2. • Define childhood caries
• Describe the importance of childhood dental caries
• Explore prevalence and distribution
• Understanding the risk factors & protective factors
– Model of causal relationship
• Review current studies and recommendations for
future research
• Describe methods of prevention
OBJECTIVES
3. • A multi-factorial chronic disease
• Primary factors for caries formation
– Susceptible tooth
– Plaque
– Individual's diet
• Children significantly affected
OVERVIEW
4. • Barriers to dental care
– Access to care
– Affordability of services
– Workforce Shortages
– Geographic location
• Policies that address these barriers
HEALTH POLICY
5. • Economic burden of dental caries
– fourth most expensive disease in the United
States
• Current methods of treatment economically
unsustainable
– ER visits for treatment
• Indirect effects of childhood caries & their
economic burden
– Nutrition deficiency, negative health
outcomes, missed school
• Methods for sustainability
ECONOMICS
6. • Children represent a vulnerable population
• They are limited in their:
– Education
– Resources
– Strength and ability to provide self care
• Strong dependence on others poses problems
– Can childhood caries be considered neglect or
abuse?
• Dentists’ role in ethics
ETHICAL
CONSIDERATIONS
7. • United States
– Most common chronic childhood disease
– Occurs more frequently than asthma, early
childhood obesity, and diabetes
• In 2012
– 60% of children ages 5 to 17 had caries
• Effects are seen by the time children start school
– >40% have caries by kindergarten
– >50% have cares by 2nd grade
DISEASE INCIDENCE
8. • Person
– Children
– Ages 2 to 19
– Male vs. Female
– Race is a significant factor
DISTRIBUTION
10. • Place
– Counties with low levels of fluoridated water
– Low-income communities
– Rural locations
DISTRIBUTION CONT.
11. • Time
– Secular time trend
DISTRIBUTION CONT.
Percentage of Children Aged 2--4 Years Who Ever Had Caries in Primary Teeth,* by Race/Ethnicity† and Sex --- National
Health and Nutrition Examination Survey, United States, 1988--1994 and 1999--2004
12. • Community
– Policy
– Healthcare availability
• Family
– SES
– Educational attainment
• Individual
– Biological
– Lifestyle /Behaviors
RISK FACTORS
13. • Policy
– Fluoridated water
• Healthcare
– Access to dentists and other healthcare
professionals
• Age
– Permanent teeth vs. deciduous teeth
• Genetics
– Child dental disease prevalence similar to parents
PROTECTIVE FACTORS
14. • Web of Causation
– Risk factors
– Protective factors
MODEL OF CAUSAL
RELATIONSHIP
15. • Cross-sectional studies
– Risk factors
– Health needs of minority populations
• Randomized controlled trials
– Effectiveness of clinical interventions
• Prospective cohort studies
– Documentation of factors that contribute to
dental caries
PUBLISHED RESEARCH
16. • Strengths
– Growing amount of literature on childhood caries
– A wide variation of studies
– Large sample size
• Limitations
– Limited research on behavioral characteristics
– Caries remain a significant problem
– Not recognized widely as a public health crisis
RESEARCH STRENGTHS
AND LIMITATIONS
17. • Improve understanding of race and SES in risk of
caries formation
• More studies on oral health care from health
care providers that are not dentists
• Intervention effectiveness
RECOMMENDATIONS FOR
FUTURE RESEARCH
18. • Primary
– Fluoride exposure
– Dental sealants
– Education about proper oral health
– Behavior modification
– Oral health risk assessments
• Secondary
– Clinical exams for early diagnosis followed by prompt
treatment
• Tertiary
– Fillings
– Dental sealant restoration
– Removal of teeth
• Replace with bridges, implants, dentures
PREVENTION METHODS
19. • Multi-factorial disease
• Current barriers to care
• Caretakers responsible for presence of caries
• Significant health crisis
• Importance of research and policy
• Our role in reducing disease incidence
DISCUSSION & CONCLUSION
Editor's Notes
Hello everyone. My name is Alex Fuller and today I will be presenting an epidemiologic overview of dental caries in adolescents. I chose this topic because oral health has always been an interest of mine and I believe the importance it plays in overall well-being is often overlooked. Hopefully this presentation will help you appreciate the significance of a healthy mouth, not only for children but for yourself as well.
