Caries is one of the commonest diseases of childhood with up to 90% of children in low- and middle-income countries being affects and 30-50% of children in high -income countries. Untreated caries causes pain, infection and sepsis which can lead to hospitalisation, systemic antibiotics, removal of teeth and general anaesthesia. Caries prevention is therefore fundamental, and interventions targeted towards mothers during pregnancy and other primary caregivers in the first year after birth can help reduce early childhood caries.
The aim of this Cochrane review was to assess the effects of interventions with pregnant women, new mothers or other primary caregivers of infants in the first year of life, for preventing early childhood caries (from birth to six years of age).
Methods
Searches were conducted in the Cochrane Oral Health’s Trials Register, Cochrane Pregnancy and Childbirth Group’s Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase CINAHL, the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and World Health Organization International Clinical Trials Registry Platform databases with no restrictions on language or publication status.
Randomised controlled trials (RCTs) and cluster-RCTs of interventions for prevention of early childhood caries (ECC) undertaken with pregnant women, new mothers or other primary caregivers of infants in the first year of life were considered. Clinical, oral health education/promotion and policy or health service verses standard care or placebo or another intervention were included. For inclusion, trials had to report at least one clinical caries outcome. Maternal fluoride supplementation and clinical interventions to the infants were excluded. Two reviewers independently selected studies, extracted data, assessed risk of bias using the Cochrane domain-based tool and the certainty of evidence using the GRADE approach. The primary outcome was clinical measures of dental caries.
Results
- 17 RCTs (4 cluster-RCTs), involving 23,732 caregivers (mainly mothers) and their children were included.
- The 17 included trials were conducted in a mix of high-, middle- and low-income countries; 3 in Brazil and the USA, 2 in Canada, Finland and Uganda and one each in Australia Sweden and the UK with one trial not reporting country location.
- 9 trials involved sociologically disadvantaged patients.
- None of the included studies was at low risk of bias with 8 out the studies having high risk of attrition bias
- A maximum of three trials (maximum of 1148 children and 130 mothers) contributed data to any comparison.
- 11 RCTs assessed four oral health education/promotion interventions against standard care:
- For child diet and feeding practice advice versus standard care;
- A probable 15 per cent reduced risk of caries presence in primary teeth was seen, RR = 0.85, (95%CI; 0.75 to 0.97), [3 trials; 782 patients; moderate-certainty evidence]
- There may be a lower mean dmfs score, MD = -0.29 (95%CI; -0.58 to 0.0), [2 trials; 757 patients; low-certainty evidence].
- There is uncertainty regarding the difference between the groups in mean dmft score, MD= -0.90 (95%CI; -1.85 to 0.05), [1 trial; 340 patients; very low-certainty evidence].
- For breastfeeding promotion and support versus standard care, there may be little or no a difference between groups in
- risk of caries in primary teeth, RR= 0.96 (95%CI;0.89 to 1.030 [2 trials; 1148 patients; low-certainty evidence] or
- mean dmft score, MD= -0.12 (95%CI; -0.59 to 0.36) [ 2 trials; 652 participants; low-certainty evidence].
- There is uncertainty whether child diet advice only compared with standard care reduces risk of caries in primary teeth, RR= 1.08 (95%CI; 0.34 to 3.37), [1 trial; 148 patients; very low-certainty evidence].
- For oral hygiene, child diet and feeding practice advice versus standard care,
- There was little or no reduced risk of caries presence in primary teeth, RR= 0.91 (95%CI; 0.75 to 1.10) [2 trials; 365 patients; low-certainty evidence].
- There is uncertain regarding difference between the groups [1 trial; 187 participants; very low-certainty evidence] in mean
- dmfs score, MD= -0.99 (95%CI; -2.45 to 0.47), and
- dmft score, MD= -0.30 (95%CI; -0.96 to 0.36).
- 6 trials assessed clinical interventions in mother’s dentition.
- 4 trials assessed chlorhexidine (CHX)or iodine-NaF application and prophylaxis versus placebo
- There may be little or no difference in risk of caries in primary teeth between antimicrobial and placebo treatment in mother’s dentition, RR = 0.97 (95%CI; 0.80 to 1.19) [3 trials; 479 patients; very low-certainty evidence].
- 2 trials compared xylitol against CHX or CHX + xylitol.
- For xylitol compared with CHX antimicrobial treatment, there may be a lower mean dmft score with xylitol MD = -2.39 (95%CI; -4.10 to -0.68), [1 trial, 113 participants; low-certainty evidence].
- There is uncertainty regarding the difference between groups in caries in primary teeth, RR= 0.62 (95%CI; 0.27 to 1.39), [1 trial, 96 participants; very low-certainty evidence].
- No trials assessed a health policy or service intervention.
Conclusions
The authors concluded: –
Moderate-certainty evidence suggests that providing advice on diet and feeding to pregnant women, mothers or other caregivers with children up to the age of one year probably leads to a slightly reduced risk of early childhood caries (ECC). The remaining evidence is low to very low certainty and is insufficient for determining which, if any, other interventions types and features may be effective for preventing ECC. Large, high-quality RCTs of oral health education/promotion, clinical, and policy and service access interventions, are warranted to determine effects and relative effects of different interventions and inform practice. We have identified 12 studies currently in progress. Those designing future studies should describe the intervention components, setting and participants, consider if and how effects are modified by intervention features and participant characteristics, and adopt a consistent approach to measuring and reporting ECC.
Comments
This new review from the Cochrane Oral Health Group has been conducted following Cochrane methodology. It has included 17 RCTs with 15 contributing data to the analysis. However, as the included studies related to 6 different interventions only a maximum of 3 trials contributed to any single meta-analysis involving only a small number of participants. None of the included studies was considered to have a low risk of bias with the authors noting a lack of methodological details being provided by the original studies. There were also a variety of definitions for caries and a range of time points assessed adding complexities to data interpretation. Discussion of agreement/disagreement with other reviews including the recent review by Moynihan et al (Dental Elf – 9th July 2019) which was commissioned to inform World Health Organisation (WHO) manual on ECC prevention is included. Given the enduring problem of ECC addition high-quality well reported studies of interventions with caregivers that can help reduce tooth decay in young children are needed as well as studies to find out which features of interventions make them effective.
Links
Primary Paper
Riggs E, Kilpatrick N, Slack-Smith L, Chadwick B, Yelland J, Muthu MS, Gomersall JC. Interventions with pregnant women, new mothers and other primary caregivers for preventing early childhood caries. Cochrane Database Syst Rev.2019 Nov 20;2019(11). doi: 10.1002/14651858.CD012155.pub2. Review. PubMed PMID:31745970.
Other references
Cochrane Oral Health Group – How can we prevent tooth decay in the first year of life?
Dental Elf – 9th July 2019
Dental Elf – Early childhood caries blogs
