After considering all factors explained in this chapter, MINSAL’s proposal was defined as FV application in the preschool setting (pre-kinder and kinder), every 3-6 months depending on caries risk, with prior screening performed by dentists. As expected, there are arguments for
and against MINSAL’s proposal; those that are relevant to this study are discussed in this section.
A possible argument for MINSAL’s proposal is given by the high pre-kinder and kinder coverage. The high rate would facilitate access to children who are gathered together in schools; however, due to the attendance rates shown, caution needs to be exercised and multiple visits to schools may need to be considered. At the same time, the fact that children are being seen in their natural environment would, hypothetically, increase children’s cooperation.
Another argument for the chosen setting is that there would be no extra costs for parents compared to, for example, if they had to take their children to other settings. This would, therefore, improve the opportunity of access to the entire population, as well as reduce the influence of economic variables, such as household income. Potentially, use of the school setting might help to reduce oral health inequalities.
However, given that a considerable percentage of the population is not caries-free at these ages, especially those more deprived populations (MINSAL, 2012c), it is possible that FV impact may be small. An alternative would be to start the FV programme at an earlier age. MINSAL, unfortunately use unpublished data to make its recommendations, thus making it difficult to determine the proportion of caries-free children by socioeconomic group. Undoubtedly, to fully understand caries prevalence, more studies are required.
It must also be recognised that there are some uncertainties related to the evidence given by MINSAL about FV efficacy. The evidence presented in the FV protocol was based on the prevented fraction of FV published by Marinho et al. (2003), where studies included children both with and without caries. This study was not based solely on the caries-free population, thus FV efficacy argued may not justify a nationwide programme that seeks to increase the percentage of caries-free children.
Furthermore, the FV effects argued by MINSAL are based on dmfs, and such an index cannot be compared directly with dmft (which is the caries index used by MINSAL) and caries prevalence (dmft > 0). This was described in more detail in Chapter 2. In other words, it is unclear whether the positive results shown previously to justify the programme can be replicated in a programme that attempts to increase the percentage of caries-free children.
Based on the FV protocol, it can be deduced that MINSAL would not provide FV to the entire population, adopting a medium and high-risk approach instead. Unfortunately, the same document does not give a clear difference between both risk classifications and, given the lack of evidence of FV in caries-free populations, the frequency of application to be used is also not clear.
Given that MINSAL’s goal is to increase the percentage of caries-free children in the entire preschool population, the question that arises here is whether the high-risk approach is the best alternative to reach such a goal, i.e., would treating the high-risk only population be enough to improve the oral health of the entire population?
The high-risk approach is based on the use of methods to detect children at high-risk such as a clinical examination as screening; this could be performed knowing the main risk indicators and predictors (Masood et al., 2012). Though, as explained in Chapter 2, the main predictor of caries is past caries experience; consequently, a screening would not be very useful if MINSAL wants to increase the percentage of caries-free children (dmft = 0).
There is, therefore, a need to analyse what might happen if the low-risk population is treated and/or how the untreated low-risk population would influence the entire population. The evidence gives some indication about this, for example, Batchelor and Sheiham (2006) analysed the occurrence of new caries lesions over a 4-year period in children aged 7 years; they found that more than 50% of new lesions (DMFS) occurred in children initially classified as caries-free, and those children classified as highest-risk (with 7 or more lesions) generated just 6% percent of all new lesions.
A controversial point of the FV protocol is the use of low socioeconomic status (SES) to identify high-risk children. Given that belonging to a public school has been used by MINSAL as a proxy of low SES (Ceballos et al., 2007;Soto et al., 2007a;Soto et al., 2009), there is no sense in performing a screening when all children are considered high-risk because they belong to a public school. In other words, how useful is performing a screening when all children have an indication for FV application?
The application of FV is a very simple process that involves painting the tooth surface with either a special brush or a gauze (Colgate-Palmolive, 2014). This means that application would not require a highly qualified professional to perform it. Therefore, the question arises about
MINSAL’s proposal: what is the opportunity cost of sending highly qualified (and highly expensive) personnel to do a very basic procedure?
The previous question is important in the Chilean context due to scarcity of dentists in the public subsystem; there are 4,000 dentists, according to Goic (2015), that must treat around 80% of the Chilean population. This is even more important when the demand for the public dental workforce is analysed, as with the explicit warranties on health programme (GES) for example; Monsalves (2012) argued that due to the high demand and the fact that most working hours are dedicated to treating GES pathologies and other priority groups, the coverage of dental care has been reduced to a small section of the population. Therefore, taking dentists (and dental staff) out of surgeries and sending them to schools to do a simple job may not be advisable.
As MINSAL is already using non-dental professionals in oral health education, it is reasonable to evaluate possibly less expensive alternatives such as nurses, for example. This could also expand the role of other health professionals during the WCP and allow them to perform the application. This approach is consistent with the opinion of Selwitz et al. (2007) who argued that prevention of dental caries cannot be achieved by reliance only on dental care teams and suggested that we need to incorporate other health professionals. Also, this approach would be compatible with MINSAL’s strategic line of strengthening the components of a comprehensive oral health care model, with a family- and community-based approach (MINSAL, 2012c).
4.6 Summary
This chapter described the Chilean health and education context and analysed the FV programme proposed by Chilean Ministry of Health (MINSAL) at the pre-kinder and kinder grades to increase the percentage of caries-free 6-year-olds. The preschool population is covered by both health and education systems with different rates depending on the child’s age.
Evidence of the percentage of caries-free children, used by MINSAL, is based on unpublished data. The FV protocol lacks conclusive evidence about the effects of FV on caries-free children. More research is required to obtain reliable information on these topics.
There are uncertainties about the use of screening to target the high-risk population and the impact that such high-risk populations could have on the entire population; further studies regarding the possible impact would be worthwhile. There are concerns about sending highly qualified and scarce personnel to perform a very simple task; other alternatives should be explored.