Early Childhood Caries Prevalence in Low Income Families in the Nassau County

Introduction

Hong Kong SAR, officially the Hong Kong Special Administrative Region of the People'southward Republic of People's republic of china, is an autonomous territory that maintains a separate legislature, executive, and judiciary from Mainland China. It is located on the south-eastern declension of People's republic of china. Hong Kong had been a colony of the British Empire since 1842 and was returned to Mainland china in 1997. The Sino-British Joint Declaration has guaranteed Hong Kong backer economic system and autonomous government for 50 years subsequently the transfer of sovereignty.^one

The level of social and economic evolution of Hong Kong and China is different. Compared to Mainland Communist china, Hong Kong had a higher human development index (0.91 vs 0.74), including higher lifespan, higher education level, and higher gross domestic production (Gdp) per capita.ⁱⁱ In 2017, the Gdp per capital of Hong Kong was 46,228 USD, while that of Mainland China was 8,830 USD.^3,4 However, Hong Kong had lower Gross domestic product per capita when compared to that of the US, which reached 59,484 USD in 2017.⁵ The total expenditure on health care was around 6% of the GDP in Hong Kong.⁶

In Hong Kong, there are 7.four million residents residing in an area of ane,104 sq km.⁷ Hong Kong was ranked the quaternary most densely populated identify in the world in 2017.^eight According to the 2016 demography, 92% of the Hong Kong population is indigenous Chinese, and 8% consists of other ethnic groups, including a big number of Filipino and Indonesian foreign domestic helpers. Nearly nine% of the ethnic minorities were under 15 years old.⁹ In 2016, there were 344,894 preschool children (0–five years former) in Hong Kong.^ten More than than 90% of the 3- to 5-twelvemonth-old children attend kindergartens, whereas home schooling is uncommon in Hong Kong.¹¹

Oral wellness is an of import part of full general health. Oral health has influences on children'south lives and futurity development. To plan the appropriate oral health promotion schemes, it is necessary for wellness policy makers and dental practitioners to understand the updated Hong Kong children's caries situation, its risk factors, and the effectiveness of the existing programs. The aim of the present review is to draw the dental caries status, its take a chance factors, and oral wellness care programs for preschool children in Hong Kong.

Method

Publications related to the oral health status of preschool children in Hong Kong, government-archived reports, and data of dental care were retrieved from electronic databases (PubMed and Scopus) and mitt searches. Dental caries experience, related adventure factors, and oral wellness promotion programs were reviewed.

Dental caries status

Early childhood caries (ECC) is defined as the presence of one or more than decayed, missing, or filled tooth surfaces in any primary tooth in a child younger than 71 months of age.¹² ECC is the most mutual chronic disease among preschool children. It was ranked every bit the 12th most prevalent condition and affected effectually 560 million children worldwide, as reported past the 2015 Global Burden of Disease Study.^thirteen Although no symptoms can be found at the early phase, ECC may cause discomfort or pain if the lesion involves the dental pulp. Moreover, it may as well crusade difficulties in sleeping and eating and may accept an consequence on children's growth and school performance.¹⁴

In Hong Kong, the first epidemiological report that reported the dental caries status of preschool children was conducted in 1968 by the Medical and Wellness Department and WHO. The results showed that the ECC prevalence in five- to 6-twelvemonth-former preschool children was 87%.^xv The second epidemiological survey was conducted in 1993, reporting that the prevalence of ECC amongst 5-year-old children decreased to 63% with a decayed, missing and filled teeth (dmft) score of 3.2.¹⁶ The situation of caries status in preschool children remains unsatisfactory. Several epidemiological studies were conducted in the past two decades. They reported that caries prevalence was ~48%–56% and that the mean dmft score ranged from 1.8 to 2.7.^17–21 According to the results of the latest territory-wide survey conducted in 2011, ECC was unevenly distributed. A pocket-size proportion (26%) of individuals carried nearly (81%) of the decay experience.²⁰ Approximately, 1 in six children (17%) anile 5 years had 6 or more decayed teeth.^twenty A recent study published in 2017 indicated that no significant comeback was observed, compared with the territory-wide survey in 2011. ECC remained prevalent (55%) amongst 5-year-onetime children, and their mean dmft score was 2.vii.²¹ In addition, most of the rust-covered teeth (>90%) were untreated.²¹

In summary, approximately one-half of the 5-year-sometime children are nevertheless suffering from ECC, and the distribution of dental caries is uneven among preschool children.^xx The summary of the dental caries situation of preschool children in Hong Kong is presented in Tabular array 1 and Figure 1.

