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In November 2007, the American Dental Association (ADA) sponsored the American Indian and Alaska Native Oral Health Access Summit, which included a presentation on the high prevalence and severity of early childhood caries (ECC) in American Indian and Alaska Native (AI/AN) children. This presentation was made by a panel of tribal health representatives, dentists and pediatricians with extensive experience working in AI/AN communities. 

The panel reported there was no evidence that the ECC situation had improved appreciably despite decades of efforts by Indian Health Service (IHS) and tribal dental programs to implement all recommended caries prevention strategies for children. The panel concluded that adequate access to oral health care for AI/AN children would never be achieved by only increasing the supply of dental professional staff and dental facilities. Decreasing the demand for dental services through more effective prevention programs was the only feasible, long-term solution. 

Largely as a result of this panel presentation, in November 2009, the ADA sponsored the first Symposium on Early Childhood Caries in American Indian and Alaska Native Children. This meeting brought together a small group of tribal representatives, academic researchers and health professionals with decades of experience in preventive and curative services for children in AI/AN communities. 

Several hypotheses were advanced about potentially unique etiological factors that result in the very severe expression of ECC that AI/AN children experience. The meeting concluded with the suggestion that a larger, multidisciplinary group should be convened to explore the issues in greater detail. Dr. Mark Crabtree, chair [at the time] of the ADA Council on Access, Prevention and Interprofessional Relations and meeting facilitator, said it was incumbent on the group to “raise its efforts to the next level.” 

This next level was achieved by assembling the October 2010 Symposium on Early Childhood Caries in American Indian and Alaska Native Children in Rapid City, South Dakota. At this meeting, fifteen experienced caries researchers, representing ten prestigious research institutions, spent two days examining the best data available on the subject. The two-fold purpose of this meeting was to identify the areas in which the current understanding of caries in the primary dentition in AI/AN children is insufficient to make progress, and to develop specific recommendations on how these gaps may be closed. The recommendations were grouped into four topical areas: epidemiology, microbiology, enamel hypoplasia and new products. Subsequent to the 2010 symposium, in order to continue to guide this effort, the ADA supported a steering committee of four caries and dental public health experts plus a part-time consultant. 

The committee prioritized the recommendations developed at the Rapid City meeting, and this prioritized list formed the basis for the February 2012 Symposium on Caries in the Primary Dentition of AI/AN Children. The steering committee recommended a new title for this initiative — The QUEST — which stands for Quantifying, Understanding and Eliminating Severe Tooth Decay in AI/AN children. The name encompasses the underlying purpose of the four topical workgroups, whose include: 

  • Epidemiology: Quantify the prevalence, severity and morbidity from CIPD in AI/AN children, including developing new metrics to assess the different dimensions of the disease.
  • Microbiology: Understand the etiologic factors that lead to severe CIPD in AI/AN children by reviewing all relevant existing data on the role of cariogenic bacteria and proposing additional areas of investigation to reduce knowledge gaps.
  • Enamel Hypoplasia: Understand the prevalence and severity of developmental defects of the enamel as a predisposing risk factor for early onset and aggressive progression of CIPD in AI/AN children.
  • New Products: Eliminate severe CIPD by exploring options for new caries-prevention products that may be more effective than those currently available.

The 2012 Symposium sought to develop a detailed roadmap of the (1) specific actions required, (2) individuals and institutions that need to be involved and (3) timeline and resources needed to implement the prioritized recommendations of the 2010 Rapid City Symposium. 

The 2013 Symposium took place in Hood River, Oregon and began with an overview of the challenges faced in trying to reduce the morbidity from severe caries in the primary dentition of AI/AN children. These AI/AN-specific presentations were followed by more global discussions on recent national and international activities that will inform the efforts of QUEST Workgroups to eliminate the identified knowledge gaps in each topical area. Each workgroup offered recommendations for further action. 

For further information on QUEST and the challenge of caries in the primary dentition of AI/AN children, contact Dr. Dee Robertson at

2013 Symposium on Early Childhood Caries in American Indian and
Alaska Native Children

September 26–27, 2013
Hood River, OR

2010 Symposium on Early Childhood Caries in American Indian and
Alaska Native Children

October 20–22, 2010
Rapid City, SD

Additional Proceedings