284 WilEY TABLE 2 Overview of risk factors and underlying determinants of prevention of ECc were considered in more detail. These included fluoride delivered through either water, salt or milk, fluoridated gars added to baby bottles toothpaste and intra-oral topical fluoride application. 24 Exposure to optimum fluoride concentration in drinking water from birth not only Nonuse and nonavailability of fluoridated toothpaste pro- Social determinants: family culture and environment vides some pre-eruptive effect for the permanent teeth. 35-38 Where salt is used as a vehicle for fluoride. the who guideline on sodium Intake must be considered. 9 Salt intake at a country level should be monitored so that adjustments can be made if required, the levels of Nutritional status of mother and infant fluoride in the salt, to ensure that the population is receiving opti- Oral flora mum levels of exposure to fluoride. Poor oral hygiene and control of dental plaque Evidence is available that, for children younger than 6 years, the Breastfeeding-beyond 12 months, especially if frequent and/or use of fluoridated toothpaste is effective in caries control. How ever, ingesting excessive amounts can lead to mild fluorosis. To mini- Saliva--quantity(reduced flow) and constituents (particularly variations mize the risk of enamel fluorosis in children while maximizing the caries-prevention benefit for all oups, the appropriate amount should be used by all children guidance on the use of fluoridated nondesirable weight gain, obesity and associated noncommunicable toothpaste for young children differs from country to country. the diseases(NCDs). worldwide obesity has more than doubled since greatest variations are found in the age at which its use shoul 1980, and 41 million children under the age of 5 years were reported begin recommendations on the concentration of fluoride that should as being overweight or obese in 2014.- Oral health promotion should be used, and in the amount of toothpaste placed on the brush For herefore be integrated with general health promotion through a com- example it is recommended that parents should brush their chil- mon risk factor approach o Specific issues with the consumption of dren s teeth twice daily using a"smear"or"rice-size"amount of fluo- free sugars by infants and young children were recognized. the first ridated toothpaste (0. 1 mg f) for children aged 3 years and under was the addition of free sugars to feeding bottles. this habit was wide. and a"pea-size"amount of fluoridated toothpaste(0.25 mg F)for spread but unnecessary in many cultures and regions. the second children aged 3-6 years. 1 42 Variation in guidance can be expected issue related to the high level of consumption of free-sugars-contain- where background exposure to other forms of fluoride differs among ing drinks and foods (including complementary foods), which is the target population groups." However the universal use of encouraged by aggressive product marketing. Consequently, compre- affordable toothpastes, containing the optimum concentration of flu- hensive programmes in health and oral health promotion that promote oride for the community and having regard for the age of the child the intake of healthier foods and diets and avoid early introduction of free sugars and consumption of sugar-sweetened beverages and high Ithough other self-applied fluorides (such as mouth rinses)are sugars foods, are essential. advocacy initiatives are important to stim effective for dental caries prevention, they are usually not recom include the adjustment of agricultural policies that lead to less sugars varnishes, gels and foams can be professionally applied according to production and more sustainable crops; appropriate and context the child s individual risk. specific nutrition information and guidelines for children which are developed and disseminated in a simple understandable and accessi- 4.1.3 The parents/ caregivers and their ble manner to all target groups in society: the implementation of an environment effective tax on sugar-sweetened beverages and high sugars foods the implementation of recommendations for the marketing of foods Although sugars intake poor oral hygiene and inadequate use of flu- and nonalcoholic beverages to children to reduce their exposure to oride are rightly given prominence as primary risk factors, reasons the power of, the marketing of less healthy foods the development of for these unfavourable behaviours need to be understood if prever nutrient profiles to identify less healthy and beverages; the establish- tive strategies are to be successful. a review of these aspects of ment of global cooperation to reduce the impact of cross-border mar- ECc risk has been published by Seow et al 3. they reported that the keting of unhealthy foods and beverages; and the implementation of a rates of ecc are highest among the socially disadvantaged groups standardized global nutrient labelling system. and indigenous and ethnic minorities. For example, there is an asso- ciation between low levels of education and low family incomes with 4.1.2 Optimum exposure to fluoride a high prevalence of ECC. The adoption of durable health habits in childhood begins at te use of fluoride for the prevention of dental caries home with the parents/ caregivers, especially the mother, as she has been a major dental public health strategy Methods of plays an important role in forming the child s oral health behaviours. delivering fluoride are well known, and those appropriate for the Therefore, parents/caregivers should be informed that their ownnondesirable weight gain, obesity and associated noncommunicable diseases (NCDs). Worldwide obesity has more than doubled since 1980, and 41 million children under the age of 5 years were reported as