Public health aspects of dental caries

Despite improvements in the oral health of children in recent decades, early childhood caries (ECC) remains a serious threat to child welfare. ECC is manifested by severe decay of primary teeth. This can be a debilitating condition that can not only affect the children but also their families and the communities in which they live. Toothache leads to school absence, which is a ready indicator of children's health. In the USA, where caries is lower than elsewhere, visits or dental problems accounted for 117 000 hours of school lost per 100 000 children (Gift et al, 1992). Because most school dental services work mainly during school hours, loss of schooling among the poor, who have higher caries rates, is high. Other manifestations of ECC include pain, infection, abscesses, chewing difficulty, malnutrition, gastrointestinal disorders, and low self-esteem (Ripa, 1988). ECC might also lead to malocclusion and poor speech articulation, and is associated with caries in the permanent dentition (Kaste et al, 1992).

The problems associated with this disease often generate fear and aversion to treatment, and severely affected patients may require extensive restorative treatment, stainless steel crowns or tooth extraction, which may involve sedation or general anesthesia(Ripa, 1988; Weinstein et al, 1992).

Treatment of ECC is expensive and if general anaesthesia is used, the cost can increase along with the medical risk to which the children involved are exposed. ECC is the most prevalent infectious disease among children, 5 times more common than asthma and 7 times more prevalent than hay fever (Rockville, 2000).

In the absence of widely accepted standards for diagnosing ECC, various diagnostic criteria have been used(Derkson, 1982; Ripa, 1988; Kelly & Bruerd, 1987; Winter, 1966). The lack of standard diagnostic criteria affects reported prevalence rates and makes it difficult to compare data from different studies (Kaste et al, 1992). Nevertheless, ECC is clearly a common problem in the United States and other countries particularly among economically disadvantaged children (Milnes, 1996; Kelly & Bruerd, 1987; Winter, 1966; Broderick et al, 1989) . Five to 10 percent of young children and twenty percent of children from families with low income have ECC and the rate is higher among the families from ethnic and racial minorities.

Most studies of ECC have focused on clarifying disease etiology by investigating demographic variables and by characterizing risk behaviours (Barnes et al, 1992; Dilley et al, 1980; Goepferd, 1986; Babeely et al, 1989). Some investigators have conducted several studies that are directly relevant to the proposed project, including evaluation of risk factors for ECC in underserved ethnic groups, the use of different criteria to diagnose ECC, the cost of treating ECC, laboratory analysis of salivary risk factors for cariogenesis, and development of caries risk assessment models. However, most studies failed to investigate the role of childhood caries in the quality of life and well-being in this vulnerable group and the effects of it later in the affected individuals' lives.

Therefore ECC is undoubtedly an important issue from public health point of view as it is so widespread, is preventable, and can impact on general well being and perhaps overall health. The accepted model for the development of caries consists of three categories of risk factors: micro-organisms, substrate/oral environment, and host/teeth. Recent scientific evidence strongly suggests that the first step in the development of ECC is primary infection by Mutans Streptococci.

The most important predisposing factors for ECC are listed as diet, nutrition and feeding behaviour. Certain inappropriate feeding practices have also been associated with ECC. The bottle contents, the frequency and duration of feeding, and how long the child is bottle-dependent, are especially important. Bottle-feeding with liquids such as Jello water and soda-pop is particularly harmful because these drinks contain sucrose, a highly cariogenic substrate. Prolonged use of a bottle containing high-fructose liquid at naptime or bedtime is strongly associated with ECC (Reisines & Douglass, 1998).

There are many studies concerning the role of type, frequency and content of consumed foods; however a reliable and valid instrument has not been developed to reliably measure diet in relation to caries development in individuals. However there is no doubt that the frequent consumption of sugary food plays a role in the development of ECC.

Other studies have shown that lack of oral hygiene and certain family characteristics also increase the risk of ECC: parents of children with ECC had less education and more caries, were more obese, were more likely to be overindulgent and less likely to say "no" to their children, and cleaned their children's teeth less frequently than parents of children without ECC (Acs et al, 1992; Winter, 1966).

Although the type of sugar consumed is an important factor in the development of caries, the frequency of sugar consumption is of greater significance. Several studies support this hypothesis (Amiutis, 2004; Zita & McDonald, 1959). Since the publication of the Vipeholm study, (Gustafsson et al, 1954) it has been accepted that the frequency of ingestion of sugar-containing foods is directly proportional to caries experience. In addition a study by Konig showed a positive correlation between the frequency with which animals ate cariogenic foods and dental caries severity (Konig et al, 1968) and Holt found that the pre-children with caries have between meal snacks approximately four times each day(Holt, 1991) .

There are many studies which suggest that children with ECC have a high frequency of sugar consumption, not only in fluids given in the nursing bottle, but also of sweetened solid foods. Results of clinical studies suggest that this dietary characteristic is likely to be one of the most significant caries risk factors in ECC (Konig et al, 1968; Sheiham, 1991). Increased frequency of eating sucrose increases the acidity of plaque and enhances the establishment and dominance of aciduric Mutans Streptococci.

The increased total time sugar is in the mouth increases the potential for enamel demineralization, and there is inadequate time for demineralization by the buffering action of saliva (Loesche, 1986). There is also evidence that the amount of sugar consumed is an important factor in caries development, although it is very likely that the frequency of eating sugar rises as the amount of sugar consumed rises. A high positive correlation between amount and frequency of eating sugary foods can therefore be assumed (Burt, 1986).

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