《儿童少年卫生学 child and adolescent health》拓展阅读：儿童青少年常见眼病和口腔疾病防控_WHO Global Consultantation on Public Health Intervention against Early Childhood Caries

Received: 13 June 2017 ed: 14 December 2017 Do:10.1111/cdoe12362 ORIGINAL ARTICLE WILEY DSMALEMDEMOLOGCY WHO Global consultation on public health Intervention against early childhood Caries Prathip PhantumvanitI Yuka Makino2oD I Hiroshi Ogawa I Andrew Rugg-Gunn45 Paula Moynihan I Poul Erik Petersen,/I Wendell EvansI Carlos Benoit Varenne- I Tippanart Vichayanrat3/ Yupin Songpaisap4, Ran Alberto Feldens'I Edward Lo 0I Mohammad H Khoshnevisan| Ramon Baez12 Margaret WoodwardI Siriruk Nakornchai 3I Chantana Ungchusaki5 Thammasat University Bangkok, Thailand Abstract world Health Organization, Genev Early Childhood Caries(ECC) is prevalent around the world, but in particular the dis ease is growing rapidly in low- and middle-income countries in parallel with chang nEwcastle University, Newcastle upon Tyne, U ing diet and lifestyles. In many countries, ECC is often left untreated, a condition The Borrow Foundation, Hampshire, UK which leads to pain and adversely affects general health growth and development, World Health Organization Regional Office and quality of life of children, their families and their communities. Importantly, ECC for Europe, Copenhagen, Denmark is also a global public health burden, medically, socially and economically. In many University of Copenhagen, Copenhagen, Denmark countries, a substantial number of children require general anaesthesia for the treat University of Sydney, Sydney, Australia ment of caries in their primary teeth (usually extractions), and this has considerable uNiversidade Luterana do brasil rio cost and social implications. a WHO Global Consultation with oral health experts Grande do sul. Brazil on"Public Health Intervention against Early Childhood Caries"was held on 26-28 uNiversity of Hong Kong. Hong Kong. January 2016 in Bangkok(Thailand) to identify public health solutions and to high- 1i shahid Beheshti University of Medical light their applicability to low- and middle-income countries. After a 3-day consulta tion, participants agreed on specific recommendations for further action. Nationa School of Dentistry, University of Texas alth Science Center. San Antonio, TX health authorities should develop strategies and implement interventions aimed at preventing and controlling ECC. These should align with existing international initia 13Mahidol University, Bangkok,Thailand tives such as the Sixtieth World Health Assembly Resolution WHA 60.17 Oral Asuranaree University of Technolog Nakhon Ratchasima. Thailand health: action plan for promotion and integrated disease prevention, WHO Guideline I The Ministry of Public Health in Thailand on Sugars and WHo breastfeeding recommendation. eCC prevention and control Bangkok, Thailand terventions should be integrated into existing primary healthcare systems. WHO public health principles must be considered when tackling the effect of social deter- minants in ECC Initiatives aimed at modifying behaviour should focus on Email: makino @who in and communities. The involvement of communities in health promotion and ECC is essential. Surveillance and research, including cost-effectiveness studies should be conducted to evaluate interventions aimed at preventing ECC in different population groups. authors alone are responsible for the views expressed in this artide, and they do not cessarily represent the views, decisions Bo 92018 The World Health Organization wileyonlinelibrary. com/journal/ cdoe ommunity Dent Oral Epidemiol. 2018: 46: 280-28

ORIGINAL ARTICLE WHO Global Consultation on Public Health Intervention against Early Childhood Caries Prathip Phantumvanit1 | Yuka Makino2 | Hiroshi Ogawa3 | Andrew Rugg-Gunn4,5 | Paula Moynihan4 | Poul Erik Petersen6,7 | Wendell Evans8 | Carlos Alberto Feldens9 | Edward Lo10 | Mohammad H. Khoshnevisan11 | Ramon Baez12 | Benoit Varenne2 | Tippanart Vichayanrat13 | Yupin Songpaisan14 | Margaret Woodward5 | Siriruk Nakornchai13 | Chantana Ungchusak15 1 Thammasat University, Bangkok, Thailand 2 World Health Organization, Geneva, Switzerland 3 Niigata University, Niigata, Japan 4 Newcastle University, Newcastle upon Tyne, UK 5 The Borrow Foundation, Hampshire, UK 6 World Health Organization Regional Office for Europe, Copenhagen, Denmark 7 University of Copenhagen, Copenhagen, Denmark 8 University of Sydney, Sydney, Australia 9 Universidade Luterana do Brasil, Rio Grande do Sul, Brazil 10University of Hong Kong, Hong Kong, China 11Shahid Beheshti University of Medical Sciences, Tehran, Iran 12School of Dentistry, University of Texas health Science Center, San Antonio, TX, USA 13Mahidol University, Bangkok, Thailand 14Suranaree University of Technology, Nakhon Ratchasima, Thailand 15The Ministry of Public Health in Thailand, Bangkok, Thailand Correspondence Yuka Makino, World Health Organization, Geneva, Switzerland. Email: makinoy@who.int Abstract Early Childhood Caries (ECC) is prevalent around the world, but in particular the dis￾ease is growing rapidly in low- and middle-income countries in parallel with chang￾ing diet and lifestyles. In many countries, ECC is often left untreated, a condition which leads to pain and adversely affects general health, growth and development, and quality of life of children, their families and their communities. Importantly, ECC is also a global public health burden, medically, socially and economically. In many countries, a substantial number of children require general anaesthesia for the treat￾ment of caries in their primary teeth (usually extractions), and this has considerable cost and social implications. A WHO Global Consultation with oral health experts on “Public Health Intervention against Early Childhood Caries” was held on 26-28 January 2016 in Bangkok (Thailand) to identify public health solutions and to high￾light their applicability to low- and middle-income countries. After a 3-day consulta￾tion, participants agreed on specific recommendations for further