THESIS. Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University

Transcription

1 Identifying Risk Factors Associated with Early Childhood Caries in Children Under Three Years of Age THESIS Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University By Christine A. Wohlford, DMD Graduate Program in Dentistry The Ohio State University 2010 Master's Examination Committee: Dr. Homa Amini, Advisor Dr. Robert Rashid Dr. Ashok Kumar Dr. Paul Casamassimo

2 Copyright by Christine A. Wohlford 2010

3 Abstract Purpose: The purpose of this study was to examine the association between risk factors and caries prevalence in children 3 and under, as well as to assess the effectiveness of anticipatory guidance. Methods: This IRB-approved retrospective chart review evaluated 757 dental records of children 0-3 years of age who visited the Nationwide Children s Hospital Baby Clinic. All parents received standardized anticipatory guidance. Results: The mean age was 22.2 months (sd 7.2). Within the cohort, 49% were African-American, 31% Caucasian and 14% Hispanic. Public insurance was reported by 87% of parents. White spots were present in 30% of children. Cavitated lesions were present in 28% of children, with 36% of those having 6 or more carious teeth. Contents of sippy cups included 90% juice, 78% milk, 22% koolaid, 16% pop, and 4% tea and sports drink. Bottle contents included 78% milk and 38% juice. A statistically significant difference was found between caries free and caries active children for nighttime feeding (p=.0008), parental education (p=.002), use of fluoride toothpaste (p=.009), frequency of sugar snacking (p=.002), and cooperation for tooth brushing (p=.018). There was no difference in brushing frequency, bottle/sippy cup use (cariogenic content), parental caries or having a family dentist. In a group analysis, child age and cooperation for tooth brushing were the most important factors predicting caries (p<.0001), followed by bedtime feeding (p=.0003) and caregiver education level ii

4 (p=.021). In a subset of patients with a recall visit (N=288), some home behaviors improved, including parental brushing, cooperation for brushing, use of fluoride toothpaste, bottle use and nighttime feeding (p<.0001), drinking tap water (p=.026), and sippy cup use (p=.004). There was no evidence of diet modification. Conclusion: Early childhood caries is a significant problem for low-income children. Early establishment of a dental home can provide early access to education, intervention, and the ultimate goal, prevention. iii

5 Acknowledgments I would like to thank my advisor, Dr. Homa Amini, for all her guidance and support while working on this project. Thank you also to Drs. Paul Casamassimo and Ashok Kumar for your contributions and endless editing, and for serving on my committee. I would like to extend a special thanks to Dr. Robert Rashid for helping me run and understand the statistical analysis. I could not have completed this project without all your help! Thank you to Beth Noel, RDH for putting together the data base and for endless hours of data entry. Your dedication to the Baby Clinic at Nationwide Children s Hospital made this project possible. Thank you also to my husband, Jake Schuette, for all your love and constant support. I could not have made it through dental school and this residency program without you! iv

6 Vita June MICDS June B.A. Biology, University of Colorado June D.M.D, Southern Illinois University 2008 to present... Pediatric Dental Resident, Department of Dentistry, The Ohio State University Fields of Study Major Field: Dentistry v

7 Table of Contents Abstract... ii Acknowledgments... iv Vita...v List of Tables... vii List of Figures... viii Chapter 1: Introduction...1 Chapter 2: Methods Chapter 3: Results Chapter 4: Discussion Chapter 5: Conclusion References vi

8 List of Tables Table 1. Variables Analyzed Table 2. Distribution of Demographics Table 3. Distribution of Caregiver Demographics Table 4. Distribution of the Children s Home Behavior Table 5. Distribution of Bottle and Sippy Cup Content Table 6. Distribution of Caries and Caries Risk Assessment Tool Table 7. Distribution of Treatment Needs Table 8. Difference Between Caries Free and Caries Active Children for Various Risk Factors Table 9. Significant Variables in Predicting Caries Experience Table 10. Changes in Home Behaviors Table 11. Sensitivity and Specificity of Caries Related Home Behaviors vii

9 List of Figures Figure 1. O.S.C.A.R. Form viii

10 Chapter 1: Introduction Dental caries in young children is a major public health problem. It is one of the most common chronic diseases affecting children, five times more common than asthma. 1 Even though progress has been made in reducing dental caries in some populations, it is still a cause of concern in others. 1 In 2008, a Progress Review of Healthy People 2010 demonstrated that the caries prevalence among children 2-4 years of age has increased from 18% in to 24% in In comparison, the caries prevalence has declined from 61% to 56% among children 15 years of age and has stayed relatively the same (52% to 53%) for children 6-8 years of age. 2 The Department of Health and Human Services addresses the state of oral health in the United States in Healthy People 2000 and Healthy People 2000 and 2010 is a comprehensive, nationwide health promotion and disease prevention agenda from which health goals are set. 3 The National Center for Health Statistics uses its database and many others to monitor the nation s progress towards achieving these goals. It is through this compilation of data that the current frustrating trends in dental caries become evident. Although dental caries can affect any child, it has been shown that 80% of decay is found in just 25% of children. 4 For example, the caries prevalence in Mexican-American children ages 6-8 was 69% in compared with 53% for all 6-8 year olds. 2 In addition, the Progress Review of Healthy People 2010 concluded that the caries rate in children 2-4 years old has significantly increased in the past decade compared to older children. The 1

