Original Paper

Caries Res 2009;43:110118

DOI: 10.1159/000209343

Received: December 6, 2007

Accepted after revision: January 27, 2009
Published online: March 24, 2009

A Cluster Randomised Trial of Effectiveness of

Educational Intervention in Primary Health Care
on Early Childhood Caries
S.Z. Mohebbi a, b J.I. Virtanen a M. Vahid-Golpayegani b M.M. Vehkalahti a
a

Institute of Dentistry, University of Helsinki, Helsinki, Finland; b Shaheed Beheshti Medical University, Tehran, Iran

Key Words
Early childhood caries Oral health education Prevention
of caries

respectively. In conclusion, oral health education given to

mothers by general health staff is a valuable tool to prevent
caries in infants and toddlers.
Copyright 2009 S. Karger AG, Basel

Abstract
Early childhood caries (ECC) remains a serious problem in
several developing and developed countries. This cluster
randomised trial evaluated the impact of a 6-month educational intervention on ECC. The trial targeted 12- to 15month-old children (n = 242) and their mothers in Tehran,
Iran, visiting 18 public health centres, randomly selected and
assigned to two intervention groups and one control group.
At baseline, each mother was interviewed and each child underwent a dental examination of all teeth for the number of
decayed teeth (dt) and of upper central incisors for the number of teeth with enamel caries (de). All mothers in the two
intervention groups (A and B) received oral health instructions from the vaccination staff. In addition, group A received
extra reminders. The outcome was defined as increments in
the number of teeth with dt or de, as percentages of children
developing new dt or de, and as the number needed to treat
(NNT). No new de appeared in group A, the mean de increment in group B was 0.2 (SD = 0.6), and in the controls, it was
0.4 (SD = 0.7) (p ! 0.05). The percentages of children developing new de were 0, 14, and 26%, respectively. No differences in dt increments were found. Regarding de, NNT for
group A was 4 and for B 9; the figures for dt were 13 and 17,

Early childhood caries (ECC) remains a serious problem in many developing countries as well as among minorities in several developed countries [Milnes, 1996; Evans and Kleinman, 2000; Sheiham and Watt, 2000], and
may lead to an increased threat to general health and
well-being [Petersen and Kwan, 2004]. The treatment of
ECC is costly, and severe cases may require treatment under general anaesthesia in hospital settings [Almeida et
al., 2000]. Studies reveal serious problems in the dental
state of young children in Iran: half of the 3-year-olds in
the whole country [Samadzadeh et al., 1999] and one
third in Tehran suffer from ECC [Mohebbi et al., 2006],
indicating a lack of proper oral health prevention and
care for children in this age group.
Because the majority of young children in several
countries receive no dental examination before the age of
3 [Samadzadeh et al., 1999; Wendt et al., 2001; Douglass
et al., 2004], professional dental services are considered
irrelevant to the public health approach for the prevention of ECC [Davies, 1998; Jones et al., 2005]. A more efficient way to reach the target group would be to integrate
oral disease prevention into broader health promotion

2009 S. Karger AG, Basel

00086568/09/04320110$26.00/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch
www.karger.com

Accessible online at:

www.karger.com/cre

Simin Z. Mohebbi
Department of Oral Public Health, Institute of Dentistry
University of Helsinki, PO Box 41
FI00014 Helsinki (Finland)
Tel. +358 9 1912 7301, Fax +358 9 1912 7346, E-Mail simin.mohebbi@helsinki.fi

[Harrison and Wong, 2003; Petersen and Kwan, 2004].

Oral health education may easily be combined into general health care, but reports of the effectiveness of such a
method on caries prevention remain controversial [Kay
and Locker, 1998; Rozier, 2001].
The effectiveness of oral health promotion programmes can be evaluated by various clinical and behavioural measures among which the presence of dental caries is one of the major outcome measurements. Applying
the primary stages of caries lesions that compromise
enamel caries is a more sensitive measure for assessing
changes in dental caries [Kingman and Selwitz, 1997;
Nyvad et al., 1999; Warren et al., 2002] and may be a practical means of evaluating the impact of interventions to
prevent caries in early childhood.
The overall purpose of this cluster randomised trial
was to plan an effective oral health educational intervention that can be integrated into the visits of children in
general health services in countries with developing oral
health systems. As a valuable tool for designing behavioural change strategies, this study took advantage of the
health belief model [Overton Dickinson, 2005] in providing oral health education. In addition, reminders such as
phone calls during the intervention period served as further cues to action in one of the intervention groups. The
study evaluated the impact of the 6-month educational
intervention aimed at preventing dentinal and enamel
caries in 12- to 15-month-olds.

