More than clean teeth! Identifying factors that contribute to the development of early childhood caries

The updated systematic review by Khan et al. reviews the evidence surrounding the possible factors that could contribute to the development of early childhood caries (ECC) in children of a particular age group. This follows a previously published systematic review across 1997-2017. These factors can then be used for the development of a Caries Risk Assessment (CRA) tool.

This review aimed to identify established and updated evidence-based factors that could contribute to a child's development of Early Childhood Caries (ECC). Four online databases were used to source evidence including the Cochrane Library, EMBASE, MEDLINE, and Scopus.

The data search selected studies published between 2017 and 2021. Three specific terms were used to search: Dental Caries, Children, and Risk Assessment. There were three teams involved in data collection, two teams then reviewed selected articles. Exclusion criteria included any duplicate studies, commentaries, and editorials. Inclusion criteria included only randomised control trials and cohort studies. Selected studies must include children younger than 72 months, define the demographics, their clinical characteristics, and have clear follow-up of the patients involved. Commonly identified factors that were mentioned in multiple studies were then collected and assigned strength depending on the evidence measured using ratios. These could then be utilised to form a draft Caries Risk Assessment tool.

512 abstracts and 52 articles were screened, having matched the criteria set. Extraction of the data was completed under four headings: the child's age at the time of study (in years/months), risk predictors, the outcome, and the quality of the evidence presented. The GRADE system was then employed to separate the studies into high, moderate, low, and very low categorisation. Eventually, 22 new studies were included that would build on the original 25 articles that were identified in the previous systematic review.

The most defining factors across the most recent systematic reviews in 2021 highlighted behavioural factors such as toothbrushing quality - parental supervision, frequency, and fluoride exposure. Specifically, the presence of plaque was used as a marker for oral hygiene evaluation. Dietary history included snacking frequency and, controversially, baby-toddler breastfeeding patterns. However, this does not take into consideration the dental impact - mainly the frequency or timing of breastfeeding (e.g. overnight). The review emphasises the importance of consideration of socio-economic factors though this may be a difficult topic of discussion if families are struggling i.e. household income and education level of parents or guardians. There is also mention of factors that do not have a significant evidence base such as the child's gender, ethnicity, and parental smoking status.

In conclusion, the factors found to be relevant in the development of ECC were the child's age, toothbrushing quality/plaque control, parental involvement in toothbrushing, fluoride exposure, pattern of dental attendance, dietary sugar exposure, and habits, clinically carious active lesion presence, the oral bacterial composition (Streptococcus mutans presence) and the socio-economic status of the child and their family. Though the review encourages identification of the caries risk factors in the mentioned groups, separated by both dental and non-dental professionals, ideally the aim would be to create a holistic care approach for management and signposting.