Addressing children's oral health inequalities: caries experience before and after the implementation of an oral health promotion program

Understanding parental perspectives on young children's oral health (≤ 4 years) growing up in a disadvantaged neighbourhood of Amsterdam, the Netherlands: an exploratory study

BACKGROUND

Families' understanding towards oral health problems among young children is poorly studied. More insight into parents' experiences, especially of those living in disadvantaged neighbourhoods, is needed to address persistent oral health inequalities. This qualitative study aims to explore parental perspectives on children's oral health (≤ 4 years) and the opportunities they see to improve children's oral health.

METHODS

Forty-seven mothers and five fathers with different migration backgrounds from a disadvantaged neighbourhood in Amsterdam, the Netherlands, participated in our study. Semi-structured interviews (n = 27), participant observations (n = 7) and one focus group discussion were conducted. A thematic data analysis was used.

RESULTS

Parents describe their daily life with young children as busy, hectic and unpredictable. Parents seem to be most concerned about parenting. Mothers, in particular, feel fully responsible for raising their children and managing daily complexities. While most parents value their children's oral health, they all experience challenges. Parents find it hard to limit daily candy intake and to handle unwilling children during tooth brushing. They feel limited support for these issues from their household, social network and professionals.

CONCLUSION

Parental struggles in children's oral health are complex and interrelated as they occur across family, societal, community and professional levels. Given the complex daily reality of families with young children, establishing and maintaining healthy oral health habits seems not at the top of parents' minds. They ask for advice in the upbringing of their children backed up by social support, increased attention to children's oral health within the community and professional assistance. Collaborating with parents as knowledgeable partners might be the first step in acting upon the endeavour to address oral health inequality among young children.

The Impact of Dental Care Programs on Individuals and Their Families: A Scoping Review

BACKGROUND

Despite significant global improvements in oral health, inequities persist. Targeted dental care programs are perceived as a viable approach to both improving oral health and to address inequities. However, the impacts of dental care programs on individual and family oral health outcomes remain unclear.

OBJECTIVES

The purpose of this scoping review is to map the evidence on impacts of existing dental programs, specifically on individual and family level outcomes.

METHODS

We systematically searched four scientific databases, MEDLINE, EMBASE, CINAHL, and Sociological Abstracts for studies published in the English language between December 1999 and November 2021. Search terms were kept broad to capture a range of programs. Four reviewers (AG, VD, AE, and KKP) independently screened the abstracts and reviewed full-text articles and extracted the data. Cohen's kappa inter-rater reliability score was 0.875, indicating excellent agreement between the reviewers. Data were summarized according to the PRISMA statement.

RESULTS

The search yielded 65,887 studies, of which 76 were included in the data synthesis. All but one study assessed various individual-level outcomes (n = 75) and only five investigated family outcomes. The most common program interventions are diagnostic and preventive (n = 35, 46%) care, targeted children (n = 42, 55%), and delivered in school-based settings (n = 28, 37%). The majority of studies (n = 43, 57%) reported a significant improvement in one or more of their reported outcomes; the most assessed outcome was change in dental decay (n = 35).

CONCLUSIONS

Dental care programs demonstrated effectiveness in addressing individual oral health outcomes. However, evidence to show the impact on family-related outcomes remains limited and requires attention in future research.

Professionals’ perspectives on how to address persistent oral health inequality among young children: an exploratory multi-stakeholder analysis in a disadvantaged neighbourhood of Amsterdam, the Netherlands

Background

Oral health promotion interventions have had limited success in reaching families in disadvantaged neighbourhoods resulting in persistent oral health inequality. This qualitative study provides insight into professionals’ perspectives on children’s poor oral health (≤ 4 years), their perceptions of the roles and responsibilities, and opportunities for child oral health promotion strategies.

Methods

Thirty-Eight professionals from different domains (community, social welfare, general health, dental care, public health, private sector) working in a disadvantaged neighbourhood in Amsterdam, the Netherlands, participated through 24 semi-structured (group) interviews. Transcripts and notes were analysed through thematic analysis.