code only. Participants received no remuneration except for the

disposable dental mirror used in the clinical examination of the
child.
Sampling, Randomisation, Blinding
Using a list provided by the Ministry of Health and Medical
Education, we randomly selected 18 of 102 public health centres
in Tehran city. For the present intervention, a sample size of 240
participants (80/study arm, 6 health centres/arm; = 0.05, twosided, power = 80%, 2530% attrition, prevalence of 510% for
dentinal or enamel caries in 1-year-olds) was chosen to detect a
20% difference in caries prevalence between the intervention and
control groups.
The baseline data were collected from January to February
2005 and the outcome data 6 months later. For both examinations, 2 working days were devoted to each health centre. At baseline, all target age children visiting the centre on these days were
selected, resulting in 1015 children per centre. The exclusion criterion was suffering from any severe disease that could pose a
barrier to the practice of oral health such as mental retardation or
a cleft palate.
Health centres were randomly assigned to the three arms: two
intervention (A and B) groups and one control (C) group. Consequently, 6 centres were devoted to each group. The randomisation
was assigned with a table of random numbers. The randomisation
and intervention processes were supervised by a dentist (A.A.)
uninvolved in the clinical examinations and interviews. Both preand post-intervention data collections were synchronised with
the childrens routine vaccination visits, and mothers were unaware of possible dental examinations on the day of their visit to
the health centres. The clinical examination and interview took
place in a room separate from the vaccination room, and the examining dentist, one of the authors (S.Z.M.), remained blinded to
the allocation of groups throughout the study. The staff were instructed to mention nothing regarding intervention to the examining dentist.

Subjects and Methods

General Description
As part of a comprehensive study of 1- to 3-year-olds (n = 504),
this present trial targeted 12- to 15-month-old children (n = 242)
and their mothers (n = 242) who were contacted at the vaccination
offices of public health centres in Tehran, Iran [Mohebbi et al.,
2008a]. The coverage of vaccination ranges from 94 to 98%
throughout the country [WHO, 2008]. Childrens vaccinations
are widely taken in public centres regardless of a familys socioeconomic status.
At baseline, each mother was first interviewed and then each
child underwent a clinical dental examination. Afterwards they
moved to vaccination offices where the vaccination staff provided
oral health instruction to all mothers belonging to the intervention groups. The length of follow-up was 6 months. The outcome
was measured as differences in caries increments and as mothers
perceptions of the usefulness of intervention.
Ethical Consideration
The study was approved by the Ethics Committee of the School
of Dentistry, Shaheed Beheshti Medical University. The mothers
provided their informed written consent to participate in the
study. The subjects were entered into a database with a numerical

Effectiveness of Educational Intervention

in Early Childhood Caries

Clinical Examination
Before the clinical dental examinations, the examining dentist
was further trained by an experienced paediatric dentist, head of
a university department of paediatrics. The training ended with
double examinations of 10 children with various levels of dentinal caries. The intra-examiner reliability, a kappa value, was 1.0
for the number of decayed teeth (dt) [WHO, 1997]. In addition, 15
more children were examined to determine intra-examiner reliability for detecting enamel caries [WHO, 1979; Kingman and
Selwitz, 1997] on the labial surfaces of the upper central incisors,
resulting in a kappa value of 0.6 for the number of upper central
incisors with enamel caries (de). The calibration process was repeated before the outcome examinations, and the kappa values
were 1.0 and 0.7, respectively.
Dental examination was carried out with the help of a headlamp and a standard plane dental mirror with the mother and
examiner sitting in a knee-to-knee position [Mohebbi et al., 2006].
Every tooth was recorded as present when visible in the mouth,
otherwise as absent. After cleaning and drying with gauze and a
sterile cotton sponge, the surfaces were visually examined. If in
doubt, a WHO probe was gently used [Nyvad et al., 1999]. The
criteria for caries diagnoses met WHO recommendations [WHO,
1997]. Dentinal caries was recorded for all teeth, but enamel car-

