口腔指南共识汇总

Oral Health Programme, Prevention of Noncommunicable Diseases

WHO Headquarters

WHO Implementation manual

WHO Implementation manual

Oral Health Programme, Prevention of Noncommunicable Diseases

WHO Headquarters

Ending childhood dental caries: WHO implementation manual

ISBN 978-92-4-000005-6

© World Health Organization 2019

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Contents

Acknowledgements

iv

Glossary

v

Abbreviations

vii

Preface

viii

1. Background

1

1.1 Early childhood caries is a highly prevalent global disease

of public health importance

1

1.2 Risk factors are known: they are diverse and, like most

noncommunicable diseases, related to social determinants of health

1

1.3 The primary care team is a key actor in prevention and

control of early childhood caries

4

2. Introduction

5

3. Definition of early childhood caries

7

4. Tackling early childhood caries

9

4.1 Early diagnosis

10

4.2 Control of risk factors: infant feeding and diet in young children

14

4.3 Control of risk factors: population-based fluoride exposure

18

4.4 Arresting carious lesions through application of sealants, fluoride

varnish and minimally invasive techniques for restoration

22

4.5 Health education and community engagement

for prevention of early childhood caries

28

4.6 Involvement of primary care teams, including community health

workers, in prevention and control of early childhood caries

32

4.7 Monitoring and evaluation

36

4.8 Building a supportive framework for integration of

early childhood caries prevention and control in

overall health initiatives

40

Annex 1

44

Review questions related to prevention of early childhood caries

44

Annex 2

45

Key interventions for preventing and controlling early childhood caries45

Annex 3

51

Useful materials

51

References

53

Ending childhood dental caries

iv

Acknowledgements

The development of this manual was led by Benoit Varenne, Dental Officer,

and Yuka Makino, Technical Officer, World Health Organization (WHO)

Headquarters, in collaboration with Poul Erik Petersen, Senior Consultant,

WHO Regional Office for Europe.

The manual was prepared under the general guidance of Faten Ben Abdelaziz,

Coordinator, Health Promotion Unit, Fiona Bull and Prasad Vinayak, Acting

Directors, Prevention of Noncommunicable Diseases, WHO Headquarters.

WHO would like to appreciate the contribution of all the experts involved in

the development of this manual.

Special thanks are due to the following, who supported development of the

content: Ramon Baez (University of Texas Health Science Center, United States

of America), Edward Lo (University of Hong Kong, China), Paula Moynihan

(WHO Collaborating Centre, Newcastle University, United Kingdom of Great

Britain and Northern Ireland; and University of Adelaide, Australia), Hiroshi

Ogawa (WHO Collaborating Centre, Niigata University, Japan), Prathip

Phantumvanit (Thammasat University, Thailand), and Andrew Rugg-Gunn

(The Borrow Foundation, United Kingdom).

Thanks are also due to the following for their review of the content: Carlos

Alberto Feldens (Universidade Luterana do Brasil, Brazil), Ray Masumo (Ministry

of Health, United Republic of Tanzania), Nigel Pitts (King’s College London,

United Kingdom), Murray Thomson (University of Otago, New Zealand),

Norman Tinanoff (University of Maryland, United States; and Science Chair

of International Association of Paediatric Dentistry) and Richard Watt (WHO

Collaborating Centre, University College London, United Kingdom).

Finally, the following WHO staff members made valuable contributions to

reviewing the content: Kaia Engesveen, Laurence Grummer-Strawn, Jason

Montez and Chizuru Nishida.

Photo credits: Carlos Alberto Feldens (Universidade Luterana do Brasil, Brazil),

Prathip Phantumvanit (Thammasat University, Thailand), Yupin Songpaisan

(Suranaree University of Technology, Thailand), and Poul Erik Petersen (WHO

Regional Office for Europe).

Funding source: funds received from the WHO voluntary contributions from

The Borrow Foundation, United Kingdom and WHO Collaborating Centre,

Niigata University, Japan were used for the development of this manual.

Glossary

v

Glossary

Atraumatic restorative treatment (ART) This is a minimally invasive technique

to treat existing dental decay and prevent further decay. ART can be used with

patients of all ages (e.g. children, adolescent, adults and elderly people). It

consists of two activities: The first is a procedure to treat decayed tooth cavities

by removing the decay using hand instruments; this is followed by filling the

cavities and any adjacent pits and fissures on biting surfaces of the teeth with

an adhesive material containing fluoride (glass-ionomer cement). The provision

of ART is not limited to dental clinics since it does not require a dental chair, drill,

piped water or electricity. Moreover, pain is rare during ART, virtually eliminating

the need for anaesthetic. Although ART is ideally delivered by an oral health

professional or auxiliary, trained primary care workers are also able to deliver ART

effectively with the appropriate instruments and consumables.

Caries prevalence Proportion of population affected by dental caries.

Caries severity Mean number of teeth affected by caries per person in

the population.

Community health workers People who provide health education, referral

and follow-up, case management, basic preventive health care, and home

visiting services to specific communities. Community health workers provide

support and assistance to individuals and families in navigating health and

social services systems. Community health workers are known by many

different names in different countries, but in almost all cases they come from

the communities they serve.

Complementary foods Foods that should be added to a child’s diet when

breast milk is no longer enough to meet the child’s nutritional needs. The

transition from exclusive breastfeeding to family foods, referred to as

complementary feeding, typically covers the period from age 6 months to

18–24 months.1

Dental caries Dental decay. Destruction of teeth results when microbial

biofilm (plaque) formed on the tooth surface converts the sugars contained

in foods and drinks into acids, which dissolve tooth enamel and dentine

over time.

Early childhood caries Caries characterized by the presence of one or more

teeth affected by carious lesions or with white spot lesions in primary teeth,

loss of teeth due to caries, or filled tooth surfaces in affected teeth of a child

aged under six years. Children with early childhood caries have been shown

to have a high number of teeth affected by progressive disease.

Healthy foods Foods that contribute to a healthy diet if consumed in

appropriate amounts.2

Impact of early childhood caries Sequelae caused by early childhood caries

for the infant or child, family and community.

Infant A child aged under 12 months.

1

Complementary feeding. Geneva: World Health Organization (https://www.who.int/nutrition/

topics/complementary_feeding/en/).

2

Healthy diet. Fact sheet 394. Geneva: World Health Organization; 2015 (https://www.who.int/

nutrition/publications/nutrientrequirements/healthydiet_factsheet394.pdf).

Ending childhood dental caries

vi

Primary care A key process in the health system: first-contact, accessible,

continued, comprehensive and coordinated care. First-contact care is accessible

at the time of need; ongoing care focuses on the long-term health of a person

rather than the short duration of the disease; comprehensive care is a range of

services appropriate to the common problems in the respective population;

coordination is the role by which primary care acts to coordinate other specialists

that the person may need. Primary care is a subset of primary health care.3

Primary health care A whole-of-society approach to health and well-

being centred on the needs and preferences of individuals, families and

communities. It addresses the broader determinants of health and focuses

on the comprehensive and interrelated aspects of physical, mental and

social health and well-being. It provides whole-person care for health needs

throughout the lifespan rather than treating only a set of specific diseases.

Primary health care ensures people receive comprehensive care – ranging

from promotion and prevention to treatment, rehabilitation and palliative

care – as close as feasible to people’s everyday environment.4

Systemic fluoride Fluoride ingested and absorbed into the body.

Topical fluoride Fluoride applied directly on to teeth.

Unhealthy foods Energy-dense, nutrient-poor foods such as foods high in

saturated fats, trans-fatty acids, free sugars or salt.5

Universal health coverage Universal health coverage means that all

individuals and communities receive the health services they need without

financial hardship. It includes the full spectrum of essential good-quality

health services, from health promotion to prevention, treatment, rehabilitation

and palliative care. Universal health coverage enables everyone to access the

services that address the most significant causes of disease and death, and

ensures the quality of those services is good enough to improve the health

of the people who receive them.6

3

Main terminology. Copenhagen: World Health Organization Regional Office for Europe (http://

www.euro.who.int/en/health-topics/Health-systems/primary-health-care/main-terminology).

4

Primary health care. Geneva: World Health Organization; 2019 (https://www.who.int/

health-topics/primary-health-care#tab=tab_1).

5

Report of the Commission on Ending Childhood Obesity: implementation plan – executive

summary. Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstream/

handle/10665/259349/WHO-NMH-PND-ECHO-17.1-eng.pdf;jsessionid=9653E50F444A1698

3630CFE740689D72?sequence=1).

6

Universal health coverage. Geneva: World Health Organization; 2019 (https://www.who.int/

en/news-room/fact-sheets/detail/universal-health-coverage-(uhc).

Abbreviations

vii

Abbreviations

ART

Atraumatic Restorative Treatment

DHIS

District Health Information System

ECC

early childhood caries

NCD

noncommunicable diseases

SDF

silver diamine fluoride

WHO

World Health Organization

Ending childhood dental caries

viii

Preface

Early childhood caries (ECC) affects teeth of children aged under six years. According to the

Global Burden of Disease Study in 2017, more than 530 million children globally have dental

caries of the primary teeth. However, as primary teeth are exfoliated due to growth of the child,

ECC has previously not been considered important.