11 increased caries prevalence in young children is a cause for major concern due to the negative impact of the disease on the child, family, and community. Before addressing the impact of the disease, it is important to look at the caries process as a whole. The Etiology of Dental Caries Dental caries is an infectious and communicable disease that is influenced by a multitude of intertwined factors. At the heart of the caries process is the host (the tooth in the oral environment), the substrate (diet), and microflora (aciduric bacteria). Children acquire some cariogenic bacteria like mutans streptococci from their caregiver at an early age. 5-6 Research varies on the level of maternal transmission. Caufield and Li found strong evidence supporting that mothers are the major source of MS in infants. For example, they found homologous MS genotypes in 71% of mother-infant pairs. 5 However, Mitchell and collegues found evidence of maternal transmission in only 41% of mother-child pairs. 7 In a study looking at initial acquisition of MS, Caufield and colleagues detected MS in 25% of infants by 19 months and 75% by 31 months of age. 6 They termed this as the window of infectivity. 6 In a study by M. Habibian et al., the researchers demonstrated that they were more likely to find detectable levels of mutans streptococci in children who had not had their teeth brushed by 12 months of age compared to children who had had their teeth brushed. 8 Also, Habibian and colleagues were more likely to find detectable levels of mutans streptococci in children who ate/drank anything more than 6.7 times a day. 8 Naturally occurring carbohydrates in cow milk, human milk, and artificial sugars added to fruit juice and soda serve as nutrients for 2

12 the bacteria. All three of these components (the host, substrate, and bacteria) make up a plaque biofilm that settles on the surface of the tooth. It is through this biofilm that the carbohydrate substrate is utilized by the bacteria and acid is produced. The caries process is initiated when the acid begins to demineralize the tooth surface at a critical ph of 5.5. The first sign of the caries process is a white, chalky appearance of the tooth. The lesion can progress to cavitation of the enamel surface in the presence of an unfavorable environment such as a constant presence of sugar, no fluoride, or reduced salivary flow Saliva can aid in the regression of the caries process due to its diluting, buffering, and remineralizing capacity. In addition to the fundamentals of the caries process, dental health professionals know there are other factors that play a role in the caries process such as social, cultural, and behavioral factors. 10 In order to represent the mulitfactoral nature of the disease, Fisher-Owens, et al. has created a conceptual model of the many influences on a child s oral health. 11 Surrounding the original model triad of host, substrate, and microflora are three levels of influence: child, family, and community. Child-level influences include child biological and genetic endowment, dental insurance, and the use dental care. 11 Family-level influences include health status of parents, socioeconomic status, culture, and social support. Finally, community-level influences include community oral health environment as well as health and dental care system characteristics. A time factor is also included to represent the changing nature of a child s oral health status. 11 For example, as a child enters adolescence or the teenage years, diet or oral hygiene can change leaving the child at an increased risk of caries. 3

13 Caries Definitions Early childhood caries (ECC) is defined as the presence of one or more decayed (noncavitated or cavitated), missing (due to caries), or filled tooth surfaces in any primary tooth in children less than 71 months of age. 10 The term severe early childhood caries (S-ECC) can be used to describe the presence of any smooth surface caries in a child younger than 3 years of age. S-ECC can also apply to children ages 3 to 5 who have 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of 4 (age 3), 5 (age 4), or 6 (age 5). 10 Caries Risk Indicators A systematic review of the literature on caries risk indicators by the AAPD concluded that previous caries experience was the strongest predictor of caries in primary teeth. 10 One study by O Sullivan and Tinanoff demonstrated that three-year-olds with ECC will have significantly more decay by the age of five years compared to caries free three-year-olds. 12 Subsequently, studies have also shown that caries in posterior primary teeth may be a strong predictor for caries in permanent teeth. 13 In a longitudinal study examining ECC as an indicator of future caries, the children from the ECC group had the highest number of new carious lesions per year after seven to ten years. 14 Many studies have demonstrated that child age, family income, and race/ethnicity are also major factors affecting the caries rate. 1-2, 4 Beltran-Aguilar and colleagues compared data from NHANES and NHANES and concluded that 4

14 decay in the primary dentition of 2-11 year olds is as high as 41% and represents the only age group where the prevalence of tooth decay has not decreased from to The highest amount of tooth decay was found in Mexican-American children, and twice as many children from low-income families had caries as those from high-income families. 4 Other studies have found that children from a low socioeconomic status and whose parents are poorly educated are also at a greater risk of 1, decay. In a study of disparities in oral health, Edelstein concluded that among children 2-4 years old, tooth decay is more prevalent in Hispanic and African-American children, children of a low socioeconomic status, and children of parents possessing less than a high school education. 20 The NHANES III data shows that minority preschoolers and preschoolers who live in poverty are two and three times more affected by dental caries, respectively. However, the data also demonstrates that as age increases, the discrepancy among groups decreases. 20 The extent of decay and the prevalence of untreated decay also correlated with age, income, and minority status. Minority children experience more decay than Caucasian children at all age groups and all income levels. 20 A higher percentage of minority children, children of a low socioeconomic status, and children of parents possessing less than a high school education had unmet dental needs. 20 Diet and Dental Caries A child s diet and oral hygiene also play roles in caries development. A diet high in fermentable carbohydrates has been shown to be a major risk factor for caries. 19, 21 The carbohydrate concentration of fruit juice ranges from 11g/100ml to more than 16g/100ml, 5

