A Family-based Preventive Programme Decreases the Incidence and Severity of Early Childhood Caries in Rural Preschool Children; The Early Smiles Programme

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A Family-based Preventive Programme Decreases the Incidence and Severity of Early Childhood Caries in Rural Preschool Children; The Early Smiles Programme

https://doi.org/10.21203/rs.3.rs-4326732/v1

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Our aim is to propose a novel family-based preventive programme (Early Smiles) that uses promotional and preventive early interventions in the family, to reduce the onset and severity of caries lesions in rural preschool children. After conducting a baseline cross-sectional study with 2-, 4- and 6-year-old children under traditional dental care (Control Group; n=101), a non-randomized community trial including children aged 2, 4, and 6 years from rural areas in southern Chile was devised (Intervention Group; n=107). Dental caries lesions were assessed using the ICDAS index and the dmft and caries significance index (SiC) were determined. Caries prevalence, the dmft, and SiC in 2-year-old children intervened in the Early Smiles program decreased by 73.11%, 81.50%, and 74.78% respectively (p<0.001). The number of cavitated lesions decreased significantly in 2- and 4-year-old children by 77.38% and 86.88% respectively (p<0.001). In the intervention Group, caries lesion severity in 2- and 4-year-old children presented less severe codes (ICDAS 3 and 4) than the control group. Interventions based on behavioural change, with the family, within the interdisciplinary health team, and early in life, seems to be highly effective in reducing the burden of caries lesions in 2-year-old children from rural areas.

Dentistry

Nutrition & Dietetics

Epidemiology

Preventive Medicine

Dental caries

Early Childhood Caries

Motivational Interview

Interdisciplinary

ICDAS

dmft

SiC

Rural

Chile.

Dental caries is the most prevalent non-communicable disease worldwide [1]. Clinically, ECC is diagnosed by the presence of one or more caries lesions (cavitated or non-cavitated), surfaces lost or restored (due to caries), in any primary tooth of a child younger than 6 years old [2]. ECC causes pain, infection and early tooth loss, with feeding problems, lack of sleep and poor school attendance, severely impacting the quality of life. Moreover, treatment may become expensive, especially when restorations and extractions are performed under general anaesthesia [3].

Since ECC is predictor of caries in permanent teeth [4], specific measures to control ECC during early childhood will avoid the compromise of the dentition during the life course. Due to the changing paradigms in pathogenesis [5], a new approach for caries treatment and oral health appears mandatory, albeit canonical practices still exist. Social determinates of the family remarkably impact children’s oral health. In fact, the most socioeconomically disadvantaged groups of the population are those with the lowest parent’s educational level, less access to preventive treatments, poor diet and deficient oral hygiene habits [6]. Rural populations present greater accumulated damage due to detrimental oral health, less access to treatment and greater social consequences. Thus, rurality explains inequities leading to higher caries rates [7].

Caries in primary teeth have remained steady in recent decades worldwide [8], and in Chile, especially in rural areas [7], [9]. These data suggest low performance of traditional oral health interventions and invite to novel strategies, such as those including the family environment, through home dental visits and the use of anticipatory guidelines [10]. Interventions based on behaviour change models have been reported to promote dental health in childhood, but the actual effect on reducing caries incidence remains controversial [11], [12], [13], [14].

Despite the efforts of the Chilean health system to improve children’s oral health through the implementation of programmes focused on children’s dental care based on a caries risk and including preventive measures, such as fluoride applications and toothbrushing with toothpaste delivered to kindergartens and schools [15], [16], the high caries prevalence observed in the population suggests limited effectiveness. The novel family-based dental health model (Early Smiles) proposed in this study uses promotional and preventive interventions with the family, taking a minimally intervention and an interdisciplinary approach, with the aim of reducing caries in rural populations.