Results

Professionals indicate that unhealthy diet, children’s non-compliance, poor parental coping, parental low oral health literacy, parent’s negative attitude, family’s daily struggles, and insufficient emphasis on childhood caries prevention in dental practices, general healthcare and social welfare organisations, underlie poor oral health. They hold parents most responsible for improving young children’s oral health, but recognise that families’ vulnerable living circumstances and lack of social support are important barriers. Interestingly, non-dental professionals acknowledge their beneficial role in child oral health promotion, and dental professionals stress the need for more collaboration.

Conclusion

A broad child-, parental-, and societal-centred educational communication strategy is perceived as promising. Professionals working within and outside the dental sector acknowledge that local and collective action is needed. This involves a better understanding of family’s complex daily reality. Furthermore, intensifying child oral health knowledge in dental practices is essential in collaboration with families, general health and social welfare organisations.

Systematic Review of Intervention Studies Aiming at Reducing Inequality in Dental Caries among Children

(1) Background: The objective is to systematically review the evidence on intervention programs aiming at reducing inequality in dental caries among children. (2) Methods: Two independent investigators searched MEDLINE, Cochrane library, and Ovid up to December 2020 to identify intervention studies assessing the impact on socioeconomic inequalities in dental caries among children. The interventions included any health promotion/preventive intervention aiming at reducing caries among children across different socioeconomic groups. Comparison groups included children with alternative or no intervention. Cochrane criteria were used to assess interventional studies for risk of bias. (3) Results: After removal of duplicate studies, 1235 articles were retained. Out of 43 relevant papers, 13 articles were identified and used in qualitative synthesis, and reported quantifiable outcomes. The included studies varied in measurements of interventions, sample size, age groups, and follow-up time. Five studies assessed oral health promotion or health-education, four assessed topical fluorides, and four assessed water fluoridation. Interventions targeting the whole population showed a consistent reduction of socioeconomic inequalities in dental caries among children. (4) Conclusion: The quality of included papers was moderate. High heterogeneity did not allow aggregation of the findings. The overall findings suggest that whole population interventions such as water fluoridation are more likely to reduce inequalities in children’s caries than target population and individual interventions.

Use of teachers as agents of oral health education: Intervention study among public secondary school pupils in Lagos

Background:

Common oral diseases are preventable and if detected early are reversible and schools provide a setting in which the oral health behavior of pupils can be influenced. We aimed to assess the effectiveness of using teachers in place of oral health professionals to deliver oral health education (OHE) in public secondary schools in Lagos State.

Methods:

This quasi-experimental study was conducted in four phases from September 2016-April 2017. A multistage sampling method was adopted to enlist the research participants from four enlisted schools, which were randomly assigned into two groups. Trained dentists delivered OHE in the first group of schools while trained teachers did in the second group and the impact of the intervention was assessed over six months. P values for significant differences were set at 0.05.

Results:

At the 3 months evaluation, the mean oral health knowledge (OHK) scores were higher among pupils in the Teachers Intervention Schools (TIS) (71.3 ± 19.3) than that in the Dentist Intervention Schools (DIS) (61.3 ± 17.7) (P = 0.023). Subsequent evaluation sessions from baseline revealed a gradual increase in the proportion of pupils with positive oral health attitude scores; with a higher proportion of pupils in the DIS (34.5%) compared to the TIS (34.0%) at 6 months assessment time. At 6 months evaluation, the proportion of pupils with poor oral health practices decreased in both groups of schools (P = 0.104).

Conclusion:

The proportion of pupils with good OHK was higher in the TIS at post-intervention periods; this difference was statistically significant at 3 months. This result suggests that teachers are as effective as dentists in delivering OHE.

Perception of Dental Caries and Parental Difficulties in Implementing Oral Hygiene for Children Aged Less Than 6 Years: A Qualitative Study

BACKGROUND

Despite extensive prevention programs, dental hygiene remains inadequate, particularly among children under the age of six, and early childhood caries (ECC) are still a concern. Oral hygiene behavior and preventive practices seem difficult to change at a family level.

AIM

The present study aimed to better understand the reasons behind this behavior and to identify the different barriers to the implementation of adequate preventive measures.

