The Development of Oral Functions in Children: A Clinical Study of Stomatognathic Dysfunction

*Ichiro Nakajima, Ryosuke Koshi, Atsushi Uchida and Taketo Yamaguchi*

#### **Abstract**

In most countries that have reached an aging society, the feeding function among the elderly population has declined and become a serious problem. Therefore, understanding the development of human oral function is required to address this problem. However, only a few research studies have reported oral motor functions and dysfunctions in children. Our chapter describes the relationship between oral motor functions (chewing, swallowing, and breathing) and maxillofacial morphology in children. In addition, case studies on children with cerebral palsy and sleep aspiration disorders will also be introduced. This study would also like to clarify the significance of human oral function development from infancy in pediatric dentistry.

**Keywords:** child, oral function, obstructive sleep apnea, cerebral palsy, achondroplasia

#### **1. Introduction**

Oral diseases include dental caries, periodontal (gum) disease, tooth loss, oral cancer, orodental trauma, and normal and birth defects such as cleft lip and palate [1]. These diseases have been known to be preventable by oral care [2]. Recently, most countries with aging societies implemented dental care significantly and strategically preventing age-related decline in oral functions [3, 4].

Oral health is a fundamental component of overall health. All children and youth should have access to preventive and treatment-based dental care. However, some children have difficulty availing of oral care and dental treatment due to their systemic disease or disability [5, 6]. Thus, caring and supporting for their oral functions remain unclear. Particularly, only a few studies have been conducted on the causes of oral dysfunctions in children with developmental motor dysfunction (i.e., cerebral palsy [CP], muscular dystrophy, etc.) and congenital malformation (achondroplasia, ectodermal dysplasia, etc.).

To clarify the relationship between systemic symptoms and oral dysfunction, symptoms of sensory-motor dysfunctions in CP and congenital malformation in achondroplasia have been examined, respectively.

Therefore, this chapter reviews the findings of previous studies and discusses the importance of establishing clinical research on oral dysfunctions in children with congenital diseases.

The contents of this chapter are as follows:


This chapter is believed to include useful content as a reference for clinical research on oral functions in children with disabilities.

#### **2. Development of eating behavior**

In this section, we briefly review the eating behavior development from the neonatal period in humans.

Oral functions consist of eating (breastfeeding and mastication), swallowing, and pronunciation/speech. The key to eating function development is the transition from breastfeeding to mastication behavior. Breastfeeding is an eating function composed of primitive reflexes, whereas mastication is a learning behavior composed of voluntary movement and chewing rhythm. In this section, we briefly describe the feeding function changes from the fetal to the neonatal to the weaning period.

#### **2.1 Breastfeeding/suckle**

The human jawbone is already formed around the 6th week of embryonic development. Moreover, the tooth germ formation of the primary teeth also begins around the 7th week. The calcification of the primary teeth begins around the 4th month. Since birth, a primitive reflex enables a newborn to suckle [7].

A newborn's oral cavity is sensitive and reflexive. For example, the sucking reflex is easily elicited by stimulating (tactile/chemical) the palate with the nipple.


The intermaxillary space and the presence of a sucking fossa in the palate are suitable forms for breastfeeding. During sucking, the tongue presses the nipple against the sucking fossa at the center of the palate (**Figure 1A**). The intermaxillary space is found in the anterior alveolar ridge of the upper and lower jaws before the primary tooth eruption. A newborn baby can use that space to hold the nipple (**Figure 1B**).

*DOI: http://dx.doi.org/10.5772/intechopen.108676 The Development of Oral Functions in Children: A Clinical Study of Stomatognathic Dysfunction*

#### **Figure 1.**

*Features of oral morphology for breastfeeding in newborns. A: sucking fossa, B: intermaxillary space, C: Tongue movement during breastfeeding.*

The baby makes peristaltic movements from the tip of the tongue to the base of the tongue, creating negative pressure in the oral cavity and ingesting milk (**Figure 1C**).

Recently, Shiv Shankar Agarwal et al.'s cross-sectional retrospective study reported that children breastfed for <6 months had an almost twofold increased probability of developing sucking habits and non-spaced dentition than those who breastfed for >6 months duration [8]. Their data suggest the possibility that nonnutritive sucking habits may act as a dominant variable in the relationship between breastfeeding duration and occurrence of convex facial profile and disocclusion in deciduous dentition.

Furthermore, the study also evaluated the effects of breastfeeding and bottle feeding methods, such as bottle and cup feeding, on infant masticatory muscle activity, indicating that masticatory muscle activity is relatively high during breastfeeding. In any case, the oral function development in humans is thought to involve the suckling condition.

#### **2.2 Mastication/chewing**

Transitioning from sucking to mastication is a characteristic eating behavior change in mammals including humans. Tooth eruption and the associated stimulation from the surrounding tissue of the periodontal membrane are believed to be associated with the initiation of mastication (**Figure 2**). The weaning period is very important for the beginning of mastication.

At 5–6 months post-birth (weaning period), the upper and lower anterior teeth erupt, making it easier to separate the lip and tongue movements.

The changes observed during this period are as follows:

1.Expansion volume of the oral cavity.

2.Easier up and down movement of the tongue.

3.Mature swallowing with closing lips.

4.Crushing food with the tongue and alveolar ridge.

5.Crushing food with the teeth.

The upper and lower second primary molars erupt around age 2 years and 6 months, and the occlusion of 20 primary teeth is completed around 3 years (**Figure 3**).

With the second primary molar eruption, the masticatory force is believed to be increased. Biting force is further increased when the first permanent molars are occluded at 6 years, resulting in the establishment of mastication corresponding to growth during school age.

