Beyond the Caries Process: Social-Economic Model for Prevention of Childhood Caries

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The American Dental Association (2014) defines oral health as “a functional, structural, aesthetic, physiologic and psychosocial state of well-being and is essential to an individual’s general health and quality of life.” Worldwide, dental caries is the most prevalent chronic disease and is largely preventable (Canadian Dental Association, 2017).

One part of the Canadian population that is impacted significantly by dental caries is children. Each province/territory in Canada has oral health care programs in place that provide some level of access to preventative and restorative dental care, yet children continue to have a high rate of caries (Canadian Paediatric Society, 2018; Oral Health Clearinghouse, n.d.) To understand why the caries rate is high among Canadian children, other influences on oral health must be identified and explored.

The etiology of dental caries is multifactorial, involving a host (tooth), agent (oral bacteria) and environmental factors (diet containing fermentable carbohydrates). The oral bacteria consume fermentable carbohydrates and create lactic acid as a by-product; this creates an acidic environment on and around the tooth surface which can demineralize the tooth structure. An excellent explanation of the caries process and how to prevent dental caries can be seen in the video “What Causes Cavities?” by Rosenberg (2016).

Rosenberg, M. [TedEd]. (2016, October 17). What causes cavities? [Video file]. Retrieved from https://www.youtube.com/watch?v=zGoBFU1q4g0

Beyond the caries process, what other factors impact a child’s oral health? An ecological model of health examines multiple levels of influence on health such as: intrapersonal, interpersonal, and community. Rimer & Glanz (2005) described the levels used in Table 1. A visual representation of the model can be seen in Figure 1.

Table 1. An Ecological Perspective: Levels of Influence. Adapted from McLeroy et al. (1988) An ecological perspective on health promotion programs. Health Education Quarterly 15:351–377.

Figure 1. Socio-ecological model adapted from Rimer, B. K., & Glanz, K. (2005). Theory at a glance: A guide for health promotion practice. Bethesda, MD: U.S. Dept. of Health and Human Services, National Institutes of Health, National Cancer Institute.

Ecological models of intervention are often utilized for prevention and health promotion in public health organizations (Richard et al, 2011). Prevention is a key role in my daily practice as a registered dental hygienist (RDH) therefore I chose to research this model and its use in dental care. I further narrowed my field of interest to dental health of children. Fisher-Owens et al (2007) described influences on the experience of dental caries in using the Ecological Model seen in Figure 2.

Figure 2. Child, family, and community influences on oral health outcomes of children. The triad was adapted from Keyes PH.Int Dent J. 1962;12:443–464; and the concentric oval design was adapted from the National Committee on Vital and Health Statistics.Shaping a Health Statistics Vision for the 21st Century. Washington, DC: Department of Health and Human Services Data Council, Centers for Disease Control and Prevention, National Center for Health Statistics; 2002:viii.

Intrapersonal Influences on Children’s Oral Health

Learning begins shortly after birth and continues throughout life. Oral hygiene practices are typically performed by guardians until a child has the manual dexterity to control a toothbrush. According to Darby & Walsh (2015) a child can be shown how to brush teeth by age two, but they likely will not have the dexterity to brush alone until age seven-eight. Allowing a child to perform oral hygiene practices on their own before they have developed the dexterity places them at higher risk for dental decay.

Snacking habits and food preferences, as well as a child's knowledge and beliefs about dental treatment all influence the risk of a child experiencing dental caries on an intrapersonal level. These are typically shaped through exposure at the interpersonal level.

Interpersonal Influences on Children’s Oral Health

Attitudes, beliefs and behaviors are developed through our interactions and continue to evolve throughout our lives.

[Children gardening]. Retrieved June 21, 2019 from wix.com

The first five years of life are a time of rapid physical growth and change...when eating behaviors that can serve as a foundation for future eating patterns develop. During these early years, children are learning what, when, and how much to eat based on the transmission of cultural and familial beliefs, attitudes, and practices surrounding food and eating

(Savage et al, 2007, p. 1).

Preferences for foods are shaped by what the child is exposed to by their interpersonal network. Socio-economic status impacts food security and quality of nourishment (Darmon & Drenowski, 2008). Cost effective options are often more desirable to lower socio-economic status (SES) families. Shupler & Raine (2017) found Canadians of lower SES consume more fruit juice than fresh fruit. These drinks often contain high amounts of sugar, a fermentable carbohydrate; this increases the risk for dental caries.