This research was approved by the Scientific Ethics Committee of the Aysén Health Service. A non-randomized community trial was carried out in 4 rural areas (in the commune of Coyhaique) of southern Chile. A total of 208 children aged 2, 4 and 6 years were divided into 2 groups, Group I: n=101 children; Control group and Group 2 Group II: n=107; Intervention group. The control population received community fluoride applications twice per year in kindergarten, following the protocol of the government programme and access to dental care [16]. Simultaneously, parents received traditional oral health education at the local dental service. Oral health of these children was examined during 2016 and their oral status was registered, serving as the comparison for the data obtained for Group II. There was not sample size calculation, as all the children born in the localities during the period were included.

Children participating in the Early Smiles program (Group II; Intervention Group), received a promotional, preventive, and family-based dental approach through the following strategies (Figure 1):

1. Home dental visits to children aged between 6 and 8 months. Counselling and an anticipatory guideline about oral health was delivered, including central aspects for caries prevention: healthy diet and avoidance of sugars consumption, promotion of breastfeeding, tooth brushing and fluoride usage.

2. Follow-up at 12 months of age in the local dental service, included an oral health examination and behavioural change interventions based on the principles of motivational interviewing (MI). In addition, toothbrushing technique was reinforced.

3. Follow-up at 18 months of age at the dental service, including oral health examination, monitoring of established goals (from the previous session) and reinforcement of behavioural change interventions (MI).

4. Follow-up at 2 years of age at the local dental service included oral health examination and cariogenic risk assessment. Caries lesion detection and severity was undertaken using the International Caries Detection and Assessment System (ICDAS) [17]. The frequency of the controls and the type of intervention were defined based on the cariogenic risk assessed (Figure 2).

5. Integration of the interdisciplinary health care team. Professionals of the primary health care team at rural areas (physicians, nurses, nutritionists, psychologists, kinesiologists, social workers, and health technicians) were trained in the dental topics that were delivered in every visit, MI, and topics of cariology related to the prevention of ECC and minimal intervention approaches.

The Early Smiles program was carried out between 2017 and 2018. Only one dentist per location carried out all the interventions and evaluated all the children in the primary health care centres. A convenience sample including all 2-, 4- and 6-year-old rural children under dental health control in the towns of Balmaceda, El Blanco, Valle Simpson and Villa Ortega was obtained. Before examination, informed consent from the parents/tutors of the participants was obtained. Dentists of the primary health care team in rural areas (n=14) were trained in ICDAS by a calibrated expert examiner (RAG). Only ICDAS codes 3 to 6 were recorded to avoid diagnostic subjectivity of codes 1 and 2. Visual caries assessment was carried out without radiographs due to the lack of available equipment in the participant rural localities. From the data obtained with ICDAS, dmft, the number of cavitated carious lesions, caries rates, caries significance index (SiC) [18], and caries prevalence were calculated. Clinical evaluations were carried out by a dentist other than the one who performed the intervention. Data were analysed in SPSS version 23, and the Mann-Whitney U test was used to assess the significance of the results (95% significance level).

Group I (control) included 101 (48.6%) children who were assessed at the baseline only in 2016 (see Fig. 1), and group II (intervention) included 107 (51.4%) children. All children in Group II were followed until the two years of intervention were complete, during 2017 and 2018. Importantly, 4- and 6-year-old children were exposed to the Early Smiles program only when they were 2- and 4-years old, respectively (Fig. 1). There were no significant differences between the groups regarding the sex of the children (Table 1). No follow up loss was reported in any group.

Table 1

Distribution of participants by age and sex in the control (Group I) and the intervention (Group II) groups.
Age	Group	Male	Female	p-value
2	I (control)	17	15	0.468
	II (Intervention)	15	19
4	I (control)	18	28	0.225
	II (Intervention)	17	15
6	I (control)	14	9	0.460
	II (Intervention)	21	20