Recently, Nabeel et al. conducted a systematic review of jaw movements, bite force, and electromyograms of mastication from children aged <6–18 years [9].

They demonstrated that after 12 years, a significant increase in bite forces and electromyogram (EMG) activities occurred, and the frontal jaw pattern became similar to that of adults, suggesting that mastication gradually improves with the development of orofacial structures and was mainly influenced by a dental eruption.

As described in this section, an oral or stomatognathic function can be considered to be closely associated with nervous and muscular development as well as maxillofacial, oral cavity, and tooth growth.

**Figure 2.** *Eruption of primary incisors.*

**Figure 3.** *Primary dentition occlusion.*

*DOI: http://dx.doi.org/10.5772/intechopen.108676 The Development of Oral Functions in Children: A Clinical Study of Stomatognathic Dysfunction*

#### **3. Cerebral palsy (CP)**

CP is a nonprogressive disorder that affects the motor system that moves the body due to a defect in the central nervous system (CNS). The defect might be before or at the time of or after the time of child's delivery [10]. The manifestation of CP is varied and depends upon the subtypes of CP. Motor system is the predominantly affected system with altered muscle tone, abnormal monosynaptic and polysynaptic reflexes, altered motor control and motor learning. The defects don't limit itself to the limbs and the trunk but also affect the face muscles, jaw muscles, which are closely associated with the head and neck muscles. Patients with CP were known to have lower feeding function than healthy subjects [11]. All clinical studies in this section were performed with ethics committee approval.

#### **3.1 Masticatory efficiency and bite force**

Nakajima et al. examined the relationships between masticatory efficiency, bite force, and masticatory rhythm in children with CP, comparing them with those in healthy children [12].

**Table 1** shows the results of the comparison of masticatory efficiency and maximum bite force between children with CP and healthy children. The age ranges of children with CP and healthy children were 6–15 (mean age, 10) years) and 6–15 (mean age, 10) years, respectively. Adenosine triphosphate granules were used as mastication samples, and the amount of pulverization was measured based on absorbance.


#### **Table 1.**

*Comparison between children with cerebral palsy and healthy children in masticatory efficiency and maximum biting force.*

As shown in **Table 1**, children with CP have significantly lower masticatory efficiency and bite force than healthy children of the same age. In the healthy children group, a significant correlation was also obtained with a correlation coefficient of 0.568 between the two indices (p < 0.01). Conversely, in children with CP, no significant correlation was observed with a correlation coefficient of −0.173 (p > 0.05).

These findings indicated that the muscle strength of mastication in CP may not be sufficiently developed to crush the mastication sample, as compared with their healthy counterpart.

Electromyogram (EMG) of the masticatory muscles (temporal and masseter muscles) during the masticatory efficiency measurement was recorded in the experiment. EMG data showed that children with CP had an unstable chewing rhythm compared to healthy children, suggesting an oral-facial sensation dysfunction that controls mastication.

#### **3.2 Orofacial sensation**

Patients with CP tend to develop accentuated involuntary muscle tonus in orofacial muscles during mastication. The muscle tonus abnormality is considered to affect oral sensation and a factor in reducing the eating function of patients with CP.

Therefore, Yoshida et al. investigated abnormalities in the lower-jaw-position sensation in patients using a lower-jaw-position discrimination test [13].

In that study, the mandibular position sensation was measured for adults with CP (CP group) and healthy adults (control group) using the following method.

This test was performed based on the extent of mouth opening to estimate a sensation associated with elongation of muscle spindles in masticatory muscles.

In the test, the participants were asked to hold a 10.0-mm metal rod (reference mouth opening) between the upper and lower incisors for several seconds and memorize its thickness. Thereafter, they were asked to hold another 0.5-mm-thick or thin metal rod and to answer whether these rods were "larger" or "smaller" than the standard mouth opening to count the wrong answers to examine the rate of miss estimate (RME).

**Figure 4** shows the comparison between both groups based on RME data.

The RMEs of patients with CP were higher than those of healthy participants for jaw opening magnitudes, suggesting that some abnormalities exist in the mandibular sensation afferent system from the peripheral to CNS in patients with CP.

This phenomenon might be explained by the excessive excitation of the gamma motor nerves of muscle spindles, considering that the RME is extremely high at rods lower than the reference rod.

In other words, it is conceivable that patients with CP remain more sensitive to oral sensation than healthy participants.

Morimoto et al. reported that vibrating stimuli in healthy adults decreased the mandibular position sensation and considered that this phenomenon was caused by the regulation of the mandibular position sensation by muscle spindles [14]. Therefore, we also investigated the RME of mandibular position sensation by applying vibration stimulation to determine whether muscle sensory abnormalities in patients with CP are related to muscle spindles.

**Figure 5** shows the comparison between both groups based on RME data after the vibration stimulation. No significant differences were observed between two groups for any interincisal distances (p > 0.05).

#### **Figure 4.**

*Comparison between CP and control groups in R.M.E. for jaw position sense. Adapted from reference [13].*

*DOI: http://dx.doi.org/10.5772/intechopen.108676 The Development of Oral Functions in Children: A Clinical Study of Stomatognathic Dysfunction*

#### **Figure 5.**

*Comparison between CP and Control groups in R.M.E of jaw position sense after vibration stimulation Adapted from reference [13].*

When the discrimination ability of patients with CP was compared before and after the stimulus application, it was found to be significantly higher after the stimulation than before the stimulation when the interincisal distance was smaller (9.5 mm) than that with the reference stick (p < 0.05).