ECC has significant influence on individuals, families and societies. The disease affects primary

teeth and permanent teeth and influences general health and quality of life across the entire

life course. ECC links with other frequent diseases of childhood, primarily due to risk factors

shared with other noncommunicable diseases (NCDs) such as high sugar intake, and the

disease relates to other health conditions such as obesity. Dental caries can lead to abscesses

and cause toothache, which may compromise ability to eat and sleep and restrict life activity

of children. Severe dental caries is associated with poor growth. Moreover, ECC is an economic

burden to the family and society; treatment of ECC under general anaesthesia for extensive

dental repair is especially costly.

Prevalence of ECC is increasing rapidly in low- and middle-income countries, and dental caries

is particularly frequent or severe among children living in deprived communities. In many

countries, access to dental care is not equitable, leaving poor children and families underserved.

Fortunately, ECC is preventable, with almost all risk factors modifiable. ECC differs from

dental caries in older children and adults in its rapid development, its diversity of risk factors,

and in the control of disease. As with most NCDs, both cause and prevention are strongly

determined by sociobehavioural, economic, environmental and societal factors, known as the

social determinants of health. ECC is influenced strongly by health behaviours and practices

of children, families and caregivers.

ECC prevention and control approaches range from changing personal behaviour, to working

with families and caregivers, to public health solutions such as building health policies,

creating supportive environments, and health promotion and orientation of health services

towards universal health coverage. Building supportive environments for integration of ECC

prevention and control into general health activities is essential. In addition, primary care

teams, including community health workers, are key to successful programmes.

The Ending Childhood Dental Caries: WHO Implementation Manual has been developed to

serve different stakeholders in their work for better health of children; these stakeholders

include community agencies, ministries of health, academia, and nongovernmental and

professional organizations.

The manual is based on evidence from systematic reviews and WHO recommendations,

especially on nutrition, including breastfeeding, and primary care workers’ programmes.

The current manual focus on tackling ECC in its global context defines the disease and

outlines known risk factors and approaches to prevention and treatment. It is intended

to inform and support:

• policy-makers on actions and rationales for ECC interventions;

• chief dental officers, ministry of health focal points and public health administrators

in the development and implementation of plans for ECC prevention and control,

using the primary health-care approach.

The manual may also be used in training activities to help primary care teams:

• understand ECC as a public health problem;

• recognize the essential risk factors for ECC, especially lack of exclusive breastfeeding,

consumption of free sugars, and inadequate exposure to fluoride in prevention of dental caries;

• identify opportunities for intervention against ECC and its causes.

1. Background

1

1. Background

1.1 Early childhood caries is

a highly prevalent global

disease of public health

importance

The first primary teeth erupt in infancy, at about age 6 months, and the primary

dentition of 20 teeth is complete by about age 30 months. In many children,

these teeth stay sound, contributing to the child’s health and well-being. But for

an unacceptably large percentage of children, these teeth do not stay sound but

are ravaged and sometimes totally destroyed by dental caries (dental decay).

This is a preventable, global, noncommunicable disease (NCD) of medical,

social and economic importance. Early childhood caries (ECC) differs from

dental caries in older children and adults in its rapid development, its diversity

of risk factors and its control. As with most NCDs, the aetiology and prevention

of ECC are strongly determined by sociobehavioural, economic, environmental

and societal factors, known as the social determinants of health (1). Societal

and economic pressures often influence health behaviours and practices of

children and families – particularly the main caregivers – and typically lead

to poor oral health. The prevalence of ECC is increasing rapidly in low- and

middle-income countries (2,3).

Figure 1 Percentages of children aged 5 and 6 years affected by dental caries in 2017–2018

Source: Petersen PE. WHO Collaborating Centre for Community Oral Health Programme and Research, University of Copenhagen 2019.

Ending childhood dental caries

2

Traditionally the prevalence and severity of dental caries are presented as

the percentages of people with dental caries and the mean number of teeth

affected by dental caries per person. Information collected by the World

Health Organization (WHO) Collaborating Centre for Community Oral Health

Programme and Research, University of Copenhagen is given in Figure 1,

which indicates that the burden of dental caries affects significant numbers

of children in all WHO regions. More recently, some surveys have recorded

sequelae of disease by recording gross infection caused by severe caries

involving pain and abscesses (4–7). Infection causes toothache, which can

result in the child being unable to eat and compromise sleep for the child and

their family. Severe dental caries is associated with poor growth (8).

1.2 Risk factors are known:

they are diverse and, like

most noncommunicable

diseases, related to social

determinants of health

Almost all risk factors for ECC are modifiable. They can be grouped into children,

family and community influences (Figure 2) (9). The relevant factors will be

considered elsewhere in detail. This is particularly the case with the importance

of the parents’ health (including nutritional status and oral health); family

beliefs and behaviours, such as infant feeding and choice of complementary

foods and drinks; and the ability, knowledge and will to purchase and provide

a healthy diet for the child. As with the causal factors of childhood obesity,

an appreciation of the effects of excessive and frequent consumption of free

sugars is essential in the understanding of the aetiology and control of ECC.

The importance of establishing good eating habits in childhood to minimize

the risk of ECC and obesity can not be overestimated. Since eating patterns

track from childhood to adulthood, establishing appropriate habits in the early

years is a major target.

1. Background

3

Figure 2 Concept of childhood caries – child, family and community influences on oral health

outcomes of children

Social

environment

Child-Level Influences

Family composition

Socioeconomic

status

Social support

Physical safety

Health status

of parents

Family

function

Culture

Health behaviors, practices,

and coping skills of family

Physical and demo-

graphic attributes

Biologic and genetic

endowment

Health behaviors

and practices

Dental

Insurance

Use of dental care

Development

Dental care system

characteristics

Health care system

characteristics

Physical safety

Physical

environment

Community

oral health

environment

Microflora

Host and Teeth

Substrate (diet)

Oral Health

Social capital

Culture

Community-Level Influences

Family-Level Influences

Environment

Time

Source: adapted from Fisher-Owens SA, Gansky SA, Platt LJ, Weintraub JA, Soobader MJ, Bramlett MD, Newacheck PW. Influences on children’s

oral health: a conceptual model. Pediatrics. 2007;120:e510–20.

Ending childhood dental caries

4

1.3 The primary care team is a

key actor in prevention and

control of early childhood

caries

Difficulties in tackling prevention and control of ECC include:

• identifying a key platform to deliver oral health promotion and

ECC prevention;

• identifying risk factors, including individual risk behaviours, culture

and environment.

For example, many countries have introduced effective school-based

programmes to improve the oral health of children (10,11). These programmes

usually involve toothbrushing with a fluoride-containing toothpaste. Although

such programmes are effective at developing healthy life skills, it is realized

that most problems of ECC occur before the child attends school and therefore

can not be impacted by these programmes.

ECC prevention and control interventions should be integrated into existing

primary care such as child and maternal health programmes alongside

vaccinations and general medical check-ups. This could lead to a continuing

programme of interventions that provide reassurance to parents and caregivers

and boost their knowledge of the need to attend health appointments (12).

Social context and cultural pressures within societies also influence ECC

by influencing families’ behaviours. Creating supporting environments for

families is an important element of oral health promotion.

Globally, there are relatively few trained oral health professionals, and

therefore it is unrealistic to rely on workforce models that require oral health

professionals to deliver prevention and treatment of ECC. Fortunately, the

majority of interventions related to ECC are proven, affordable and feasible

in the places where people normally live and can be carried out by non-oral

health professionals in the community or primary care facilities.

Therefore, primary care teams including nurses, midwives and community

health workers, who have worked in the community and primary care facilities

and advised and cared for families and communities, can contribute to

preventing and controlling ECC.

To this end, all sectors of the community should use primary care teams to

promote healthy behaviours at local and national levels.

2. Introduction

5

2. Introduction

The Ending Childhood Dental Caries: WHO Implementation Manual has

been developed following the request by different stakeholders, including

countries, academia, and nongovernmental and professional organizations,

involved in the prevention and management of ECC.

The development process was initiated in January 2016 in Bangkok at the WHO

Expert Consultation on Public Health Intervention against Early Childhood

Caries. The WHO Collaborating Centre for Oral Health Education and Research

at Mahidol University organized this consultation in collaboration with

the WHO Oral Health Programme, to agree on a set of key messages and

interventions for a future action plan (13).

The expert consultation discussed a number of research questions relevant

to the continuing work in the prevention of ECC, and the need for a new

systematic review on action programmes was recognized. Subsequently,

the WHO Collaborating Centre for Nutrition and Oral Health at Newcastle

University conducted a systematic review on the effect of modifiable risk

factors for ECC, focusing on 12 key questions (see Annex 1) (14).

This manual is based on updated evidence from systematic reviews and WHO

recommendations, especially on nutrition, including breastfeeding, and

community health workers’ programmes.

After the manual was drafted, the contents were reviewed by experts in the

fields of oral health and nutrition, including a specialist in breastfeeding.

Experts assessed whether the manual is applicable for different resource

settings (high-, middle- and low-resource settings), practitioners, policy-

makers and academia staff from different countries.

