Oral diseases are a major public health concern, affecting over 3.5 billion people worldwide (12). More specifically, dental caries contributes significantly to the global burden of oral diseases. It is estimated that over half a billion children worldwide have untreated caries of the primary dentition, which can have a significant impact on their quality of life (13).

Early childhood caries (ECC) is defined as the presence of at least one decayed (cavitated or non- cavitated), filled, or missing (due to caries) teeth in children under the age of six (14). The consequences of ECC on the oral health, general health, and well-being of children can last a lifetime (15). When left untreated, dental caries can impair a child's ability to function, limit their participation in daily activities, and even have an effect on their development (16). Even though considerable progress has been made, dental caries in children under six remains a worldwide problem (17).

In the global context, the circumstances and prevalence for dental caries in children varies (15). In the United Kingdom in 2015, nearly 23% of children aged 5 years were found to have ECC. In Australia, the 2012–2014 National Child Oral Health Study reported that 34% of children aged between 5 and 6 years had caries in their primary teeth and 26% had untreated decay in their primary dentition (15). The situation is dire for developing countries. By the age of five, more than half of Brazilian children have dental caries, with 80% going untreated (15). China's most recent national oral health survey found more than 70% of Chinese children aged 5 had dental caries (15).

Similar to many developing countries, South Africa has a significant burden of ECC. This has put great burden on the public health system as high numbers of children require dental treatment for ECC under general anaesthesia (18). In addition, there are high levels of unmet treatment needs among South African children8. The most recent oral health survey in South Africa (1999–2002), focused on children only, found that 60.3% of children under the age of 6 years had caries, and 80% of this group had untreated caries (19). As there are no health information systems that monitor or carry out sentinel surveillance of oral health diseases, the overall current oral health status of children in South Africa is unknown (2). However, recent studies have reported that high ECC prevalence and high unmet treatment needs persists among South African children. Kimmie-Dhansay et al., reported that the lifetime prevalence of ECC for South African children under 71 months was 44.5% (20). Specifically, in 4- and 5-year-olds, the overall prevalence of ECC increased from 57% between 1975 and 1979, to almost 62% between 2010 and 2014.

The prevalence of ECC in rural areas was higher than the urban areas. Mohamed and Barnes (21) found that 67.5% of children (between 6 months and 6 years old) from low socioeconomic communities in the Western Cape Province had evidence of dental caries that necessitated some form of dental treatment. Furthermore, the unmet treatment need of 4- to 5-year- old children in the Western Cape increased since the previous National Children's Oral Health Survey (1999–2002) and shows that the problems persist and have not been addressed (21). Similarly, in the Province of Kwa-Zulu Natal, Reddy & Singh (2015), reported that more than 70% of 6-year olds were affected by dental caries, with nearly all (94%) requiring dental treatment (22).

Several risk factors have been proposed as contributing to the increased prevalence of ECC. These include oral health behaviors, socioeconomic status, and other family-level factors such as education levels, ethnicity, health attitudes and family size, among others (23). Early childhood caries have a significant global impact, and requires prompt intervention to improve children's oral health (24). The availability of oral health care is one of the structural risk factors for ECC that can be mitigated by government policy (15).

Globally, children aged under six years of age are seen regularly by primary health care teams for vaccinations and general health checks, often by nurses, midwives, and community health workers, and less often by oral health professionals. An oral health policy that is designed and developed to meet the needs of this group will ensure that oral health equity is realized. This would be consistent with the promotion and protection of mothers', women's, and children's rights to health as a basic human right, as emphasized in international health conventions (36).

It is well known that a mother's oral health status is a strong predictor of her child's oral health status (43). Children born to mothers with high levels of untreated caries were more than three times more likely to have higher levels of caries experience (treated or untreated dental caries) than children born to mothers with no untreated caries (44, 45). Similarly, children of mothers with high levels of tooth loss were more than three times more likely to have higher levels of caries experience than children of mothers with no tooth loss (45).