Conversely, in healthy participants, it was significantly lower after the stimulus than before the stimulus when the interincisal distance was smaller (9.5 mm) than that with the reference stick (p < 0.05).

Generally, it is known that following the application of vibration stimulus to voluntary muscles including the masticatory muscle and these muscles exhibit tonic vibration reflex (TVR) in which the muscles slowly shrink [14].

Vibration stimulation increases the excitability of muscle spindles and increases the impulse of GIa afferent nerve fibers. As the next step, monosynaptically connected alpha motor neurons are excited, causing continuous muscle contraction.

Assuming that TVR was expressed in both CP and control groups in the experiment, the result may suggest that the effect of TVR-induced muscle sensation was different between the two groups.

It was noteworthy that the discrimination ability in patients with CP increased by the vibration stimulation. Recently, vibration therapy is increasingly used to reduce signs and symptoms associated with this developmental disability [15]. These findings may support the effectiveness of these vibration therapies for orofacial muscles to improve oral functions in patients with CP.

#### **3.3 Dental treatment and oral health care**

Oral care and dental treatment are very important for patients with CP to maintain oral function. In dental clinics, patients with CP tend to accentuate involuntary muscle tonus in orofacial and other muscles when they must hold their jaw open, such as during teeth cleaning and dental treatment.

This abnormal muscle activity causes muscle fatigue and mental stress for patients. Clinically, drug-induced sedation is used for patients with CP; however, no studies have examined its effects in detail. Therefore, to investigate how to control the muscle tonus, the authors investigated the effects of laughing gas (N2O) inhalation sedation on orofacial muscle tonus using EMG as an index [16]. In this study, the mean frequency of orofacial muscle EMG discharge was measured with other sedative indexes,

#### **Figure 6.**

*The comparison of reduction rate of mean frequency between CP and MR groups during inhalation of N2O Adapted from reference [14].*

blood pressure, and heart rate. The study patients were 15 patients with CP and 15 with mental retardation (MR) as the control. By forcing the jaw opening for dental treatment, the enhanced level of the mean EMG frequency was higher in patients with CP than in those with MR. After N2O inhalation, the mean frequency was significantly reduced in both patients with CP and MR.

**Figure 6** shows the comparison of the reduction rate of mean frequency in patients with CP and MR. As shown in **Figure 7**, N2O selectively suppressed the muscle tonus in patients with CP.

In general, γ motor neuron blocking with phenol is a commonly used method to suppress accentuation of the limb skeletal muscles in patients with CP.

Therefore, hyperactivities of γ motor neurons may be involved in the increased muscle tonus of the orofacial area in patients with CP. The presence of muscle spindles has also been confirmed in the masseter muscle. However, the present study demonstrated that N2O also suppressed the muscle tonus in the frontalis and digastric muscles, which are thought to have no muscle spindles innervated by γ motor neurons.

Therefore, these results indicated the possibility that N2O suppressed the functions of the upper central nervous system related to the accentuation of the muscle tonus.

#### **4. Obstructive sleep apnea in achondroplasia children**

Sleep-related breathing disorders (SRBDs) during childhood are known to cause growth failure because of disturbed sleep and growth hormone secretion rhythm [18].

Furthermore, sleep-disordered breathing has also been found to affect brain development [18].

There is strong evidence that childhood SRBDs are associated with behavioral and emotional regulation, scholastic performance, sustained attention, selective attention, and alertness deficits. Failing to treat SDB appears to leave children at risk for long-term neurobehavioral deficits. Thus, a research platform has been created to validate the diagnosis and treatment of sleep apnea during childhood.

Obstructive sleep apnea (OSA) is classified as one of the SRBDs occurring when there are recurrent episodes of upper airway collapse and obstruction during sleep associated with arousals with or without oxygen desaturations.

*DOI: http://dx.doi.org/10.5772/intechopen.108676 The Development of Oral Functions in Children: A Clinical Study of Stomatognathic Dysfunction*

Achondroplasia (hereinafter referred to as AP) is an autosomal dominant genetic disease with an incidence rate of 1 per 10,000 people.

There are abnormalities such as growth failure [19]. OSA symptoms have been reported in children with AP [20]. However, the relationship between OSA symptoms and maxillofacial morphology in children with AP is not yet sufficiently clarified. Therefore, A fact-finding survey on OSA symptoms for achondroplasia was implemented [21], and factors of maxillofacial morphology that cause apnea were analyzed using cephalometric X-ray data [22].

#### **4.1 Respiratory symptoms and oral findings**

A questionnaire survey was performed on a total of 30 children with AP (AP group), comprising 20 preschool and 10 school-aged children. The control group consisted of healthy kindergarten, primary school, and junior high school children to compare the incidence of snoring, apnea, mouth breathing, and malocclusion. Data from the control group were also obtained from the results of a questionnaire survey of kindergarten, primary school, and junior high school children, a survey of physical growth of preschool children, and a survey by the Japanese Society of Pediatric Dentistry. Except for the height and weight at birth, children aged 1.5 and 3 years were significantly smaller than those in the control group, except for the birth weight in the AP group.

**Table 2** shows the incidences of snoring, apnea, mouth breathing, and cross/open bite at both preschool and school ages in the AP and control groups, respectively.


#### **Table 2.**

*Symptoms in children with achondroplasia.*

At preschool age, the incidences of snoring, apnea, mouth breathing, and cross/ open bite were significantly higher in the AP group than those in the control group, respectively (P < 0.01). At school age, the incidences of mouth breathing and cross/ open bite in the AP group were significantly higher than those in the control group, respectively (P < 0.01). The incidence of snoring and apnea was higher than those in the control group, respectively (P < 0.05).

