Promoting Prevention

Please define the condition known as early childhood caries (ECC).

There are many names for what we call early childhood caries. Baby bottle tooth decay (BBTD) or bottle mouth are used but we don’t want to call it bottle related because ECC can derive from other sources, like breast-feeding or eating other fermentable carbohydrates.

In my opinion, ECC means any bout of caries in the primary dentition of preschoolers. It usually begins at an early age depending on the dietary risk factors. Breast milk impacts the maxillary incisors as does sleeping with a bottle. Solid foods, such as sugar cane, impact the occlusal surfaces of the first molars. The pattern of decay may be different depending on the particular risk factors associated. The risk factors are the consumption of fermentable carbohydrates and how they are ingested. If the mother or the caregiver has active dental decay in her mouth, she will transmit pathogenic bacteria. If siblings have caries or if there is visible plaque, they will be at risk. Also, if there is any perinatal problem, such as low birth weight or premature birth, it is another risk factor.

Why would low birth weight be a risk factor?

We don’t know too much yet except that low birth and earlier births significantly increase the risk. The primary research is being done in Israel, and the research has been replicated a few times there. It makes sense to me that if there is a relationship between a pregnant woman’s periodontal status and low birth rate, a mother’s immune function is potentially related to caries in her child. We know that maternal depression is related to immune functioning, stress, and also caries. Caries is truly a multifactorial disease.

What is the age range of children who are most at risk for ECC?

Preschool-aged children are most at risk, beginning from the moment their dentition erupts. Erupting dentition are particularly vulnerable to caries because the enamel is relatively thin at the incisal surface. We need to begin intervention with high-risk children as soon as their teeth erupt—before 1 year-of-age.

How prevalent is ECC in the United States?

The incidence in the general population is approximately 4% to 5%.^1-3 The problem is that ECC is much more prevalent in ethnic minority populations, low income populations, and Native American populations.^1-3 In these populations, the incidence may be as high as 70%. It is heartbreaking because children in these communities think that dental disease is normal.

However, I believe the middle and upper classes do have this disorder. There is not a lot of evidence because this is a disease where the third world affects the first world. Many caretakers of middle and upper children are from the third world. When you have a nanny from Guatemala, for example with a nidus infection in her mouth, she can transfer that infection to the child. Plus, she may be giving the child fermentable carbohydrates and not cleaning his or her teeth.

In Washington state, there are many people who want to live their lives as organically as possible. They tend to use more holistic medicinal methods like having natural child birth and participating in La Leche League International, the breast-feeding advocacy organization. In this population, we have found a significant amount of caries in children who are breast-feeding for an extended period of time. We explain to them that their children should be visiting a dentist regularly but they have to make their own decisions. The main point is that this disease is not confined to low income people, although the incidence is much higher in these populations.

Figure 1. This child’s first dental examination. Having the mother
hold the child on her lap is just one of the many positions possible.

What are the best methods for examining a very young patient?

We do a lot of training on how to work with very young children (see Figure 1). We teach dental personnel to ignore crying. We tend to use a “knee-to-knee” technique in the examination. I really love to work on a mat on the floor. I will manipulate children with games and such so I can see their teeth. And if they cry you can see their teeth. We also use toothbrushes. If you put a toothbrush near children’s mouths and you hold their hands, they open. This becomes a wonderful mouth prop. So by hook or by crook, we are going to see their teeth and we are going to do it fast. We do most of the examinations when we are in our office or in the waiting room, before they even know. You don’t need a dental chair or a light to do this.

What about instrumentation for detecting caries?

These examinations are visual and without x-rays. Usually detection of ECC is pretty easy and doesn’t require years of experience. You can see a black hole or, more likely, a white and brown opaque area in multiple teeth. There is no reason to use a sharp explorer for a young child.

When should dental hygienists start thinking about applying topical fluoride products, like fluoride foams and gels?

Fluoride foams and gels are inappropriate with this age group because these children will swallow the fluoride, but there are wonderful topical fluoride products called fluoride varnishes. Every time you examine a child who is at risk for caries, you should put fluoride varnish on his or her dentition. First, try to dry the teeth as best as possible and then apply the varnish. You do not have to do a prophy beforehand. In fact, there are questions about the value of prophies in this population. We strongly believe, and there is a lot of evidence supporting this belief, that fluoride varnish is efficacious in controlling caries in children. Fluoride varnishes are safe and can reverse early white spot lesions. I believe that at risk children should have a fluoride varnish applied at every dental visit.

Should we consider all children candidates for fluoride varnish?

For children whose parents do not have dental disease and who clean their teeth, have good diets, drink fluoridated water, and use a fluoridated dentifrice, I don’t think fluoride varnishes are indicated. On the other hand, I believe that at risk children should receive fluoride varnish more than twice per year.

We currently have a National Institutes of Health (NIH) grant to test a novel application of fluoride—three applications within a 2 week period done in the permanent dentition. We found that in a study of 156 children, such an application is equal or superior to biannual fluoride varnish applications. Now we are doing a full phase three clinical trial.