being overweight or obese in 2014.29 Oral health promotion should therefore be integrated with general health promotion through a com￾mon risk factor approach.30 Specific issues with the consumption of free sugars by infants and young children were recognized. The first was the addition of free sugars to feeding bottles. This habit was wide￾spread but unnecessary in many cultures and regions. The second issue related to the high level of consumption of free-sugars-contain￾ing drinks and foods (including complementary foods), which is encouraged by aggressive product marketing. Consequently, compre￾hensive programmes in health and oral health promotion that promote the intake of healthier foods and diets and avoid early introduction of free sugars and consumption of sugar-sweetened beverages and high sugars foods, are essential. Advocacy initiatives are important to stim￾ulate relevant political action. Comprehensive programmes may include the adjustment of agricultural policies that lead to less sugars production and more sustainable crops;31 appropriate and context￾specific nutrition information and guidelines for children, which are developed and disseminated in a simple, understandable and accessi￾ble manner to all target groups in society; the implementation of an effective tax on sugar-sweetened beverages and high sugars foods; the implementation of recommendations for the marketing of foods and nonalcoholic beverages to children to reduce their exposure to the power of, the marketing of less healthy foods; the development of nutrient profiles to identify less healthy and beverages; the establish￾ment of global cooperation to reduce the impact of cross-border mar￾keting of unhealthy foods and beverages; and the implementation of a standardized global nutrient labelling system.32 4.1.2 | Optimum exposure to fluoride The appropriate use of fluoride for the prevention of dental caries has been a major dental public health strategy.33,34 Methods of delivering fluoride are well known, and those appropriate for the prevention of ECC were considered in more detail. These included fluoride delivered through either water, salt or milk, fluoridated toothpaste and intra-oral topical fluoride application.24 Exposure to optimum fluoride concentration in drinking water from birth not only benefits the primary dentition, helping to control ECC, but also pro￾vides some pre-eruptive effect for the permanent teeth.35-38 Where salt is used as a vehicle for fluoride, the WHO Guideline on Sodium Intake must be considered.39 Salt intake at a country level should be monitored so that adjustments can be made if required, the levels of fluoride in the salt, to ensure that the population is receiving opti￾mum levels of exposure to fluoride. Evidence is available that, for children younger than 6 years, the use of fluoridated toothpaste is effective in caries control.40 How￾ever, ingesting excessive amounts can lead to mild fluorosis. To mini￾mize the risk of enamel fluorosis in children while maximizing the caries-prevention benefit for all age groups, the appropriate amount should be used by all children. Guidance on the use of fluoridated toothpaste for young children differs from country to country. The greatest variations are found in the age at which its use should begin, recommendations on the concentration of fluoride that should be used, and in the amount of toothpaste placed on the brush. For example, it is recommended that parents should brush their chil￾dren’s teeth twice daily using a “smear” or “rice-size” amount of fluo￾ridated toothpaste (0.1 mg F) for children aged 3 years and under and a “pea-size” amount of fluoridated toothpaste (0.25 mg F) for children aged 3-6 years.41,42 Variation in guidance can be expected where background exposure to other forms of fluoride differs among the target population groups.24 However, the universal use of affordable toothpastes, containing the optimum concentration of flu￾oride for the community and having regard for the age of the child, is an essential public health goal. Although other self-applied fluorides (such as mouth rinses) are effective for dental caries prevention, they are usually not recom￾mended for use by children younger than 6 years of age. Fluoride varnishes, gels and foams can be professionally applied according to the child’s individual risk. 4.1.3 | The parents/caregivers and their environment Although sugars intake, poor oral hygiene and inadequate use of flu￾oride are rightly given prominence as primary risk factors, reasons for these unfavourable behaviours need to be understood if preven￾tive strategies are to be successful. A review of these aspects of ECC risk has been published by Seow et al43; they reported that the rates of ECC are highest among the socially disadvantaged groups and indigenous and ethnic minorities. For example, there is an asso￾ciation between low levels of education and low family incomes with a high prevalence of ECC.43 The adoption of durable health habits in childhood begins at home with the parents/caregivers, especially the mother, as she plays an important role in forming the child’s oral health behaviours. Therefore, parents/caregivers should be informed that their own TABLE 2 Overview of risk factors and underlying determinants of ECC Free sugars added to baby bottles Free sugars in foods and drinks Nonuse and nonavailability of fluoridated toothpaste Social determinants: family, culture and environment Genetic susceptibility Hypoplasia of enamel Nutritional status of mother and infant Oral flora Poor oral hygiene and control of dental plaque Breastfeeding—beyond 12 months, especially if frequent and/or nocturnal Saliva—quantity (reduced flow) and constituents (particularly variations in proteins present) 284 | PHANTUMVANIT ET AL