Corresponding Author
School of Dentistry
Faculty of Medical Sciences
The University of the West Indies
Saint Augustine
Trinidad and Tobago
rahul.naidu @sta.uwi.edu
Dental caries (tooth decay) is a public health problem affecting young children in the Caribbean. Developing appropriate solutions and effective interventions to address this problem can only be achieved through a better understanding of the disease process and it socio-environmental influences. Increasing the available data on the prevalence of dental caries in the Caribbean through coordinated oral health surveillance along with community-based prevention programmes are urgently needed. Oral health promotion strategies for this age group should also consider the social determinants of caries and also be linked to the wider public health agenda in the region.
There has been a general decline in dental caries (tooth decay) prevalence among 12-year-old children in Latin America and the Caribbean (LAC) since the last quarter of the 20th Century [1]. Factors contributing in this improvement are believed to be fluoridation, greater access to dental treatment for children through programs using the atraumatic restorative treatment (ART) and oral health promotion initiatives. Of concern however is that this trend is not reflected in younger children. In their systematic review Giminez et al analyzed data in the LAC region from 2000 to 2016 reported that except for Brazil, caries prevalence in the primary dentition has not shown a decline and generally shows a peak prevalence at 6 years of age [2]. Significantly, decayed teeth in this age group are likely to have developed during the preschool years suggesting that early childhood caries (ECC) in the Caribbean is of concern. ECC is defined as the presence of one or more decayed, missing due to caries, or filled tooth surfaces in any primary teeth in children under 6 years of age [3].
Globally ECC is recognized as an important public health problem and shows a higher prevalence among poor and disadvantaged populations and in developing countries, contributing to inequalities in oral health [4]. If untreated, severe ECC can cause pain and infection often 3 needing emergency intervention including tooth extraction under general anaesthetic. As well as the economic impact of high treatment costs when decay is advanced, ECC also negatively affects growth and development and quality of life of the child and family [5, 6, 7]. This disease therefore has impact at individual and societal level.
Understanding the aetiology of ECC and the interplay of risk factors is key to its prevention and control. Current research has provided a greater understanding of the caries process in particular the role and function of the oral microbiome. There are more than 700 bacterial species in the oral microbiome, making it the most microbiologically diverse environment in the body. The presence of an oral biofilm (dental plaque) on tooth surfaces along with fermentable carbohydrate (free sugars) in the diet is necessary for the caries process to
begin.
In a low sugar environment oral microorganisms in the biofilm are mainly commensal and maintain an ecological balance that does not lead to caries. Where demineralization of tooth enamel occurs it can still be reversed at this stage by dietary changes, oral hygiene and topical fluoride. However in a high sugar diet, acid production in the biofilm significantly increases along with the proliferation of acid tolerant bacteria such as Mutans Streptococci and Lactobacilli. These cariogenic (cavity forming) bacteria then become the dominant species in the biofilm, replacing species associated with early, reversible lesions [6, 18]. Caries therefore develops due to a catastrophic ecological shift in the biofilm microflora. This is consistent with the ecological plaque hypotheses (EPH) which describes the oral biofilm as a dynamic microbiological ecosystem influenced by the local environment [8]. Therefore notwithstanding the role of good oral hygiene, maintaining an ecologically balanced and diverse oral microbiome is crucial to the control of the disease process.
Keystones for prevention of caries in children are reducing sugar in the diet, effective oral hygiene and brushing with fluoride toothpaste). However, caries is a multifactorial disease influenced by wider sociocultural and socioenvironmental factors. Community-based preventive programs must be appropriate to the socioeconomic and cultural spectrum and these issues must be considered when developing dental public health programs. Oral health promotion strategies for ECC should include, health education, supervised tooth brushing, early dental attendance, caries risk assessment professionally applied fluoride varnish and inter-professional working (i.e. involvement of all health professionals that have contact with families with young children). The WHO states that dental caries should be classified as a non-communicable disease NCD [9]. This implies the need for a common risk factor approach that links to the broader public health agenda for NCD’s in the Caribbean region. A significant common risk factor for NCD’s and the focus of recent international health promotion campaigns, is sugar. Reducing free sugars in the diet should also underpin approaches to prevention and management ECC. Based on research indicating the role of sugar in obesity and caries, the WHO advises that free sugars in the diet (i.e. food and beverages) should be limited to less than 10% (ideally below 5%) of daily energy intake, across the life course [10].
These nutritional messages should include advice on safe options for bottle feeding, low sugar snacks and drinks and healthy balanced diets for infants and young children. Also in Caribbean countries advanced dental treatment for children is unaffordable for many patients. Clinical approaches must therefore be supported by public health interventions as dental caries should be viewed as a behavioral disease with a bacterial component [8]. Addressing the public health problem of ECC in the Caribbean requires coordinated oral health surveillance along with community-based prevention. To improve oral health during early childhood, health promotion strategies should consider the social determinants of ECC and be linked to the wider public health agenda.
References
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