Community interventions and strategies for caries control in Latin American and Caribbean countries

Abstract Dental caries remains highly prevalent in Latin American and Caribbean countries (LACC). However, this disease can be controlled through interventions that implement evidence-based strategies in an affordable manner and that target all population groups instead of the most affluent only. Therefore, the aim of this report was to summarize the main scientifically documented community interventions and strategies based on restriction of sugars consumption, use of fluoride, and the use of occlusal sealants for caries control in LACC. A critical literature review was carried out in a systematic manner that included defined search strategies, independent review of the identified publications, and compilation of results in this report. Three systematic searches were conducted using the PubMed, LILACS, and SciELO databases to identify studies related to community interventions and strategies for caries control in LACC. Of the 37 publications identified, twenty-six focused on fluoride use, eight on occlusal sealant use, and three on the restriction of sugar consumption. Documented community interventions for sugars restriction were scarce in the region and were based on food supplementation, sugar replacement, and education. Thus, local and/or national policies should prioritize investment in upstream, coherent, and integrated population-wide policies such as taxes on sugary drinks and stronger regulation of advertising and promotion of sugary foods and drinks mainly targeting children. The main fluoride-based strategies used drinking water, refined domestic salt, cow milk, toothpaste and, to a lesser extent, mouth-rinses, acidulated phosphate fluoride (APF) gels, and varnishes to deliver fluoride to the population. Evidence of fluoride use was seen in Argentina, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela. Studies reporting the use of occlusal sealants were mainly located in Brazil, Chile, Colombia, Costa Rica, Peru, Mexico, and Venezuela. Community interventions restricting sugar consumption should be implemented at the individual level and through public policies. The use of fluoride must be monitored at the local, regional, and national levels so as to achieve maximum anti-caries effect while also minimizing the risk of dental fluorosis. Moreover, fluoridated water and salt programs, used as a mutually exclusive community level strategy for caries control, should expand their benefits to reach non-covered areas of the LACC while also simultaneously providing adequate surveillance of the fluoride concentration delivered to the population. Regulating the concentration of soluble fluoride (for anti-caries effect) in dentifrice formulations is also necessary in order to provide the population with an effective strategy for disease control. Targeting culturally appropriate, economically sustainable caries control interventions to rural populations and native ethnic groups such as indigenous people, quilombolas (African-origin), and riverside Amazonian people remains a crucial challenge.

摘要
龋病在拉丁美洲及加勒比国家（Latin American and Caribbean Countries, LACC）仍呈高度流行态势。不过，该疾病可通过以可负担的方式落实循证策略的干预措施加以控制，且干预措施应覆盖所有人群，而非仅针对高收入群体。有鉴于此，本报告旨在总结LACC地区用于龋病防控的、经科学文献证实的主流社区干预措施与策略，这些措施与策略基于限制糖摄入、使用氟化物以及应用牙合面窝沟封闭剂三大方向。

本报告采用系统方式开展了批判性文献综述，涵盖明确的检索策略、对检出文献的独立评审，以及研究结果的汇总整理。研究团队通过PubMed、LILACS及SciELO三大数据库开展了三次系统检索，以筛选与LACC龋病防控社区干预措施及策略相关的研究。本次检索共检出37篇文献，其中26篇聚焦氟化物应用、8篇聚焦牙合面窝沟封闭剂应用，另有3篇围绕糖摄入限制展开。

该地区针对糖摄入限制的有据可查的社区干预措施较为匮乏，现有措施主要基于食品补充、糖类替代及健康教育三大方向。因此，地方及/或国家政策应优先投入资源，制定上游层面连贯统一、覆盖全人群的综合政策，例如对含糖饮料征税，以及加强针对儿童的含糖食品与饮料广告促销监管力度。

主流的氟化物干预策略包括通过饮用水、精制家用食盐、牛乳及牙膏为人群提供氟化物；另有少量方案采用漱口液、酸化磷酸氟（acidulated phosphate fluoride, APF）凝胶及氟保护漆来实现氟化物的人群递送。氟化物应用的相关证据覆盖阿根廷、伯利兹、玻利维亚、巴西、智利、哥伦比亚、哥斯达黎加、古巴、多米尼加共和国、厄瓜多尔、萨尔瓦多、危地马拉、海地、洪都拉斯、墨西哥、尼加拉瓜、巴拿马、巴拉圭、秘鲁、乌拉圭及委内瑞拉。报道牙合面窝沟封闭剂应用的研究主要集中于巴西、智利、哥伦比亚、哥斯达黎加、秘鲁、墨西哥及委内瑞拉。

限制糖摄入的社区干预措施应兼顾个体层面落实与公共政策推动双路径。需在地方、区域及国家层面开展氟化物应用监测，以在实现最大抗龋效果的同时，将氟牙症的发病风险降至最低。此外，作为龋病防控社区层面互斥策略的氟化饮水与氟化食盐项目，应将覆盖范围拓展至LACC的非覆盖区域，同时同步开展充分的氟化物浓度监测，确保输送至人群的氟化物浓度合规。此外，还需规范牙膏制剂中可溶性氟化物（用于实现抗龋效果）的浓度，为人群提供有效的龋病防控策略。将符合文化适配要求、具备经济可持续性的龋病防控干预措施推广至农村人群及原住民群体（如土著居民、quilombolas（African-origin）及亚马逊河畔居民）仍是一项关键性挑战。