action. National health authorities should develop strategies and implement interventions aimed at preventing and controlling ECC. These should align with existing international initia￾tives such as the Sixtieth World Health Assembly Resolution WHA 60.17 Oral health: action plan for promotion and integrated disease prevention, WHO Guideline on Sugars and WHO breastfeeding recommendation. ECC prevention and control interventions should be integrated into existing primary healthcare systems. WHO public health principles must be considered when tackling the effect of social deter￾minants in ECC. Initiatives aimed at modifying behaviour should focus on families and communities. The involvement of communities in health promotion, and popula￾tion-directed and individual fluoride administration for the prevention and control of ECC is essential. Surveillance and research, including cost-effectiveness studies, should be conducted to evaluate interventions aimed at preventing ECC in different population groups. The authors alone are responsible for the views expressed in this article, and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. Received: 13 June 2017 | Accepted: 14 December 2017 DOI: 10.1111/cdoe.12362 280 | © 2018 The World Health Organization wileyonlinelibrary.com/journal/cdoe Community Dent Oral Epidemiol. 2018;46:280–287

PHANTUMVANIT ET AL NDA-WILEY KEYWORDS Early Childhood Caries, health promotion, prevention, public health 1 INTRODUCTION WHO International Classification of Diseases, 11th edition(ICD-11 The modified definition of ECC which was proposed in 1999, and The findings of the 2015 Global Burden of Diseases study 2 adopted by the american academy of pediatric dentistry(AAPD)in revealed that dental caries of the primary dentition was the 12th 2003-1-ECC experience is the presence of one or more decayed most prevalent disease (560 million children) in all ages combined. (noncavitated or cavitated lesions ) missing(due to caries) or filled The significance of the dental, medical, social and economic costs of tooth surfaces in any primary tooth in a child under the age of Early Childhood Caries(ECC)has increased in all regions of th sixO--was accepted during the meeting world. The aetiology of ECC is complex, and the disease progresses ted ICD-11 cl on of eccl reads as follows more rapidly than caries in the permanent dentition ecc is due to "early childhood caries(Ecc) is characterized by the presence of one the strong influence of health behaviours and practices of children or more teeth affected by severe carious lesions or with white spot and families, mostly mothers and/or caregivers. In addition, structural lesions in anterior and posterior primary teeth, extraordinary loss of factors and poor socioeconomic conditions have an important impact teeth due to caries or filled tooth surfaces in affected teeth. ECc is on the development of ECc and lead to inequalities which are mostly found in young children under the age of 6. those children increasing in low- and middle- income countries. 4 Moreover, ECC is with eCC have been shown to have a high number of teeth affected an economic burden to society. treatment of Ecc under general by progressive disease. Consequences of ECc include a anaesthesia(GA)for extensive dental repair is especially costly. In of pain or discomfort, abscesses, carious lesions in both the primary England, over 60 000 children had decayed teeth extracted under and permanent dentitions, risk for delayed physical growth and Ga between 2012 and 2013; a conservative estimate of the cost of development, increased days with restricted activity, and diminished these admissions for the extraction of decayed teeth was f27.6 mi oral health-related quality of life. the aetiology is frequently linked lion, which is equivalent to the cost of running 3 secondary schools. with a high-frequent consumption of sugared drinks or food, lack of Many countries have introduced effective school-based pro. breastfeeding, and/or poor oral hygiene. Additionally the disease grammes to improve oral health, but it is realized that, in many often manifests in children living in poor families and in poor envi- countries, the disease occurs before the child attends school and can ronmental settings. benefit from these programmes A WHO Global Consultation on ECC was held in Bangkok(Thailand) on 26-28 January 2016 to explore possible public health solutions to 3 THE GLOBAL STATUS OF ECC the worldwide problem of ECC. the 3-day meeting was organized by the WHO Collaborating Centre for Oral Health Education and To assess the impact of the classification of ECC proposed in 1999 Research, Mahidol University, in collaboration with the WHO Oral Dye et al conducted a systematic literature review of the preva Health Programme; nineteen experts from 13 countries, including aca- lence and measurement of dental caries in young children from demic experts from the wHo Collaborating Centres and the WHo 1999 to 2014. The criterion for lesion detection as reported in 71% Expert Panel on Oral Health, attended from all 6 WHO regions. Reviews of the 87 papers reviewed, used cavitation in enamel as a minimal were presented on the definition of ECC, global epidemiology of ECC, threshold. Only 15% of papers reported noncavitated and/or cavi- pattern and development of ECC, aetiology of ECC, infant feeding and tated as the caries detection level, which is aligned with AAPD'S diets of the young child, strategies for prevention considering modifi- ECC definition. The current variation in detection level limits able risk factors, and sociobehavioural factors and effective public ability to obtain valid estimates of disease prevalence rates around health initiatives. Group discussions on each of these topics were held the globe. 13 to reach an agreement on conclusions and recommendations. The WHO Oral Health Programme has maintained its"WHO Oral The purpose of this report is to provide a summary of the meet- lealth Country/Area Profile Programme( CAPP)" for oral diseases ing"A WHO Global Consultation on ECCaB to provide an overview surveillance since 1995. Essentially, the data presented in the CAPP follow the who manual Oral Health action this important public health problem Since the introduction of AAPD's ECC definition, data on the percent- age of children under the age of 6 with one or more treated/ untreated caries lesions(prevalence)have been reported for 44 of the 194 w 2 DEFINITION OF ECC Member States. It was noted that the prevalence ranged from 0.0% in Nigeria to 98% in Cambodia, and bosnia and herzegovina. It should be It is considered to be a high priority to disseminate globally the defi- noted that while some of the surveys included in the database nition and diagnostic criteria for ECC and to include ECC in the included noncavitated carious lesions, most surveys did not