Parental influences play a major role in the caries prevalence of their children, and it has been reported that poor oral hygiene practices of parents and frequent consumption of sweets increased the likelihood of mother-to-child (neonatal) infection transfer. Family living conditions and perceptions also play a role, whereby changes in the family set-up (from two parents to one) may affect the ability of parents to adequately prioritize and care for the oral health of the child, thereby increasing their risk of dental caries (46).

Due to their reliance on parents and caregivers, children face unique oral health challenges. The Fédération Dentaire Internationale (FDI) policy statement on perinatal and infant oral health, advocated that perinatal and infant oral health care are critical components of early intervention, facilitating behavioral changes that result in good oral health, successful caries prevention, and disease management. Importantly, these efforts should be approached through a collaborative, integrated effort by parents, schools, health ministries, and other stakeholders (47).

The WHO's Implementation Manual entitled “Ending Childhood Dental Caries” stated that for the development of a supportive environment, it is important to integrate childhood dental caries prevention and control within primary care, such as maternal and child health programmes to ensure engagement of non-oral health professionals in oral health care (48). It also encourages the development of a national policy to support new skills and competencies of primary care teams, and to ensure their initial and ongoing childhood dental caries prevention and control training (48). In this way, non-oral health professionals will understand the severity and impact of childhood dental caries as a serious public health problem.

On assessing the integration of oral health within MCH services in Tshwane, Molete & Phakela, found that 38% of caregivers with low educational levels did not value the importance of primary dentition and consequently did not take their children to oral health facilities in the first few years of life (49). Furthermore, primary health care mother-to-child clinics did not prioritize oral health since the nurses were overburdened and lacked adequate oral health knowledge. It was also demonstrated that dental practitioners in general practice do not regard themselves as having to play a role in the prevention of oral disease in pre-school children (49).

Globally there is no evidence of integrated mother and child oral health policies, nor of policies that specifically focus on the under six-year-old population for the prevention of childhood dental caries. In Australia, the 2014–2024 National Oral Health Plan serves as a blueprint for action across different disciplines, sectors and jurisdictions, encouraging integrated health care to ensure that Australian children and adults have adequate oral health. In Japan there is a comprehensive governmental strategy (the 8,020 campaign) to improve oral health. More specifically, this strategy explicitly advocates for oral health care for pregnant mothers and children up to 5-years-old (15). Developing an integrated maternal and child oral health policy with policies specific to women and children would enable the creation of a strategic framework. Such a framework can then be adapted using the existing policy, strategy and plan as a guideline to assist with implementation. The National Health Act, 2003 (Act 61 of 2003), the Children's Act, 2005 (Act 38 of 2005), the National Health Insurance (NHI) Bill, the National Oral Health Policy 2010, and the Skills Development Act, 1998 (Act 97 of 1988) are examples of laws and policies into which an IMCOH and be integrated. The guiding principles of these policies envision a shifting narrative for South Africa's political and social landscape for mothers, children, and women.

Brillas and Lee (2022) conducted an integrative review with the aim to identify major maternal and oral health frameworks. They focused on integrating oral health into perinatal care and proposed that such a framework should consider the contextual factors, intervention levels and enabling factors, with policy development being one of the key interventions. Furthermore, they underlined that policymakers need to examine the manner in which oral health is systematically integrated into existing primary health care initiatives through interprofessional training and collaboration (50). A such, an Integrated Maternal and Child Oral Health (IMCOH) policy would need to be comprehensive, focused and contextual. Its vision should encompass the overarching aim of the policy, which in South Africa, will be to increase access to oral health services for women and children, thus ultimately reducing their burden of oral disease. The mission would be to ensure that antenatal, perinatal and neonatal services include oral health education and promotion, screening and referral where necessary. This mission would align with that of the South African Maternal, Perinatal and Neonatal Health Policy (35).

