Early childhood caries: THE IMPORTANCE OF NURSING CARE

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1 Early childhood caries: THE IMPORTANCE OF NURSING CARE Francine Morais da SILVA, Nursing Student Nursing Student Eder Propp ANFLÔR, Nurse Cíntia Vieira da ROSA, Teacher Female Doctor Simone ALGERI. ABSTRACT Federal University of Rio Grande do Sul School of Nursing Address São Manoel, 963 Neighborhood: Rio Branco CEP: Porto Alegre, RS Brazil. Contextualization: Early childhood caries is the occurrence of dental caries in children under five years of age. It is a public health issue, with high prevalence in the Brazilian child population. Objective: The aim of this study was to identify the role of the nurse recommended by the literature in relation to Early Childhood Caries in different levels of care to Health. Methodology: This study was conducted through an integrative literature review, methodology recommended by Cooper (1982) that includes analysis of various primary research on a given subject, establishing comparative analysis between them. The study involved a sample of 13 items inserted in LILACS, SciELO and MEDLINE published between the years 2001 and 2011, in Portuguese, English and Spanish. Analysis and interpretation of results: In this integrative review was identified as a result of the work of nurses regarding the early childhood caries five factors that stand out, they are: 1 - Conducting regular oral hygiene with the methods: mechanical removal, use fluoride, flossing, chlorhexidine and xylitol; 2 - Recommendations to parents about nutrition, vertical transmission, dental visits and medication use ; 3 - early detection of signals, 4 - and 5 Health Education - Difficulties and limitations of professionals during practices implemented for promotion and prevention. Final Thoughts: The role of nurses in relation to early childhood caries is associated with risk factors for the disease. Thus, it is necessary that there is a reflection on the type of care developed. The awareness and active participation of nurses in oral health are crucial; making the main objective is the promotion of health, which necessarily must go through its own training. Descriptors: dental caries, oral hygiene, nursing, child feeding. 1 INTRODUCTION Early childhood caries, also known as early childhood caries, is the occurrence of dental caries in children under five years of age. It is a problem of public health in Brazil reaches 27% of children months of age [1], causing pain, problems in speech and chewing function, systemic diseases and psychological consequences. The Brazilian caries prevalence at five years of age is 60%, revealing that the target set by the World Health Organization (UNO) for 2000 has not yet been reached, ie 50% of caries-free children in this age group [2]. According to the National Oral Health Policy [3], the oral health teams should interact with professionals in other fields, allowing the approach of the individual as a whole and allowing the exchange of knowledge between the teams. Promoting oral health is a broad concept that includes policies that oportunizem access to treated water, fluoridated water, use of fluoridated toothpaste and ensure the existence of basic dental care. Risk factors and protective to other hazards must be addressed during the promotion of 100

2 oral health. Besides eating healthy with reduced consumption of sugars and encouraging oral hygiene care by health professionals. The early childhood caries is the most prevalent chronic diseases during childhood, so it is necessary that nurses undertake a comprehensive child care, acting through prevention, health promotion and recovery, consistent with the principles of the Unified (SUS). Studies show that only 53.1% of nursing students and 4.9% of the maternal-infant nurses received information about Dentistry for Baby in college [4]. Such data identify the lack of oral health care during the training. Currently, the implementation of prevention strategies, which should be based on knowledge of disease etiology, multifactorial and complex, which participate socioeconomic, behavioral, and microbiological variables [2]. 2 OBJECTIVE This work aims to identify nurses' actions based on literature regarding the Early Childhood Caries in different levels of care to Health. 3 LITERATURE REVIEW 3.1 Oral Health The concept of quality of life expanded vision of health professionals in relation to care. It is known that only treat signs and symptoms of a disease does not promote the integral health [5]. Thus, health is constituted by living conditions, not only related to access to health services, but a series of constraints and determinants [6]. The oral health as part of general health, also relates to feeding status, education, income, sanitation, housing, employment, leisure and other determinants. The high prevalence of caries in children worldwide points to the importance of prevention strategies in oral health in primary health care. The high rates of early childhood caries reflect poor oral health in children 0-4 years of age, contributing to the increased risk and progression of disease in adulthood [6]. These indexes confirm that there is still a lack of information and low priority of governments in relation to the oral health of this age group. There is a separation of what is meant by hygiene, as well as health. This lack of thinking in oral health as part of general hygiene and any failure to observe the patient as a whole, occurs in various segments of healthcare, not just nursing. Often the patient is fragmented systems, which results in loss in its full reinstatement and their quality of life. Oral health should not be neglected, since the oral cavity, as well as any area of the human body, can become a source of spread of pathogens that can compromise overall health. A poor oral health leads to caries, periodontal disease, can lead to pain, problems with speech function, gastrointestinal disorders and psychological problems [7]. Dentistry for Babies is a global trend of dental care that is currently being spread due to the aggressive manifestation of early childhood caries and its rapid progression, which may cause even the complete destruction of the tooth in a short period. Currently it is known that whatever is learned early in life, both in relation to overall health as oral health, provides a good basis for subsequent health [8] ages. Thus, the earlier it is started on oral health care, the easier the act of preventing the establishment of bad habits, which are the main responsible for the occurrence of caries in the first years of life. 3.2 Teething and physiology of caries Teething The primary dentition (primary) is characterized by a group of 20 primary teeth (ten for each arch), four incisors, two canines, and four molars in each jaw. The deciduous teeth are formed between 12 and 18 weeks of intrauterine life and erupt on average after six months, with the primary dentition is complete 101