Caries Res 2009;43:110118

111

Table 1. The main content of the oral health instructions included

in the educational intervention to prevent caries in 12- to 15month-old children

Main subjects
Main messages1
in the pamphlet

Feeding
habits

After the first tooth eruption, try to stop

nighttime feeding for the child
Do not let your child sip from the bottle
during the day or sleep with the bottle at night

Sugar intake

Try not to use sugary snacks and drinks more

than twice daily (the same for both adults and
children)2
Avoid adding sugar to the childs bottle content
Give water to your child after taking medicines

Transmission Avoid tasting your childs food with the same

of bacteria
spoon you use to feed him/her2
Avoid sharing spoons, glasses or any other
feeding utensils with your child2
Oral hygiene Brush or at least wipe your childs teeth after
the time of first tooth eruption2
Use less than a pea size amount of the
childrens fluoride toothpaste to brush your
childs teeth at least twice daily2
Brush your own teeth with fluoride toothpaste
at least twice daily2
1

The main contents of the pamphlet were based on Kay and

Locker [1998]; Reisine and Douglass [1998]; Seow [1998]; Davies
et al. [2002]; Ribeiro and Ribeiro [2004]; Gussy et al. [2006];
Hallett and ORourke [2006]; van Palenstein Helderman et al.
[2006]. Requests for the intervention pamphlet and protocol:
simin.mohebbi@helsinki.fi.
2 Included in the verbal oral health instructions and reminder
phone calls.

ies (de) for the upper central incisors only, on their labial surfaces.
All dmft were due to dt in this child population.
Interview
The language of the interview and structured questionnaire
was Persian. The examining dentist, a native Iranian, interviewed
the mother before the clinical examination. The interview used
the structured questionnaire covering background factors including the childs gender and date of birth, the mothers age, family income and parents level of education assessed separately for
father and mother using a 7-point scale ranging from illiterate to
doctoral degree [Mohebbi et al., 2008b]. The parents level of education was defined as the highest level of either parents education.
The question about family income per month was open-ended.
The parents level of education and family income as the most
commonly applied indicators for the socio-economic status of a
family were included [Reisine and Psoter, 2001].

112

Caries Res 2009;43:110118

Intervention to Prevent Caries

The educational intervention took place by means of a pamphlet created for this present study to cover the main topics (table 1) relating to caries prevention in infants and toddlers. The
pamphlet was in Persian, the language of Tehran inhabitants. The
pamphlet used simple language so that less-educated parents
could also read it. It contained happy colours and illustrations of
babies to maintain the mothers attention and interest. Verbal instructions and reminder phone calls were provided for one of the
intervention groups. No oral health promotion other than education was provided in the intervention.
The interventions were integrated into the health staffs duties. Prior to the intervention, two members of the health staff in
each centre received 12 h of training from the dentist who supervised the intervention. This training covered their duties, the importance of keeping the examining dentist blinded to the grouping, and the use of the pamphlet, the contents of the verbal instructions and the reminder phone calls. In addition, the staff
were asked to emphasise for all mothers the importance of being
on time for the next vaccination in order to reduce drop-outs.
This date was written on the vaccination chart as well. The intervention supervisor was available throughout the intervention period for any question from the vaccination staff. The heads of the
health centres were informed about the process and importance
of the intervention in order to provide maximal support for the
staff.
Pamphlet and Reminder (Group A). The staff at the vaccination
offices provided the mothers with the pamphlet on caries prevention together with 5 min of oral health instructions in early childhood. In addition, telephone numbers were collected and the
health centre staff phoned these mothers twice at 2-month intervals to remind them of the oral health instructions given. Scripts
were provided for verbal instructions and the reminder phone
calls (table 1). The staff reported two phone calls for all mothers
in group A. For quality assurance the intervention supervisor
checked that the staff carried out the reminder phone calls as
scheduled.
Pamphlet Only (Group B). The vaccination staff gave the same
pamphlet on caries prevention to the mothers with no more explanation than the comment that it would be useful to read. No
verbal oral health instructions or reminder phone calls were provided.
Controls (Group C). The control group received no oral health
information during the 6-month period. After the outcome examinations, these mothers also received the same pamphlet on
caries prevention from the vaccination staff.
Evaluation of the Intervention
The evaluation covered those children who attended the outcome examination. Outcomes were determined as increments in
the number of dt or de and as percentages of children developing
new dt and de. Calculations of the de increments included those
children who could be at risk for developing new de, thus excluding the children who had caries on both incisors at baseline. Based
on these percentages, the number needed to treat (NNT) was defined separately for dt and de as a measure of assessing the effectiveness of interventions. The NNT reveals how many patients
should be treated in order to prevent one with negative outcome,
here either new dt or de. The smaller the NNT, the greater the effectiveness of the intervention. In addition, the groups were com-