Caries prevalence (dmft > 0) in 2-year-old children decreased by 73.11% (p < 0.001) and was significant (Table 2), unlike at 4 years old (p = 0.347), and at 6 years old (p = 0.296). The dmft decreased by 81.50% in 2-year-old children (p < 0.001), when compared to Group I. Although the difference in dmft was not statistically significant in 4- and 6-year-old children, there was a decreasing trend. The SiC decreased by 74.78% in the 2-year-old group (p < 0.001), while at 4 years of age, it decreased by 16.92% (p = 0.068) and by 14.02% at 6 years of age (p = 0.302). There was a significant difference in the reduction of carious lesions in children aged 2 and 4 years in the Early Smiles intervention (Table 2). In 2-year-old children of Group II, the number of cavitated caries lesions decreased by 82.24% (p < 0.001); in 4-year-old children, it decreased by 86.88% (p < 0.001). No statistically significant reduction was detected in 6-year-old children (p = 0.080).

Table 2

dmft index (average and SD), SiC (average and SD) and number of cavitated lesions in study groups
Variable	Age	Group I (control) ± SD	Group II (Intervention) ± SD
dmft (mean)	2	4.00 ± 4.10	0.74 ± 1.85	< 0.001 *
	4	6.33 ± 5.28	4.66 ± 4.61	0.177
	6	5.22 ± 4.47	4.12 ± 3.94	0.306
dmft > 0 (%)	2	65.63	17.65	< 0.001 *
	4	78.26	68.75	0.347
	6	82.61	70.73	0.296
SiC	2	9.00 ± 2.10	2.27 ± 2.72	< 0.001 *
	4	12.47 ± 3.14	10.36 ± 1.86	0.068
	6	10.13 ± 3.00	8.71 ± 2.27	0.302
Number of	2	107	19	< 0.001 *
cavitated	4	221	29	< 0.001 *
Lesions	6	73	86	0.080
* = p < 0.05

The Early Smiles intervention group showed higher distribution of cavitated lesions with less severe codes (ICDAS 3 and 4) compared to the control group (Table 3 and Fig. 3) at 2- and in 4-year-old children. In 6-year-old children, no significant differences were observed in the distribution of caries lesion severity between groups (p > 0.05).

Table 3

Number of cavitated lesions (NCL) according to severity (ICDAS code) in both study groups and its distribution (%).
Age	ICDAS code	Group I (control) NCL (%)	Group II (Intervention) NCL (%)
2	3	34 (29.76%)	13 (68.42%)	0.003 *
	4	26 (23.81%)	2 (10.53%)	0.009 *
	5	38 (35.71%)	4 (21.05%	< 0.001 *
	6	9 (10.71%)	0 (0.00%)	0.142
4	3	52 (23.53%)	15 (51.72%)	0.049 *
	4	33 (14.93%)	0 (0.00%)	0.003 *
	5	88 (39.82%)	13 (44.83%)	< 0.001 *
	6	48 (21.72%)	1 (3.45%)	0.002 *
6	3	27 (36.99%)	35 (40.7%)	0.239
	4	11 (15.07%)	15 (17.44%)	0.782
	5	26 (35.62%)	28 (32.56%)	0.147
	6	9 (12.33%)	8 (9.3%)	0.817
* = p < 0.05

Rurality seems to be a key social determinant in the damaged induced by caries [19]. The most economically disadvantaged social groups have parents with low educational levels, limited access to preventive treatments, unhealthy diet and poor oral hygiene habits, impacting the social environment of families [20]. The results of this intervention show that after 2 years of follow-up, the implementation of Early Smiles in a rural population of 2-year-old children had a positive impact on caries experience, significantly decreasing caries prevalence and the severity of existing caries lesions. In 4-year-old children, the positive impact of the intervention was related to a reduction in the number of cavitated caries lesions and their severity. Moreover, effective prevention and reduction in the extent of the damage could reduce costs and improve coverage to dental care. In contrast, in 6-year-old children, no significant impact of this intervention was observed, which is expected because children started the intervention when they were 4 years old, suggesting that starting preventive interventions at older ages is associated with more damage due to caries already present on children’s teeth [21].

