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Preventive Programmes of Early Childhood Caries in Belarus
Shakavets Natallia, MD, Professor of the Department of Pediatric Dentistry of the Belarusian State Medical University, Minsk
Шаковец Наталья Вячеславовна, доктор медицинских наук, профессор кафедры стоматологии детского возраста Белорусского государственного медицинского университета, Минск
Программы профилактики раннего детского кариеса
в Беларуси
Summary. Early childhood caries (ECC) remains difficult to control despite its well-known aetiology. It was determined that dental caries prevalence among 800 infants and toddlers was 31.1% in Minsk. Main risk factors were early transmission of mutans streptococci, high-frequency feeding in late infancy including both bottle use and breastfeeding, late oral hygiene practice, especially without fluoridated toothpaste, visible dental plaque. The prevalence of early childhood caries was 2.45 times higher in children who consume extrinsic sugar. The frequency of night feeding during the last 2 to 3 months, and night bottle feeding were the strongest predictors of early childhood caries. The most clinical and cost-effective preventive measure in caries-free children was semi-annual fluoride varnish application (62.0% caries reduction). The clinical efficacy of fissure sealants for prevention of early childhood caries was 59.4% (OR: 2.7; 95% CI: 1.3-5.8). Keywords: early childhood caries, mutans streptococci, toothbrushing, feeding practice, risk factors, fissure sealing.
Резюме. Кариес в раннем детстве по-прежнему трудно контролировать, несмотря на его хорошо известную этиологию. Установлено, что распространенность кариеса зубов среди 800 младенцев и малышей в Минске составила 31,1%. Основными факторами риска были ранняя передача стрептококков, использование в позднем младенчестве бутылочек и грудное вскармливание, поздняя гигиена полости рта, особенно без фторированной зубной пасты, видимый зубной налет. Распространенность кариеса в раннем детстве была в 2,45 раза выше у детей, потребляющих сахар. Частота ночных кормлений в течение последних 2-3 месяцев, а также ночного кормления смесью из бутылочки были самыми сильными предикторами развития кариеса раннего детского возраста. В большинстве клинических случаев эффективной мерой пресечения развития кариеса у детей было использование фтор-лака (в 62,0% отмечали редукцию кариеса). Клиническая эффективность герметиков фиссур для профилактики кариеса у детей раннего возраста составила 59,4% (отношение шансов: 2,7; 95% доверительный интервал -1,3-5,8).
Ключевые слова: кариес раннего детства, стрептококки, зубная щетка, практика кормления, факторы риска, герметизация фиссур.
Early childhood caries (ECC) remains difficult to control despite its well-known aetiology. The common risk indicators associated with ECC include early colonization with mutans streptococci, lack of toothbrushing and frequent sugar consumption [1]. The crucial importance of early childhood for a child's further development is recognized by all professions involved in developmental care.
To foster general well-being and quality in a child's life, a wide set of health and nonhealth outcomes must be achieved. There is consensus in the literature that the child's quality of life is characterized by four core domains: physical symptoms (pain and fatigue), functional status (ability to perform age - appropriate daily activities), psychological functioning (affective states, adjustment indices and self-esteem) and social
functioning (the number, type and quality of social contacts and relationships). ECC is associated with physical symptom ms such as discomfort, pain, infection, abscesses, gastrointestinal disorders, malnutrition, including retarded growth because of pain and reluctance to eat. Thus, the consequences of ECC can reach well beyond the dental area and negatively influence general health and development of the child [2].
The purpose of this study was to investigate the prevalence and intensity of ECC in infants and toddlers in Belarus, risk factors and the efficacy of Early Childhood Caries preventive programmes targeting this group of children.
In 2011-2012, 800 children (767 children in randomly selected paediatric clinics in Minsk and 33 toddlers from orphan's home) aged 6 to 36 months were examined for caries. Caries severity was determined using the dmft index. Parents were suggested to fill in the questionnaires about children oral hygiene and feeding practice. The results were analyzed statistically (descriptive statistics, Spearman rank, Mann -Whitney U-test).