According to the National MCWH policy draft, policy goals are categorized into three main areas for mothers, children and adolescents (33). These goals would seamlessly translate into the objectives of an IMCOH policy if the relevant health workers receive training to execute the required services. An IMCOH policy would establish a broad framework for providing high-quality, all-inclusive maternal and oral health services and should guide the development and revision of guidelines and standard operating procedures for maternal and child oral health at PHC level in South Africa. As with key strategic objectives of the MPNH and the MCWH policies, an IMCOHP can be structured in line with those of the South African National Department of Health (35), with four key objectives: to enhance effective leadership and accountability; to strengthen health system delivery platforms; promote coordinated, relevant, multi- disciplinary and sectoral community engagement to improve pregnancy and oral health outcomes and finally to establish a sustainable and contextual surveillance system for maternal and child oral health.

OBJECTIVE 1: Enhance effective leadership and accountability to provide quality, comprehensive, and integrated maternal and child oral health care and treatment services across the healthcare continuum

Human resource needs, planning, as well as management, is essential for the delivery of quality oral health services and should be reflected in integrated policies, with clear roles and responsibilities at each level of government. Although the number of health personnel in South Africa has increased over the years, the increasing burden of disease continues to stress and constrain the public health system. This could be attributed to an increase in the country's young population, urbanization, lack of quality and equitably distributed clinical services and possibly, the lack of appropriate human resource distribution at the various levels of oral service delivery (7).

Appointing Provincial Oral Health Managers is essential to address the significant oral disease burden and poor state of public oral health services in the country. More specifically, the appointment of Community Dentistry specialists into the various government level structures is recommended to co-ordinate oral health management including the implementation of an integrated maternal and oral health policy. Community Dentistry specialists are trained to assess the dental needs of the population, conduct oral health surveys and surveillance of oral health and disease. Furthermore, they are trained to plan and implement appropriate evidence-based interventions, formulate oral health policies and strategies as well as to manage public oral health services (27).

OBJECTIVE 2: Strengthen health system delivery platforms by addressing the World Health Organisation (WHO) “building blocks” for quality maternal and child oral health services along the continuum of healthcare

This objective is based on the MCWH policy draft goal for mothers, which is to ensure access to high quality antenatal care (ANC) and quality care during and after delivery to mothers and their babies (33). An IMCOH policy would include children, adolescents and women of child-bearing age. Due to the high prevalence of HIV and AIDS in South Africa, particularly among mothers and children, education on common oral manifestations of HIV is essential for this vulnerable population. In addition, it would include addressing the myth that pregnant women should not seek oral health treatment during their pregnancy because it puts the foetus's health at risk.

In the draft MCWH policy, the goal for children is to enable each child to reach his/her maximum potential within the resources available, and to enable as many children as possible to reach adulthood with their potential uncompromised by illness, disability, environmental hazard or unhealthy lifestyle (35).

Oral health is the gateway to general health. If a child's oral health could be optimized from birth, their general health would only improve, making it easier for them to reach their full potential. Children can be accessed at the mother-to-child clinics that will ensure early intervention and referral. In general, the integration of health services aims to improve service efficiency and quality, which consequently maximises the use of resources and opportunities (11). In contrast to a vertical approach (focus on a single risk factor or intervention), an integrated approach consists of a collection of core interventions that can be considered part of a health care “package” (10). The common risk factor approach (CRFA) considers risk factors which may be common in the numerous chronic conditions in the context of the larger socio-environmental milieu. Diet, hygiene, smoking, alcohol use, stress, and trauma all have an impact on oral health. Since these causes are shared by a number of other chronic diseases, a collaborative (inter-professional) approach is preferable to a disease-specific approach (11). One of the principal objectives of the South African Oral Health Promotion Framework will be to incorporate oral health promotion activities into general health promotion using the CRFA. Importantly, the bidirectional relationship between oral health and other diseases and conditions provides compelling evidence for a bidirectional relationship between oral health and primary health care (11), especially to ensure the continuum of health care.