KEYWORDS Early Childhood Caries, health promotion, prevention, public health 1 | INTRODUCTION The findings of the 2015 Global Burden of Diseases study1,2 revealed that dental caries of the primary dentition was the 12th most prevalent disease (560 million children) in all ages combined. The significance of the dental, medical, social and economic costs of Early Childhood Caries (ECC) has increased in all regions of the world. The aetiology of ECC is complex, and the disease progresses more rapidly than caries in the permanent dentition. ECC is due to the strong influence of health behaviours and practices of children and families, mostly mothers and/or caregivers. In addition, structural factors and poor socioeconomic conditions have an important impact on the development of ECC and lead to inequalities which are increasing in low- and middle-income countries.3,4 Moreover, ECC is an economic burden to society. Treatment of ECC under general anaesthesia (GA) for extensive dental repair is especially costly.3 In England, over 60 000 children had decayed teeth extracted under GA between 2012 and 2013; a conservative estimate of the cost of these admissions for the extraction of decayed teeth was £27.6 mil￾lion, which is equivalent to the cost of running 3 secondary schools.5 Many countries have introduced effective school-based pro￾grammes to improve oral health,6,7 but it is realized that, in many countries, the disease occurs before the child attends school and can benefit from these programmes. A WHO Global Consultation on ECC was held in Bangkok (Thailand) on 26-28 January 2016 to explore possible public health solutions to the worldwide problem of ECC. The 3-day meeting was organized by the WHO Collaborating Centre for Oral Health Education and Research, Mahidol University, in collaboration with the WHO Oral Health Programme; nineteen experts from 13 countries, including aca￾demic experts from the WHO Collaborating Centres and the WHO Expert Panel on Oral Health, attended from all 6 WHO regions. Reviews were presented on the definition of ECC, global epidemiology of ECC, pattern and development of ECC, aetiology of ECC, infant feeding and diets of the young child, strategies for prevention considering modifi￾able risk factors, and sociobehavioural factors and effective public health initiatives. Group discussions on each of these topics were held to reach an agreement on conclusions and recommendations. The purpose of this report is to provide a summary of the meet￾ing “A WHO Global Consultation on ECC” 8 to provide an overview of ECC prevention strategies, and to emphasize the urgent need for action this important public health problem. 2 | DEFINITION OF ECC It is considered to be a high priority to disseminate globally the defi￾nition and diagnostic criteria for ECC and to include ECC in the WHO International Classification of Diseases, 11th edition (ICD-11). The modified definition of ECC which was proposed in 1999, and adopted by the American Academy of Pediatric Dentistry (AAPD) in 20039-11—“ECC experience is the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces in any primary tooth in a child under the age of six10”—was accepted during the meeting. The suggested ICD-11 classification of ECC12 reads as follows: “Early childhood caries (ECC) is characterized by the presence of one or more teeth affected by severe carious lesions or with white spot lesions in anterior and posterior primary teeth, extraordinary loss of teeth due to caries, or filled tooth surfaces in affected teeth. ECC is mostly found in young children under the age of 6. Those children with ECC have been shown to have a high number of teeth affected by progressive disease. Consequences of ECC include a higher risk of pain or discomfort, abscesses, carious lesions in both the primary and permanent dentitions, risk for delayed physical growth and development, increased days with restricted activity, and diminished oral health-related quality of life. The aetiology is frequently linked with a high-frequent consumption of sugared drinks or food, lack of breastfeeding, and/or poor oral hygiene. Additionally, the disease often manifests in children living in poor families and in poor envi￾ronmental settings.” 3 | THE GLOBAL STATUS OF ECC To assess the impact of the classification of ECC proposed in 1999, Dye et al13 conducted a systematic literature review of the preva￾lence and measurement of dental caries in young children from 1999 to 2014. The criterion for lesion detection, as reported in 71% of the 87 papers reviewed, used cavitation in enamel as a minimal threshold. Only 15% of papers reported noncavitated and/or cavi￾tated as the caries detection level, which is aligned with AAPD’s ECC definition. The current variation in detection level limits our ability to obtain valid estimates of disease prevalence rates around the globe.13 The WHO Oral Health Programme has maintained its “WHO Oral Health Country/Area Profile Programme (CAPP)” for oral diseases surveillance since 1995.14 Essentially, the data presented in the CAPP follow the WHO manual—“Oral Health Survey Basic Methods.” 15 Since the introduction of AAPD’s ECC definition, data on the percent￾age of children under the age of 6 with one or more treated/untreated caries lesions (prevalence) have been reported for 44 of the 194 WHO Member States. It was noted that the prevalence ranged from 0.0% in Nigeria to 98% in Cambodia, and Bosnia and Herzegovina. It should be noted that while some of the surveys included in the database included noncavitated carious lesions, most surveys did not. PHANTUMVANIT ET AL. | 281