Prevalence of Early Childhood Caries
The prevalence of early childhood caries was 31.1% (table 1). The prevalence increased from 6.7% in 1-year-olds to 57.3% in 2-year-olds and 63.5% in 3-year-olds. The mean d1-4mft was 1.7 ±2.9 and the mean d1-4mfs was 2.72 ±5.27. The mean d1 was 0.42, d2- 0.33, d3 - 0.85, d4 - 0.04, m - 0.04 and f - 0.02. The data suggests that dentine caries was more prevalent and almost all car-
ies lesions in infants and toddlers were untreated [3].
White spot lesions were diagnosed in 114 children (15.0%) and were more evident in toddlers from ages 1.5 to 2 years old (28.0%). The most affected teeth were central upper incisors (33.6%), lateral upper incisors (37.6%) and first upper molars (29.3%). Early childhood caries of type I was diagnosed in 24.5%, type II in 66.7% and type III in 8.8% children. Figure 1 represents the distribution of dental caries lesion in the oral cavity of infants and toddlers in Belarus.
Risk Factors for Early Childhood Caries
Infant Feeding Practices. Most of the children were breastfed at least for one year: 36.0% up to one year, 18.5% up to one and a half years, 11.9% up to two years, and 1.2% to 2.5 years. Up to 43.5% of infants and toddlers were breastfed at will. The severity of dental caries increased significantly in infants who were breastfed beyond 12 months (table 2).
There was also an association between the duration of breastfeeding and dental caries prevalence (Table 3): caries prevalence was more than two times higher in children who were breastfed for two years compared to children who stopped breastfeeding by one year of life (56.0% and 24.2% respectively) [3].
Up to 45.9% of infants and toddlers were bottle fed. More often, the content of the bottle was baby formula (33.1%), juice (35.8%) and water (17.8%). The prevalence of dental caries in children who were bottle fed beyond the age of one
Table 1 Dental caries experience in infants and toddlers
Age groups 6-12 mo (n=376) 13-18 mo (n=229) 19-24 mo (n=143) 25-36 mo (n=52) Total (n=800)
Dental caries prevalence 6.7% 47.6% 57.3% 63.5% 31.1%
Caries free 93.3% 52.4% 42.7% 36.5% 68.9%
d1-4mft, M (SD) 0.30 (1.13) 2.10 (1.77) 3.29 (3.75) 4.58 (4.16) 1.70 (2.87)
d1-4mfs, M (SD) 0.58 (2.67) 3.42 (5.22) 4.97 (6.56) 7.29 (7.55) 2.72 (5.27)
Figure 1. Dental caries patterns in infants and toddlers
year and who consumed sugar-containing drinks from the bottle more often than two times during the night is seen in table 3. The prevalence of caries was highest in children who were bottle fed with fruit water (53.6%), sweet tea (61.5%) and fruit juice (61.5%). Children bottle fed with cow milk had a caries prevalence of 37.5% [4].
The prevalence of early childhood caries was significantly high in children who had breast or bottle feeding before bed or at night (table 4). The prevalence of early childhood caries was 40.6% in children who practiced night breastfeeding. There was also a moderate correlation between frequency of night feeding and dental caries severity in children aged 13 to 18 months and those aged 19 to 24 months [3]. The frequency of night feeding
during the last 2 to 3 months, and night bottle feeding were the strongest predictors of early childhood caries [4].
Sugar Consumption. As high as 44.5% of infants and toddlers consume extrinsic sugar every day. Among these, early childhood caries was diagnosed at 48.8%. The prevalence of early childhood caries was 19.9% in those who did not consume extrinsic sugar Index d1-4mft was 3.2 times higher in children who consumed extrinsic sugar (table 5). There was an association between mother's education level and children's consumption of extrinsic sugar: mothers with high education rarely gave extrinsic sugar to their infants and toddlers [4].
