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Systematic Review: Is there evidence-based research that evaluates the effectiveness of the current recommendation that the first oral health visit occur six months after the

eruption of the first tooth or by age one?

by

Heather K. Blair, RDH

BS, Vermont Technical College, 2011

Thesis Submitted in Partial Fulfillment

of the Requirements for the

Master's Degree in Public Health

Concordia University

October 2015

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Abstract

This systematic review evaluates the effectiveness of the current recommendation that the

first oral health visit occur six months after the eruption of the first tooth or by age one.

Early childhood caries is defined as dental decay before age 6. Early childhood caries is

an epidemic, which is a public health concern due to the growing prevalence within the

United States. Approximately 28% in 2004, which was a 4% increase from 1994. This

study will evaluate whether the recommended preventive visit by age one helps to lessen

the incidence of early childhood caries, by addressing questions such as: the risk factors,

how parent/guardian education impacts preventive care appointments, the most common

barriers to accessing preventive dental care, what the incidence of dental surgeries area

associated with early childhood caries and what the history has indicated as the trend for

early childhood caries.

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Introduction to the Study

These days it is not uncommon to hear a colleague, friend, family member or

child complain about having to go to the dentist to have a filling. For many people their

six month routine preventative care (dental prophylaxis) visit, is not their only routine

appointment.

Problem Statement

Many people, especially children have an oral disease – Dental Caries (Tinanoff,

Kanellis, & Vargas, 2002). Dental caries affects 60 – 90% of children (Yokoyama et al.,

2013). In children ages 0 -5, this form of dental caries is referred to as early childhood

caries. Dental caries is the most common chronic infectious disease of childhood, it is

five times more prevalent than asthma and seven times more prevalent than hay fever

(Benjamin, 2010).

Early childhood caries is considered a serious public health problem in both

developing and industrialized countries (Colak, Dulgergil, Dalli & Hamidi, 2013). It can

have a long-term effect on those it touches, children may experience dental pain, tooth

loss, impaired growth, decreased weight gain, delayed speech, negative appearance and

self-esteem, decreased school performance, school absences, and a negative quality of

life (Chou, Cantor, Zakher, Mitchell & Pappas, 2013). It could ultimately result in the

potential for loss of life, if untreated infection progresses, as in the case of Deamonte

Driver (Gavett, 2012). Early childhood caries may predict future dental health, as the

biggest predictor for future oral disease is a history of oral disease. According to

Kagihara, Niederhauser & Stark (2009), there has been an increase of 15.2% in children

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aged 2-5 years old from 1994 and 2004, and in preschool children more than one in four

experienced early childhood caries.

In both the general public and the health industry there seems to be confusion

regarding the age of the first preventive dental appointment. There are many reasons for

this: lack of insurance or funding, oral health awareness of the parent/caregiver, no

referral from the pediatrician, lack of access to dental care or dentists not taking children

under a certain age, and no transportation. Many professional organizations recommend

the first dental visit at age one or six months after the eruption of the first tooth, these

include the American Dental Association, American Academy of Pediatrics Dentistry,

and the American Academy of Pediatrics.

The goal of my systematic review is to provide a summary of the evidence-based

research that evaluates the current recommendation that the first oral health visit occur

six months after the eruption of the first tooth or by age one.

Purpose Statement

The purpose of my systematic review is to provide a summary of the evidence-

based research that evaluates the current recommendation that the first oral health visit

occur six months after the eruption of the first tooth or by age one.  This review will

evaluate the prevalence, incidence of early childhood caries, along with the, benefits and

any drawbacks associated with this visit.

Research Questions and Associated Hypotheses

What are the risk factors associated with Early Childhood Caries?

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How does education of the parent/guardian impact early preventive dental

care?

What are the barriers to obtaining early preventive dental care?

What is the incidence of dental surgeries for Early Childhood Caries?

What has the history shown for prevalence of Early Childhood Caries in

recent years?

These questions are designed to provide evidence to support the hypothesis that

early preventive dental visits will lessen the incidence of early childhood caries.

