www.fob.usp.br/revista or www.scielo.br/jaos EFFICACY OF AN ORAL HEALTH PROMOTION PROGRAM FOR INFANTS IN THE PUBLIC SECTOR EFICÁCIA DE UM PROGRAMA DE… [602540]

T
OABSTRACT
RESUMO
www.fob.usp.br/revista or www.scielo.br/jaos
EFFICACY OF AN ORAL HEALTH PROMOTION
PROGRAM FOR INFANTS IN THE PUBLIC SECTOR
EFICÁCIA DE UM PROGRAMA DE PROMOÇÃO DE SAÚDE BUCAL
EM BEBÊS NO SERVIÇO PÚBLICO
Marina de Lourdes Calvo FRACASSO1, Daniela RIOS2, Maria Gisette Arias PROVENZANO3, Suzana GOYA4
1- PhD, Student: [anonimizat], Assistant Professor at the State University of Maringá; Professo r of the Superior
Teaching Center of Maringá – PR.
2- PhD, Professor of the Superior Teaching Center of Maringá – PR.
3- MSc, Professor of the Superior Teaching Center of Maringá – PR.
4- DDS, Specialist in Community Dentistry by Bauru Dental School.
Corresponding address: M a r i n a d e L o u r d e s C a l v o F r a c a s s o – A l a m e d a O c t á v i o P i n h e i r o B r i z o l a , no 6 – 6 5 – C E P – 1 7 0 1 2 – 1 0 0
Telephone +55 (14) 3227-2665. Email: [anonimizat].
Received: May 20, 2005 – Modification: July 1, 2005 – Accepted: October 03, 2005
his study compared the caries index (dmft), presence of sucking habits and facial alterations in children attended by the
preventive program for infants and children assisted by spontaneous demand, at the same age, at the public sector of Maringá,
PR. A total of 100 children were evaluated (1-6 years), who were divided into 2 groups: GI – children attended by the infant
program with educational and preventive care and bimonthly follow-up, since the 1st y e a r o f a g e ; G I I – c h i l d r e n a s s i s t e d f o r
conventional treatment (preventive and restorative) according to the needs, and follow-up as requested by the parents. Data
collection was performed by interview with the parents and clinical examination for evaluation of the dmft and facial alteratio ns.
Analysis of data (Mann-Whitney test for dmft comparison and chi-square test for all other comparisons) demonstrated a
significant difference (p<0.05) in relation to the dmft index (GI: 0.2; GII: 3.0), percentage of caries-free children (GI: 88%; GII:
57%) and non-nutritive sucking habits (GI: 47%; GII: 75%). The breastfeeding and bottle utilization practices were similar for
both groups. Facial alterations were more frequently observed (p<0.05) in GII (48%) than GI (8.4%), especially for the variable s
(p<0.05) high arched palate (GI: 10.2%; GII: 35.4%), anterior open bite (GI: 14.2%; GII: 35.4%) and mouth breathing (GI: 6.1%;
GII: 29.1%). It was concluded that the infant program is more effective than the spontaneous demand program, reaching the
goal of oral health maintenance in the child population.
Uniterms: O r a l h e a l t h ; I n f a n t ; P u b l i c s e c t o r ; D e n t a l c a r i e s ; M a l o c c l u s i o n s .
objetivo do trabalho foi comparar o índice de cárie (ceo), presença de hábitos de sucção e alterações faciais em crianças
atendidas no programa de atendimento preventivo a bebês, com crianças atendidas por demanda espontânea, na mesma idade,
no serviço público de Maringá-PR. Foram avaliadas 100 crianças (1-5 anos), divididas em 2 grupos: GI-crianças atendidas no
programa de bebês com atendimento educativo-preventivo e retornos bimestrais, desde o 1ș ano de vida; GII-crianças atendidas
para tratamento convencional (preventivo e curativo) de acordo com a necessidade, sendo o retorno responsabilidade dos
familiares. A coleta dos dados foi realizada por meio de entrevista com os pais e através de exame clínico, para avaliação do c eo
e alterações faciais. A análise dos dados (Teste de Mann-Whitney para comparações de ceo e teste qui-quadrado para todas
outras comparações) mostrou diferença significante (p<0,05) em relação ao índice ceo (GI: 0,2; GII:3,0), componente livre de
cárie (GI:88%; GII:57%) e hábitos de sucção não nutritiva (GI:47%; GII:75%). As práticas de amamentação e uso da mamadeira
foram semelhantes nos grupos. Constatou-se maior presença de alterações faciais (p<0,05) no GII (48%) do que no GI (8,4%),
destacando-se as variáveis (p<0,05) palato ogival (GI: 10,2%; GII:35,4%), mordida aberta anterior (GI:14,2%; GII:35,4%) e
respiração bucal (GI: 6,1%; GII: 29,1%). Concluiu-se que o programa de atendimento a bebês é mais efetivo que o atendimento
de demanda espontânea, cumprindo o objetivo de manutenção da saúde bucal na população infantil.