15 while human milk and formula have 7g/100ml. 22 In a study examining the cariogenicity of different drinks, Bowen and Lawrence found that the highest level of smooth surface caries was found in the rodent models that were given cola, 10% surcrose, and 10% honey. 23 In addition, animals fed human milk experienced significantly more smooth surface caries compared to those fed cow s milk. 23 The authors also suggested one reason for this difference is because human milk contains 7% lactose while cow milk contains 5% lactose. 23 Also the composition of cow milk differs from that of human milk. 23 The authors concluded that cow s milk had a relatively low cariogenicity. In another study, Peres and colleagues confirmed that human milk is more cariogenic than cow milk. 24 Lim and colleagues found that children who consumed more soft drinks compared to milk or 100% fruit juice were at a higher risk of caries. 25 Frequency and 21, modality of consumption are both factors that influence the caries rate. In a study examining the relationship between oral hygiene, diet, and mutans streptococci, researchers found that children with detectable levels of mutans streptococci consumed non-milk extrinsic sugars an average of 5 times per day. Children with no detectable levels of mutans streptococci consumed non-milk extrinsic sugars on average of only 3.9 times per day. 8 In addition, only 3% of children who had started brushing by 12 months of age had detectable levels of mutans streptococci compared to 19% who had not started to brush by 12 months of age (p=0.003). 8 Thitasomakul and colleagues studied children 9 to 18 months old and concluded that the highest incidence of caries was found in children who had sweet tasting foods and started snacking at 5 months of age, had sugary snacks, had soft drinks, and did not have their teeth brushed daily at 9 months of age. 27 6

16 This study also found a correlation between mothers oral health and ECC. Children of mothers with greater than 10 decayed teeth and who were not placed on calcium supplements while pregnant had a higher incidence of caries. 27 Excessive juice consumption may also be associated with malnutrition, diarrhea, flatulence, and abdominal distention. 22 According to the American Heart Association and the US Department of Agriculture, children 1 to 6 years old should be limited to 4 to 6 oz per day of sweetened beverages and naturally sweet beverages, such as fruit juice. 28 The American Academy of Pediatrics policy statement relating to oral health explains that for children 0 to 3 years of age and with erupted teeth, juice should be limited to 1 cup (8 oz) per day and served only at meal time. In addition, carbonated beverages should not be part of the child s diet and the contents of a nighttime bottle should be limited to water. Recent research has demonstrated that today s children are getting more sugar-sweetened beverages and 100% fruit juice than needed for a healthy diet. An analysis of the NHANES III, and the NHANES found that the percapita daily caloric contribution from sugar-sweetened beverages and 100% fruit juice across all youth has increased from 242 kcal/day to 270 kcal/day. 28 There was also a statistically significant decrease in milk consumption among children 2 to 5 years (-3%, P<.05) between and The study also found that children 2 to 5 years of age who drank sugar sweetened beverages consumed an average 15.5 oz per day. 28 Similarly, in the same age group, those who drank 100% juice consumed an average of 10 oz per day. 28 The results of this study also demonstrated a large increase in sugar-sweetened beverages among African-American and Mexican-American youths. 28 7

17 In a study looking at beverage consumption of mother-toddler dyads, the researchers demonstrated that children s beverage intake was significantly correlated with that of their mothers. 29 Specifically, a positive mother-child correlation for soft drinks was found. 29 In addition, mothers who consumed more than 12 fl oz of soft drinks daily were 3.8 times more likely to have a child with a poor diet. 29 There is also evidence that early dietary habits are good predictors of later dietary habits Significant correlations were found between consumption of sweets and soft drinks at the ages of 10 months and 2 years (r=0.47 and r=0.26) In another study, 72% of children who were fed a sweetened feeding bottle during infancy had a higher sugar intake as an adolescent 31, 33 compared to 28% of children who were not fed a sweetened bottle. The AAP recommends that juice should not be introduced into the diet before 6 months of age, children should only be given water in a bottle or sippy cup when it is not mealtime, children should not be given juice at bedtime, children should be encouraged to eat whole fruits rather than juice, and eat sugary food only at mealtime. 22 Some studies have found no negative dental consequences of prolonged breast 30, 34 feeding or breastfeeding in general compared to other forms of feeding. One study using data from the NHANES found infant breastfeeding of any duration was not associated with an increased risk for ECC or S-ECC. 35 On the other hand, poverty, Mexican-American ethnic status, and maternal smoking during pregnancy were all independently associated with ECC. 35 Others have linked prolonged breast or bottle feeding to an increased caries experience, especially in the maxillary anterior teeth Some researchers have concluded that these teeth play a role in the development of 8

18 proper tongue function and speech, as well as the timely eruption of the permanent teeth and thus are crucial to a young child s dentition. 37 In addition, children with ECC have a greater risk of developing malocclusion problems in the primary dentition. 37 Adverse Effects of ECC ECC has a detrimental effect on children. In addition to damaging the dentition and causing premature loss of teeth, ECC can also lead to a dental abscess, facial cellulitis, or even death. Children with moderate to severe swelling often need to be treated in a hospital. This leads to time out of school and time off work for parents. Children with dental problems are estimated to lose an annual 52 million hours of school annually. 38 Studies have shown that children with poor oral health perform worse in school compared to healthy children. 39 One in five (20%) children living below the FPL had a dental visit for pain compared to only 11.2% of all children. 20 Oral health is an integral part of general health. Dental problems are associated with other health problems such as heart disease and diabetes, growth alteration, other 1, infections in the body, and overall lower oral health related quality of life. A higher risk of low body weight has been demonstrated in children with ECC Subsequently, one study found that the advancement of ECC, as measured by age, may negatively affect growth when measured by body weight. 42 Fortunately, there is evidence that adverse growth changes can be reversed by full dental rehabilitation. 43 Aside from the pain and problems inflicted by ECC on children and their families, the caries experience in children under the age of three years is also of special importance due to its cost on society. Children with untreated decay are often seen in emergency 9