Mohebbi /Virtanen /Vahid-Golpayegani /

Vehkalahti

Baseline
(n = 242)
18 public health centres
Randomisation of

Fig. 1. Flow chart of the 6-month interven-

tion to prevent caries in 12- to 15-monthold children. Group A: educational pamphlet, 5 min of oral health instructions, 2
recall phone calls of the oral health instructions at 2-month intervals. Group B:
educational pamphlet with a comment
that it would be useful to read. Group C: no
oral health-related information during the
6-month period. All groups received a
comment emphasising the importance of
the on-time visit for the next vaccination.

Group A
Pamphlet and reminder
(n = 77)

Group B
Pamphlet only
(n = 85)

Group C
Control
(n = 80)

Phone call

Drop-outs
(n = 22)

Drop-outs
(n = 26)

Drop-outs
(n = 17)

Phone call

6 months
Outcome examination
(n = 55)

pared according to de findings in all children at the outcome examination.

The subjective evaluation of the study was carried out as a
short interview by means of the two following questions asked
from the mother: (1) How satisfied were you with the pamphlet?
and (2) How much did the pamphlet influence your oral health
behaviour? The response was given on a 6-point scale from very
much to very little, respectively. The response included the alternative of no opinion.
Statistical Analysis
The Kruskal-Wallis and Mann-Whitney U test served for assessing the statistical significance of the differences in averages,
and the 2 test for differences in frequencies.
Logistic regression was applied to estimate odds ratios (ORs)
and their 95% confidence intervals (95% CIs) of dental caries increments for the intervention groups in comparison with the controls while controlling for the childrens backgrounds. Goodness
of fit was assessed by means of the Hosmer-Lemeshow test. A p
value of less than 0.05 denoted statistical significance. NNT was
calculated as 1/ARR where ARR = absolute risk reduction, and
then rounded up. The data were analysed with SPSS, version 13.

Results

At baseline, 242 (group A = 77, group B = 85 and group

C = 80) mother-and-child pairs were enrolled in the study
(fig. 1), of whom 177 pairs (group A = 55, group B = 59
and group C = 63) attended the outcome examinations.
Of those who attended both baseline and outcome exEffectiveness of Educational Intervention
in Early Childhood Caries

the public health centres

later

Outcome examination
(n = 59)

Outcome examination
(n = 63)

aminations, 50% were boys: 40% in group A, 59% in

group B and 54% in group C (p = 0.11). The parents level
of education was low for 14%, moderate for 49% and high
for 37%. The parents level of education was low for 12%
in group A, 12% in group B and 16% in group C. Family
income was low for 10% of families; moderate for 50%
and high for 40% of families. The family income was low
for 7% in group A, for 12% in group B, and for 11% in
group C. The parents level of education and family income showed no differences between the groups. The
mean age of the children was 12.3 months (SD = 0.4) at
baseline and 18.3 months (SD = 0.6) at outcome. The
groups showed no differences regarding childrens age or
dental findings at baseline (table 2).
The drop-outs (n = 65) were not different from those
who attended the outcome examinations (n = 177) in
terms of the baseline percentage of children with dt (3 vs.
2%) and de (8 vs. 9%), number of dt (!0.1 vs. !0.1) and de
(0.1 vs. 0.2), number of teeth (6.1 vs. 6.3), and background
factors.
Regarding enamel caries on upper central incisors, of
those teeth with de at baseline, 6 of 14 teeth in group A,
5 of 9 teeth in group B and none of 5 teeth in the control
group recovered. Table 3 describes the increments in the
number of de and in the percentage of children developing new de in those at risk. Group A revealed no increment in de, whereas group B showed slightly lower increments in the number of de (mean = 0.2, SD = 0.6) and the
Caries Res 2009;43:110118