ILEY The World Bank classifies Member States into 4 income groups and community oral health environment such as accessibility to fluo- using gross national income (GNI)per capita each year: low, lower nidation and to the healthcare system. and high. 6 Table 1 provides information abou For ECC prevention, the majority of the emphasis was placed on he percentage of children under the age of 6 with one or more trea. the amount of consumption of free sugars and the frequency with ted/untreated caries lesions (prevalence)and the mean number of which they are consumed, infant feeding practices, poor removal affected teeth among children under the age of 6 for 25 countries dental plaque and the low availability of fluoride. Reasons for these where the data were available from the capp and the world Banks caries-inducing behaviours lie in the family-their own experiences national income category did not change from 1999 through 2015. 6 circumstances and lifestyles. However, the family (or caregivers)are These countries were chosen as it is easier to interpret the data from subjected to strong cultural, economic and marketing influences stable economies. Most caries lesions remain untreated regardless of which shape beliefs, attitudes and behaviours the lack of the use of national income categories. For example it has been reported that fluoride is an important environmental factor for ECC. Some fac- the d component constitutes 100% of dft (dmft) index in Finland, tors were conceived as being nonmodifiable risks (e. g genetic profile. Greece, Japan and Philippines. It was considered critical to gather salivary components)and were not considered further more empha- more solid information on caries experience in the primary dentition, sis was given to"modifiable"risk factors as they could lead to rec especially in low- and middle- income countries, as there were only 6 ommendations or policies for changes in practice. specific reviev countries: Uganda, Syrian Arab Republic, Mexico, Sri Lanka, Malaysia were presented on infant feeding practices and social and beha- and philippines in these categories where the data were available. to vioural determinants. assist, it was recommended that subnational surveys of young chil dren should be carried out using the WHo Oral Health Survey basic Methods which also include important guidances for risk factor analy- 4.1.1 Infant feeding and diet of the young child sis that should be applied to preschool children Breastfeeding is the natural way of providing young infants with the The impact of ECC on the child the family and society is not nutrients they need for healthy growth and development. virtually fully portrayed by the epidemiological statistics given in Table 1. all mothers can breastfeed, provided they have accurate information Self-reported information is required, because ECc causes pain and and the support of their family, the healthcare system and society at difficulty in speaking and eating, and may lead to underweight and large WHo recommends exclusive breastfeeding for the first stunting 17,8 ECC has adverse effects on the quality of life of chil- 6 months of life, followed by continued breastfeeding with appropri- dren, family and caregivers regardless of social groups 19In addition, ate complementary feeding for up to 2 years or beyond. 25 The great ECC has substantial resource implications. Treatment under general importance of breastfeeding for the health of the child and mother anaesthesia for extensive dental repair/restoration is usually carried is acknowledged. 26 Breastfeeding in infancy may protect against out in hospital and is time- consuming and costly the experience can dental caries. 27 Further research is needed to understand th also be traumatic for both the child and the family. It is worth reported higher risk of caries in children breastfed after 12 months oting that caries severity in primary teeth is a predictor for caries Tham et al" suggested a 2-3 times greater risk of dental caries if experience in the permanent dentition. ECC is not only a problem breastfeeding is frequent and/or nocturnal after 12 months. How for children and their families but also a public burden and a threat ever, this observation was based on a meta analysis in which some globally, and therefore, public health approaches are required to of the included studies had not controlled for confounding factors. tackle ecc The protective effect may be confounded by high and frequent con sumption of free sugars in children after the age of 12 months. In 4 PREVENTION AND CONTROL OF ECC particular, cohort studies with adequate control for confounding fac- tors (including intake of free sugars in complementary foods and 4.1 Risk factors drinks)are required. Discontinuation of breastfeeding or replacement The primary risk factor for ecc is undoubtedly exposure to sugars hrough the diet there is, however, evidence of varying quantity 2 Free sugars in drinks and foods play a major role in the develop- ent of dental caries and other chronic diseases. the wHo pub- and quality to suggest that the factors shown in table 2 are related lished a guideline on Sugars Intake for Adults and children in 2015. to ECC, although some risk factors appear to be much more impor- which includes a strong recommendation that the intake of free sug- tant than others, and there may be interactions among them fisher- ars is reduced in both children and adults. 8 The who guideline is Owens et al used a multilevel conceptual model to explain how based on systematic reviews of the evidence pertaining to the intake risk factors can apply at 3 different levels: the child the family and of sugars and risk of overweight and obesity and the risk of dental the community. At the child level, these could include genetic, bio- caries. The evidence for an association between intake of free sugars gical, health behaviours and practice and physical and demographic and dental caries was provided primarily from epidemiological stud attributes: at the family level: socioeco ies of children which demonstrated a positive association between tion, and health status, and practice behaviours of families; and at amount of free sugars consumption and dental caries the guideline the community level: culture, social environment and social capital, recommends that children and adults reduce their daily intake of

