DOI: 10.1111/ipd.

12094

Effectiveness of an oral health program for mothers and their

infants

PATR
ICIA B. V. MEDEIROS1, SIMONE A. M. OTERO1, JO E. FRENCKEN2, EWALD M.

BRONKHORST3 & SORAYA C. LEAL1
1
Department of Dentistry, Faculty of Health Sciences, University of Brası́lia, Brası́lia, Brazil, 2Department of Global Oral
Health, College of Dental Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands, and
3
Department of Preventive and Restorative Dentistry, Radboud University Nijmegen Medical Centre, Nijmegen,
the Netherlands

International Journal of Paediatric Dentistry 2015; 25: 29–34 and multivariate logistic regression were used in
analyzing data.
Background. The baby oral health program Results. Statistically significant differences were
(bOHP) provides pregnant women and their observed in the mean age of mothers
future babies with oral care. (G1 = 33.8 years; G2 = 35.6 years; P = 0.015) and
Aim. To assess the bOHP effectiveness by compar- mean decayed, missed and filled surface (DMFS)
ing caries prevalence in infants enrolled and not score (G1 = 24.71; G2 = 32.58; P < 0.001), not in
enrolled in the oral health program (OHP). SES (P = 0.758) and EL (P = 0.109). Mean age
Design. Mothers who had been invited to partici- and mean dmfs scores of G1 and G2 children were
pate in the bOHP from 2006 to 2009 were con- 4.2 and 4.4 years (P = 0.068), and 0.25 and 4.12
tacted. Two groups were formed: 87 pairs of (P < 0.001), respectively. The odds ratio (OR) for
mothers and infants who effectively participated children in G2 to develop dentine lesions, as
in the OHP (G1) and 107 pairs who did not (G2). opposed to those in G1, was 48.56.
Mothers and infants were given a dental examina- Conclusion. The bOHP was effective in preventing
tion. Socio-economic status (SES) and education caries in infants enrolled in the program.
level (EL) questionnaires were completed. t-tests

their families4,5. Low socio-economic status

Introduction
and level of education of mothers increase the
Dental caries, despite being largely preventable, chance that a child will develop ECC6,7. There-
is the most prevalent childhood disease1 and fore, especially in these situations, all efforts
instead of decreasing, its incidence in children should be made to prevent ECC occurrence.
aged 2–4 years is rising beyond the targeted The strategies currently implemented for con-
11% proposed by Healthy People 20102. In Bra- trolling the disease, however, do not seem to
zil, the 2010 epidemiological oral health survey be effective. Previous studies have highlighted
showed that <50% of 5-year-old children were the importance of including the whole family
free of cavitated dentine carious lesions and in oral health preventive strategies directed
80% of these lesions were untreated3. toward the child8,9. Concentrating attention
The first signs of dental caries in an infant only on the child’s oral health is inadequate8.
might occur in the first erupting tooth. This Some publications have shown the great
situation is termed early childhood caries potential for educational programs addressed
(ECC). It progresses rapidly. If left untreated, it toward pregnant women, through anticipatory
can lead to pain, which can negatively affect a guidance and motivational interviewing, in
child’s behavior, and can have a negative preventing ECC in their children10,11. More-
impact on the quality of life of children and over, providing guidance to mothers during
their pregnancy resulted in a long-term effect
of maintaining a low level of caries prevalence
Correspondence to:
in their children12. Simple strategies, such as
Prof Soraya C. Leal, Campus Darcy Ribeiro, Departamento
de Odontologia, Faculdade de Ciências da Saúde questioning mothers about their own oral
Universidade de Brası́lia, Asa Norte, Brası́lia-DF, CEP health, can help a dentist in identifying chil-
70710-900, Brazil. E-mail: [email protected] dren most at risk of ECC13. Assessment of

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 29
30 P. B. V. Medeiros et al.

strategies combining oral health programs by telephone and invited to come with their
addressed toward mothers having low educa- children to the dental clinic for a check-up.
tion levels during pregnancy and with regular One hundred and seventy-seven women
preventive oral visits for their infants during agreed to participate, signing the informed
the first years of life, however, has not been consent. They were allocated to two groups:
available. Therefore, this study aimed to assess G1 – pairs of mothers and infants who had
the effectiveness of an oral health program participated in the bOHP after their infants
combining oral health education for pregnant were born, visiting the clinic at least once per
women and provision of oral care for their year, and G2 – mothers who did not return to
infants at regular intervals, up to the age of the bOHP after delivering or came only once
5 years, to prevent the occurrence of ECC. (Fig. 1). The research protocol was approved
by the local ethical committee and the study
conforms to the STROBE guidelines.
Materials and methods