Potential Significance

As previously discussed, early childhood caries is the most common chronic

multifactorial infectious disease of childhood that affects many children.  This is at the

cost of the child’s oral health, emotional health, possibly systemic health and potentially

future oral health.  However, there is a monetary cost associated with these interventions,

according to the Burden of Oral Disease in Vermont 2013, Expenditures for dental

services in the United States in 2003 were $74.3 billion, 4.4 percent of the total spent on

health care that year.  In Vermont, 2010 health care expenditures totaled $4.93 billion;

dental services accounted for 4.3 percent of the total, or $214 million.  Medicaid claims

for restorations (fillings), extractions, and endodontic treatment (root canal) for children

ages 0 – 5 in 2009, totaled 2,201.  The total cost to the Medicaid program was 2.2 million

dollars, with an average per child cost of $1004 for restorative care and the maximum

cost for an individual child totaling $10,126.  This is just a small sampling of what the

cost of oral health care can be.  This is an indication that in addition to the physical,

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emotional and mental toll that oral disease can take on a child and family, it can also have

a significant financial impact.  Which makes the early preventive dental visit worthy of

evaluation.

Background Literature Review

Search Strategy

A comprehensive literature search was conducted using PubMed, American

Dental Association, Academic Search Premier and CINHAL to identify relevant

published studies. The search terms/phrases that were used included: oral health, dentists

treating young children, age one dental visit, infant oral health, effects of early dental

visits, early preventive dental visit, and age one dental visit. There was a limit place on

language – English only. No limit was placed on country, however most articles were

from the United States. The dates included studies within the last 15 years. The

inclusion criteria focused on a study population of children ages 0 – 6 years old, dental or

medical appointments in which oral health was discussed, oral health interventions for

young children, and study outcomes – relating to oral health. The exclusion criteria was

limited to studies in other languages.

Theoretical Foundation

Health Belief Model

The Health Belief Model (HBM) will be used to exam and encourage people to

develop a routine of early preventive dental visits to lessen the incidence of early

childhood caries. DiClemente, Salazar & Crosby (2013), discuss the Health Belief

Model noting that it has been part of the public health practice for over 50 years and was

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“initially used to identify determinants of being screened for tuberculosis” (p. 86).  The

HBM was developed in the 1950s in response to people failing to adopt disease

prevention strategies with the emphasis on these six areas: perceived susceptibility,

perceived severity, perceived benefits, perceived barriers, cue to action, and self-efficacy

(BUSPH, 2013). The HBM is successful when a person feels that a negative health

consequence can be avoid is a positive action is taken (an early preventive dental visit)

(ReCAPP, 2015). This is a value-expectancy model in which people must feel that

adopting the new behavior will out weight the negative risk or perceived threat of not

adopting the behavior or the perceived barrier to the risk (Riverside Community Health

Foundation, n.d.).  Health belief theories allow for insight into the multiple factors that

influence health behaviors, whether they are negative behaviors or positive changes to

improve personal or community health.

Applying the Health Belief Model to the question (How does early preventive

dental care impact the incidence of early childhood caries?) a qualitative study comes to

mind to assess parental knowledge regarding the benefits of preventive oral health care at

a young age.  If parents knew that early childhood caries is an infectious disease that has

the potential to being when teeth begin to erupt and is the most common chronic

childhood disease, which can lead to pain, interfere with ability learn, and could

potentially lead to death if left untreated with an acute infection (AAPD, n.d.).  Then they

may be more apt to take their children for preventive care, as they would not want them

to develop caries – have acute tooth pain, affect their ability to learn and potentially set

them up for life long oral health problems (Chou, Cantor, Zakher, Mitchell & Pappas,

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2013).  Early childhood caries is not a normal part of childhood, the HBM is a

mechanism to have people weight the risk of not having early preventive dental visits.

With education, support from their healthcare providers and method of payment (private

insurance, Medicaid, or private pay) then parents may increase their likelihood of

scheduling that early appointment.

Literature Review

The next three paragraphs will briefly review outcomes of interest, the

interventions or exposures and relationships among studies.

As previously noted Early Childhood Caries is the most common, chronic,

infectious disease in childhood and there are many interventions that have been

introduced to help combat this disease. One suggested intervention would be to have

primary care providers develop a strong foundation for the dental caries process, which

would include both enamel demineralization/remineralization, as well as how to prevent,

identify and refer for early intervention (Kagihara, Niederhauser & Stark, 2008).

