al. Enamel hypoplasia and dental caries in very-low birthweight children: a case-controlled, longitudinal study. Pediatr Dent 1997; 19: 42–9. 41 Li Y, Navia JM, Bian JY. Caries experience in deciduous dentition of rural Chinese children 3-5 years old in relation to the presence or absence of enamel hypoplasia. Caries Res 1996; 30: 8–15. 42 Matee M, Van’t Hof M, Maselle S et al. Nursing caries, linear hypoplasia, and nursing and weaning habits in Tanzanian infants. Community Dent Oral Epidemiol 1994; 22: 289– 93. 43 Rodrigues CS, Sheiham A. The relationships between dietary guidelines, sugar intake and caries in primary teeth in low income Brazilian 3-year-olds: a longitudinal study. Int J Paediatr Dent 2000; 10: 47–55. 44 Tinanoff N, Palmer CA. Dietary determinants of dental caries and


Dental caries in preschool children

45 46











dietary recommendations for preschool children. J Public Health Dent 2000; 60: 197–206. Zero DT. Sugars – the arch criminal? Caries Res 2004; 38: 277–85. Burt BA, Pai S. Sugar consumption and caries risk: A systematic review. J Dent Educ 2001; 655: 1017–23. Heller KE, Burt BA, Eklund SA. Sugared soda consumption and dental caries in United States. J Dent Res 2001; 80: 1949–53. Levy SM, Warren JJ, Broffitt B et al. Fluoride, beverages and dental caries in the primary dentition. Caries Res 2003; 37: 157–65. Sohn W, Burt BA, Sowers MR. Carbonated soft drinks and dental caries in the primary dentition. J Dent Res 2006; 85: 262–6. American Association of Pediatric Dentistry. Policy on breast-feeding. Pediatr Dent 2003; 25: 111. Valaitis R, Hesch R, Passarelli C et al. A systematic review of the relationship between breastfeeding and early childhood caries. Can J Public Health 2000; 91: 411–7. Milgrom P, Riedy CA, Weinstein P et al. Dental caries and its relationship to bacterial infection, hypoplasia, diet and oral hygiene in 6- to 36-month-old children. Community Dent Oral Epidemiol 2000; 28: 295– 306. Dini EL, Holt RD, Bedi R. Caries and its association with infant feeding and oral health-related behaviours in 3-4-year-old Brazilian children. Community Dent Health 2000; 28: 241–8. Chan SC, Tsai JS, King NM. Feeding and oral hygiene habits of preschool children in Hong Kong and their caregivers’ dental knowledge and attitudes. Int J Paediatr Dent 2002; 2: 322–31. Ollila P, Niemela M, Uhari M et al. Prolonged pacifier sucking and the use of a nursing bottle at night: possible risk factors for dental caries in children. Acta Odontol Scand 1998; 56: 233–7. Reisine ST, Psoter W. Socioeconomic status and selected behavioral


A. Arora et al.











determinants as risk factors for dental caries. J Dent Educ 2001; 65: 1009–16. Featherstone JDB. Tipping the scales towards caries control. Dimensions Dent Hyg 2004; 2: 20–7. Vanobbergen J, Martens L, Lesaffre E et al. The value of baseline caries risk assessment model in the primary dentition for the prediction of caries incidence in permanent dentition. Caries Res 2001; 35: 442–50. Armfield JM, Spencer AJ. Community effectiveness of fissure sealants and the effect of fluoridated water consumption. Community Dent Health 2007; 24: 4–11. Ismail AI, Sohn W. The impact of universal access to dental care on disparities in caries experience in children. J Am Dent Assoc 2001; 132: 295–303. Ellwood RP, Davies GM, Worthington HV et al. Relationship between area deprivation and the anti-caries benefit of an oral health program providing free fluoride toothpaste to young children. Community Dent Oral Epidemiol 2004; 32: 159–65. Davies GM, Worthington HV, Ellwood RP et al. A randomized controlled trial of the effectiveness of providing free fluoride toothpaste from the age of 12 months on reducing caries in 5-6 year old children. Community Dent Health 2002; 19: 131–6. Maes L, Vereecken C, Vanobbergen J et al. Tooth brushing and social characteristics of families in 32 countries. Int Dent J 2006; 56: 159–67. Kay EJ, Locker D. Is dental health education effective? A systematic review of current evidence. Community Dent Oral Epidemiol 1996; 24: 231–5. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002278. DOI: 10.1002/14651858.CD002278. Skeie MS, Riordan PJ, Klock KS et al. Parental risk attitudes and












caries-related behaviours among immigrant and western native children in Oslo. Community Dent Oral Epidemiol 2006; 34: 103– 13. Mouradian WE, Wehr E, Crall JJ. Disparities in children’s oral health and access to dental care. J Am Med Assoc 2000; 284: 2625–31. Newacheck PW, Hughes DC, Hung YY et al. The unmet health needs of America’s children. Pediatr 2000; 105: 989–97. American Academy of Pediatric Dentistry. Infant oral health. Pediatr Dent 2000; 22: 47–8. Savage MF. Early preventive dental visits: effects on subsequent utilization and costs. Pediatr 2004; 114: e418–23. Slack-Smith LM. Dental visits by Australian preschool children. J Paediatr Child Health 2001; 39: 442–5. Burt BA. Concepts of risk in dental public health. Community Dent Oral Epidemiol 2005; 33: 240–7. Vanobbergen J, Martens L, Lesaffre E et al. Assessing risk indicators for dental caries in the primary dentition. Community Dent Oral Epidemiol 2001; 29: 424–34. Sheiham A, Watt RG. The common risk factor approach: a rational basis for promoting oral health. Community Dent Oral Epidemiol 2000; 28: 399– 406. Statistics Canada. Reading the Future: A Portrait of Literacy in Canada 1997. Ottawa: Statistics Canada, 1997 [Cited 18 Mar 2010]. Available from: http:// 4198665-eng.pdf Baker DW, Gazmararaian JA, Williams MV et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health 2002; 92: 1278–83. Milsom KM, Blinkhorn AS, Tickle M. The incidence of dental caries in the primary molar teeth of young children receiving National Health Service funded dental care in practices in the north west of England. Br Dent J 2008; 205: 384–5.

ª 2011 Blackwell Publishing Asia Pty Ltd

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 fact...
78KB Sizes 0 Downloads 11 Views