The World Bank classifies Member States into 4 income groups using gross national income (GNI) per capita each year: low, lower middle, upper middle and high.16 Table 1 provides information about the percentage of children under the age of 6 with one or more trea￾ted/untreated caries lesions (prevalence) and the mean number of affected teeth among children under the age of 6 for 25 countries where the data were available from the CAPP and the World Bank’s national income category did not change from 1999 through 2015.16 These countries were chosen as it is easier to interpret the data from stable economies. Most caries lesions remain untreated regardless of national income categories. For example, it has been reported that the d component constitutes 100% of dft (dmft) index in Finland, Greece, Japan and Philippines. It was considered critical to gather more solid information on caries experience in the primary dentition, especially in low- and middle-income countries, as there were only 6 countries: Uganda, Syrian Arab Republic, Mexico, Sri Lanka, Malaysia and Philippines in these categories where the data were available. To assist, it was recommended that subnational surveys of young chil￾dren should be carried out using the WHO Oral Health Survey Basic Methods which also include important guidances for risk factor analy￾sis that should be applied to preschool children. The impact of ECC on the child, the family and society is not fully portrayed by the epidemiological statistics given in Table 1. Self-reported information is required, because ECC causes pain and difficulty in speaking and eating, and may lead to underweight and stunting.17,18 ECC has adverse effects on the quality of life of chil￾dren, family and caregivers, regardless of social groups.19 In addition, ECC has substantial resource implications. Treatment under general anaesthesia for extensive dental repair/restoration is usually carried out in hospital and is time-consuming and costly. The experience can also be traumatic for both the child and the family.20,21 It is worth noting that caries severity in primary teeth is a predictor for caries experience in the permanent dentition.22 ECC is not only a problem for children and their families but also a public burden and a threat globally, and therefore, public health approaches are required to tackle ECC.3 4 | PREVENTION AND CONTROL OF ECC 4.1 | Risk factors The primary risk factor for ECC is undoubtedly exposure to sugars through the diet. There is, however, evidence of varying quantity and quality to suggest that the factors shown in Table 2 are related to ECC, although some risk factors appear to be much more impor￾tant than others, and there may be interactions among them. Fisher￾Owens et al23 used a multilevel conceptual model to explain how risk factors can apply at 3 different levels: the child, the family and the community. At the child level, these could include genetic, bio￾logical, health behaviours and practice, and physical and demographic attributes; at the family level: socioeconomic status, family composi￾tion, and health status, and practice behaviours of families; and at the community level: culture, social environment and social capital, and community oral health environment such as accessibility to fluo￾ridation and to the healthcare system. For ECC prevention, the majority of the emphasis was placed on the amount of consumption of free sugars and the frequency with which they are consumed, infant feeding practices, poor removal of dental plaque and the low availability of fluoride. Reasons for these caries-inducing behaviours lie in the family—their own experiences, circumstances and lifestyles. However, the family (or caregivers) are subjected to strong cultural, economic and marketing influences which shape beliefs, attitudes and behaviours. The lack of the use of fluoride is an important environmental factor for ECC.24 Some fac￾tors were conceived as being nonmodifiable risks (e.g genetic profile, salivary components) and were not considered further. More empha￾sis was given to “modifiable” risk factors as they could lead to rec￾ommendations or policies for changes in practice. Specific reviews were presented on infant feeding practices and social and beha￾vioural determinants. 4.1.1 | Infant feeding and diet of the young child Breastfeeding is the natural way of providing young infants with the nutrients they need for healthy growth and development. Virtually, all mothers can breastfeed, provided they have accurate information and the support of their family, the healthcare system and society at large. WHO recommends exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding with appropri￾ate complementary feeding for up to 2 years or beyond.25 The great importance of breastfeeding for the health of the child and mother is acknowledged.26 Breastfeeding in infancy may protect against dental caries.27 Further research is needed to understand the reported higher risk of caries in children breastfed after 12 months. Tham et al27 suggested a 2-3 times greater risk of dental caries if breastfeeding is frequent and/or nocturnal after 12 months. How￾ever, this observation was based on a meta-analysis in which some of the included studies had not controlled for confounding factors. The