3 between 24 and 30 months of age. The signs of the rash are mild swelling and bulging gums, showing dental crowns, which are close to breaking out in the oral cavity. Other signs and symptoms described are pain, drooling, gum irritation, fever, loss of appetite and irritability. Tooth eruption is a physiological process, so the symptoms are not severe, disappearing soon. The permanent teeth are 16 in number for each arch and erupt around six years old [9]. It is exactly in the primary dentition early childhood caries presents its higher prevalence, and its control should be a priority, because it may cause malocclusion of permanent teeth, phonetic problems and reduced self -esteem [10] Concept of caries Early childhood caries is defined as the presence of one or more lesions (cavitated or not), (related to caries) or restored tooth loss tooth surfaces in any primary tooth in children up to 71 months old. In children younger than three years of age, any sign of decay (recessed or not) on smooth surface is indicative of severe childhood caries. It is also considered history of severe childhood caries is from three to five years of age, the child has four or more surfaces affected in previous deciduous teeth at three, five or more surfaces at four or six or more surfaces at five age [10, 11]. Dental caries and periodontal diseases are the most prevalent diseases in the oral cavity can also affect children and when not handled properly, lead to premature loss of dental elements, resulting in delayed development of speech, physical and psychological [12, 10] Physiology of caries The bacteria adhere to a thin acellular layer composed of salivary proteins and lipids, phosphoproteins that cover the surfaces of the teeth, called the acquired pellicle. Then builds up the film acquired enamel, initial microbial adhesion and maturation of dental plaque. The decay therefore results from bacterial action on carbohydrates, causing demineralization of the inorganic portion of the tooth, and then the disintegration of the organic part of the tooth [ 13 ]. The deciduous incisors are the teeth most affected by the disease, as they are the first to erupt in the oral cavity and are more exposed to the medium [ 14, 15 ]. Importantly, the consequences of early caries going beyond pain and infection. Eating disorders are the most frequent, for this reason, it is observed that children with caries have lower height and weight than children free of the disease [ 10 ]. Probably this change in the pattern of growth is related to decreased food intake because of pain and disease progression Etiology and risk factors Early childhood caries is not a new phenomenon. Over the years has had several concepts that help to understand the multiple etiologies involved as early childhood caries and caries baby [11]. Early childhood caries is an multifactorial disease, triggered by three factors: cariogenic microorganisms, fermentable substrates (such as sucrose) and vulnerability of the host [13, 10, 16]. The main cariogenic organisms are the mutans streptococci, especially Streptococcus mutans. These pathogens are not present in the oral cavity of the newborn, thus being the mother the primary source of transmission through saliva to clean the pacifier with your mouth, taste the food of the child using the same spoon, drinking from the same cup and give mouth kissing son [6]. Horizontal transmission are also described in nurseries and kindergartens [10]. Pacifier use leads to deviation in the position of the teeth can increase the occurrence of Candida albicans and Lactobacilli in the oral cavity, increasing the risk of caries activity [17]. The child's diet plays an important role in oral health. Among cariogenic foods are sucrose, glucose and fructose, which are capable of converting non- cariogenic and anticariogenic cariogenic foods. The frequent use of these substrates is a risk factor for caries [13]. Maciel et al. (2007) points out that scientific 102