19 departments. 44 Emergency visits and hospitalizations are highly costly to families and society. Even in non-emergent situations, the cost of treating a young child with multiple carious teeth can be very high due to the need for treatment under general anesthesia. 26 Indications for general anesthesia include patients who are unable to cooperate in outpatient setting due to a mental, physical or medical disability; patients who are extremely uncooperative, fearful, or anxious, or when general anesthesia may 10, 45 protect the developing psyche or reduce medical risk. This results in a greater cost to third party payers-either insurance companies or government agencies. 26 In one study on caries experience and general anesthesia in children, Jamieson and Vargas found that 73% of children undergoing GA were on Medicaid at the time of the surgery. 45 In another study, researchers found that 2% of children used 25% of all Medicaid dental expenses in the 6 and under age group. 46 Multiple studies have also found a high 26, percentage of relapse among GA cases. One such study found that 79% of children with ECC treated under general anesthesia (compared to only 29% in the control group) had new carious lesions detected at subsequent dental visits. 47 Foster and colleagues found the recurrence of caries within 6 to 24 months after GA to be as high as 53.4%. 48 Jamieson and Vargas found 26% of patients who received GA treatment needed operative treatment within the 3 years following the procedure. In addition, 73% of these patients had recurrent decay and 27% had new carious lesions. 45 Even more distressing are the results of a study that found that two-thirds of the children who had undergone GA presented to the dental clinic as walk-in emergencies for pain or loss of restorations. 48 This all leads to more time and costs involved in treating children with 10

20 ECC. One technique that is often employed on the GA population in order to address and decrease the future dental caries risk is the implementation of an immediate postoperative follow-up appointment. One study demonstrated that compliance with the immediate post-operative follow-up appointments may decrease caries relapse risk. 48 However, some studies have reported that only % of patients return for the 2- week follow-up appointment after GA, and rates are even lower for 6-month and 12-45, 48 month recalls. Compliance is difficult to control in the population most at risk for ECC. The Dental Home When addressing the role of ECC in our society, it is of utmost importance to discuss prevention. The children with the highest risk of having unmet dental needs are also least likely to utilize preventative dental visits. Based on a study by Charlotte et al., in 2003, 72% of all US children had a dental visit within the last 12 months. 49 However, only 62.5% of children living at or below 200% of the FPL had a preventative dental visit within the last 12 months. 49 The researchers concluded that children were significantly less likely to have a dental visit within the past 12 months if they were younger than 5, non-white, lower income, had no dental insurance or personal doctor, were not born in United States, or parents were non-english speaking, unemployed, and did not graduate high school. 49 The establishment of a dental home is crucial in the fight against ECC. A dental home is more than just a facility for dental treatment, it is a place that is accessible, 11

21 family-centered, provides continuous and comprehensive care, compassionate, and culturally competent. 50 It is through a dental home that early intervention can be achieved and early prevention can be utilized. Anticipatory guidance for the parents and caregivers is an important part of the dental home. The effectiveness of dental anticipatory guidance is debated. Successful programs are often not realistic on a larger scale. One study by Harrison and Wong looked at an oral health promotion program that included one-on-one counseling and follow-up phone visits by a lay person of similar background. 51 They found this to be effective in adopting healthy behaviors and improving oral health. 51 One area of prevention that leaves much to be desired is the role of the pediatric primary care provider. Enlisting more and more pediatricians and OBGYNs in our fight against ECC is essential. In addition to a mother s prenatal visits, most children are seen multiple times for immunizations or checkups prior to their first birthday. This leaves an opportunity for pediatricians to discuss the importance of establishing a dental home by age one, reviewing the basic oral hygiene and dietary instructions, and making the appropriate referral. One study by Pierce, et. al, looked at the accuracy of pediatricians in dental screenings and referrals and found that after two hours of training in infant oral health, providers still under-referred patients with dental disease. 52 It would likely be more helpful and realistic for pediatricians to focus time on the benefits of establishing a dental home and aiding in the referral process rather than performing dental exams. As the caries incidence continues to rise in young children, it is clear how crucial it to understand as much as possible about the disease and who it effects. Current 12

22 literature has focused on ECC and school aged children. Little has been done on the population under three years of age. This study will hopefully help to identify the most important caries related risk factors which can then be used by dentist and pediatrician alike to aid in prevention of this oral disease. This study will also allow us to take a closer look at the home oral hygiene and dietary behaviors of our young children. These habits will help us uncover flaws in our maternal counseling and anticipatory guidance that will hopefully change the way we approach the prevention of ECC. The purpose of this study is to identify which risk factors best predict caries rate in children up to three years old. In addition, by looking at a subset of patients with recall visits, we will identify which caries related risk factors are easiest to modify through anticipatory guidance and which are most difficult to change. 13