protective effect may be confounded by high and frequent con￾sumption of free sugars in children after the age of 12 months. In particular, cohort studies with adequate control for confounding fac￾tors (including intake of free sugars in complementary foods and drinks) are required. Discontinuation of breastfeeding or replacement of breastfeeding by infant formula is not recommended. Free sugars in drinks and foods play a major role in the develop￾ment of dental caries and other chronic diseases. The WHO pub￾lished a Guideline on Sugars Intake for Adults and Children in 2015, which includes a strong recommendation that the intake of free sug￾ars is reduced in both children and adults.28 The WHO guideline is based on systematic reviews of the evidence pertaining to the intake of sugars and risk of overweight and obesity and the risk of dental caries. The evidence for an association between intake of free sugars and dental caries was provided primarily from epidemiological stud￾ies of children which demonstrated a positive association between amount of free sugars consumption and dental caries. The Guideline recommends that children and adults reduce their daily intake of 282 | PHANTUMVANIT ET AL

PHANTUMVANIT ET AL WILEY TABLE 1 Percentage of children with one or more treated/untreated caries lesions and mean number of dft/ dmft among children"in countries where the income category did not change from 1999 to 2015 eated/untreated Income category Mean dft (dmft) d (% f(% AFRO 2002 82 Low income AFRO Uganda A34555234 793 65 Lower middle income EMRo Syrian Arab Republic 2009 61 Lower middle SEARo Sri Lanka 2002-200365 3.5 1999 Lower middle WPRo Philippines 1999 85 74 3010 1001 Lower middle income WPRo Philippines 990 Lower middle income WPRo 2011 Upper middle income PAHo Mexico 2008 4.2 5 Upper middle income WPRo Malaysia 52005 High income High income EMRo Kuwait 52004 686 8813 High income EMRo United Arab Emirates 2001-20028 Denmark 2014 High income EURO Finland 2009 0.3 100 EURO High income 34 High income EURo Ireland(fluori 5552455545 2001-200237 8 High income EURO Ireland(non-fluoridated 2001-200255 High income URO 20 的23 08 18 High income EURO Italy 2012 EURO Norway High income EURO Sweden 3 High income EURo Switzerland 2003 EURO United Kingdom 31 (England, Wales and NI) High income PAHO Bahamas 5 1999-200058 24 High income PAHO Canada(Ontario) 2006 WPRO 2003-2004 High income WPRO Australia 5 2009 1.8 6128 High income 2012 WPRO Japan 3 2011 0.6 High income WPRo New zealand 2-42009 High income WPRo New Zealand 2013 High income VPRO 2005 High income Children under the age of six. WHO region AFRO: African region, EMRO: Easter Mediterranean region, EURO: Euro region, PAHO: American region SearO:SouthEastregionWpro;WesternPacificregionDatafromhttps://www.mahse/capp/country-oral-health-profiles/according-to-wHo-rE gions/. Accessed March 5, 2017. free sugars to <10% of their total energy intake. a further reduction intakes of free sugars threaten the nutrient quality of diets by pro- to below 5% is suggested to protect oral health throughout life and viding substantial energy without specific nutrients. 8 It was recog ovide additional health benefits. moreover. for countries wit ized that controlling free sugars intake has positive influences on low intake of free sugars, levels should not be increased. higher both oral health and general health, through the prevention of

free sugars to <10% of their total energy intake. A further reduction to below 5% is suggested to protect oral health throughout life and provide additional health benefits. Moreover, for countries with a low intake of free sugars, levels should not be increased. Higher intakes of free sugars threaten the nutrient quality of diets by pro￾viding substantial energy without specific nutrients.28 It was recog￾nized that controlling free sugars intake has positive influences on both oral health and general health, through the prevention of TABLE 1 Percentage of childrena with one or more treated/untreated caries lesions and mean number of dft/dmft among childrena in countries where the income category did not change from 1999 to 2015 Income category WHO region Country Age Year Children with one or more treated/untreated caries lesions (%) Mean dft (dmft) d (%) f (%) Low income AFRO Uganda 3 2002 45 1.7 82 4 Low income AFRO Uganda 4 2002 59 2.4 79 3 Low income AFRO Uganda 5 2002 65 3.1 68 4 Lower middle income EMRO Syrian Arab Republic 5 2009 61 3.3 85 12 Lower middle income SEARO Sri Lanka 5 2002-2003 65 3.5 94 3 Lower middle income WPRO Philippines 2 1999 59 4.2 100 0 Lower middle income WPRO Philippines 3 1999 85 7.4 100 1 Lower middle income WPRO Philippines 4 1999 90 8.8 99 0 Lower middle income WPRO Philippines 5 2011 88 5.6 100 0 Upper middle income PAHO Mexico 1-4 2008 – 4.2 95 5 Upper middle income WPRO Malaysia 5 2005 76 5.6 95 4 High income EMRO Kuwait 4 2004 68 3.7 92 8 High income EMRO Kuwait 5 2004 76 4.8 88 13 High income EMRO United Arab Emirates 5 2001-2002 83 5.1 – 6 High income EURO Denmark 5 2014 – 0.4 75 25 High income EURO Finland 5 2009 61 0.3 100 – High income EURO Greece 2-3 2005 – 1.9 100 – High income EURO Greece 4-5 2005 – 3.4 97 – High income EURO Ireland (fluoridated area) 5 2001-2002 37 1.3 85 8 High income EURO Ireland (non-fluoridated area) 5 2001-2002 55 2.2 82 5 High income EURO Israel 5 2007 65 3.3 82 15 High income EURO Italy 4 2004 22 0.8 80 18 High income EURO Italy 5 2012 63 1.4 – – High income EURO Norway 5 2003 36 1.4 – – High income EURO Sweden 3 2011 4 – –– High income EURO Switzerland 2 2003 13 4.3 – – High income EURO United Kingdom (England, Wales and Nl) 5 2013 31 0.9 89 11 High income PAHO Bahamas 5 1999-2000 58 2.4 92 4 High income PAHO Canada (Ontario) 5 2006 – 1.5 – – High income WPRO Australia 4 2003-2004 38 1.7 76 12 High income WPRO Australia 5 2009 42 1.8 61 28 High income WPRO Brunei Darussalam 3 2012 39 2 – – High income WPRO Brunei Darussalam 5 2012 59 3.9 – – High income WPRO Japan 3 2011 25 0.6 100 – High income WPRO New Zealand 2-4 2009 20 0.8 50 38 High income WPRO New Zealand 5 2013 43 1.9 – – High income WPRO Singapore 3-4 2005 26 0.7 86 14 High income WPRO Singapore 4-5 2005 37 1.4 93 7 a Children under the age of six. WHO region AFRO; African region, EMRO; Easter Mediterranean region, EURO; Euro region, PAHO; American region, SEARO; South East region, WPRO; Western Pacific region, Data from https://www.mah.se/CAPP/Country-Oral-Health-Profiles/According-to-WHO-Re gions/. Accessed March 5, 2017. PHANTUMVANIT ET AL. | 283