As a result of comparing the two groups, the AP group showed significantly higher incidences of snoring, apnea, mouth breathing, and reverse or open bite in infants and schoolchildren than those in the control group.

#### **4.2 Craniofacial morphology (CFM)/airway morphology (AWM) in children with AP and healthy children**

**Figure 7** shows the measurement points of cephalometric photography.

#### **Figure 7.**

*Measurement items (A) Maxillofacial morphology (B) Airway morphology. Adapted from reference [17].*

**Table 3** shows the comparison between children with AP and healthy groups in the measurement items of craniofacial/airway morphology.

In CFM, values for facial depth, nasal floor length, point A, point pog, and saddle angle were significantly lesser (p < 0.01), and those for mandibular plane angle and gonial angle were remarkably greater (p < 0.01) among AP group compared to the healthy. In AWM, D-AD1, D-AD2, and upper pharynx values were significantly lesser (p < 0.05among AP group.

These findings have been reported as common features in the unique facial features of children and adults with OSA [23].

The AP group showed CFM/AWM that was characteristic of upper airway stenosis, a retruded chin position, and a greater mandibular plane angle because of partial early ossification of the cranial bones and an greater lower facial height because of a greater mandibular angle. This suggests that that AP group will frequently encounter sleep snoring and sleep apnea compared to the healthy.

#### **4.3 Diagnosis and treatment**

In general, pediatric patients with achondroplasia undergo surgical procedures such as adenoidectomy and tonsillectomy in the field of otorhinolaryngology.

*DOI: http://dx.doi.org/10.5772/intechopen.108676 The Development of Oral Functions in Children: A Clinical Study of Stomatognathic Dysfunction*


**Table 3.**

*Morphological features of children with achondroplasia.*

Sato et al. reported one case that adenoidectomy and tonsillectomy dilated the pharynx and improved the craniofacial and pharyngeal morphologies, apparently thus improving the sleep apnea [24].

A new diagnosis and treatment system for sleep apnea patients will be expected under the collaboration between pediatric dentistry and otolaryngology.

#### **5. Conclusions**

Clinical studies on developmental motor dysfunction are still limited. Further research developments that enable statistical review are warranted.

#### **Acknowledgements**

This work has received funding from the Nihon University School of Dentistry.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Notes/thanks/other declarations**

We thank the staff of Nihon University Dental Hospital for their support.

*Pediatric Dentistry - A Comprehensive Guide*

### **Author details**

Ichiro Nakajima1 \*, Ryosuke Koshi1 , Atsushi Uchida2 and Taketo Yamaguchi3

1 Department of Community Dentistry, Nihon University School of Dentistry, Tokyo, Japan

2 Department of Dentistry, Saitama, Japan

3 Department of Dentistry, Saitama Prefecture Kaikoen, Saitama, Japan

\*Address all correspondence to: nakajima.ichirou@nihon-u.ac.jp

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*The Development of Oral Functions in Children: A Clinical Study of Stomatognathic Dysfunction DOI: http://dx.doi.org/10.5772/intechopen.108676*

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#### **Chapter 3**

## Perspective Chapter: Oral Health and Community Prevention in Children

*Irma Fabiola Díaz-García, Dinorah Munira Hernández-Santos, Ana Bertha Olmedo-Sánchez and Luz Elena Nápoles-Salas*

#### **Abstract**

The child population is the most affected by the presence of caries. A preventable disease, which causes pain and school absenteeism, generates a significant expense in its treatment. If left untreated, it causes early tooth loss and malocclusion. Altering the quality of life at an early age leaves sequels. Primary care is essential in the prevention of oral diseases. Contact with the health team in first-level medical units, which begins during pregnancy and continues in the following stages of the child, plays an important role in its prevention, diagnosis, and treatment. Across the health system, these primary care practitioners play an important role in children oral health which includes provide preventive care, referral to dentists or dental care providers and caries risk assessment. This team will know how to refer the child to the dentist specialized in the treatment. This strategy largely represents community prevention. To this must be added the family, and the school, making use of the promotion of oral health in favor of children. Efforts to prevent childhood dental caries cannot only focus on individuals and their biology and behaviors individually. It should consider the backup determinants of children's dental health as well.

**Keywords:** oral health, community prevention, early childhood caries, primary care, preventive dental care

#### **1. Introduction**

Children have the right to health and to enjoy their childhood in the best possible way. Healthy children have better opportunities to grow, develop, and learn and later become healthy and productive adults [1].

Child health should be understood as the necessary capacity for children or groups of children to develop and reach their potential, satisfy their needs, and develop the talents that allow them to successfully interact with their biological, physical, and social environment [2].

The period of childhood covers between 0 and 18 years. The notion of health status is different during childhood than in adulthood. Due to their development, children have a constant dynamic in their health and are exposed during this time to multiple biological, environmental, cultural, and behavioral influences. It may be that these influences become risk or protective factors and/or promoters of health [1].

Oral health plays a primary role in the physical, mental, social, and economic wellbeing of individuals and populations. The oral cavity and the structures that surround it are essential parts of the human body, an integral part of its daily functioning, and contribute substantially to the general well-being of people [3]. All children and youth should have access to preventive services and treatment-based dental care [4].

Oral health promotion plays a fundamental role in the promotion of general health, since the interrelation between oral and general health has been approved [5]. Oral health promotion aimed at the entire child population is the general objective of a public dental health system. According to the United Nations Convention on the Rights of the Child, every child has the right to good oral health [6].