Oral health program Calibration

From 2006 to 2009, 240 pregnant women, Two trained and calibrated examiners per-
who would deliver at the University of Bras
ılia formed the oral examination for mothers and
Hospital, were invited to participate in an oral children at the paediatric dental clinic of the
health program (OHP) aimed at providing University of Bras
ılia Hospital. The Caries
women with information about good oral Assessment Spectrum and Treatment (CAST)
hygiene behavior and to offer them and their instrument was used in assessing their caries
infant’s oral care. Of these, 194 signed the status13. The training was conducted as fol-
informed consent form and were effectively lows: 1 day of theory and 3 days of calibrat-
enrolled in the OHP. During pregnancy, moth- ing examiners, using a number of children
ers received all necessary dental care and were and adults of ages comparable with those of
taught about good oral health habits and participants in the OHP. During both CAST
caries-avoidance diets, not only for themselves training and calibration, examiners were
but also for their future babies. The number of supervised by a senior epidemiologist. They
visits depended on individual treatment needs, were also trained and calibrated in using the
so they were not the same for all the pregnant visible plaque and gingival bleeding index.
women. At their final visit before delivering,
mothers were told to return with their infants Oral examination and data collection
when they were 3 months old. Another
Mothers and children were both submitted to
appointment was then scheduled after every
the following sequence of examinations:
3 months. From this moment onward, the
OHP was focused on maintaining the oral 240 pregnant

health of the infant. During the visits, mothers

46 pregnant were not
were taught about (a) diet – sugar consump- interested in the OHP

tion and breast and bottle feeding; (b) oral

hygiene – how to clean the mouths of the 194 pregnant + 194 babies enrolled in
the OHP
infants and when to start using a toothbrush
and toothpaste; and (c) non-nutritive sucking
17 lost of follow-up
habits. The infants were given an oral exami-
nation and, where appropriate, fluoride ther-
177 women + 177 children
apy and/or ART restorations were provided. reassessed in 2011

Participant selection
87 who participated in the 90 who did not participate
OHP (G1) in the OHP (G2)
In 2011, all 194 women, who had participated
in the OHP from 2006 to 2009, were contacted Figure 1. Study flow diagram.

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 OHP effectiveness 31

anamnesis, toothache assessment, visible pla- G2 are presented in Table 1. No statistically

que index14, gingival bleeding index15, and significant differences were observed between
caries diagnosis according to the CAST instru- the two groups in relation to level of educa-
ment. After the assessment of visible plaque tion and socio-economic status, and nor was
and gingival bleeding, each participant had observed regarding the age of the children
his/her teeth brushed by the examiner. Ten from both groups. A statistically significant
percent of the sample was re-examined difference was observed for the age of the
2 weeks later for intra- and inter-examiner mothers of the two groups (P = 0.015). Moth-
consistency. ers from G1 were younger, on average 1 year
In addition, mothers completed a question- and 9 months, than the mothers from G2.
naire from which socio-economic data were The mean DMFS score of G1 mothers was
retrieved, based on the principles proposed by 24.71 (SD = 12.31) and of the G2 mothers
Graciano and Lehfeld 16. In terms of income, was 32.58 (SD = 13.41). This difference was
4 categories were identified and regarding statistically significant (P < 0.001).
mother’s level of education, 3 groups were
formed.
Effectiveness of the OHP
The effectiveness of the program was mea-
Reliability of data collection
sured according to the caries prevalence in
Intra-examiner consistency results (к) in diag- the children. The mean dmfs scores for chil-
nosing carious lesions for primary and perma- dren from G1 and G2 were 0.25 (SD = 0.93)
nent dentition were 0.61 and 0.89 for and 4.12 (SD = 6.56), respectively, being sta-
examiner 1 and 0.87 and 0.91 for examiner tistically significantly different (P < 0.01).
2, respectively. The kappa coefficient value Children from G1 had attended the program
for inter-examiner consistency for primary on average 2.8 times a year. Analyses showed
dentition was 0.74 and for permanent denti- that no child belonging to the G1 had
tion it was 0.87, showing a high level of reported toothache or had a tooth extracted
agreement. due to caries. This was not observed for chil-

Table 1. Socio-demographic characteristics of the sample.