113

Table 2. Baseline dental findings in 12- to 15-month-old children who attended outcome examinations (n = 177)

Groups

Age
months

Teeth

dt

Children
with dt

de

Children
with de

A = pamphlet + reminder
B = pamphlet only
C = control
p value

55
59
63

12.3280.47
12.3480.35
12.3380.48
0.246

6.382.0
6.281.7
6.481.9
0.411

0.0480.19
0.0280.13
0.0380.25
0.719

2 (4)
1 (2)
1 (2)
0.710

0.2580.67
0.1580.48
0.0880.37
0.283

7 (13)
6 (10)
3 (5)
0.301

dt = Number of teeth with dentinal caries; de = number of upper central incisors with enamel caries. Figures in parentheses are
percentages.

Table 3. Incremental changes in the number of upper central incisors with enamel caries (de) and the percentages of children developing new de during the 6-month intervention among those children at risk for developing new de (n = 165) and of all children having de at the outcome examination (n = 177)

Groups

Number
at risk1

Number
excluded2

New de

Children
with new de

All children with NNT

de at outcome

A = pamphlet + reminder
B = pamphlet only
C = control

48
56
61

7
3
2

0.080.0
0.280.6
0.480.7

0 (0)
8 (14)
16 (26)

4 (7)
10 (17)
18 (29)

p (A vs. C)
p (B vs. C)

<0.001
0.066

<0.001
0.208

4
9

<0.01
0.14

Figures in parentheses are percentages.

1 Number of children at risk of developing new de on upper central incisors.
2 Number of children excluded (no risk for new de, due to caries on both incisors at baseline).

percentage of children with new de than did the controls.

The NNT was 4 [1/(0.260.0)] for group A and 9 [1/(0.14
0.0)] for group B. Table 3 also shows differences between
the groups in de occurrence among all children at the
outcome examination. For group A, the percentage of
children with de was lower than that for the controls (7
vs. 29%; p ! 0.01). The numbers of children with de at
baseline and of those excluded because of not being at risk
of new de were evenly spread out over the health centres
(table 4). Further evaluation of the data revealed no differences in between- and within-group variances.
Increments in dentinal caries as the numbers of new
dt (A = 0.1, B = 0.1, C = 0.2) and the percentage of children
developing new dt (n for A = 3, B = 4 and C = 8) in the
intervention groups were minor and showed no differences from the control group (table 5). The NNT resulted
in a slightly lower estimate for group A than for group B
[13 = 1/(0.130.5) vs. 17 = 1/(0.130.7)].
114

Caries Res 2009;43:110118

When background factors and intervention grouping

were entered into a logistic regression model to control
for confounding or heterogeneity (table 6), intervention
was the only factor that was directly proportional to the
occurrence of either new de or new dt. With the control
group as the reference, the OR for developing new de or
dt was 0.1 (95% CI 0.00.4) for group A and 0.4 (95% CI
0.21.0) for group B.
The majority of mothers were satisfied (88% for very
much or much) with the pamphlet in both intervention
groups with no differences according to their backgrounds. Regarding self-perceived changes in their oral
health behaviours, 64% of mothers considered such
changes to be very much or much, 20% moderate, 12%
little and 4% had no opinion about them. Those in group
A noted that the pamphlet had more influence on changing their oral health behaviours when compared to group
B (p = 0.05).
Mohebbi /Virtanen /Vahid-Golpayegani /
Vehkalahti

Table 4. Comparison of health centres according to numbers of

Table 5. Incremental changes in the number of decayed teeth (dt)

children (n = 177) and enamel caries (de) findings on the upper

central incisors

and the percentage of children developing new dt during the

6-month intervention (n = 177)

n (all)

Groups

Children Children excluded Children getting

All children
with de at because of not being new de when being with de at
baseline
at risk for new de
at risk for new de outcome

Group A (pamphlet + reminder)

8
1
1
10
1
1
12
1
1
8
2
2
8
0
0
9
2
2

0
0
0
0
0
0

0
1
1
1
0
1

Group B (pamphlet only)

