A Comparison of Early Childhood Caries Risk Assessment Techniques in a Pediatric Medical Clinic Yoo-Lee Yea, DDS University of Washington

Beltrán-Aguilar et al, MMWR 2005; NHANES 2-5 year olds

Risk Assessment in Medical Clinics Collaborative efforts towards reducing overall health consequences Well-child care visits Well-child care visits Training of medical residents Training of medical residents Opportunities for preventive oral health care Caries risk assessment & early identification of high risk children Caries risk assessment & early identification of high risk children

Risk Assessment in Young Children Past caries & white spot lesions By clinical exam By clinical exam Most significant predictor of future caries Most significant predictor of future caries Bacterial levels By lab technique By lab technique Most accurate prediction model Most accurate prediction model Sociodemographic variables By interview By interview Demers et al 1992, Grindefjord et al 1995, Powell 1998

Specific Aims 1) 1)Compare the sensitivity & specificity of 3 ECC risk assessments 2) 2)Determine the feasibility of each risk assessment technique 3) 3)Identify the most effective technique for medical providers in a busy pediatric medical clinic

Risk Assessment Techniques CAMBRA oral health interview time: 3 minutes materials cost: $0.50 Ivoclar CRT bacterial test time: 1 minute cost: $8.00 Cariostat plaque acid test time: 30 seconds cost: <$8.00

Study Design Cross-sectional study 120 subjects, ages 3 years & younger Harborview Medical Center Children’s Clinic in Seattle, WA Inclusion criteria Exclusion criteria ASA I ASA II or above Eruption of primary teeth No erupted primary teeth Written consent Non-English w/o interpreter

5-minute Encounter Sequence Eligibility & Informed Consent CAMBRA Interview (17 questions) Cariostat Clinical Examination CRT (SM) & CRT (Lb) If dental caries evident, Healthy Mothers Healthy Babies brochure given Oral Hygiene Recommendations

HMC Children’s Clinic

Results

Results Each risk assessment was associated with the clinical dental examination Each technique varied in: Cost Cost Time Time Incubation period Incubation period Needed training skills Needed training skills Ease of use Ease of use Child acceptability Child acceptability

Each of the three RAs were found to be significant with the visual exams Each of the techniques showed tradeoffs Recommended combination: CRT (SM) & CAMBRA (snacking question) CRT (SM) & CAMBRA (snacking question) Conclusions

Limitations Cross-sectional design Bacterial techniques analyze only one factor of a multifactorial etiology

Recommendations Inform physicians: Of predictive ECC risk assessment techniques Of predictive ECC risk assessment techniques Choice of technique needs to be tailored to each individual clinic Choice of technique needs to be tailored to each individual clinic

Acknowledgments Thesis Committee:Thesis Committee: Colleen Huebner PhD, MPH Colleen Huebner PhD, MPH Rebecca Slayton DDS, PhD Rebecca Slayton DDS, PhD Joel Berg DDS, MS Joel Berg DDS, MS Penelope Leggott DDS, MS Penelope Leggott DDS, MS Maternal & Child Health Bureau (#T76MC )Maternal & Child Health Bureau (#T76MC ) OMNII Postdoctoral Research FellowshipOMNII Postdoctoral Research Fellowship HMC Children’s Clinic (Elinor Graham MD, MPH)HMC Children’s Clinic (Elinor Graham MD, MPH) Patients, Parents & Staff Patients, Parents & Staff Lloyd Mancl PhD for his biostatistical expertiseLloyd Mancl PhD for his biostatistical expertise

Questions?

Caries: a multi-factorial disease Acid producing bacteria ( ie S. mutans ) Acid producing bacteria ( ie S. mutans ) Vertical transmission from caregiver to infant Vertical transmission from caregiver to infant Eruption of teeth (host) Eruption of teeth (host) Frequency of sugar consumption Frequency of sugar consumption Saliva Saliva Salivary flow Salivary flow pH pH Anti-microbial peptides Anti-microbial peptides Anatomy of teeth Anatomy of teeth Enamel defects Enamel defects More prevalent in premature, LBW, low SES children (Seow 1991) Fluoride Fluoride

Early Childhood Caries (ECC) Presence of 1 or more decayed, missing, or filled tooth surfaces in any primary tooth in a child 71 months of age or younger The occurrence of any sign of caries during the first 3 yrs is indicative of severe early childhood caries (S-ECC) AAPD, 2005

Consequences of ECC High risk for new caries High risk for new caries In both primary & permanent dentitions In both primary & permanent dentitions Pain & infection Pain & infection Hospitalizations & emergency department visits Hospitalizations & emergency department visits Increased treatment costs & time Increased treatment costs & time Insufficient physical development (esp. ht & wt) Insufficient physical development (esp. ht & wt) Loss of school days Loss of school days Diminished ability to learn Diminished ability to learn Decreased oral health-related quality of life Decreased oral health-related quality of life

Public Health Utilization of Medicaid for dental care in children is <30% EPSDT: 16% of eligible children received dental care EPSDT: 16% of eligible children received dental care <5% of WA state children on Medicaid visited a dentist by age 2 in 2003

Screen Children (<3 yrs old) Positive for caries Falsepositive Negative Falsenegative Treatment need? yes yes no no Flow Diagram: From Screening to Outcome Action Treatment & Prevention Prevention Prevention? Treatment?Prevention? Outcome Healthy Healthy Healthy Not Healthy