Statistical analysis
Data were analyzed, using the statistical pack- G1 G2

age IBM SPSS (version 20.0 for Windows, Group Mean SD Mean SD P-values
Armonk, NY, USA), by an oral statistician. To
test the differences between the two groups, Mother age (years) 33.8 5.3 35.6 4.1 0.015
Child age (years) 4.2 0.8 4.4 0.8 0.068
Student’s t-test was used for scale variables
and the chi-square test for nominal variables. Score N N Total
A multiple logistic regression was applied to
identify which variables influenced the pres- Education level* 0 20 10 30
ence of cavitated dentine lesions. CAST scores 1 59 72 131
2 8 8 16
were converted into decayed, missed and Total 87 90 177
filled surface (DMFS)/dmfs for calculating SES† 0 1 0 1
mothers’ and infants’ caries prevalence, 1 35 36 71
2 50 54 104
respectively. 3 1 0 1
Total 87 90 177

Results
*0, elementary school complete; 1, high school complete; and 2,
college degree.
†
Background variables SES: 0, < the Brazilian minimum wage; 1, 1–2 times the Brazilian
minimum wage; 2, 2–5 Brazilian minimum wage; and 3, > then 5
Socio-demographic characteristics of the pairs Brazilian minimum wage (the Brazilian minimum wage =
of mothers and children from both G1 and R$ 678.00 = US$ 301.33 = € 226.00).

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
32 P. B. V. Medeiros et al.

dren in G2. Only 8 children of the G1 had Table 3. Results of multiple logistic regression between
variables that were associated with the presence of
developed a cavitated dentine lesion, whereas cavitated lesions in the children.
73 of G2 children presented such condition
(Table 2). Caries-related variables P-values OR 95% CI
A multiple logistic regression model was
Child belong to G2 <0.001 48.56 17.17–137.35
applied, to estimate the effect in children Child’s age (years) 0.016 1.063 1.011–1.118
belonging to G2, as opposed to those belong- Mother’s age (years) 0.133 1.007 0.998–1.017
ing to G1, while correcting for difference in Mother’s mean DMFS score 0.222 1.026 0.984–1.070
age (child and mother) and mean DMFS
OR, odds ratio; 95% CI, 95% confidence interval; P, probability
score (mother). Presence versus absence of value.
cavitated dentine lesions was the dependent
variable. The results of this analysis are pre- whole family and community members, as
sented in Table 3. After correction for the suggested by Weintraub et al.9
background variables, the effect of being in Perhaps the best way to start discussing ECC
G2 as opposed to G1 remained significant, would be by questioning the dental commu-
with an OR of 48 for the chance of develop- nity about why there are still so many chil-
ing cavitated dentine lesions in children from dren affected by ECC when we know how to
G2. Of the background variables, only the age prevent it and avoid its clinical signs. ECC
of the child had a significant influence. For mainly occurs among children in developing
each month that a child was older, the countries17 and among economically disad-
chance of having a cavitated dentine lesion vantaged children in developed countries6,18.
increased by approximately 6%. It is considered an important oral health prob-
lem leading to serious short-term (e.g., pain
and disturbed sleep) and long-term (e.g.,
Discussion
increased treatment costs and parental time)
It is common knowledge that a randomised adverse effects if left untreated19. Therefore,
clinical trial (RCT) is the best study design for there is a need for the development of preven-
testing a therapy protocol. Therefore, some tive strategies that can control the disease,
might argue that the findings of the present especially in these vulnerable populations. For
investigation might not offer a high level of this reason, the present study evaluated the
evidence, as it was not planned to be a RCT. effectiveness of an oral health preventive pro-
It is important to state that the aim of this gram that was implemented with the aim of
study was, however, to evaluate the OHP avoiding ECC occurrence through treating
effectiveness and not a specific intervention. mothers from low social circumstances, edu-
In addition, it would have been unethical to cating them and offering regular dental care
involve just some of the pregnant women in for themselves and their children.
the program, as all of them presented with In this OHP, which is ongoing, women who
similar needs. It would have been ideal if the deliver at the university hospital are invited
OHP, besides involving the infant and to come for a dental visit and, while receiving
mother, could have also been extended to the dental treatment, are given instructions on
how to deal with the oral health of their
Table 2. Number of infants who had a tooth extracted due infants. After delivery, the child is immedi-
to caries had a complaint of toothache and presented a
cavitated dentine lesion according to the two groups. ately enrolled in the program and is followed-
up until the age of 5 years. The program has
G1 G2 Total P-values been shown to be very effective in preventing
cavitated dentine lesions but analysis of the
Extraction due to caries No 87 88 175 0.615
Yes 0 2 2 number of pregnant women initially enrolled
Toothache No 87 63 150 <0.001 in the program identified an unexpected out-
Yes 0 27 27 come. Although the services were provided
Cavitated dentine lesion 0 8 73 81 <0.001
>1 79 17 96 free of charge, less than half of the 194 preg-
nant women who received dental treatment