23 Chapter 2: Methods This study was an IRB-approved retrospective chart review of 764 dental records of children who presented to the Baby Clinic at Nationwide Children s Hospital Dental Clinic in Columbus, Ohio from A registered dental hygienist acts as the coordinator and main operator of the baby clinic and staffs the Baby Clinic 4 days a week. The hygienist is accompanied by a dental assistant or dental student. At every appointment, the hygienist completes the O.S.C.A.R form with the patient s caregiver. This form includes questions regarding family demographics, oral health status, and caries related risk factors. Patient information collected includes age, race, gender, insurance type, and any medical conditions. In addition, caregivers answer questions relating to the patient s oral home care and diet such as frequency of brushing, use of toothpaste, fluoridation status, contents of bottle/sippy cup, and snacking. Information collected pertaining to the caregiver includes race, gender, marital status, employment status, education level, and oral health status (presence of family dentist, frequency of dental visits, and presence of cavities). In addition, the caregiver is also asked if they see any problems with their child s mouth or teeth. The patient s caries risk level (based on the clinical portion of the Caries Risk Assessment Tool), number of carious teeth present, and treatment needs are also recorded. All of this information makes up the O.S.C.A.R form. Figure 1 displays the O.S.C.A.R form. 14

24 Anticipatory guidance and oral health instructions are provided during this question and answer portion of the appointment. The hygienist explains the best choice for the questions concerning home care and diet after the caregivers have responded. For example, if the caregiver is putting the child to sleep with a bottle or sippy cup containing milk or a sugary drink, then the hygienist recommends eliminating nighttime feeding and informs the caregiver that only water should be given in a bottle or sippy cup when it is not meal time. There are also examples of different toothpastes and sugary drinks, and photos of white spots and decayed primary incisors displayed in the exam room to aid the discussion. The patient s O.S.C.A.R form is updated at every recall appointment. Every question is asked again and the changes are documented in the margin. The number of teeth present, the patient s caries risk level, and the number of carious teeth is documented again as well. There is one main hygienist who staffs the Baby Clinic four days a week. On her off days, another registered hygienist performs the duties with a pediatric dental resident, dental assistant, or dental student. After the O.S.C.A.R form is completed, the hygienist performs a toothbrush prophylaxis (with prophy paste) in the knee-to-knee position with the caregiver. The dental assistant or student charts which teeth or restorations are present. Next, a dentist performs an exam and discusses treatment options/risks/benefits with the caregiver. A treatment plan is then completed. The examining dentist could be a pediatric dentist, pediatric dental resident, or pediatric dental fellow. Lastly, fluoride varnish is applied to the teeth. 15

25 Study Population The study population included patients from 764 randomly selected charts. Random days were selected and all the charts from that day were included in the study. The patients O.S.C.A.R form did not need to have all responses completed to be included in the study. Non-English caregivers could also be included in the study because an interpreter was present during the appointments. Exclusion criteria included patients 37 months and older. Patients with a handicapped condition, as evident by a caregivers Yes response to the presence of a Handicapped Condition on the O.S.C.A.R form, were also excluded from the analysis. Statistical Analysis The data from the O.S.C.A.R forms were entered into an Excel spreadsheet by the coordinator of the Baby Clinic or the primary researcher. All entries were double checked for accuracy. The database was only accessible to those directly involved in the study. The variables analyzed can be divided into five categories: demographics, caries related risk factors, oral health status of caregivers, oral health status of children, and Caries-risk Assessment Tool. Descriptive statistics, Chi-Square, Pearson s Correlation, Fisher s Exact, McNamara s, and step-wise logistic regression were used to analyze the data. The software used included JMP 8 (SAS, Inc; Cary, NC) and SAS 9.13 (SAS, Inc; Cary, NC). Descriptive statistics were used to analyze the distribution of the patient s age (with the mean and standard deviation), race, gender, and insurance type, and caregiver s marital status, employment status, highest education level, and presence of caries. 16

26 Descriptive statistics were also used to calculate the frequencies of daily tooth brushing, cooperation with brushing, use of a fluoridated toothpaste, first dentist checkup, presence of fluoridated tap water, drinking tap water, breastfed, bottle or sippy cup use, drink pop or juice in bottle or sippy cup, put to bed with bottle/sippy cup/breastfed, drink from a regular cup, eat sugary snacks, and snack more than twice a day. In addition to a caries distribution, descriptive analysis also calculated the number of patients who were cariesfree, had white spots, and the patient s treatment needs. Chi-Square test, Pearson s Correlation, and Fisher s Exact tests were run using JMP 8 (SAS, Inc; Cary, NC) to compare caries free and caries active children with regard to patient and caregiver demographics, caries related risk factors and caregiver oral health status. A p value of <0.05 was considered statically significant. To analyze the variable as a group, a stepwise logistic regression analysis was run using JMP 8 (SAS, Inc; Cary, NC) which identified significant variables in predicting caries experience. SAS 9.13 (SAS, Inc; Cary, NC) was used to obtain 95% confidence intervals. McNemar s test was used to analyze the difference between patients home behaviors from the initial visit to recall visit. Due to the retrospective nature of this study, a calibration and comparative analysis could not be performed on the examining dentists to test for reliability and validity. Because this study is only investigating risk factors of ECC, the only data analyzed from the exam were the number of carious teeth. 17