Dental fear and anxiety can be influenced by a variety of factors. Alasmari et al (2018) found that among other factors, the education level of parents, social class of the child’s family and maternal anxiety played a role in children's levels of dental anxiety. Children who develop a fear of dental treatment are more likely to be resistant to preventative and restorative dental care, which increases their risk for dental caries.

New experiences can be intimidating, and some level of fear can be expected at a first dental visit. The Canadian Dental Association (n.d.) recommends a child be assessed by a dentist within 6 months of the eruption of the first tooth or by one year of age; this early introduction to the dental office will help children learn that dental visits are a regular part of health care.

Community Influences on Children’s Oral Health

Community and policy levels interact in regard to water-fluoridation. This is a cost-effective measure that has decreased dental decay in children by reaching all members of society regardless of socio-economic status. The Government of Canada (2018) reported that, in addition to other factors, widespread adoption of community water fluoridation helped to decrease the percentage of dental caries in Canadian children from 74% in 1970-1972 to 25% in 2007-2009. The decision to fluoridate water supplies is made by local governments; therefore, not all communities in Canada have fluoridated water. The Public Health Agency of Canada (2017) presented the estimated percentage of the population with fluoridated water systems in each province and territory found in Table 2.

Table 2. Estimated Percentage of the Canadian Population with Fluoriated Water Systems in each Province and Territory. Adapted from Public Health Agency of Canada. (2017). The State of Community Water Fluoridation across Canada. Retrieved June 13, 2019, from http://www.publichealth.gc.ca

Municipalities in collaboration with the appropriate provincial authorities ultimately decide whether or not to fluoridate their water (University of Toronto, 2012). These statistics show that not all communities have equal access to fluoridated water which in turn influences the level of prevention of dental caries in those communities.

The Canadian Dental Association (2012) supports water fluoridation as a safe, effective and economical way to prevent dental decay among all community members. The CDA encourages individual municipalities to make an informed decision about whether or not to fluoridate their water. Components to consider include:

• Dental health of community members

• The size of the group not likely exposed to adequate fluoride from other sources

• The minimum level of fluoride required to be beneficial

(Canadian Dental Association, 2012)

Should a municipality choose not to fluoridate their water, another option to provide elementary school-age children with additional fluoride exposure is through a fluoride mouthrinse program. The Nova Scotia Department of Health and Wellness determines which schools are eligible, targeting populations at a greater risk for dental caries including those with low socio-economic status, low levels of parental education, low income, and those who do not seek regular dental care.

At eligible schools, Public Health dental hygienists and trained community members run the program weekly. Each child has the option to participate or decline the fluoride mouthrinse; a consent form must be submitted by a parent or guardian for the child to participate. Having the option for additional fluoride exposure can help decrease the incidence of dental caries for children in these vulnerable populations (Nova Scotia Department of Health and Wellness, 2004a; Nova Scotia Department of Health and Wellness, 2004b).

In conclusion, oral health as a component of overall health, is constantly changing, and various factors determine the state of oral health. For dental caries in children, creating stronger knowledge among children and their families will play an important role in prevention. As a RDH I can help at the intrapersonal level by giving children one-on-one oral hygiene instruction using tell-show-do, a basic teaching technique for reinforcing instructions, such as oral hygiene with children (Wilkins, 2013; Gutierrez, 2015). For the interpersonal level, I can provide information to caregivers and guardians about the impact of diet and oral hygiene supervision on incidence of dental caries in children. At the community and policy level, I can advocate for water fluoridation and support public health initiatives to improve oral health of Canadian children. By influencing health at each of the socio-ecological levels, I hope to make a larger impact on my community and play my role in prevention of dental caries in children.