Here you can see an overview of what my presentation will cover. I will be discussing what childhood caries are and why they are an important health topic to focus on. To better understand the disease we will explore its characteristics including prevalence, distribution, risk factors, and protective factors. We will review current studies and their strengths and limitations. This will lead us to recommendations for future research. Lastly, we will look at the different levels of prevention available for childhood dental caries before wrapping up the presentation.
Early Childhood Caries are most commonly referred to as tooth decay or cavities. Once a child’s first tooth erupts, they become susceptible to the disease. Most people do not consider caries to be a disease, when in fact they are a transmittable infectious disease that is considered chronic in adolescents. Children often obtain carious bacteria orally from caretakers with active decay through the sharing of utensils, mothers cleaning their child’s pacifier by putting it in their mouth, or simply by a kiss on the lips.
Dental caries are caused by the breakdown of the tooth enamel (Centers for Disease Control and Prevention [CDC], 2009). Breakdown of the outer layers of the tooth is a consequence of the interaction between cariogenic and non-cariogenic bacteria, salivary components, and dietary sources of fermentable carbohydrates (sucrose and glucose) (Garcia-Godoy & Hicks, 2008).
To put it more plainly, enamel is the hard, outer layer of the tooth. Plaque, which is constantly forming on your teeth, consists of a sticky film of bacteria (American Dental Association [ADA], 2013). These bacteria are used to break down food and drinks that you consume. However, when that food contains sugar, the bacteria produce acid that destroys the tooth’s enamel (CDC, 2009; ADA, 2013). The stickiness of the plaque allows constant exposure of this acid to the tooth, which enables it to break down the solid layers of the tooth (ADA, 2013). This process is known as demineralization.
Although dental caries affect all age groups, I have chosen to focus on children because they are most vulnerable to its effects when they still contain deciduous¸ or baby teeth. It also is a completely preventable disease that lies out of their control until they are old enough to manage their own oral hygiene and make their own decisions on what they consume. Many of these abilities do not come until later in life when they hold a job.
Photo source: http://health-careforall.com/2011/07/teeth-baby-bottle-tooth-decay-and.html
Growing concern for oral health disparities has resulted following health reports that label dental caries as a pandemic and global crisis. Various barriers exist for families in dire need of oral care services. Several of these include financial barriers, low dentist participation rates in public programs, geographic barriers, and shortage of dentists (National Conference of State Legislatures [NCSL], 2013). However, through the use of policy, the opportunity to overcome these barriers is possible.
Children from low-income families constitute the majority of those affected by dental caries. Affordability and access to dental services poses as a major obstacle to receiving care. From 1999 to 2004 the prevalence of dental caries among children ages 2 to 11 living in poverty was more than two times greater than those not in poverty (U.S. Department of Health and Human Services [HHS], 2007). A 2007 report by the HHS found that among children in this age group, 15.01% living in households greater than 200% of the federal poverty level (FPL) reported untreated decay in their primary teeth, compared to 32.52% of children living in households less than 100% FPL. The inability to afford dental services resulted in 4.6 million children that did not obtain needed dental care in 2008 alone (Berg et al., 2012).
It is important that policymakers find ways to allow greater ease of access for these populations. One example is the provision of grants to local health departments to aid dental clinic development (NCSL, 2013). Due to the fact that state health departments are a primary source of care for low-income families, this would strengthen and expand the services provided at a care center frequently relied upon. Although Medicaid and the Children’s Health Insurance Program (CHIP) include dental benefits as mandated by federal law, utilization of dental services under these plans remain low; only 35% of children under Medicaid received dental care in 2009 (NCSL, 2013). Much of this lack of use stems from non-participation of dentists in either program. Policies focusing on incentivizing acceptance of Medicaid and CHIP by dentists would help close the gap in access and affordability for low-income populations.
