A Comparison of Early Childhood A Comparison of Early Childhood Caries Risk Assessment Techniques Caries Risk Assessment Techniques

in a Pediatric Medical Clinicin a Pediatric Medical Clinic

Yoo-Lee Yea, DDSYoo-Lee Yea, DDS

University of WashingtonUniversity of Washington

Beltrán-Aguilar et al, MMWR 2005; NHANES

2-5 year olds2-5 year olds

Risk Assessment in Medical ClinicsRisk Assessment in Medical Clinics

Collaborative efforts towards reducing Collaborative efforts towards reducing overall health consequencesoverall health consequences Well-child care visitsWell-child care visits Training of medical residentsTraining of medical residents

Opportunities for preventive oral health careOpportunities for preventive oral health care Caries risk assessment & early identification of Caries risk assessment & early identification of

high risk childrenhigh risk children

Risk Assessment in Young ChildrenRisk Assessment in Young Children

Past caries & white spot lesionsPast caries & white spot lesions By clinical examBy clinical exam Most significant predictor of future cariesMost significant predictor of future caries

Bacterial levelsBacterial levels By lab techniqueBy lab technique Most accurate prediction modelMost accurate prediction model

Sociodemographic variablesSociodemographic variables By interviewBy interview

Demers et al 1992, Grindefjord et al 1995, Powell 1998Demers et al 1992, Grindefjord et al 1995, Powell 1998

Specific AimsSpecific Aims

1) Compare the sensitivity & specificity of 3 ECC risk assessments

2) Determine the feasibility of each risk assessment technique

3) Identify the most effective technique for medical providers in a busy pediatric medical clinic

Risk Assessment TechniquesRisk 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 DesignStudy Design

Cross-sectional studyCross-sectional study

120 subjects, ages 3 years & younger120 subjects, ages 3 years & youngerHarborview Medical Center Harborview Medical Center Children’s ClinicChildren’s Clinic in Seattle, WAin Seattle, WA

Inclusion criteriaInclusion criteria Exclusion criteriaExclusion criteriaASA IASA I ASA II or aboveASA II or above

Eruption of primary teethEruption of primary teeth No erupted primary teethNo erupted primary teeth

Written consentWritten consent Non-English w/o interpreterNon-English w/o interpreter

5-minute Encounter Sequence5-minute Encounter SequenceEligibility &

Informed Consent

CAMBRA Interview(17 questions)

CariostatClinical

ExaminationCRT (SM) &

CRT (Lb)

If dental caries evident,Healthy Mothers Healthy Babies brochure given

Oral HygieneRecommendations

HMC Children’s ClinicHMC Children’s Clinic

Table 1. Demographic Characteristics of Sample

n = 120 %

Age 0 to 1 year 10 8.3 1 to 2 years 55 45.8 2 to 3 years 25 20.8 3 to 4 years 24 20.0 4 years & up 6 5.0

Race African/African-American 63 52.5 Asian/Asian-American 12 10.0 Hispanic 28 23.3

Other/Mixed 17 14.2

Gender Male 60 50 Female 60 50

Overall Caries Experience 35 29.2

ResultsResults

Caries Risk Assessments Sensitivity (%) Specificity (%)A: CRT (SM ) 71.4 54.1

B: CRT (Lb ) 80.0 42.4A + B combination 91.4 29.4C: Cariostat 65.7 55.3D: CAMBRA-snacking 82.9 44.7A + D combination 94.3 21.2C + D combination 91.4 25.9

ResultsResultsEach risk assessment was associated with Each risk assessment was associated with the clinical dental examinationthe clinical dental examination

Each technique varied in:Each technique varied in: Cost Cost Time Time Incubation periodIncubation 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 Each of the three RAs were found to be significant with the visual examssignificant with the visual exams

Each of the techniques showed tradeoffsEach of the techniques showed tradeoffs

Recommended combination:Recommended combination: CRT (CRT (SMSM) & CAMBRA (snacking question)) & CAMBRA (snacking question)

ConclusionsConclusions

LimitationsLimitations

Cross-sectional designCross-sectional design

Bacterial techniques analyze only one Bacterial techniques analyze only one factor of a multifactorial etiologyfactor of a multifactorial etiology