Unitermos : Saúde bucal; Bebê; Serviço público; Cárie dentária; Maloclusões.
372J Appl Oral Sci. 2005;13(4):372-6

INTRODUCTION
The early childhood may be regarded as the most
important period for the future of oral health, since during
this stage the children’s teeth erupt, are colonized by bacteria,
and there is establishment of the diet and hygiene habits
that will define the oral health conditions of the individual2.
Thus, the early care, by dentistry for infants, whose goal is
to provide ideal conditions for proper cranial-facial
development, plays an important role for oral health
prevention and promotion18.
The American Academy of Pediatric Dentistry18 (2001)
recommends that the first visit of the child to the dentist
should occur in the period between eruption of the first
deciduous tooth and the first year of life, for prevention of
future dental problems, especially early childhood caries.
Studies on this type of caries, consider several possible
risk factors for its occurrence1,2,6,11,12,19,20,23,25 . Oral hygiene,
dietary habits and breastfeeding, utilization of fluoride,
salivary parameters, socioeconomic level and parental
educational level are the main factors cited in the
literature1,2,6,11,12,19,20,23,25. The investigation of Aquino3 (1999)
revealed that the industrialized food most consumed by
children was milk (87.2%), followed by sugar (66.3%), which
is introduced early (between 0 and 5 months) and in large
amounts. Thickeners were also very frequent (44.7%),
especially between 6 and 11 months, being corn starch the
most consumed. Thus, adoption of an improper hygiene, as
well as lack of information of mothers on the oral hygiene of
infants, jeopardizes the children to early occurrence of dental
caries.
Ferreira and Gaiva11 (2001) stated that mothers are still
unaware of the dental care needs of their infants. Thus,
there is the need to establish practical actions targeted to
health education and establishment of dental care to infants,
on city health services7,8,13,24.
Another important information that should be provided
to parents is related to the benefits of breastfeeding. Besides
fulfilling the nutritional and immunological needs of the infant,
breastfeeding directly influences the child’s facial
development, stimulating the anteroposterior mandibular
growth and reinforcing the physiological neural circuit of
breathing. Moreover, many studies report that when mothers
breastfeed their children for more than 6 months, there is
reduction in the prevalence of non-nutritive sucking habits
with consequent prevention of malocclusions5,14,17,21.
The establishment of educational-preventive programs
directed to infants in the public sector has been increasingly
advocated, since many users of public health centers are
within this age range, and often are not assisted due to poor
training of professionals, as well as lack of health policies
that address this type of care to the community4,10,23.
T h u s , t h i s s t u d y e v a l u a t e d t h e e f f i c a c y o f a n
educational-preventive program for infants in the public
sector of Maringá, PR, by the analysis of the oral health of
participating children.MATERIAL AND METHODS
After approval by the Institutional Review Board
(protocol n. 62/03 – COPEP, report n. 072/2003), 100 children
of both genders, aged 1 to 6 years, in the primary dentition,
registered and assisted at the same health center (Integrated
Health center – NIS III Iguaçu), at the city of Maringá, PR,
were examined.
The children were equally divided into two groups, Group
1 composed of 50 children attended at the dental care
program for infants, and Group 2 composed of 50 children
attended by spontaneous demand at the health center.
The Dental Care Program for Infants (Group I) follows
an educational-preventive protocol, in which the child is
inserted in the program before 1 year of age and is followed
until 6 years of age. Upon inclusion of the infant, the parents
and/or caretakers participate in an educational lecture that
emphasizes the advantages of breastfeeding, the need of
home and professional oral health maintenance measures,
as well as the need to establish interceptive measures for
harmful dietary, hygiene and non-nutritive sucking habits,
to prevent the appearance of carious lesions and
malocclusion. These orientations are reinforced to parents
bimonthly, at each follow-up of the infant, when plaque
disclosure and mechanical plaque control is performed by
the professional.
The attendance by spontaneous demand (Group II)
corresponds to assistance without pre-established follow-
up periods. The attendance routine includes preventive and
restorative measures. Initially, a hygienist provides
information on the toothbrushing technique, followed by
plaque disclosure and toothbrushing. After this procedure,
the dentist performs the restorative treatment required. At
completion of treatment, the child’s caretakers are informed
as to the importance of follow-up for oral health
maintenance.
