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 龋齿（dental caries）在拉丁美洲及加勒比国家（LACC）仍处于高流行水平。该疾病可通过实施负担得起的循证策略、覆盖全体人群而非仅富裕群体的干预措施得到有效控制。因此，本报告旨在总结拉丁美洲及加勒比国家中，基于限制食糖摄入、使用氟化物及应用窝沟封闭剂（occlusal sealants）这三项龋病控制策略的主要经科学验证的社区干预措施。

本研究采用系统方式开展批判性文献综述，涵盖明确的检索策略、对检出文献的独立评审，并将研究结果汇编于本报告中。研究通过PubMed、LILACS及SciELO数据库开展三次系统检索，以识别与拉丁美洲及加勒比国家龋病控制社区干预措施相关的研究。在检出的37篇文献中，26篇聚焦氟化物应用、8篇聚焦窝沟封闭剂应用，3篇聚焦食糖摄入限制。

该区域针对食糖摄入限制的已报道社区干预措施较为匮乏，相关干预主要基于食物补充、食糖替代及健康教育。因此，地方及/或国家政策应优先投资于上游、连贯且整合的全人群政策，例如对含糖饮料征税，以及加强主要针对儿童的含糖食品及饮料广告促销监管。

主要的氟化物应用策略包括通过饮用水、精制家用食盐、牛乳、牙膏为人群提供氟化物，漱口水、酸性磷酸氟（APF）凝胶及氟保护漆（varnishes）的应用占比相对较低。有氟化物应用证据的国家包括阿根廷、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。针对食糖摄入限制的社区干预措施，应同时从个体层面及公共政策层面推进实施。氟化物的应用必须在地方、区域及国家层面进行监测，以在实现最大抗龋效果的同时，尽可能降低氟牙症的发生风险。此外，作为两种互斥的社区层面龋病控制策略，氟化饮水及氟化食盐项目应将受益范围扩大至拉丁美洲及加勒比国家的未覆盖区域，同时同步对输送给人群的氟化物浓度开展充分监测。调节牙膏制剂中可溶性氟化物的浓度以保障抗龋效果同样必要，以此为人群提供有效的疾病控制策略。

针对农村人口及原住民族群（如土著人群、非裔起源的基隆博拉人（quilombolas）及亚马逊河畔居民），制定符合文化习惯、经济可持续的龋病控制干预措施，仍是一项至关重要的挑战。