SOCIOECONOMIC SIGNIFICANCE AND PREVENTION OF EARLY CHILDHOOD CARIES

Karijes u ranom detinjstvu ima epitet najčešćeg infektivnog i hroničnog pedijatrijskog oboljenja, koje podrazumeva prisustvo karijesa na bilo kom mlečnom zubu kod dece starosti do šest godina, a nastaje kompleksnim procesom, koji uključuje transmisiju infektivnih bakterija, navike u ishrani i oralnu higijenu. Često nastaje kao posledica prolongiranog dojenja ili učestalog konzumiranja zaslađenih napitaka putem flašice. Danas se smatra aktuelnim problemom javnog zdravlja ne samo u zemljama koje su u razvoju nego i u razvijenim zemljama širom sveta usled visokog stepena zastupljenosti. Rezultati mnogobrojnih studija ukazuju na postojanje vodećih faktora rizika koji su zajednički za sva podneblja, poput socio-ekonomskih, kulturoloških i faktora vezanih za higijensko-dijetetske navike. Ipak, najvećim pojedinačnim faktorom rizika smatra se siromaštvo. Ovo oboljenje je često praćeno komplikacijama, kao što su pulpitisi i hronični apikalni parodontitisi i može izazvati jak bol, koji remeti svakodnevne aktivnosti deteta, ishranu i spavanje. Takođe, utiče na rast i razvoj dece. Neophodni ekstenzivni i skupi stomatološki tretmani se nekada moraju obaviti u opštoj anesteziji, a krajnji rezultati nisu zadovoljavajući. Međutim, donošenjem, evaluacijom i kontinuiranim sprovođenjem programa prevencije i strateških mera, mogu se postići dobri rezultati. Veoma je važna uloga države i zajednice u donošenju odluka o usmeravanju resursa na prevenciju, kao najekonomičniju meru i podizanju svesti građana o značaju oralnog zdravlja. Uloga profesionalaca i roditelja u prenošenju znanja, o veštinama i navikama u održavanju oralne higijene, neophodna je mera u cilju očuvanja zdravlja čitave populacije.


Introduction
Early childhood caries (ECC) is the most common infectious and chronic pediatric disease 1 .It is a disease of the oral cavity which implies at least one decayed (noncavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces in any primary tooth in a child 71 months of age or younger 2 and develops through a complex process that involves the transmission of infectious bacteria, dietary habits and oral hygiene 3 .This disease is often the result of prolonged breastfeeding and frequent consumption of sugar containing beverages in a baby bottle, especially at night, and is otherwise known as 'baby bottle tooth decay'.
It is believed that one of the contri-buting factors is hypoplasia of the enamel, which may be a consequence of multiple factors 4 .However, the greatest single risk factor is poverty 5 .The presence of socio-cultural components as a risk factor suggests that ECC needs to be seen as a symptom of a child's health deterioration and lack of adequate care 6 .
Nowadays, it is considered one of the topical public health issues in developing countries, as well as developed countries around the world, due to its high prevalence.The presence of this specific type of tooth decay varies significantly, from 4-90% and depends on the geographic area, as well as the type and number of risk factors present 7,8 .Results of numerous studies 3,4,6,[9][10][11][12] indicate the presence of risk factors that are common to all the cou-ntries of the world, such as socioeconomic, cultural and factors related to hygiene and die-tary habits.This disease is often followed by complications, such as chronic pulpitis and apical periodontitis and can cause severe pain that disturbs children's daily activities, eating and sleeping, and affects growth and development.It requires extensive and costly dental treatments that sometimes need to be performed under general anesthesia, and the final results are still unsatisfactory.
Implementation of preventive strategies is the only adequate and cost-effective approach to maintain and improve the oral health of children and the promotion of oral health should be part of healthy life strategies 3 .
Preventive methods have already been developed and should be applied within prevention programs, with the community and family as primary factors.The role of oral health care professionals is identification and elimination of risk factors prior to dental treatment, which is crucial for successful management of ECC 13 .