The manual intends to inform and support policy-makers on actions and

rationales for ECC interventions. Oral health focal points in ministries of health

(e.g. chief dental officers) and public health administrators are considered

important in the development and implementation of plans for ECC prevention

and control using the primary health-care approach. The manual includes the

following elements:

• definition of ECC;

• tackling ECC:

–

early diagnosis;

–

control of risk factors: infant feeding and diet in young children;

–

control of risk factors: population-based fluoride exposure;

–

arresting carious lesions through application of sealants, fluoride

varnish and minimally invasive techniques for restoration such as

Atraumatic Restorative Treatment (ART);

–

health education and community engagement for prevention of ECC;

–

involving primary care teams, including community health workers,

in prevention and control of ECC;

–

monitoring and evaluation;

–

building a supportive framework for integration of ECC prevention

and control in overall health initiatives.

Ending childhood dental caries

6

The manual may also be useful in training activities for primary care teams to

help them understand ECC as a public health problem, recognize the essential

risk factors for ECC, and identify opportunities for intervention against ECC

and its sequelae.

Key points

• ECC is a highly prevalent global disease.

• ECC is a noncommunicable disease of medical, social and economic importance.

• ECC risk factors are linked to family lifestyle and community norms.

• Prevention and control of ECC require a primary health-care approach.

• Building supportive environments for integration of ECC prevention and control into other

public health activities is crucial.

• Primary care teams, including community health workers, are key to successful programmes to

prevent ECC.

• Countries should develop and deliver strategies for prevention and control of ECC.

The misfortune of dental general anaesthetics for infants and young children

Extraction of infected carious teeth is often the only option – a traumatic experience for both child

and family. If facilities exist, these extractions are often carried out under general anaesthesia in a safe

environment, but this is expensive. It is of considerable concern that in several high-income countries,

dental extractions are among the most common reasons for hospital admission in infants and children.

In 2016–2017, a total of 30 238 children aged 0–9 years were admitted to hospital for extraction of

decayed teeth in England (population 53 million). This figure excludes extractions under general

anaesthetic in young children carried out by community dental services and private hospitals. Tooth

extraction was the most common reason for hospital admission for children aged five to nine years.

The average cost of admitting a child aged 5 years or under for tooth extraction is £800–900 (15–17).

Similarly high numbers of hospital admissions for dental extractions in young children have been

reported in Australia (18), the United States of America (19), Israel (20) and New Zealand (3).

Box 1

Box 2

3. Definition of early childhood caries

7

3. Definition of early

childhood caries

Dental caries (tooth decay) is a disease that may affect the teeth of people

of all ages, including young children. It is the most common NCD among

children around the globe. The disease affects primary teeth (milk teeth) and

permanent teeth.

Cavitation occurs due to loss of tooth substance (enamel and dentine) by

acids formed by bacteria in dental plaque, which accumulates on the tooth

surface. This process is due to the bacterial metabolism of sugars derived from

dietary sugars.

Tooth decay is the destruction of the tooth, which is made from calcified tissue.

Under normal circumstances, the loss of calcium (demineralization) is compensated

by the uptake of calcium (remineralization) from the tooth’s microenvironment.

This dynamic process of demineralization and remineralization takes place more

or less continually and equally in a favourable environment of the mouth. In

an unfavourable environment, the remineralization rate does not sufficiently

neutralize the rate of demineralization, and caries occurs.

Early stages of dental caries are often without symptoms, while advanced

stages of dental caries may lead to pain, infections and abscesses, or even

sepsis. Advanced stages often result in tooth extraction (the tooth is pulled

out). The development of caries is influenced by the susceptibility of the

tooth, bacterial profile, quantity and quality of the saliva, level of fluoride,

and amount and frequency of intake of sugars.

Dental caries influences general health and quality of life. Dental caries links

with several frequent diseases of childhood, primarily due to common risk

factors. For instance, dental caries can co-occur with obesity, as both diseases

are related to diet and nutrition. Moreover, nutritional status affects teeth

pre-eruptively, although this is less important than the post-eruptive local

effect of diet. Undernutrition coupled with a high intake of sugars may

exacerbate caries.

Across the world, dental caries is particularly frequent or severe among

underprivileged and disadvantaged groups of children. Socioeconomic factors

also play a crucial role in the scope of services covered by primary oral health

care. In many countries, poor children are underserved by dental care since

access to dental care is not equitable.

Ending childhood dental caries

8

ECC is characterized by the presence of one or more teeth affected by carious

lesions or with white spot lesions in primary teeth, loss of teeth due to caries,

or filled tooth surfaces in affected teeth of a child aged under six years. Those

children with ECC often have been shown to have a high number of teeth

affected by progressive disease. Consequences of ECC include a higher risk of

pain or discomfort, abscesses, carious lesions in both the primary and permanent

dentitions, risk for delayed physical growth and development, increased days

with restricted activity, and diminished oral health-related quality of life. The

aetiology is frequently linked with a high-frequent consumption of sugared

drinks or food, lack of breastfeeding, and/or poor oral hygiene. Additionally,

the disease often manifests in children from poor families or living in poor

environmental settings (21).

Photo credit: Petersen PE.

Photo credit: Petersen PE.

Figure 3 Image of early childhood caries

4. Tackling

early childhood

caries

4.1

Early diagnosis

4. Tackling early childhood caries

11

Key message

• Detect early

caries lesions for

early intervention.

Background information

Because caries lesions progress faster in primary dentition than in permanent

teeth (22,23), the early detection of carious lesions is key to managing ECC and

preventing adverse problems associated with its occurrence; it is also likely to

be painless and less expensive.

Especially for children under six years of age, main caregivers assisted by health

professionals are the important entry point to detecting early caries lesions.

An oral health professional (dentist, dental therapist or nurse, dental hygienist)

will be able to diagnose ECC according to the WHO clinical criteria (24). In

addition, suspicious white spot lesions that may indicate the early process

of caries in teeth should be detected carefully. Primary care teams, if trained

appropriately, can also detect early caries lesions (25). A mouth mirror and

satisfactory lighting of the mouth cavity are required for careful examination

of all teeth present. Images of tooth conditions may help the identification

of lesions.

The images included in this section are intended to complement established

criteria for determining whether a child has existing or has had ECC (24).

Rationale for implementation of key interventions

Action

Rationale

Early detection of carious lesions is key to

managing ECC. Main caregivers assisted by health

professionals are the important entry point to

detecting early caries lesions.

Caries lesions progress faster in primary dentition

than in permanent teeth.

Integrate oral health check-ups into primary care,

including community-based health interventions,

to encourage early diagnosis of ECC.

Children may be seen for vaccinations or

consultation for systemic health problems. Children

aged under six years may be seen frequently by

primary care staff or general health-care providers

and less often by oral health professionals.

Early detection of ECC and immediate intervention

offer the opportunity to manage ECC and prevent

associated problems.

12

Ending childhood dental caries

Figure 4 Visual inspection of teeth

(a) Sound teeth in both jaws

(primary teeth)

Photo credit: Feldens CA.

Photo credit: Phantumvanit P.

Photo credit: Feldens CA.

(d) Suspicious white spot lesions, which

may indicate early process of caries in

teeth of upper jaw (primary teeth)

(b) Sound teeth in upper jaw

(primary teeth)

(e) Tooth decay in front teeth of

upper jaw (primary teeth)

(g) Deep carious lesions in upper jaw

(primary teeth)

(c) Sound teeth in lower jaw

(primary teeth)

(f) Deep carious lesions in both jaws

(primary teeth)

(h) Deep carious lesions in lower jaw

(primary teeth)

Photo credit: Feldens CA.

Photo credit: Feldens CA.

Photo credit: Feldens CA.

Photo credit: Feldens CA.

Photo credit: Feldens CA.

4. Tackling early childhood caries

13

4.2

Control of risk

factors: infant

feeding and diet

in young children

4. Tackling early childhood caries

15

Key messages

• Promote, protect and

support exclusive

breastfeeding up to age six

months, and introduction

of nutritionally adequate

and safe complementary

(solid) foods at age six

months together with

continued breastfeeding

up to two years of age

or beyond.

• Prevent the intake of free

sugars from drinks and

foods, and promote a

healthy balanced diet for

young children.

Background information

Infant feeding practices, complementary feeding practices and diet in

young children have immediate and long-lasting effects on child oral and

general health.

WHO recommends that infants are exclusively breastfed up to six months of

age, after which breastfeeding should continue alongside complementary

feeding up to two years of age or beyond because of the many health benefits

of breastfeeding for both mother and infant, including oral health (26). The

WHO Global Guidance on Ending the Inappropriate Promotion of Foods for

Infants and Young Children states explicitly that commercial complementary

foods should not be advertised for infants aged under six months (27).

Evidence suggests that infants who are breastfed in the first year of life have

lower levels of dental caries than those fed infant formula (28). Breast milk

has a relatively higher concentration of lactose and a relatively lower content

of protective factors such as calcium and phosphorus compared with cow’s

milk and other milks that form complementary drinks (29). This has raised

concerns among the oral health profession about the risk breastfeeding poses

to dental caries. One systematic review suggested a higher risk of ECC when

breastfeeding extends beyond one year of age, but the data analysis did not

control adequately for important confounders such as intake of sugars from

other sources (30). A systematic review including more recent data has shown

that infants who are breastfed two years of age do not have a greater risk of

ECC than those breastfed up to one year of age (14).