Another intervention could be to introduce motivational interviewing with mothers of

young children to evaluate whether or not there would be a decrease in early childhood

caries and an increase in early preventive dental visits (Manchanda, Sampath & De

Sarkar, 2014). Lastly, a final intervention could be a computer simulation model which

identifies by geographic area which areas to focus on based on surveys from parents and

Medicaid insurance claims (Hirsch, Edelstein, Frosh & Anselmo, 2012). The potential

interventions could have a positive impact on the oral health of the children in the

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communities that are served. These interventions and others have noted both positive and

negative results in their outcomes in lessening the incidence of early childhood caries.

Interventions and exposures are a method to let the study investigators know

whether or not the outcome made a positive impact or not. A study by Plutzer & Keirse

(2014), found that providing first-time mothers with instruction on the prevention of early

childhood caries had a positive effect by increasing personal oral health and decreasing

dental service expenditures over time. A surprising outcome in a systematic review by

Chou, Cantor, Zakher, Mitchell & Pappas (2013), revealed that there was no conclusive

evidence that primary care providers that were doing oral health screenings had an effect

on the reduction of early childhood caries, although they did find a correlation between

topical fluoride application and lessened dental caries. In the final study that reviewed

outcomes, it focused on the small town of Chelsea, MA and found that there were many

factors that facilitated early childhood preventive visits and that there were some

significant barriers that influence the perceived inability to make and attend these

appointments. Within all these studies there are both positive results noted and negative

results that help to further develop more interventions that could be studied. These

outcomes will help begin the discussion on the relationships between programs and

their outcomes.

The relationships or correlations that are recognized as a result of a good study

can be very beneficial to shaping the future of early childhood caries. There are times

when it is not the desired health response that is the most motivating part of a study,

rather it is a benefit that is a result of the desired health response, such as a noted

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reduction in the cost of dental care for children due to early preventive care (Savage, Lee,

Kotch & Vann, 2004). In North Carolina, there was an oral health program developed to

focus on preschool aged children which was integrated into primary care medical offices

and was successful in the reduction of dental caries in the targeted vulnerable population,

indicating that oral health could be addressed in a medical setting with a specific program

to target a specific population (Achembong, Kranz, & Rozier, 2014). In a systematic

review with a focus on the importance of early preventive dental visits from a young age,

found that there was a positive relationship noted for visits under age 3, however they

could not find significant evidence to support the age 1 visit, but further recommended

that more research is warranted (Bhaskar, McGraw & Divaris, 2014). These studies all

show a correlation with their topic of study and a decrease in the incidence of early

childhood caries. The relationships that are developed during the span of the studies and

correlation with lessening, maintaining or increasing early childhood caries have the

potential to change the standard of recommended oral health care.

Methods

This systematic review will be conducted in a manner to determine the whether

there is an oral health benefit in children attending early preventive dental. The use of a

systematic review will be to provide a comprehensive review of current literature on

early preventive dental visits and their impact on oral heath in an effort to answer the

proposed research questions, by combining the results of the reviewed studies. The

review of current literature will determine the answer for the hypothesis: If children are

exposed to early preventive dental visits, they will have better oral health. The null

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hypothesis would then be that early preventive dental visits have no effect on the oral

health of children.

Inclusion and exclusion criteria

Please refer to Table 1 for a list of inclusion and exclusion criteria.

Table 1

Inclusion/Exclusion Criteria

Inclusion Criteria Exclusion CriteriaPopulation: Children under age 6English language articlesFull text availablePeer reviewed study articlesArticles written in years 2010-2015Human studies

Non-English language articlesStudy articles written prior to 2010

Please refer to Table 2 for the results of the electronic search

Table 2

Electronic Search Results

Search Engine Used

Search Terms Number of Studies identified

Number of Studies Excluded

Exclusion Criteria Used

Academic Search PremierBoolen/Phrase

Early Childhood Preventive Dental VisitAnd age onePeer-ReviewedFull Text

9 6 Not AnimalEnglish OnlyPrior to 2000

CINAHLBoolen/Phrase

Early Childhood Preventive Dental Visit

2 0 Not AnimalEnglish OnlyPrior to 2000

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And age onePeer-ReviewedFull Text

