A randomized trial of the effectiveness of home visits in preventing early childhood caries

One-to-one dietary interventions undertaken in a dental setting to change dietary behaviour

BACKGROUND

The dental care setting is an appropriate place to deliver dietary assessment and advice as part of patient management. However, we do not know whether this is effective in changing dietary behaviour.

OBJECTIVES

To assess the effectiveness of one-to-one dietary interventions for all ages carried out in a dental care setting in changing dietary behaviour. The effectiveness of these interventions in the subsequent changing of oral and general health is also assessed.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 24 January 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE via OVID (1950 to 24 January 2012), EMBASE via OVID (1980 to 24 January 2012), CINAHL via EBSCO (1982 to 24 January 2012), PsycINFO via OVID (1967 to 24 January 2012), and Web of Science (1945 to 12 April 2011). We also undertook an electronic search of key conference proceedings (IADR and ORCA between 2000 and 13 July 2011). Reference lists of relevant articles, thesis publications (Dissertations Abstracts Online 1861 to 2011) were searched. The authors of eligible trials were contacted to identify any unpublished work.

SELECTION CRITERIA

Randomised controlled trials assessing the effectiveness of one-to-one dietary interventions delivered in a dental care setting.

DATA COLLECTION AND ANALYSIS

Abstract screening, eligibility screening and data extraction decisions were all carried out independently and in duplicate by two review authors. Consensus between the two opinions was achieved by discussion, or involvement of a third review author.

MAIN RESULTS

Five studies met the criteria for inclusion in the review. Two of these were multi-intervention studies where the dietary intervention was one component of a wider programme of prevention, but where data on dietary behaviour change were reported. One of the single intervention studies was concerned with dental caries prevention. The other two concerned general health outcomes. There were no studies concerned with dietary change aimed at preventing tooth erosion. In four out of the five included studies a significant change in dietary behaviour was found for at least one of the primary outcome variables.

AUTHORS' CONCLUSIONS

There is some evidence that one-to-one dietary interventions in the dental setting can change behaviour, although the evidence is greater for interventions aiming to change fruit/vegetable and alcohol consumption than for those aiming to change dietary sugar consumption. There is a need for more studies, particularly in the dental practice setting, as well as greater methodological rigour in the design, statistical analysis and reporting of such studies.

Maternal dietary counseling reduces consumption of energy-dense foods among infants: a randomized controlled trial

OBJECTIVE

To evaluate the impact of a dietary counseling in reducing the intake of energy-dense foods by infants.

DESIGN

A randomized controlled trial.

SETTING AND PARTICIPANTS

São Leopoldo, Brazil. Mothers and infants of a low-income-group population were randomized into intervention (n = 163) and received dietary counseling during 10 home visits, or control (n = 234) groups.

MAIN OUTCOMES MEASURES

Child consumption of sugar-dense (SD) and lipid-dense (LD) foods at 12 to 16 months.

ANALYSIS

The effect of the intervention was expressed by relative risks and 95% confidence intervals. Poisson regression analysis was used to determine the association between exclusive breastfeeding and the energy-dense foods intake.

RESULTS

A smaller proportion of infants from the intervention group consumed candy, soft drinks, honey, cookies, chocolate, and salty snacks. In the intervention group, there was a reduction of 40% and 50% in the proportion of infants who consumed LD and SD foods, respectively. Being breastfed up to 6 months reduced the risk for consumption of LD and SD foods by 58% and 67%, respectively.

CONCLUSIONS AND IMPLICATIONS

Dietary counseling to mothers may be effective in reducing the consumption of energy-dense foods among infants, and it is helpful in improving early dietary habits.

Quality of cluster randomized controlled trials in oral health: a systematic review of reports published between 2005 and 2009

OBJECTIVES

To assess the quality of methods and reporting of recently published cluster randomized trials (CRTs) in oral health.