References:

Alasmari, A. A., Aldossari, G. S., & Aldossary, M. S. (2018). Dental Anxiety in Children: A Review of the Contributing Factors. Journal Of Clinical And Diagnostic Research, 12(4), SG01-SG03. doi:10.7860/jcdr/2018/35081.11379

American Dental Association. (2014). ADA Policy--Definition of Oral Health. Retrieved May 31, 2019, from https://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/ada-policy-definition-of-oral-health

Canadian Dental Association. (2012, March). CDA Position on Use of Fluorides in Caries Prevention. Retrieved June 21, 2019, from https://www.cda-adc.ca/en/about/position_statements/fluoride/

Canadian Dental Association. (2017, March). The State of Oral Health in Canada. Retrieved June 13, 2019, from https://www.cda-adc.ca/stateoforalhealth/_files/TheStateofOralHealthinCanada.pdf

Canadian Dental Association. (n.d.). Dental Care FAQs. Retrieved June 22, 2019, from https://www.cda-adc.ca/en/oral_health/faqs/dental_care_faqs.asp

Canadian Paediatric Society. (2018, February 28). Oral health care for children – a call for action. Retrieved May 31, 2019, from https://www.cps.ca/en/documents/position/oral-health-care-for-children

Darby, M. & Walsh, M. (2015). Dental Hygiene: Theory and Practice. St. Louis, Missouri; Elsevier.

Darmon N. & Drewnowski A. (2008). Does social class predict diet quality?, The American Journal of Clinical Nutrition, Volume 87, Issue 5, May 2008, Pages 1107–1117, https://doi.org/10.1093/ajcn/87.5.1107

Fisher-Owens, S. A., Gansky, S. A., Platt, L. J., Weintraub, J. A., Soobader, M. J., Bramlett, M. D., & Newacheck, P. W. (2007). Influences on Childrens Oral Health: A Conceptual Model. Pediatrics, 120(3). doi:10.1542/peds.2006-3084

Government of Canada. (2018, February 08). Fact sheet - Community water fluoridation. Retrieved June 12, 2019, from https://www.canada.ca/en/services/health/publications/healthy-living/fluoride-factsheet.html

Gutierrez, K. (2015, June 16). Struggling to Keep Learners Engaged? Get Back to Basics. Retrieved June 21, 2019, from https://www.shiftelearning.com/blog/tell-show-do-apply-model-elearning

Nova Scotia Department of Health and Wellness. (2004a). Standards for the Nova Scotia Fluoride Mouthrinse Program. Retrieved June 28, 2019 from https://novascotia.ca/dhw/healthy-development/documents/Standards-for-the-Nova-Scotia-Fluoride-Mouthrinse-Program.pdf

Nova Scotia Department of Health and Wellness. (2004b). Development of an Innovative Population Health Measurement Tool to Determine Eligibility for the Fluoride Mouthrinse Program. Retrieved June 28, 2019 from https://novascotia.ca/dhw/publications/Public-Health-Education//Final_Rep_FMP_Crit_Com.pdf

Oral Health Clearinghouse. (n.d.). Provincial / Territorial Oral Health Programs. Retrieved May 31, 2019, from http://www.oralhealthroundtable.ca/provincial-oral-health-programs

Public Health Agency of Canada. (2017). The State of Community Water Fluoridation across Canada. Retrieved June 13, 2019, from http://www.publichealth.gc.ca

Richard, L., Gauvin, L., & Raine, K. (2011). Ecological Models Revisited: Their Uses and Evolution in Health Promotion Over Two Decades. Annual Review of Public Health, 32(1), 307-326. doi:10.1146/annurev-publhealth-031210-101141

Rimer, B. K., & Glanz, K. (2005). Theory at a glance: A guide for health promotion practice. Bethesda, MD: U.S. Dept. of Health and Human Services, National Institutes of Health, National Cancer Institute.

Rosenberg, M. [TedEd]. (2016, October 17). What causes cavities? [Video file]. Retrieved from https://www.youtube.com/watch?v=zGoBFU1q4g0

Savage, J. S., Fisher, J. O., & Birch, L. L. (2007). Parental Influence on Eating Behavior: Conception to Adolescence. The Journal of Law, Medicine & Ethics, 35(1), 22-34. doi:10.1111/j.1748-720x.2007.00111.x

Shupler, M., & Raine, K. D. (2017). Socio-economic status and fruit juice consumption in Canada. Canadian Journal of Public Health, 108(2), 145-151. doi:10.17269/cjph.108.5664

University of Toronto. (2012, April). Water Fluoridation Questions and Answers. Retrieved June 13, 2019, from http://www.caphd.ca/sites/default/files/WaterFluoridationQA.pdf

Wilkins, E.M. (2013) Clinical practice of the dental hygienist. (11th Ed.) Philadelphia, PA; Lippincott Williams & Wilkins.