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Dental Caries of Refugee Children Compared With US Children

Susan Cote, RDH, MS*; Paul Geltman, MD, MPH*; Martha Nunn, DDS, PhD*; Kathy Lituri, RDH, MPH*;Michelle Henshaw, DDS, MPH*; and Raul I. Garcia, DMD*

ABSTRACT. Objective. Dental care is a major unmethealth need of refugee children. Many refugee childrenhave never received oral health care or been exposed tocommon preventive oral health measures, such as atoothbrush, fluoridated toothpaste, or fluoridated water.Oral health problems among refugee children are mostlikely to be detected first by pediatricians and familypractitioners. Given the increased influx of refugees intothe United States, particularly children, it is importantfor the pediatric community to be aware of potential oralhealth problems among refugee children and be able tomake referrals for treatment and recommendations forthe prevention of future oral diseases. The purpose ofthis study was to describe the prevalence of caries expe-rience and untreated decay among newly arrived refugeechildren stratified by their region of origin and comparedwith US children.

Methods. Oral health assessments were conductedwithin 1 month of arrival to the United States as part ofthe Refugee Health Assessment Program of the Massa-chusetts Department of Public Health. The outcome vari-ables include caries experience and untreated decay. Car-ies experience is determined by the presence of anuntreated caries lesion, a restoration, or a permanentmolar tooth that is missing because it has been extractedas a result of dental caries. Untreated caries is detectedwhen 0.5 mm of tooth structure is lost and there is browncoloration of the walls of the cavity. Comparisons of therefugee children with US children in Third NationalHealth and Nutrition Examination Survey data weremade using 2 test of independence and multiple logisticregression.

Results. Oral health screenings were performed on224 newly arrived refugees who ranged in age from 6months to 18 years and had a mean age of 10.6 years (SD:4.82; median: 10.7 years). African refugees represented53.6%, with the majority from Somalia, Liberia, and Su-dan. Eastern European refugees composed 26.8% of thestudy sample. The remaining 19.6% come from a numberof countries, such as Afghanistan, Pakistan, and the Mid-dle East. Refugee children had 51.3% caries experienceand 48.7% with untreated decay. Caries experience inrefugees varied by region of origin, with 38% from Africaexhibiting a history of caries compared with 79.7% ofEastern Europeans. The highest proportion of children

with no obvious dental problems was from Africa(40.5%) compared with 16.9% from Eastern Europe. USchildren had caries experience similar to that of refugees(49.3%) but significantly lower risk of untreated decay(22.8%). Comparisons between refugee children and USchildren found significant differences for treatment ur-gency, untreated caries, extent of dental caries, and pres-ence of oral pain. White refugee children, primarily fromEastern Europe, were 2.8 times as likely to have cariesexperience compared with white US children, with 9.4times the risk of untreated decay compared with whiteUS children. In contrast, African refugee children wereonly half as likely to have caries experience comparedwith white US children (95% confidence interval: 0.3-0.7)and African American children (95% confidence interval:0.3-0.7). However, African refugee children were similarto African American children in risk of untreated decay(odds ratio: 0.94).

Conclusion. African refugee children had signifi-cantly lower dental caries experience as well as feweruntreated caries as compared with similarly aged EasternEuropean refugee children. They were also less likely tohave ever been to a dentist. Possible reasons for thesefindings may include differences in exposure to naturalfluoride in the drinking water, dietary differences, accessto professional care, and cultural beliefs and practices.The prevalence of caries experience and untreated cariesdiffered significantly between refugee children and USchildren. These differences varied significantly by race.When refugee children were compared with US children,the African refugee children had only half the cariesexperience of either white or African American children.However, African refugee children had similar likeli-hood of having untreated caries as compared with Afri-can American children, despite that very few Africanchildren had previous access to professional dental care.These findings are consistent with previous studies onhealth disparities in the United States. White refugeechildren, primarily from Eastern Europe, were also 3times as likely to have caries experience compared witheither white or African American children and were 9.4times as likely to have untreated caries as white USchildren. Refugee children are more likely to establishprimary medical care before seeking dental treatment.With the limited access to dental care among refugees,pediatricians should be particularly alert to the risk oforal diseases among refugee children. Pediatrics 2004;114:e733e740. URL:; children, dental caries, health disparities,oral health, refugees.