A second issue in the oral health sector is the impact of dental workforce shortages. In the United States, approximately 6,000 dentists retire each year while an estimated 5,000 dental students graduate; the outcome is 31 million people living in designated shortage areas (NCSL, 2013). This is an obvious problem for rural residents and those who do not have means of transportation to a dentist. Several policies have been created to address this issue in numerous states. Tax incentives provided to dentists for services in underserved communities and expansion of services provided by dental hygienists without supervision of a dentist have both proven to be effective (NCSL, 2013).
Another avenue would allow non-dental health providers to perform dental screenings, deliver oral health education to families, and utilize a referral system for children who present signs and symptoms of oral health disease. One approach examined by Sams et al. (2013) supports an expanded role of primary health care providers in prevention of dental disease, such as screening for pediatric oral disease, providing fluoride therapy, and counseling parents. The adoption of state policies in support of Medicaid prevention oral health programs in medical settings could help overcome access, affordability, and shortage barriers in dental care (Sams et al., 2013). The authors propose effective uptake of these programs by primary care providers would require reimbursement for their services, following completion of required training and certification.
Prevention, the hallmark of public health, is our final focus on policy implementation methods to address dental caries in children. As we are all familiar with, water fluoridation is a popular policy implemented in many communities in the United States. For communities that lack availability to fluoridated water, school fluoride mouthrinse programs have been proposed (NCSL, 2013). School-based dental sealant programs also have been implemented by states for underserved communities and have very high effectiveness rates. Lastly, some states mandate dental checkups before children may begin school (NCSL, 2013). This is an important method of prevention, as many children enter school with caries already present or are at high risk of developing them at this time. We can see from these examples that policy implementation can provide a highly effective method for prevention of caries.
Rural Photo: http://handsonblog.org/2011/03/29/tips-for-community-engagement-in-rural-and-urban-communities/
Tap water photo: http://www.bu.edu/today/2008/health-matters-tap-water-is-tops/
Pediatrician photo: http://www.nymomsworld.com/blog/2013/03/our-best-picks-for-pediatricians-in-queens/
From a general viewpoint, all forms of dental disease experienced by all age groups are costly. In 2006, U.S. expenditures on dental care amounted to 91.5 billion dollars (Griffin, 2009). Cavities themselves have been listed as the fourth most expensive disease in the United States (Berg & Stapleton, 2012). This, coupled with the 500 million visits Americans make to their dentists each year, amounts to high expenses (Centers for Disease Control, 2011). Narrowing our focus even further, the estimated yearly restoration bill in the U.S. for children’s decayed teeth is greater than $2 billion; this makes childhood caries the single most expensive, uncontrolled disease of childhood (Berg & Stapleton, 2012). This places an astounding financial burden on families, states, and taxpayers; which is economically unsustainable (Berg & Stapleton, 2012).
Those who are unable to afford dental care often resort to treatment in a hospital emergency care center once their condition has escalated. This method of treatment, although it is the only option for some, is costly to hospitals and taxpayers. In 2009, roughly 830,000 nationwide emergency room (ER) visits were for preventable dental conditions (Sanders, 2012). To bring this point home, more than 10,000 visits to Iowa emergency rooms were for dental related issues, costing Medicaid and other public programs nearly 5 million dollars (Sanders, 2012). In regards to children, dental emergencies are the second leading cause for outpatient surgeries at children’s hospitals (Berg & Stapleton, 2012).
Children are a population that needs to be focused on in regards to oral health. While other age groups have seen improvements over the past few decades, conditions have only worsened in children. The disparities that are present are also cause for concern. In the United States, 80% of cavities prevalence is found in 20% of children (Berg & Stapleton, 2012). This means children are very disproportionately affected. Children under the age of six enrolled in Medicaid and treated for dental caries in a hospital setting make up fewer than 5% of those receiving dental care, yet consume 25% to 45% of dental resources (Berg & Stapleton, 2012).