The presence of caries in children increases the risk of infections, malocclusion, and feeding and language difficulties, impacting school absenteeism, general health, and family finances [7]. In addition, the presence of untreated caries is another of the great problems faced by the child population. Statistical data show that in 2015, 7.8% of the global child population (573 million children) had untreated dental caries. The prevalence of untreated caries in deciduous and permanent teeth peaks at ages 1 to 4 years and 15 to 19 years, respectively [8]. Early childhood caries (ECC) remains the most common chronic childhood disease, with almost 1.8 billion new cases per year worldwide. It affects approximately 37% of children aged 2 to 5 years in the United States, and up to 73% of socioeconomically disadvantaged preschool children in both developing and industrialized countries [9].

#### **2. Primary health care**

Primary health care (PHC) is one of the most important measures to promote the health of the population, and it represents "essential medical care". The interventions are scientifically proven. It focuses on equitable distribution, community participation, an emphasis on prevention, the use of appropriate technology, and the involvement of a wide range of other health departments [10].

The concept of primary health care (PHC) was defined at the Alma Ata conference in 1978. After the conference, the concept of PHC was gradually developed during the 1980s by the health promotion approach. Health promotion according to the WHO (1984) includes the following points: 1) health promotion involves the population as a whole, in the context of their daily lives, rather than focusing on people at risk of specific diseases; 2) it is aimed at action on the determinants or causes of health; 3) combine diverse, but complementary, methods or approaches; 4) it aims at a particularly effective and concrete public participation; and 5) health professionals have an important role in fostering and promoting health [11].

#### **2.1 Primary health care and oral health**

The evolution of this paradigm caused that, in 2009, at the seventh world conference of the WHO, dental care was integrated into primary health care services. It includes several domains, such as risk assessment, oral health assessment, preventive intervention, communication and education, as well as interprofessional collaborative practice [12].

#### *Perspective Chapter: Oral Health and Community Prevention in Children DOI: http://dx.doi.org/10.5772/intechopen.108840*

The integration of oral health into primary care has been implemented in some health care systems to reduce the burden of oral disease and improve the access to oral health care, especially for disadvantaged individuals and communities [13].

#### **2.2 Primary care and oral health in children**

In primary health care, interprofessional collaboration provided by medical personnel is a very helpful preventive strategy for children's oral health. Medical providers have numerous opportunities to see children from birth to at least 3 years old. On average, there will be 12 visits on a regular basis during this time; the medical office is a space that serves to extend access to preventive oral health services for children. Basic preventive oral care that may be provided by the physician includes as follows: 1. oral health risk assessment; 2. anticipatory oral health guidance; 3. application of fluoride varnish; 4. dental referral; and 5. prescription of fluoride supplements [12].

From the point of view of primary oral health care, what should be considered "essential" oral health care is crucial, especially in developing countries [11]. Children who had an early preventive dental visit were more likely to use preventive services later and incur lower dental costs over time [4].

The preventive services offered by the PHC are of great importance for oral health, and many mothers in the gestation stage are first attended by health workers in these centers, such as gynecologists, family doctors, nursing assistants (midwives), and activists accredited socio-sanitary, are people who come into contact with them long before a dentist. So, they can identify oral problems, such as the presence of tooth decay before a dentist. The dental surgeon must establish communication with them in such a way as to make an effective and timely referral to the dental outpatient department of a nearby public/private hospital. Therefore, it is important to meet expectant mothers/fathers-to-be at an early stage.

Untreated dental caries in mothers increases the risk of caries development among their children, as maternal transmission and early caries in children have been established. Vertical colonization of Streptococcus mutans from mother to child is well documented. Studies have shown that these Streptococcus are initially acquired by children from their mothers at around 2 years of age, which is the window of infectivity [14].

Primary care physicians frequently see children with pain due to dental cavities, as well as increased school absenteeism, eating problems, sleep loss, and risk of serious infections. The American Academy of Pediatrics (AAP) has recommended that primary care health care professionals conduct oral health risk assessments beginning at 6 months of age and refer patients to a dentist at 12 months of age [15].

#### **2.3 Primary health care and children with special needs**

For children with special care needs and for their parents, APS will help in the prevention and control of many oral ailments. Infants and children with special health care needs may be at increased risk of developing oral conditions such as delayed tooth eruption, malocclusion, tooth decay, dental abnormalities, trauma, infections, and enlarged gums. It is very important that a general health professional is aware of these conditions and makes a referral to the appropriate dental specialist.

All of the conditions these children experience are attributed to various congenital syndromes, medications, or inherent immune deficiencies and include Down syndrome, Treacher-Collin syndrome, and ectodermal dysplasia. Various medications

cause gingival enlargements; for example, dilantin (phenytoin sodium) and phenobarbital, which are prescribed for epilepsy, can cause gingival hyperplasia. It is very important that a general health professional is aware of these conditions.

These children may need regular dental referrals. Like all children, they should have their first visit within 6 months after the eruption of the first tooth or at 12 months of age. However, future visits may need to be more frequent [14].

#### **3. Community prevention**

Oral Health Promotion Programs (OHPP) for children are implemented globally in various communities and have been shown to be a useful intervention to control dental caries [5]. Dentists and oral health providers prioritize oral health promotion through education and prevention programs for all family members, children and parents, at all socioeconomic levels. Since they are the only means to avoid dental caries [16].

Unfortunately, dental programs and oral health prevention programs rarely receive the same level of attention as medical care among decision-makers when cost-effective allocation of scarce health resources is taken into account. This occurs despite statistics showing a high prevalence of oral diseases.