Complementary feeding practices and dietary habits in the early years of

life may modify the risk posed by exposure to dietary free sugars. It is well

established that the amount of dietary free sugars consumed is the primary

causative factor for dental caries (31), and the amount of free sugars should

be no more than 5% of energy intake (32). Free sugars include all mono-

and disaccharides added to foods and drinks by manufacturers, cooks or

consumers, plus the sugars that are naturally present in honey, syrups, fruit

juice and fruit-juice concentrates. Free sugars do not include sugars naturally

present in milk and milk products or in whole fresh fruits and vegetables (32).

A systematic review has indicated that consumption of drinks containing

free sugars increases the risk of ECC, although the observational studies on

which this was based failed to control adequately for confounding factors (14).

Studies show that consumption of liquids containing free sugars from an infant

feeding bottle is independently associated with risk of ECC (14,33). Adding free

sugars to complementary foods is also associated with a higher risk of ECC,

although the data are limited (14,33).

Additionally, it is reported that some commercially produced complementary

foods include free sugars, leading to children exceeding the WHO

recommendation for sugar intake (34,35).

Children should be encouraged to eat a combination of different foods to help

them obtain the right amounts of essential nutrients and avoid a diet high in

free sugars. A good combination of different foods includes:

• staple foods, such as cereals (e.g. wheat, barley, rye, maize, rice) and starchy

tubers or roots (e.g. potato, yam, taro, cassava);

• legumes (e.g. lentils, beans);

• vegetables and fruits;

• foods from animal sources (e.g. meat, fish, eggs, milk) (36).

16

Ending childhood dental caries

Rationale for implementation of key interventions

Action

Rationale

Promote, protect and support exclusive

breastfeeding up to age six months and

introduction of nutritionally adequate and safe

complementary (solid) foods at age six months

together with continued breastfeeding up to two

years of age or beyond.

Breastfeeding is associated with better general health

and a lower risk of ECC in infants and children (14).

Limit consumption of liquids containing free sugars,

including natural unsweetened juices.

Consumption of free sugars increases risk of dental

caries, including ECC. Consumption of free sugars in

drinks, including from feeder bottles, increases risk of

ECC (14).

Limit consumption of complementary foods that

contain free sugars.

Consumption of free sugars increases risk of dental

caries, including ECC. Consumption of complementary

foods high in sugars increases risk of ECC (14).

Encourage a combination of different foods that is

high in fruits, vegetables and low in free sugars for

young children.

A combination of different foods that is high in fruits

and vegetables is associated with reduced risk of NCD

including dental caries. (14,36).

4. Tackling early childhood caries

17

18

Ending childhood dental caries

4.3

Control of risk

factors: population-

based fluoride

exposure

4. Tackling early childhood caries

19

Key messages

• Effective use of fluoride is

an essential component of

any strategy to control ECC.

• There is substantial

evidence that the

appropriate use of fluoride,

principally through water

fluoridation and use

of fluoride-containing

toothpastes, reduces the

prevalence, severity and

impact of ECC.

Background information

Fluoride is a key agent in reducing the prevalence and severity of dental

caries (37). Effective use of fluoride is strongly supported by WHO (38–40).

There are two ways to use population-based fluoride to prevent dental caries:

systemic exposure and topical exposure.

For systemic exposure, fluoridation of drinking water is an effective, safe and

economically beneficial public health measure that is listed among the 10

greatest public health achievements of the twentieth century. Fluoridated

drinking water reaches about 350  million people worldwide (41–45).

A systematic review of the best available evidence pertaining to water

fluoridation from cohort studies showed consistent evidence of a protective

effect (14). Lack of piped drinking water precludes installation of water

fluoridation in many communities globally, but when possible it has great

advantages of reaching everyone without their effort, and being of low cost

to the community. A distinct advantage of fluoridation is that it benefits the

people who are most difficult to reach with other preventive programmes, and

very often the people with the greatest health burden (37,41–43).

The enrichment of dietary salt with iodine has provided an effective way of

preventing goitre. In parallel, adding fluoride to salt has been successful in

preventing dental caries in many countries, with an estimated 300 million

users of fluoridated salt worldwide (14,37). Where salt is used as a vehicle for

fluoride, the WHO guideline on sodium intake must be considered (46). Salt

intake at the country level should be monitored so that adjustments to the

levels of fluoride in salt can be made if required to ensure the population is

receiving optimum levels of fluoride exposure.

A third way of providing fluoride to communities is milk fluoridation. This

can be cost-effective if the community has a well-developed milk distribution

system, such as an existing school milk programme (14,47–51).

For topical exposure, toothbrushing twice a day with a fluoride-containing

toothpaste is the most effective preventive measure for ECC. Toothpastes

containing 1000–1500 μg/g (ppm) fluoride are effective in preventing dental

caries. Parents and caregivers should brush their young children’s teeth twice

a day (52). In several communities around the world, children are taught to

brush daily in nursery or school with an appropriate fluoride-containing

toothpaste (11). Since toothpaste is not intended to be swallowed, such

programmes can coexist with fluoridation of water, salt or milk, bringing

substantial added benefit (37,53).

For both systemic and topical fluoridation, the risk of adverse effects of

fluoridation, such as mild enamel fluorosis, is very low when the correct

dose of fluoride for caries prevention is considered carefully. The population

exposure to fluoride should be measured before programme implementation.

An adequate surveillance system through periodic urinary fluoride monitoring

in the child population should be considered. Assessment of enamel fluorosis

and the level of dental caries in the child population should be undertaken

regularly (54).

Although exposure to fluoride reduces the development of dental caries and

delays the onset of the cavitation process, it does not completely prevent

dental caries if implemented as an isolated action. Addressing the cause (free

sugars) is therefore essential in preventing and reducing dental caries (55).

20

Ending childhood dental caries

Rationale for implementation of key interventions

Action

Rationale

In communities where there is little fluoride

available naturally, fluoride-based community

programmes using water, salt or milk should

be introduced.

It was shown in the 1930s that dental caries prevalence and

severity are inversely related to fluoride concentration in

drinking water (37). Although some populations drink water

naturally containing an adequate concentration of fluoride,

the majority of populations drink water with much lower

natural fluoride concentrations. Fluoride concentration in

drinking water was adjusted to the optimum level in 1945

in Grand Rapids in the United States (37); since then, at

least 78 studies globally have demonstrated that water

fluoridation prevents ECC (44). There have been fewer

studies of the effectiveness of fluoride added to salt or

milk, but these demonstrate effectiveness (37). There is no

contradiction to the WHO recommendation of reducing

the intake of salt, as only limited salt intake is needed

for achievement of the caries-preventive effect. These

methods of providing fluoride are low in cost and have

the advantage of benefiting the people who are the most

difficult to reach with other preventive programmes – very

often the people with the greatest health burden (40).

Brushing infants’ and children’s teeth with an

affordable, effective fluoride-containing toothpaste

should be routine.

Since fluoride was first added to toothpastes 70  years

ago, a very large number of trials have demonstrated

its effectiveness in caries prevention (52). Effectiveness

increases as the concentration of fluoride in the

toothpaste increases but, for infants and young children,

the concentration of fluoride is decided after considering

benefit and risk; in most countries, concentrations are in

the range 1000–1500 ppm.

Toothpaste manufacture is a skill. It is important that

added fluoride is available to provide its caries-preventive

effect and that the shelf-life of toothpaste is suitable; this

should be audited by national authorities. Authorities

should also take steps to ensure effective toothpastes are

affordable for the whole population, and that parents and

caregivers have adequate skills and motivation to brush

their children’s teeth.

Brushing twice a day is more effective than less frequent

brushing, as it maintains adequate fluoride around the

teeth for a greater proportion of the day (56). Toothbrushing

is a life skill; in many countries, it is part of school routines

aimed at improving health (40).

4. Tackling early childhood caries

21

4.4

Arresting carious

lesions through

application of

sealants, fluoride

varnish and minimally

invasive techniques

for restoration

4. Tackling early childhood caries

23

Key messages

• Application of fluoride

sealants and varnish with

glass-ionomer cement

by primary care teams

can help to prevent

deterioration of ECC-

affected dentition.

• Application of silver

diamine fluoride by primary

care teams can arrest

dental caries.

• If restoration of decayed

primary teeth is required,

minimally invasive

techniques such as

Atraumatic Restorative

Treatment (ART), can

be used by primary care

teams and oral health

professionals to stabilize

caries lesions.

Background information

Management of ECC should aim to reverse the disease process and to prevent

or slow down the progression of carious lesions to cavitation and tooth

destruction. Young children are usually apprehensive and may not cooperate

fully during dental treatment. The use of non-invasive or minimally invasive

treatment approaches is preferred because they are less resource-demanding,

are more efficient and cost-effective, and cause less discomfort than other

methods (57).

Placement of pit-and-fissure sealants in molar teeth can reduce the

development and progression of new carious lesions into dentine (58).