27 Figure 1 O.S.C.A.R Form 18

28 Figure 1 Continued 19

29 Chapter 3: Results Demographics A total of 764 charts were reviewed. A total of 40 charts were excluded due to age and presence of handicapped condition, leaving 724 total children included in the study. See Table 1 for a list of all variables analyzed. The demographics are displayed in Tables 2-3. The mean age of the children was 22.2 months (SD 7.2). There were 371 (51%) females and 352 (49%) males. The ethnic distribution of the patients was as follows: 351 (49%) African-American, 226 (31%) Caucasian, 102 (14%) Hispanic, 8 (1%) Asian, and 35 (5% ) other. Six-hundred and twenty-six (87%) patients were on public insurance, 77 (11%) private, and 16 (2%) had no insurance. Forty-four percent of caregivers (317) reported that they were the only caregivers in the house and 56% (398) reported 2 caregivers or extended family. Fifty-one percent of caregivers were unemployed (364), 32% (228) full-time employed, and 17% (122) part-time employed. Caregiver education level was as follows: 290 (41%) graduated high school, 169 (24%) had some college experience, 140 (20%) had some high school experience, and 109 (15%) graduated college. When caregivers were questioned on their own oral health status, 447 (63%) reported that they did not have cavities, while 263 (37%) reported having cavities. With regard to dental visits, 450 (63%) had a family 20

30 dentist, but only 307 (43%) caregivers went to the dentist every six months for a checkup and 292 (41%) went only because of pain. Home Prevention The distribution of the child s home behaviors is shown in Tables 4-5. Seventyseven percent (559) of the children in our study had not seen a dentist yet for a first checkup. Responses from the questionnaire section concerning the child s home behavior are as follows. Ninety-two percent of adults (666) cleaned their child s mouth or teeth at least once a day and 48% of children (335) were getting their teeth brushed twice a day and 37% (256) once a day. Sixty-three percent of the children (453) were cooperative for tooth brushing. Ninety-one percent (658) used toothpaste when brushing, while only 58% (408) used a fluoridated toothpaste. Ninety-four percent (677) had fluoridated tap water, but 42% (302) did not drink tap water and 56% (506) drank nonfluoridated bottled water. Diet Forty-eight percent of the patients in our study were breastfed, while only 6% of those were currently breastfeeding. Twenty-seven percent (194) still took a bottle, 83% (599) used a sippy cup, 42% (306) were put to bed with a bottle or sippy cup, and 54% (389) used a regular cup. The reported contents of the bottle and sippy cup, shown in Table 5, included 81% and 78% milk, 39% and 90% juice, 3% and 22% Kool-Aid, and 2% and 17% pop, respectively. Sixteen percent drank formula from their bottle. Eightythree percent (603) of children ate sugary snacks and 65% (441) snacked one to two times a day. 21

31 Caries Incidence The distribution of caries is shown in Table 6. Twenty-eight percent (198) of children had caries while 72% (520) were caries free. Of the children with caries, 26% (51) had 1-2 carious teeth, 32% (63) had 3-5, 19% (38) had 6-8, and 14% (27) had 9 or more carious teeth. Thirty percent (216) of patients had white spot lesions. Information from the Caries Risk Assessment Tool demonstrated that 63% of patients were low risk, 7% moderate risk, and 30% high risk. Treatment The distribution of treatment needs is shown in Table 7. Fifteen percent of children with caries needed general anesthesia for restorative treatment. Four percent and 3.5% of children with caries needed hold-and-go and sedation treatment, respectively. Caries Risk Factor Analysis Each caries risk factor was analyzed independently against caries status. Children with more one or more carious teeth were considered caries active. Table 8 displays results of analysis. A statistically significant difference was found between caries free and caries active children for age (P<0.0001), child cooperation with brushing (P=0.009), use of toothpaste (P=0.001), use of fluoridated toothpaste (P=0.014), fluoridated tap water (P=0.047), pop in sippy cup (P<0.0001), Kool-Aid in sippy cup (P=0.001), children put to bed with a bottle or sippy cup (P=0.001), children who drink out of a regular cup (P=0.003), children who eat sugary snacks (P=0.002), caregivers education level (P=0.002), caregivers who visit dentist every six months (P=0.0494), and caregivers who visit dentist only in pain (P=0.027). 22

32 When all of the caries risk factors were analyzed as a group and confounding variables removed, child age was the most important factor for predicting caries (P<0.0001). See Table 9. The second most significant variables were night-time feeding (being put to bed with a bottle or sippy cup) (p=0.0001) and child cooperation while brushing (P=0.0014). Finally, parental education was also found to be statistically significant in predicting caries (P=0.0092). Specifically, the difference was most significant between a high school education and a college education. Changes in Home Behavior In a subset of patients (N=288) who presented for an initial visit and recall visit, changes in home behaviors were analyzed and shown in Table 10. Home behaviors that had a statistically significant improvement from initial to recall visit included parental brushing, cooperation with tooth brushing, use of fluoridated toothpaste, bottle use, and nighttime feeding (P<.0001). For example, at the recall visit there was a significant change in the number of children who now had their teeth brushed by an adult, started to use fluoride toothpaste, stopped using a bottle, and stopped bedtime bottle or sippy cup use. There was also a statistically significant improvement in the number of children who started drinking tap water (P=.026) and stopped using a sippy cup (P=.004). However, there was no improvement in snacking on sugary foods or snacking frequency. Sensitivity and Specificity The sensitivity and specificity of a few caries related home behaviors are shown in Table 11. The caries risk factors in the table are those that were significantly associated with caries. The presence of white spots demonstrated a high level of both 23