The 2016 Global Burden of Disease Study estimated that oral diseases affect at least 3.58 billion people worldwide. Dental caries is the most prevalent chronic disease among children, and dental care is the largest uncovered health care need [5]. It is a major public health problem [4].

#### **3.1 Working together for health**

Community participation in disease prevention is part of primary health care. To understand what it consists of, it is essential to recognize that the health of individuals and groups is defined by multiple factors, some of these determinants are very close and others far from individual control, in addition to this, there are social inequalities in health, that is, a distribution unequal opportunity to enjoy health. The impact of interventions on the different levels of health determinants is variable. Thus, policies (macroeconomic, employment, rights, etc.) influence more and more people than interventions closer to individuals [17].

Evidence of the importance of social determinants makes health a collective issue. This statement has two implications. The first is that although medical services can improve health, this is not a consequence of medicine but of all its determinants, one of which, but not the only one or the most important, is health services. The second is that health services must be reoriented to incorporate the collective dimensions of health and to address modifiable determinants from their sphere of social responsibility [18].

Oral health does not escape social determinants, for example, the population in contexts of poverty, social exclusion or low educational level, is more frequently exposed to unhealthy hygienic-dietary habits, and this situation is observed in relation to the presence of dental caries due to its multifactorial nature. Certain dietary habits increase the risk of appearance, while the frequency of brushing decreases it in the permanent dentition [7].

In the child population, oral health disparities are well documented, with low-income minority children experiencing the highest prevalence and disease of *Perspective Chapter: Oral Health and Community Prevention in Children DOI: http://dx.doi.org/10.5772/intechopen.108840*

caries [19]. In some low- and middle-income countries, the presence of caries in children aged 5 to 6 years exceeds 90%, indicating that dental caries is a permanent public health problem [5].

Evidence shows that childhood caries is associated with impaired cognitive development, increased school absenteeism, poorer school performance, increased job loss for parents, and poorer quality of life [19].

For this reason, simultaneous action at various levels is of the utmost importance, to enhance the effects of health interventions, so it is convenient to align the actions on the person and their immediate environment, such as the family and the place of study or work, with those that act further away from it, such as the policies that influence the neighborhood, the workplace, or the municipality.

Community work in favor of health is a network, and it consists of creating alliances to establish shared objectives and act cooperatively to achieve them. This network must include not only the different services involved (intersectionality) but also the community itself (community participation), since the commitment of each other will facilitate the implementation and maintenance of changes [17].

#### **3.2 Preventive community strategies for oral health in children**

Preventive dental care can significantly improve oral health in children [20]. Interventions that integrate the participation of health and non-health sectors have been shown to be more effective in preventing diseases, since they cover the complexity of the problem, promoting awareness, autonomy, and the involvement of family networks among groups of increased risk [7].

#### *3.2.1 The school and the family main actors in community health*

There is more evidence that schools and parents are needed to reinforce good practices in children. Good oral health practices in the first 5 years of a child's life are critical to lifelong oral health. Factors including toothbrushing, fluoridation, dietary advice, and visiting the dentist, among others, improve oral health and behavior [21].

Since childhood caries is a public health problem, the WHO emphasizes the urgent need to act to control it and suggests its population-based prevention, through educational interventions on oral health (such as avoiding free sugars in complementary foods and beverages, promoting breastfeeding, using toddler finger brushes or soft brushes for children twice a day) aimed at pregnant women, new mothers, and primary health care providers, as well as interprofessional education with other health professions.

The family plays an essential role in interventions to improve brushing in young children. A clear example is the result of research, which shows that toothbrushing behaviors of young children are strongly associated with those of their parents, or caregivers, and with the level of family support for brushing [19].

Various factors have been identified that affect dental caries in children, including poor oral hygiene and nutritional status, as well as the level of knowledge, habits, attitudes, and self-efficacy related to oral health among school teachers and parents. These variables must be taken into account when developing oral health education programs for preschool children.

Oral health education can be reinforced throughout the school years, an influential period in children's lives. Lifelong beliefs, positive attitudes, and personal skills develop among children during the school years. During the children's school career, oral health education should be promoted in all their courses. In addition, it must be

regularly reinforced at home with school programs designed for it. School staff and parents should be involved in the school's oral health promotion efforts [22].

#### *3.2.2 Dental and non-dental staff*

In addition, it recommends that, in order to bring childhood caries prevention measures closer to a greater number of children, they should be planned at appropriate times, such as the vaccination period. There is also a need to develop a training package for dental and non-dental staff to provide adequate prevention and management of this disease. On the other hand, interventions aimed at mothers, both during pregnancy and in the first year after childbirth, can effectively prevent this condition in a critical way [23].

#### *3.2.3 Use of fluorides*

The combination of community, professional, and individual measures to control the caries process in children is the most effective strategy, for example, promoting proper nutrition, improving diet, fluoridating water, increasing the use of topical fluorides and dental sealants by primary health care providers, and using fluoride toothpaste.

The most effective public health preventive measure against caries is water fluoridation. The cost benefit is undeniable. The application of topical fluorides in the form of varnish in children reduces caries rates, proven by strong scientific evidence. Evidence recommends twice-yearly varnish application for high-risk populations, including indigenous children. Regular use of fluoride mouth rinses has been shown to reduce dental caries in older children, independent of other sources of fluoride [4].