Early Smiles considered aspects such as home visits by the dentist, with the aim of addressing the prevention of caries disease in the family social context. Home visiting has been associated with decreased parental stress and increased parental skills [2], increased health literacy, and use of dental services, especially in low-income populations [22]. Lower caries prevalence in interventions that have included home visits promoting feeding or breastfeeding habits has been reported [23], [24]. Although the evidence on improvement in caries indices and quality of life during childhood through these interventions is not conclusive [25], the reduction in caries prevalence in the Early Smiles program (Table 2) suggests that the educative concepts and the delivery of preventive measures at home were well received and effectively incorporated by the families of the participants. Though the efficacy of MI in decreasing the incidence of childhood caries lesions is controversial, it appears to reduce lesion severity [26], [27]. It has been reported that children who received preventive education using MI resulted in lower caries incidence and dmft values than those who received traditional education after 1.9 years. [28] Furthermore, it has been reported that the use of MI in a rural population decreased the incidence of caries lesions and their severity after a year [13].

The Early Smiles program considered the participation of the interdisciplinary health team. They were taught on the available evidence regarding aetiology, prevention and treatment of caries disease, so they could reinforce these concepts when they delivered health care, independently of the dentist’s surveillance. Preventive and promotional instruments developed by the health team constitute innovative aspects of the Early Smiles model, which included principles of family medicine [29]. Accordingly, this intervention focuses on the family and its influence on the oral health of children, considering a common approach to caries with other non-communicable diseases, such as diabetes and obesity.

We acknowledge some limitations in the study, such as the sample size, which should be considered when interpreting the results. The sample size was for convenience, with the objective of ensuring control over the intervention in geographically dispersed rural populations, selecting those with a permanent dentist residing in the location. It is important to mention that the Aysén Region is a large geographical region, with more than 108,494 km² and a population of about 100,000 inhabitants, with inherent difficulties to deliver health and dental care. Formal theoretical training added to a clinical training session in the rural communities was carried out, but formal calibrations might have been needed. Since radiographs were not used in this study, it is possible that some caries lesions had gone underdiagnosed. A long-term follow-up would allow a better assessment of the effectiveness of the program.

Although the Early Smiles program produced a dramatical decrease in caries lesion prevalence, when the approach was taken late in childhood (4 years old), the impact at 6 years old is negligible. The latter clearly suggests that MI and family-based early interventions focused on the aetiological factors involved in caries [30] are more appropriate to cause an impact in caries trends over time. It is reasonable to speculate that these behavioural changes introduced early in life will persist throughout the life course, causing a lower burden of disease later in life.

The promotional and preventive interventions included in the Early Smiles program seem to be a highly effective alternative to reduce the onset and severity of caries in 2-year-old children from rural areas. Its effectiveness could also be partially observed in 4-year-old children who underwent this comprehensive and interdisciplinary approach. These results suggest that dental caries management during childhood should be reassessed. Dentists at primary health care services should change from diagnosing and treating caries lesions to embracing a facilitatory role for behavioural change for oral health with the family, with a more comprehensive and interdisciplinary approach.

Author contributions

ND, FM and RAG conceived the original idea. RAG and VP trained the dental and health team, ND and FM carried out all the procedures at the community. FM-ND-VP and RAG analyzed the data, and FM and ND drafted the first version. RAG edited the final manuscript. All authors revised and approved the final version of the article.

Conflict of interest:

Authors have no conflict of interest to declare.

Acknowledgements

This study was financed by the National Fund for Health Research and Development Project SA16i0064 FONIS of the Chilean Ministry of Education.

The authors thank the collaboration of the Faculty of Dentistry of the University of Talca and the Aysén Health Service, for their collaboration in implementing this study. The authors also thank Verónica Godoy, for her collaboration in the revision of the anticipatory guidelines and advice.

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The authors declare no competing interests.

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A Family-based Preventive Programme Decreases the Incidence and Severity of Early Childhood Caries in Rural Preschool Children; The Early Smiles Programme

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