7
0
0
6
1
0
12
1
0
13
3
2
8
1
1
13
0
0

1
2
1
1
2
1

1
2
1
2
3
1

Group C (control)
9
0
5
0
15
3
9
0
13
0
12
0

2
1
6
5
2
0

2
1
8
5
2
0

p (A vs. C)
p (B vs. C)

0
0
2
0
0
0

<0.01
0.336

< 0.05
0.08

Discussion

The present randomised trial demonstrated that an

educational intervention to prevent caries implemented
by general health staff and targeting mothers of young
children was effective in slowing down the development
of enamel caries, especially among those motivated by
the health staff. In future, this early prevention may lead
to lower prevalence of dentinal caries, as suggested in a
study of older children [Hausen et al., 2007].
The main barrier to implementing caries prevention
programmes for infants and toddlers is that they are unavailable in dental service settings [Wendt et al., 2001;
Douglass et al., 2004]. On the other hand, oral health interventions are frequently inconsistent with existing preventive programmes implemented by other health professionals in several countries, while new approaches in
public health no longer aim to prevent a single disease
[Sheiham and Watt, 2000]. The early onset of dental carEffectiveness of Educational Intervention
in Early Childhood Caries

New dt

Children
NNT
with new dt

A = pamphlet + reminder 55
B = pamphlet only
59
C = control
63

0.180.6
0.180.1
0.280.7

3 (5)
4 (7)
8 (13)

p (A vs. C)
p (B vs. C)

0.188
0.265

0.177
0.276

13
17

Figures in parentheses are percentages.

ies, its infectious nature and the common risk factors between caries and other chronic conditions require prevention to be provided along with general health services.
In this present study, the vaccination offices of public
health centres seemed suitable for this purpose. The general health staff may combine parts of oral health educational material into their general health promotion instructions by taking advantage of the highly recommended common risk factor approach in health promotion
[Sheiham and Watt, 2000].
The encouraging finding of the success of the present
educational intervention in caries prevention is in line
with the results of some previous studies on oral health
education and dietary counselling for mothers of very
young children [Ekstrand et al., 2000; Feldens et al.,
2007]. In a systematic review, however, Rozier [2001]
raised reservations about the effectiveness of educational
methods on caries prevention. Some studies have been
successful in inhibiting caries in young children by focusing only on dietary modification [Feldens et al., 2007],
while others have covered more comprehensive oral
health topics [Plutzer and Spencer, 2008]. The broad content of the present pamphlet was determined according
to the high prevalence of dental caries and insufficient
oral hygiene in primary dentition in Iranian children
[Samadzadeh et al., 1999]. The need for emphasis on the
transmission of bacteria was also great as the sharing of
eating utensils between mother and child is a common
habit. In the present intervention groups, half of the few
cases with enamel caries at baseline seemed to recover in
the outcome examination, which could be attributed to
the intervention. Although some of the initial lesions can
recover per se, 64% of them have been reported to proCaries Res 2009;43:110118

115

Table 6. Factors related to development

of any new caries, either enamel caries

(de) on upper central incisors or new
decayed teeth (dt) during the 6-month
intervention (n = 177), as explained by
a logistic regression model

Variables in the model

Estimate
Standard OR
of strength error

95% CI

Intervention groups (control = 0)

Pamphlet only (group B) = 1
Pamphlet + reminder (group A) = 2

0.893
2.249

0.441
0.662

0.4
0.1

0.21.0
0.00.4

0.043
0.001

Childs age
Childs gender: boys = 0, girls = 1
Parents level of education
Family income

0.514
0.110
0.001
0.001

0.417
0.401
0.178
0.001

1.7
0.9
1.0
1.0

0.73.8
0.42.0
0.71.4
1.01.1

0.217
0.784
0.998
0.739

All variables were used in their continuous form except for intervention groups and
gender.