Table i Early childhood caries (ECC) in Hong Kong preschool children Note: aYear of publication was presented instead because yr of conduct was not specified. Abbreviations: ECC, early childhood caries; dmft, rust-covered, missing and filled teeth.

Figure i Prevalence of early childhood caries among five-year-old Hong Kong children.

Adventure factors

It is necessary to understand the hazard factors related to dental caries when planning and implementing programs to ameliorate the oral health situation of preschool children. Four etiological factors, which are susceptible host, cariogenic bacteria, fermentable carbohydrate substrate, and time, are well documented. Other ecology gamble factors, including the use of fluoride, parental oral health-related noesis, access to dental care service, and sociodemographic groundwork were as well plant to accept a human relationship with ECC amidst preschool children in Hong Kong.

Tooth brushing

Tooth brushing is i of the essential dental caries prevention strategies. Prior to the eruption of the showtime chief teeth, caregivers are asked to make clean the babe's gum with moist gauze or a washcloth wrapped around the finger. From the eruption of the first tooth to age two years, children are recommended to have their teeth cleaned with a soft toothbrush with toothpaste. At age two–6 years, a kid can begin to use a pea-sized amount of fluoride toothpaste and brush his or her teeth twice daily.²²

As reported past the two territory-wide surveys in Hong Kong conducted in 2001 and 2011, there was an increment in tooth brushing frequency among five-year-old children. In 2011, 70.6% of the children brushed their teeth twice daily, whereas 3.nine% of them brushed three times or more.²⁰ In 2001, 53.0% and 1.4% of them did, respectively.¹⁸ However, 4.7% of children were nevertheless brushing their teeth less than once daily in 2011.^18,20 Moreover, the recent survey in 2017 showed that 30.5% of the children had never brushed their teeth earlier the age of 2 years. Over lxx% of the caregivers reported that they assisted their children in performing tooth brushing daily.²¹

Sugar consumption

Fermentable carbohydrates are a key factor in caries development. Cariogenic leaner produce acids afterwards carbohydrate intake and subsequently demineralize the tooth surface. A positive human relationship can exist institute between the length of exposure time of the teeth to carbohydrate and dental caries. The frequent intake of sugary snacks could lengthen the fourth dimension of exposure.²³ Results of the recent epidemiological studies in Hong Kong indicated that xl% of the v-twelvemonth-old children who had snacked on sugary food twice or more than daily had statistically significant higher caries prevalence, when compared to those who snacked less than twice daily.^nineteen,21 Merely one-tertiary (35.6%) of the five-year-quondam children did not accept a daily snacking addiction, as reported by the 2011 survey.^xx Present, refined saccharide is widely available in grocery stores in Hong Kong. Caregivers may indulge their young children with sweets that lead to the excessive intake of saccharide.

Use of fluoride

There is evidence that both systemic and topical uses of fluoride are beneficial for caries prevention.²⁴ In Hong Kong, water fluoridation was implemented in the early 1960s. At nowadays, all Hong Kong residents (100%) ordinarily eat fluoridated tap water daily.²⁵ Fluoride toothpaste is commercially available and is affordable to most of the families in Hong Kong. It is suggested that children tin can kickoff tooth brushing with fluoride toothpaste at the age of 2 years. The results of the 2011 territory-wide survey report showed that the bulk (94.three%) of the children in Hong Kong used toothpaste.^xx However, simply half of the parents indicated that their children used fluoridated toothpaste, while one-third did not know whether their children'due south toothpastes independent fluoride.²⁰ Nevertheless, most of them (74.7%) reported that they understood the benefit of fluoride on caries prevention.^twenty

Parental oral health-related cognition

Studies have found that there was a relationship between parental oral health-related knowledge and dental caries prevalence.^xix–21 Children whose parents had better oral health literacy had lower dental caries prevalence.²¹ After comparison the 2001 and 2011 territory-wide surveys, there was an improvement in parental oral wellness-related cognition related to the risk factors of dental caries and gum diseases. Nearly all of the parents (95.4%) understood that the overconsumption of sugary snacks increased the risk of dental caries, and 58.three% of them perceived that brushing with fluoride-free toothpaste was some other risk cistron.^twenty Around one-third of the parents (28.9%) misunderstood that a lack of calcium would increase the risk of tooth disuse.^xx

Access to dental care

Although children are asked to have their teeth checked as early equally 6–12 months old, 75.4% of the parents reported that their 5-twelvemonth-old preschool children had never visited a dentist.²¹ As well, it was establish that children who had dental attendance experience had significantly higher dental caries prevalence.²¹ The reason for that might be attributed to trouble-oriented dental care-seeking behavior. As reported past the 2011 survey, half of the children (48.three%) visited a dentist due to their dental problems such as molar decay, toothache, and trauma.²⁰ For those children who had dental attendance experience, less than half of the parents (44.9%) preferred to have the decayed teeth of their children restored, whereas 11.one% parents preferred to leave the rust-covered teeth untreated.^xx

