Early Childhood Caries (ECC)
Early childhood caries is the most common childhood disease throughout the world. It is the most common day surgery procedure at pediatric hospitals in Canada, accounting for 30% of all day surgeries. This number does not take into account the numerous children being treated in general practice, private pediatric offices, and private surgical facilities. ECC is a complex, multifactorial, and largely preventable chronic disease that is influenced by biomedical factors, and the social determinants of health (Canadian Dental Association, 2014).
ECC is a infectious, diet-dependent disease that can begin immediately after tooth eruption & progresses rapidly. It has negative effects on both the primary and permanent dentition leading to negative lifelong quality of life impacts (WHO, 2019). It is often accompanied by serious complications affecting children, their families, communities, and the healthcare system. This can include: acute/chronic pain which may interfere with eating, sleeping, & proper growth, tooth loss/malocclusion which can increased dental treatment & expenses throughout life, and compromised general health (Canadian Dental Association, 2010). The negative impacts can have lifelong implications to a child’s self-esteem and their ability to communicate/socialize (Canadian Dental Association, 2014).
Dental disease severity in children (and adults) is often measured by a dmft/DMFT score (lower case - primary teeth, uppercase - permanent teeth). This score counts any teeth that are D - Decayed, M - Missing, or F - Filled. As this number increases the severity of disease (active or treated) increases. There can also be a mixed score in children who have both primary and permanent teeth (Health Canada, 2010).
The first primary tooth erupts around 6 months, the primary dentition complete by 30 months, after that a mixed dentition until 12-13 years. In some children teeth stay sound and healthy, however in an unacceptably large percentage of cases these teeth become decayed (WHO 2019). 57% of 6-11 year olds have a combined dmft + DMFT of at least one, with the average number being 2.5. 59% of 12-19 year olds have a DMFT (permanent teeth) count of at least one, with the average being 2.49 (Health Canada, 2010).
Social Ecological Model
The social ecological model focuses to explain how an area of health is an integrated response of the interactions between an individual, their close relationships, community, and the physical, social, and political environments they live within (Agency for Toxic Substance & Disease Registry, 2015). As the above image depicts the levels are nested around the individual. The microsystem closest to the individual contains the strongest and direct influence. The further the system is separated from the individual the more indirect the impact the factors may have on the individual (Kilanowski, 2017).
There are 4 levels within the SEM. Below is an explanation of each level (CDC, 2021) (Agency for Toxic Substances and Disease Registry, 2015).
Individual
The first level includes personal & biological factors that increase the likelihood of a specific issue. These factors can include age, education, income and attitudes/beliefs.
Relationship
The second level includes close relationships. A person’s closest social circle includes peers, family members, and friends.
Community
The third level explores the settings in which social relationships occur. This includes schools, workplaces, or neighbourhoods. Factors can include the physical and social environment in these settings, poverty stricken areas, rural/urban areas.
Societal
The fourth level looks at the broad societal factors that influence health. These factors can include social & cultural norms. They can also include the health, economic, education, and social policies that maintain or help to alleviate inequalities between societies.
As dental (and health) professionals we can often see a issue, and immediately see a solution. For example, a child with a broken leg - possible surgery & a cast, a child with cavities - fix the broken teeth & tell the caregivers to take better care of their teeth. But is that really all that goes into someone having poor dental health? Is it as simple as telling someone to brush their teeth? How can multiple levels aid in prevention? I will use the social ecological model to explore how ECC is impacted and prevented by multiple levels, individuals, and policies.
SEM & ECC
Individual
While ECC is largely preventable, there are biological factors that can affect an individual's susceptibility to decay. This includes microflora, diet, and teeth morphology (WHO, 2019). Regardless of these biological factors if a child (and their caregiver) does not understand the importance of good oral hygiene they are more susceptible to childhood, and lifelong decay.
As a child grows older their ability to perform oral hygiene increases, however they need a good base from their caregiver to establish the importance of hygiene.
Relationship
Prevention of ECC is largely responsible by immediate caregivers - the primary line of defence. Caregivers are often the main contributor for child learning about proper oral health, the benefits & risk factors of inadequate care. As dental professionals we know that children are unable to properly perform adequate oral hygiene until they are 9-10 years old. After proper education by a dental professional, it is a caregivers responsibility to perform oral hygiene at regular daily intervals, and be monitoring any early signs of ECC (WHO, 2019).
While good oral hygiene is lead by caregivers, there are also significant barriers as to why a child may not receive proper oral hygiene. Caregivers must realize and understand the importance of good oral hygiene. Reports have displayed that ECC is more likely (and more severe) when parental beliefs do not include good hygiene (Pierce et al., 2019). Family social supports & function can play a drastic impact on delivery of good oral hygiene. Diet provided to children by their caregivers also has a large impact. Preventions of the intake of sugars from drinks and foods is key while encouraging a combination of healthy foods drastically reduces the prevalence of ECC, and also promotes good overall health (WHO, 2019). Socioeconomic factors such as low household income and level of parental education/employment can increase the incidences of ECC (Pierce et al., 2019). ECC is a significant economic burden to the family and society. Often treatment requires general anaesthesia which is is especially costly and time consuming for families (WHO, 2019).
