Understanding Early Childhood Caries (ECC) and Its Global Impact

Early childhood caries (ECC) is recognized as one of the most widespread diseases affecting children globally, particularly in low-income and middle-income countries.^1,2 According to the Fourth Chinese National Oral Health Survey conducted in 2015, an alarming 71.9% of 5-year-old children were afflicted by dental caries, with a staggering 95.9% of these cases remaining untreated.³ The consequences of ECC include significant pain and challenges with chewing, which can ultimately result in malnutrition, gastrointestinal disorders, sleep disruptions, and hindered social interactions.⁴ Numerous factors contribute to the high incidence of ECC, including a high consumption of sugary foods that interact with the salivary bacterium Streptococcus mutans,⁵ inadequate oral hygiene practices, limited access to dental care, lower family income, and various sociobehavioral risk factors.⁶ However, several comprehensive interventions can be employed to combat ECC. Public health initiatives, such as educating parents about dental health, promoting positive oral health behaviors among parents, increasing accessibility to dental services, and fostering interdisciplinary cooperation, are critical to addressing the common risk factors associated with ECC.^7–10 A notable example is the Childsmile intervention program, funded by the Scottish government, which successfully provided tailored oral health support to infants and their families from the earliest stages of life, resulting in decreased prevalence and morbidity related to dental decay across all socioeconomic strata.¹¹ Furthermore, research conducted in Hong Kong suggests that parents equipped with oral health knowledge can effectively prevent ECC among preschool children.¹² By implementing multidisciplinary strategies, including dental care practices by primary care workers, we can significantly enhance caries prevention and control for young children.^13,14 Understanding the factors influencing the adoption of preventive dental procedures in primary care settings is essential for improving dental care delivery.^15,16 Identifying the gaps in dental practices among pediatric primary care physicians (PCPs) is crucial for developing effective public health strategies and fostering collaborative efforts aimed at enhancing children’s oral health within the primary care framework.

With approximately 8 million children aged 0 to 4 in China as of 2019,¹⁷ the prevention and management of ECC in this demographic is vital for alleviating the global burden of dental caries. The rapid economic growth in China has led to an increase in sugar consumption and improved living standards,¹⁸ making ECC prevention a formidable challenge. Acknowledging this pressing issue, the Chinese Health Committee has launched the Healthy China Programme and the Healthy Oral Action Plan 2019–2025 to prioritize ECC prevention from an early age.^19,20 The Action Plan sets a goal to reduce the prevalence of dental caries from 34.5% in 2016 to 30% by 2025 among 12-year-old children. Additionally, the government has established the National Children’s Oral Disease Comprehensive Intervention Project Work Specifications, mandating that all PCPs involved in these intervention projects receive training and obtain a medical license.^21,22 Regular monitoring by the government ensures the effectiveness of these interventions at community health centers, focusing on metrics such as PCPs’ oral health knowledge, dental screening rates, dental caries prevalence, and the fit and sealant rate. Prior to these oral health-targeted programs, a systematic health management program was implemented as an integral part of the National Public Health Services for all children under six years old in primary care settings.²³ According to the National Standard for Basic Public Health Services for Children, pediatric PCPs are required to examine, evaluate, provide appropriate dental advice, and make necessary referrals during health management visits.²³ This project mandates a dental screening rate of 90% for children, with budget allocations for community health centers contingent upon PCPs passing spot checks. In 2018, national coverage for systematic management of children under three reached an impressive 91.2%.²⁴ However, current research has not yet reported on the dental examination behaviors of pediatric PCPs in China. Identifying the actual state of oral care practices will aid in developing targeted promotion strategies.

This study aims to achieve two primary objectives: 1) to assess the extent of dental screening, caries risk assessment (CRA), and referral activities conducted by pediatric PCPs, and 2) to investigate the factors influencing CRA and referral practices for children identified as high caries-risk in western China.

Research Methodology and Ethics Approval

Ethics Approval for the Study

Ethical approval for this study was obtained from the Institutional Review Board of the Stomatology School at Sichuan University (IRB reference number: WCHSIRB-D-2019-013). A written informed consent form was distributed to participants to outline the survey’s content, with each respondent signing an electronic informed consent form.