284 WilEY TABLE 2 Overview of risk factors and underlying determinants of prevention of ECc were considered in more detail. These included fluoride delivered through either water, salt or milk, fluoridated gars added to baby bottles toothpaste and intra-oral topical fluoride application. 24 Exposure to optimum fluoride concentration in drinking water from birth not only Nonuse and nonavailability of fluoridated toothpaste pro- Social determinants: family culture and environment vides some pre-eruptive effect for the permanent teeth. 35-38 Where salt is used as a vehicle for fluoride. the who guideline on sodium Intake must be considered. 9 Salt intake at a country level should be monitored so that adjustments can be made if required, the levels of Nutritional status of mother and infant fluoride in the salt, to ensure that the population is receiving opti- Oral flora mum levels of exposure to fluoride. Poor oral hygiene and control of dental plaque Evidence is available that, for children younger than 6 years, the Breastfeeding-beyond 12 months, especially if frequent and/or use of fluoridated toothpaste is effective in caries control. How ever, ingesting excessive amounts can lead to mild fluorosis. To mini- Saliva--quantity(reduced flow) and constituents (particularly variations mize the risk of enamel fluorosis in children while maximizing the caries-prevention benefit for all oups, the appropriate amount should be used by all children guidance on the use of fluoridated nondesirable weight gain, obesity and associated noncommunicable toothpaste for young children differs from country to country. the diseases(NCDs). worldwide obesity has more than doubled since greatest variations are found in the age at which its use shoul 1980, and 41 million children under the age of 5 years were reported begin recommendations on the concentration of fluoride that should as being overweight or obese in 2014.- Oral health promotion should be used, and in the amount of toothpaste placed on the brush For herefore be integrated with general health promotion through a com- example it is recommended that parents should brush their chil- mon risk factor approach o Specific issues with the consumption of dren s teeth twice daily using a"smear"or"rice-size"amount of fluo- free sugars by infants and young children were recognized. the first ridated toothpaste (0. 1 mg f) for children aged 3 years and under was the addition of free sugars to feeding bottles. this habit was wide. and a"pea-size"amount of fluoridated toothpaste(0.25 mg F)for spread but unnecessary in many cultures and regions. the second children aged 3-6 years. 1 42 Variation in guidance can be expected issue related to the high level of consumption of free-sugars-contain- where background exposure to other forms of fluoride differs among ing drinks and foods (including complementary foods), which is the target population groups." However the universal use of encouraged by aggressive product marketing. Consequently, compre- affordable toothpastes, containing the optimum concentration of flu- hensive programmes in health and oral health promotion that promote oride for the community and having regard for the age of the child the intake of healthier foods and diets and avoid early introduction of free sugars and consumption of sugar-sweetened beverages and high Ithough other self-applied fluorides (such as mouth rinses)are sugars foods, are essential. advocacy initiatives are important to stim effective for dental caries prevention, they are usually not recom include the adjustment of agricultural policies that lead to less sugars varnishes, gels and foams can be professionally applied according to production and more sustainable crops; appropriate and context the child s individual risk. specific nutrition information and guidelines for children which are developed and disseminated in a simple understandable and accessi- 4.1.3 The parents/ caregivers and their ble manner to all target groups in society: the implementation of an environment effective tax on sugar-sweetened beverages and high sugars foods the implementation of recommendations for the marketing of foods Although sugars intake poor oral hygiene and inadequate use of flu- and nonalcoholic beverages to children to reduce their exposure to oride are rightly given prominence as primary risk factors, reasons the power of, the marketing of less healthy foods the development of for these unfavourable behaviours need to be understood if prever nutrient profiles to identify less healthy and beverages; the establish- tive strategies are to be successful. a review of these aspects of ment of global cooperation to reduce the impact of cross-border mar- ECc risk has been published by Seow et al 3. they reported that the keting of unhealthy foods and beverages; and the implementation of a rates of ecc are highest among the socially disadvantaged groups standardized global nutrient labelling system. and indigenous and ethnic minorities. For example, there is an asso- ciation between low levels of education and low family incomes with 4.1.2 Optimum exposure to fluoride a high prevalence of ECC. The adoption of durable health habits in childhood begins at te use of fluoride for the prevention of dental caries home with the parents/ caregivers, especially the mother, as she has been a major dental public health strategy Methods of plays an important role in forming the child s oral health behaviours. delivering fluoride are well known, and those appropriate for the Therefore, parents/caregivers should be informed that their own