Different types of sealant material have their own merits, but glass-ionomer

sealants, which are less demanding on technique and moisture control, are

often suitable for use in young children and in community settings.

Systematic reviews have shown that regular application of 5% sodium

fluoride varnish can prevent the development of new caries in primary

teeth and can help remineralization of early enamel lesions (59–62). As the

health-care worker controls the amount of fluoride varnish being used, it is

regarded as an appropriate professionally applied topical fluoride agent of

choice. However, regular applications every three to six months are required

to maintain effectiveness.

Carious lesions that have progressed to cavitation should be stabilized in order

to preserve tooth structure and to prevent negative health consequences such

as pain and infection. Annual or semi-annual application of 38% silver diamine

fluoride (SDF) solution is effective in arresting the progression of cavitated

carious lesions in primary teeth and in hardening these lesions (63). The

effectiveness of SDF is greater with semi-annual application. This can minimize

discomfort and potential pulp damage, and help to keep the caries-affected

primary teeth symptomless and functional until their natural exfoliation. This

is a painless, simple and low-cost treatment that can be widely promoted as an

alternative to conventional invasive caries management techniques, especially

in populations and areas with low accessibility to dental care services.

Covering cavitated carious lesions with flowable fluoride-releasing glass-

ionomer cement may have outcomes similar to SDF application, but the

level of skill required by dental personnel is greater (64). In addition, daily

toothbrushing with a fluoride-containing toothpaste plays an essential role

in arresting ECC (64).

If restoration of decayed primary teeth is required, preference should

be given to the use of minimally invasive techniques such as ART using

adhesive materials such as glass-ionomer cement, especially when provided

in community settings. These techniques do not require a local anaesthetic

injection and, being less invasive, are more “child-friendly”. Survival of single-

surface ART restorations using high-viscosity glass-ionomer in primary teeth

is high (65) and can be comparable to that of restoration placed using a

conventional approach (66).

The oral health-care system of the country, the availability of dental personnel

and resources, the local community setting, the dental health status of the

child, the cooperation of the child, and the child’s preferences are among the

various factors that need consideration when choosing the most appropriate

method to manage and arrest ECC lesions in a population.

24

Ending childhood dental caries

Figure 5 Application of sealants

Figure 6 Fluoride varnish

(a) Caries lesions on occlusal

surfaces of lower molars presented

as dentine shadows

Photo credit: Feldens CA.

(a) Active enamel lesions of early

childhood caries in anterior teeth

Photo credit: Feldens CA.

Photo credit: Feldens CA.

(b) Lesions treated with fluoride

varnish

a

Photo credit: Feldens CA.

(c) Sealant being applied

c

Photo credit: Feldens CA.

(b) Acid etching

b

(d) After sealant application

Photo credit: Feldens CA.

d

a

b

4. Tackling early childhood caries

25

Figure 7 Silver diamine fluoride (SDF) application

(a) Cavitated lesions on upper incisors

Photo credit: Feldens CA.

Photo credit: Feldens CA.

(b) SDF application with cotton pellet

Photo credit: Feldens CA.

(b) If microbrush is available, apply

SDF by microbrush

(c) Two weeks after SDF application

Photo credit: Feldens CA.

a

b

b

c

26

Ending childhood dental caries

(b) Use spoon excavator to remove soft caries

from cavity of teeth

(c) Clean the cavities with

small cotton pellets damped

with water; dry the cavities

with dry cotton pellets

(f) Using finger, with thin

petroleum jelly press on

top of glass-ionomer

restoration over tooth

(d) Paint dentine

conditioner thoroughly

inside cavity; clean with

water and dry cotton

(g) ART is completed

(e) Press mixed glass-

ionomer from capsule

into cavity

Photo credit: Songpaisan Y.

Photo credit: Songpaisan Y.

Figure 8 Atraumatic Restorative Treatment (ART)

(a) Cavitated lesion on

lower molar

Photo credit: Songpaisan Y.

Photo credit: Songpaisan Y.

Photo credit: Songpaisan Y.

Photo credit: Songpaisan Y.

Photo credit: Songpaisan Y.

Photo credit: Songpaisan Y.

a

c

f

b

d

g

e

4. Tackling early childhood caries

27

Rationale for implementation of key interventions

Action

Rationale

Application by primary care teams of sealant on pits

and fissures of primary molars that are deep or with

initial caries.

Compared with control with no sealant, placement

of resin or glass-ionomer sealant in primary molars

can reduce the development of new carious lesion

involving dentine (58).

Application by primary care teams of sodium

fluoride varnish to primary teeth in children with

ECC or teeth with signs of early caries.

Topical application of fluoride varnish two to

four times a year can reduce the development of

new carious lesions into dentine or the need for

restoration of teeth (59,60). Fluoride varnish can

reverse incipient carious lesions in primary teeth

and promote remineralization of early enamel

caries in children (61,62).

Keep carious lesions clean by daily toothbrushing

with a fluoride-containing toothpaste, with support

from caregivers.

Daily toothbrushing with a 1000–1500 ppm fluoride

toothpaste can arrest or slow down progression

of active carious lesions in primary teeth of young

children (64).

Application of SDF by primary care teams to carious

lesions that have extended into dentine.

Annual or semi-annual application of 38% SDF

solution is simple, inexpensive and highly effective

in arresting soft cavitated carious lesions in primary

teeth (63).

Use by primary care teams and oral health

professionals of flowable fluoride-releasing glass-

ionomer cement to cover surface of carious

dentine lesions.

Application of flowable fluoride-releasing glass-

ionomer cement to cover surface of carious dentine

lesions can arrest lesions in primary teeth (64).

If restoration of decayed primary teeth is required,

primary care teams and oral health professionals

can use minimally invasive techniques such

as ART using adhesive materials such as glass-

ionomer cement.

Placement of dental adhesive materials using

minimally invasive techniques does not require

a local anaesthetic injection and is suitable

for young children who may not cooperate

during treatment. Survival of single-surface ART

restorations using high-viscosity glass-ionomer in

primary teeth is high (65) and may be comparable

to that of restoration placed using a conventional

approach (66).

4.5

Health education

and community

engagement for

prevention of early

childhood caries

4. Tackling early childhood caries

29

Key messages

• Advocate the importance

of primary teeth to parents

and caregivers, non-oral

health professionals and

the community by raising

awareness of the impact of

ECC on the quality of life of

young children.

• Engage parents and

caregivers, nursery staff and

school health personnel in

the prevention of ECC and

promotion of oral health.

• Target ECC prevention

and oral health

promotion towards low-

resource communities.

• Apply scientifically

sound oral health

education messages.

Background information

Although an intake of free sugars, poor oral hygiene and inadequate use of

fluoride are rightly given prominence as primary risk factors, reasons for these

unfavourable behaviours need to be understood if preventive strategies are to

be successful. A review of these aspects reported that rates of ECC are highest

among socially disadvantaged groups and indigenous and ethnic minorities;

for example, there is an association between low levels of education and low

family incomes with a high prevalence of ECC (67).

The family represents the child’s primary source of learning about health

and risk factors (68,69). Awareness of oral health and attentiveness to ECC

prevention among parents can be raised through health communication and

by providing them with sound information about disease and intervention. A

systematic review outlines the efficacy of behavioural interventions against

ECC as applied at the individual and family levels (70).

In addition to parents, caregivers such as kindergarten and nursery staff are

vital in young children’s health learning, and they may be instrumental in

development of viable health practices. They may carry out accompanying

ECC preventive actions, particularly by providing a healthy diet, organizing

regular toothbrushing with children, facilitating fluoride administration, and

contributing to early detection of dental caries (71,72).

In countries where formal education starts before the age of five years,

preschools and schools have great potential for influencing the health of

young children. Children may spend a large amount of time in preschool

and school and can be reached at a life stage when their health habits are

being formed. Health promotion may be conducted by preschool teachers

when they have adequate background and knowledge about health and

risk factors (10). Preschools also provide a convenient platform for training

children in regular toothbrushing and for administration of fluoride.

Mass communication through media such as television and radio, books,

pamphlets, flyers and posters is important in improving oral health knowledge

and practices of parents and caregivers specifically in relation to child oral

health (70). A systematic review summarized the evidence of the efficacy

of oral health educational programmes directed at pregnant mothers for

prevention of ECC in children (73). In general, such intervention programmes

may have a positive effect in the fight against ECC.

A range of public health interventions are shown to be beneficial in prevention

and control of dental caries among young children. Home visits and telephone

communication are important in outreach care (74); they are valuable in

engaging parents in prevention of poor oral health in children, and the

personal contact may raise parents’ understanding of oral health support

for infants. Community programmes based on the principles of motivational

interviewing have been used successfully for pregnant women, mothers

and other caregivers in avoiding dental caries and promoting oral health in

infants (72,75,76). A systematic review found that midwifes have an excellent

opportunity for oral health promotion during pregnancy (77).

Importantly, prevention of ECC also requires addressing the social and

economic factors that face many families affected by ECC in low-resource

communities. In particular, universal health coverage is vital for all people and

communities to receive the health care they need without suffering financial

hardship (78,79). Universal health coverage includes the full spectrum of

essential care, including health promotion, prevention, treatment, rehabilitation

and palliative care, and the experience of good-quality health services.

