Epidemiology of ECC & Effectiveness of Interventions

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1 Epidemiology of ECC & Effectiveness of Interventions Oct 20, 2010 Ananda P. Dasanayake, BDS, MPH, Ph.D, FACE Professor & Director, Graduate Program in Clinical Research New York University College of Dentistry 1

2 Charge What s in a name? ECC, S-ECC etc., How much of it is out there? Prevalence & morbidity How can we prevent/reduce it? Summary of intervention approaches Based on all of the above, now what? Our priorities 2

3 "What's in a name? That which we call a rose by any other name.." Over the last 5 decades, tooth decay that initially attack the maxillary primary incisors have been referred to as : Labial caries Caries of the incisors Rampant caries Nursing bottle caries Nursing caries Baby bottle tooth decay Maxillary anterior caries Early childhood caries Severe early childhood caries Rampant infant and early childhood dental decay 3

4 ECC/S-ECC Definitions over the years One maxillary incisor with caries At least one maxillary incisor with caries Two or more primary upper front teeth with caries Three decayed maxillary incisors with caries on buccal surfaces and confirmed by child s eating and feeding habits Three or maxillary incisors with caries etc., etc., 4

5 Are we capturing the same disease with these various definitions? Are we or is our progress limited by our own definitions? Do we need a different metric to capture the Definition Concerns true essence? A composite of number of lesions, age of onset (induction/incubation), and rate of progression? Would you add exposure to the disease definition? 5

6 Current Definitions ECC: At least 1 primary tooth surface that is either filled, missing due to caries, or has a cavity or a non-cavitated lesion in a child who is 71 months old or younger. S-ECC: Any sign of smooth surface caries in 36-month old or younger children. S-ECC in 3-5 year olds: At least 1 primary maxillary anterior smooth surface that is either cavitated, filled, or missing due to caries or more than 4-6 decayed, missing, or filled surfaces in the mouth. 6

7 Potential challenges in using these definitions Validity of non-cavitated lesion detection Distinction between esthetic fillings and fillings due to caries Determination of missing due to caries 7

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9 Sharp Eyes and No Probes.. System Sensitivity Specificity Explorer Visual (University) Visual (Private Practice) Lussi, A. Caries Res 1991:25: /28/2010 Dasanayake 9

10 Using these definitions, when we say prevalence of ECC is x% in a given population Before we look at ECC/ S-ECC prevalence is there a considerable submerged part? 10/28/2010 Dasanayake 10

11 Mean dfs 6-19 DMFS >=20 DMFS N=2, year olds, Biased Sample, No Calibration 11

12 Average Caries Burden Over Time Why? Are we capturing the true essence? 12

13 How is this compared to national objectives? 13

14 Caries in AI/AN Children and HP2010 How can we move forward? 14

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16 ECC/S-ECC among AI/AN Children Any child age 5 years or younger with decay on their upper front teeth or six or more teeth with decay is considered to have severe ECC. (1999 IHS Survey Definition) 16

17 ECC/S-ECC Prevalence IHS 1999 Approximately 6/10 children < 5 years of age 17

18 Is ECC/S-ECC Also Changing Over Time? 18

19 Is ECC/S-ECC a Different Disease Entity? AI/AN children acquire Hib earlier than the U.S. population As a result, a second generation 4-dose vaccine given at 2, 4, 6, and 15 months did eliminate Hib in the general population but not in the AI/AN children A new vaccine that was immunogenic as early as 2 months brought a 99% reduction in Hib meningitis in AI/AN children 19

20 Some Additional Questions If the disease trend is on the up rise, why? Is the estimate that 60% prevalence of ECC/S- ECC in 2-5 year old AI/AN children similar to that in the general AI/AN children population of same age? What proportion of children with ECC/S-ECC receive care? What proportion ends up in the OR? Any other associated morbidities/mortalities? 20

21 Number of Medicaid claims/1000 for children months of age by state and race/ethnicity Restoration Crown Pulp Tx Extraction Sedation NHW AI/AN NHW AI/AN Hispanic NHW AI/AN Hispanic AK NM OK Junhie Oh & Dee Robertson 21

22 Burden of Inadequate Access to Care Can this be fatal? 10/28/2010 Dasanayake 22

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24 How can we do this? 24

25 ECC Prevention Strategies Reducing the microbial burden Increasing the resistance of teeth Water fluoridation Prenatal fluoride Topical fluoride Fluoride toothpaste Reduce prenatal challenges that might lead to hypoplasia? Reducing the availability of refined carbohydrates Combination 25

26 log(10) M S * * * 3T 6M 7M 12M 18M 24M 36M * P < 0.05 Treatment Control Mixed Model: Group x Time (p=0.0002) 10/28/

27 The Effect of Chlorhexidine Varnish on Caries Increment in Children dfs 3.8 *NS Treatment Control Power, timing, agent, dose, and frequency, effect on other cariogenic flora, target? MS is just one member of the biofilm environment 10/28/

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29 Results Glass half-full: Promising findings, Xylitol application can be routine, yet 24-42% still got caries despite the treatment.

30 Intervention: (mean age 1.8 yrs) All in a fluoridated community All got counseling Three arms: 4 applications of 0.1 ml Duraphat per 0, 6, 12, & 18 months 2 0 & 12 months Counseling only

31 RCT in 0-5 year olds 31

32 RCTs in 0-5 year olds 32

33 Now what? We need to re-visit our current definitions Using a new definition, we need to get a valid estimate of the disease burden Further understanding of the real causal factors One-Size-Fits-All prevention approaches may not work and there are no Silver Bullets Solution? Culturally appropriate innovative prevention strategies based on the population specific patho-physiology and the common risk factor approach? 33

34 10/28/2010 Dasanayake 34