Over the last decades, major progress has been made in reporting the public health significance of dental caries. The burden of dental caries has been well-described in terms of its prevalence, impact on well-being, and societal costs.1 Dental caries is one of the most common childhood diseases, affecting more than 486 million young children worldwide.2 In addition, social inequalities in childhood dental caries have become a major concern. Data from across the globe consistently demonstrate that children from lower socioeconomic status (SES), deprived regions, and minority ethnic groups are having disproportionately higher levels of dental disease than their more privileged peers.3 As a consequence, disadvantaged children more often experience negative impacts on quality of life, well-being, and social functioning. For example, children with higher caries levels are almost three times more likely to miss days from school as a result of dental pain and have poorer school performance, than those with low levels of caries (Fig 5-1).4
Fig 5-1 Childhood dental caries often presents with a high degree of destruction and clearly reduced quality of life. (Image courtesy of P. van Meurs, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands.)
It is increasingly recognized that restorative dental treatment and chairside prevention alone will not be sufficient to tackle inequalities in childhood dental caries. Action is also required at community and population levels to address the broader determinants underlying these inequalities. Ideally, action should be focused on closer integration of dental and general health, since dental caries shares many risk factors with other chronic diseases.
This chapter describes the rationale for integrated interventions to prevent dental caries in childhood. Furthermore, without claiming to be comprehensive, a number of caries-preventive interventions are described that are based on the Common Risk Factor Approach (CRFA) or use partnership across different sectors and disciplines.
Determinants of childhood dental caries
To prevent dental caries and reduce inequalities thereof, the underlying determinants should be understood to identify potential opportunities for intervention. Traditionally, researchers have mainly focused on understanding the biologic and behavioral risk factors of dental caries. Behaviors such as poor oral hygiene, lack of fluoride use, and a cariogenic diet, are key risk factors of dental caries and they are more prevalent among children with low SES.5 Yet these factors only explain a small part of the inequality in dental caries.6,7 In recent decades, empirical attention has shifted towards investigating the broader social context in which children’s health behaviors are shaped and biology is affected, known as the “social determinants.” Social determinants refer to the conditions in which people are born, grow, live, and age.8
In 2007, Fisher-Owens et al9 presented a comprehensive conceptual model of factors influencing childhood dental caries, identified from the literature. The model acknowledges the multilevel nature of influences on children’s oral health, and includes a wide range of determinants such as proximal psychosocial factors (eg, parental attitudes, stress, family functioning, and social support) and more distal factors (eg, living environment, culture, social capital, and the [dental] health care system). These determinants are suggested to operate at child-, family-, and community level. The model has been increasingly used as a theoretical basis for the development of community and population-based dental health promoting interventions at upstream, midstream, and downstream levels (Fig 5-2).
Fig 5-2 Fisher-Owens’ model of influences on children’s oral health (modified from Fisher-Owens et al9).
The rationale for the Common Risk Factor Approach and interdisciplinary action
In 2000, Watt and Sheiham10 introduced the CRFA as a rational basis for promoting oral health. The CRFA encourages an integrated approach to chronic disease prevention, by addressing risk factors common to many chronic diseases in the context of the wider social environment. The conceptual basis for the CRFA stems from the evidence that many noncommunicable diseases (NCDs), including a range of oral diseases, share the same social determinants and a small set of behavioral risk factors, namely sugar, tobacco, alcohol, and diet. Hence, working in partnership across relevant sectors and professions is essential to improve both oral and general health outcomes and would lead to more efficient use of resources, effort, and expertise. The CRFA has now been widely accepted and endorsed by (dental) policy makers and researchers. This is reflected, for example, in the World Health Organization (WHO) global action plan, which now recognizes oral health as an integral element to reduce the global burden of NCDs (Fig 5-3).11
Fig 5-3 The common risk factor approach (modified from Sheiham and Watt12).
Interventions using interdisciplinary partnerships for the prevention of dental caries
The sections below describe a number of caries-preventive interventions using partnerships across different disciplines and across various settings.