30

Ending childhood dental caries

Rationale for implementation of key interventions

Action

Rationale

Primary care teams, especially community health

workers, should advocate the importance of primary

teeth to parents, caregivers and the community at

large, and raise awareness of the impact of ECC on

quality of life of young children.

The adoption of durable health habits in childhood

begins at home with parents and main caregivers, as

they play an important role in forming the child’s oral

health behaviours.

Providing oral health education to parents and

caregivers on ECC risk factors may reduce the risk of

ECC (14,71,72).

Health education must be based on scientifically sound

information (80).

Relevant ministries and local municipalities must

establish oral health education programmes in

preschools, including toothbrushing with use of

fluoridated toothpaste.

Health education in preschools, including

toothbrushing programmes with toothpaste

containing fluoride 1000–1500 ppm, is effective in

reducing dental caries when activities are carried out

by preschool teachers (10,11).

Mass communication should be organized to

improve oral health knowledge and practices of

parents and caregivers.

Several media may be used to increase awareness

among parents and caregivers about ECC prevention,

diet and oral health practices (70).

Home visits and telephone communication should

be introduced in outreach care.

Personal contact with parents of children affected

by ECC is relevant for early detection of disease, ECC

prevention, and appropriate health care coverage

of children (74). Community health workers may

undertake this outreach activity.

Motivational interviewing of parents and pregnant

women by trained primary care workers and oral

health professionals is useful for avoiding dental

caries among children.

Community programmes including motivational

interviewing are useful in engaging mothers and

pregnant women in dental caries prevention

(72,75–77).

4. Tackling early childhood caries

31

4.6

Involvement of

primary care teams,

including community

health workers,

in prevention and

control of early

childhood caries

4. Tackling early childhood caries

33

Key messages

• Primary care teams,

including community

health workers, are key

actors in the prevention

and control of ECC.

• An important function

of national and local

authorities is to advocate

and facilitate training on

ECC prevention and control

for all first-contact health

agents – that is, primary

care teams, including

community health workers,

nurses and midwives.

Background information

In most countries, children aged under five or six years are seen by primary

care teams including nurses, midwives and community health workers, and

less often by oral health professionals. Children may be seen for vaccinations

or consultation for systemic health problems.

Primary care teams are already trained to deliver a range of services (e.g.

child immunization, family planning, health promotion) and to treat minor

conditions and injuries, and they have the educational background and clinical

skills needed to learn about oral health promotion and control of ECC. Primary

care teams often have profound knowledge of the community, enabling

them to gather support from family, friends and organizations, and to offer

continuity of care (81).

Primary care workers should have a basic set of practical skills and knowledge

about oral disease prevention and oral health promotion. These should enable

them not only to advise and treat children affected by ECC when they first

seek help for oral health problems, but also to carry out outreach work in

schools and at health promotion sessions in various locations and settings

where community members gather. Such settings may include meeting

halls, religious sites, workplaces, and any other places that are appropriate

for information, education and communication activities aimed at modifying

behaviours and environments for good oral hygiene, a balanced diet and a

good nutritious status, and towards oral health and quality of life (81).

WHO has developed guidelines on health policy and system support to

optimize community health worker programmes (82). The preservice training

programme suggests that community health workers will gain the following

core competences:

• promotion and preventive services, and identification of family health and

social needs and risk;

• integration of work activities within the wider health-care system in relation

to the range of tasks to be performed in accordance with community health

workers’ roles, including referral for health care, collaboration with other

health workers in primary care teams, patient tracing, community disease

surveillance, monitoring, and data collection, analysis and use;

• consideration of the social and environmental determinants of health;

• providing psychosocial support;

• interpersonal skills related to confidentiality, communication, community

engagement and mobilization;

• personal safety.

Additionally, community health workers will gain competency in diagnostic

practices, treatment and care in alignment with expected roles.

Primary care workers, including community health workers, should be able to

play a role in the prevention and control of ECC by undertaking the following

activities (81):

• Promotion of oral health and prevention of ECC:

–

conduct routine oral and dental examinations during outreach work;

–

encourage regular general and oral hygiene;

–

promote healthy nutrition and an active lifestyle;

–

provide information, education and communication sessions about

toothbrushing with a fluoride-containing toothpaste;

34

Ending childhood dental caries

–

facilitate healthy environments with restricted access to sugars (e.g.

schools, marketplaces).

• Control of ECC:

–

arrest ECC lesions through application of sealants, fluoride varnish and

minimally invasive techniques such as ART;

–

avoid cross-infection by effective implementation of appropriate

hygiene and disinfection measures;

–

recognize children who need to be referred to a higher level, and have

the connections and facilities to do so.

Rationale for implementation of key interventions

Action

Rationale

Advocate and facilitate training for primary care

workers, including community health workers,

nurses and midwives.

Primary care teams are key actors in prevention and

control of ECC. In most countries, children aged

under five or six years are seen by primary care teams,

including nurses, midwives and community health

workers, and less often by oral health professionals.

Primary care teams often have profound knowledge of

the community, enabling them to work with support

from family, friends and organizations, and to offer

continuity of care (81).

4. Tackling early childhood caries

35

Ending childhood dental caries

4.7

Monitoring and

evaluation

4. Tackling early childhood caries

37

Key messages

• Preschool children may be

included in national and

subnational oral health

surveys as part of regular

population surveillance

programmes. Such surveys

should be based on the

WHO Oral Health Surveys:

Basic Methods and include

assessment for risk factors.

• Promote evaluation,

surveillance and research,

including into cost-

effectiveness, for the

prevention of ECC in

different communities.

Background information

It is important that community programmes established for prevention of ECC

and health promotion are evaluated. Regular surveys every three years or so

may be organized at the local or national level by public health administrators

and health-care personnel in order to assess the adequacy, effectiveness and

acceptance of implemented programmes. At the local community level,

analysis of programme performance may be relevant annually. Surveillance

of ECC programmes will help health administrators to learn about experiences

and outcomes from interventions against ECC in very young children.

Moreover, when outcomes and costs of programmes (e.g. time, number of

staff, expenses) are measured concurrently, it may be possible to assess the

cost-effectiveness of alternate programmes.

The WHO STEPwise approach to health surveillance should be adopted and

put into practice (83). Step 1 focuses on self-assessment of oral conditions

and risk factors. The fifth edition of the WHO Oral Health Surveys: Basic

Methods is relevant for surveillance of preschool children and ECC programme

evaluation (24). This tool helps in collection of information on self-reported

severe tooth decay, painful teeth and discomfort, modifiable risk factors such

as consumption of sugars and dietary patterns, oral hygiene, quality of life, and

socioeconomic and environmental conditions. Information can be obtained

based on use of a WHO simplified oral health questionnaire about children

addressed to parents or caregivers.

The questionnaire is designed for self-completion or for use in interviews. Basic

requirements of anonymity, purpose of questions, clarity and length have to

be considered. If an interview mode is used, variation can occur due to intra-

or inter-interviewer variability. Similar questionnaires are prepared by WHO for

primary school teachers engaged in oral health education of young children.

The simplified questionnaires include core questions considered essential in

the surveillance of ECC; they should be adapted to local or national settings.

Step 2 implicates the collection of clinical oral health data. A WHO oral health

assessment form is used to record ECC lesions. Clinical examination conducted

by oral health professionals should include careful assessment of the teeth for

any signs of severe decalcification, location and number of affected teeth, and

any urgent need for immediate care of ECC. Other symptoms of ill-health are

likely to have been recorded by general health personnel when children are

brought to the health service facility.

In countries with a shortage of oral health professionals, children are not

examined clinically by oral health professionals. Primary care teams involved

in interventions for controlling and preventing ECC may use the photographs

for caries assessment shown in Section 4.1.

As suggested for regular oral health surveys conducted according to WHO

methods and criteria, examiners must be trained to make reliable clinical

judgements. Training will ensure uniform interpretation, understanding and

application by all examiners of the criteria and codes for ECC. Assistance in

calibration for consistency may be available from WHO.

38

Ending childhood dental caries

Rationale for implementation of key interventions

Action

Rationale

Preschool children may be included as a

target group in national and subnational oral

health surveys as part of regular population

surveillance programmes.

It is important that community programmes

established for prevention of ECC and health

promotion be evaluated. National or subnational

concerns may call for incorporation of preschool

children in oral health surveillance programmes (24).

4. Tackling early childhood caries

39

Ending childhood dental caries

4.8

Building

a supportive

framework for

integration of early

childhood caries

prevention and

control in overall

health initiatives

4. Tackling early childhood caries

41

Key messages

• Oral health focal points

in ministries of health

(e.g. chief dental officers)

are important in leading

development and

implementation of plans for

ECC prevention and control

using the primary health-

care approach.

• ECC prevention

intervention is linked to

other health intervention

initiatives such as

promoting, protecting and

supporting breastfeeding,

regulation of marketing

of foods and drinks high

in free sugars, and actions

against childhood obesity.

• For development of a

supportive environment,

it is important to integrate

ECC prevention and control

within primary care, such

as maternal and child

health programmes.

