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Seeking a solution

Early childhood caries in American Indian children defies traditional preventive approaches to infection

Seeking a solution
Wenyuan Shi, Ph.D.

Phoenix—When L. D. Robertson, M.D., began his 20-year career in 1981 as a pediatrician with an Indian Health Service clinic, he saw immediately that many of his young patients had serious tooth decay.

During his tenure, he counseled mothers about how to prevent early childhood caries by using good oral hygiene practices, not giving a child a bottle at bedtime, limiting sweets and using fluoride supplements if their water system was not fluoridated.

Some 10 years ago, he said, as he was discussing this with a young mother of a child with severe ECC, she cut him off in mid-sentence and said, "I've followed all the recommendations you've given me—I stopped the bottle before age 12 months, I never put sugared beverages in the bottle and I never gave a bottle at bedtime. Don't blame me because his teeth are decayed!"

"That really put me in my place," he said. "It made me realize that just blaming the parents is a convenient excuse, but this disease is a lot more complicated than that." Dr. Robertson was one of 20 participants invited to a Symposium on Early Childhood Caries in American Indian/Alaska Native Children in November 2009 in Phoenix. The ADA Council on Access, Prevention and Interprofessional Relations hosted the symposium Nov. 4 in cooperation with the IHS Division of Oral Health.

Participants included tribal health officials, pediatric dentists, dental public health staff and consultants who have decades of direct experience with early childhood caries in AI/AN communities, plus researchers with expertise in the science of cariology and clinical caries prevention research.

Dr. Donald W. Marianos, a public health consultant, said that prevention of early childhood caries in this specific population has seen very limited or no improvement over the past 30 years, despite implementation of community water system fluoridation, fluoride rinses, dental sealants and oral health education.

"I've been concerned about this issue since 1976, when I started working with IHS," said Dr. Marianos.

With a dozen years of experience as an HIS dentist and nine years as the director of the Centers for Disease Control and Prevention's Division of Oral Health, he says that AI/AN populations don’t show the same improvements with oral health preventive strategies as the general U.S. population.

"We need a much more focused research agenda to find out what makes these children at a greater risk," he said. "The bottom line is what we've done in the past has had very little impact. We need to find out why and find new preventive interventions that will be more effective."

According to statistics presented at the symposium, ECC prevalence is about 400 percent higher in AI/AN children than for all U.S. races. In addition, ECC is often much more aggressive and destructive in AI/AN children. In some AI/AN communities, up to 50 percent of the children have such severe caries that they require full mouth restoration under general anesthesia—a rate about 50–100 times that in all other U.S. races. Severe ECC often leads to a lifetime of oral health problems.

Symposium participants reviewed ECC statistics and disease etiology; discussed the preventive efforts that have been tried but found ineffective in this population; considered cultural, demographic and organizational factors that might affect clinical research and programs to control ECC in AI/AN communities; and developed recommendations for planning future ECC prevention programs and long-range clinical research.

Dr. Robertson said it was first reported more than a century ago that tooth decay results from an infectious process, but has been largely approached from a surgical model—restoring cavities after they occur. He agrees with Steve Holve, M.D., IHS chief clinical consultant in pediatrics, who says ECC should be considered an infectious disease of childhood with a dental manifestation rather than a dental disease.

Dr. Robertson is enthusiastic that the symposium is a first step for health care providers—both dentists and pediatricians—as well as researchers to take a different approach to ECC in this population, to find out why it's really such a different disease for them and what to focus on next.

"It was very gratifying to have this group of top researchers and clinicians with a lifetime of direct experience get together and focus on ECC among AI/AN children," Dr. Robertson said. "ECC is not just a dental problem. It's a disease that requires both dentists and pediatricians to get on board to help find more effective ways to prevent it among AI/AN children."

Microbiologist David R. Drake, Ph.D., professor at the University of Iowa Dows Institute for Dental Research, also participated in the symposium.

He said many scientists agree that the severe ECC seen in AI/AN children seems to be a different disease than ECC in the general U.S. population.

"It develops so rapidly in these children, you have to see it to believe it," said Dr. Drake. "I have seen many 2-year-olds who need full-mouth extractions under general anesthesia. The symposium was a way for us to work together to put a national spotlight on this population group's disease and to see what we can do."

Currently, Dr. Drake is in the third year of a five-year study funded by the NIDCR that is examining the oral flora of young children and mothers at an American Indian reservation in South Dakota.

"We are studying the transmission of the types of micro-organisms in the mouths of children from birth to 3 years of age to see what might be different. We are also looking at detailed dietary and behavioral assessments."

The symposium participants, he added, "need to work as a group to understand why these children develop severe, rapid caries and why traditional approaches like fluoridation and education have failed in this population."

Wenyuan Shi, Ph.D., professor and chairman, oral biology, University of California, Los Angeles School of Dentistry, and professor, microbiology and immunology, UCLA School of Medicine, also attended the symposium.

Dr. Shi said his lab "has processed tens of thousands of saliva samples, but I have never seen a population with such a high percentage of streptococcus mutans within the oral flora, making me think ECC in American Indian children may be a different disease."

According to the report of the proceedings, "At the conclusion of the symposium, many participants agreed that ECC in AI/AN children may represent a different disease from that experienced by other populations of children. To achieve control of ECC among AI/AN children, new multimodal approaches will be required, with an enhanced emphasis on controlling the infectious etiology of the disease. Control will also require the development of new metrics to better characterize the disease and measure the effectiveness of new prevention approaches."

"Early childhood caries is a complex infectious disease of bacterial origin," said Dr. Daniel M. Meyer, senior vice president, ADA Division of Science and Professional Affairs. "There needs to be a continuing focus on epidemiology, risk assessment, prevention, chemotherapeutics and disease management if progress is to be made on eradicating the adverse effects from this serious illness."

The report is available by clicking here.