Impact of socioeconomic factors on the occurrence of ECC
There is an evident discrepancy in the prevalence of early childhood caries among children belonging to ethnic minorities whose parents have lower economic income 3,4,12,14-18 , compared to children living in families that are better-off.Lack of care regarding children's oral as well as general health has been evident in poor, large families, resulting in frequent occurrence of malnutrition, which can lead to more illness in early childhood and the occurrence of enamel hypoplasia which increase the risk of ECC 4 .Risk factors are also low educational level of parents, especially single 19 and illiterate mothers [20][21][22][23][24][25] , and poor access to dental care in remote communities 3,4 , which has resulted in parents lack of awareness regarding this disease, and irregular visits to the dentist.All the above stated causes have led to a high percentage of children suffering from ECC in high-risk communities.
The high variability of data regarding the presence of ECC in different countries is probably the consequence of different diagnostic criteria of the disease.In developed countries with advanced programs for oral health care ECC prevalence is approximately 5% 26 , while in north-eastern Europe the situation is worse, with values up to 20% 26,27 .Significantly higher values have been recorded in Iran, 59% 26 and Alaska (66.8%) 3 .After conducted survey of ECC among children of the indigenous population in the territory of Canada and the United States, the American Academy of Pediatric Dentistry has announced that the prevalence of this disease in some communities exceeds 90% 3 .The high percentage of children with untreated caries in such communities has resulted in undergoing expensive pediatric dental surgeries under general anesthesia, with additional costs related to transportation and accommodation of children's families from remote communities to urban centers 28 .Considering that general anesthesia comes as a potential health risk, the benefits of this treatment may be shortlived, because there may be a relapse and recurrent cavities if proper oral hygiene behaviors are not maintained postoperatively 3 .There are data on a significant number of indigenous children who need to repeat dental treatment under general anesthesia 3 .The results of research conducted in the eastern Balkans indicate that the incidence of ECC in Sofia among three-year-old children is godina 30,0%, u Srbiji u Južnobačkom regionu kod trogodišnjaka 22,07%, a kod dece predškolskog uzrasta na istom području 30,5% 29 .Ove vrednosti su kategorizovane kao srednje, u odnosu na nisku, koja je zabeležena u Finskoj i Švedskoj, odnosno visoku, kod dece Srednjeg Istoka, iz azijskih zemalja, Hispanoamerikanaca i Meksikanaca 29 .Rezulatati istraživanja sprovedenog u Srbiji ukazuju na direktnu povezanost uzrasta deteta i težinu KRD-a 29 .Povećanje broja zuba sa uzrastom, uz nepromenljive uslove sredine, kao što su navike u ishrani, oralna higijena i profilaksa fluorom, povećava i broj obolelih zuba i dovodi do pogoršanja bolesti.
Rezultati više studija otkrivaju postojanje obrnute proporcionalnosti između učestalosti KRD-a i nivoa obrazovanja majki 29,33,35 .Takođe, zabeleženo je postojanje direktne korelacije između radnog statusa roditelja i prevalence i težine bolesti 29,36,37 .Manja zastupljenost i stepen težine oboljenja kod dece zaposlenih roditelja, naročito majki, objašnjava se nivoom obrazovanja ovih žena i činjenicom da njihova deca provode dosta vremena u vrtićima, koji su integrisani u sistem preventivne stomatološke zaštite.32.0%, 30.0% in Croatia among children from 2-5 years of age, 22.07% in Serbia in the South Backa region among three-yearold children, while it is 30.5% among preschool children in the same area 29 .These figures were marked as mean values, compared with the low ones recorded in Finland and Sweden, and high ones among children of the Middle East, Asian countries, Hispanics and Mexicans 29 .The results of research in Serbia indicate a correlation between the age of the child and the severity of ECC 29 .As the number of teeth increases with age in unchanging environmental conditions such as eating habits, oral hygiene and use of fluoride, the number of teeth affected by decay also increases and leads to a worse degree of disease.
The influence of gender and the presence of gender dimorphism have been recorded by some authors, whose findings indicate an increased incidence of ECC among male children 29,30 .However, it is necessary to conduct more studies to assess if the different prevalence of the disease between the genders is a consequence of better hygiene among girls or culturally conditioned eating habits among boys.
It has been recorded that the third and each subsequent child in a family is at a higher risk of developing ECC 29 .According to the American Academy of Pediatric Dentistry the most probable explanation is early 'vertical' and 'horizontal' transmission of mutant streptococci among male children and mothers or close male relatives 31 .However, the recorded data is not consistent with respect to the impact of the total number of children in the family on the occurrence of the disease 32,33 .
Analysis of ECC occurrence in preschool institutions and other environments has shown that the prevalence of ECC is twice lower among children in kindergarten, even though there is a greater possibility of transmission of mutant streptococci from one child to another within a group 29 .More severe forms of the disease were common among children who were not in kindergarten 29 , and the reason for this is the importance of regular consumption of meals 34 and intensive medical and educational work with children in preschool institutions, which includes not only teachers but dentists as well 29 .
The results of several studies reveal an inverse proportion between ECC incidence and mothers level of education 29,33,35 .
There is also a direct correlation between the employment status of parents and the prevalence and severity of the disease 29,36,37 .Lower prevalence and degree of severity of disease among children whose parents are employed, especially mothers, are explained by the level of education and the factthat their children spend considerable time in kindergartens, which are integrated into the program of preventive oral health care.
The total monthly income as an indicator of the socioeconomic status is a significant risk factor for the occurrence and severity of this disease.A linear in crease in the prevalence and moresevere forms of ECC has been followed by a decrease of the total annual family income 29,32,33 .The most probable reason for low prevalence of this disease among wealthy children is the fact that their parents spend more on their wellbalanced nutrition in terms of quality and quantity as well as on fluorideprophylaxisandoralhygiene 29 .
Parent awareness and attitude towards oral health are one of the crucial factors.The parents knowledge and willingness to primarily correct own behaviours in order to maintain their own oral health as well as their children's oral health, affect the incidence and severity of the disease 29 .
The influence of environment has also been the focus of studies, indicating a higher incidence of ECC in remote communities 29 .
The most probable reasons are poor access to dental and social services due to remoteness, unemployed population depending on agriculture, social and language barriers.