gress to dentinal caries because of the lack of proper use

of fluorides [Ismail, 1997]. In accordance with Gussy et
al. [2006], the present study recommended brushing or
wiping childrens teeth with fluoride toothpaste as soon
as they erupted into the mouth. The WHO oral health
programme emphasises the importance of public health
approaches to the effective use of fluoride by means of
daily brushing with fluoride toothpaste; an additional
source of fluoride should be considered for high to moderate caries prevalence [Jones et al., 2005].
The use of primary stages of caries lesions is helpful in
detecting changes in caries levels in areas with moderate
or low prevalence of caries [WHO, 1997] which is often
the case for very young children. Enamel caries is more
prevalent than dentinal caries in the primary teeth of
children aged 618 months [Drury et al., 1999], which
speaks for the feasibility of using enamel caries increment
as an outcome measurement of interventions to prevent
caries in early childhood. Applying recordings of enamel
caries significantly adds to the time required for data collection [Drury et al., 1999]. Furthermore, the lower reliability of applying the enamel criteria rather than the
dentine criteria [Ismail, 1997] should also be considered
when interpreting the results. In this study, however, only
the upper central incisors were examined for enamel caries because in 1-year-olds, these teeth have normally
erupted. In addition, lighting and moisture control in the
field environment were best controlled on the upper central incisors.
The reliability of the enamel caries diagnoses was
moderate to substantial, but in addition to lower increments in enamel caries development, the recovery of
enamel caries occurred only in the intervention groups,
116

Caries Res 2009;43:110118

and not in the controls. To avoid bias, the examiner was

kept strictly blinded to the allocation of groups throughout the intervention period. Thus, the possible error in
the measurement of the outcome is expected to be similar
in all groups.
The NNT values obtained speak for high effectiveness
of the present interventions, especially regarding prevention of enamel caries. The rounded up NNT values give
a useful tool for the interpretation of the interventions
from a clinical and cost-effective point of view. However,
the NNT values represent rough estimates since the calculations are based on outcome findings only. Nevertheless, our further analyses by means of a logistic regression
model controlling for other possible interfering factors
such as socio-demographic factors resulted in a similar
verification of the effectiveness of the interventions.
The mothers motivation to follow the oral health instructions could be a potential determinant of success in
the prevention of dental caries in their children [Weinstein et al., 2004]. In the present study, the motivation
provided through verbal instructions and reminder
phone calls served as additional cue to action for mothers, and could foster behavioural changes according to
the health belief model [Overton Dickinson, 2005]. The
best outcome occurred in the group where the mothers
received extra motivation. In addition, mothers in the
pamphlet and reminder group reported more positive
self-perceived behavioural changes than in the group receiving the pamphlet only. That no new enamel caries
developed in the former group of children is a promising
finding. However, this positive outcome did not occur for
dentinal caries because of its low prevalence in this young
age group, thus diminishing the power of the study for
Mohebbi /Virtanen /Vahid-Golpayegani /
Vehkalahti

detecting dentinal caries during the intervention period.

The 6-month period is the shortest time period during
which changes in caries increment may usually occur in
the primary dentition [Kay and Locker, 1998] and also
was the longest possible time period in the vaccination
schedule for 1-year-olds in Iran.
Almost one third of the enrolled participants were lost
to follow-up. Those absent for the outcome assessment
had either moved away or were taking the vaccination at
another health centre closer to their summer residence.
Unfortunately, drop-outs could not be located as this
study was designed to cover only those health centres
originally selected. However, the baseline data showed no
difference between the drop-outs and those who participated in the outcome examination.
The increasing pressure on health care finances raises
questions about the cost-effectiveness of providing health
services. Such is also the case with preventive interventions, since they have long been presumed to reduce disease, and therefore lower the demand for health services
and their resultant costs [Kay and Locker, 1996]. Exact
costs were not calculated in this study, as our interventions were integrated in the health staffs regular duties
and no extra personnel were used. A recent report

[Kowash et al., 2006] shows the best cost-benefit ratio for

an oral health education programme, in comparison to
several other preventive programmes, including water
fluoridation, fissure sealant therapy, and slow-release fluoride device. Their findings support our results regarding the use of oral health education as a feasible tool for
the prevention of ECC in countries with developing oral
health systems.
In conclusion, this study recommends that non-dental
staff working in general health settings provide mothers
with education in infant and toddler oral health care as a
feasible way of preventing or slowing caries increments in
early childhood in countries with developing oral health
systems. Furthermore, enamel caries appears to be a good
measure for evaluating the effects of interventions to prevent ECC.

Acknowledgments
This study was partly supported by the Iran Centre for Dental
Research. We are grateful to the health staff at the public health
centres for their excellent collaboration. Our special thanks go to
Dr. Amir Abbasi for his supervision of the intervention process.

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