An Integrated Care Pathway for Pediatric Oral Health: A Multicenter Study on Dental Caries, Malocclusions, and Oral Hygiene in Three Italian Regions

1. Introduction

Oral health is a key component of overall health and well-being during developmental age, with significant repercussions on physical growth, psychosocial development, and quality of life [1]. Dental caries are among the most prevalent chronic diseases worldwide and affect children in both primary and permanent dentitions, with consequences on nutrition, phonation, school performance, and self-esteem [2]. A recent systematic review and meta-analysis of studies conducted between 1995 and 2019 reported pooled prevalence estimates of 46.2% for caries in primary teeth and 53.8% in permanent teeth among children globally, indicating a persistent burden despite advances in preventive strategies [3]. Longitudinal investigations highlight the progressive nature of the disease and the close linkage between caries incidence in primary dentition and early-life risk factors [4].

In Italy, national surveys have documented pronounced socioeconomic inequalities in oral health. Children from socioeconomically disadvantaged families display higher caries severity—measured by the DMFT index—than their more affluent peers, reflecting differential access to both treatment and preventive services [5]. Vulnerable subgroups, including migrant children from low- and middle-income countries and children from low-socioeconomic status (SES) households, exhibit particularly elevated dmft scores, largely driven by environmental and behavioral determinants [6,7]. School-based oral health promotion programs have shown potential to mitigate these disparities, yet their implementation remains fragmented and only partially integrated within regional health systems [8].

1.1. Key Risk Factors: DMFT, Breastfeeding, Gender, and Oral Hygiene

The DMFT index (Decayed, Missing, Filled Teeth) remains the standard epidemiological indicator for quantifying caries experience and planning preventive and therapeutic interventions [9]. Increasing evidence has clarified its association with modifiable early-life and behavioral factors.

Prolonged or inappropriate breastfeeding practices—especially beyond 12 months and in the absence of adequate oral hygiene—have been associated with higher dmft/DMFT values in primary dentition. Extended exposure to fermentable carbohydrates contributes to the development of cariogenic biofilm; longitudinal studies have shown that on-demand or nocturnal breastfeeding without toothbrushing significantly predicts caries onset and progression [4]. Systematic reviews identify breastfeeding duration and related practices as modifiable risk factors for early childhood caries (ECC) [10,11].

Gender-related differences in caries experience have also been described. Several studies report higher DMFT values in girls than in boys, particularly in primary dentition, possibly due to earlier tooth eruption, differences in enamel maturation, dietary habits, or gender-specific hygiene behaviors [3,6]. Moreover, orthodontic treatments required for the correction of malocclusions can further increase caries risk in both genders by promoting plaque accumulation and increasing the levels of cariogenic microorganisms such as Streptococcus mutans and Lactobacilli [12].

Among all determinants, oral hygiene emerges as the most directly modifiable factor. Parental deficits in knowledge regarding brushing techniques, fluoride use, and dietary control translate into suboptimal oral hygiene behaviors in children, especially in migrant and low-SES families [7,13]. Although restorative techniques—including the use of bulk-fill composites for posterior teeth in pediatric patients—show satisfactory medium-term outcomes [14], they cannot substitute for comprehensive, hygiene-centered preventive programs aimed at reducing incidence of new lesions and the need for retreatment.

1.2. Malocclusions and Gaps in Integrated Care

Beyond caries, oro-dental malocclusions substantially contribute to the global oral disease burden in childhood. Their prevalence ranges between 50% and 70% in many pediatric populations and they may affect periodontal status, masticatory function, speech, and aesthetics [12]. Caries and malocclusions often share behavioral and environmental risk factors, such as poor oral hygiene and high consumption of cariogenic foods and beverages, which can accelerate DMFT progression during the mixed dentition phase.

Despite the availability of evidence-based preventive and interceptive strategies—including topical fluoride applications, fissure sealants, and structured educational interventions [10,15] —the current Italian context is characterized by fragmented policies and heterogeneous practices. Parental education remains suboptimal [13]; school-based interventions are frequently limited to short-term pilot projects [8]; and migrant families face multiple cultural, linguistic, and organizational barriers in accessing oral health services [7]. A comprehensive, standardized care pathway that jointly addresses caries prevention, malocclusion management, and DMFT reduction through tailored, multidisciplinary interventions is still lacking.