Demographic Profile of the Study Population

In August 2021, we conducted a cross-sectional survey to gather data regarding CRA and dental referral behaviors among pediatric PCPs in Chengdu, Sichuan Province, China. The survey utilized an electronic structured questionnaire disseminated through a WeChat work group, a widely used multipurpose communication platform in China.²⁵ The Sichuan Maternal and Child Health Academic Association facilitated this process, serving as a professional organization for pediatricians and support staff in daily communications. Given that not all pediatric PCPs were members of the WeChat group, we employed a snowball sampling technique to reach a broader participant base.²⁶ All active pediatric PCPs were invited to participate. To ensure sufficient responses, we distributed the questionnaires twice weekly throughout August 2021. The required sample size was calculated using the formula , where Z corresponds to the standard normal distribution value based on the desired confidence level (Z = 1.96 for 95%), and E represents the desired margin of error (E = 0.5). The value of P that maximizes P(1-P) is set at P = 0.5. Due to the lack of specific data regarding the proportion of pediatric primary care patients receiving dental care, we estimated the maximum sample size using 0.5. In the absence of statistical data for pediatric PCPs, we based our estimation on the number of pediatricians and general physicians. According to the Statistical Yearbook 2018 of the Sichuan Health Commission,²⁷ there were 6467 pediatricians and 2745 general physicians, with 80% considered as primary physicians (N=7370). Thus, the minimum sample size needed for this study was determined to be 366. Prior to initiating the formal survey, we conducted a pilot study with a limited population, involving five pediatric PCPs and two dentists to complete the questionnaire. Their feedback was then utilized to refine the questions for clarity and comprehensibility.

Evaluation of Dental Screening, Caries Risk Assessment, and Referral Practices

We evaluated dental screening activities by asking the question, “Did you check for dental caries in children during systematic health visits?” Participants responded using a Likert scale that included options such as “usual,” “sometimes,” “occasional,” and “never.”

The activities related to CRA were assessed in accordance with the Caries-risk Assessment Form for children aged 0 to 3 years, developed by the American Academy of Pediatric Dentistry (AAPD).²⁸ The following questions were posed to gather information on CRA activities:

1) How often did your child consume sugary foods in the past month? 2) Has your child used fluoride toothpaste recently? 3) Did you take your child for regular dental visits? 4) Does your child sleep with a bottle? 5) Does the child’s mother have any untreated dental caries?

Responses were categorized as “usual,” “sometimes,” “occasional,” or “never.” For analysis, “usual” and “sometimes” were assigned a value of one, while “occasional” and “never” received a value of zero. Consequently, the CRA score could range from 0 to 5, with a cumulative score of 5 indicating complete CRA activities, thereby reducing the potential for social desirability bias.²⁹

Dental referral practices were assessed through the following questions:

Would you refer a child to a dentist in the following scenarios: (1) when the child’s teeth are erupting; (2) when the child is approaching their first birthday; (3) when white spots are observed on the child’s teeth; (4) when the child has dental caries identified during screening; (5) when the child exhibits dentition problems; (6) when the child’s parents indicate that the child sleeps with a bottle; and (7) when the child does not brush their teeth?

Responses of “usual” and “sometimes” were scored as one, while “occasional” and “never” were given a score of zero. Questions (1) and (2) are considered optimal times to establish a dental home,³⁰ while (3), (6), and (7) highlight children at high risk for caries, and (4) and (5) pertain to children with existing caries. A cumulative score of 3 from questions (3), (6), and (7) indicated good dental referral practices for children identified as high caries-risk.

Identification of Covariates Influencing Dental Practices

Previous studies have identified various factors associated with dental screening and referral behaviors among PCPs for children at high risk for caries.^16,31 To account for these variables, we included them as covariates in our analysis. Demographic data encompassed sex (male or female), age categories (18–30 years, 31–40 years, 41–50 years, or 51–60 years), education level (two-year college and below, bachelor’s degree, or master’s degree and above), work experience (20 years), and the number of children served per week (continuous variable). The working environments of the PCPs were classified by the level of their work institution (community health service center, township health center, or well-child department in a hospital), type of institution (public or private), whether they had a dental department within the same facility (yes or no), and whether there was collaboration with another dental clinic (yes or no). Additional data collected included the PCPs’ self-confidence regarding their dental knowledge (ranging from not at all to extremely confident, scored 1–5), whether they had received pediatric dental knowledge training (from dental professionals, pediatric dentists, or self-taught), and their subjective perceptions of difficulties in making dental referrals (from not at all to extremely difficult).