OBJECTIVE 3: Promote coordinated, relevant, trans-multi-disciplinary and inter-sectoral community engagement to improve pregnancy and oral health outcomes

Health care workers (HCW) are key role players for the implementation of the policy across the healthcare continuum. By encouraging the integration of medical, dental, and other health-care services, health care providers will be enabled to promote collaborative efforts with individuals, families, communities, policymakers, and governments, in order to offer easily accessible and consistent oral health messages and services to pregnant women, infants, and children, particularly those from vulnerable populations who are at increased risk for health disparities (47).

At primary health care facilities, HCW are the first point of contact for pregnant women, thus it is imperative that oral health services be included and an integral as part of a comprehensive health package. Health care workers should be trained to carry out oral health screening, oral health promotion and education and to refer if need be.

Inter-professional collaboration is a better way of providing comprehensive health care, and policymakers are leading the movement towards more integrated health care (10). There is a need for effective policies on interdisciplinary approaches to improve the oral health of underserved populations. Primary oral health care is not a new concept; in fact, it forms the basis of the United Nations Millennium Declaration Goal: “All people, everywhere shall have access to a skilled, motivated, and facilitated health worker within a robust health system” (51).

Promoting inter-professional education and collaborative practices to improve the quality and accessibility of care in underserved areas is necessary to combat the increasing prevalence of dental caries in South African children. Since infants and young children are more likely to attend post-natal and mother-to-child visits than seek preventive oral health care, cross-trained health (medical and nursing personnel) may be able to provide early oral health assessments and guidance through early primary-care visits (47).

Furthermore, in order to expand community access, increasing the scope of practice of community health workers (CHW) to include oral health promotion and education for mothers and children will be an efficient use of resources and benefit underserved communities. CHW can advocate for the importance of primary teeth to parents, caregivers and the community at large, and raise awareness of the negative impacts of childhood dental caries on quality of life of young children (48). In the West Rand District of Gauteng, CHWs are trained in basic oral health as they are inducted in the district in efforts to incorporate oral health into their activities. A basic oral health manual for CHWs has been developed for this purpose and tabled for national dissemination later. This is an imperative step toward incorporating oral health into the activities of CHW (52).

OBJECTIVE 4: Establish a sustainable and contextual surveillance system for maternal and child oral health

A key component of the policy process is policy evaluation. This would only be possible with a surveillance strategy that is built into a standardized and reliable oral health information system (40). Monitoring is commonly used to describe the process of systematically gathering data to provide answers to such inquiries. When the primary focus of an evaluation is to determine “how successfully a project, program, or policy is being implemented against predicted results,” the term performance monitoring is frequently used. The importance of monitoring is determined by key stakeholders' perceived need to learn more about what is going on the ground (53).

Ramphoma has suggested that oral health issues in South Africa have been ineffectively addressed mainly due to the absence of a systematic oral health surveillance strategy (27). Public health action relies largely on linking data from surveillance to health policies and programmes. Proper surveillance ensures that countries, and communities, have the necessary information for immediate disease control or to plan strategies towards disease prevention. Ultimately, surveillance aspires to assist governments as well as health authorities or professionals to control disease burdens affecting their populations (54). However, such information systems rely on the collection of contextually appropriate oral health indicators.

The information that an indicator provides must cover relevant public oral health disease burdens in a way that it is: measurable and robust, easy to understand, be relevant to oral health-related quality of life, clearly related to common modifiable risk factors and be instrumental to oral disease prevention, as well as, the promotion of oral health through health systems response (10). A minimum set of oral indicators at Provincial and District level needs to be established that can be tailored to target populations.

Monitoring of oral health services is critical for resource, people, and infrastructure planning (5). Regular audits will provide patient utilisation trends, types of dental care provided and the community disease burden. The type and frequency of dental treatments provided can be used to determine human resource management, infrastructure development, and equipment maintenance. It will also inform policies regarding personnel and dental resource distribution to achieve optimal health care delivery. Mukhari-Baloyi et al., suggest that the NOHP, which is currently the operational framework for oral health activities in South Africa, should be reviewed to identify flaws and improvements to inform a more appropriate and relevant to the South African context policy (2).