METHODS

We searched PubMed for CRTs that included at least one oral health-related outcome and were published from 2005 to 2009 inclusive. We developed a list of criteria for assessing trial quality and reporting. This was influenced largely by the extended CONSORT statement for CRTs but also included criteria suggested by other authors. We examined the extent to which trials were consistent with these criteria.

RESULTS

Twenty-three trials were included in the review. In 15 (65%) trials, clustering had been accounted for in sample size calculations, and in 18 (78%) authors had accounted for clustering in analysis. Intraclass correlation coefficients (ICCs) were reported for eight (35%) trials; the outcome assessor was reported as having been blinded to allocation in 12 (52%) trials; 17 (74%) described eligibility criteria at individual level, but only nine (39%) described such criteria at cluster level. Sixteen of 20 trials (80%), in which individuals were recruited, reported that individual informed consent was obtained.

CONCLUSIONS

These results suggest that the quality of recent CRTs in oral health is relatively high and appears to compare favourably with other fields. However, there remains room for improvement. Authors of future trials should endeavour to ensure sample size calculations and analyses properly account for clustering (and are reported as such), consider the potential for recruitment/identification bias at the design stage, describe the steps taken to avoid this in the final report and report observed ICCs and cluster-level eligibility criteria.

Reassessment at 6-7 years of age of a randomized controlled trial initiated before birth to prevent early childhood caries

OBJECTIVES

To assess whether the effect of providing mothers with guidance during pregnancy and when the child was 6 and 12 months old, which had drastically reduced the prevalence of early childhood caries at 20 months of age, would be sustained at 6-7 years of age.

METHODS

Children, whose mothers had been enrolled in a randomized controlled trial during pregnancy and a comparison group of similar school children, were examined for the presence of caries by the South Australian School Dental Services (SA SDS) at 6-7 years of age.

RESULTS

Of 625 eligible trial participants, 277 (44%) participated in the follow-up and dental records were available for 187 of them (30%). Loss to follow-up and reasons for it were similar in the intervention and control groups. At 6-7 years of age, 33% of children in the trial had caries compared with 42% in the SA SDS comparison group (n = 263). All measures of caries severity (d(3)mft, d(3)mfs and SiC(30)) were lower, but not significantly so, in the intervention than in the control group. Children in the comparison group of school children had more severe caries than those in the trial (P < 0.01) and in the intervention group especially (P < 0.005). Children in both randomized groups suffered significantly less toothache than those in the comparison group (P < 0.001).

CONCLUSIONS

Providing new mothers with guidance on caries prevention helps to reduce early childhood caries and has a sustainable effect up to school age.

Encouraging consumption of water in school and child care settings: access, challenges, and strategies for improvement

Children and adolescents are not consuming enough water, instead opting for sugar-sweetened beverages (sodas, sports and energy drinks, milks, coffees, and fruit-flavored drinks with added sugars), 100% fruit juice, and other beverages. Drinking sufficient amounts of water can lead to improved weight status, reduced dental caries, and improved cognition among children and adolescents. Because children spend most of their day at school and in child care, ensuring that safe, potable drinking water is available in these settings is a fundamental public health measure. We sought to identify challenges that limit access to drinking water; opportunities, including promising practices, to increase drinking water availability and consumption; and future research, policy efforts, and funding needed in this area.

Impact of an oral health intervention on pre-school children < 3 years of age in a rural setting in Australia

AIM

Australian pre-school children living in rural areas experience higher levels of dental caries than those in metropolitan areas. This may be because of a lack of community water fluoridation. The aim of this study was to evaluate the effectiveness of a community-based intervention to improve the oral health of children in non-fluoridated rural Victoria, Australia.

METHODS

The study was conducted across three local government areas in Victoria, with two receiving the intervention and one remaining with standard care. Although multifaceted, the primary strategy of the intervention was the promotion of early exposure to fluoridated toothpaste, including the distribution, by maternal and child health nurses (MCHNs), of an oral health starter kit including toothpaste, toothbrush and information to parents at their child's 7-8-month health check. Children were followed up annually to the age of three.

