Interventions with pregnant women, new mothers and other primary caregivers for preventing early childhood caries

Abstract

Dental caries is one of the most common chronic diseases of childhood and is associated with adverse health and economic consequences for infants and their families. Socioeconomically disadvantaged children have a higher risk of early childhood caries (ECC). 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 ECC (from birth to six years of age). Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 14 January 2019), Cochrane Pregnancy and Childbirth Group's Trials Register (to 22 January 2019), Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Register of Studies, to 14 January 2019), MEDLINE Ovid (1946 to 14 January 2019), Embase Ovid (1980 to 14 January 2019) and CINAHL EBSCO (1937 to 14 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on language or publication status. Randomised controlled trials (RCTs) comparing one or more interventions with pregnant women, mothers, or other caregivers of infants in the first year of life (intervention types included clinical, oral health education/promotion such as hygiene education, breastfeeding and other dietary advice, and policy or health service), versus standard care or placebo or another intervention. For inclusion, trials had to report at least one caries outcome. Two review authors independently assessed trial eligibility, extracted data, assessed risk of bias, and assessed certainty of evidence using the GRADE approach. We included 17 RCTs (4 cluster‐randomised), involving 23,732 caregivers (mainly mothers) and their children. Eleven RCTs assessed four oral health education/promotion interventions against standard care: child diet advice, child diet and feeding practice advice, breastfeeding promotion and support, and oral hygiene with child diet and feeding practice advice. Six trials assessed clinical interventions in mother's dentition, four trials chlorhexidine (CHX, a commonly prescribed antiseptic agent) or iodine‐NaF application and prophylaxis versus placebo, and two trials xylitol against CHX or CHX + xylitol. At most, three trials (maximum of 1148 children and 130 mothers) contributed data to any comparison. For many trials, risk of bias was judged unclear due to lack of methodological details reported, and there was high risk of attrition bias in some trials. None of the included trials indicated receiving funding that is likely to have influenced their results. The trials were performed in high‐, middle‐ and low‐income countries. In nine trials, participants were socioeconomically disadvantaged. For child diet and feeding practice advice versus standard care, we observed a probable 15 per cent reduced risk of caries presence in primary teeth with the intervention (RR 0.85, 95% CI 0.75 to 0.97; 3 trials; 782 participants; moderate‐certainty evidence), and there may be a lower mean dmfs (decayed, missing, filled primary surfaces) score (MD ‐0.29, 95% CI ‐0.58 to 0; 2 trials; 757 participants; low‐certainty evidence); however, we are uncertain regarding the difference between the groups in mean dmft (decayed, missing, filled teeth) score (MD ‐0.90, 95% CI ‐1.85 to 0.05; 1 trial; 340 participants; very low‐certainty evidence). For breastfeeding promotion and support versus standard care, we observed that there may be little or no difference between groups in the risk of caries presence in primary teeth (RR 0.96, 95% CI 0.89 to 1.03; 2 trials; 1148 participants; low‐certainty evidence), or mean dmft score (MD ‐0.12, 95% CI ‐0.59 to 0.36; 2 trials; 652 participants; low‐certainty evidence). Dmfs was not reported for this comparison. We are uncertain whether child diet advice only compared with standard care reduces risk of caries presence in primary teeth (RR 1.08, 95% CI 0.34 to 3.37; 1 trial; 148 participants; very low‐certainty evidence). Dmfs and dmft were not reported for this comparison. For oral hygiene, child diet and feeding practice advice versus standard care, we observed little or no reduced risk of caries presence in primary teeth (RR 0.91, 95% CI 0.75 to 1.10; 2 trials; 365 participants; low‐certainty evidence), and are uncertain regarding difference between the groups in mean dmfs score (MD ‐0.99, 95% CI ‐2.45 to 0.47; 1 trial; 187 participants; very low‐certainty evidence) and dmft score (MD ‐0.30, 95% CI ‐0.96 to 0.36; 1 trial; 187 participants; very low‐certainty evidence). We observed there may be little or no difference in risk of caries presence 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 participants; very low‐certainty evidence). No trials assessing this comparison reported dmfs or dmft. For xylitol compared with CHX antimicrobial treatment, we observed 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); however, we are uncertain regarding the difference between groups in caries presence in primary teeth (RR 0.62, 95% CI 0.27 to 1.39; 1 trial, 96 participants; very low‐certainty evidence). Neither trial evaluating this comparison reported dmfs. No trials assessed a health policy or service intervention. 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. Interventions with pregnant women, new mothers and other primary caregivers for preventing tooth decay in young children Question Does providing pregnant women, new mothers and other primary caregivers of children in the first year of life with preventive dental care (other than fluorides) and information about healthy child diet and feeding practices prevent tooth decay in their children? Background Tooth decay in young children (early childhood caries or ECC) is very common, affecting billions of children worldwide, particularly poor children. Early childhood caries can have long‐lasting negative effects on health and it costs a lot to treat. It is well known that sugar and dental plaque (bacteria in the mouth) cause tooth decay. The attitudes, beliefs, and habits of pregnant women, mothers and other primary caregivers, influence the dental health of their children. Study characteristics We searched for evidence available up to 14 January 2019. We found 17 randomised controlled trials, which is the type of research that provides the most reliable results. The trials involved 23,732 caregivers (mainly mothers) and their children. The trials took place in a mix of high‐, middle‐, and low‐income countries. Participants were from low‐income communities in nine trials. Eleven of the included trials evaluated oral health education and promotion interventions compared to usual care. We divided these into four subcategories: breastfeeding support (two trials), child diet advice only (one trial), child diet and feeding advice (three trials), or child diet and feeding advice combined with advice on keeping teeth clean (five trials). Preventive dental care aimed at reducing bacteria in the mother’s mouth was evaluated in six trials: four compared putting a special varnish on the teeth compared with a 'placebo' (an inactive treatment that looked the same as the varnish), and two compared the use of chewing gum containing xylitol versus a chlorhexidine dental gel. None of the included trials assessed programmes aimed at improving access to preventive dental services. Main results We found some evidence that children whose mothers (or other caregivers) received advice on healthy diet and feeding practice for infants and children were less likely to have tooth decay up to the age of six than those whose caregivers received the usual care. The other oral health education interventions (breastfeeding support; advice about best child diet; advice about child diet, feeding and teeth cleaning) did not show that these interventions reduced the risk of tooth decay in young children compared with usual care. However, the findings of these studies were so uncertain that we cannot conclude these interventions do not work. We found mixed evidence about treatments to reduce bacteria in mothers' mouths and cannot reach firm conclusions about whether or not these could potentially prevent early childhood caries. None of the included trials indicated receiving funding that is likely to have influenced their results. Authors' conclusions 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 tooth decay in their children during their early years. We need more high quality studies that have a large number of participants in order to find out if there are other interventions with caregivers that can help reduce early childhood tooth decay, and which features of interventions make them effective. We are aware of 12 studies currently in progress.