METHODS

A qualitative study was conducted in the pediatric dentistry service of the Montpellier University Hospital (France) in 2019. A thematic analysis concerning three domains was performed: family environment, dental literacy, and oral hygiene.

RESULTS

The main barriers encountered by the parents were, respectively, (1) a weakness in the organization of familial life, together with a low-medium family income and a lack of authority, (2) ignorance of the necessity of treating carious primary teeth, and (3) a lack of time for brushing or supervising their children's teeth.

CONCLUSION

These results showed that oral hygiene and primary teeth care could not be easily achieved in the family environment of the participants, and oral health strategies should be focused not only on children but also on their parents.

Clinical efficacy of a two-year oral health programme for infants and toddlers in Singapore

INTRODUCTION

Dental caries, which is prevalent in Singapore preschoolers, is a disease that has a major impact on children's health and places a high cost on the society and health services. Oral health programmes for young children implemented in some parts of the world have been shown to be effective in the prevention of dental caries. We aimed to examine the clinical efficacy of a two-year oral health programme for infants and toddlers in Singapore.

METHODS

90 children and their caregivers participated in the programme, and 64 children, who were 24 months older than the intervention group at the initial visit, were recruited as controls in a quasi-experimental study design. We evaluated the presence of severe early childhood caries (SECC) and d₃mfs in the control group at the initial visit and in the intervention group after the completion of the two-year programme.

RESULTS

Some children in the intervention (7.8%) and control (31.3%) groups (p < 0.001) had SECC (difference 23.5%, 95% confidence interval 11%-36%). A higher percentage of children in the intervention group had d₃mfs = 0 and habits associated with low risk for caries. The odds of SECC in the control group were three times higher than that for the intervention group, and the effect was significant (p = 0.037) after adjustment for other significant risk factors.

CONCLUSION

The preventive oral health programme in Singapore was successful in reducing SECC among infants and toddlers when targeted behaviour modifications were implemented.

The healthcare system and the provision of oral healthcare in EU Member States: France

The French oral health system is based on the provision of dental treatment and is organised around a fee-per-item model. The system is funded by a complex mix of public and complementary health insurance schemes. The system is successful in that it provides access to affordable dental treatment to the majority of the French population. However, France had the highest health expenditure as a share of gross domestic product (GDP) of all European Union countries in 2008 and rising oral health inequalities may be exacerbated by the manner in which oral health care is provided and funded. In addition, there is no organised national strategy for the prevention of oral diseases or for oral health promotion.

WITHDRAWN: Community-based population-level interventions for promoting child oral health

BACKGROUND

Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health.

OBJECTIVES

Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions.

SEARCH METHODS

We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science.

SELECTION CRITERIA

Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity.

MAIN RESULTS

This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.

AUTHORS' CONCLUSIONS

This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Community-based population-level interventions for promoting child oral health

BACKGROUND

Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health.

OBJECTIVES

Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions.

SEARCH METHODS

We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science.

SELECTION CRITERIA

Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity.

MAIN RESULTS

This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.

AUTHORS' CONCLUSIONS

This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Longitudinal study of caries progression in 2- and 3-year-old German children

OBJECTIVE

This 2-year longitudinal study in 2- and 3-year-old kindergarten children investigated lesion progression on different surfaces of primary teeth.

METHODS

The study was conducted between September 2008 and September 2010 on a sample of 400 children from the Kyffhäuser district (Thuringia, Germany). A calibrated investigator recorded (non)cavitated caries lesions according to World Health Organization (WHO), International Caries Detection and Assessment System (ICDAS) and Universal Visual Scoring System (UniViSS) criteria. Nonparametric methods and linear regression using a mixed-effects model with an unbalanced design were used for data analysis.

RESULTS

There was a significant increase in the prevalence of noncavitated caries lesions during the 2-year period, with the highest chance for change on all surfaces compared to cavitated lesions. First visible sign lesions on occlusal surfaces had the highest chance for change (estimate 0.38), whereas established lesions revealed the highest chance for change on proximal (estimate 1.05) and smooth surfaces (estimate 0.62). Proximal lesions exhibited the greatest chance for change irrespective of severity level.