Social Risk Factors. There is a significant association between mothers' educational level,
Table 2 Severity of dental caries in infants with different duration of breastfeeding
Duration of breastfeeding
Variable <3 mo (n=116) <6 mo (n=90) <12 mo (n=267) <18 mo (n=148) >18 mo (n=75) P Mann - Whitney
d1-4mft 1.02 (2.74) 1.21 (2.43) 0.84 (2.08) 2.99 (2.88) 4.67 (3.71) P,-2=0,39 P1-3=0,71 P,4<0,001* pu<0,001* P2-3=0,17 p2-4<0,001* p25<0,001* p3-5<0,001* P3-4<0,001* P3-5<0,001*
d1-4mfs 1.53 (4.40) 1.72 (4.12) 1.57 (4.48) 4.82 (5.83) 7.05 (6.75) p,-2=0,46 P1-3=0,74 P,-4<0,001* p14<0,001* P2-3=0,17 P2-4<0,001* p24<0,001* p3-5<0,001* P3-4<0,001* P3-5<0,001*
di 0.29 (0.90) 0.22 (0.76) 0.21 (0.81) 0.75 (1.46) 1.07 (1.94) P,-2=0,58 Pi-2=0,28 P1-4<0,001* p14<0,001* 1-2-3=0,69 p2-4<0,001* p24<0,001* p3-5<0,001* P3-4<0,001* P-4-5=0,24
Table 3 Dental caries experience and feeding practice in children up to 3 years old
Variable N dmft>0 P
0-12 mo 86 24.2%
Duration of breastfeeding 13-18 mo 48 32.2% р<0.0001
>19 mo 107 56.0%
night 101 43.4%
Time of breastfeeding Day 4 21.1% р=0.02
day and night 124 30.0%
Duration of bottle feeding <12 mo 9 17.0% р=0.02
>12 mo 99 27.0%
Frequency of night drinking >2 times 26 26.0% р=0.003
<2 times 20 45.5%
instant tee 8 10.5%
Night bottle feeding milk formula 34 16.3% р<0.0001
sweet beverage 15 50.0%
their dental caries severity and presence of dental caries in their kids. The prevalence of early childhood caries was 27.6% in children with families with good dental health habits as against a prevalence of early childhood caries of 58.5% in children with families with poor oral habits.
Oral Hygiene Practices. As high as 46% of infants had not started brushing, 26% brushed irregularly, and only 28% brushed regularly. Up to 37.8% of children had visible dental plaque
in their mouth. Visible dental plaque was association with the presence of early childhood caries and it was a strong predictor of early childhood caries [4]. Also, only 33% parents brushed their kid's teeth with fluoridated toothpaste. The prevalence of early childhood caries was lower in children who used fluoridated toothpaste.
Streptococci Mutans Count. A strong correlation was established between
Table 4 Dental caries experience and feeding practice in children up to 3 years old
Variable N dmft>0 P
0-12 mo 86 24.2%
Duration of breastfeeding 13-18 mo 48 32.2% р<0.0001
>19 mo 107 56.0%
night 101 43.4%
Time of breastfeeding day 4 21.1% р=0.02
day and night 124 30.0%
Duration of bottle feeding <12 mo 9 17.0% р=0.02
>12 mo 99 27.0%
Frequency of night drinking >2 times 26 26.0% р=0.003
<2 times 20 45.5%
instant tee 8 10.5%
Night bottle feeding milk formula 34 16.3% р<0.0001
sweet beverage 15 50.0%
Table 5 Dental caries severity in children with different food habits
Variable No extrinsic sugar intake(n=421) Extrinsic sugar intake (n=338) Mann-Whitney
d1-4mft 0.86 (1.90) 2.75 (3.47) p<0,001
d1-4mfs 1.38 (3.67) 4.41 (6.37) p<0,001
d, 0.27 (0.88) 0.62 (1.42) p<0,001
Table 6 Early childhood caries severity in children with different dental plaque pH level
Variable рН=5.5 рН=6.0 рН=6.5 рН=7.0 P
d1-4mft>0 n (%) 46 (90.2%) 73 (85.9%) 29 (56.9%) 1(5.6%) p1.2=0,012 p13<0,0001* p, „<0,0001* p24<0,0001* p2 3<0,0001* p34=0,0014*
d1-4mft M (SD) 6,27 (3.58) 4.66 (2.88) 2,45 (3.38) 0,22 (0.94)
«*» -p<0.008
Streptococci mutans count and early childhood caries severity. Not all infants and toddlers had Streptococci mutans in their oral cavity: only 45.8% of infants and toddlers were Streptococci mutans positive. The Streptococci mutans level was moderate (SM 1) in 20.0% of kids, high (SM 2) in 22.0% of kids and very high (SM 3) in 3.8% of kids. The prevalence of early childhood caries increased from 1.9% in children with SM 0 to 100% in kids with SM 3.