#### **4. Integration of oral health in general medical care: the pediatrician our ally**

Oral health is an indicator of overall health, quality of life, and well-being. Most oral diseases and conditions share modifiable risk factors with major noncommunicable diseases, such as cardiovascular disease, cancer, chronic respiratory disease, high levels of stress, and diabetes. There is a proven relationship between oral and general health. It is reported, for example, that diabetes is related to the development and progression of periodontitis. In addition, there is a causal link between high sugar consumption and diabetes, obesity, and tooth decay [24].

Pediatricians are the custodians of children's overall health and are the ideal health care staff to impart information and instructions on oral health care to this child population. This is mostly due to the number of children seen by pediatricians, which is much higher than what general dentists see. However, it is a responsibility that must be shared between these three professions, the dentist, the pediatrician, and the general practitioner. Many of the aspects that pediatricians can observe and that may go unnoticed by dentists are issues such as diet, weight, maturation, vaccines, different diseases, and growth [25].

#### **4.1 Gap in pediatric knowledge about oral health**

Pediatricians have begun to play an important role in promoting oral health in their patients, taking preventive measures such as monitoring, referral to dental

#### *Perspective Chapter: Oral Health and Community Prevention in Children DOI: http://dx.doi.org/10.5772/intechopen.108840*

services, and prior oral health counseling. However, it must also be recognized that there is also some limitation on the part of pediatricians, both in knowledge and in understanding certain clinical areas that are critical. This include differentiating the first clinical signs of dental caries, which is the recommended age to go to the dentist for the first time, the transmission of bacteria from the mother to her baby as part of the etiology of caries, and the use of fluoride [26].

The problem is serious because, if pediatricians do not identify certain factors, they will not refer these patients to a dentist, which has the consequence that there is no preventive care, and this being an important element for the oral care of children. To this is also added that sometimes the communication between the pediatrician and the dentist is not completely coordinated. This is because many pediatricians do not consider referring patients to the dentist as a necessity as soon as oral ailments are detected [27].

#### **5. Oral health disparities at an early age**

Oral diseases in children are an urgent public health problem worldwide. It is estimated that early childhood caries affects around 600 million children worldwide, but this condition is entirely preventable. Dental health professionals around the world must act to improve the use of prevention measures and quality dental health care to improve global oral health [28].

Most children in the United States have benefits for having good oral health, such as a socially acceptable smile, frequent visits to the dentist directly, as well as not suffering from pain in their teeth. Many of them have the health insurance that parents have, which partially covers the cost of treatment [29].

In a systematic review in which 72 articles were included, it was determined that the prevalence of early childhood caries amounted to 98%, being present in children ranging from 4 to 12 years of age [30]. Mainly the groups of children with low socioeconomic status and people with a lower degree of education are affected. Oral diseases are expensive to treat, which is why they seriously affects the most disadvantaged population [31].

#### **5.1 Social gradients in health**

Different studies show a strong association between economic position and the prevalence of oral diseases, which has been named "social gradient in health" [32].

While social gradients in perceived oral health and overall health exist in adult and child populations, not many studies have evaluated whether social gradients exist in a low-income population, specifically in a community of low-income mothers and their young children. It is important to know this perspective from the course of life, since mothers are the main source of transmission of tooth decay bacteria to their children. If there are social gradients in the oral health of low-income mothers, these gradients can be passed on to their young children and persist into adulthood [33].

Policies should focus on improving oral health education, as this could lessen gradients in oral health in low-salary mothers and their kids. Strong connection has been found between maternal-dental education and general health. If associations are causal, attempts to rise the education of low-income mothers can lead to have a better progress in their oral health. This result can break with the pattern of transmission of health gradients from education to their young children [34].

Children who are in this economic situation experience longer dental appointments to repair or remove teeth that are in an unfavorable state; in turn, they are patients who experience pain or who may be dealing with a picture of infection. These patients are usually taken to dental care under emergency and not as prevention [29].

#### **5.2 Disparities by race and ethnicity**

An ethnic group is defined as a group of people who identify with each other based on their affinities, such as the language itself, ancestral, social, national, cultural experiences, gastronomy, and religion [35].

Taking into account internationalization and the increase in migrant groups, the number of children of non-native origin will grow even more in the future, and with it the possibility of an increase in inequalities in oral health [36].

It has been reported that race and ethnicity also represent an important stratification factor for oral health disparities, as a result of an unbalanced distribution of dental services and care, as well as the economic situation among different racial communities. These groups are severely affected by tooth loss, lack of oral hygiene, tooth decay, and eating difficulties, among others [37].

There is an important theoretical and empirical literature on ethnic inequalities in health, which considers how exclusionary social processes such as labor market segregation, unemployment, income inequality, and poverty disproportionately affect racialized and immigrant groups and translate into health disparities [38].

Another difference that has been found depending on the community to which you belong is when choosing dental treatment. For example, African Americans are less likely to choose endodontic treatment than Hispanics. Also due to their economic situation, degree of education, and access to dental health, they report having worse access to oral health, a very bad perception of oral health and a high prevalence of dental caries. Language also plays an important role in gaining access to dental health. Namely, in the United States, people who do not speak English very well can face different barriers, which brings repercussions for their health [39].

#### **5.3 Actions to improve inequality in oral health**

Currently, there is considerable evidence that inequalities in oral health are attenuated with the passage from childhood to adolescence. This socioeconomic stabilizaton in health during puberty is thought to improve when the impact of the family and family environment decrease, and that school, peers, and youth culture have a special role in children's lives [40].

Puberty is a phase when behaviors related to oral health are not supervised as closely by parents as they are during infancy. School and neighborhood potentially play a bigger role that can influence oral health and related behaviors. In addition, the transition from childhood to adolescence is a period of sensitive development in oral health, a stage that is accompanied by the replacement of primary teeth with permanent teeth. A reduction in tooth decay in early adolescence may mean less lifelong exposure of permanent teeth to oral health risk factors [41].

