A Comparison of Early Childhood Caries Risk Assessment Techniques in a Pediatric Medical Clinic
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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
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Beltrán-Aguilar et al, MMWR 2005; NHANES
2-5 year olds2-5 year olds
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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
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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
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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
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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
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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
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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
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HMC Children’s ClinicHMC Children’s Clinic
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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
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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
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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
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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
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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
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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
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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
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Questions?Questions?
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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
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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
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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
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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
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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