Salrnry Ions. Calcium, phosphorus and potassium is lower in the salivary content of children with early childhood caries. The normal salivary calcium-phosphorus ratio in children in Belarus is 1.6:10. Children with early childhood caries have lower calcium-phosphorus ratio.
Dental Plaque pH. The mean dental plaque pH was 6.09. The dental plaque pH level was higher in caries free children (6.45) than in children with early childhood caries (5.99). There is a significant correlation between the
prevalence and severity of early childhood caries and dental plaque pH (table 6). Also, the dental plaque pH in children with night feeding was lower than the dental plaque pH of children without night feeding [5].
Early Childhood Caries Preventive
Programmes
Effectiveness of Fluoride Varnish, Traditional Health Education for Mothers and Motivational Interviewing of Mothers for Caries Prevention. A randomized control trial was implemented to assess the effectiveness of various caries prevention strategies for children with risk for early childhood caries. The study recruited children with high levels of Streptococci mutans. The children were randomized in seven groups: group 1 were children who received applications of "Cervitec" varnish 4 times a year, group 2 received applications of "Cervitec" varnish 2 times a year and 5% fluoride varnish applications 2 times a year; and group 3 had semi-annual dental visits. Group 4 were children who did not need restorative treatment whose mothers received motivational interviewing [6]; group 5 were children who did not need restorative treatment but who received semi-annual fluoride varnish (5% NaF) applications; group 6 were children who did not need restorative treatment but who received fluoride varnish (5% NaF) applications 4 times a year; and group 7 were children who did not need restorative treatment whose mothers received traditional health education. Groups 3 and 7 were the control groups. There were no statistically significant differences in the age, gender and dental status between the groups [3].
After 3 years, the most significant reduction in caries prevalence and severity was in group 2: caries prevalence reduced by 59.1% compared to a 38.2% reduction in group 1. Caries severity was only 1.35 compared to 2.04 in group 1 and 3.30 in group 3. The study highlighted that Cervitec varnish applications had no significant impact on preventing dental caries. The use of
antimicrobial and remineralizing agents showed great promises for preventing early childhood caries in children with Streptococci mutans in their saliva [7]. Also, the prevalence of early childhood caries reduced by 27.2% in group 4; 62.0% in group 5; and 78.4% in group 6. There were no significant difference between group 5 and 6 (p=0.21) and between group 4 and group 7 (p=0.19). This implies that the prevalence of early childhood caries in children with no caries lesions, can be reduced with semi-annual fluoride varnish applications [3].
Effectiveness of Fissure Sealants. A randomized control trial was conducted to determine the effectiveness of fissure sealants for preventing early childhood caries in children aged 1.5 to 2 years with signs of dental caries. Children in the active arm A had their primary molars fissured sealed with glass ionomer cements while those in the control group received no intervention. In both groups children brushed with fluoridated dentifrice at home. Three years following the intervention, occlusal caries was diagnosed in 19.4% of children in the intervention group and 41.6% of those in the control group. The mean retention time of the sealant was 12.5 (5.3) months. The clinical efficacy of fissure sealants for prevention of early childhood caries was 59.4% (OR: 2.7; 95% CI: 1.3-5.8).
Fissure sealant was also found to reduce the rate of progression of non-cavitated lesions. When fissure sealant was applied to 73 molars with non-cavitated lesions, the sealants reduced the rate of cavitation of carious lesions in molar teeth when compared with non-cavi-tated lesions that were not fissure sealed. The rate of reduction was 75.2% (OR: 19.95; 95% CI: 5.47-71.48; p<0.001) after three years of monitoring. Glass ionomer cement, sealing of the sound fissures and fissures with early non-cavitated lesions was highly effective in prevention early childhood caries [8, 9].