According to The Lancet, dentistry is in crisis globally: "Current dental care and public health responses have been largely inadequate, inequitable and costly, leaving billions of people without access to even basic public oral health care" [42].

Public policies and programs focused on children's oral health generally have two main objectives: to diminish the effect of oral conditions on the community and *Perspective Chapter: Oral Health and Community Prevention in Children DOI: http://dx.doi.org/10.5772/intechopen.108840*

to lessen obstacles that restrict access to oral health services. Exemplifications are potable water, fluoridation, and education programs aimed to improve and promote oral health literacy and as a result a healthy behavior. It also includes surveillance actions to supervise trends and identify high-risk-need groups and programs that supply screening and preventive services in schools or other community spaces [43].

#### **6. Risk factors for oral diseases at an early age**

Oral health is a situation that affects both children and young people and the elderly. Efforts to improve oral health should be supported by research that includes socioeconomic, biological, and demographic factors, which increase susceptibility to develop oral diseases. Birth cohorts are longitudinal studies in which follow-up is performed from birth. This type of study is scarce, and in oral health much more. There are currently four different studies of this type: the one in the city of Pelotas in Brazil, the longitudinal study of Australian children, the Christchurch health and development study, and the Dunedin multidisciplinary development and health study [44].

The results of this study show us that various factors are involved for the development of dental caries in childhood, whether protective or risky. Oral health education and the use of dental services are influenced by the belief mainly of parents that it is not necessary to go to this type of assistance until the child starts school [44].

Tooth decay is a multifactorial disease that is affected by cariogenic plaque, fermented carbohydrates, time, a susceptible tooth, environmental factors such as saliva, fluoride availability, dental knowledge of parents, access to dental care, and socioeconomic issues [45].

The type of diet consumed in the child population plays a very important role. The intake of foods with high sugar content represents a great risk to oral health and consequently, for the subsequent development of oral diseases. These are easy to acquire, being able to generate among other aspects, caries, diabetes, hypertension, and obesity. The risk factors require a time of exposure to them to be able to cause some oral damage in individuals; that is why, at an early age, many damages cannot be easily observed, so you have a period where apparently there is no disease [46].

Malocclusions are one of the oral diseases that most affect the population, because they are multifactorial. The appearance of a malocclusion at an early age represents an indicator that this disease can be maintained at other ages and/or condition the appearance of others. This condition, in addition to causing morphofunctional damage, leaves the individual more susceptible to trauma. Several studies report that the presence of an increased highlight in children was a risk factor for suffering a traumatic injury [47].

#### **7. Oral health from childhood and healthy aging**

Oral health in childhood and early childhood play a very important role, as they are precursors of good oral health later in life. That is why children have been the main objective to promote oral health and to develop scopes to prevent oral diseases. Many resources have been researched for a better understanding of the factors that affect oral health in children, primarily preschool children, mothers, and caregivers (National Institute of Dental and Craniofacial Research [48].

As more studies show us about the effects of early-life experiences, experts are focusing on prevention and medical care, including activities that promote oral health during preconception, pregnancy, and the first 3 years of life. Health promotion activities represent a key element in decreasing morbidity, mortality, improving overall health and wellbeing [48].

A significant body of scientific evidence has established a strong relationship between oral health, overall health, and healthy aging. These tests are clear enough to justify their application in public health programs, in dental establishment, and in local groups in ways to promote healthy aging. The implementation of policies favorable to oral health would represent an effective and efficient use of public financial resources [49].

Aging is a serious global health problem for low-, middle-, and high-income countries. As we encourage the prolongation of life expectancy, this turns out as a monumental challenge. With age, a person becomes more vulnerable to the disease, and this leads to decreased intrinsic ability and functional ability [50].

It is not possible to achieve healthy aging without providing all people with access to the services and education that are necessary to maintain oral health and the functions we perform with it: eating, talking, and smiling. In ways to delay functional decline and rise people's health and well-being, it will be important not only to provide medical attention and long-term care insurance for all but also to include these systems of care into a much wider social infrastructure that therefore stimulate healthier behaviors [50].

#### **8. Conclusions**

Primary care plays a key role in the prevention of oral diseases in childhood. All primary care workers must direct their efforts so that children do not suffer from any oral disease or are diagnosed and treated early. On many occasions, they are the first contact with the future mother, with the new mother, and with the children in their early childhood. Therefore, their collaboration is invaluable to promote oral health in the family and in children.

Involve people, families, community leaders, health care practitioners, educators, and policy-makers will help in the making of a framework to be used in and with the community. Addressing disparities is recognized as a crucial part of improving oral health. This can be more efficient when used in a culturally sensitive framework that addresses concerns particular to specific communities.

Community prevention as part of primary health care involves the whole of society. The public and private health sector, the school, and the family are essential actors in health promotion. We all have the commitment to ensure a future with well-being for children. A child free of oral conditions is a child with a better chance of developing healthily.

#### **Conflict of interest**

"The authors declare no conflict of interest."

*Perspective Chapter: Oral Health and Community Prevention in Children DOI: http://dx.doi.org/10.5772/intechopen.108840*

#### **Author details**

Irma Fabiola Díaz-García\*, Dinorah Munira Hernández-Santos, Ana Bertha Olmedo-Sánchez and Luz Elena Nápoles-Salas Universidad de Guadalajara, Guadalajara, Jalisco, México

\*Address all correspondence to: irma.dgarcia@academicos.udg.mx

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Section 3