1.3. Rationale and Objectives of the Proposed Care Pathway

The present project proposes an innovative, integrated care pathway for children and adolescents, with specific emphasis on the prevention and management of dental caries and oro-dental malocclusions. The model is structured around three core components:

• Risk assessment, including breastfeeding history, SES indicators, migrant status, oral hygiene behaviors, and baseline dmft/DMFT;
• Clinical interventions, such as minimally invasive restorative procedures, fissure sealants, topical fluoridation, and interceptive orthodontic treatments;
• Longitudinal follow-up, supported by telemedicine tools and AI-based monitoring systems.

In Italy, an estimated 5.6 million children under 14 years of age are at risk of developing oral diseases. Recent national and regional data report ECC prevalences between 9% and 35% among preschoolers in southern regions and a mean DMFT of 1.88 among 12-year-olds, with clear socioeconomic gradients [16,17,18,19]. dmft values reaching 2.9 in socially disadvantaged preschool children [20,21] highlight the existence of a considerable unmet need for effective prevention.

Marked regional differences have also been documented. In southern Italy, 10–11-year-old children show high rates of interceptive malocclusions, associated with suboptimal dietary patterns and deficient oral care practices. These findings are consistent with international evidence indicating that prolonged breastfeeding is associated with increased caries risk (e.g., odds ratio 2.1 in Chinese children aged 3–5 years) and that family-level behaviors strongly influence dmft among Polish children aged 5–6 years [22,23,24]. Behavioral determinants appear predominant: school-based interventions can reduce caries incidence by 35–50%; perinatal education targeting caregivers can prevent ECC onset; and combined clinical-behavioral scoring systems enable refined risk stratification [25,26,27]. However, barriers to the uptake of educational initiatives—including cultural resistance, socioeconomic constraints, and limited availability of services—continue to exacerbate vulnerabilities in low-SES communities [28,29].

In this context, calls for a “caries-free future” stress the importance of upstream, prevention-oriented approaches. Evidence from cohorts of children with craniofacial anomalies shows that, even in anatomically complex clinical scenarios, optimized oral hygiene can significantly reduce caries occurrence [30,31]. Building on this evidence, the present multicenter project proposes a comprehensive pathway integrating early screening, prophylactic sealants, interceptive orthodontics, and AI-supported telemonitoring. By prioritizing hygiene enhancement in high-risk groups (e.g., children exposed to prolonged breastfeeding, children from migrant and low-SES families), the program aims to achieve clinically meaningful reductions in dmft, improve equity, and provide an evidence-based model suitable for national scale-up.

2. Materials and Methods

2.1. Study Design

A prospective, multicenter, interventional pilot study was designed to implement and evaluate a structured care pathway for the improvement of oral health in individuals in developmental age (0–14 years), with a specific focus on the prevention and treatment of dental caries and oro-dental malocclusions. The project, entitled “Proposal for a care program for individuals in developmental age for the improvement of oral health, with particular attention to the prevention and treatment of caries pathology and oro-dental malocclusions” (CCM 2024 Program ID: 10 – Oral health in pediatrics), has a duration of 24 months.

The study involves three Italian regions (Umbria, Emilia-Romagna, Abruzzo) and primarily targets socially vulnerable pediatric populations, including children from low-SES families and children with a migrant background, in order to address documented oral health inequalities.

The coordinating institution is the National Institute for the Promotion of the Health of Migrant Populations and for the Fight against Poverty-Related Diseases (INMP, Lazio). Ethical approval was obtained from the institutional review boards (IRBs) of all participating centers (e.g., INMP Ethical Committee and university IRBs). Written informed consent was collected from parents or legal guardians; assent was obtained from children older than 7 years, in accordance with ethical principles. Data management followed the provisions of the EU General Data Protection Regulation (GDPR), with use of anonymized identifiers.

2.2. Participant Recruitment and Inclusion/Exclusion Criteria

A minimum sample size of 600 children aged 0–14 years was planned, recruited across three types of settings: (i) fixed university dental clinics; (ii) school-based screening initiatives; and (iii) mobile dental units serving underserved areas in Lazio, Abruzzo, Emilia-Romagna, and Umbria. In practice, 795 children aged 6–11 years with complete dmft/DMFT data were included in the present baseline analysis.