ABBREVIATIONS. PROH, Program for Refugee Oral Health;NHANES III, Third National Health and Nutrition ExaminationSurvey; CI, confidence interval; OR, odds ratio.

From the *Department of Health Policy and Health Services Research,Northeast Center for Research to Evaluate and Eliminate Dental Disparities,Boston University Goldman School of Dental Medicine, Boston, Massachu-setts; and Department of Pediatrics, Boston University School of Medicine,Boston, Massachusetts.Accepted for publication Jul 29, 2004.doi:10.1542/peds.2004-0496No conflict of interest declared.Reprint requests to (S.C.) Delta Dental Plan of Massachusetts, 465 MedfordSt, Boston, MA 02129. E-mail: scote@deltadentalma.comPEDIATRICS (ISSN 0031 4005). Copyright 2004 by the American Acad-emy of Pediatrics. PEDIATRICS Vol. 114 No. 6 December 2004 e733 by guest on April 17, from

Unmet dental needs are the single most fre-quently reported health need of children.1,2Pediatricians and family physicians are a crit-ical component in oral health as they are often thefirst to see these children. In fact, in a national surveyof pediatricians, 90% responded that they had animportant role in identifying dental problems andcounseling families on the prevention of dental car-ies.3 Because refugee children may be more likely toestablish primary medical care before seeking dentalcare, it is important for pediatricians and family phy-sicians to be aware of the oral health needs of refugeechildren.

In 2002, the United Nations estimated that therewere 12 million refugees worldwide.4 They havebeen defined as people who are outside their nativecountry and cannot return because of a well-foundedfear of persecution because of race, religion, nation-ality, political opinion, or membership in a particularsocial group.4 Refugees present with a wide range ofunique health care needs, reflecting conditions intheir native countries, time in migration, and expe-riences in refugee camps. Refugees countries of or-igin reflect current world political conditions. Al-though during the past 3 decades refugees whoentered the United States were primarily from theformer Soviet Union and Southeast Asia, more re-cently there have been increasing numbers fromEastern Europe, Africa, the Middle East, and CentralAsia.5

Many refugees originate from areas where diseasecontrol, diagnosis, and treatment are lacking andwar or civil unrest has disrupted the function ofhealth care systems. For example, refugee childrenfrequently experience malnutrition, anemia, andpoor growth6 and are also at an increased risk forcertain conditions, such as hepatitis, intestinal para-sitoses, latent tuberculosis infection, and dental prob-lems.710 Vastly different health care beliefs, as wellas cultural and linguistic barriers, contribute to theirdifficulties in gaining access to health care services inthe United States.

Several studies have noted a high prevalence ofdental disease and unmet dental care needs in refu-gees. Chilean and Polish refugees in Sweden havebeen shown to have poorer oral health status com-pared with corresponding Swedish populationgroups.11 Similarly, refugee children in Hollandwere found to have inferior oral health status com-pared with Dutch children, with 85% of refugee chil-dren having a history of dental caries.12 In 1986, theWorld Health Organization documented high levelsof dental caries in the former Yugoslavia when com-pared with other Europeans.13 Because of war anddeteriorating socioeconomic conditions, the previ-ously poor state of oral health in the former Yugo-slavia has subsequently worsened.14 In 1996, a studyof adult refugees and immigrants in Italy also founda greater burden of dental problems, with highercaries prevalence, poorer oral hygiene, and greaterunmet dental needs being particularly high amongYugoslav refugees.15

In the United States, an assessment conducted inSan Francisco in the late 1980s of recently arrived

refugee and immigrant school children from Asia,Central America, and the Philippines found that 77%of the refugee and immigrant children needed dentaltreatment, as compared with 25% of comparablyaged US children. In addition, refugee children, ascompared with immigrant children, had more cariesin their permanent teeth but fewer caries in theirprimary teeth and fewer serious dental conditions.16