Other economic repercussions of caries that need to be considered for children are the disease’s cause for decline in their nutrition and overall wellbeing (Sanders, 2012). When caries lead to other negative health impacts, additional costs are incurred for treatment of the correlated outcomes. Another negative impact that dental caries has on children is their effect on their schooling. Approximately 51 million school hours are lost each year for dental related issues (Berg & Stapleton, 2012). This leads to learning and social deficiencies that can impact children later in life.
To address the unnecessary cost burdens of childhood caries, the current approach to dental care needs to be restructured. The traditional “drill and fill” management approach needs to be changed to an early risk assessment approach beginning at a child’s 12-month-checkup (Berg & Stapleton, 2012). If children visit a dentist by age one for preventative services, they will have lower dental-related costs later in life (Berg & Stapleton, 2012). Other more sustainable approaches should be implemented as well. A joint alliance between medical professionals and dentists should be formed to make oral health service delivery available in a variety of settings by a diverse, expanded array of providers (Berg & Stapleton, 2012). Cost-effective, population-wide prevention should be expanded such as fluoridation of public water systems and dental sealant programs. Dental sealants, which are clear plastic coatings that provide a barrier to bacteria and are applied to chewing surfaces, prevent 60% of decay at only a third of the cost of filling a cavity (Sanders, 2012).
I think we can safely say that when people are choosing to have teeth removed rather than undergo restorative care due to the fact that it is considerably cheaper, an economic revision is needed.
Photo source: http://www.greatprograms.org/Economic_impact_assessment/resources_for_economic_impact_assessment.htm
When dealing with a population as vulnerable as children, a number of ethical complications should be considered. The limited power, intelligence, education, resources, and strength and ability to provide self-care are all factors which place children in a position of vulnerability, increasing their chances for poor health outcomes (Mattheus, 2010). A child’s current state of health is based on their dependence on caretakers, which in turn is affected by the caretaker’s own state of vulnerability (Mattheus, 2010). These statements bring into question whether parent neglect is to blame.
Child neglect has been described as ‘the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in serious impairment of a child’s health or development’ (Heads et al., 2013). In regards to oral health, this may present itself in the form of decayed, missing, unfilled teeth, and poor oral hygiene. According to Heads et al. (2013) Rampant caries and poor dental hygiene are not a reliable indicator for neglect; socioeconomic status, parental attitudes, barriers to access, and the dentist’s management of care all need to be taken into consideration. However, neglect is considered in cases where caretakers are aware of their child’s need for treatment but persistently fail to act in the absence of any barriers, compromising their child’s health and wellbeing (Heads et al., 2013).
This brings us to the topic of the role of dental care providers in terms of ethics. Although dentists are mandatory reporters, the presence of dental caries is not enough to report neglect or abuse. However, if other signs of abuse are present dentists have the responsibility to report their suspicions. Dentists may also be asked to review a child’s dental health as part of an investigation into neglect (Heads et al., 2013).
A second, more heart-wrenching ethical dilemma presents itself after having read about a young child and young father whose barriers to dental care lead to grim results. In 2007, a 12-year-old boy residing in Maryland named Deamonte Driver died from an infected tooth (Sanders, 2012). This occurred after months of his mother searching to find a dentist that would see her children and accept their Medicaid coverage (Sanders, 2012). In 2011, a 24-year-old Cincinnati resident, Kyle Willis, died from an infected tooth due to his inability to afford antibiotics needed to treat his infected tooth (Sanders, 2012). To me, this poses a huge ethical dilemma for the dental profession. At what point do dentists realize that providing treatment to those in need is more important than their method of payment?
When people think of childhood disease, obesity, asthma, and diabetes are most likely the first to come to mind. However, early childhood caries affects more children in the U.S. than any other disease. Childhood caries occurs 5 times more frequently than asthma, 4 times more frequently than early childhood obesity, and 20 times more than diabetes (Mattheus, 2010; Berg & Stapleton, 2012).
