Silver Lining in Tiny Smiles: Jockey Club Children Oral Health Project

Discover the Jockey Club Children Oral Health Project, a pioneering Initiative encompassing free dental check-ups and the application of silver diamine fluoride (SDF) solution, for preschool dental wellness in Hong Kong

In the bustling metropolis of Hong Kong, where the pace of life is fast and families are constantly on the move, it’s easy to overlook the importance of dental health in our youngest citizens. However, recent statistics reveal a concerning reality — approximately half of five-year-old children in Hong Kong suffer from early-onset dental caries, with more than 90% of these cases left untreated. To address this pressing issue, the Faculty of Dentistry at the University of Hong Kong, supported by a generous donation from the Hong Kong Jockey Club Charities Trust, has launched the “Jockey Club Children Oral Health Project.”

Taking Aim at Tooth Decay: The Project’s Objectives

The primary objective of the Jockey Club Children Oral Health Project is to detect and control tooth decay in preschool children, preventing its progression and the potential for more severe consequences. Initiated as a pioneer scheme in the academic year 2019/2020, the project garnered positive feedback, leading to its expansion to include all kindergartens in Hong Kong on a voluntary basis starting from the 2020/21 academic year.

The project offers a range of free-of-charge services to participating schools, encompassing dental check-ups and the application of silver diamine fluoride (SDF) solution. SDF, widely used in countries like the USA, Australia, and Japan, has proven effective in slowing down tooth decay and is safe for children, with no significant impact on general health. The application of SDF helps stop active decay, a crucial step in preventing further deterioration.

Individual dental reports are sent to parents after the check-up, providing insights into their child’s oral health. Additionally, at the end of the school year, a comprehensive report on the dental health of all participating children is provided to the schools. This holistic approach aims not only to address existing dental issues but also to empower parents with information and promote a collaborative effort between home and school in fostering good oral health practices.

Safeguarding our Children‘s Oral Health

Emphasising the high prevalence of tooth decay among Hong Kong’s preschool children, Prof Chu Chun Hung, the project’s lead, said the impact of severe cases on children’s growth and development is long-lasting. Prof Chu believes that dentists, educators, parents, and policymakers all play crucial roles in ensuring the success of the Jockey Club Children Oral Health Project.

In this exclusive interview, Professor Chu shares his insights into the project’s impact, challenges, and the vision for the crucial initiative that aims to transform the lives of Hong Kong’s youngest residents by safeguarding their oral health.

In the words of Prof Chu, let us safeguard our children through the power of oral care!

Q: What motivated the establishment of the Jockey Club Children Oral Health Project, and how has it evolved since its inception?

Prof Chu C H: Studies have shown that the prevalence of dental caries in preschool children in Hong Kong was high, and showed an increase from 3- to 5–year old. Early childhood caries (ECC) can affect the appearance of children thereby impairing their social development. It can also cause pain and problems with chewing. This can in turn lead to poor nutrition intake and ultimately affect their growth and development. ECC can also lead to infection which can spread locally affecting the development of the permanent teeth, or systemically which can be life threatening (The Guardian, 2017).

Despite the high prevalence of ECC in preschool children, the increase in prevalence from 3– to 5–year old, and its impact on the well-being of children, there is no organized dental care for preschool children in Hong Kong. The School Dental Care Service provided by the Department of Health of Hong Kong covers children in primary schools only. The outreach kindergarten dental service was therefore established in 2019 to fill this service gap thereby improving the oral health of preschool children. 

In addition to filling the service gap, it also allows children to receive dental care in a familiar environment. This help to reduce their anxiety. 

Q: Could you elaborate on the prevalence of childhood caries amongst Hong Kong pre-schoolers and its impact on their overall health and development?

Prof Chu C H: ECC is the most prevalent non-communicable disease in children. Surveys that the Department of Health and the Faculty of Dentistry, HKU have published indicated that approximately half of 5-year-old children are suffering from ECC and that more than 90% of ECC is left untreated (Chen et al., 2017; Gao et al., 2018, Department of Health 2013). The prevalence increases from 3-year-old (22%) to 5-year-old (55%) (Chen et al., 2017; Gao et al., 2018).

The oral health of children is generally perceived as being unimportant or less important because the primary dentition will normally be completely replaced by the permanent dentition – when the child reaches 13 years old. It therefore appears that any problem caused by caries of a primary tooth will be solved automatically once the primary tooth is replaced by the permanent successor. However, it is obviously unjustified to ask the child to bear with the suffering inflicted by carious teeth, such as poor aesthetics and pain, until the tooth exfoliates.