Healthy teeth: all aboard! GigaGaaf in the Netherlands
In the 1980s, a new system of nonoperative caries treatment program (NOCTP) was introduced in the municipality of Nexø on the Danish island Bornholm.13 In this program, oral health professionals used risk criteria to assess an individualized recall interval and need for (preventive) treatment with an emphasis on the mechanical plaque control of plaque-stagnation areas (eg, erupting molar teeth). In the year 2000, 18-year-olds living in Nexø had a remarkably low number of mean decayed, missing, and filled tooth surfaces (dmfs) (1.25 ± 2.01) and a high percentage (56%) did not have any caries experience.14 Dmfs scores were significantly lower in the Nexø group in comparison to four Danish low caries municipalities.13 These differences could not be explained by other caries-related background variables. The program was implemented in several other countries with varying, but mostly positive results in studies by Kuzmina and Ekstrand14 (Russia), Arrow15 (Australia), Vermaire et al16,17 (the Netherlands), and Ekstrand and Qvist18 (Greenland).
The NOCTP program formed the basis of a currently conducted randomized controlled trial in the Netherlands on the effectiveness and cost-effectiveness of a mixed individual and community-based approach to improve oral health in 0- to 5-year-old children and to reduce socioeconomic inequalities in oral health (Healthy Teeth; all aboard! / GigaGaaf intervention).19 In this program, all children in the intervention group visiting a well-baby clinic are referred to a participating dental health clinic at approximately 6 to 9 months of age (from the eruption of the first tooth). Well-baby clinics are visited by 95% of the Dutch child population and offer 13 consultations for parents and their child between birth and 4 years of age. When referred to the dental health clinic, parents receive advice and oral health instruction to keep their child’s oral health in perfect condition and they receive a second appointment before the second birthday. From that point onwards, children follow the NOCTP program where both the need for caries-preventive measures and recall interval are individually assessed using the NOCTP-adapted risk criteria. These criteria include parental motivation, understanding, tooth eruption phase, and caries activity (Fig 5-4). To enhance parental motivation, motivational interviewing (MI) is used as a communication strategy in this intervention (see Motivational Interviewing textbox overleaf). Preliminary results on behavior change show that children referred to dental clinics by the use of well-baby clinics, had a 16 times higher odds of children having their first preventive dental visit.20 Final results on the (cost-) effectiveness, including clinical results are expected in 2022.
Fig 5-4 Nonoperative caries treatment inactivates caries lesions by improving oral hygiene and fluoride application. Irreversible pulpal inflammation does not allow this approach (image courtesy of R.J.M. Gruythuysen, the Netherlands).
A different approach, using the same infrastructure of well-baby clinics, is the “Toddler Oral Health Project” (translated from the Dutch name “Gezonde Peutermonden”) in the Netherlands.21 In this project, oral health coaches are detached at well-baby clinics, to provide oral health care and tailored oral health advice according to the NOCTP methodology on the location itself. Results of a randomized controlled trial evaluating the effectiveness of the program are also expected by the end of 2022.
Childsmile in Scotland
In 2006, the Scottish National Health Service (NHS) started an intervention program, named Childsmile, to improve the oral health of children in Scotland and to reduce socioeconomic inequalities in both oral health and access to dental care.24 Childsmile consists of three programs:
- a core program
- a practice-based program
- a nursery- and school-based program.
The core program includes the provision of free toothbrushes and fluoridated (1,000 to 1,500 ppm) toothpaste on at least six occasions during children’s first 5 years, and daily supervised tooth brushing for all children attending nurseries, as well as primary schools in the 20% most deprived areas. In the practice-based program, families of infants at increased risk of developing dental caries are visited by a Dental Health Support Worker (DHSW) on referral by a health visitor. The DHSW gives one-to-one oral health support, makes a first appointment with an NHS dental service, and links families to other community activities or resources that support oral health (eg, food cooperatives). The length and intensity of care is tailored to the family’s needs. The nursery- and school-based program is offered to children living in the 20% most deprived area’s in Scotland. These children are provided with twice-yearly fluoride varnish applications from the age of 3 years by teams of dental nurses and DHSWs. Furthermore, good oral health is promoted and oral health education is given by these teams.