Recruitment strategies prioritized high-risk groups (e.g., low-SES and migrant families) to allow extrapolation of potential impacts to the approximately 5.6 million Italian children aged 0–14 years (Italian Istitute of Statistics data (ISTAT) [32].

Inclusion criteria:

a) age between 0 and 14 years;b) written informed consent from parent/legal guardian;c) residence in one of the participating regions;d) presence of at least one oral health risk factor (e.g., dmft/DMFT > 1, clinically evident malocclusion, poor oral hygiene);e) at least one vulnerability indicator (low SES and/or migrant background).

Exclusion criteria:

a) acute systemic conditions contraindicating dental examination;b) orthodontic emergencies requiring immediate management outside the project;c) absence of informed consent.

The sample was stratified by age group (preschool: 3–5 years; school-age: 6–12 years; early adolescence: 13–14 years), sex, SES (assessed through parental educational level and employment status), and migrant status (parental country of birth categorized as low-/middle-income vs. high-income). Demographic and behavioral data (age, sex, ethnicity, parental education, breastfeeding history, oral hygiene practices) were collected using standardized questionnaires administered to parents or caregivers.

2.3. Clinical Methods

Clinical examinations were performed by calibrated dentists in school, mobile, and fixed clinical settings, following non-invasive, standardized protocols.

Caries assessment.

Caries experience was recorded using the dmft (primary dentition) and DMFT (permanent dentition) indices. Lesion severity was classified according to the International Caries Detection and Assessment System (ICDAS, codes 0–6). Visual-tactile examinations of occlusal, proximal, buccal, lingual, and palatal surfaces were conducted using a dental mirror and probe under artificial lighting, following WHO (World Health Organisation)-compatible criteria.

Malocclusion evaluation.

Oro-dental malocclusions were assessed using the Index of Orthodontic Treatment Need (IOTN), considering both aesthetic and dental health components. Where indicated, basic postural assessments were performed to document possible occlusal-postural relationships (e.g., temporomandibular joint discrepancies, cervical and lumbar muscle tension).

Periodontal and oral hygiene status.

Oral hygiene was evaluated using the Simplified Oral Hygiene Index (OHI-S), gingival bleeding on probing, and a plaque index. Where feasible, salivary tests for cariogenic bacteria (Streptococcus mutans and Lactobacilli) were conducted using chairside diagnostic kits.

Additional assessments.

When available, digital intraoral scanners were used to obtain three-dimensional records of malocclusions. Parents completed structured questionnaires on oral hygiene behaviors, perceived caries and malocclusion risk, and socioeconomic indicators (education level, employment status, area-level gross domestic product proxies) (ISTAT)[32]. A brief medical history (systemic diseases, allergies, current medications) preceded each oral examination. Soft tissues (lips, cheeks, tongue, palate, and floor of the mouth) were inspected and palpated to detect eventual mucosal lesions or anomalies.

All procedures were painless and were performed by calibrated examiners. Inter-examiner agreement was assessed, yielding kappa values > 0.85.

Interventions within the care pathway

• Tier 1 (Universal):School-based education and health promotion interventions (workshops, digital materials, social media, mobile apps) focused on toothbrushing, fluoride use, healthy dietary patterns, and counseling regarding weaning and breastfeeding beyond 12 months.
• Tier 2 (Targeted):Preventive and interceptive clinical interventions in children at higher risk, including pit and fissure sealants, fluoride varnish application, interceptive orthodontics, and minimally invasive restorative procedures.
• Tier 3 (High-risk):Telemedicine and AI-supported follow-up at 6, 12, and 24 months for children with high baseline caries risk, poor hygiene, or complex malocclusions, with the aim of reinforcing adherence to recommendations and enabling early detection of new lesions.

2.4. Data Collection and Management

Data were recorded on a secure, multicenter digital platform to ensure standardization across the participating sites. Baseline, 6-month, 12-month, and 24-month follow-up assessments are planned to monitor changes in dmft/DMFT, oral hygiene status, and malocclusion severity. Follow-up questionnaires assess adherence to recommendations, satisfaction with care, and perceived barriers to service utilization.