Children are more greatly affected by caries than any other age group. In the United States, 3 in 10 toddlers and preschoolers are affected by early childhood caries (Berg & Stapleton, 2012). In 2012, 25% of children ages two to five had dental caries, while 50% ages 12 to 15 were found to have dental caries (Sanders, 2012). Childhood caries affects 60% of children ages 5 to 17 (Sanders, 2012). By the time young individuals reach age 17, only 15% have not experienced caries (Guzman-Armstrong, 2005). Oral health problems will likely occur as these individuals age.
Once a child’s first tooth erupts, it is ideal that they visit a dentist for an early risk assessment. By the time they start school, most children will have had several visits to the family primary care physician or their pediatrician for checkups. However, oral health is overlooked during this time. When entering into kindergarten, more than 40% of children have already experienced tooth decay (Berg & Stapleton, 2012). This escalates to more than 50% by the time they reach the second grade (Berg & Stapleton, 2012).
As we have clearly established children and teens are those affected by childhood caries specifically and the population most affected by caries overall. Children between the ages of two and nineteen are most often concentrated on. Although younger children are more vulnerable to caries, the incidence of caries increases with age due to lifetime exposures to cariogenic bacteria. Studies show that incidence between male and female children are similar and thus not a determinant of childhood caries; however, race is. Black, non-hispanic children and Hispanic children of Mexican origin have more untreated decay than white, non-hispanic children (Centers for Disease Control [CDC], 2011; National Institute of Dental and Craniofacial Research [NIDCR], 2013). From 2001-2004 the rates of untreated caries for two to five-year-olds among Hispanics, Blacks, and Whites were 29.2%, 24.2%, and 14.5% respectively (CDC, 2011). These rates increased in the 6-19 age group to 30.6%, 28.1%, and 19.4%, again following the same order (CDC, 2011).
Photo source: http://www.theguardian.com/uk/the-northerner/2012/sep/17/week
Here we see a table demonstrating the distribution of childhood caries discussed in the previous slide. This table is very informative as it provides many different comparisons. We can compare male and female differences in different age groups during different time intervals as seen in the first two rows. We can also similarly compare different races and poverty levels.
No geographic maps are available that present numbers or trends of caries in the United States. However, levels of fluoridated water have been mapped. Due to the fact that decreased exposure to fluoridated water has been linked to increase in caries prevalence, this may help show caries trends as well. The two graphs shown depict fluoridation by county and by percent of the population in each state. This varies quite a bit, making it hard to decipher any geographic trend.
As discussed earlier, access and affordability to dental care play a critical role in caries formation. Those living in low-income communities as well as rural localities experience these barriers along with others, causing these populations more likely to experience dental decay. For example, 17 million low-income children a year go without basic dental care (Sanders, 2012). In rural communities, residents age 18 to 64 are approximately two times more likely to have lost all of their teeth than urban residents (Russel, 2013).
Dental caries follow a secular time trend, meaning gradual changes in the disease rate occur over long periods of time (Friis & Sellers, 2014). Although there have been major strides in the dental field over the past several decades, dental caries in children continue to remain a major health concern considering the incidence of caries in children ages two to four raised from 18% in 1988-1994 to 24% in 1999-2004 (CDC, 2011).
Three primary factors are needed in order for caries formation to occur. According to Lovern, Broukal, and Ogannesian (2012) these are a susceptible tooth, plaque, and the individual’s diet. Although these factors directly contribute to formation, many external factors can increase a child’s risk of caries. Three levels may be examined that contribute to the development of early childhood caries. These are the community, family environment, and elements of the individual.