Long-term results on the cost-effectiveness of the program are expected to be published in due time, but already reported clinical results show that – compared to 10 years earlier – in all categories of deprivation, an increasing percentage of children were found to have no caries into dentin.23 Preliminary results presented at the European Association of Dental Public Health (EADPH) Congress show that obvious caries experience risk significantly decreased and the frequency of dental practice visits increased from zero contact to more than five contact moments (adjusted odds ratio = 0.5, 95% CI 0.46 to 0.54).25 Also, the use of DHSWs has recently been studied. This was found to be an effective way of linking children to primary dental care services for prevention at a younger age.26 Hence, this mixed individual-/community-based approach can be considered successful for the Scottish situation (Fig 5-5).
Fig 5-5 Percentage of first year primary school children (approx. 5 years old) in Scotland with no obvious decay between 2008 and 2018 by level of deprivation (Scottish Index of Multiple Deprivation [SIMD] quintile: 1 most deprived, 5 least deprived)(reproduced from National Dental Inspection Programme27 with permission from Public Health Scotland).
Motivational interviewing
To prevent the development of dental caries, dental health professionals traditionally provide (the caregivers of) their patients with information on an individual basis from a top-down perspective. This means that the dental health professional tries to transfer his/her knowledge and skills on oral hygiene behavior to the patient or his/her care giver by trying to influence (or rather convince) them. This manner of health promotion is still commonly applied in dentistry. However, evidence of its effectiveness is weak and because of its individual character it can be considered a relatively expensive (and therefore not cost-effective) way of decreasing the caries risk in children. Lack of dental knowledge is one of the identified caries determinants in children.
Alternatively, a more recently introduced, individually delivered way of oral health promotion can be applied as well, using the motivational interviewing (MI) technique. This increasingly applied counseling approach, originally designed for addiction counseling, is based on equivalence between patient/client and health professional. This technique is based on the transtheoretical model of change22 and is developed by Miller and Rollnick.23 It is described as a directive client-centered counseling style to change people’s behavior intrinsically. This change is achieved by resolving identified ambivalence in behavior in a directive way by first exploring the stage of behavior change the patient (or their caregiver) is in. According to the model, these stages of change are:
- Precontemplation stage: the patient may or may not perceive negative issues but, if present, these issues are not considered serious enough to motivate them to change their behavior. In this stage, he/she has little or no motivation to change since the patient doesn’t consider him/herself to have a problem.
- Contemplation stage: the patient is aware that his/her behavior is problematic but he/she is uncertain (ambivalent) about making an actual change in his/her behavior. In this stage, the patient may have considered changing his/her behavior but has not put any effort into changing yet.
- Preparation stage: the patient has decided to change his/her behavior and has made commitment to do so. Positive and negative consequences of their behavior are considered and the patient has concluded that the negative aspects outweigh the benefits. He/she may have made a plan to change but has not undertaken any action.
- Action stage: the patient is actively involved in changing his/her behavior. The patient understands that he/she is responsible for this change.
From this point on, the patient can either move to:
- Relapse stage: the patient was not successful in continuing the changed behavior and usually enters the contemplation stage of action stage again.
- Maintenance stage/success: the patient has successfully changed his/her behavior for at least 6 months.
The major difference between MI and traditional health promotion strategies is the fact that people are motivated intrinsically by the health professional rather than being persuaded. Furthermore, an important starting point of MI is that it is considered the oral health professional’s task to help the patient to identify and resolve their present ambivalence in changing his/her behavior, but not to identify and resolve it for them. MI has been subject to over 200 studies, including in oral health, with promising results. Being able to provide (caregivers of) the patients with all the information they need to go to the next phase in their behavior change, can be considered more effective than providing them with lots of information patients will not process. The principle is of “readiness to change.”
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