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 OHP effectiveness 33

between 2006 and 2009 returned, showing counseling of mothers and regular infant den-
that the program was not effective in moti- tal visits. A program in which motivational
vating mothers sufficiently. Possible explana- interviewing and counseling was delivered to
tions for the low attendance might be related mothers during pregnancy provided prelimin-
to social determinants. In a survey conducted ary evidence that this kind of approach has an
in the USA, mothers reported that the need impact on caries reduction in children11.
to arrange free transportation for visiting a Although all mothers in the present study
dentist is a barrier for those who do not own were instructed about good oral health
a car20. In the present study, although this measures during their pregnancy, this guid-
aspect was not assessed, it was also a probable ance per se was insufficient for prevention of
barrier, as most of the mothers lived in satel- cavitated dentine lesions development, espe-
lite cities, on average 35 km away from the cially in children from G2. This shows the
dental clinic, and did not own a car. importance of regular dental visits for routine
The present study showed that both groups check-ups in preventing the occurrence of
were composed of women with similar socio- ECC. The present study is in line with
economic and education levels. Most of the others9,24, which recommended that dentists
mothers were classified as poor and having a should motivate and encourage mothers to
low level of education; characteristics that are attend caries prevention and dental service uti-
known to be associated with caries prevalence lization programs to prevent early childhood
in children21. Women from the two groups, caries development in their children. In con-
however, differed in two aspects: age and clusion, the oral health program was shown to
mean DMFS scores. Mothers from G1, who be effective in preventing cavitated dentine
attended the OHP, were slightly younger than lesions in those children who attended the pro-
the mothers from G2, and they also presented gram at least once a year from a very early age.
a lower mean DMFS score. The fact that the
women with higher caries experience were
those who decided not to attend the bOHP Why this paper is important to paediatric dentists
might be related to their views regarding the • It shows that counseling of mothers and regular infant
importance of oral health. As shown previ- dental visits can be effective in preventing the early
childhood caries.
ously, clinical indicators such as caries experi- • This paper shows the importance of regular dental vis-
ence have little influence on self-perceptions its for routine check-ups in preventing early childhood
of oral health and quality of life22. According caries.
• This study supports the idea that dentists should moti-
to Camargo et al.23, in addition to income and
vate mothers to attend caries prevention and dental
education, maternal behavior plays an impor- service utilization programs to prevent early childhood
tant role in routine dental visits for children. caries in their children.
As caries prevalence in children and conse-
quences of untreated dental caries were the
parameters for the bOHP effectiveness, the Acknowledgements
results indicate that the bOHP was extremely
successful. Just a few children, <10%, from We express our appreciation to the University
G1 developed cavitated dentine lesions. None Hospital staff and to the families that partici-
of them had toothache or had a tooth pated in the bOHP. We thank Ana Luiza de
extracted due to dental caries. These results Souza for examining mothers and children
are in line with those from Plutzer et al.10, in and FINATEC for supporting the presentation
which an oral health program based on of the results of this work at the ORCA con-
repeated rounds of anticipatory guidance, ini- ference, 2013.
tiated during the pregnancy, was successful in
reducing the incidence of severe ECC in very Conflict of interest
young children.
The success of the program can be regarded The authors declare no potential conflict of
as a reflection of an association between interest.

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
34 P. B. V. Medeiros et al.

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