– Prof Chu Chun Hung, project lead, Jockey Club Children Health Project

Q: The project involves the application of silver diamine fluoride (SDF) solution. Could you explain your motivation for using the SDF solution as part of the project?

Prof Chu C H : Compared with dental fillings, the traditional way of managing caries, the cost-effectiveness of SDF therapy is much higher. The investment of time and money in treating a carious lesion is much lower. More importantly, without having to drill holes in teeth, the acceptance of SDF therapy is much higher among preschool children. The effectiveness of SDF in arresting caries has been widely documented. As has been reported in a meta-analysis, the overall caries arrest rate was 81% (Gao et al., 2016b).

Though arresting caries, we hope to prevent caries from progressing to the pulp before the primary teeth are exfoliated. This prevents the pulp space from becoming a pathway for bacterial invasion and thereby preventing the child from, among others, pain and any negative effect on the growth and development of his/her permanent teeth caused by dentoalveolar infection. Also, through arresting the caries, we reduce the damage done to the crown by the caries. For those primary teeth that are meant to stay in the mouth longer, reducing the damage to the crown increases the chance of these teeth being restorable when the child has become eligible for School Dental Care Service and when the child can cope with the operative treatment better. 

Q: The project provides oral screening and SDF treatment to participating children. How is parental consent obtained for such treatments, and what alternatives are offered to parents who prefer not to use SDF?

Prof Chu C H: The consent forms are sent to and collected from the parents through the participating kindergarten in advance. Among the participating kindergartens, the percentage of parents giving consent to oral screening was 96% (year 2022 to 2023) whereas the percentage of parents giving consent to SDF was 81% (year 2022 to 2023). For those parents who refused SDF, they will still benefit from being informed of the oral health status of their children and to see if there is any urgent item that needs to be followed up by private dentists. They will also be benefit from the information we provide regarding dietary and oral hygiene habits conducive to good oral health.  

Q: What specific outcomes have been observed in the children who have undergone SDF treatment as part of the project? Are there any long-term studies or data that showcase the effectiveness of this approach?

Prof Chu C H: Long term studies have showcased the effectiveness of the SDF approach (See response to Question 3). The project has been interrupted by COVID-19, during which time many carious teeth would not have received SDF annually because of suspension of the kindergarten in 2019-2022.

We are still working on the results of the project since 2019. However, The effectiveness of such an outreach approach has been demonstrated in the data we collected between 2010 to 2018 where the caries prevalence was 43% in the academic year 2010 to 2011. It increased to 44% in the year 2012 to 2013. However, it finally decreased to 34% in the year 2017 to 2018.

Q: The project involves collaboration with schools and parents. How do you ensure that the educational aspects of oral health are effectively communicated to both children and their families?

Prof Chu C H: Our outreach team pays a visit to each participating kindergarten once per year. This means that we will only see each child once a year. It is not sensible to expect 3-to 6-year old children to exercise self-discipline regarding their dietary and oral hygiene habits. That’s why we organised oral health talks for parents and teacher workshops for kindergarten teachers empowering them to be responsible for the important task of keeping an eye on the self-care aspect of the oral health of the children. In addition, our service also provides individual counselling to parents of children with severe caries or special oral problems.

Q: The Jockey Club Children Oral Health Project has expanded significantly, covering all kindergartens in Hong Kong. How has the project been received by the community, and what kind of feedback have you received from participating schools and parents?

Prof Chu C H: The number of kindergartens that participated in one or more components of our service has increased from 559 in year 2020 to 2021, to 707 in year 2022 to 2023. From the questionnaire surveys we have collected from the kindergartens and parents, the satisfaction rates have been around 99% for kindergarten teachers and 97% for parents over the last 3 years (from the report produced by our team).

Q: What challenges have you encountered during the implementation of the project, and how have you addressed them to ensure its success?

Prof Chu C H: The closure of kindergartens due to COVID-19 would mean that our outreach service could not continue. In addition, staying home all day long having nothing to do would increase the frequency of snack intake. This together with the avoidance of seeking professional dental care due to the pandemic would put children’s oral health at major risk. During that period, we shifted our focus to delivering oral health talks to parents and teacher workshops to teachers via video seminars to disseminate to the public the importance of self-care.

Even after schooling has been resumed, some kindergartens were still worried that our outreach service may increase the risk of transmission of COVID-19. To overcome this, our staff members, including project assistants, dentists, and administrative staff members explained to the kindergartens, via telephone and in person, that the guidelines of infection control were strictly followed in our service, and in addition, indefinitely avoiding professional dental care would also be detrimental to the well-being of the children.