Probiotics for Early Childhood Caries Prevention. Probiotics and their effect on oral
health have been a focus of numerous trials in recent times. The first evaluation of the anti-caries effect of probiotics over a 7 months period among preschool children was conducted by Näse, et al. (2001). The effectiveness of short-term consumption of bio-drinks with seven probiotic strains with impact on salivary counts of Streptococcus mutans and lactobacilli, and pH value of dental plaque of preschool children (aged 2 to 6 years) in Belarus was conducted. This probiotic drink contains strains of Lactobacilli bacidophi-lus, Lactobacilli bulgaris, Streptococcus ther-mophiles, Lactobacilli casei, Bf. bifidum, Bf. longum, Bf. infantis; and was produced in Belarus. The children consumed 100 ml of the probiotic bio-drink twice a day after meals. A significant decrease in total Streptococcus mutans and lactobacillus counts in saliva was observed during the period of intervention: the level of salivary Streptococcus mutans decreased in 92% of the study participants and lactobacilli levels decreased in 52% of the study participants. The levels of the salivary
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2. Alazmah A. Early Childhood Caries: A Review. J Con-temp Dent Pract, 2017, vol.18, no.8, pp.732-737.
3. Shakovets N.V. Kariyeszubovudeteyrannego vozrasta: Avtoref. dis. ...d-ra med.nauk [Dental caries in young children]. Minsk, BSMU, 2016, 40 p. (in Russian).
4. Shakavets N., Tserakhava T Feeding practice in young children as risk factor of ECC. 20th European Association of Dental Public Health Conference. Istanbul, Turkey 17-19 September, 2015. Istanbul.
5. Shakavets N., Tserakhava T Three year results of ECC prevention in children with Streptococcus mutans in saliva. 21st Congress of the European Association of Dental Public Heatth. 29 September - 1 October, 2016, Budapest, p.62.
6. Weinstein P., Harrison R., Benton T Motivating mothers
Address for correspondence
220004, Republic of Belarus, Minsk, Sukhaya str., 28
(Republican Clinical Dental Clinic)
Belarusian State Medical University
Department of Pediatric Dentistry
Shakavets Natallia, e-mail: childstom@bsmu.by
mutans streptococci count did not change in 36% of the participants, and increased in 12% of the participants. Also, at baseline the mean dental plaque pH value was 5.94±0.08: 40% of children had dental plaque pH value of 5.5 and no one had a pH value of 7.0. After the intervention, the dental plaque pH value increased in 76%; 36% of children had dental plaque pH value of 7.0 and nobody had pH value of 5.5. The mean pH value after intervention was 6.64±0.06. Probiotics decrease salivary Streptococcus mutans and lactobacil-li counts, and decreases the acidity of dental plaque in preschool children [10].
Gaps and Recommendations
There is the need to conduct epidemiologi-cal studies on early childhood caries in preschool children in all the regions of Belarus using both the WHO criteria and ICDAS II. This should help with the identification of disparities in the prevalence and severity of early childhood caries between rural and urban populations of Belarus; and help with the design and implementation of effective preventive strategies.
to prevent caries: confirming the beneficial effect of counseling. J Am Dent Assoc, 2006, vol.137, no.6, pp.789-793.
7. Shakavets N. Dental status and risk factors of ECC in young children in Belarus. 3rd International Congress USSI EDI, Novi Sad 15-16 May, 2014, Novi Sad, pp.73-76.
8. Shakavets N., Tserakhava T Efficacy of pit-and-fissure sealing for ECC prevention. Int Dent Journal, 2016, suppl.1, p.101.
9. Klenovskaya M., Shakavets N. Clinical efficacy of glass ionomer fissure sealing in young children with high caries risk. 21st Congress of the European Association of Dental Public Heatth, 29 September - 1 October, 2016, Budapest, Hungary, pp.67-68.
10. Shakovetz N., Borutta A., Kneist S. Veränderungen des Plaque-pH-Wertesbei Vorschulkindernnach Konsumeine-sprobiotischen Trinkjoghurts. Oralprophylaxe & Kinderzahnheilkunde, 2013, Vol.35, pp.120-126.
Received 18.12.2017 Accepted for printing 02.04.2018
Адрес для корреспонденции
220004, Республика Беларусь, г. Минск, ул. Сухая, 28
(Республиканская клиническая стоматологическая поликлиника)
Белорусский государственный медицинский университет
Кафедра стоматологии детского возраста
Шаковец Наталья Вячеславовна, e-mail: childstom@bsmu.by
