Early childhood caries (ECC) is a preventable oral disease in young children, but still highly prevalent worldwide (23% to 90% in 5-year-olds).¹ Distribution of caries experience, also in the case of ECC, is polarized, resulting in higher caries rates in children from lower socioeconomic families or lower parental educational background, reflecting strong parental influences.² Especially in severe cases ECC affects the children’s and their parent’s quality of life. The Specific affected Caries Index (SaC), describing the mean caries experience in children with a decayed, missing, or filled teeth (dmft) > 0,³ is in this age group of 3-year-olds in Germany already 3.6 dmft (Fig 9-1).⁴ In many cases the care index of ECC is low, eg in 3-year-olds in Germany it is only about 25%, even though all restorative treatment including general anesthesia is covered by health insurance in Germany (Fig 9-1).⁴ In addition, the low care index in primary teeth is very low, which is presumably due, among other reasons, to lack of knowledge in dental practitioners,⁵ and to the low ability and willingness of these small children to cooperate for invasive dental treatment.⁶

Main aspects in the etiology of ECC and, therefore, measures for its prevention are known: Regular tooth brushing with fluoride toothpaste in children starting with the first tooth, which usually erupts arounds the age of 6 months, and no use of nursing bottles containing sugary drinks.¹⁰ Despite this knowledge on the most important home measures of preventing ECC, transposing this information for the implementation of these measures for a healthy dentition in early childhood still remains a great challenge.

The primary aim of pediatric dentistry is the achievement of a high OHRQoL, to which a healthy dentition via a working prevention of ECC can significantly contribute.

How do we learn: different theories

Social cognitive theory: learning from a model

Social cognitive theory (SCT) describes that a person (model) is observed, and if it appears to be meaningful and if it is possible for the imitator (learner) to imitate this behavior, the behavior is imitated. Often the model and/or the imitator (the learner) are not aware of his or her position. Learning from the model, therefore, includes both a thinking (conscious) imitation, and an unconscious imitation (imitation without explicitly thinking about it).¹³ There are certain requirements for learning according to the SCT¹⁴:

• the learner must have an emotional relationship with the model and/or the model must be important in some way (eg, parent, teacher, employer)
• the behavior must be attainable and comprehensible
• model behavior must have been successful and reinforced
• the learner must be strengthened to show the adopted behaviors.

Similarly, in the kindergarten setting the educators and other/older children may be models that have an influence on young children’s behavior, eg a kindergarten teacher brushes teeth with fluoride toothpaste with a group of children (also her own teeth) on a daily basis after lunch. This might be used as a public health approach to compensate for parents who don’t brush their children’s teeth. Attained behavior in early childhood is thought to be a key factor also for behavior later in life, and in adulthood, which is highly important for prevention of a lifestyle disease like caries.¹⁶

Behaviorism: learning through reinforcement and success

Behaviorism refers to the concept in scientific theory of investigating and explaining the behavior of humans and animals using scientific methods, ie without introspection or empathy.¹⁷ This paradigm of operant conditioning, also called “learning by success” describes a learning of stimulus-response patterns. The findings of behaviorist research are the basis for various behavioral therapeutic procedures, including the so-called systematic desensitization of patients with a phobia.¹⁸ This is also highly relevant in pediatric dentistry as young children receiving an invasive dental treatment in a carious tooth but without help or guidance in coping positively with this situation might gain a negative or even painful experience in the dental office, resulting in dental anxiety and negative stimulus-response patterns.

Cognitivism: learning through insight and cognition

Cognitivism is a learning theory that should be distinguished from behaviorism and constructivism. It describes the learning process like a classic “data computing process” and regards each person as an individual who is not “controlled” by others and with ability to think, as human beings stand out from the animal world.¹⁹

Constructivism: learning through personal experience and interpretation

Constructivist “learning is a cognitively structuring acquisition of novel events in the systemic environment.”²⁰ “The constructivist orientation can only help in the sense that it emphasizes the basic autonomy of the ‘learner’ and points out that in all circumstances it is only the ‘learner’ themselves who can construct their conceptual structures.”²¹