Q: Can you talk about the role of family care and school education in promoting oral health among children? How do these factors contribute to the overall success of the project?

Prof Chu C H: Self-care plays a vital role in the maintenance of good oral health. It is unrealistic to hope that SDF can be of much help if good dietary and oral hygiene habits are not observed at home and in the kindergarten.

Hence, the continuous surveillance of the self-care from the parents and teachers is essential. Apart from this, extra workload is incurred upon the teachers by the outreach service. This includes the preparation of the premises for the screening, the distribution and collection of the consent forms and tabulation of the personal information of the children. The teachers must have a good understanding of the importance of oral health so as to consider the above-mentioned extra workload worthwhile.

Q: What are your future goals and aspirations for the Jockey Club Children Health Project? How do you envision the impact of this project on the oral health of Hong Kong’s children in the long run?

Prof Chu C H: It may appear that the earliest point of interception of a child by our outreach service is when he/she reaches the age of 3. According to one of our studies (Chen et al. 2017), the mean dmft and caries prevalence of 3-year-old children is 1.4 and 38% respectively. While this outreach service may be able to help prevent the increase of the mean dmft and caries prevalence from 3- to 5-year-old, it may appear that it will have no effect on the oral health status of children younger than 3-year-old.

However, that is not true. In the shorter term, parents who have been informed of the importance of the health of the primary teeth and have acquired the knowledge and skill required for good self-care will apply these knowledge and skill to their younger children immediately instead of waiting until they have reached the age of 3.

In the longer term, we hope to increase the dental awareness of the community by dissemination of the message through the parents and kindergarten teachers to their friends and relatives. This way, dietary and oral hygiene habits conducive to good oral health can be instilled from Day 1 of every individual. This maximises the benefits of preventive care. This is our ultimate goal.

Q: In your view, how can oral health be elevated as a significant medical concern for children, both within the community and on a broader public health scale?

Prof Chu C H: The oral health of children is generally perceived as being unimportant or less important because the primary dentition will normally be completely replaced by the permanent dentition – when the child reaches 13 years old. It therefore appears that any problem caused by caries of a primary tooth will be solved automatically once the primary tooth is replaced by the permanent successor. However, it is obviously unjustified to ask the child to bear with the suffering inflicted by carious teeth, such as poor aesthetics and pain, until the tooth exfoliates.

Carious primary teeth may not exfoliate normally anyway. In addition, problems related to space loss, impact on the development of the permanent tooth, poor nutrition, impact on social development, loss of life are obviously not solved by the carious primary tooth being replaced by its permanent successor. Disseminating these messages to the public raises the importance of oral health of children at an individual level.

As with any disease in general, preventing the occurrence of, or treating a disease at an early stage will cost a lot less resources than allowing the disease to progress and treating the disease in its advanced stage. By educating people to take good self-care; of their teeth as early as possible, the resources required to treat advanced dental problems can be minimized. Disseminating these messages to the public and policy makers raises the importance of oral health of children at a public health level.

This is why in addition to the existing channels of the outreach kindergarten dental service, such as oral health talks to the parents and teacher workshops to the teachers, staff members of the Faculty of Dentistry, HKU will also write columns in newspapers, attend interviews of the media, such as this one, to spread the above message.

Q: Is there anything else you’d like to convey to dentists, kindergartens, parents, and the public about the importance of oral health for children and the role of the Jockey Club Children Health Project?

Prof Chu C H: Success in oral health promotion needs support from different stakeholders, which include dentists, kindergartens, parents, and the public.

References

1. Chen KJ, Gao SS, Duangthip D, Li SK, Lo ECM, Chu CH (2017). Dental caries status and its associated factors among 5-year-old Hong Kong children: a cross-sectional study. BMC Oral Health, 17(1):121. 
2. Department of Health, Government of the Hong Kong Special Administrative Region (2013). Oral Health Survey 2011. Hong Kong. 
3. Gao SS, Zhao IS, Hiraishi N, Duangthip D, Mei ML, Lo ECM, Chu CH (2016b) Clinical trials of silver diamine fluoride in arresting caries among children: a systematic review. JDR Clinical & Translational Research, 3:201-210. 
4. Gao SS, Duangthip D, Lo ECM, Chu CH (2018). Risk factors of early childhood caries among young children in Hong Kong: a cross-sectional study. Journal of Clinical Pediatric Dentistry. 
5. The Guardian (2017). How can a child die of toothache in the US? https://www.theguardian.com/inequality/2017/jun/13/healthcare-gap-how-can-a-child-die-of-toothache-in-the-us. Assessed on 22 March 2019.