Moreover, an open-ended question was included to gather qualitative insights: “Do you have any comments or suggestions regarding dental health promotion for children?” This aimed to obtain additional perspectives on dental care from the viewpoint of pediatric PCPs.

Statistical Methods Utilized in the Analysis

Chi-squared test statistics were employed to compare differences in demographic characteristics among PCPs engaged in various dental care activities. To analyze the factors associated with both CRA and dental referrals for high caries-risk children, multivariable logistic regression was utilized. The reliability of the questionnaire was assessed using Cronbach’s alpha, while the Kaiser–Meyer–Olkin (KMO) measure was applied to evaluate sampling adequacy prior to conducting multivariable analysis. The open-ended questions provided qualitative data regarding the dental care practices of PCPs, which were synthesized and categorized during analysis.

All data analyses were carried out using SPSS 23.0 (IBM Corporation). A significance level of P < 0.05 was established for the study.

Findings from the Study

A total of 524 questionnaires were collected, of which 504 were retained for analysis. Participants who indicated “not serving any children per week” were excluded from the analysis. Responses deemed illogical, such as selecting “no dental department in the same work facility” while also indicating a preference for such a department, were discarded. To ensure data accuracy, we randomly selected forty-five (9%) participants to verify responses; two provided corrections, and forty-three were confirmed as accurate. The Cronbach’s alpha value of 0.882 indicates high internal consistency within the scale. The KMO measure indicated an excellent value of 0.81, with Bartlett’s test of sphericity yielding a significant value (3735, p =0.000), confirming the adequacy of the sampling process.

Demographic Characteristics of Survey Participants

Of the 504 PCPs who completed the questionnaire, 471 (93.5%) were females (Table 1). The majority of participants (231, 45.8%) fell within the age range of 31–40 years. Additionally, 205 (47.2%) participants held a bachelor’s degree or higher, while 275 (55.5%) had over ten years of professional experience. In terms of workplace distribution, 165 (32.7%) operated within community health centers, 137 (27.2%) worked in township health centers, and 202 (40.1%) were situated in well-child departments of hospitals. On average, each PCP served 119 children per week (SD: 114.1).

Table 1 Chi-Square Analysis of Dental Care Practices Across Different Demographic Groups

Prevalence of Dental Screening, Caries Risk Assessment, and Referral Practices

Among the total sample, nearly all PCPs indicated that they conducted dental screening for children during systematic health management visits (93.8%). A majority of PCPs inquired about children’s bottle-sleeping habits (81.9%) and the frequency of sugary food consumption (79.8%), while fewer PCPs addressed the caries status of the mothers (49%). Only 31.3% of PCPs reported that they “usually or sometimes” performed complete CRA activities. However, an impressive 96.2% of PCPs stated that they usually or sometimes referred children with existing dental caries to dentists. Furthermore, 88.7% of PCPs mentioned referring children with white spots on their teeth to dental professionals, while referrals were less frequent for children who slept with a bottle (58.9%) or had not yet developed a brushing routine (60.7%). Less than half (49.0%) of respondents reported being able to refer all high caries-risk children to dentists (Table 2).

Table 2 Frequency of Dental Screening, Caries Risk Assessment, and Dental Referral for High Caries-Risk Children Among Participants

Identifying Factors Influencing CRA and Referral Practices

Table 3 highlights various factors associated with CRA and dental referral behaviors for children identified as high caries-risk. The data indicate that a higher rate of CRA activities correlates significantly with encountering a greater number of caries during systematic care visits (aOR: 2.37, 95% CI: 1.08–5.18), receiving dental knowledge training from pediatric dentists (aOR: 2.26, 95% CI: 1.36–3.75), and self-education in pediatric dental knowledge (aOR: 2.87, 95% CI: 1.51–5.45).

Table 3 Multivariable Logistic Regression Results: Factors Associated with Caries Risk Assessment and Dental Referral for High Caries-Risk Children

Additionally, a higher rate of referrals for high caries-risk children was associated with having a dental department within the same facility (aOR: 1.72, 95% CI: 1.09–2.70), increased distance from the capital city (aOR: 1.00, 95% CI: 1.00–1.00), and the frequency of encountering caries during well-child visits (aOR: 1.88, 95% CI: 1.01–3.50). Furthermore, dental training by a dentist (aOR: 1.86, 95% CI: 1.15–3.01), pediatric dental knowledge training (aOR: 1.69, 95% CI: 1.04–2.74), and higher confidence in dental knowledge (aOR: 1.29, 95% CI: 1.04–1.61) were also linked to increased referral rates.