RESULTS

Infants in the intervention arm experienced less caries (cavitated and pre-cavitated lesions included) than infants in the control arm at the first and second examinations (3.1% with caries in the intervention vs. 6.9% in the control group at exam 1 (adjusted P= 0.07) and 10.8% vs. 19.5% at exam 2 (adjusted P= 0.11), respectively). However potential benefits disappeared at the third examination (29.5% vs. 28.9%, adjusted P= 0.67).

CONCLUSIONS

This study suggests that an oral health promotion intervention delivered via local MCHNs promoting early exposure to fluoride may be successful in reducing caries in the second year of life but less so in older children when participants have less contact with MCHNs.

Oral health follow-up studies in the 1993 Pelotas (Brazil) birth cohort study: methodology and principal results

The aim of this study was to describe oral health follow-up studies nested in a birth cohort. A population-based birth cohort was launched in 1993 in Pelotas, Rio Grande do Sul State, Brazil. Two oral health follow-up studies were conducted at six (n = 359) and 12 (n = 339) years of age. A high response rate was observed at 12 years of age; 94.4% of the children examined at six years of age were restudied in 2005. The mean DMF-T index at age 12 was 1.2 (SD = 1.6) for the entire sample, ranging from 0.6 (SD = 1.1) for children that were caries-free at age six, 1.3 (SD = 1.5) for those with 1-3 carious teeth at six years, and 1.8 (SD = 1.8) for those with 4-19 carious teeth at six years (p < 0.01). The number of individuals with severe malocclusions at 12 years was proportional to the number of malocclusions at six years. Oral health problems in early adolescence were more prevalent in individuals with dental problems at six years of age.

Long-term effectiveness of a nutritional program in reducing early childhood caries: a randomized trial

OBJECTIVES

To investigate the effectiveness of home visits advising mothers about healthy feeding practices during the first year of life on the occurrence of early childhood caries and severe early childhood caries at 4 years of age.

METHODS

We conducted a parallel randomized trial of mothers of single, full-term children with birthweight > or = 2500g in São Leopoldo, Brazil. The intervention group received monthly advice up to 6 months and then at 8, 10 and 12 months by undergraduate nutrition students, based on the "Ten Steps for Healthy Feeding'', a Brazilian national health policy for primary care based on World Health Organization guidelines. The primary outcome was the occurrence of early childhood caries at age four. Secondary outcomes included the occurrence of severe early childhood caries and the number of affected teeth: decayed (white spots and cavities), missing and filled teeth (d(1+)mft). Blinded observers ascertained feeding habits in the home and one blinded dentist performed dental examinations in a municipal clinic. This study is registered with ClinicalTrials.gov, number NCT00629629.

RESULTS

Of 500 mother-child pairs (200 intervention, 300 control) enrolled, 340 (141 intervention, 199 control) completed 4 year follow-up. As 138 (69.3%) controls but only 76 (53.9%) intervention children had early childhood caries, home counseling reduced incidence by 22% (RR 0.78; 95% CI 0.65-0.93). Severe early childhood caries incidence was reduced by 32% (RR 0.68; 95% CI 050-0.92). The mean number of affected teeth was lower for the intervention group (3.25) compared with the control group (4.15) (Mann Whitney U-test; p=0.023). No adverse effects were noted.

CONCLUSIONS

Home nutritional advice during the first year of life decreases caries incidence and severity at four years of age in a low income community.

Effectiveness of a nutrition program in reducing symptoms of respiratory morbidity in children: a randomized field trial

OBJECTIVES

To assess the effectiveness of home visits advising mothers about breast feeding and weaning in reducing symptoms of respiratory morbidity at the age of 12 months.

METHODS

A randomized field trial was conducted with mothers who gave birth within the public health system in the Brazilian city of Sao Leopoldo (2001/2002). The intervention group received dietary advice during the first year based on a Brazilian national health policy for primary care, which is based on WHO guidelines. Morbidity data was assessed in 397 children at 12 months.