2.5. Statistical Methods

Descriptive statistics were calculated as means ± standard deviations (SD) for continuous variables (e.g., dmft/DMFT, IOTN scores, anthropometric measures) and as absolute/relative frequencies for categorical variables (e.g., ICDAS categories, hygiene levels, SES, migrant status). For the longitudinal component, pre–post changes will be analyzed using paired t-tests or Wilcoxon signed-rank tests, depending on data distribution.

Between-group differences (e.g., by SES, migrant status, gender, oral hygiene level) were assessed using chi-square or Fisher’s exact tests for categorical variables, and independent t-tests, one-way ANOVA, or non-parametric equivalents (Kruskal–Wallis) for continuous variables. Multivariable linear and logistic regression models were used to explore associations between predictors (gender, breastfeeding history, hygiene level, age, body mass index (BMI), SES) and caries outcomes (dmft/DMFT), adjusting for potential confounders. An intention-to-treat framework with multiple imputation is planned to manage attrition and missing data in the longitudinal analyses. Subgroup analyses by region and SES are envisaged.

Sample size calculations indicated that a minimum of 600 participants would provide >90% power (α = 0.05, SD = 1.5) to detect a 20–30% relative reduction in mean dmft following the intervention. Statistical analyses were performed using SPSS (IBM Corp.) and/or R (R Foundation for Statistical Computing). Two-sided p-values < 0.05 were considered statistically significant. An exploratory cost-effectiveness analysis will estimate the incremental cost per dmft point averted.

Table 1. summarizes the main clinical parameters and tools used. 

Domain	Variable/Index	Description
Caries experience	dmft (primary dentition)	Number of decayed (d), missing (m), and filled (f) primary teeth
	DMFT (permanent dentition)	Number of decayed (D), missing (M), and filled (F) permanent teeth
	ICDAS	International Caries Detection and Assessment System (codes 0–6)
Periodontal / oral hygiene	OHI-S	Simplified Oral Hygiene Index
	Gingival bleeding on probing	Presence/absence of bleeding on gentle probing
	Plaque index	Semi-quantitative assessment of plaque accumulation
General and risk factors	Demographic/socioeconomic data	Age, sex, migrant status, parental education, employment, area-level GDP
	Behavioral factors	Breastfeeding history, brushing frequency, fluoride use, dietary habits
	Anthropometric measures	Weight, height, BMI
	Medical history and soft tissue examination	Systemic conditions, medications; oral mucosa inspection and palpation

Table 1. summarizes the main clinical parameters and tools used. 

Domain	Variable/Index	Description
Caries experience	dmft (primary dentition)	Number of decayed (d), missing (m), and filled (f) primary teeth
	DMFT (permanent dentition)	Number of decayed (D), missing (M), and filled (F) permanent teeth
	ICDAS	International Caries Detection and Assessment System (codes 0–6)
Periodontal / oral hygiene	OHI-S	Simplified Oral Hygiene Index
	Gingival bleeding on probing	Presence/absence of bleeding on gentle probing
	Plaque index	Semi-quantitative assessment of plaque accumulation
General and risk factors	Demographic/socioeconomic data	Age, sex, migrant status, parental education, employment, area-level GDP
	Behavioral factors	Breastfeeding history, brushing frequency, fluoride use, dietary habits
	Anthropometric measures	Weight, height, BMI
	Medical history and soft tissue examination	Systemic conditions, medications; oral mucosa inspection and palpation

3. Results

3.1. Descriptive Statistics

A total of 795 children in developmental age (mean age 7.14 ± 0.73 years; range 6–11 years) were included in the baseline analysis, with complete dmft/DMFT data available for all participants.

The sample included 404 males (50.8%) and 391 females (49.2%), indicating a balanced gender distribution. Anthropometric data, available for most participants, showed a mean weight of 26.15 ± 5.62 kg (n = 590), mean height of 126.29 ± 7.24 cm (n = 557), and mean BMI of 16.22 ± 2.86 kg/m² (n = 556), consistent with national reference values for Italian pediatric populations.

Breastfeeding history was available for all subjects: 546 children (68.7%) were classified as “breastfed” (including probable prolonged breastfeeding), and 249 (31.3%) as not breastfed or breastfed only briefly.