33 sensitivity and specificity, 93% and 94% respectively. This was the only caries related risk factor with a high level of sensitivity and specificity. 24

34 Table 1 Variables Analyzed Child Information Parent or Caregiver Information Child Caries Related Risk Factors Oral Health Status of the Caregiver and Child Treatment Needs Age Race Gender Insurance Type Age Race Gender Marital Status Employment Status Education Level Frequency of Brushing Who Brushed Time of Day of Brushing Child Cooperation While Brushing Use of Toothpaste First Checkup Status Water Fluoridation Status Drinks Tap or Bottled Water Fluoride Supplementation Breast Feeding History Use of Bottle, Sippy Cup, or Regular Cup Type of Liquid in Bottle or Sippy Cup Eats Sugary Snacks Snacking Frequency Presence of Family Dentist Time From Last Dental Visit and Frequency of Dental Visits for Caregiver Presence of Cavities in Caregiver Number of Carious Teeth in Child Hold and Go Sedation General Anesthesia 25

35 Table 2 Distribution of Demographics Demographics N (%)* Gender Female 371 (51) Male 352 (49) Insurance Type Public 626 (87) Private 77 (11) None 16 (2) Ethnicity African-American 351 (49) Caucasian 226 (31) Hispanic 102 (14) Other 43 (6) *Percents based on the number responding to that question. Table 3 Distribution of Caregiver Demographics Parent/Caregiver Demographics N (%)* Marital Status Single Caregiver 317 (44) Two or More Caregivers 398 (56) Employment Status Unemployed 364 (51) Part time Employment 122 (17) Full time Employment 228 (32) Education Level Some High School 140 (20) High School Graduate 290 (41) Some College 169 (24) College Graduate 109 (15) Dental History Presence of Family Dentist 450 (63) Dental Visit Every 6 months 307 (43) Dental Visit Only in Pain 292 (41) Presence of Cavities 263 (37) *Percents based on the number responding to that question. 26

36 Table 4 Distribution of the Children's Home Behavior Caries Related Home Behaviors N (%)* Fluoridated Tap Water 677 (94) Adults Cleaned Their Child s Mouth or Teeth at Least Once a Day 666 (92) Children Used Toothpaste 658 (91) Ate Sugary Snacks 603 (83) Still Drinking From a Sippy Cup 599 (83) First Dental Checkup 559 (77) Snacked One to Two Times Per Day 441 (65) Children Were Cooperative For Brushing 453 (63) Children Used a Fluoridated Toothpaste 408 (58) Drank Non-Fluoridated Bottled Water 406 (56) Used Regular Cup 389 (54) Children s Teeth Brushed Twice a Day 335 (48) Breastfed 350 (48) Put to Bed With a Bottle or Sippy Cup 306 (42) Did Not Drink Tap Water 302 (42) Children s Teeth Brushed Once or Twice a Day 256 (37) Still Drinking From a Bottle 194 (27) Currently Breastfed 40 (6) *Percents based on the number responding to that question. Table 5 Distribution of Bottle and Sippy Cup Content Contents Bottle N (%)* Sippy Cup N (%)** Juice 74 (38) 542 (90) Milk 153 (79) 468 (78) Kool-Aid 6 (3) 130 (22) Pop 3 (2) 100 (16) Tea 2 (1) 21 (4) Sports Drinks 2 (1) 21 (4) Ensure/Pedisure 2 (1) 10 (2) Water Only 3 (2) 5 (<1) Formula 27 (14) 5 (<1) Sugar Free Drinks 1 (<1) 4 (<1) Pedialite 1 (<1) 3 (<1) *Percents are based on the number of children using a bottle (N=194). **Percents are based on the number of children using a sippy cup (N=599). 27

37 Table 6 Distribution of Caries and Caries Risk Assessment Tool Distribution of Caries N (%) Caries Status Caries Free 520 (72) Caries Active 198 (28) Number of Carious Teeth 1-2 Teeth 51 (26)* 3-5 Teeth 63 (32)* 6-8 Teeth 38 (19)* 9 or More 27 (14)* CAT Low Risk 451 (63) Moderate Risk 50 (7) High Risk 214 (30) *Percents based on the number of caries active children (N=198). Table 7 Distribution of Treatment Needs Treatment N (%)* Hold and Go 34 (17) Sedation 27 (14) General Anesthesia 113 (57) *Percents based on the number of caries active children (N=198). 28

38 Table 8 Difference Between Caries Free and Caries Active Children for Various Risk Factors Caries Risk Factors p values Age (in months) <0.0001* First Dental Check-up (yes or no) Adult Brushes (yes or no) Brushing Frequency (1, 2, or 3 times a day) Cooperation for Tooth Brushing (yes or no) 0.009* Toothpaste (used or not used) 0.001* Fluoride Toothpaste (used or not used) 0.014* Child Breastfed (yes or no) Eats Sugary Snacks (yes or no) 0.002* Frequency of Snacking (1-2, 3-4, or <4 times a day) Fluoride in Tap Water (yes or no) 0.047* Drinks Fluoride Water (yes or no) Drinks Out of a Regular Cup (yes or no) 0.003* Bottle Use with Cariogenic Content (yes or no) 0.13 Sippy Cup Use with Cariogenic Content (yes or no) Juice in Sippy Cup (yes or no) Kool-Aid in Sippy Cup (yes or no) 0.001* Pop in Sippy Cup (yes or no) <0.0001* Nightime Feeding (yes or no) 0.001* Parental Caries (yes or no) Parental Education (some high school, high school graduate, some college, college graduate) 0.002* Caregiver Visits Dentist Only in Pain (yes or no) 0.027* Caregiver Visits Dentist Every 6 months (yes or no) Presence of Family Dentist (yes or no) *indicates statistically significant p value (p<0.05) 29

