Interview: “It is a matter of social justice and human rights”
Early childhood caries is a highly transmissible disease that can be prevented almost entirely, if the right measures are taken at the right time. A new policy guideline on “perinatal and infant oral health’, which has been in the making for four years and submitted for adoption at the General Assembly of this year’s FDI congress in New Delhi, aims to provide guidance and recommendations for oral health care providers in the dental care of pregnant women and young children. Dental Tribune ONLINE spoke with Dr Francisco Ramos-Gomez, professor in the Division of Paediatric Dentistry at the University of California in Los Angeles, USA, and one of the authors of the policy, about its implications for the prevalence of dental disease during childhood and the future of the dental profession as a whole.
Dental Tribune ONLINE: Dr Ramos-Gomez, early childhood caries (ECC) is estimated to be concentrated in only 30-40 percent of children worldwide. What do we know about how prevalent the disease is in countries like India?
Dr Francisco Ramos-Gomez: Unfortunately, there are only very prevalence few reports that include data from children aged 3 to 5, as most of the surveillance studies that have been conducted worldwide begin with a six-year old molar, which is an age that is already very late considering how early ECC can occur in a child’s life. However, we expect the prevalence of ECC to be over 60 per cent in some areas of the world.
According to reports, the majority of dentists in India are unfamiliar with concepts like the “Age One Visit” to prevent early childhood caries. Could you please explain why prevention of the disease is pivotal?
ECC is transmitted from the parent or caregiver to the child and, if left untreated, can lead to infection and severe pain. As a consequence, children can experience difficulties in eating and speaking, which will have an effect on their readiness for school and their overall quality of life. Most dentists, unfortunately, tend not to see children before they have reached the age of 5 or 6. They do not realise that poor oral health and malnutrition, especially during pregnancy, can lead to disruption in the formation of enamel, among other things. A lot of general dentists who are exposed to these conditions do not have the means or the experience to deal with oral diseases in children at this early age. You need to have skilled paediatric and general dentists.
What in your opinion are the most important oral health challenges that prenatal women and infants are confronted with?
There are several challenges that mothers and their children have to deal with including those posed by a poor diet and malnutrition. Many infants, particularly in developing countries, are exposed to high amounts of sugars, to name just an example.
There is also a general lack of good oral health hygiene during and prior to when the first tooth is erupting in the mouth. Fluoride is something I have to mention here as well, because many dental providers do not recommend the use of fluoridated toothpaste at a young age, which really goes against new guidelines put up by organisations like the American Dental Association, the American Academy of Pediatrics, the American Academy of Pediatric Dentistry, and others, who recommend the use of fluoridated toothpaste as soon as the first tooth is in the mouth. Water fluoridation has been one of the most effective public health strategies for caries reduction in the last 68 years. Therefore, it is essential to have a whole campaign about the need and the effectiveness of daily use and consumption of fluoridated water.
Besides fluoridation, what tools are currently available for dentists to help prevent diseases like ECC?
The concept of early risk assessment was proposed in the US almost 20 years ago. In 2003, the American Academy of Pediatrics finally endorsed the "Age 1 visit", which really emphasises ensuring that these very young children are being seen or risk assessed.
Caries Management by Risk Assessment, also called CAMBRA, has three main domains. First, you have all the risk factors and second, you look at the protective factors present. Finally, you have the clinical findings. You try to balance the risk factors, with the goal of improving the clinical findings, by introducing as many protective factors as possible.
By age 1, we look into the mouth to ensure that the child has no signs of early childhood caries, which is generally characterised by very chunky white lesions around the tooth. These are the first signs of disease progression in these young kids. Then we start treating the white spot lesions with combination therapy, including fluoride, phosphate and calcium.
How successful has the implementation of this concept been in your country and can you talk a little bit about the results?
It is still work in progress, since many providers remain reluctant to see infants or pregnant women. However, with early risk assessment we now have a new consensus that defines the need for those measures and a standard of care for these vulnerable populations. It also ensures that we get the appropriate training, especially for future generations of dentists.
So far, a few clinical trials have been conducted, using a fluoride varnish application, for example. It has shown to be very effective, as long as there is parental engagement to some extent. You really have to address changing the behaviour of the caregiver or the parent. They then bring these changes to their children. We actually spend a lot of time teaching and learning about parental engagement and how we can convey the value of good oral health to these families at a very early stage. They might have had a bad experience with their dentist in the past, but we need to show them that this is a 100 per cent preventable disease.
Adults have control of what they do at home, like reducing the child’s consumption of unhealthy snacks and sugary foods like juice or sugar liquid substances, throughout the day and the night.
The one recommendation we usually struggle the most with is to emphasise the need for brushing or removing the plaque, especially at night, and exposing the child to fluoride toothpaste. This should generally be the last thing touching the teeth before they go to bed.
With this in mind, what are the prospects for such a concept to be implemented in countries like India, where oral health awareness is relatively low?
We need interprofessional collaboration between medicine, dentistry and related areas like nursing. I also think that corporate sponsors are essential to establishing these kind of measures in a country like India. I would strongly recommend, especially after the FDI has had the chance to adopt the policy statement, that we work together with manufacturers like Colgate, Crest, Oral-B, and other, to ensure that every child in these countries has access to the three most important weapons against dental disease, which are a toothbrush, fluoridated toothpaste, and safe, clean, fluoridated drinking water where appropriate and available. Regardless if you live in India or any other country in the world, we need to push this for every child. It is a matter of social justice and human rights that they have also access to these important equities.
You already spoke about interprofessional collaboration. Does this mean that the problem cannot be solved by the dental profession alone?
It is essential that we take a multidisciplinary approach for the implementation and integration of oral health into primary care. We need to emphasise and ensure that we are working in unison with physicians, physician assistants, and paediatricians throughout the world to convey a loud and clear message that dental diseases can be detected very early on, and that children do not have to go through their young lives suffering from dental pain. I am actually a strong believer that the whole area of interprofessional multidisciplinary collaboration is essential for the future success and growth of our profession.
Thank you very much for the interview.