RecommendationsRecommendations

Inform physicians:Inform physicians: Of predictive ECC risk assessment techniquesOf predictive ECC risk assessment techniques Choice of technique needs to be tailored to Choice of technique needs to be tailored to

each individual cliniceach individual clinic

AcknowledgmentsAcknowledgments• Thesis Committee:Thesis Committee:

• Colleen Huebner PhD, MPHColleen Huebner PhD, MPH• Rebecca Slayton DDS, PhDRebecca Slayton DDS, PhD• Joel Berg DDS, MSJoel Berg DDS, MS• Penelope Leggott DDS, MSPenelope Leggott DDS, MS

• Maternal & Child Health BureauMaternal & Child Health Bureau (#T76MC00011-21-00)(#T76MC00011-21-00)

• OMNIIOMNII Postdoctoral Research FellowshipPostdoctoral Research Fellowship• HMC Children’s ClinicHMC Children’s Clinic (Elinor Graham MD, MPH) (Elinor Graham MD, MPH)

• Patients, Parents & StaffPatients, Parents & Staff• Lloyd Mancl PhD for his biostatistical expertiseLloyd Mancl PhD for his biostatistical expertise

Questions?Questions?

Caries: Caries: a multi-factorial diseasea multi-factorial disease Acid producing bacteria (Acid producing bacteria ( ie ie S. mutansS. mutans)) Vertical transmission from caregiver to infantVertical transmission from caregiver to infant

Eruption of teeth (host)Eruption of teeth (host) Frequency of sugar consumptionFrequency of sugar consumption SalivaSaliva Salivary flowSalivary flow pHpH Anti-microbial peptidesAnti-microbial peptides

Anatomy of teethAnatomy of teeth Enamel defectsEnamel defects

More prevalent in premature, LBW, low SES children More prevalent in premature, LBW, low SES children (Seow 1991)(Seow 1991)

FluorideFluoride

Early Childhood Caries (ECC)Early Childhood Caries (ECC)Presence of 1 or more decayed, missing, or Presence of 1 or more decayed, missing, or filled tooth surfaces in any primary tooth in a filled tooth surfaces in any primary tooth in a child 71 months of age or youngerchild 71 months of age or younger

The occurrence of any sign of caries The occurrence of any sign of caries during the first 3 yrs is indicative of during the first 3 yrs is indicative of severe early childhood caries (S-ECC)severe early childhood caries (S-ECC)

AAPD, 2005AAPD, 2005

Consequences of ECCConsequences of ECC High risk for new caries High risk for new caries In both primary & permanent dentitionsIn both primary & permanent dentitions

Pain & infectionPain & infection

Hospitalizations & emergency department visitsHospitalizations & emergency department visits

Increased treatment costs & timeIncreased treatment costs & time

Insufficient physical development (esp. ht & wt)Insufficient physical development (esp. ht & wt)

Loss of school daysLoss of school days

Diminished ability to learnDiminished ability to learn

Decreased oral health-related quality of lifeDecreased oral health-related quality of life

Public HealthPublic HealthUtilization of Medicaid for dental care in Utilization of Medicaid for dental care in children is <30%children is <30% EPSDT: 16% of eligible children EPSDT: 16% of eligible children

received dental carereceived dental care

<5% of WA state children on Medicaid <5% of WA state children on Medicaid visited a dentist by age 2 in 2003visited a dentist by age 2 in 2003

Screen Children(<3 yrs old)

PositivePositivefor cariesfor caries

NegativeNegativefor cariesfor caries

FalseFalsenegativenegative

FalseFalsepositivepositive

Treatment need?

yesyes

yesyes

nono

nono

Flow Diagram:Flow Diagram: From Screening to OutcomeFrom Screening to Outcome

Action

Treatment &Treatment &PreventionPrevention

PreventionPrevention

Prevention?Prevention?

Treatment?Treatment?Prevention?Prevention?

Outcome

HealthyHealthy

HealthyHealthy

HealthyHealthy

Not HealthyNot Healthy