Sociodemographic groundwork

In that location are a number of studies showing that socioeconomic factors are related to children's dental caries experience.^xvi,17,19,21 From 1993 to 2017, all oral health surveys concluded that household income was significantly associated with preschool children'south dental caries experience. Children from families with higher income and whose parents had a higher didactics level had lower dental caries prevalence. These results indicated that social inequality exists among the dental wellness of preschool children in Hong Kong. Underprivileged children may have a higher risk of developing caries lesions. Also, the demographic characteristics also impact the dental caries experience. As Hong Kong was colonized by the British Empire, its culture, foods, and living lifestyles are slightly dissimilar from Mainland People's republic of china. The epidemiological survey conducted in 2009 reported that children who were born in Mainland Prc had significantly higher dental caries experience than those built-in in Hong Kong.¹⁶

In add-on, there has been a change in the legislation that influenced the demographic characteristics of Hong Kong children. Since 2001, babies born in Hong Kong from Mainland women whose spouses are not Hong Kong Permanent Residents were entitled "Type 2 Babies". They have the right of residency in Hong Kong besides as the opportunity to benefit from Hong Kong'southward educational activity and health care organization. After that, the number of Type Ii Babies increased significantly from 620 in 2001 to 35,736 in 2011, and the number of live births increased from 48,219 to 95,451.²⁶ Although Hong Kong was recognized every bit one of the lowest birth charge per unit districts/countries in the world at the end of the 20th century, the number of births dramatically increased between 2001 and 2011 because of this policy. As a outcome, Hong Kong'due south health care services were under great pressure. Studies conducted in 2009, 2011, and 2016 indicated that the ECC prevalence of preschool children slightly increased compared to that in 2001.^19–21

To solve this problem, the Hong Kong government implemented the zippo-quota policy on obstetric services for Mainland women whose spouses were not Hong Kong residents in 2013. Blazon II babies were no longer entitled to have the right of residency in Hong Kong since then. Therefore, the number of Blazon II Babies decreased to 823, and the number of live births decreased to 62,305 in 2014.²⁶ The influence of this demographic policy on the situation of ECC must be monitored in a future epidemiological report.

The summary of significant risk factors studied in Hong Kong is presented in Table 2. Based on the recent studies conducted in 2009 and 2016, similar caries take chances factors were plant. Depression family income, frequent snacking habits, and low level of parental dental noesis were the significant factors remaining in the final model of multivariate analyses. A primary prevention program should aim to encourage changes in dietary behaviors and ameliorate parental knowledge about child oral health. In add-on, underprivileged children who come up from depression-income families should be prioritized.

Table 2 Risk factors of early childhood caries reported by surveys in Hong Kong Notes: Yeah: the chance factor was significantly associated with ECC; No: the risk factor was non significantly associated with ECC; –: the risk factor was not reported in the study. Abbreviation: ECC, early childhood caries.

Oral wellness intendance programs

According to these risk factors, there were several oral health promotion programs that have been launched to control the disease and improve the oral health status of preschool children.

Water fluoridation

Water fluoridation is the controlled addition of fluoride to a public h2o supply, which aims to prevent dental caries. Results of the contempo Cochrane review showed that the introduction of h2o fluoridation resulted in a 35% reduction in caries experience (dmft score).²⁷ The first community water fluoridation plan to preclude caries was launched in Michigan, US, in 1945.²⁸ It was ranked as one of the ten neat public health achievements of the 20th century in the US by the Centers for Disease Control and Prevention.²⁹ It was reported that at that place were 25 countries/districts that had water fluoridation programs effectually the globe in 2012, and Hong Kong was the only place where 100% of the population consumed fluoridated water.²⁵

