Dental cavities are one of the major non-communicable diseases affecting sixty to ninety percent of children. The problem with dental care is that is isn’t being targeted due to its expensive nature. In 2011, The United Nations general assembly identified oral hygiene as a public health concern (Oral Health Worldwide, 2015).

As per the Ottawa Charter, the individual as a whole must be tended to achieve a healthy lifestyle. Individual, lifestyle, community, social, political, socio-economic, cultural and environmental conditions all play a vital role in shaping health (The Ottawa Charter for Health Promotion, 2018).

This paper will provide a health promotion program that will tackle the issue of dental care in children between the ages of three to nine in England using the PRECEDE-PROCEED model.

1. Phase 1: Social Diagnosis

In order to proceed with the stated model, the various dimensions of dental care in children must first be thoroughly understood. This can be achieved by asking the stakeholders involved – the parents. Some questions that need to be tackled include:

1. Do the parents understand the importance of dental hygiene?
2. Do the parents teach their children the importance of brushing their teeth twice a day?
3. Do the parents brush their children’s teeth?
4. Do the parents take their children for continuous dental check-ups?
5. What are the risk factors that hinder dental practices?
6. Do the parents reduce their child’s consumption of sugary drinks and sweets?

2. Phase 2: Epidemiological Diagnosis

There has been very little research on parents’ perspectives about their children’s dental care practices and dental health in England. One of the few studies found was a qualitative study conducted in Barnsley and Bradford in England – two areas of relative low socioeconomic status. The study sample included parents with children under the age of seven. The parent’s involvement in their children’s dental care was studied. The research results proved that although parents are aware of the importance of tooth brushing in children, they are not informed about nationwide guidelines about the issue. Also, due to parental stressors, children’s behaviors and other environmental factors such as grandparent’s influences, parents usually don’t end up brushing their child’s teeth but simply remind him/her to do so themselves (Marshman et al., 2016, pp. 122-130). This raises some questions: how do parents know if the child’s teeth are being brushed? Will the seven year olds – or in some cases younger – actually brush their own teeth if left unattended?

According to WHO and FDI World Dental Federation, the 1981 launched “Global Oral Health Goals” weren’t accomplished by their intended date – the year 2000 in all the intended countries. As such, new aims were set to be accomplished by 2020. The new founded objectives were planned to act as guides for local governments to set their own plans for their countries. One of the main targets was primary prevention through early detection and diagnosis. The Global goals for oral health included establishing policies and strong programs for oral health and diminishing health inequities affecting access to dental care through decreasing the prevalence of cavities, plaque formation, school absences and impairments in social life due to pain (Hobdell et al., 2003, pp.285–288).

The appearance of plaque on teeth is one of the serious problems youngsters deal with in England. According to Public Health England, one out of four 5 year old children has plaque formation on their teeth at the beginning of the academic year, most cases of cavities under the age of six go untreated and 12 percent of 3 year old children have cavities with a mean of three decayed teeth (Child oral health: applying All Our Health, 2018).

According to recent statistics, there have been 7926 reports of tooth extractions in hospitals under the age of five. Amid 2012 and 2014 in England, it was shown that thirty percent of children didn’t visit a dentist. Between the years 2012 and 2013, plaque formation on teeth was the primary cause of inpatient admissions for the age group lying between five and nine years (Child oral health: applying All Our Health, 2018).

22, 574 children within the age group of five to nine years were admitted for dental cavities from 2010 to 2011. While 25,812 children within the same age range were admitted for the same condition from 2013 to 2014 which only means that this number is not decreasing and is showing its peak level of admissions due to dental problems (The state of children’s oral health in England, 2015).

A key factor to keep in mind is demographics which play a crucial role in health inequalities because of socio-economic status, presence of fluoride in water and visiting dentists.

1. For five year olds:
   1. Thirty-four percent have poor oral health in North West England.
   2. Twenty percent have cavities in South East England (Child oral health: Applying All Our Health, 2018).
2. In three year olds:
   1. Thirty-four percent have poor oral health in Leicester.
   2. Two percent have poor oral health within Gloucestershire (The state of children’s oral health in England, 2015).