Clinically evaluated oral hygiene was rated as optimal in 547 children (68.8%), mediocre in 200 (25.2%), and insufficient in 48 (6.0%).

IOTN scores were available for 781 children, with a mean value of 2.24 ± 1.32 (range 1–5), indicating a non-negligible proportion of subjects with a need for interceptive or corrective orthodontic treatment.

Caries burden was overall low. In the permanent dentition, mean DMFT was 0.17 ± 0.64 (range 0–4), mainly driven by the decayed component (D: 0.10 ± 0.43). Missing teeth due to caries were rare (M: 0.001 ± 0.04, n = 794), as were filled teeth (F: 0.07 ± 0.45). In primary dentition, the mean dmft was 1.53 ± 2.37 (range 0–12), with mean values of 1.17 ± 2.05 for decayed teeth (d), 0.12 ± 0.73 for missing teeth (m), and 0.24 ± 0.71 for filled teeth (f; n = 794).

Listwise valid cases for multivariable analyses totaled 540, reflecting missing data primarily for anthropometric and certain questionnaire variables.

3.2. Distribution of DMFT/Dmft by Gender

No statistically significant differences in caries experience were observed by gender. Females exhibited slightly higher caries in permanent dentition (mean DMFT 0.19 ± 0.67) compared with males (0.16 ± 0.62), while dmft values in primary dentition were similar in girls and boys (1.58 ± 2.41 vs. 1.49 ± 2.34, respectively). In both sexes, the decayed component was predominant, and the restorative component (F) remained modest. Independent t-tests indicated no significant differences for either DMFT or dmft (p > 0.05).

Table 2. Caries experience (DMFT/dmft) by gender. 

Variable	Males (n = 404)	Females (n = 391)	p-Value *
DMFT, mean ± SD	0.16 ± 0.62	0.19 ± 0.67	>0.05
D (decayed, permanent), mean ± SD	0.10 ± 0.42	0.11 ± 0.45	>0.05
M (missing, permanent), mean ± SD	0.00 ± 0.00	0.00 ± 0.04	>0.05
F (filled, permanent), mean ± SD	0.06 ± 0.40	0.08 ± 0.50	>0.05
dmft, mean ± SD	1.49 ± 2.34	1.58 ± 2.41	>0.05
d (decayed, primary), mean ± SD	1.13 ± 2.01	1.21 ± 2.08	>0.05
m (missing, primary), mean ± SD	0.11 ± 0.70	0.13 ± 0.76	>0.05
f (filled, primary), mean ± SD	0.24 ± 0.71	0.25 ± 0.72	>0.05

*Independent t-test for males vs. females.

Table 2. Caries experience (DMFT/dmft) by gender. 

Variable	Males (n = 404)	Females (n = 391)	p-Value *
DMFT, mean ± SD	0.16 ± 0.62	0.19 ± 0.67	>0.05
D (decayed, permanent), mean ± SD	0.10 ± 0.42	0.11 ± 0.45	>0.05
M (missing, permanent), mean ± SD	0.00 ± 0.00	0.00 ± 0.04	>0.05
F (filled, permanent), mean ± SD	0.06 ± 0.40	0.08 ± 0.50	>0.05
dmft, mean ± SD	1.49 ± 2.34	1.58 ± 2.41	>0.05
d (decayed, primary), mean ± SD	1.13 ± 2.01	1.21 ± 2.08	>0.05
m (missing, primary), mean ± SD	0.11 ± 0.70	0.13 ± 0.76	>0.05
f (filled, primary), mean ± SD	0.24 ± 0.71	0.25 ± 0.72	>0.05

*Independent t-test for males vs. females.

3.3. Associations with Breastfeeding History

Children with a history of breastfeeding (n = 546; 68.7%) displayed slightly higher caries experience than non-breastfed or briefly breastfed children (n = 249). Mean DMFT values were 0.19 ± 0.66 versus 0.14 ± 0.61 (p = 0.278, independent t-test), and mean dmft values were 1.62 ± 2.45 versus 1.36 ± 2.22 (p = 0.162), respectively. These differences were principally attributable to variations in the decayed components (D/d). None of these comparisons reached statistical significance. ANOVA models did not show any significant interaction with age (p > 0.05).