In Hong Kong, the water fluoridation program was introduced in 1960 with a fluoride level of 0.viii parts per million (ppm). After that, the mean dmft score of the 12-yr-old children decreased dramatically from 4.4 in 1960 to 1.five in 1968.^fifteen,xxx After, the concentration of fluoride increased to 1.0 ppm in 1976.³¹ Notwithstanding, the results of this survey indicated that the prevalence of dental fluorosis among vii- to 12-year-old children also increased to 64%.³⁰ Therefore, the concentration was adjusted to be 0.7 ppm in 1986. Later, the epidemiological survey in 1988 reported that the dental fluorosis remained prevalent (47%). Then, the concentration of fluoride was reduced to 0.5 ppm in 1988.³² Until at present, the fluoride level has remained at 0.5 ppm in Hong Kong. Optimal fluoride concentration in drinking water was determined by diverse factors including ecology temperature, daily h2o consumption, and access to dissimilar sources of fluoride.³³ The corporeality of fluoride ingested during the summer time was higher than that during the winter fourth dimension.³⁴ For people living in tropical or subtropical regions like in Hong Kong, they tend to consume more than water than those living in cooler regions.³⁴ Likewise, young children may exist at risk of ingesting fluoride from toothpaste which is commercially available and affordable for most of the families. Therefore, the fluoride concentration in Hong Kong has been adjusted to be 0.five ppm, which is lower than that in the cooler areas such as in the Us (0.seven ppm).³⁵ Although water fluoridation is one of the most significant dental public health projects benefitting all residents in Hong Kong, the caries statuses of preschool children were unsatisfactory. Additional effective testify-based oral health programs for preschool children are needed.

Oral wellness pedagogy

The Oral Health Educational activity Unit (OHEU) was set by the Department of Health in 1989, with the main aim of improving the oral health condition of Hong Kong children.³⁶ The OHEU has developed oral health literatures for unlike age groups and organized customs-based oral health projects. The "Brighter Smiles for the New Generation" plan was implemented by OHEU targeting three- to 5-year-old children who studied in local kindergartens and nurseries.³⁷ It aims to help immature children establish tooth brushing habits and healthy eating habits. Educational materials including instructor'southward manuals, pupil handbooks, oral wellness education VCDs, and posters were provided to the participating kindergartens with the aim of improving the oral health knowledge of teachers, parents, and children.³⁷ Information technology was reported that this program could reach ~600 kindergartens (60%) in Hong Kong.³⁸ In each year, the number of participating children was estimated to be ~100,000.³⁸ Besides, the Brighter Smiles Playland was launched to provide complimentary dental facilities and interactive games for 4-twelvemonth-old students in kindergartens.³⁹ Classes are provided to teach children near tooth brushing and oral health-related knowledge. A website called "Tooth Society", which contains the information on oral wellness for the general population, was besides established by the OHEU.³⁶ The oral wellness data and materials tin can be downloaded without whatever charge if needed.

Customs dental services

A number of nongovernmental organizations (NGOs) in Hong Kong are operated past non-profit-making social service agencies, religious groups, labor unions, and so on. They generally provide direct and indirect wellness or educational services to citizens. Some of them provide dental intendance services for Hong Kong residents. For example, Projection Concern Hong Kong, one of the non-profit NGOs providing health services for people with low income, has initiated a projection named "Smiley Action Days" since 2014.⁴⁰ This project aimed to enhance the oral health, dental knowledge, and self-care power of Hong Kong citizens in different districts by empowering the dental intendance team of the mobile dental clinics to provide bones and preventive dental care. A big-scale oral health promotion public upshot comprising mobile dental services was held in different districts.⁴¹ Children in the selected districts could enroll and received the dental examination, topical fluoride treatment, and oral health education on the mobile public effect.⁴¹ Still, this short-term project tin only benefit a small portion of preschool children in Hong Kong.

Kinesthesia of Dentistry, The University of Hong Kong, the just dental school in Hong Kong, has implemented the "Preschool Oral Health Programme" for preschool children.⁴² A pilot program was started in 2008 and provided costless dental care services for 19 kindergartens. Ii years subsequently, the project was expanded, roofing over 100 kindergartens.⁴³ Several oral wellness promotion activities take been done, such as an oral wellness education workshop for teachers. Oral health education materials including dental models, posters, and booklets are provided to participating schools. Lectures and seminars for parents are too organized in a school hall. Moreover, this program too provides oral examination and topical fluoride (silver diamine fluoride or SDF) for caries command in a schoolhouse-based setting.⁴² Several randomized clinical trials evaluated the effectiveness of SDF in arresting dentine caries in preschool children in Hong Kong. A 30-month clinical trial reported that the caries abort rates were 55.2% and 66.ix% when 12% and 38% SDF annually were applied, respectively.⁴⁴ Another thirty-month study showed that 48% of the decayed surfaces became arrested when 30% SDF was applied annually.⁴⁵ These information indicated that SDF treatment tin do good preschool children, specially the ones with established dental caries.