4 evidence shows that the local post -eruptive effect of diet is much more important than the pre -eruptive effect, confirming that sugar is the most cariogenic part of diet. The exclusive breastfeeding until six months of life is undeniably the best source of nutrition for the child at this age, it transmits antibodies from mother to baby, conferring immunity and protection against infections. Moreover, it provides energy and nutrients for growth and development, and is essential for psychic development for baby [2, 17]. Although human milk has a higher concentration of lactose (which would make more cariogenic) and lower protein content, their is less cariogenic than cow's milk because of the addition of sucrose to cow's milk, which makes it much more cariogenic [9, 16]. Milk is not the only substrate cariogenic diet, other liquids, such as chocolate milk, fruit juice, sweetened teas, fermented milk and carbonated beverages are a risk factor for the disease [6, 16]. The development of caries is also associated with the exposure time of the tooth with sugar. It is known that food induces fermentable ph drop staying in the oral cavity for a time of 5 to 15 minutes [18]. The habit becomes more aggravated when parents offer a bottle before bed or during the night because during sleep the protective effect of saliva is absent, since salivary flow rate and oral ph is reduced, favoring the cariogenic action beyond lack of hygiene during sleep. The slow pace of swallowing during sleep associated with reduced salivary flow allows permanent contact with the milk teeth [6]. Regarding host susceptibility, children with higher caries risk are those with low socioeconomic status, ethnic and racial minorities, children of single mothers and fathers with less education [11, 10]. Early caries is considered a "polarized" disease. This phenomenon of "bias" is used to define the concentration of the disease in socially disadvantaged and minority groups who own vulnerability to diseases because they are more susceptible or more exposed to risk factors [13, 19]. The identification of this phenomenon is intended to alert the authorities to the need to care for these groups. 4 METODOLOGY 4.1 Type of study This is a study of integrative review (IR), research method recommended by Cooper (1982), which includes the analysis of various primary research on a given topic, making comparisons between them in order to define more comprehensive conclusions about a specific phenomenon. The integrative review is an enriching for nursing method, since many times the professional does not have available time to perform the reading of the large volume of scientific knowledge, besides the difficulty of performing a critical analysis of the subject [20]. Cooper (1982) five-step guides to RI, that they are: problem formulation, data collection, data evaluation, analysis and interpretation of data and presentation of results. 4.2 Formulation of the problem We selected the topic to be addressed and subsequently defined the guiding question to be answered: How nurses can work in different health care levels in relation to Early Childhood Caries? 4.3 Data Collection American and Caribbean Health Sciences (LILACS), Scientific Electronic Library Online (SciELO) and Medical Literature - These databases were used for this research article that addressed the care with caries that were indexed in virtual databases were used Latino Literature Analysis and Retrieval Sistem online (MEDLINE), in Portuguese, Spanish and English. Descriptors in Health Sciences Headings (MeSH) used in the literature search were: nursing, dental hygiene, infant feeding and dental caries. 103

5 Inclusion criteria were: articles that answered the core question, published in the period , in Portuguese, Spanish and English, which were available for free online and in full. Theses and dissertations were not included in the review. DeCS Dental Dental Dental Nursing Total caries caries caries AND Base AND AND AND oral de dados nursing child feeding hygiene LILACS SCIELO MEDLINE Total Table 1 - Results of the distribution of articles published between 2001 and 2011, according to descriptors and databases. 104