Background information

The aetiology of ECC is complex due to the multilevel web of factors that

direct risk mechanisms. Intervention approaches include changing personal

behaviours, working with families and caregivers, and instigating public health

solutions such as creating supportive environments that promote equity and

reduce inequalities.

Population-directed ECC interventions should target pregnant women, new

mothers and primary care teams with the aim of raising awareness about

the importance of breastfeeding and common risk factors, particularly the

addition of free sugars to drinks and foods (32).

Oral health focal points in ministries of health (e.g. chief dental officers)

are important to lead development and implementation of plans for ECC

prevention and disease control using the primary health-care approach.

Public health agencies and officers, community leaders and civil society

organizations have responsibilities for creating a supportive environment for

prevention and control of ECC through integrating ECC prevention and control

in overall health initiatives.

For example, ECC prevention and control should be integrated into public

health programmes such as:

• initiatives to promote, protect and support breastfeeding, and to ensure

regulation of food products that function as breast-milk substitutes (e.g.

infant formula, follow-up formula) (26,27);

• initiatives to promote safe drinking water to reduce the intake of sugar-

sweetened beverages (84);

• regulation of marketing of foods and drinks (including commercial

complementary food and drinks) to children, especially reducing both

the exposure of children to, and power of, marketing of foods high in free

sugars (85,86);

• taxation of foods and drinks high in free sugars (87);

• existing primary care such as child and maternal health programmes

alongside vaccinations and general medical check-ups;

• childhood obesity initiatives through control of common risk factors (e.g.

free sugars) (88).

Population-directed and individual fluoride administration for the prevention

and control of ECC are vital and should be integral components of existing

primary care systems and essential health services provided to children.

Additionally, it is important to consider the design of essential oral health

services packages  – for example, the promotion of affordable fluoride

toothpaste to prevent dental decay; urgent treatment aimed at relief of oral

pain and providing emergency treatment; and minimally invasive techniques

for restoration to treat existing dental decay and prevent further decay (81).

This basic oral health package should be integrated into the existing primary

care system with consideration of health financing (general tax and health

insurance) towards universal health coverage whereby children can receive

the health services they need without suffering financial hardship.

Implementation of community ECC activities should be monitored according

to the District Health Information System (DHIS). Performance of oral health

work carried out by primary care teams should be assessed continuously for

identification of future roles of non-oral health professionals.

42

Ending childhood dental caries

Responsible agencies must collaborate with related departments and ministries and cooperate with civil society and

public and private stakeholders in implementing ECC prevention and control, while avoiding potential conflicts of

interest. In addition, the responsible agencies should identify the most suitable policy approach given the national

circumstances and develop new or strengthen existing policies.

Rationale for implementation of key interventions

Action

Rationale

Integrate ECC prevention within primary care

(e.g. child and maternal health programmes)

and ensure engagement of non-oral health

professionals in oral health work.

In most countries, children aged under five or six years

are seen by primary care teams, including nurses,

midwives and community health workers, and less often

by oral health professionals.

Promote, protect and support exclusive

breastfeeding up to age six months and

introduction of nutritionally adequate and safe

complementary (solid) foods at age six months

together with continued breastfeeding up to two

years of age or beyond.

Breastfeeding is associated with better general health

and a lower risk of ECC in infants and children (14).

Align ECC intervention with health promotion

initiatives against childhood obesity by avoiding

consumption of free sugars in foods and drinks,

including complementary foods and drinks.

Intake of free sugars has a negative impact on oral and

general health, such as dental caries, weight gain, obesity

and associated NCDs (32).

Increase efforts to ensure access to clean safe

drinking water to avoid unnecessary consumption

of sugar-sweetened beverages.

Intake of free sugars has a negative impact on oral and

general health, such as dental caries, weight gain, obesity

and associated NCDs (32).

Regulate marketing of foods and drinks (including

complementary food) to children, and especially

reduce exposure of children to, and power of,

marketing of foods high in free sugars.

Intake of free sugars has a negative impact on oral and

general health, such as dental caries, weight gain, obesity

and associated NCDs (32).

Introduce taxation policies on foods and drinks

high in free sugars.

Taxes or levies on sugar-sweetened beverages are

recommended by WHO as a measure to reduce

consumption of sugar-sweetened beverages (87).

Advocate appropriate use of fluoride for caries

prevention. This should provide guidance for both

public health interventions and health workers

advising individuals and caregivers.

Fluoride is a key agent in reducing prevalence of dental

caries (38–40). Because ECC severity and social, cultural

and economic conditions differ between countries, each

country should formulate and implement its own policy

on appropriate use of fluoride.

Integrate ECC surveillance into existing national

or subnational surveillance systems (e.g. DHIS).

It is important that national programmes established

for prevention of ECC and health promotion are

evaluated. National or subnational concerns may call

for incorporation of preschool children in oral health

surveillance programmes (24).

4. Tackling early childhood caries

43

Action

Rationale

Develop a national policy to encourage the

development of new skills and competencies

of primary care teams and ensure their initial

and continuing training for ECC prevention

and control.

It is essential that non-oral health professionals (primary

care teams, primary care workers) appreciate ECC as

a public health problem impacting on infants and

children, families and communities. This should be in

terms of pain, infection, child growth and development,

as well as the economic bearing of the disease. Health

professionals should understand the key risk factors for

ECC and how to identify them, and they should recognize

their responsibilities in the work against ECC.

Ending childhood dental caries

44

Annex 1

Review questions related to

prevention of early childhood

caries

1. Does breastfeeding beyond one year increase the risk of early childhood

caries compared with breastfeeding until less than one year of age?

2. Does breastfeeding beyond one year increase the risk of early childhood

caries compared with consumption of cow’s (or similar) milk as the main

milk source from age one year?

3. Does breastfeeding beyond two years increase the risk of early childhood

caries compared with breastfeeding for less than two years?

4. Does breastfeeding beyond two years increase the risk of early childhood

caries compared with consumption of cow’s (or similar) milk as the main

milk source from age two years?

5. Does consumption of liquids that contain free sugars from an infant

feeding bottle increase the risk of early childhood caries?

6. Does consumption of complementary drinks that contain free sugars

increase the risk of early childhood caries?

7. Does consumption of complementary foods to which free sugars have

been added increase the risk of early childhood caries?

8. Does oral hygiene provided by a parent or caregiver reduce the risk of

early childhood caries?

9. Is oral health education for caregivers effective in preventing early

childhood caries?

10. Does an optimum concentration of fluoride in water reduce the risk of

early childhood caries?

11. Does consumption of fluoridated milk reduce the risk of early

childhood caries?

12. Does salt fluoridation reduce the risk of early childhood caries?

Annex 2

45

Annex 2

Key interventions for preventing and controlling

early childhood caries

Action

Rationale

Early diagnosis

Early detection of carious lesions is

key to managing ECC. Main caregivers

assisted by health professionals are an

important entry point to detect early

caries lesions.

Caries lesions progress faster in primary

dentition than in permanent teeth.

Integrate oral health check-ups into

primary care, including community-

based health interventions, to

encourage early diagnosis of ECC.

Children may be seen for vaccinations or

consultation for systemic health problems.

Children aged under six years may be seen

frequently by primary care staff or general

health-care providers and less often by oral

health professionals.

Early detection of ECC and immediate

intervention offer the opportunity

to manage ECC and prevent

associated problems.

Control of risk

factors: infant

feeding and diet in

young children

Promote, protect and support exclusive

breastfeeding up to age six months and

introduction of nutritionally adequate

and safe complementary (solid) foods

at age six months together with

continued breastfeeding up to two

years of age or beyond.

Breastfeeding is associated with better

general health and lower risk of ECC in

infants and children.

Limit consumption of liquids

containing free sugars, including

natural unsweetened juices.

Consumption of free sugars increases

risk of dental caries, including ECC.

Consumption of free sugars in drinks,

including from feeder bottles, increases

risk of ECC.

Limit consumption of complementary

foods containing free sugars.

Consumption of free sugars increases

risk of dental caries, including ECC.

Consumption of complementary foods

high in sugars increases risk of ECC.

Encourage a combination of

different foods that is high in fruits,

vegetables and low in free sugars for

young children.

A combination of different foods that is

high in fruits and vegetables is associated

with reduced risk of NCDs, including

dental caries.

Ending childhood dental caries

46

Action

Rationale

Control of risk

factors: population-

based fluoride

application

In communities where there is little

fluoride available naturally, fluoride-

based community programmes

using water, salt or milk should

be introduced.

It was shown in the 1930s that dental

caries prevalence and severity are

inversely related to fluoride concentration

in drinking water. Although some

populations drink water naturally

containing an adequate concentration of

fluoride, the majority of populations drink

water with much lower natural fluoride

concentrations. Fluoride concentration

in drinking water was adjusted to the

optimum level in 1945 in Grand Rapids

in the United States; since then, at least

78 studies globally have demonstrated

that water fluoridation prevents ECC.

There have been fewer studies of the

effectiveness of fluoride added to salt or

milk, but these demonstrate effectiveness.

There is no contradiction to the WHO

recommendation of reducing the intake

of salt, as only limited salt intake is needed

for achievement of the caries-preventive

effect. These methods of providing

fluoride are low in cost and have the

advantage of benefiting the people who

are the most difficult to reach with other

preventive programmes – very often the

people with the greatest health burden.