3.4. Oral Hygiene Levels and Caries Burden

Oral hygiene status was strongly associated with caries indices. Given the non-normal distribution of some caries variables, Kruskal–Wallis tests were used. Children with insufficient hygiene (n = 48; 6.0%) exhibited the highest caries experience (DMFT 0.42 ± 1.02; dmft 2.85 ± 3.12). Those with mediocre hygiene (n = 200; 25.2%) showed intermediate values (DMFT 0.25 ± 0.72; dmft 1.92 ± 2.68), whereas children with optimal hygiene (n = 547; 68.8%) presented the lowest indices (DMFT 0.09 ± 0.48; dmft 1.22 ± 2.09).

Post hoc pairwise comparisons indicated statistically significant differences between insufficient versus optimal hygiene (p < 0.001 for both DMFT and dmft) and between mediocre versus optimal hygiene (p = 0.002–0.008). Linear regression analyses adjusted for age and gender confirmed oral hygiene as a significant predictor of caries (β = −0.28 for DMFT; R² = 0.12; p < 0.001).

Table 3. Caries experience (DMFT/dmft) according to oral hygiene level. 

Oral Hygiene Level	n	DMFT, mean ± SD	dmft, mean ± SD
Optimal	547	0.09 ± 0.48	1.22 ± 2.09
Mediocre	200	0.25 ± 0.72	1.92 ± 2.68
Insufficient	48	0.42 ± 1.02	2.85 ± 3.12
p-Value (Kruskal–Wallis)	—	<0.001	<0.001

Table 3. Caries experience (DMFT/dmft) according to oral hygiene level. 

Oral Hygiene Level	n	DMFT, mean ± SD	dmft, mean ± SD
Optimal	547	0.09 ± 0.48	1.22 ± 2.09
Mediocre	200	0.25 ± 0.72	1.92 ± 2.68
Insufficient	48	0.42 ± 1.02	2.85 ± 3.12
p-Value (Kruskal–Wallis)	—	<0.001	<0.001

3.5. Multivariable Analyses

Multiple linear regression models (listwise n = 540) were constructed with DMFT and dmft as dependent variables. Independent variables included gender (reference: male), breastfeeding history (reference: no), hygiene level (ordinal: 1 = insufficient, 2 = mediocre, 3 = optimal), age, and BMI.

Oral hygiene emerged as the strongest independent predictor of caries experience. For DMFT, hygiene had a β coefficient of −0.31 (p < 0.001), and for dmft a β coefficient of −0.26 (p < 0.001). Breastfeeding history showed a modest positive association with DMFT (β = 0.09, p = 0.041). Gender was not significantly associated with caries indices (p = 0.214). Model fit was acceptable, with R² values of 0.18 for DMFT and 0.15 for dmft, indicating that the included variables explain a meaningful proportion of variance in caries experience.

No significant interaction terms (e.g., breastfeeding × hygiene) were detected (p = 0.312). Nevertheless, stratified analyses suggested higher caries burden in subgroups with both breastfeeding exposure and poor hygiene (mean dmft 2.41 ± 2.89), supporting a multifactorial model of risk.

4. Discussion

This multicenter pilot study quantified caries experience using dmft/DMFT indices in a sample of 795 Italian children aged 6–11 years and examined major determinants—including gender, breastfeeding history, and oral hygiene—within the framework of a structured care pathway for pediatric oral health.

The overall caries burden in this cohort was low, with mean DMFT of 0.17 ± 0.64 in permanent dentition and dmft of 1.53 ± 2.37 in primary dentition. These values are substantially below national benchmarks. The Second Italian National Pathfinder survey of 5,342 12-year-olds, for example, reported a mean DMFT of 1.88 ± 1.92, with 22.4% of children exhibiting severe caries (DMFT > 3) and marked SES gradients (odds ratio 2.45 for the lowest vs. highest SES quintile) [5]. Preschool cohorts (3–5 years) from low-SES or migrant families in Italy have been reported to have mean dmft scores around 2.9, compared with 1.2 in non-migrant peers [6]. In the present study, 82% of children had DMFT = 0, and the decayed component predominated, indicating early detection and limited restorative history. This favorable profile likely reflects proactive school- and community-based screening, the high proportion of children with optimal hygiene (68.8%), and the wider dissemination of fluoroprophylaxis in Italy, which has contributed to the reduction of national mean DMFT at 12 years from approximately 3.0 in the 1980s to values below 1.0 [2,4].