6 In search of articles, 394 articles were found in LILACS, SciELO and 52 in 520 in MEDLINE, yielding a total of 966 articles. The significant decrease of total articles was due to the crossing of the descriptors when used together "dental caries" and "child." So in that sense, the work focused on the items that contemplated "dental caries", "child" and "nursing", cross each other. 4.4 Evaluation of data Initially, 39 articles were selected by reading titles and established terms. After reading the titles and abstracts, 18 articles were selected to be read in their entirety. With the critical reading of texts, 13 were selected for use in this integrative review. For the organization and categorization of the selected studies was developed and completed an Instrument Analysis (APPENDIX A), covering the following information: identification of the article (title, authors, authors' title, journal name, year of publication, volume, number and descriptors); objective of the study, methodology (type of study, population / sample, place of study, data collection), results and conclusions. 4.5 Analysis and interpretation of results After categorization of searches using the instrument of analysis, data were summarized, compared and analyzed in detail by preparing a summary table (APPENDIX B), containing the following information: title, author, methodology and care caries prevention, thus forming a database for easy access and management. Data were analyzed and discussed, with the identification of resulting conclusions and implications of the integrative review. 4.6 Presentation of results The final phase of the study is to present the main results shown in the analysis of the articles available in the literature, providing a critical reflection on the information collected. 4.7 Ethical aspects With the approval of the study design during labor discipline Completion of course I was referred to the Committee on Research of the School of Nursing, Federal University of Rio Grande do Sul (COMPESQ - EEUFRGS, ANNEX I) and was approved under number Regarding ethical aspects, all items used were properly referenced as standards of the Brazilian Association of Technical Standards (ABNT). 105

7 5 PRESENTATION AND ANALYSIS OF RESULTS In this integrative review, we analyzed 13 articles that addressed the treatment in relation to early childhood caries, 10 articles (76.9%) were published in Portuguese, two in English (15.4%) and (7, 7%) in Spanish. The nature of the studies, it can be noticed the predominance of qualitative articles on the subject (61.5% of the sample). The 13 articles were analyzed and classified into five categories, according to the results: regular oral hygiene, advice to parents, and caregivers, early signs of carie, health education and professional limitations. 5.1 Regular Oral Hygiene Measures of body hygiene of the child should include strategies to teeth cleaning. For this reason, care of the oral cavity should be provided daily and regular basis is the responsibility of parents and health professionals to maintaining oral hygiene and prevention of early childhood caries. Nurses should be aware of the cleaning of the oral cavity, both in primary care as hospital admissions situation occurring change in eating habits and meal times, medication administration and changes in daily hygiene routine [10, 22, 23]. Among the measures for the realization of oral hygiene were cited among the authors mechanical removal of biofilm, the flossing, fluoride use, use of chlorhexidine and xylitol use. Graph 1 shows the percentage of citations of each method of cleaning the oral cavity in children. There is a higher prevalence of quotes about the mechanical removal, and by ten articles ( 36 % of the sample ), followed by use of fluoride, with seven articles (28 %), flossing, five articles (20 %) and use of chlorhexidine and xylitol, both presented in two articles (8 %). Graph 1 - Distribution of articles in the method of oral hygiene Direct Source, Recommendations for Parents and Caregivers In this category, ten articles (76.9% of the sample) reported some kind of recommendation to parents and caregivers relevant to the problem. The first person that parents encounter when they enter the gateway of health services, whether in hospital or network basic service is usually the nurse. Nurses can and should guide the family on issues of health and oral hygiene. 106