Preventive measures and guidelines in fighting ECC
The tendency of an increased number of ECC affected children can serve as awarning, considering that it is well known that tooth decay is a preventable disease.ECC develo-pment canbe reduced or prevented by imple-menting simple and low-cost measures at family level, where children receive their first knowledge about the importance of oral hygiene.The state and the community have a special role, as well as professionals, in recognizing the importance of ECC and discovering preventive measures, the implementation of which will decrease its prevalence and establish control of the disease.Oral health promotion, well desi-gned strategies and preventive programs are the methods that have proved to be effective.

Role of familyin ECC prevention
Proper oral hygiene and the use of fluoride tooth paste are the most important factors in the prevention of tooth decay 10 .Children up to 8 years of age are not able to brush their teeth on their own, which makes proper oral hygiene there sponsibility of parents 10 .The use of adapted toothpastes with low fluoride concentration (up to500 ppm) in a small amount (a 'pea-size') is a recommendation of the European Academy of Pediatric Dentistry (EAPD) 38 .The information on ECC risk factors and prevention is very important for parents, and is provided during the first visit to the dentist 10 .

Preventive strategies
Not only does the primary prevention of tooth decay havea role to maintain oral health, but it also decreases the need for restorative and dental surgical interventions 3 .Since ECC results from the interplay of oral bacteria, substrate and the host, as well as from the family, economic and social situation, oral health-promotion strategies which emphasize the community development and address the determinants of health are related to strategies that focus on disease prevention 10 .

Promotion of Oral Health Care
Promotionof oral health care, as well as of general health, should be part of healthy life strategies, because all health strategies are based on similar problems, such as socioeconomic challenges, availability and price of nutritious foods in remote communities, exposure of environment to tobacco smoke, unacceptably low rates of breastfeeding and awareness of quality food and its accessibility 3 .

Prevention of disease
ECC prevention begins by raising people's awareness of the importance of oral health.It is implemented during the prenatal, perinatal and continuing on postnatal period of mother and infant, in the context of family and preschool programs 39,40 .Since there is evidence of vertical transmission of cariogenic bacteria, primarily from mother to child, including pregnant women in screening examinations and dental rehabilitation, educating them about the importance of oral hygiene and diet, as well as providing advice on the use of fluoride toothpaste, are strategies that Postojeći vodiči u razvijenim zemljama podržavaju bezbednu oralnu negu u trudnoći, u cilju redukcije ili usporavanja razvoja KRD-a kod odojčadi [41][42][43] .