39 Table 9 Significant Variables in Predicting Caries Experience Odds Risk Factor P values Ratio 95% Confidence Limits Age (months) <0.0001* Nighttime feeding (0 vs 1) * Child Cooperation (0 vs 1) * Parental Education (College vs HS) * *indicates statistically significant p value (p<0.05) Table 10 Changes in Home Behaviors Home Behavior p value Children Now had their Teeth Brushed by an Adult <0.0001* Started Using a Fluoridated Toothpaste <0.0001* Stopped Using a Bottle <0.0001* Stopped Night-time Feeding <0.0001* Started Drinking Tap Water 0.026* Stopped Using a Sippy Cup 0.004* Snacking on Sugary Foods Snacking Frequency *indicates statistically significant p value (p<0.05) Table 11 Sensitivity and Specificity of Caries Related Home Behaviors Caries Risk Factor Sensitivity (%) Specificity (%) Child Cooperation for Tooth Brushing Night-time Habits Parental Education Eats Sugary Snacks Caregiver Vists Dentist Only in Pain White Spots Pop in Sippy Cup Kool-Aid in Sippy Cup

40 Chapter 4: Discussion With the caries incidence on the rise in children, research on caries risk factors and prevention is very important. An attempt to halt, or at least curb, the steady increase of ECC would be beneficial to not only children s oral health, but to their overall wellbeing. In addition, society would also benefit from a lower incidence of ECC. A better understanding of how to prevent ECC can be achieved through studying large sample sizes of at-risk populations. In our study, twenty-eight percent of the population had caries. This is slightly higher than the national average. A Progress Review of Healthy People 2010 demonstrated that the caries prevalence among children 2-4 years old was estimated at 24% in Our finding is expected considering the population we studied. Eighty-seven percent of our patients were on public insurance and over 63% were minorities. Finlayson and colleagues looked at low income children (under 6 years old) living in the Detroit area and reported that 33% of the children had decay. 18 Warren and colleagues also concluded that caries was associated with low income children. 16 Seventy-seven percent of children had not seen a dentist yet for a first checkup. The mean age of our population studied was 22.2 months. This signifies that the children most at risk are not getting referred to the dentist at an appropriate age. Twenty-two months is too late for a dental checkup for many of these children. General anesthesia 31

41 was recommended for 57% of children who had caries at this first dental appointment. Intervention needs to happen earlier in order for prevention to be an option. A significant relationship was found between caries-free and caries-active children for consumption of sugary snacks (P=0.002). Seow and colleagues found a similar finding in that the consumption of sugary snacks was a caries risk indicator. 53 Thitasomakul and colleagues also reported a high incidence of caries in children 9-18 months of age who ate sugary snacks. 27 They also found the highest incidence of caries in those children who did not have daily brushing by 9 months of age and in children of mothers who had more than 19 decayed teeth. 27 Tsai and colleagues found that caries was strongly associated with a lack of proper brushing and a high consumption of sweets. 21 However, in this study, we did not find a significant relationship between caries-free and caries-active children for parental caries or for adults brushing or frequency of brushing. In this study, all the home behaviors were self-reported, therefore the number of parents with caries may be underestimated and the number of parents that brush their child s teeth may over-reported. Parental brushing may not have a significant impact on caries if diet doesn t change. There are many factors that can alter the caries rate, simply brushing may not change the status if it is not done properly or if there are too many other negative factors impacting the oral cavity. This study also concluded that children who were uncooperative for tooth brushing were more likely to have caries (P=0.009). Seow and colleagues found that difficulty in brushing was a risk factor for early childhood caries. 53 Williamson and 32

42 colleagues also concluded that behavior issues were more prevalent in children with caries. 54 There were a few unexpected findings from the study. When the caries distribution was examined, only 26% of children with caries had one to two carious teeth and 33% had more than six carious teeth. The number of children with six or more carious teeth seems high considering our age group studied. Yet, when considering the population studied, maybe this shouldn t be a surprise. Another interesting finding was that 16% of children who took a sippy cup drank pop in the sippy cup. Carbonated beverages should not be a part of a child s diet. They contribute to an excess amount of sugary drinks consumed. We also found that carbonated beverages and Kool-Aid in the sippy cup were significantly related to caries-active children, P< and P=0.001, respectively. Our study found that children drinking out of a regular cup, using toothpaste, and using fluoridated toothpaste demonstrated a higher probability of having caries. It is likely that age is the confounding factor and explains the odd trends. Transition to a regular cup occurs at an older age and we found a very strong correlation between increasing age and increasing incidence of caries. Also, many children don t start using fluoridated toothpaste until they are older, which would mean that their age puts them more at risk for caries. Overall, a prolonged exposure to a sugary diet will lead to an increase in caries incidence in children. A direct correlation exists between an increase in age and an increase in caries incidence, regardless of some habits. For all of the home behaviors and risk factors, there are many other variables that play a role in the 33