Interventions with pregnant women, new mothers and other primary caregivers for preventing tooth decay in young children

Does providing basic dental care and/or oral health information to pregnant women, new mothers and primary caregivers prevent tooth decay in young children?

Key messages

• Providing information to pregnant women, mothers and caregivers about a healthy child's diet and feeding methods, such as breastfeeding, bottle-feeding and solid food introduction, could slightly reduce the risk of tooth decay in young children.

• More research is needed to understand the benefits and harms of different types of support programmes, especially for children in low-income settings, that have the potential to prevent early tooth decay.

Why is it important to prevent tooth decay in young children?

From birth to six years, tooth decay (often called early childhood caries) is common and generally worse for children living in poverty. Tooth decay causes pain, it can have long-lasting negative effects on child health, and it is expensive to treat.

What causes tooth decay in young children?

Sugar and plaque (a layer of bacteria on the teeth) cause tooth decay. However, the attitudes, beliefs, and habits of pregnant women, mothers and other caregivers influence whether tooth decay is likely to occur in their children.

What did we want to find out?

We wanted to know which programmes for pregnant women, new mothers and other caregivers of children (up to 1-year-old) prevent tooth decay and reduce the number of decayed teeth, missing teeth, and fillings required.

Programmes included:

• dental care treatments;

• oral (mouth) health and dietary education/promotion;

• policy or health service changes to make it easier to access dental care.

We also wanted to find out if there were harmful effects of these programmes when delivered on their own or in combination.

What did we do?

We searched for studies that compared the programmes we were interested in up to 3 January, 2023 against:

• usual care;

• a placebo (pretend treatment that looks the same as the one being tested); or

• other programmes.

We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sample sizes.

What did we find?

We found 23 studies conducted across 12 countries involving 25,930 caregivers (mainly pregnant women or new mothers) and their children. Programmes included oral health and dietary education/promotion (15 studies), dental care treatments (6 studies), and a combination of both (2 studies). The length of programmes ranged from two weeks to three years. No studies examined policy or health service changes designed to improve dental care access.

Caregivers and children were from low-income communities in 13 studies and mainly from high-income communities in one study. Most studies reported how they were funded, with two supported by companies in the oral hygiene industry. However, this was unlikely to have influenced findings in those studies, although this was not stated by the authors.

Main results

In oral health and dietary education/promotion programmes compared against usual care, the risk of tooth decay in children up to the age of 1:

• is probably reduced slightly when caregivers received advice about child diet and infant/child feeding practice (3 studies, 782 participants).

• did not appear to make a difference when caregivers received breastfeeding support (2 studies, 1148 participants), advice about child diet (1 study, 148 participants), or advice about child diet, feeding and teeth cleaning (5 studies, 1326 participants).

We do not know if giving mothers a high or low dose of vitamin D supplements while pregnant has an effect on the risk of tooth decay (1 study, 496 participants) either.

There were mixed findings in dental care programmes comparing the application of teeth varnish against a placebo (4 studies, 632 participants), or chewing gums containing different dental gels (2 studies, 361 participants) to reduce bacteria in the mother’s mouth. It is unclear if these could prevent tooth decay in young children. We also do not know if programmes combining oral health education and dental care treatments, compared against usual care (2 studies, 324 participants), have an effect on the risk of tooth decay.

Only four studies reported whether caregivers or children experienced any harmful effects. For the mouth health and dietary education programmes, no harmful effects were reported. Some minor harmful effects, such as a burning sensation and nausea, were reported by some mothers who received dental treatments.

What are the limitations of the evidence?

We are moderately confident that providing dietary advice and feeding practice to caregivers can probably reduce the risk of tooth decay in young children. However, we have little to very little confidence about the evidence for most of the other findings. This is because there were many differences between studies in the types of programmes examined, and few studies investigated the same programme or combination of programmes.

How up to date is the evidence?

This review updates our previous review which was up to date to 3 January 2023. We are aware of 13 ongoing studies, and we plan to include these in the next update.

Authors' conclusions: 

There is moderate-certainty evidence that providing advice on diet and feeding to pregnant women, mothers or other caregivers with children up to the age of one year probably leads to a slightly reduced risk of early childhood caries (ECC). The remaining evidence is low to very-low certainty and is insufficient for determining which, if any, other intervention types and features may be effective for preventing ECC, and in which settings.

Large, high-quality RCTs of oral health education/promotion, clinical, and policy and service access interventions, are warranted to determine the effects and relative effects of different interventions and inform practice. We have identified 13 ongoing studies. Future studies should consider if and how effects are modified by intervention features and participant characteristics (including socioeconomic status).

Read the full abstract...
Background: 

Dental caries, a common chronic disease of childhood, is associated with adverse health and economic consequences for infants and their families. Socioeconomically disadvantaged children have a higher risk of early childhood caries (ECC). This review updates one published in 2019.

Objectives: 

To assess the effects of interventions undertaken with pregnant women, new mothers or other primary caregivers of infants in the first year of life, for preventing ECC (from birth to six years).