Use of fluoride in ECC prevention
Many national and international organizations, associations and governments (World Health Organization, the American Dental Association, the American Academy of Pediatric Dentistry, the Canadian Dental Association, the Canadian Academy of Pediatric Dentistry and others) have recognized and supported the use of fluoride as a safe and highly efficient strategy aimed at caries prevention and control 3 .There are a lot of fluoride products, as well as methods and recommendations for their use.
Water Fluoridation -Water fluoridation is the most efficient and expensive method that does not requiredaily responsibilities and it promotes equality, because all citizens benefit, regardless of their socioeconomic status 44,45 .The World Health Organization has announced that water fluoridation is a significant advantage, especially in high risk populations, where this implementing method is culturally acceptable and technically feasible 46 .
Topical fluoride-Topical fluorides are also effective in preventing caries.A Cochrane review article reveals that fluoride varnishes significantly reduce tooth decay in both primary and permanent teeth 47 .Four varnish applications are recommended for the high-risk population between 9 and 24 months of age 3 .
Systemic fluoride-Systemic fluorides are suitable for use among children at high risk of dental caries, and may be necessary in case there are no other sources of fluoride to be applied, such as toothpaste or water 3 .However, there are no consistent data on the efficiency of this method of applying fluorides in caries prevention in primary dentition 48 Fluoride toothpaste -Guidelines supported by the CAD and the AAPD recommend the use of fluoride toothpaste in a 'pea-size' amount twice a day for children aged 2-5 (AAPD) or 3-6 (CAD) with their parents assistance, and for infants under 2 (AAPD) or 3 years of age (CAD), in a 'rice grain-size' amount, especially for children at high risk of dental caries 3 Zalivači fisura -Zalivači kao preventivna mera su indikovani za primenu na okluzalnim površinama zuba u cilju zaštite jamica i fisura od pojave karijesa.Postoji preporuka na osnovu nekih istraživanja za upotrebu ove metode kod sve dece koja su u visokom karijes riziku i na stalnim i na mlečnim molarima 49,50 .
Fissure sealants -The use of sealants is an established preventive measure for occlusal tooth surfaces to protect pits and fissures from tooth decay.According to some research, it is recommended to implement this method among children with a high risk of dental caries on both permanent and primary molars 49,50 .

Role of health care professionals in ECC prevention
The role of dentists refers primarily to informing parents/caregivers about the importance of primary dentition, etiology and prevention of ECC, as well as the importance of their own oral health care.Including professional providers in counselling and educational programs for parents makes it possible to maintain knowledge about the measures to be implemented in order to eliminate risk factors for developing this disease.Providing advice on the use of fluoride at home and implementing prophylactic measures at the dentist's surgery in accordance with contemporary guidelines are also important measures for preventing early childhood caries.AAPD has recommended that every infant should receive an oral health risk assessment from a child health professional by 6 months of age 41 .
Children with an increased risk of oral diseases or identified white spots or caries lesions should be provided with necessary treatment 42 .
Medical providers specializing in other fields, such as gynaecologists, neonatologists and paediatricians, also have an important role in ECC prevention, because their collaboration with dentists enables the implementation of ECC preventive measures at prenatal, perinatal and postnatal levels.In populations at high risk of dental caries (the indigenous population ofthe U.S. and Canada), guidelines and recommendations have been issued for initiating the training of other dental health and primary health care providers, for the purpose of implementing preventive measures more efficiently 3 .

ECC prevention guidelines
The AAPD recognizes caries "as a common chronic disease resulting from an imbalance of multiple risk factors and protective factors over time.To decrease the risk of developing ECC, the AAPD encourages professional and at home preventive measures that include: 1. reducing the parent's/sibling's MS levels to decrease transmission of cariogenic bacteria.

Conclusion
ECC is a disease with global-level issues that, despite preventive measures, is still largely present in some communities.The main reasons are a multiple risk factors, related not only to hygiene and dietary habits, but also the level of parental education, socioeconomic living conditions and cultural distinctions.Significant results can be achieved by the introduction, evaluation and implementation of prevention programs and strategic measures.The role of the state and the community is very important in making decisions on directing their resources to prevention, as the most costeffective measure, as well as in increasing public awareness of the importance of oral healt has part of general health.The role of professionals prior to medical treatment and alsoparents at family level in providing the knowledge, skills and oral hygiene habits with their children is a necessary measure aimed at preserving the health of the entire population.