nondesirable weight gain, obesity and associated noncommunicable diseases (NCDs). Worldwide obesity has more than doubled since 1980, and 41 million children under the age of 5 years were reported as being overweight or obese in 2014.29 Oral health promotion should therefore be integrated with general health promotion through a com￾mon risk factor approach.30 Specific issues with the consumption of free sugars by infants and young children were recognized. The first was the addition of free sugars to feeding bottles. This habit was wide￾spread but unnecessary in many cultures and regions. The second issue related to the high level of consumption of free-sugars-contain￾ing drinks and foods (including complementary foods), which is encouraged by aggressive product marketing. Consequently, compre￾hensive programmes in health and oral health promotion that promote the intake of healthier foods and diets and avoid early introduction of free sugars and consumption of sugar-sweetened beverages and high sugars foods, are essential. Advocacy initiatives are important to stim￾ulate relevant political action. Comprehensive programmes may include the adjustment of agricultural policies that lead to less sugars production and more sustainable crops;31 appropriate and context￾specific nutrition information and guidelines for children, which are developed and disseminated in a simple, understandable and accessi￾ble manner to all target groups in society; the implementation of an effective tax on sugar-sweetened beverages and high sugars foods; the implementation of recommendations for the marketing of foods and nonalcoholic beverages to children to reduce their exposure to the power of, the marketing of less healthy foods; the development of nutrient profiles to identify less healthy and beverages; the establish￾ment of global cooperation to reduce the impact of cross-border mar￾keting of unhealthy foods and beverages; and the implementation of a standardized global nutrient labelling system.32 4.1.2 | Optimum exposure to fluoride The appropriate use of fluoride for the prevention of dental caries has been a major dental public health strategy.33,34 Methods of delivering fluoride are well known, and those appropriate for the prevention of ECC were considered in more detail. These included fluoride delivered through either water, salt or milk, fluoridated toothpaste and intra-oral topical fluoride application.24 Exposure to optimum fluoride concentration in drinking water from birth not only benefits the primary dentition, helping to control ECC, but also pro￾vides some pre-eruptive effect for the permanent teeth.35-38 Where salt is used as a vehicle for fluoride, the WHO Guideline on Sodium Intake must be considered.39 Salt intake at a country level should be monitored so that adjustments can be made if required, the levels of fluoride in the salt, to ensure that the population is receiving opti￾mum levels of exposure to fluoride. Evidence is available that, for children younger than 6 years, the use of fluoridated toothpaste is effective in caries control.40 How￾ever, ingesting excessive amounts can lead to mild fluorosis. To mini￾mize the risk of enamel fluorosis in children while maximizing the caries-prevention benefit for all age groups, the appropriate amount should be used by all children. Guidance on the use of fluoridated toothpaste for young children differs from country to country. The greatest variations are found in the age at which its use should begin, recommendations on the concentration of fluoride that should be used, and in the amount of toothpaste placed on the brush. For example, it is recommended that parents should brush their chil￾dren’s teeth twice daily using a “smear” or “rice-size” amount of fluo￾ridated toothpaste (0.1 mg F) for children aged 3 years and under and a “pea-size” amount of fluoridated toothpaste (0.25 mg F) for children aged 3-6 years.41,42 Variation in guidance can be expected where background exposure to other forms of fluoride differs among the target population groups.24 However, the universal use of affordable toothpastes, containing the optimum concentration of flu￾oride for the community and having regard for the age of the child, is an essential public health goal. Although other self-applied fluorides (such as mouth rinses) are effective for dental caries prevention, they are usually not recom￾mended for use by children younger than 6 years of age. Fluoride varnishes, gels and foams can be professionally applied according to the child’s individual risk. 4.1.3 | The parents/caregivers and their environment Although sugars intake, poor oral hygiene and inadequate use of flu￾oride are rightly given prominence as primary risk factors, reasons for these unfavourable behaviours need to be understood if preven￾tive strategies are to be successful. A review of these aspects of ECC risk has been published by Seow et al43; they reported that the rates of ECC are highest among the socially disadvantaged groups and indigenous and ethnic minorities. For example, there is an asso￾ciation between low levels of education and low family incomes with a high prevalence of ECC.43 The adoption of durable health habits in childhood begins at home with the parents/caregivers, especially the mother, as she plays an important role in forming the child’s oral health behaviours. Therefore, parents/caregivers should be informed that their own TABLE 2 Overview of risk factors and underlying determinants of ECC Free sugars added to baby bottles Free sugars in foods and drinks Nonuse and nonavailability of fluoridated toothpaste Social determinants: family, culture and environment Genetic susceptibility Hypoplasia of enamel Nutritional status of mother and infant Oral flora Poor oral hygiene and control of dental plaque Breastfeeding—beyond 12 months, especially if frequent and/or nocturnal Saliva—quantity (reduced flow) and constituents (particularly variations in proteins present) 284 | PHANTUMVANIT ET AL