In contrast, a study in Israel of refugees from ruralareas of Ethiopia noted relatively low rates of dentalcaries in refugee children, with only 13.2% of 5- to6-year-olds and 18.2% of 12-year-olds exhibiting den-tal caries.17 It is interesting that none of these Ethio-pian children had ever been to the dentist beforeemigration to Israel. All foods consumed by theseEthiopian refugees in their native culture werehomemade without the use of refined sugar, which istypical of many parts of Africa. Throughout EastAfrica, dental caries prevalence is low comparedwith developed countries, with a lower prevalence inrural versus urban areas.18 In addition, differenceshave been noted in caries prevalence between highand low socioeconomic groups, with the prevalenceand severity of dental caries generally higher amongprivileged Africans who reside in urban centers,where sugar consumption is limited to those of ahigher socioeconomic status and considered a lux-ury. In contrast to the indigenous African rural dietthat is low in refined sugar, refugees are often ex-posed to dietary changes that may include increasedquantities of refined sugar. Such dietary changesmay be compounded by disrupted family eating pat-terns within refugee camps, with these new dis-rupted patterns persisting as refugees resettle in anew country.18

All newly arrived refugees in the United States areentitled to a comprehensive health assessment onarrival through the Federal Refugee Act of 1980(45CFR400.107). In Massachusetts, the medicalscreening of newly arriving refugees was consoli-dated in 1995 as the Refugee Health AssessmentProgram under the auspices of the MassachusettsDepartment of Public Health. The program is con-tracted to a limited network of clinical sites aroundthe state. An earlier report by the programs medicalproviders noted that 63% of newly arrived refugeechildren in Massachusetts had significant oral healthproblems, which were the most prevalent healthproblems among these children.6 As a result, oralhealth assessments by a dental hygienist were incor-porated into the Refugee Health Assessment Pro-gram with the establishment of the Program for Ref-ugee Oral Health (PROH). PROH was firstimplemented at the International Clinic of BostonMedical Center, the largest clinical site in the state.This report presents data collected in 20012002 froma cohort of refugee children, stratified by their regionof origin. Comparable oral health data from childrenwho live in the United States was obtained from theThird National Health and Nutrition ExaminationSurvey (NHANES III). The results of these analysesprovide new information on the oral health status ofdiverse refugee populations.

e734 DENTAL CARIES OF REFUGEE CHILDREN by guest on April 17, from


Refugee DataOral health assessments of newly arriving refugees were con-

ducted as part of the Refugee Health Assessment Program startingin January 2001. This article reports findings from screeningscompleted by September 2002. The screenings of refugee childrenwere performed within 90 days of arrival in the United States. Adental hygienist visually screened each refugee child by using apenlight and a disposable mirror. An intra-oral examination wasperformed on each child to detect the presence of any oral pathol-ogy. A parent and/or a child was interviewed about the lastdental visit of the child and whether the child currently had oralpain. These interviews were conducted through hospital interpret-ers, when needed. Data were collected from a retrospective chartreview of the medical records. Oral health findings and demo-graphic information for each refugee child in the study wererecorded. Demographic information included age, gender, race/ethnicity, and country of origin. The Institutional Review Board ofthe Boston University Medical Center approved and monitoredthe study.

The Basic Screening Survey of the Association of State andTerritorial Dental Directors was the survey instrument used forinformation on caries experience, untreated caries, treatment ur-gency, and early childhood caries.19 Caries experience is deter-mined by the presence of an untreated caries lesion, a restoration(which presumably was once a caries lesion), or a permanentmolar that is missing because it was extracted as a result of dentalcaries. Untreated caries is detected when the screener can readilyobserve the following criteria: (1) a loss of at least 0.5 mm of toothstructure at the enamel surface and (2) brown to dark-browncoloration of the walls of the cavity. Early childhood caries isdefined as any child 3 years old with any 1 of his or her upper6 primary anterior teeth decayed, filled, or missing as a result ofcaries. Treatment urgency code is an estimate of how soon thechild should visit the dentist for clinical diagnosis and necessarydental treatment. Treatment urgency is classified into the follow-ing categories: (1) urgent/emergency care is defined as needingtreatment within 24 hours for signs and symptoms including pain,infection, and swelling or soft-tissue ulceration of 2 weeks du-ration; (2) early care is defined as needing dental treatment thatshould be administered within several weeks for problems such ascaries without signs or symptoms, spon...


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