Oral health is part of general health and should be accessible to all people regardless of age, race, creed, color, sex, or socioeconomic status.1 Dentistry has sought to change the curative approach of oral problems to a broader work aiming to identify and reach the determinants of the health disease process. These changes promote awareness for maintaining health with early initiation of dental care, thus avoiding and/or reducing the sequelae of the main problems that affect the oral health of the population.2 Dentistry for babies has been gaining great attention worldwide and has become an alternative in the prevention and control of oral diseases in early childhood.3

Early childhood is a fundamental period in the psycho-social development of the individual; oral health promotion measures for children under 5 years are essential for maintaining health and proper development of digestion, phonation, and respiration.1 The age at the first preventive dental visit has a positive and significant effect on oral health costs, which are, on average, lower for children who received early preventive treatment.4

A local study5 demonstrated the great demand for dental care of children 2–5 years of age with presence of pain and sequelae of oral diseases in the city of Gurupi, Tocantins State, northern region of Brazil. The public program for the promotion of oral health in children (POHC), called Baby's Mouth, was implemented in 2010 in partnership with the City Hall and Centro Universitário UnirG (University Center of Gurupi). This program encompasses the period from gestation until 5 years of age. The children have been enrolled in this public program since birth. The professionals treated edentulous children, and all of them received clinical examination, oral cleaning, and quarterly control. The project also provided orientation to mothers regarding diet, and they received a returning card. The professionals followed-up the child's dental eruption, occlusion stabilization, and monitored them up to 5 years of age; if any changes were detected during this period, the staff intervened according to the dental standards of the American Academy of Pediatric Dentistry.6

The aim of this study was to assess the efficacy of the Baby's Mouth early dental care prevention and promotion program in preventing oral diseases (caries, gingivitis, or malocclusions) in children attended since 2010.

This was a cross-sectional and cohort study carried out in the Legal Amazon region, covering the micro-region of Bananal Island, within the scope of the public health network of Gurupi (TO), with an area of 1,836,091km2 and a total population of 76,755 individuals, approved by the Human Research Ethics Committee of the Centro Universitário UnirG, under protocol number 19895713.0.0000.5518.

In the present study, the mean family income of 1–2 minimum wages, and the mean age of the groups was 3.662±0.753 years in G1, 3.698±0.711 years in G2, and 3.714±0.744 years in G3. In all groups, most mothers had completed secondary education.

When analyzing the percentage components of the program in Table 1, a statistical significance was observed among the groups regarding the presence of partners; in G1 and G2, the majority were married. The mean number of children per mother was two children in G1, one child in G2, and three or more children in G3; this difference was statistically significant.

Table 2 indicated that, although several mothers reported not having received information about oral health in prenatal care, those in G3 had received practically no information; this difference was significant between the groups.

G1 and G2 mothers enrolled their children in the program for prevention, while G3 mothers intended to take their child to dentist dental appointment only when treatment for caries or pain was needed. Patients in G2, the loss to follow-up was due to the fact that most mothers (54%) forgot the time of the consultation in the PCU; and 25% of the mothers claimed that they could not attend because they started to work.

Regarding the mothers’ knowledge about the question “when should the child be taken for the first visit to the dentist?,” mothers in G1 (69%) and G2 (74%) answered “before the first tooth erupted,” while 49% of the mothers in G3 answered “when the first tooth erupted” and 29%, “when the child presents some discomfort or pain.”

The deft index varied among the groups: G1, 0.05; G2, 1.96; and G3, 3.3.

Regarding caries (Table 3), a linear relationship was observed between variables, in which all groups presented a significant difference. For gingivitis, no significant differences were observed when comparing G1 and G2, but significant differences were observed between G1 and G3. In the occlusions, a statistically significant relationship was observed among the three groups relating the lack of attendance in the program and the presence of malocclusion. In G2 and G3, the prevalence of these alterations was increased, since the patients participated partially or did not participate in the program.

Of the malocclusions, the most prevalent was open bite, followed by the anterior and posterior crossbite; the group that never attended the program (G3) presented a statistical difference in this oral alteration as much as G1.

No difference between G2 and G3 regarding hygiene and habits was observed.

Infant care programs are more effective than spontaneous demand, fulfilling the goal of maintaining oral health in the child population. Nonetheless, to prove the success and effectiveness of a program, the results achieved should be clinically evaluated after a certain period.10 Therefore, this project was evaluated, in order to outline the profile of the participant community, to obtain a diagnosis of the results obtained, to identify the major obstacles that interfere with the program, and to seek solutions to achieve the goal of the proposal in primary health.

Several authors11–13 agree with the implementation of preventive programs for infants, as they state that oral health education to those responsible for the children have led to great benefits. Information on oral health care should be provided to mothers during pregnancy, to increase their knowledge about gestational care, its general and oral implications, and to prevent problems that may occur both in the mothers themselves and in their children.14 Pregnant women who receive this information become health promoters in the family, as well as multiplying agents of oral health education. During the gestational period, the emotional system of the woman is more sensitive, making them more receptive; therefore, this is an ideal phase for implanting new ideas and concepts regarding oral health.15 The present study found that children who started participating in the program, and women who have received pertinent information since pregnancy, presented fewer oral diseases than those who never participated in the program.