Brushing infants’ and children’s teeth

with an affordable, effective fluoride-

containing toothpaste should

be routine.

Since fluoride was first added to

toothpastes 70 years ago, a very large

number of trials have demonstrated

its effectiveness in caries prevention.

Effectiveness increases as the

concentration of fluoride in the

toothpaste increases but, for infants

and young children, the concentration

of fluoride is decided after considering

benefit and risk; in most countries,

concentrations are in the range

1000–1500 ppm.

Toothpaste manufacture is a skill. It is

important that added fluoride is available

to provide its caries-preventive effect and

that the shelf-life of toothpaste is suitable;

this should be audited by national

authorities. Authorities should also take

steps to ensure effective toothpastes are

affordable for

Annex 2

47

Action

Rationale

the whole population, and that parents

and caregivers have adequate skills and

motivation to brush their children’s teeth.

Brushing twice a day is more effective

than less frequent brushing, as it

maintains adequate fluoride around

the teeth for a greater proportion of the

day. Toothbrushing is a life skill; in many

countries, it is part of school routines

aimed at improving health.

Arresting carious

lesions through

application of

sealants, fluoride

varnish and

minimally invasive

techniques

Application by primary care teams

of sealant on pits and fissures of

primary molars that are deep or with

initial caries.

Compared with control with no sealant,

placement of resin or glass-ionomer

sealant in primary molars can reduce

the development of new carious lesion

involving dentine.

Application by primary care teams of

sodium fluoride varnish to primary

teeth in children with ECC or teeth with

signs of early caries.

Topical application of fluoride varnish

two to four times a year can reduce the

development of new carious lesions

into dentine or the need for restoration

of teeth. Fluoride varnish can reverse

incipient carious lesions in primary teeth

and promote remineralization of early

enamel caries in children.

Keep carious lesions clean by daily

toothbrushing with a fluoride-

containing toothpaste, with support

from caregivers.

Daily toothbrushing with a 1000–

1500 ppm fluoride toothpaste can

arrest or slow down progression of

active carious lesions in primary teeth of

young children.

Application of SDF by primary care

teams on to carious lesions that have

extended into dentine.

Annual or semi-annual application of 38%

SDF solution is simple, inexpensive and

highly effective in arresting soft cavitated

carious lesions in primary teeth.

Use by primary care teams and oral

health professionals of flowable

fluoride-releasing glass-ionomer

cement to cover surface of carious

dentine lesions.

Application of flowable fluoride-releasing

glass-ionomer cement to cover surface of

carious dentine lesions can arrest lesions

in primary teeth.

Ending childhood dental caries

48

Action

Rationale

If restoration of decayed primary teeth

is required, primary care teams and oral

health professionals can use minimally

invasive techniques such as ART using

adhesive materials such as glass-

ionomer cement.

Placement of dental adhesive materials

using minimally invasive techniques does

not require a local anaesthetic injection

and is suitable for young children who

may not cooperate during treatment.

Survival of single-surface ART restorations

using high-viscosity glass-ionomer

in primary teeth is high and may be

comparable to that of restoration placed

using a conventional approach.

Health education

and community

engagement for

prevention of ECC

Primary care teams, especially

community health workers, should

advocate the importance of primary

teeth to parents, caregivers and

the community at large, and raise

awareness of the impact of ECC on

quality of life of young children.

The adoption of durable health habits in

childhood begins at home with parents

and main caregivers, as they play an

important role in forming the child’s oral

health behaviours.

Providing oral health education to parents

and caregivers on ECC risk factors may

reduce the risk of ECC.

Health education must be based on

scientifically sound information.

Relevant ministries and local

municipalities must establish oral

health education programmes in

preschools, including toothbrushing

with use of fluoridated toothpaste.

Health education in preschools, including

toothbrushing programmes with

toothpaste containing fluoride 1000–

1500 ppm, is effective in reducing dental

caries when activities are carried out by

preschool teachers.

Mass communication should be

organized to improve oral health

knowledge and practices of parents

and caregivers.

Several media may be used to increase

awareness among parents and caregivers

about ECC prevention, diet and oral

health practices.

Home visits and telephone

communication should be introduced

in outreach care.

Personal contact with parents of children

affected by ECC is relevant for early

detection of disease, ECC prevention,

and appropriate health care coverage of

children. Community health workers may

undertake this outreach activity.

Motivational interviewing of parents

and pregnant women by trained

primary care workers and oral health

professionals is useful for avoiding

dental caries among children.

Community programmes including

motivational interviewing are useful in

engaging mothers and pregnant women

in dental caries prevention.

Annex 2

49

Action

Rationale

Role of primary care

teams, including

community

health workers, in

prevention and

control

Advocate and facilitate training for

primary care workers, including

community health workers, nurses

and midwives.

Primary care teams are key actors in

prevention and control of ECC. In most

countries, children aged under five

or six years are seen by primary care

teams, including nurses, midwives and

community health workers, and less often

by oral health professionals.

Primary care teams often have profound

knowledge of the community, enabling

them to work with support from family,

friends and organizations, and to offer

continuity of care.

Monitoring and

evaluation

Preschool children may be included

as a target group in national and

subnational oral health surveys

as part of regular population

surveillance programmes.

It is important that community

programmes established for prevention of

ECC and health promotion be evaluated.

National or subnational concerns may call

for incorporation of preschool children in

oral health surveillance programmes.

Building a supportive

framework for

integration of ECC

prevention and

control into overall

health initiatives

Integrate ECC prevention within

primary care (e.g. child and maternal

health programmes) and ensure

engagement of non-oral health

professionals in oral health work.

In most countries, children aged under

five or six years are seen by primary care

teams, including nurses, midwives and

community health workers, and less often

by oral health professionals.

Promote, protect and support exclusive

breastfeeding up to age six months and

introduction of nutritionally adequate

and safe complementary (solid) foods

at age six months together with

continued breastfeeding up to two

years of age or beyond.

Breastfeeding is associated with better

general health and a lower risk of ECC in

infants and children.

Align ECC intervention with health

promotion initiatives against childhood

obesity by avoiding consumption

of free sugars in foods and drinks,

including complementary foods

and drinks.

Intake of free sugars has a negative

impact on oral and general health, such

as dental caries, weight gain, obesity and

associated NCDs.

Increase efforts to ensure access to

clean safe drinking water to avoid

unnecessary consumption of sugar-

sweetened beverages.

Intake of free sugars has a negative

impact on oral and general health, such

as dental caries, weight gain, obesity and

associated NCDs.

Ending childhood dental caries

50

Action

Rationale

Regulate marketing of foods and

drinks (including complementary food)

to children, and especially reduce

exposure of children to, and power of,

marketing of foods high in free sugars.

Intake of free sugars has a negative

impact on oral and general health, such

as dental caries, weight gain, obesity and

associated NCDs.

Introduce taxation policies on foods

and drinks high in free sugars.

Taxes or levies on sugar-sweetened

beverages are recommended by WHO as a

measure to reduce consumption of sugar-

sweetened beverages.

Advocate appropriate use of fluoride

for caries prevention. This should

provide guidance for both public health

interventions and health workers

advising individuals and caregivers.

Fluoride is a key agent in reducing

prevalence of dental caries. Because ECC

severity and social, cultural and economic

conditions differ between countries, each

country should formulate and implement

its own policy on appropriate use

of fluoride.

Integrate ECC surveillance into existing

national or subnational surveillance

systems (e.g. DHIS).

It is important that national programmes

established for prevention of ECC and

health promotion are evaluated. National

or subnational concerns may call for

incorporation of preschool children in oral

health surveillance programmes.

Develop a national policy to encourage

the development of new skills and

competencies of primary care teams

and ensure their initial and continuing

training for ECC prevention and control.

It is essential that non-oral health

professionals (primary care teams, primary

care workers) appreciate ECC as a public

health problem impacting on infants and

children, families and communities. This

should be in terms of pain, infection, child

growth and development, as well as the

economic bearing of the disease. Health

professionals should understand the key

risk factors for ECC and how to identify

them, and they should recognize their

responsibilities in the work against ECC.

Annex 3

51

Annex 3

Useful materials

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Population-based use of fluoride

Basic methods for assessment of renal fluoride excretion in community prevention programmes for oral health. Geneva:

World Health Organization; 2013 (https://www.who.int/oral_health/publications/9789241548700/en/).

Fluoride and oral health. Geneva: World Health Organization; 2016 (https://www.who.int/oral_health/publications/

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(https://www.who.int/oral_health/publications/prevention-dental-caries-through-use-fluoride/en/).

Role of non-oral health professionals and community health workers in

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Health Assembly, Geneva, 23 May 2007. Geneva: World Health Organization; 2007 (http://apps.who.int/iris/bitstream/

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Strategy for oral health in South-East Asia, 2013–2020. New Delhi: World Health Organization Regional Office for South-

East Asia; 2013 (https://apps.who.int/iris/handle/10665/205929).

Global action plan for the prevention and control of noncommunicable diseases 2013–2020. Geneva: World Health

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Note

Note

Note

ISBN 978-92-4-000005-6