This is particularly good news for children whose parent do not bring them back for return visits. We are performing the study in a Head Start setting with high risk, migratory people. These results may have a big impact on public health. There are also many technical reports and case histories that show repeating applications of fluoride varnish can arrest caries. Dental hygienists need to be familiar with fluoride varnish.

What role do sealants play in preventing ECC?

Sealants are technique sensitive and when you are working with young children, sealing the occlusal surfaces that are at risk can be difficult. However, there are some promising new materials that are not as technique sensitive.

Children who are at high risk for caries may benefit from sealants. If a child is caries active, the decision depends on what the dietary risk is. If the child is sleeping with a bottle, the occlusal surfaces are not at risk, rather the smooth surfaces are. If a child is walking around with soda pop, taking a little sip at a time, or sucking on sugar cane or candy, the occlusal and interproximal surfaces are at risk. The preventive measures should reflect what the risk is. Sealants are a good idea.

How successful is counseling mothers in order to decrease the incidence of caries in their children?

Traditionally, health education was not very effective. The evidence shows that traditional education, such as handing out brochures and lecturing mothers, does not work. A few years ago, I found a technique called motivational interviewing. Motivational interviewing is a very brief counseling technique and it is the only effective counseling technique documented to be effective with addictive behaviors, like alcoholism, drug addiction, and smoking. Motivational interviewing began to be applied a few years ago to various health-related problems where a positive behavior needed to be established.

How did this approach work?

We did some focus group research on women of East Indian descent who who were living in Surrey, British Columbia. Their children had a very high rate of dental caries—70% in kids who where around 5 years of age.⁴

Through focus groups, we determined what the women were willing to do to prevent caries in their children. Then I trained facilitators to do motivational interviewing. We have a detailed 15 page protocol and worked with more than 200 women. We trained the facilitators to motivate the mothers to ask questions, instead of telling the mothers what to do. For example, they would ask a question first to establish a rapport with the mothers like: “Tell me about what it is like to be the mother of Joey.” Then the mothers were asked about their own dental health problems. Usually low income mothers have had problems with dental care, eg, it’s too expensive, it doesn’t work, it’s painful. So the mother begins telling a story and the next question is: “What do you want for your child?” The facilitator leads the mother to the point where she asserts that she wants her child to be healthy and avoid the same problems she has experienced with dental care.

The goal is to have the mother keep talking because whatever comes from her mouth she believes, but if it comes from the facilitator’s mouth, there is resistance. Then the facilitator goes through the list of what the mother can do to lower her child’s risk of caries and she is given a choice. Various strategies that other mothers have found effective are explained but the mother is not lectured. The facilitator reviews a checklist with the mother. For example, if the first strategy is to screen the child’s teeth for decay, the mother is asked, “What kinds of problems would you have in doing that?” Another is to not add anything sweet to the child’s bottle, which is a popular practice for this population. The facilitator then asks “How do-able is this? What about Grandma?” So a strategy for overcoming the objections is settled on and then the mothers receive follow-up phone calls. We found that this process if very effective. The caries rate in these children was reduced by two thirds.⁴

How can the dental hygienist be more effective in the detection and treatment of ECC?

The key lies in repeated visits and repeated contact. When children have an active rampant caries process, we need to put them on a very short “leash.” The parents need to be counseled on diet and oral hygiene. Dental hygienists need to connect with the parents in the hope that they will start paying more attention to their child’s oral health.

We ask parents to bring the child back to the office much more frequently, even though there is a cost associated with it. We explain that we can control the disease, but if we wait 6 months, there will be more disease, rendering us ineffective. We have children at high risk come back again and again for easy, brief, inexpensive appointments. Just to keep someone healthy is like a Venn diagram with two circles that overlap (see Figure 2). One circle is self-care, the other is professional care, and where they overlap is health. If patients are not taking good care of themselves, we have to take more care of them. If they take better care of themselves, they need less professional care. If they do neither, they have disease. We explain this to the parents. We only change our strategy when the following has been accomplished: the parents are in better control of the disease, their children are cleaning more effectively and using fluoride at home, there is no plaque on the dentition, and the white spot lesions and the early frank lesions are beginning to reverse or arrest. This strategy is effective in controlling caries.

What is the role of the dental hygienist in the examination, detection, and treatment of ECC?

First of all, dental hygienists should be promoting dental visits for children at less than 1 year-of-age, depending on the risk factors. Working in conjunction with dentists, they should attempt to engage in primary prevention with the understanding that ECC is not only a disorder of the poor.

References

1. Weinstein P. Public health issues in early childhood caries. Community Dent Oral Epidemiol. 1998;26(suppl 1):84-90.
2. Milnes AR. Description and epidemiology of nursing caries. J Public Health Dent. 1996;56:38-50.
3. Weinstein P, Milgrom P. Early Childhood Caries: A Team Approach to Prevention and Treatment. Seattle: University of Washington; 1999.
4. Weinstein P, Harrison R, Benton T. Motivating parents to prevent caries: positive 1 year findings. J Am Dent Assoc. In press.

From Dimensions of Dental Hygiene. February 2004;2(2):24-25, 27-28.