Insights from Qualitative Data Analysis

A total of 154 responses to the open-ended questions were analyzed, revealing that most respondents held a positive perspective towards children’s dental care. Common sentiments included:

Feedback on Dental Care Training and Communication

A lack of systematic pediatric dental knowledge hampers my ability to provide accurate information to parents. There is an urgent need for training from dental professionals.

Both online and face-to-face training opportunities should be made available to enhance our professional knowledge of dental care.

Collaboration between physicians and dentists is essential to improve the convenience of dental referrals.

Suggested Improvements in Primary Care Policies

We require more time to engage with parents to enhance their home care practices for their children’s dental health.

Incorporating primary dental care services for children, such as fluoride varnish applications, into the Primary Public Health Care Package would greatly benefit children in remote areas.

Some parents do not prioritize concerns regarding deciduous teeth. There is a pressing need for public education on dental care to dispel misconceptions.

In-Depth Discussion on Findings

The primary finding of this study indicates that while dental screening by pediatric PCPs is effectively implemented, CRA and referral practices for children at high caries risk remain inadequate during systematic health management in western China. An increase in CRA activities and referrals for high caries-risk children correlates positively with dental knowledge training provided by dental professionals to pediatric PCPs. Therefore, enhancing multidisciplinary cooperation between dental professionals and PCPs emerges as a promising strategy to elevate CRA and referral practices among pediatric PCPs.

This study presents several limitations. Firstly, the representativeness of the sample poses a challenge. The respondents were recruited from the Children Health Academic Association of Sichuan Province, which may not accurately reflect conditions across the entire country, particularly given the vast diversity in China, especially within more developed eastern regions. Secondly, participant bias may have occurred due to the online survey’s reliance on the WeChat work group, as individuals who do not regularly check their messages could miss the survey. Additionally, the respondents who participated may already have a heightened interest in oral health, possibly reflecting a bias towards more extensive dental practice. To address potential participant bias, it is essential to incorporate regular administrative monitoring of dental care implementation activities by PCPs during systematic health care. Conducting in-depth interviews with key opinion leaders could provide further insights into the dental care practices of PCPs. Thirdly, the reliance on self-reported dental practice information may introduce social desirability bias and memory bias,³² potentially leading to an overestimation of actual dental activities. Future studies should evaluate the effectiveness of dental implementation on children’s health outcomes, with a focus on the impact of early childhood caries prevention as a key indicator for assessing the dental care activities of PCPs.

Our findings indicate that while dental screening is frequently conducted, CRA and referral activities for high caries-risk children are less common, mirroring trends observed in previous studies. One study in the United States found that nearly all pediatric providers conducted dental screenings, yet only half referred patients at least once during well-child visits.¹⁴ Another study reported an average dental referral rate of 40%.³³ In this study, five questions evaluated CRA behaviors; while many PCPs inquired about sugary food intake and bottle-sleeping habits, fewer addressed the mother’s caries history. The results also demonstrated that most PCPs are inclined to refer children with mild to high caries risk to dentists. These trends may reflect limitations in dental knowledge among PCPs or a shortage of dental workforce,^34,35 leading to a lag in disseminating updated pediatric dental knowledge to PCPs in a timely manner. Subsequent analyses supported this hypothesis, revealing that PCPs who engaged more frequently in dental practices for high caries-risk children were those who received dental knowledge training from pediatric dental professionals, consistent with findings from previous studies.^36,37 Moreover, feedback from open-ended questions indicated that most PCPs favored enhanced training and collaboration with pediatric dentists. Given that oral health is often deprioritized, health policymakers should consider increasing training opportunities to enhance PCPs’ oral health knowledge, enabling them to focus more on children’s dental health, conduct more comprehensive screenings, and provide appropriate guidance.

This study contributes to the growing understanding of the current dental practices of pediatric primary care providers in China. To our knowledge, it is the first study to identify the dental implementation practices of pediatric PCPs at the primary care level in China. Oral health continues to pose a significant public health challenge that is frequently overlooked worldwide.³⁸ An integrated care approach within primary healthcare settings can facilitate and maintain universal access to essential oral healthcare services.^39</