In the present study, the marital status of the parents was significant, the mothers in G3 had more children and were, on average, ten years younger than G1. According to Moimaz et al.,16 the presence of caries in children and the maternal history of caries were associated with maternal level education, low family economic status, and number of dental appointments. However, the marital status of the parents was not significant (0.695), but the number of children in the house was strongly associated with dental caries (p<0.0001).

Although the G1 and G2 mothers received a card with program enrollment and information about the date of the scheduled return, many abandoned the program (G2). These mothers claimed several reasons that led them to miss the consultations, from lack of time, returning to work, and also forgetting. When they believed that all was well in the first visits to the dentist, they became less vigilant and began to seek health professionals only when a disease manifested, demonstrating the difficulty of accepting new paradigms in promoting and maintaining health.17 The mothers’ profile may interfere in the participation and collaboration in preventive actions, taking considering the socio-economic status,18 the age of the mothers, the number of children, and the presence of a partner.19

A significant association was observed between sucrose consumption and caries prevalence in children.20 It is known that approaching pregnant woman and the baby, even in the first months of life, is extremely important for the introduction of educational and preventive diet, allowing increased parental involvement in breastfeeding, solid and liquid diet after six months of life, and the motivation of infant oral hygiene. Oral diseases related to the type of child's diet should be directed to those responsible.21

Although children are not able to care for their oral hygiene at ages 0–5 years, most G3 mothers allowed their child to perform oral hygiene. In a study where 71% of the mothers reported being aware of the need for supervised daily brushing, only 40% of them helped their children, i.e., when interviewed, they seem to recognize the importance of oral hygiene and presented knowledge in giving satisfactory answers.22 The caries and gingivitis prevalence observed in G2 and G3 indicate that the epidemiological approach with a questionnaire does not always reflect the reality of family habits and attitudes, but rather often shows only the theoretical knowledge of these questions.

In Brazil, an epidemiological study conducted in 2010 showed a 13.6% reduction in malocclusion at the age of 12 years. Even though there is a drop in the prevalence of malocclusions at this age, this occlusal alteration can still be considered a public health problem.23 In the present study, the G1 results of malocclusion was not as high as expected; however, two important factors, genetic inheritance and persistent oral habits, must be taken into account. The genetic factor can be attenuated by avoiding deleterious habits that can stimulate greater deformities and sequelae in these children.24 The open bite was the most prevalent occlusion in the groups of the present study, which, despite knowing the possible genetic/hereditary etiological factors present in the child, may also have been acquired by the non-nutritive habits of pacifier and finger suction.

Even for children of G1 and G2 who were enrolled at up to 6 months of age, some had sucking habits such as bottle and pacifier, the program staff worked to discontinue them. The non-nutritive pacifier sucking habit was the most frequent among all infant habits in the present study. Pacifier sucking is a damaging habit for occlusion and maxillary bones, causing imbalance of the stomatognathic apparatus.25 A major obstacle to the success of preventive programs has been the lack of adherence of families to the guidelines, since in addition to the increasingly early insertion of inappropriate habits that lead to oral diseases, the lack of attendance at consultations can compromise control and encouragement of guidance by the team.26

Dental caries is a multi-factorial disease that involves tooth structure, biofilm dysbiosis adhered to the dental surface, and dietary carbohydrates, which can result in the dissolution of the mineral of the teeth.27 However, the simple removal of microorganisms is not enough to manage the progression of a carious lesion; it is necessary to control the etiological factors. Some strategies have been proven to be effective in reducing the incidence of caries in children, such as counseling for early adoption of oral health-promoting dietary practices, daily brushing with 1000ppm fluoride toothpaste concentration.28 In a study with children aged from 0 to 5 years old, 40% (589/1487) had dental caries; the highest prevalence and severity of caries was observed between the ages of 1 and 2 years.8 Caries affects a higher number of children due to inadequate diet habits (high sugar consumption) and poor oral hygiene.28

The data from the present study demonstrated that the program was efficient in preventing caries, even in those children who did not continue in the prevention program, when compared with those who never participated. According to the WHO oral health classification,7 the deft index in G1 was considered very low; in G2, low; and in G3, average. It demonstrates that the program was effective in controlling caries disease in the first 5 years of age.

The present study demonstrated that children most protected from caries and periodontal disease were those who participated effectively in the program (G1). Oral diseases were not prevented in those who received counseling but left the program (G2). Thus, regular visits reinforce and motivate correct prevention procedures and, consequently, reduce oral diseases.16

According to Lee et al.,29 the first visits of this program focus on oral hygiene in children, dietary counseling, information on oral habits, and prevention of dental injuries, which lead to a reduction dental treatment costs. In this sense, it is necessary that public policies periodically evaluate their health programs, with longitudinal studies, searching for ideal samples and considering them as important indicators for health promotion. This will bring a direct return to the population studied, as it allows a reduction in treatment costs and attendance of the sequelae of the main oral problems that affect children. Such actions reach positive results will be reflexes in improving the quality of life of this community.

The group of children aged 3–5 years who actually attended the Baby's Mouth oral health program presented a lower number of individuals with caries, gingivitis, occlusion, and less harmful habits than those who dropped out or never attended the program. In order to promote children's oral health, parents should follow the guidelines for healthy habits as early as possible.

The authors declare no conflicts of interest.