PubMedBoolen/Phrase

Early Preventive Dental VisitAnd age onePeer-ReviewedFull Text

18 12 Not AnimalEnglish OnlyPrior to 2000

Number of duplicate articles: 2

Data analysis plan

At the completion of performing a literature review, there were twenty-nine

articles using the electronic search using three different search engines. After removing

two articles that were duplications between the three search engines, there were twenty-

seven left to screen. Of these articles, eighteen were then excluded, as they did not fit the

search guidelines and were article that had results for adults or for other diseases, some

just focused on pregnant mothers prior to birth and others only looked at older children.

Please refer to Figure 1 for the results of inclusion and exclusion criteria.

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Figure 1. Results of Inclusion and Exclusion Criteria.

Quantitative Studies (n=8 )

Studies included in systematic review (n =9)

Qualitative Studies (n=1) (n1)11)

Full-text articles assessed for eligibility (n = 9)

Records excluded(n = 19)

Records screened(n = 28)

Records after duplicates removed(n = 2)

Additional records identified through other sources (n = 1)

Records identified through database searching (n = 29)

Full-text articles excluded, with reasons

(n = 0)

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Table 3 (A demonstration of how results will be presented)

Included Studies and Effects

Author(s) and Year

Research Design

Main Argument/ Hypothesis

Key concepts/ assumptions

Results

Bhaskar, McGraw, Divaris, 2014

Bisakha, Blackburn, Morrisey, Kilgore, Becker, Caldwell, Menachemi, 2015

Systematic Review

Econometric Cohort Study

Review of the early preventive dental visits and whether there is a correlation with less dental disease.

Early preventive dental visits are considered important there is little information available to support this.

Dental caries is the most common chronic childhood disease. The standard of care is a visit by age 1.

Some studies have shown an increase in restorative care that is associated with early preventive dental visits. Other studies show a decrease in the amount spent on restorative care and an increase spent on preventive

The recommendation for the year 1 visit is weak. Recommends more research.There are benefits noted of an exam before age 3 for children at high risk. There is a link between early preventive dental visits, being associated with more preventive visits and may be associated with reduced restorative visits, lessening expenditures.

The results of the study found that children that had early preventive visits had less nonpreventive dental visits and more preventive dental visits.There is a feeling that this improves the quality of life, due to less oral health problems. The study also found a need for continued research in this area.

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Savage, Lee, Kotch,Vann, 2004

Longitudinal cohort study

Determine how early preventive dental visits impacted the costs of dental services among pre-school aged children

care for those that have had early preventive visits.

There is evidence that supports the reassessment of strategies for high-risk preschool aged children. Early childhood caries is a disease that is on the rise and with it are the rise costs associated with the restoration of the teeth affected.

Medicaid children that utilized the early preventive dental visit model were associated with less cost for oral health care and had more preventive care appointments. Although it was noted that children from minorities had greater difficulty in finding a dental home and those in counties with fewer dentists had difficulty accessing care.

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References

AAPD.  (n.d.).  Early Childhood Caries.  Retrieved from http://www.mychildrensteeth.org/assets/2/7/ECCstats.pdf

Achembong, L. N., Kranz, A. M., & Rozier, R. G. (2014). Office-based preventive dental program and statewide trends in dental caries. Pediatrics, 133(4). Doi:10.1542/peds.2013-2561

Benjamin, R. M. (2010). Oral Health: The Silent Epidemic. Public Health Reports,125(2), 158–159.  Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821841/

Bhaskar, V., McGraw, K. A., & Divaris, K. (2014). The importance of preventive dental visits from a young age: systematic review and current perspectives. Clinical, Cosmetic and Investigational Dentistry, 6. http://dx.doi.org/10.2147/CCIDE.S41499

Bisakha, S., Blackburn, J., Morrisey, M. A., Kilgore, M. L., Becker, D. J., Caldwell, C., & Menachemi, N. (2013). Effectiveness of preventive dental visits in reducing nonpreventive dental visit and expenditures. Pediatrics, 131(6). doi: 10.1542/peds.2012-2586