Learning is in principle “self-directed learning.” This means that learning cannot be taught directly. It is true that information can be conveyed, but everyone has to “understand” it. “Understanding” means: to integrate new knowledge into existing patterns, to consider it personally important and relevant, and also to “occupy” knowledge emotionally and to formulate it “with one’s own words,” to provide it with meanings. It’s like the proverb, “You can lead a horse to water but you can’t make it drink!”^20,22

Learning and the potential role of sensory perception

Despite different learning theories it is clear that not all information received will be retained and especially not processed further for behavioral changes – if at all. Our brain capacity and functionality is extremely high, but still limited. Via sensory organs (eye, ear, etc), we absorb information that is processed and stored in the brain in ultra-short-, short-, or long-term memory depending on the quality of the information, the importance of the information, and on how the information got into the brain in the first place. A rough distinction is made between the probability of retaining information via different ways of intake (Table 9-1), which should be considered for the approach of parental counseling, eg on prevention of ECC in dental office.²³

Table 9-1 Rough assessment of the probability of retaining information via different ways of intake²³

Ethical considerations in modern patient-doctor relationships

In the past decades a change from a rather so-called “paternalistic” approach to more participative approaches with informed consent has occurred in medicine and dentistry.²⁴ In contrast to the traditional (“paternalistic”) asymmetric patient-doctor relationship, contemporary medicine relies on the mature patient and a symmetric, partnership-based relationship that is oriented towards the autonomy of the patient and includes his or her competencies.²⁵ A schematic diagram illustrates the roles of the patient and dental practitioner (Fig 9-2).

According to Beauchamp and Childress²⁶ there are four basic principles in medical ethics which are to be considered and balanced against each other for decision taking in medicine:

• respect for autonomy
• beneficence
• non-maleficence
• justice.

Why do we need informed consent?

Modern society acknowledges the individual in medicine, and with “informed consent” (Table 9-2) authority on decision is given to the individual (patient or the research participant) who may be a single non-expert, to veto power over some interventions, even against the will of many expert physicians.²⁷

Table 9-2 Arguments for informed consent in medicine (modified from Eyal²⁷)

Table 9-3 Elements in the process and approach of informed consent²⁹

Health literacy and belief in self-efficacy

Self-efficacy mechanisms describe the expectation of a person to be able to perform desired actions successfully on the basis of his/her own competencies. This means “the higher the level of induced self-efficacy, the higher the performance accomplishments.”³²

In principle, the caregiver’s oral health literacy is an important success factor for caries prevention in pediatric dentistry. Measures such as parental training in oral hygiene for toddlers and improving health literacy and at best also self-efficacy are important aspects, so that preventing ECC by brushing the primary teeth with fluoride toothpaste in the home setting is performed sufficiently and starts early.

Posing questions may help to guide parents, and puts the responsibility to answer on the “learning parent,” decreasing the hierarchy in the “teacher-learner” or “patient-doctor” relationship (Fig 9-2):

• What do you wish for your children’s teeth?
• What do you think you need for a good oral health of your child?
• What do you think you need to keep your child’s teeth healthy?

According to the “Rubicon model of action phases,”³³ there are steps between the motivational process of the predecisional phase and the volitional processes of the postdecisional phase, which means that there are “clear boundaries between motivational and action phases.”³³

Already in 12-year-old children in Germany the lack of self-efficacy shows an impact on the oral health of permanent teeth (Table 9-4). Health professionals should therefore consider for the parents (individually) how they may be able to address their conviction of self-efficacy, and later on also in the growing child.

Table 9-4 Relationships between categorized caries experience and self-efficacy conviction in 12-year-olds in Germany (modified from Institute of German Dentists [IDZ]³⁴)

Evidence of different aspects in counseling for preventing ECC

Tooth brushing with fluoride toothpaste and a low frequency of sugar intake are the basis for preventing and managing caries not only in children.¹⁶

Table 9-5 Evidence-based catalog of measures for caries prevention in the primary teeth (modified from Public Health England³⁵)

* Evidence levels range from I (very high) to V (very low).

The following catalog of measures should be recommended in an individual setting to promote healthy primary teeth.³⁵

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