CONCLUSION

Our study demonstrated that each type of carious lesion had different changing rates. Greater lesion severity correlated with greater chances to change and receive treatment. This information is crucial for dental practitioners in decision-making processes.

Clinical consequences of untreated dental caries in German 5- and 8-year-olds

Background

About half of all carious lesions in primary teeth of German 6- to 7-year-old children remain untreated, but no data regarding the clinical consequences of untreated dental caries are available. Therefore, this cross-sectional observational study aimed to assess the prevalence and experience of caries and odontogenic infections in the primary dentition of 5- and 8-year-old German children.

Methods

Dental examinations were performed in 5-year-old pre-school children (n = 496) and in 8-year-old primary school children (n = 608) living in the Westphalian Ennepe-Ruhr district. Schools and preschools were selected by sociodemographic criteria including size, area, ownership, socio-economic status. Caries was recorded according to WHO criteria (1997). The Lorenz curves were used to display the polarisation of dental caries. Caries pattern in 5-year-olds was categorized by Wyne’s (1997) definition of early childhood caries (ECC). Odontogenic infections as clinical consequence of untreated dental caries were assessed by the pufa index. The ‘untreated caries-pufa ratio’ was calculated, and the Spearman’s rank correlation coefficient (ρ) was used for evaluating the correlation between dmft and pufa scores. Categorical data were compared between groups using the chi-square test and continuous data were analysed by t-test.

Results

Caries prevalence and experience in the primary dentition was 26.2 %/0.9 ± 2.0 dmft in 5-year-olds and 48.8 %/2.1 ± 2.8 dmft in 8-year-olds. ECC type I (22 %) was the prevalent caries pattern in 5-year-olds. About 30 % of the tooth decay was treated (5y: 29.7 %/8y: 39.3 %). The Lorenz curves showed a strong caries polarisation on 20 % of the children. Pufa prevalence and experience was 4.4 %/0.1 ± 0.5 pufa in 5-year-olds and 16.6 %/0.3 ± 0.9 pufa in 8-year-olds. In 5-year-olds 14.2 % and in 8-year-olds 34.2 % of the d-component had progressed mainly to the pulp. A significant correlation between dmft and pufa scores exists in both age groups (5y: ρ = 0.399; 8y: ρ = 0.499). First deciduous molars were most frequently affected by odontogenic infections, presenting virtually all pufa scores (>95 %).

Conclusions

Prevalence and experience of odontogenic infections and the untreated caries-pufa ratio were increasing from the younger to the elder children. Dmft and pufa scores in primary teeth predict a higher caries risk in permanent teeth. The pufa index highlights relevant information for decision makers to develop effective oral health care programs for children at high risk for caries.

Oral health and oral health-related behaviour in preschool children: evidence for a social gradient

This study aims to investigate the social gradient in the reported oral health-related behaviour and oral health status of preschool children. Participants were 1,057 children born between October 2003 and July 2004 in Flanders, Belgium. Oral health examinations were performed by trained dentists when the children were 3 and 5 years old (respectively, in 2007 and 2009); data on dietary habits, oral hygiene habits and dental attendance of the children were obtained through structured questionnaires completed by the parents. Maternal educational level, measured in four categories, was used as a proxy of socio-economic status. Logistic and ordinal regressions showed a social gradient for the oral health-related behaviours: a lower educational level of the mother was related to a higher consumption of sugared drinks between meals and to a lower brushing frequency and dental attendance of the child. Children from low-educated mothers also had seven times more chance to present with caries experience than children from mothers with a bachelor degree. Contrary to the expectations, there was a deviation from the gradient in 3-year-olds from the highest educational group showing an increased risk for caries experience (OR = 3.84, 95 % CI = 1.08-13.65). Conclusion. Already in very young children, a graded relationship is observed between socio-economic position, oral health and related behaviours. The results suggest that different approaches are required to promote oral health during early childhood depending on the mother's educational background. As children from the highest social group also have an increased caries risk, specific techniques may be needed.