BUSPH. (2013). The health belief model. Retrieved from http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-Models2.html

Chou, R., Cantor, A., Zakher, B., Mitchell, J. P. & Pappas, M.  (2013). Preventing dental caries in children <5 years: systematic review updating USPSTF recommendation.  Pediatrics, 132(2), 332-350.  doi: 10.1542/peds.2013-1469

Çolak, H., Dülgergil, Ç. T., Dalli, M., & Hamidi, M. M. (2013). Early childhood caries update: A review of causes, diagnoses, and treatments. Journal of Natural Science, Biology, and Medicine, 4(1), 29–38. doi:10.4103/0976-9668.107257

DiClemente, R. J., Salazar, L. F., & Crosby, R. A. (2013). Health Behavior Theory for Public health. Burlington, MA: Jones & Bartlett Learning

Gavett, G.  (2012). Tragic results when dental care is out of reach.  Frontline.  Retrieved from http://www.pbs.org/wgbh/pages/frontline/health-science-technology/dollars-and-dentists/tragic-results-when-dental-care-is-out-of-reach/

Hirsch, G. B., Edelstein, B. L., Frosh, M., & Anselmo, T. (2012). A simulation model for

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designing effective interventions in early childhood caries. Preventing Chronic Disease, 9. Doi.org/10.5888/pcd9.110219

Isong, I., Dantas, L., Gerard, M. & Kuhlthau, K. (2014). Oral health disparities and unmet dental needs among preschool children in Chelsea, MA: exploring mechanisms, defining solutions. Journal of Oral Health & Hygiene, 2. doi: 10.4172/2332-0702.1000138

Kagihara, L. E., Niederhauser, V. P. & Stark, M.  (2008). Assessment, management, and prevention of early childhood caries.  Journal of the American Academy of Nurse Practitioners, 21.  doi/10.1111/j.1745-7599.2008.00367.x

Manchanda, K., Sampath, M., & De Sarkar, A. (2014). Evaluating the effectiveness of oral health education program among mothers with 6-18 months children in prevention of early childhood caries. Contemporary Clinical Dentistry, 5(4). Doi:10.4103/0976-237x.142815.

Nursing Theories.  (2013). Health belief model.  Retrieved from http://currentnursing.com/nursing_theory/health_belief_model.html

Plutzer, K., & Keirse, M. J. N. C. (2014). Influence of an intervention to prevent early childhood caries initiated before birth on children’s use of dental services up to 7 years of age. The Open Dentistry Journal, 8. doi: 10.2174/1874210601408010104

ReCAPP. (2015). Theories & approaches health belief model. Retrieved from http://recapp.etr.org/recapp/index.cfm?fuseaction=pages.theoriesdetail&PageID=13#definition

Riverside Community Health Foundation. (n.d.). Theories and models frequently used in health promotions. Retrieved from http://www.engage.cune.edu/learn/pluginfile.php/35603/mod_forum/intro/theories-and-models-frequently-used-in-health-promotions.pdf

Savage, M. F., Lee, J. Y., Kotch, J. B. & Vann, W. F. (2004). Early preventive dentalvisits: effects on subsequent utilization and costs. Pediatrics, 114(4). doi: 10.1542/peds.2003-0469-F

Tinanoff, N, Kanellis, M. J., & Vargas, C. M. (2002). Current understanding of the epidemiology, mechanisms, and prevention of dental caries in preschool children. Pediatric Dentistry, 24:6, 543-549. Retrieved from http://www.aapd.org/assets/1/19/Tinanoff11-02.pdf

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Yokoyama, Y., Kakudate, N., Sumida, F., Matsumoto, Y., Gilbert, G. H., & Gordon, V. V., (2013). Dentists’ dietary perception and practice patterns in a dental practice-based research network. PLOS ONE, 8(3), 1-6. Doi:10.1371/journal.pone.0059615

VDOH.  (2013).  Burden of oral disease in Vermont 2013 [PDF Document].  Retrieved from http://healthvermont.gov/family/dental/documents/burden_of_oral_disease.pdf