8 Should help children maintain good oral hygiene, through guidelines for about periodontal and dental disorders and prevention methods. The guidelines for oral health to parents, even if they are simple, and promote positive outcomes are essential for the prevention of early childhood caries [21, 10]. 5.3 Early detection of signals Nine articles (69.2 % of the sample) report on early signal detection and referral to the dental team, they are: [24, 25, 26, 27, 28, 22, 13, 29, 30]. The nurse maintains frequent and close contact with the patient in both the basic unit and in hospital. Therefore presents greater opportunity to develop early detection of dental problems and advise parents about the importance of prevention. They may also notice the signs of changes in the oral cavity and make referral to the team of dentistry, for dental treatment when needed [24, 25]. Thus, it is necessary that this information is known by health professionals, who often do not prioritize the oral cavity of children because they think that it is just the dental field. The earlier the diagnosis, the greater the chances of interventions, allowing a better prognosis and a more rapid and effective treatment, it would prevent the demand for dental care only occurs after the lesion cavitation [24, 25, 27]. The identification of children with risk profile or need for treatment by nurses allows alert authorities to appropriate care, particularly in underserved communities [26, 13, 30]. The professional should inspect the oral cavity of newborns and children up to five years, noting premature teeth abnormalities (cleft lip, cleft palate) and monitoring the eruption of primary teeth (is considered abnormal lack of eruption until 15 months) [26, 22, 28, 29]. Should also note gingivitis, tooth alignment and malocclusion (open bite), avoiding the use of pacifiers and thumb sucking and the oral health of the mother. From two to six years of primary teeth should be observed by the presence of cavities and fractures and evaluate the diet and brushing techniques. If you find any change, you must send to the dentist [22]. It is possible that both parents and caregivers obtain an improved ability to diagnose lesions such as white spot caries, this approach should integrate programs for prevention and control of early childhood caries [25]. The use of risk assessment to help determine reliable indicators tools, allowing nurses to be more involved in this identification. Nurses, using such tools should be able to view the teeth and mouth of the child and to have a reliable track record and understand the instrument [28]. 5.4 Health education In the category health education, seven articles (53.8 % of the sample) indicate the importance of educational measures (for parents, caregivers and professionals) in the prevention of early childhood caries [21, 24, 25, 27, 22, 28, 13]. The prevention only occurs when it educates, with education being an instrument of social transformation [25]. The data and advice given by health professionals promote changes in attitudes are positive and are essential, especially during the period of hospitalization in pediatric units, because many times the child does not consult with any frequency, and an important contact for admission actions education. There is a need for a multidisciplinary and multi-professional work, focused on oral health education, basic to comprehensive care to children. Educational measures at an early stage, involving the pediatric 107

9 dentist, pediatric and maternal-child nurses should be adopted. Through educational measures, the concept of oral health is connected to the promotion of health, and not just the restorative medical concept [21, 25]. Nurses must always seek better health for their patients, from educational processes. Is necessary, therefore, a movement of health education, where professionals organize themselves in a nonhierarchical way, but from that attributions based on skills, which, when aggregated, promote changes in attitudes, social representations and behavior [27]. The need for expansion of educational practices in health through educational programs for acquiring skills and skill in the practice of hygiene, as well as for the transmission of the value of oral health [28, 29]. Health education helps caregivers better understand the information and techniques to wield health care, so must be aroused the interest of the family for health care, educating children and parents to adopt a lifestyle that promote good general and oral health. The high prevalence of the disease points to the lack of knowledge of caregivers regarding oral hygiene practices. Often it is not negligence, but of lack of knowledge. It is known that the guidance for oral hygiene, when started with the child patient, generates positive results until adulthood. It is essential conditioning the child to adopt healthy eating habits and proper oral hygiene, and parents the biggest influencers in health education of the children [24]. Therefore, it can be seen that the best and simplest strategy to prevent early childhood caries is through education, advising parents about their causes and stressing the importance of educational and preventive programs. Children aged between 0 and 7 years depend on responsible for performing oral hygiene. The guidance, motivation and training of those responsible in the correct application of simple and inexpensive procedures for oral hygiene prevent the installation of caries and its consequences [13]. 5.5 Limitations of professionals This category was included in the study because four articles of the sample (30.8 %) cited the limitations encountered by nurses while conducting the promotion practices and prevention of early childhood caries [24, 25, 28, 30]. These limitations relate to the lack of training, lack of time, lack of priority and lack of resources. The lack of information or training to hinder actions were reported by four authors. There is a deficit of knowledge regarding oral health and pathogenesis of dental caries by professionals and nursing students as well as doctors and medical students [25]. Those are the most knowledgeable professionals who participate in scientific meetings and events that contribute to a process of continuing education. Despite the interest of the team, you can see the little knowledge on the subject [24]. Oral health in Norway includes a small portion of the curriculum in academic nursing education. I believe not only in this country but in Brazil, infant oral health is not emphasized, predominating matters other than the prevention and promotion. It needed more motivation and education of nursing professionals from academic education [30]. The lack of time to care for oral hygiene was mentioned by only one article (Skeie et al., 201). This demonstrates the importance of optimization of time and labor, it is unacceptable that such a relevant care as it ceases to be realized due to lack of time. The lack of priority in relation to this matter was only described by Skeie et al. (2011). The lack of material resources and improvisation of the same was described by Schneid et al. (2007). According to the author, in his study showed that some nurses used a rolled gauze and spatula dipped in water with baking, or just warm water to the achievement of oral hygiene care. 108