RESULTS

A total of 23.3% of the children in the intervention group and 39.7% of the controls had one or more of the following symptoms during the month preceding assessment: cough, stuffy nose, runny nose, or breathlessness. The risk of respiratory morbidity symptoms was 41% lower for the intervention group (RR: 0.59; 95% CI: 0.43-0.81). The number of families needed to be visited to avoid one children presenting symptoms of respiratory morbidity (Number Needed to Treat) was 6.1. The intervention-group status was also associated with a longer duration of exclusive (RR:1.59; 95% CI: 1.21-2.07; p=0.001) and total breastfeeding (RR: 1.25; 95% CI:1.02-1.55; p=0.032) later introduction of solid foods (RR:1.11; 95% CI: 1.02-1.21; p=0.023), and a lower proportion of current medication use (RR:0.56; 95% CI:0.34-0.91;p=0.016).

CONCLUSION

A nutrition education program during the first year of life has a positive impact on reducing respiratory symptoms in infants.

Prevention of early childhood caries (ECC)--review of literature published 1998-2007

AIM

This was to examine the literature published during the last decade and review the effectiveness of methods used for the prevention of early childhood caries (ECC).

STUDY DESIGN

A critical review of papers.

METHODS

A broad search of the PubMed database was conducted from 1998 through September 2007, using "early childhood caries", "baby bottle tooth decay", "nursing caries", "infant caries", "caries prevention" and "oral health education" as index terms. Relevant papers published in English between 1998 and 2007 were identified after a review of their abstracts. Papers were selected if they reported a prospective controlled design with preventive or non-invasive intervention directed to children under the age of 3 years. A defined endpoint measure of cavitated or non-cavitated clinical caries, expressed as incidence or prevalence, was required. The targeted publications were critically assessed by the author concerning design, methodology and performance.

RESULTS

The initial search revealed 66 papers of which 22 met the inclusion criteria. The results reinforced the role of fluoride toothpaste as the most cost-effective home-care measure and semi-annual fluoride varnish applications as the best professional method for infants at risk. The evidence concerning the preventive effect of antibacterial agents, primary-primary prevention and dental health education were inconclusive but the included studies supported the importance of early start, outreach activities and motivational interviewing as key factors to overcome cultural and socioeconomic barriers.

CONCLUSIONS

Although there is a body of evidence for the use of fluoride in preventing ECC, further high-quality studies are needed to further establish the best way to maintain oral health in infants.

Caries increment in children aged 3-5 years in relation to parents' dental attitudes: Oslo, Norway 2002 to 2004

OBJECTIVES

To assess the relationship between parents' dental attitudes and the caries increment in their children from the age of 3 to 5 years.

METHODS

Data based on parental questionnaires and dental examinations were collected from children participating in a follow-up study from age 3 years (n = 354) in 2002 to 5 years (n = 304) in 2004. The children were categorized as western-native (WN) and immigrants (IM). The items used were significantly related to caries experience in a multicentre study [Pine et al. (2004)Community Dent Health, vol. 21, pp. 121-30]. The responses to attitudinal items were weighted as positive if they would promote good dental health, and negative if not. Composite attitudinal variables relating to hygiene, diet and indulgence were calculated as a summation of the weighted responses to selected items. Regression analyses (bivariate and multiple) were performed to assess associations during the period between the attitudinal predictors/other control variables and caries increment (Deltad(3-5)mfs).

RESULTS

Bivariate logistic regression analyses revealed that 'Attitude to Diet' and 'Parental Indulgence' were clearly related to caries increment. The more exposed children were to negative parental attitudes, the higher the OR. 'Attitude to Diet' also persisted in a multiple logistic regression model, showing a higher OR value than caries experience. 'Immigrant Status' was the most potent predictor of caries increment. Parents were found to be more indulgent among IM than among WN groups.

CONCLUSION

Parental dental attitudes are clearly shown to be associated with caries increment in early childhood. The relationship is of such strength that it deserves to be taken into account in future preventive dental strategies.