Discussion

After the initiation of h2o fluoridation in 1961, there was a pregnant improvement regarding the oral health status of preschool children in Hong Kong during the 1960s to 1990s. Notwithstanding, the overall caries condition of preschool children has remained unchanged in the last two decades. The latest oral wellness survey showed that 55% of the 5-year-old children had dental caries. In Mainland China and Taiwan, where the majority indigenous grouping was also Chinese, the prevalence of dental caries among 5-year-old children was 79% and 81%, respectively.^46,47 All the same, when compared to its counterparts in terms of economic development, the state of affairs in Hong Kong remained unsatisfactory. For case, in the Uk, the prevalence of dental caries of 5-year-old children ranged from 27% to 41% in 2014, whereas the prevalence was 44% in 2015 in Australia.^48,49 The unsatisfactory ECC situation in Hong Kong may be due to the deficiencies of the current oral health care arrangement in delivering accessible preventive and curative dental services to preschool children in Hong Kong. Although several oral health promotion programs take been launched, misconceptions about the importance of principal dentition and misunderstandings regarding the run a risk factors of ECC remained usually found amid Hong Kong parents.^twenty There notwithstanding exist areas for continued improvement regarding the oral hygiene practices and parents' oral health-related knowledge in hereafter projects. In addition, dental caries is caused by similar modifiable risk factors of other not-infectious disease. For example, excessive carbohydrate consumption could increase the risk of diabetes and dental caries. Rather than focusing on individualistic approaches, a mutual risk approach should be adopted to resolve both the dental and full general health problem.^l Child oral health programs should be integrated with other public health sectors. The collaboration and empowerment of stakeholders in dental care services for immature children should be built and strengthened.

Community-based dental care services should be expanded in Hong Kong to deal with the brunt of dental caries. Although some NGOs have provided dental services to residents with low income, most of the projects were implemented in the short-term period and benefitted a small portion of the kid population. At present, the Hong Kong government provides just emergency dental services for the general population, including preschool children, in eleven dental clinics around Hong Kong.⁵¹ There is no authorities-subsidized dental care service, specifically for preschool children. The dental visit or dental treatment is more often than not self-financed. Free oral examination, preventive dental treatment, and basic restorative dental treatment are provided but for the schoolchildren (6–12 years one-time) who have paid Us$ two.50 (HK$ xx) annually. There are 8 governmental clinics in total to serve the schoolhouse children. As there is no regulation regarding the dental fees in Hong Kong post-obit the "free merchandise" policy, the dental treatment fees vary amid clinics and are unaffordable for many families. This may be why the utilization of dental services by preschool children was low.

Effective evidenced-based oral health programs including supervised molar brushing program and topical fluoride application in a school setting should be established to improve the oral wellness of Hong Kong preschool children. The successful story of supervised molar brushing program from Scotland can exist an example. The governmental dental care programme called Childsmile was launched in 2005. This programme has provided a free-menstruum feeder loving cup to children by the historic period of 1 year. A supervised tooth brushing program complemented with a costless gear up of toothbrush and toothpaste has been offered to nursery children.⁵² Results of the epidemiological studies showed that caries prevalence of v-year-one-time children in Scotland reduced from 46% in 2005 to 32% in 2013, and the hateful dmft score decreased from 2.ii to 1.iii.^53,54 In improver, results of several systematic reviews show that apply of SDF in a school setting is effective in absorbing dental caries among preschool children.^55,56 A new guideline issued past the American Academy of Pediatric Dentistry supports the apply of SDF equally part of a comprehensive caries management plan for young children.⁵⁷ Thus, SDF handling for children complemented with dental health education and counseling to the parents would be very beneficial in improving child oral health, peculiarly for children with high caries risk.

Moreover, in that location is a shortage of dental resources, especially pediatric dentists in Hong Kong. In 2018, at that place were around 2,552 registered dentists in Hong Kong, and the dentist-to-population ratio was 1:2,900.^7,58 A majority of registered dentists (89%) are general practitioners, whereas there are only 36 registered pediatric dentists (one%).⁵⁹ Thus, the ratio of pediatric specialists to preschool children is very low, ~i:9,500.^10,59 To accost the shortage of dental workforce in Hong Kong, Faculty of Dentistry, The Academy of Hong Kong has taken more students with an ~40% increase in the number of undergraduate dental students since 2016.⁶⁰ The Dental Council of Hong Kong has also increased the frequency of licensing examination from once to twice a yr for non-locally trained dentists since 2015.⁶¹

Determination

Although there are some existing governmental and nongovernmental oral health promotion programs for preschool children, dental caries remain prevalent among preschool children in Hong Kong. At that place is a necessity to revise preventive programs to reduce child oral health disparities. Effective evidence-based community projects including tooth brushing program and topical fluoride treatment in a school setting should be implemented to improve the oral health condition of preschool children in a sustainable way.

Disclosure

The authors report no conflicts of interest in this work.

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