Therefore, childhood oral cavity health should be considered a priority because of its detrimental health impacts. A child with dental health issues fails to attend an approximate of three school days. Oral health problems result in severe pain for children – up to 38 percent of which report that they are unable to sleep due to tooth aches. As such, parents end-up missing work to stay home with their child (Child oral health: Applying All Our Health, 2018).

Moreover, an increase in cavities at an early age in life leads to abscess formation within gums predisposing individuals to further tooth decay along the road – even in their permanent teeth and if teeth have to be removed, it might affect teeth arrangements leading to orthodontic issues (The state of children’s oral health in England, 2015).

In addition, since the oral cavity is a common place for bacterial growth. If teeth are left un-brushed, bacteria will reproduce which will lead to tooth decay because of demineralization and gum disease that increases the risk of endocarditis and other cardiovascular diseases (Oral Health Worldwide, 2015).

As a result, this crucial public health issue will lead to several expensive implications if not targeted by a robust plan. Below the age of five years, tooth removal expenditure is about 7.8 million pounds with an average of 836 pounds per child. However, the process doesn’t end here because these procedures require constant follow-up and maintenance. It is also imperative to mention that without implementing strong interventions, cavity formation will recur in this age group leading to an unending cycle (Child oral health: Applying All Our Health, 2018).

As a response to this health crisis, the Children’s Oral Health Improvement Program was established and it included stakeholders from NHS England, the Local Government Association, the British Dental Association, and the Institute of Health Visiting (Launch of the Children’s Oral Health Improvement Programme Board, 2016).

Five aims were to be achieved by the year 2020.

• Children’s dental care: a concern in national documents.
• Availability of evidence based practice and training.
• Availability of regularly updated data about oral health.
• Publishing research of new programs that reduce costs.
• Mass Media Campaigns.

They even set evaluation standards:

• Fewer children who have dental carries.
• Reduction in night void of sleep due to tooth aches.
• Decreased pain experienced by children because of cavities.
• Reduction in the use of general anesthesia to treat cavities.
• Decrease in school (children) and work (parents) absences.
• Diminish inequalities and inequities in oral health (Launch of the Children’s Oral Health Improvement Programme Board, 2016).

Therefore, early or primary prevention has proven to be crucial in preventing unhealthy oral cavities especially due to its increased prevalence. The intervention of introducing tooth brushing in a school environment decreases plaque formation on teeth and encourages constructive behaviors towards dental care (Herrera Serna and Lopez Soto, 2018).

The time frame for this program is a five year plan – targets are expected to be seen by 2025.

The objective for this program based on the previous mentioned epidemiological data is:

1. To reduce by half the number of children between the ages of five to nine who are admitted to hospitals for dental caries.
2. To reduce by half the number of tooth extractions for children under the age of five in hospitals.

3. Phase 3: Behavioral and Environmental Factor

To be able to proceed with the program, the determinants of poor oral health in children aged three to nine living in England must first be established.

Risk Factors:

Age, Sex and Heredity	Age : 3 to 9 years old (Child Oral Health Applying all our health, 2018) Heredity : epidermolysis bullosa and other enamel affecting genetic factors (Bretz et al., 2003, pp.185–189).
Behavior	Parents don’t have time to brush their child’s teeth or they simply give in to the child’s tantrum and don’t proceed with the process of brushing (Marshman et al., 2016, pp. 122-130). Starting tooth brushing at a late age. Lack of dental visits. Intermittent tooth brushing. Absence of or minimal fluoride in toothpaste. Eating Habits: •         Drinking sugary drinks and excess candy (Child Oral Health Applying all our health, 2018).
Social as well as Environmental factors	Single/Unemployed parents (don’t have time or money to cook – buy fast/cheap food). Living in deprived areas. Parents are unaware of importance of dental hygiene (Child Oral Health Applying all our health, 2018). Lack in dental health education in schools. Advertisements about sugary drinks and foods.

