– Guidance for healthy dental and oral behavior: Multilevel prevention of early childhood caries

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

Though the treatment of ECC usually improves the oral health-related quality of life (OHRQoL),7 invasive approaches pose not only risks and efforts on the children or families, but also a considerable burden for the health systems, as general anesthesia might be needed for restorative and surgical interventions.8,9

Fig 9-1 Caries experience (dmft) and its single components as well as initial lesions (it) in a representative sample of 3-year-olds (n = 95,127) in kindergarten in Germany, 2016 (modified from Team DAJ4).

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.

Communicating beneficial information and its transformation into an actual change of behavior is not simple, and its effectiveness can quickly be overrated.11 This means that health care providers (eg, dental practitioners) need to consider psychologic components in the communication with patients (eg, behavior change techniques and theory) as it is in general a far step from “knowledge” towards “attitude” and finally to a long-term change of behavior.12

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.

This means in the specific case of ECC prevention that children may or will adopt the behavior of regular tooth brushing from their parents and/or older sibling, if they observe them brushing their teeth every time before bedtime, especially when this behavior is positively reinforced.15 In addition, the diet of the child is influenced and shaped in childhood, likely due to the availability of certain (sugary) food and the observation of parental dietary habits.

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

Information intake

Probability of retaining

Do it yourself


Tell / explain to somebody


Listen & see






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).

Fig 9-2 Depending on the model of patient-doctor relationship, the proportion in the decision making process varies. In the participative model, dental practitioner and patient have a symmetric, partnership-based relationship.

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)

Main arguments for informed consent



Protection of study participants


“The autonomous individual acts freely in accordance with a self-chosen plan”28

Prevention of abusive conduct

Informed consent sets a bulwark against offenses such as assault, deceit, coercion, and exploitation


Trust is needed in any patient-doctor relationship. The process of informed consent contributes to the restoration of trust.


The patient holds “proprietary” rights over themselves and their body


Patients retain a high degree of control over what happens to them

Personal integrity

Protection of patients’ sense of personal integrity

The process or the approach of informed consent relies on certain requirements and main elements in the process of clarification and decision making,29 presented in Table 9-3.

These aspects are essential in the understanding of the modern patient in an equal partnership-based relationship and for approaches improving the health literacy, which is needed in the areas of disease management, as prevention and health promotion for oneself, and for people for whom one bears responsibility.30 The support of the caregivers’ self-efficacy31 and of their health literacy via intrinsic motivation may have long-term effects. In the case of ECC, (oral) health literacy (of the guardian) may lay the foundation to maintain a healthy (primary) dentition and a high (oral health-related) quality of life from early childhood onward.

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


The patient’s ability to understand and to decide





The explanation of the relevant information

Process of clarification


A recommendation of a procedure


Understanding of (3) and (4)


The decision for a procedure

Decision taking


The acceptance of the treatment request

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

In the context of ECC prevention, parents may first consider in the motivational phase “what and how to achieve oral health in their child” and then secondly act (eg, brush with fluoride toothpaste regularly) and reflect on their actions (postdecisional phase, to see that it is working – or not).

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

Three aspects (oral hygiene, diet/carbohydrate intake, fluorides) may therefore be the target of counseling approaches to prevent ECC (Fig 9-3).

Nonetheless, the level of evidence for and the effectiveness of different caries preventive measures differ (Table 9-5).

Fig 9-3 Possibilities to intervene in the carious process by counseling (orange arrow).

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

Advice (for all 0- to 3-year-olds)

Level of evidence*

Parents/caregivers should brush (or supervise) tooth brushing


Use of toothpaste containing at least 1,000 ppm fluoride


From the breakthrough of the first tooth, a fluoride toothpaste should be brushed with twice a day


Breastfeeding provides the best nutrition for babies


The frequency of consumption and the amount of sugary foods and beverages should be reduced


Teeth should be brushed before bedtime and once a day


From an age of 6 months a free-flow cup should be introduced and from 1 year it is not advisable to feed from a bottle anymore


Sugar-free medication should be recommended


When weaning, sugar should not be added to the porridge or drinks


A very small amount of toothpaste should be used when brushing your teeth

Clinical practice

* 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

In addition, the method of counseling may play an essential role. Dental practitioners should be aware that there is a difference in the likelihood of behavioral change after the bare telling of the information on how domestic prevention of ECC regarding tooth brushing, fluoride use, and nutrition (nursing bottle and content) should be performed compared to, for example, the use of a certain communication technique like motivational interviewing (MI).

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Jan 3, 2022 | Posted by in General Dentistry | Comments Off on – Guidance for healthy dental and oral behavior: Multilevel prevention of early childhood caries

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