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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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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

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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

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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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