In contrast with some meta-analyses reporting slightly higher caries prevalence in girls [3], no significant gender differences in dmft/DMFT were observed. This may reflect the narrow age range (mixed dentition) and the balanced gender distribution. The slightly higher DMFT and filled components observed in females could be related to different patterns of care-seeking or restorative access but did not reach statistical significance.

Breastfeeding history showed a tendency toward higher dmft/DMFT among breastfed children, though differences were not statistically significant. This finding is consistent with literature suggesting that the caries impact of breastfeeding depends on duration, nocturnal feeding behavior, concomitant dietary practices, and oral hygiene [4,10,11]. The dichotomous classification of breastfeeding used here likely obscured nuanced dose–response relationships. The presence of a non-negligible caries experience in non-breastfed children further supports the multifactorial etiology of caries in this age group [13].

Oral hygiene emerged as the predominant determinant of caries risk. Children with insufficient hygiene had nearly three-fold higher dmft and more than four-fold higher DMFT than those with optimal hygiene. The clear gradient and the independent association in multivariable models are consistent with international evidence linking caregiver knowledge, brushing frequency, and fluoride use to caries outcomes [7,13,15]. These findings reinforce the central role of hygiene promotion as the cornerstone of effective caries prevention, even in populations with relatively low baseline burden.

Overall, the results support the potential of integrated, school- and community-based care pathways to maintain low caries levels and reduce residual inequities. The tiered model evaluated here—combining universal educational measures, targeted clinical interventions, and high-risk telemonitoring—aligns with global recommendations for upstream, family-centered strategies and may usefully inform national oral health policies.

4.1. Limitations

The present baseline analysis is cross-sectional and conducted prior to the full implementation of the care pathway; thus, causal inferences regarding the effects of gender, breastfeeding, or hygiene on dmft/DMFT are limited. Longitudinal follow-up will be necessary to examine temporal relationships and to evaluate the impact of the integrated pathway on caries progression and malocclusion outcomes.

Attrition and missing data, especially among families served by mobile units and those with higher social vulnerability, may introduce selection bias and reduce statistical power for multivariable analyses. Recruitment through schools and mobile units may preferentially capture families already partially engaged with health services, potentially underestimating caries burden in non-reached or more marginalized populations.

Breastfeeding exposure was coded dichotomously (yes/no), without information on duration, nocturnal feeds, or complementary feeding patterns, limiting the capacity to model dose–response effects. Oral hygiene assessment, although based on clinical criteria, has an intrinsic component of subjectivity and was not systematically supplemented with objective measures such as plaque disclosing in all participants.

The restricted age range (6–11 years) reduces generalizability to preschool children, who may show higher dmft values, and to adolescents. Finally, the lack of detailed data on free-sugar intake and systematic microbiological assessment of salivary cariogenic flora limits the possibility of disentangling the specific contributions of hygiene, diet, and microbiological factors.

5. Conclusions

This multicenter pilot study found that Italian children aged 6–11 had promising dental health, with very low DMFT and moderate dmft scores. The research showed that oral hygiene is the main factor that can be changed to reduce the risk of cavities. Gender differences were negligible, and breastfeeding exerted only a modest effect in this context, whereas hygiene level explained a substantial proportion of variability in dmft/DMFT.

The proposed tiered care pathway—integrating school-based education, mobile and clinic-based preventive and restorative services, and telemedicine support for high-risk children—appears feasible and appropriate for sustaining low caries levels and reducing residual inequalities, particularly among low-SES and migrant families. Should longitudinal data confirm projected dmft reductions in the order of 20–30%, substantial decreases in restorative needs and long-term healthcare costs for the National Health Service may be anticipated.

By prioritizing early, hygiene-focused interventions in vulnerable subgroups and embedding dental services within broader pediatric and community health strategies, the model outlined herein offers a replicable framework for regional and national policies aimed at improving oral health equity and moving towards a “cavity-free” future for Italian children.