A child’s community they reside in has the ability to influence caries formation through policy development and the availability of oral healthcare resources. Communities that lack policy directed toward water fluoridation experience higher rates of dental caries versus communities with fluoridated water. For example, roughly 19% of communities in western United States have fluoridated water (Milgrom & Reisine, 2000). When comparing children in this geographic region living in communities with or without fluoridated water, a 60% reduction in dental caries was found among children living in communities with fluoridated water (Milgrom & Reisine, 2000). A lack in availability of dentists, either due to a low dentist to population ratio or the fact that some do not accept Medicaid, leads to missed oral health risk assessments. This also makes it difficult to follow through with preventative dental care.
A child’s family environment also has major implications for their oral health status. A low level of educational attainment by caretakers can influence a child’s oral health. Children with caretakers achieving less than a high school education are 11% more likely to have had no dental visits and 13% more likely to have had dental visits when caretakers are college-educated (Mattheus, 2010). Level of education can also limit knowledge of dental standards and importance of fluoride, leading to higher incidence of early childhood caries in these households (Mattheus, 2010).
Many studies suggest children living in low-income households are at a higher risk of developing dental caries. From 1999 to 2004 the prevalence of childhood caries among children ages 2 to 11 living in poverty was more than two times greater than those not in poverty (U.S. Department of Health and Human Services [HHS], 2007). Lower income leads to an inability to afford dental coverage or out-of-pocket services. Without the ability to pay, professional dental care is neglected decreasing the overall utilization of services by the entire family.
Biological determinants, along with a child’s lifestyle and behaviors, are additional risk factors. A cariogenic diet consisting of sugary, sticky foods increases risk for dental caries. When comparing young children who consumed 3 or more sweetened drinks per day to those who have none, the former had an average of 47.1% more decayed, missing, and filled deciduous teeth (Armfield et al., 2013). Exposure to these types of foods leads to increased presence of bacteria and plaque in the mouth, a direct source of dental caries. Age plays a role in caries formation. As children age, more teeth erupt making formation of dental caries possible. Genetics are also an important consideration in the prevalence of dental caries. The density and structure of the tooth as well as salivary composition are inherited from parents (Hassell & Harris, 1995). Depending on parents’ history of cavity formation, children may also be more vulnerable as well.
Certain factors that lead to dental caries have the ability to act as protective factors if approached correctly. As mentioned previously, implementation of policy related to fluoridation of public water in communities can protect children against dental caries formation. Exposure to fluoridated water has the ability to counteract the effects seen by drinking sugar-sweetened beverages (Armfield, Spencer, Roberts-Thomson, & Plastow, 2013). When dentists and other health care professionals are available to provide screening and education for oral health, high risk children can be identified and prevention efforts toward caries can be provided. These help protect against caries formation.
As children age, permanent teeth emerge which are more resilient than baby teeth (Armfield et al., 2013). This acts as a protective factor as children age. A study by Armfield et al. (2013) found a strong correlation between sugar-sweetened beverages and caries formation in deciduous teeth, but no association between drink consumption and caries in permanent teeth could be found for children residing in optimally fluoridated areas for more than half their life. This shows that on top of fluoridation acting as a protective factor, permanent teeth naturally provide better protection against dental caries than deciduous teeth.
A child’s genetic makeup inherited from their parents has the ability to protect against caries. The density and structure of the tooth as well as salivary composition most likely provide direct genetic control in caries formation (Hassell & Harris, 1995). A study conducted on 5,400 individuals from 1,150 families, revealed that the amount of dental disease in offspring was quantitatively related to dental disease in their parents (Hassell & Harris, 1995). Thus, if parents demonstrate higher resistance to caries, their children will too.
Please refer to the model of causal relationship handout attached with this presentation. With this you can see the information we covered in the previous two slides. For my topic, I chose the web of causation model. Dental caries are often referred to as a multi-factorial disease given the complex interaction of environmental, behavioral, and biological factors that interact in order for the disease to form. This model provides a visual representation of some of the main factors that lead to dental caries in children. As you can see, the model is first divided into three different levels or categories. These include community, family, and individual determinants. As you work your way to the right, you can see the overarching causes of dental caries, what these are composed of, and what roles those play in caries formation. This model also demonstrates that although I separated the determinants into different categories, many interact with one another across the different levels. Boxes enclosed in red outline indicate factors necessary for caries formation. In contrast, boxes enclosed in yellow highlight determinants that also have the ability to act as protective factors for children.