Data collection of both groups was performed by 2 dental
professionals of the Health Secretariat of the city of Maringá,
in charge of providing assistance to the children. This blind
study was divided into two parts. The first comprised a
semi-structured interview to the mothers or caretakers, using
a pre-tested questionnaire including questions on the type
of feeding offered, frequency and period of feeding and
presence of non-nutritive sucking habits.
The second part of the study comprised intraoral clinical
examination conducted by the two aforementioned dental
professionals, previously calibrated (Kappa 0.6 for the dmft
index and 0.7 for facial alterations). When the children had
more than 2 years of age, examination was performed on the
dental chair, and on a child dental bed before this age. All
exams were performed with aid of a dental mirror and probe.
Tongue depressors and artificial light were also employed.
Evaluation was performed of the facial alterations (high
arched palate, anterior open bite, posterior cross bite,
protruded maxillary central incisors, mandibular protrusion,
abnormal swallowing and mouth breathing) by visual exam;
and dmft index, according to the WHO criteria, grouped by
age range15.
373EFFICACY OF AN ORAL HEALTH PROMOTION PROGRAM FOR INFANTS IN THE PUBLIC SECTOR

Data were processed and analyzed on the Stat Statistic
software. Comparisons of caries prevalence between the
studied groups were made using Mann-Whitney test
(p<0.05). In all other comparisons chi-square test was applied
(p<0.05).
RESULTS
Lower mean dmft index and a higher percentage of caries-
free children were observed for Group I compared to Group
II (Table 1), and the difference was statistically significant
(p<0.05).
Concerning the presence of non-nutritive sucking habits
(finger, dummy, diaper and others), the children in Group I
presented a prevalence of 47%, compared to 67% for Group
II, which was a statistically significant difference (p<0.05).
When the caretakers were questioned on the type of habit
presented by the child, it was noticed that the dummy was
more cited for both groups (GI = 38.7% and GII 62.5%). Thisstudy observed that only 24.08% of children in Group I
made use of dummy after 3 years of age, compared to 41.6%
in Group II (Table 2).
A considerable part of children examined received
breastfeeding up to two years of age (GI = 24.48% and GII =
20.83%), as demonstrated in Table 3. Utilization of the baby
bottle is also an important habit, since the study revealed
that this is routinely adopted by mothers in both groups,
with a relatively high frequency (GI = 89.8% and GII = 87.5%),
with no statistical difference between them when analyzed
by the chi-square test (p<0.05).
An important finding of the study was related to facial
alterations, since the clinical examination revealed that 81.6%
of children in Group I and 52% in Group II did not present
facial alterations, with a statistically significant difference
between groups (p<0.05). When alterations were individually
analyzed, it was possible to observe that the most frequent
were high arched palate, anterior open bite and mouth
breathing, as displayed in Figure 1.
DISCUSSION
The challenge to work with health promotion in the public
sector, especially with infants, has called the attention of
several investigators involved with health education.
According to Ferreira and Gaiva10 (2001) there is the need to
establish practical actions directed to health education,
especially in the field of dentistry, in public health centers,
besides establishment of the dental care for infants. In the
opinion of Silva, et al.22 (2001), preventive measures for
infants would prevent the appearance of early childhoodGroups (N) Dmft* ((±) SD) caries-free*
Group I (50) 0.2a (0.72) 88% a
Group II (50) 3.0 b (3.39) 57% bTABLE 1- Mean of dmft index and percentage of caries-
free children in the study sample
* Means followed by different letters in each column and
group are significantly different (p<0.05)
Duration of the habit Group I N Group II N
Less than 6 months 4.08 % 02 6.25 % 03
6 to 12 months 2.02 % 01 4.13 % 02
12 to 24 months 6.12 % 04 4.10 % 02
24 to 36 months 10.10 % 05 16.06 % 08
Persistence of the habit 24.08 % 13 41.66 % 21
Absence of the habit 53.6 % 25 27.8 % 14TABLE 2- Duration of the habit of dummy sucking among the children in the study sample
Period of breastfeeding Group I N Group II N
Less than 6 months 32.65 % 16 33.33 % 17
6 months to 1 year 28.57 % 15 29.16 % 16
1 to 2 years 24.48 % 11 20.83 % 09
More than 2 years 8.16 % 04 6.25 % 03
Does not know 4.08 % 02 4.18 % 02
Did not receive 2.06 % 02 6.25 % 03TABLE 3- Period of breastfeeding among the children in the study sample
374FRACASSO M de L C, RIOS D, PROVENZANO M G A, GOYA S

caries, an impairing and painful condition, whose treatment
is long, costly and stressing for both children and parents,
and professional, who has the difficult task to reestablish
the oral health condition.