Search strategy: 

We searched Cochrane Oral Health's Trials Register, Cochrane Pregnancy and Childbirth's Trials Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL EBSCO, the US National Institutes of Health Ongoing Trials Register (clinicaltrials.gov) and WHO International Clinical Trials Registry Platform (apps.who.int/trialsearch). The latest searches were run on 3 January, 2023.

Selection criteria: 

Randomised controlled trials (RCTs) comparing interventions with pregnant women, or new mothers and other primary caregivers of infants in the first year of life, against standard care, placebo or another intervention, reporting on a primary outcome: caries presence in primary teeth, dmfs (decayed, missing, filled primary surfaces index), or dmft (decayed, missing, filled teeth index), in children up to six years of age. Intervention types include clinical, oral health promotion/education (hygiene education, breastfeeding and other dietary advice) and policy or service.

Data collection and analysis: 

Two review authors independently assessed study eligibility, extracted data, assessed risk of bias, and assessed certainty of evidence (GRADE).

Main results: 

We included 23 RCTs (5 cluster-randomised), involving 25,953 caregivers (mainly mothers) and their children. Fifteen trials assessed oral health education/promotion interventions against standard care. Six trials assessed a clinical intervention for mother dentition, against placebo, or a different type of clinical intervention. Two trials assessed oral health/education promotion plus clinical intervention (for mother's dentition) against standard care. At most, five trials (maximum of 1326 children and 130 mothers) contributed data to any comparison. Enamel-only caries were included in the diagnosis of caries in some studies. For many trials, the risk of bias was unclear due to lack of methodological details reported. In thirteen trials, participants were socioeconomically disadvantaged. No trial indicated receiving funding that was likely to have influenced their results.

Oral health education/promotion interventions

Child diet and feeding practice advice versus standard care: We observed a probable 15 per cent reduced risk of caries presence in primary teeth with the intervention (RR 0.85, 95% CI 0.75 to 0.97; 3 trials; 782 participants; moderate-certainty evidence), and there may be a slightly lower mean dmfs (MD -0.29, 95% CI -0.58 to 0; 2 trials; 757 participants; low-certainty evidence); however, the evidence is very uncertain regarding the difference between groups in mean dmft (MD -0.90, 95% CI -1.85 to 0.05; 1 trial; 340 participants; very low-certainty evidence).

Breastfeeding promotion and support versus standard care: We observed little or no difference between groups in the risk of caries presence in primary teeth (RR 0.96, 95% CI 0.89 to 1.03; 2 trials; 1148 participants; low-certainty evidence) and in mean dmft (MD -0.12, 95% CI -0.59 to 0.36; 2 trials; 652 participants; low-certainty evidence). dmfs was not reported.

Child diet advice compared with standard care: We are very uncertain about the effect on the risk of caries presence in primary teeth (RR 1.08, 95% CI 0.34 to 3.37; 1 trial; 148 participants; very low-certainty evidence). dmfs and dmft were not reported.

Oral hygiene, child diet and feeding practice advice versus standard care: The evidence is very uncertain about the effect on the risk of caries presence in primary teeth (RR 0.73, 95% CI 0.50 to 1.07; 5 trials; 1326 participants; very low-certainty evidence) and there maybe little to no difference in mean dmfs (MD -0.87, 95% CI -2.18 to 0.43; 2 trials; 657 participants; low-certainty evidence) and mean dmft (MD -0.30, 95% CI -0.96 to 0.36; 1 trial; 187 participants; low-certainty evidence).

High-dose versus low-dose vitamin D supplementation during pregnancy: We are very uncertain about the effect on risk of caries presence in primary teeth (RR 0.99, 95% CI 0.70 to 1.41; 1 trial; 496 participants; very low-certainty evidence). dmfs and dmft were not reported.

Clinical interventions (for mother dentition)

Chlorhexidine (CHX, a commonly prescribed antiseptic agent) or iodine-NaF application and prophylaxis versus placebo: We are very uncertain regarding the difference in risk of caries presence in primary teeth between antimicrobial and placebo treatment for mother dentition (RR 0.97, 95% CI 0.80 to 1.19; 3 trials; 479 participants; very low-certainty evidence). No trial reported dmfs or dmft.

Xylitol compared with CHX antimicrobial treatment: We are very uncertain about the effect on caries presence in primary teeth (RR 0.62, 95% CI 0.27 to 1.39; 1 trial, 96 participants; very low-certainty evidence), but we observed there may be a lower mean dmft with xylitol (MD -2.39; 95% CI -4.10 to -0.68; 1 trial, 113 participants; low-certainty evidence). No trial reported dmfs.

Oral health education/promotion plus clinical interventions (for mother dentition)

Diet and feeding practice advice for infants and young children plus basic dental care for mothers compared with standard care: We are very uncertain about the effect on risk of caries presence in primary teeth (RR 0.44, 95% CI 0.05 to 3.95; 2 trials, 324 participants; very low-certainty evidence) or on mean dmft (1 study, not estimable). No trial reported dmfs.

No trials evaluated policy or health service interventions.