Dr Yuka Makino is the World Health Organization (WHO) Technical Officer for Oral Health at the WHO Regional Office for Africa in Brazzaville, Congo, and a lead author of the recently published Ending childhood caries: WHO implementation manual. The WHO Oral Health Programme published the manual to inform and support policy makers, oral health professionals, and primary care workers on actions and rationales for early childhood caries (ECC) interventions.

FDI spoke with Dr Makino about how ECC affect children, parents, and the wider community. We also discussed the importance of involving educators as well as parents/caregivers in developing and reinforcing children’s good oral health and hygiene habits.

This interview has been edited for length and clarity. The interviewee alone is responsible for the views expressed in this interview, it does not necessarily represent the views, decisions or policies of WHO.

More than 530 million children globally have dental caries in their primary teeth, making it the most common chronic disease among young children. Has the burden of dental caries in children increased or decreased over the last 10 years? Are there any forecasts on what this number may be in the future if countries continue to take a "business as usual" approach and do nothing to address the problem?

Over the last 25 years (1990-2015), the Global Burden of Disease Study (2015) estimated the percentage of change of the prevalence of dental caries in primary teeth to be 3.2%. At the same time, published studies have shown that the prevalence of early childhood caries has increased, especially in low- and middle-income countries. Therefore, I assume that, if we continue the same traditional approach (e.g. disease-specific, silo approach) and do not raise awareness about the importance of primary teeth (i.e. primary teeth have often not been considered important because they are exfoliated as the child grows), the situation may continue (not much change) or worsen, especially in low- and middle-income countries.

Although the WHO report focuses on early childhood caries (ECC), i.e. those aged under the age of six, many of the recommendations will be applicable to children across all age groups. How do ECC impact a child's permanent [secondary] teeth and their overall health?

Early childhood caries (ECC) incurs a higher risk of pain, discomfort, abscess, and/or a higher risk of caries lesions in both the primary and permanent dentition. ECC can also limit children from going to school and diminish their oral-health-related quality of life.

Moreover, ECC represents a socio-economic burden to the family and to society: treatment of ECC under general anesthesia for extensive dental repair is extremely costly. ECC represents an individual burden, a public health burden, as well as a socio-economic burden.

Like many other chronic diseases, dental caries can be prevented and controlled through a range of approaches. What do you think are the most effective ways to prevent tooth decay in young children?

I think what we need to consider is a multi-disciplinary approach to prevent and control tooth decay: we have to think about the child level, the family level, and also the community level. As you know, ECC is preventable, and most of the risk factors are modifiable. Risk factors are strongly determined by the child’s environment, socio-economic situation, and other societal factors.

ECC itself is strongly influenced by the health behaviour and practices of the family and caregivers. Therefore, an effective ECC prevention and control approach actually has a very broad range, from changing children’s individual behaviours but also working with the family and caregivers. It’s also important to consider the community as well. Public health solutions should be implemented, such as building health policy and creating supporting environments for prevention and control of ECC by integrating ECC prevention and control in overall health initiatives. 

Often, oral health interventions are conducted in silos, leading people to forget about oral health.

Because oral health is linked with other noncommunicable diseases (NCDs) and other health issues, an integrated approach is quite crucial. An effective way to prevent and control ECC may be to integrate it with promoting, protecting and supporting breastfeeding, integrating it with regulation of marketing of food and drinks, especially those high in free sugars, and action against childhood obesity.

It is important to integrate ECC prevention and control within primary care, such as maternal and child health programmes.

Of course, we should not forget effective use of fluoride as an essential componenet of any strategy to control ECC.

Finally, because quality data is lacking on ECC and primary dentition, it is also important to gather data on the caries experience on primary dentition. This could possibly translate into preschool children being included in the national or subnational oral health survey as part of a regular population surveillance program. A comprehensive approach is crucial.

The WHO Ending Childhood Dental Caries implementation manual proposes health education and community engagement strategies to tackle ECC. What role can teachers and other educators play in promoting oral health?

Preschools and schools have great potential for influencing the health of young children, as children spend so much time there. Educators can reach children at the life stage when lifelong health habits are being formed.

I think health promotion interventions could be conducted by preschool teachers, but they first need to have an adequate background in health and understand risk factors. So, oral health education should be part of the pre-service and in-service training of teachers.

In addition to oral health education and training for educators, we also need to create an enabling environment. In order to do that, the Minister of Health and the Minister of Education need to collaborate to develop "health-promoting schools", including establishing school health policy, securing a healthy physical environment, development of curricula and facilitating access to health services. Local municipalities can also establish oral health programmes that can provide a convenient platform for oral health education, including toothbrushing with a fluoride toothpaste and for administration of fluoride in collaboration with primary care workers. If we create an oral health education programme or activity, this should not be in a silo. This should be part of a broader health- promoting approach.

FDI's Brush Day & Night toothbrushing programme in schools highlights the importance of involving parents and caregivers to reinforce children's good oral health habits. What are some of the best ways to involve them in their children's oral healthcare routines?

I like how Brush Day & Night underlines the importance of parent involvement in the school oral health programme. From that perspective, I would like to introduce the concept of the “health-promoting school” and the parent’s involvement in the health promoting school.

WHO developed the concept of the health-promoting school, which seeks to create an environment to support healthy behaviour and promote health in the school context and enable schoolchildren to make healthier choices and adapt healthy behaviours throughout their lives.

As the school often serves as the centre of the community, the goal of a health-promoting school is to not only improve the health of the children, but also to strengthen the community and improve the health of other community members, including parents. Parent involvement here is critical.

Some countries have reported to WHO that it has been difficult to involve the wider community in health-promoting school activities. Other countries have shared information on what has worked to involve parents and increase overall community participation.

Best practices for involving the wider community (including parents) include: conducting health education workshops, health check-ups, and fitness activities for parents, organizing health fairs/festivals, conducting a community survey and/or health assessment, and organizing health campaigns for the community.

Moreover, one of the critical components of a health-promoting school is the development of a policy or a programme, and it’s important that parents be represented in this process. This way, parents can be empowered to be a role model for their children and add their voices to those who are promoting the importance of children’s health and children’s oral health.

Brush Day & Night is supported by Unilever.