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Epidemiology of ECC &Effectiveness of Interventions
Oct 20, 2010Ananda P. Dasanayake, BDS, MPH, Ph.D, FACE
Professor & Director, Graduate Program in Clinical ResearchNew York University College of Dentistry
Charge
• What’s in a name?
•ECC, S-ECC etc.,
• How much of it is out there?
•Prevalence & morbidity
• How can we prevent/reduce it?
•Summary of intervention approaches
• Based on all of the above, now what?
•Our priorities
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Over the last 5 decades, tooth decay that initially attack themaxillary primary incisors have been referred to as :
•Labial caries•Caries of the incisors•Rampant caries•Nursing bottle caries•Nursing caries•Baby bottle tooth decay•Maxillary anterior caries•Early childhood caries•Severe early childhood caries•Rampant infant and early childhood dental decay
"What's in a name? That which we call a roseby any other name….."
ECC/S-ECC Definitions overthe years…
• One maxillary incisor with caries
• At least one maxillary incisor with caries
• Two or more primary ‘upper front teeth’ with caries
• Three decayed maxillary incisors with caries onbuccal surfaces and confirmed by child’s eatingand feeding habits
• Three or maxillary incisors with caries etc., etc.,
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• Are we capturing the ‘same disease’ with thesevarious definitions?
• Are we or is our progress limited by our owndefinitions?
• Do we need a different metric to capturethe true essence?• A composite of number of lesions, age of onset
(induction/incubation), and rate of progression? Wouldyou add ‘exposure’ to the ‘disease’ definition?
Definition Concerns
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ECC: At least 1 primary tooth surface that is either filled, missingdue to caries, or has a cavity or a non-cavitated lesion in a child whois 71 months old or younger.
S-ECC: Any sign of smooth surface caries in 36-month old oryounger children.
S-ECC in 3-5 year olds: At least 1 primary maxillary anteriorsmooth surface that is either cavitated, filled, or missing due tocaries or more than 4-6 decayed, missing, or filled surfaces in themouth.
Current Definitions
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Potential challenges in using these definitions…
•Validity of non-cavitated lesion detection•Distinction between esthetic fillings and fillings due to caries•Determination of missing due to caries
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10/28/2010 Dasanayake 9
Sharp Eyes and No Probes..
System Sensitivity Specificity
Explorer 60.5 87.4
Visual(University)
65.0 82.5
Visual (PrivatePractice)
61.8 83.3
Lussi, A. Caries Res 1991:25:296-303
10/28/2010 Dasanayake 10
is there a considerablesubmerged part?
Using these definitions, when wesay prevalence of ECC is x% in a
given population
Before we look at ECC/S-ECC prevalence…
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2.9 3.2 3.3 2.7
45.8
38
0
10
20
30
40
50
Mea
n2-11 dfs 6-19 DMFS >=20 DMFS
88-94 99-02
N=2,663 2-5 year olds, Biased Sample, No Calibration
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11.1
14.6
Why? Are we capturing the true essence?
Average Caries Burden Over Time
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How is this compared to nationalobjectives?
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How can we move forward?
Caries in AI/AN Children and HP2010
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Any child age 5 years or younger with decayon their upper front teeth or six or more teeth with
decay is considered to have severe ECC.
(1999 IHS Survey Definition)
ECC/S-ECC among AI/AN Children
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ECC/S-ECC Prevalence – IHS 1999
Approximately 6/10 children < 5 years of age
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Is ECC/S-ECC Also Changing Over Time?
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Is ECC/S-ECC a Different Disease Entity?
•AI/AN children acquire Hib earlier than the U.S. population•As a result, a second generation 4-dose vaccine given at 2, 4,6, and 15 months did eliminate Hib in the general populationbut not in the AI/AN children•A new vaccine that was immunogenic as early as 2 monthsbrought a 99% reduction in Hib meningitis in AI/AN children
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• If the disease trend is on the up rise, why?• Is the estimate that 60% prevalence of ECC/S-ECC in 2-5 year old AI/AN children similar to that
in the general AI/AN children population ofsame age?
• What proportion of children with ECC/S-ECCreceive care?
• What proportion ends up in the OR?• Any other associated morbidities/mortalities?
Some Additional Questions
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Number of Medicaid claims/1000 for children 24-35months of age by state and race/ethnicity
0
100
200
300
400
500
600
700
800
900
NHW AI/AN NHW AI/AN Hispanic NHW AI/AN Hispanic
AK NM OK
Restoration
Crown
Pulp Tx
Extraction
Sedation
Junhie Oh & Dee Robertson
10/28/2010 Dasanayake 22
Can this be fatal?
Burden of Inadequate Accessto Care
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How can we do this?
ECC Prevention Strategies…• Reducing the microbial burden
• Increasing the resistance of teeth
• Water fluoridation
• Prenatal fluoride
• Topical fluoride
• Fluoride toothpaste
• Reduce prenatal challenges that might lead tohypoplasia?
• Reducing the availability of refinedcarbohydrates
• Combination 25
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0
1
2
3
4
5
6
7
3T 6M 7M 12M 18M 24M 36M
log
(10
)M
S
Treatment Control* P < 0.05Mixed Model: Group x Time (p=0.0002)
** *
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The Effect of Chlorhexidine Varnish onCaries Increment in Children
2.5
3.8
0
0.5
1
1.5
2
2.5
3
3.5
4
dfs
Treatment Control
*NS
Power, timing, agent, dose, and frequency, effect onother cariogenic flora, target? MS is just onemember of the biofilm environment
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Results
Glass half-full: Promising findings, Xylitol application canbe routine, yet 24-42% still got caries despite the treatment.
Intervention: (mean age 1.8 yrs)•All in a fluoridated community•All got counseling•Three arms:
•4 applications of 0.1 mLDuraphat per arch @ 0, 6,12, & 18 months•2 applications @ 0 & 12months•Counseling only
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RCT in 0-5 year olds
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RCTs in 0-5 year olds
Now what?
• We need to re-visit our current definitions
• Using a ‘new definition’, we need to get a validestimate of the disease burden
• Further understanding of the real causal factors
• One-Size-Fits-All prevention approaches may notwork and there are no Silver Bullets
• Solution? Culturally appropriate innovativeprevention strategies based on the populationspecific patho-physiology and the commonrisk factor approach?
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