Community
Minimizing a child’s risk of developing dental caries can be greatly aided by dental professions. Educating & encouraging good oral health habits to caregivers at an early age is key. Caregivers play an essential role in ensuring their children achieve optimal oral health. Caregivers often need guidance on how to effectively brush, information on tooth-friendly snacks/drinks, and knowledge about bedtime routines (no bottles to bed). Caregivers also need to understand the connection between oral & systemic health - a healthy mouth is more than just a good smile (Canadian Dental Association, 2014). This educational component is why regular dental visits beginning before 12 months is important. Children who did not have their first dental visit before the age of 24 months have an increased prevalence of ECC (Pierce et al., 2019). This first visit is something all dental professionals should be advocating for & implementing in their daily practices.
Children can also benefit from in office preventative techniques such as regular topical fluoride applications and molar pit and fissure sealant placement (Canadian Dental Association, 2014). Children can often be apprehensive and uncooperative with dental treatment, which is why minimally invasive preventative treatment approaches are beneficial. Placement of pit and fissure sealants can reduce the development & progression of caries in molars. Regular application of topical fluoride varnish can prevent the development of new caries in primary teeth, and help remineralize early enamel lesions (WHO, 2019).
Societal
While preventive measures at home and at the dental office are important for ECC control, there are many policies, programs to increase access to care that can immensely aid in prevention.
In many areas of Canada and the world dental care is financially unattainable. More importance needs to be placed on accessible publicly funded programs for children’s oral health. Within Canada some provinces have these programs, such as in Nova Scotia, children's routine dental care is covered until they are 14 years old (Nova Scotia Government, 2020). These publicly funded dental care plans are beneficial in preventing ECC, and setting children up for lifelong good oral hygiene.
The WHO suggested ECC prevention and control interventions could be integrated into existing primary healthcare such as child/maternal health programs alongside vaccines and general checkups. (WHO, 2019). Many individuals do not have access to regular dental visits, which makes the primary healthcare team a vital component.
There are school-based program to improve children's oral health. While these programs are effective at developing healthy life skills many cases of ECC develop before a child attends school (WHO, 2019). Some school-based programs involve dental professionals educating children on proper oral health. However, children are often incapable of providing dental care by themselves, their caregivers are often responsible for care.
Mass communication through media is beneficial in providing caregivers education and the skills to provide oral care to children. (WHO, 2019).
Water fluoridation is an effective, safe, and economical public health measure that reaches those in all socioeconomic levels preventing caries in all age, especially ECC (WHO 2019).
There are multiple important individuals, stakeholders, programs, and systems that need to work cohesively to minimize & control ECC. By using the SEM, we can identify that these approaches need to involve improving behaviours and opinions on an individual level by working with families/caregivers, on a societal level with public health (and dental professionals) creating supportive environments while advocating for and promoting dental health and general health (WHO, 2019). Childhood access to care and prevention of ECC is a portion of dentistry that i am very passionate about and something I strive to improve within my personal clinical teaching, and practice. Hopefully someday I can play a greater (more policy related) role in ECC control.
References
Agency for Toxic Substances and Disease Registry. (June 2015) Models and Frameworks for the Practice of Community Engagement.
https://www.atsdr.cdc.gov/communityengagement/pce_models.html
Canadian Dental Association (2010). Childhood Caries. https://www.cda-adc.ca/en/about/position_statements/ecc/
Canadian Dental Association (2014). CDA Essentials: The Canadian Dental Association Magazine. 1(4). https://www.cda-adc.ca/en/services/essentials/2014/issue4/files/assets/common/downloads/publication.pdf
CDC (2021). The Social-Ecological Model: A Framework for Prevention. https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html
Health Canada (2010) Summary Report on the Findings of the Oral Health Component of the Canadian Health Measures Survey 2007-2009. http://publications.gc.ca/collections/collection_2010/sc-hc/H34-221-1-2010-eng.pdf
Kilanowski, J.F. (2017). Breadth of the Socio-Ecological Model. Journal of Agromedicine, 4,295. From https://doi.org/10.1080/1059924X.2017.1358971
Nova Scotia Government (2020). Nova Scotia Children's Oral Health Program https://novascotia.ca/dhw/children-dental/Pierce, A., Singh, S., Lee, J., Grant, C., Cruz de Jesus, V., Schroth, R., (November 2019) The Burden of Early Childhood Caries in Canadian Children and Associated Risk Factors. Frontiers in Public Health. 7(328). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861386/pdf/fpubh-07-00328.pdf
World Heath Organization (2019). Ending Childgood Dental Caries: WHO implementation Manual. https://apps.who.int/iris/rest/bitstreams/1266137/retrieve
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