A large array of research articles examining childhood caries are available when searching research databases such as PubMed and EBSCO.
A majority of research exploring dental caries in children is performed using cross-sectional studies. Cross-sectional studies collect disease measures at the level of the individual during a single period of observation (Friis & Sellers, 2014). Cross-sectional studies are beneficial when determining trends in risk factors for specific diseases and health needs of minority populations (Friis & Sellers, 2014). Both of these are valuable in researching dental caries, especially due to the fact that low-income families are impacted most by their occurrence. A study by Brewster, Sherriff, and Macpherson (2013) used a cross-sectional population sample of primary school children from Scotland that had undergone routine dental inspection. The study sought to find the most effective method for identifying at-risk children when using a directed-population approach. The authors concluded that a directed-population approach may be insufficient and that work needs to be done to find an adequate method of reaching those most in need of dental health services.
Randomized controlled trials are also frequently used to study dental caries prevalence. These studies allow researchers to examine the effectiveness of clinical interventions through comparison of randomly assigned groups. Alkarimi et al. (2013) used a randomized controlled trial to assess how dental treatment of caries affected children’s weight, height, and subjective health outcomes. They found that physical measures were not significantly affected but dental outcomes and a child’s satisfaction with their teeth, smile, and appetite experienced significant improvement.
Prospective cohort studies are also beneficial in researching dental caries in children. Prospective cohort studies follow study participants as they age, allowing researchers to document factors that contribute to dental caries as they occur. At the end of the study, researchers can examine dental caries prevalence and link it to contributing factors that were documented over the time span. A study by Pukallus et al. (2013) used a prospective cohort to track the incidence of dental caries in Australian children starting at 6 months of age until 6 years. The study was performed to determine healthcare costs of delivering a child dental care telephone education program and to quantify the potential savings due to prevention aimed at children from a low socioeconomic, socially disadvantaged community. The authors found that the telephone prevention program provided significant savings to the health system by reducing the prevalence of caries in children who received the intervention.
Current strengths in dental caries research stem from the increased attention that childhood caries has received over the past couple of decades. A growing amount of literature on childhood dental caries has stemmed from this attention. More researchers are dedicating their time and resources to understand the caries formation process, risk factors for caries, and behavioral factors linked with dental caries. Through this augmented understanding, effective interventions and prevention programs can be formed to help lessen the prevalence of this chronic disease. A wide variation in studies is another strength paired with the growing amount of literature. Researchers are not only looking at different aspects of dental caries but are also applying different types of studies in their research. Lastly, because so many individuals in the U.S. and across the world are afflicted with tooth decay, many individuals are available as study samples to help health care professionals better understand the disease.
With strengths come limitations. The first limitation I recognized is that although there is a wide variation in research, few studies currently exist that examines children and their caretaker’s behavior in regards to oral health care. Behavior is an important aspect of oral health due to the fact that it is largely up to the individual whether they implement oral hygiene practice into their daily living. Understanding behavioral barriers along with barriers concerning access to care will help create a well-rounded approach during widespread interventions. Secondly, even with growing research on the topic, childhood dental caries remain a significant problem. The next necessary phase is to turn research into action to help fight childhood caries. Lastly, there is still a disconnection between research on caries and public mindset. Many individuals do not realize caries is the number one chronic disease affecting children in the U.S. and many do not consider it to be a serious condition. Copious amounts of people choose to ignore the presence of caries in their children’s mouths, not realizing how detrimental they can be.
One thing I noticed while gathering research is that race and SES are two primary indicators for the presence of dental caries in children. However, studies often combined the two factors making it difficult to tell if race is a significant factor by itself or is primarily noted due to the fact that racial minorities also form a large portion of low-income populations. Thus, I think it would be important to see whether the same differences are seen among the same race across different socioeconomic levels and among various races in the same SES. This would help decipher whether race is truly a risk factor of childhood caries or whether it is simply amplified for those living in low-income communities.