4. Phase 4: Educational and Organizational Diagnosis

1. Environment

Time frame: within three years

1. Reduce media commercials for sugary drinks by 50 percent.
2. Increase media announcements about the importance of dental care.
3. Increase advertisements giving tutorials about the proper technique of tooth brushing before starting to play games on I pads for children.
4. Teaching parents the importance of low-sugar substitutes as school snacks.
5. Increase access to healthy foods such as vegetables and fruits by decreasing their cost.
6. Preparing programs in school to target dental practices by having teachers allocate time for tooth brushing once a day in school for children between the ages of three to six.
7. Provide fluoride toothpaste and toothbrushes with cartoons on them to all students in schools and nurseries.

2. Behavior

1. Utilization of sugary drinks will decrease by at least 20 percent within the first year and 35 percent by the following two years.
2. Increase in parental ability to reduce their children’s sugar consumption.
3. Observe a visible increase in children aged three to nine that have dental check-ups twice a year.
4. The prevalence of tooth brushing will increase in children within the age group of three to six.

5. Phase 5: Administrative and Policy Diagnosis

To target health education:

• Schools will provide children with free dental check-ups in September and February for one week by having each school visited by two NHS dentists to provide education on brushing techniques with return demonstration.
• Dental education will be re-enforced with the child’s return demonstration by the dentist and providing parents with pamphlets with every dental check-up outside school.

6. Phase 6: Implementation

In May 2018, NHS England introduced a new policy to provide children with dental check-ups at earlier ages since every child less than 19 has free NHS dental coverage in their plan to encourage lifelong healthy oral habits (70,000 more toddlers to get their first dental check-up as NHS England targets childhood dental health, 2018).

In addition, fluoride in water is present in some areas of England. However, the concentration of fluoride has to be regulated to achieve targeted levels in other areas. Every four years, check-ups are performed to make sure fluoridation schemes are kept up-to-date (Water fluoridation: health monitoring report for England 2018, 2018).

Moreover, in 2018, the United Kingdom government implemented the “Sugar Tax” enforcing soft drink companies to reduce the amount of sugar in their products. Companies who refused to partake are now forced to pay taxes. These funds go to healthy breakfasts and sports services in schools (Soft Drinks Industry Levy comes into effect, 2018).

To add to existing policies, assemble resources from schools, parents and dentists to lobby for:

• Distribution of toothbrushes and toothpastes to children in schools and nurseries.
• An increase in taxes on billboards and commercial advertisements of sugary drinks and sweets which will cover the decrease in the costs of healthy food items such as fruits and vegetables.

7. Phase 7: Process Evaluation
   1. Are toothbrushes and toothpastes being provided to all students in all of the schools in England?
   2. Has there been a decrease in sugary drinks and food advertisements? Are the manufacturers decreasing their sugar contents?
   3. Has there been any increase in commercials about the importance of dental care? Have there been any commercial tutorials for children about dental practices?
   4. Has there been a decrease in the cost of fruits and vegetables?
   5. Have schools been incorporating dental care teaching sessions in their program?
   6. Are NHS dentists going to schools in September and February of each academic year to give dental check-ups?
   7. Is the assembled association of parents, dentists and schools lobbying the government for the needed changes?
   8. Should anything be amended?
8. Phase 8: Impact Evaluation (they have been met if)
   1. Behavioral
      1. Parents will make time to brush their children’s teeth.
      2. Tooth brushing will start at a young age.
      3. Children will see an NHS dentist twice a year either during the academic year or with parental visits.
      4. Tooth brushing will be carried out twice daily with fluoride toothpaste.
      5. Parents will encourage their children to have healthy snacks increasing the intake of fruits and vegetables and decreasing the intake of sugary drinks and candy.
      6. Utilization of sugary drinks will decrease by 50%.
   2. Social and Environmental
      1. Schools will incorporate dental health practices in their curriculum.
      2. 50 % decrease in advertisements about sugary drinks and candy is marked.
      3. An increase in advertisements about dental care and tooth brushing techniques is marked.
9. Phase 9: Outcome Evaluation
   1. Have the number of children between the ages of five to nine who are admitted to hospitals for dental caries decreased by 50 %?
   2. Have the number of tooth extractions for children under the age of five in hospitals decreased by 50%?

In conclusion, this program aims to advocate for oral health in children aged three to nine by instilling in them the essential skills for proper dental care at the early stages of development in an environment that supports early prevention strategies.

References:

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