The dental care program for infants was created following
the world tendency of establishment of oral health
promotion measures as early as possible, searching for
improvement in the health conditions of children attending
the health center in the city of Maringá, PR. Infants are
included in the program until one year of age, so that follow-
up may be really early, allowing introduction of proper diet
and hygiene habits by the parents, after professional health
orientation. The great challenge is to work with a population
that usually does not receive any type of care in the center,
as well as stimulate the children’s caretakers as to the
importance of regular attendance to the program,
encouraging them to perform the preventive measures
routinely at home. Thus, some children are still not regularly
taken to preventive follow-up by the parents, present dental
caries and then attend the health center only when the need
of restorative treatment is noticed.
The present study revealed that, 5 years after
establishment of the dental care program for infants, there
was improvement in the oral conditions of children
participating in the program. The caries index (dmft) of 0.2
presented by the children attending the preventive dental
care program to infants (Group I) was significantly lower
than the index of 3.0 of children assisted by spontaneous
demand (Group II) (Table 1), which confirms reports in the
literature8,13,23,24 i n w h i c h t h e a u t h o r s h i g h l i g h t t h e
importance to begin oral health follow-up as early as possible,
establishing conditions for oral health maintenance.
Concerning the percentage of caries-free children, Group I
presented 88% compared to 57% in Group II, which further
reveals the larger need of restorative treatment in the group
not attending a preventive program. Within this context, it
is important to mention the limitation of restorative
procedures, since according to Tinanoff, et al.23 ( 2 0 0 2 ) ,
infants with early childhood caries would have difficult
access to dental treatment in public health centers,
especially due to poor training of health professionals to
deal with this type of alteration. Moreover, the cost of
prevention for the health center is significantly lower.Breastfeeding is a relevant factor in the child’s
development as a whole, stimulating the anteroposterior
mandibular growth and reinforcing the physiological neural
circuit of breathing, especially in the first six months of age,
preventing the occurrence of malocclusion5,17. The study
groups clearly demonstrate the importance of a
multidisciplinary team in the health center, to guide, stimulate
and follow mothers as to breastfeeding. It was noticed that
most children examined received breastfeeding.
On the other hand, the study demonstrated that
utilization of the bottle by children seems to be a common
option, which is often adopted together with breastfeeding9.
According to Barros, et al.6 (2001), a harmful aspect related
to children fed by the bottle is the utilization of the bottle to
sleep, leading the child to fall asleep before oral hygiene is
performed, jeopardizing the child to early childhood caries.
Another important aspect in early dental care programs
is the stimulation and orientation of mothers to reduce the
incorporation of non-nutritive sucking habits, including
dummy sucking. The study revealed that the sucking habit
was more frequently present in Group II. In this same group,
there was a long period before the child abandoned the
habit, since 41.6% still presented the habit after 3 years of
age. These data are in agreement with the study of Oliveira14
(1995), who observed presence of harmful habits, especially
dummy sucking, in 48% of 3-year-old children. This author
concluded that harmful habits are more prevalent at 3 years
and are reduced with the increase in age, reaching 16% at 6
years of age.
The present study demonstrated that incorporation and
maintenance of non-nutritive sucking habits, frequently
assigned to dummy sucking, would induce facial alterations
at an early age, being able to interfere with the normal facial
pattern in case it is not abandoned. The best outcome
observed for Group I (Figure 1) as to the prevalence of facial
alterations may be assigned to the routine follow-up,
encouraging the child to abandon this practice, as well as
orientation to the mothers, therefore preventing
malocclusion, since significant alterations were observed
in the facial pattern, such as open bite, high arched palate
and abnormal swallowing, especially for Group II, for which
dental care does not prioritize the education of mothers and
children.
Reported data on the importance of early interceptive
work for non-nutritive sucking habits reinforce the findings
of many studies in the literature5,16,21 t h a t a d d r e s s t h e
importance of presence of a dental professional in programs
for pregnant women and for infants, to provide this
information before facial alterations are established, leading
to damages in the child’s normal development and requiring
clinical care, most often unavailable in the public sector. If
the dental care is provided after the habit is established, it
should be abandoned until 3 years of age, when the pattern
of neuromuscular contraction becomes mature and
malocclusion may be perpetuated by the abnormal function
established14,16.
Thus, considering the present findings, oral health
promotion measures for infants assisted in the public sector
FIGURE 1- Prevalence of facial alterations in the children
examined, expressed as percentages
375EFFICACY OF AN ORAL HEALTH PROMOTION PROGRAM FOR INFANTS IN THE PUBLIC SECTOR

are viable and fundamental to meet the demand of an age
range that does not receive dental care and follow-up.
CONCLUSION
Based on the results achieved, it was concluded that the
early dental care program, focused on educational and
preventive actions, presented children with lower caries
index, presence of non-nutritive sucking habits and
prevalence of facial alterations when compared to children
assisted by spontaneous demand.
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