More research also needs to be conducted on the efficacy of providers other than dentists in reducing caries prevalence. Other countries use dental therapists as an alternative to care, while some states now allow dental hygienists to perform care without supervision of a dentist. Primary care providers can also partake by providing dental screenings and high-risk assessments. Without sufficient evidence to back up the cost savings and health benefits of these methods, dentists and the general public are not likely to accept them as alternative methods of care.
Lastly, interventions and prevention methods need to be designed and tested. Dental caries are 100% preventable, thus understanding what methods are effective, have the ability to reach a large number of people, and are cost-effective is important in making strides to improving the oral health of populations. If this is to happen, higher volumes of research examining operational interventions is required.
As you can see prevention methods for childhood dental caries are numerous; the main reason being that caries are a completely preventable disease. Primary prevention methods focus on stopping the disease before it starts using health promotion. Ensuring a child has exposure to fluoride is important; fluoride has been shown to significantly decrease incidence of caries. Research suggests a 40% reduction or greater in childhood caries after extensive application of fluoride to surfaces of the teeth during early medical visits (Milgrom & Reisine, 2000). Exposure to fluoride can come in the form of fluoridated drinking water, tooth pastes, mouth washes, and fluoride treatments. Dental sealants, explained earlier in the presentation, have also been used as a highly effective prevention method. Both fluoride treatment programs and dental sealant programs have been provided as school-based interventions to ensure access to at-risk children.
Some individuals may not know what it takes to maintain a healthy mouth or the specific steps to take to prevent caries. Educating populations about the importance of caries prevention can motivate parents to ensure their children are brushing, flossing, and using mouth rinse. Expanding knowledge can also help in terms of behavior modification as well. Changing children’s eating habits to contain healthier non-sugary foods and helping them establish an oral hygiene routine is critical in caries prevention. Lastly, risk assessments performed by primary care providers, pediatricians, or dentists can help identify at-risk children and help providers work with caretakers to implement an action plan to prevent caries from forming.
Secondary prevention is used when cavities have been found in the mouth. Oral health screenings and clinical examinations can help identify the presence of caries early on. Early diagnosis and prompt treatment are hallmark methods of secondary prevention. Tertiary prevention is used during advanced stages of caries. This would be when a child has rampant caries and the cavity has reached the pulp of the tooth, threatening a systemic infection. Methods of tertiary prevention for childhood caries include fillings, dental sealant restoration, or completely removing the tooth (Scottish Intercollegiate Guidelines Network, 2000). Once teeth have been removed they can be artificially replaced with bridges, implants, or dentures. These help children return to optimal functional levels (Friis & Sellers, 2014).
Hopefully this presentation helped you realize the current status of dental caries in the United States and the importance in increasing attention on treatment and prevention. Dental caries is a multi-factorial disease. Many different approaches must be taken to combat its occurrence. Currently, the lack of access to care, inability to afford dental services, deficiency of dental providers, and lack of knowledge about oral hygiene are the fundamental barriers to treatment and prevention of caries. Due to the fact that children are incapable of caring for themselves and lack the cognitive ability to understand the importance of a healthy diet and brushing, caretakers are held responsible for the presence of caries. Economic burdens, physical pains, and risk for other social and physical harms are strong evidence for the importance of addressing this health crisis.
If we are to effectively decrease childhood dental caries in the United States and all over the world, attention must be multiplied focusing on the importance of prevention and treatment by both the public and health care professionals. In order to do this, research must be conducted to fully understand the disease occurrence, risk factors, and what effective prevention methods can be used. Policies must be implemented that increase prevention efforts and aid available access to oral care. We as public health professionals must also be aware of all diseases and conditions currently affecting populations whether locally or around the world. Enhancing our own knowledge can strengthen the alliance in protecting the public’s health.