10 Most health professionals do not assume attitudes towards this issue. There is a need for more information and even motivation to care for oral health to its prevention. Nurses who work with children should be better prepared to provide information to the core family and children [24]. 6 FINAL CONSIDERATIONS Currently, the prevalence of early childhood caries is high, affecting 60 % of Brazilian children between zero and five years of age [2]. As emphasized earlier, early childhood caries is a major public health problem that interferes with the quality of life of the child as well as your family. The high prevalence highlights the need for greater attention to the issue. Oral health plays an important role in the overall health of the child, as they interfere with infant growth and development, both in physiological aspects such as emotional and social aspects. It was observed during the integrative review, the best way to prevent the development of disease is the intervention of risk factors. The nurses in this sense should be aware of multifactorial disease and to recognize such factors in order to modify them, because their consequences can last into adulthood. In this integrative review identified themselves as nurses' actions regarding the early childhood caries performing regular oral hygiene (mechanical removal, use of fluoride, flossing, chlorhexidine and xylitol), advice to parents on this subject, the early detection of signs and health education. It is essential, therefore, that the participation of nurses addressing educational and preventive strategies. We notice that there are many precautions that can be performed, however, these results do not reflect the real situation of nursing work towards the disease. Scientific evidence shows that the earlier start cleaning the oral cavity of the baby, the less difficulty in accepting future of oral health care. For this reason, oral hygiene should be initiated as early as possible, even before the eruption of teeth, using gauze or cotton diaper, thus promoting the disruption of biofilm. After the eruption of the first molars, hygiene should be performed with toothbrush. Nurses promotion of oral hygiene, whether by parents, through guidance on the correct way for each age group. The study indicated that a key to preventing decay factor is the care with diet. The nurse should alert caregivers about the importance of a proper diet. Exclusive breastfeeding, as recommended by the Ministry of Health should be stimulated by the sixth month of the baby's life. However, breastfeeding at night should not be encouraged and, if practiced, should alert the nurse to mothers and caregivers for the subsequent cleaning of the oral cavity. It is believed that the study achieved the intended goal, as well as identifying care regarding the early childhood caries, also discussed the obstacles encountered in day- to-day by the nursing staff in carrying out these practices. Among the difficulties are gaps in professional training itself, with poor integration of the subject in the curriculum, lack of time, lack of resources and lack of priority. Activities that promote oral health are not prioritized in the daily public health teams. For this reason, it would be interesting to create a protocol for oral care, with guidelines for nurses. There needs to be a reflection on the type of care that is being developed. Nurses should be aware of the totality of the patient so that all your needs are met. This work had the greatest limitation the lack of studies that emphasize the role of nurses and even other health professionals, other than the dentist in disease prevention. It is necessary, therefore, review the curriculum of nursing education, with the inclusion of relevant topics in today's societ. From the considerations made, it is necessary awareness and active participation of nurses in the prevention of oral health for promoting quality of life of these children. The professional's performance after installation of caries is not a priority, but that the goal of nursing is the promotion of health. 109

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13 29 MIÑANA, V. y GRUPO PREVINFAD/PAPPS INFANCIA Y ADOLESCENCIA. Promocion de la salud bucodental. Revista Pediatria de Atencion Primaria, v. 13, n. 51, p , jul/set Disponível em: < 30 SKEIE, M.S. et al. Do public health nurses in Norway promote information on oral health?. BMC Oral Health, v. 11, p , APPENDIX A - Instrument Analysis Título do artigo: Autor: Titulação: Autor: Titulação: Periódico: Ano: Volume: Número: Descritores/Palavras-chave: Objetivo do estudo: Metodologia 1) Tipo de Estudo: 2) População/Amostra: 3) Local do Estudo: 4) Coleta de Dados: Resultados: Conclusões: 112

14 ANNEX I - Letter of approval from COMPESQ - UFRGS 113