At the September, 2007 Early Childhood Caries (ECC) conference in Calgary, AB, health practitioners heard a clear message from Canadian paediatric dentists: The prevalence of ECC is not decreasing, and ECC is now present in all strata of society, not just high risk groups.
ECC is the most common infectious disease in children. It is a form of tooth decay that develops on teeth shortly after they erupt into the mouth, and its risk factors are present well before tooth eruption. ECC is a serious condition with many consequences. It is painful, can lead to serious infection requiring hospitalization, eating difficulties and numerous other dental and social problems. When one considers that we are dealing with a problem that is largely preventable and that has known risk factors, one wonders why the prevalence of the disease cannot be reduced.
In any given year for example, there are more cases of ECC in First Nations children than there are cases of notifiable diseases (rubella, measles, chicken pox, pertussis) among all children in Canada. First Nations communities have been reported as having ECC prevalence rates between 32 and 79 percent. High prevalence rates are also noted in immigrant and refugee populations and in children from lower socioeconomic backgrounds.
Provincial reports confirm the national situation. Over a given period in Newfoundland and Labrador, dental caries was the second most frequent treatment category for day surgery where 60 percent of the cases were children, many 0 - 4 years of age. Similarly, in Quebec, it was noted that 39 percent of emergency visits in Montreal Children's Hospital were due to dental disease, 70 percent of these visits involving children five years or younger. In Ontario, a study of 5-year old Toronto children showed that 9.6% had a record of ECC. In the late 1990s, dental treatment was further identified as the most common surgical procedure for children in British Columbia hospitals.
What is particularly concerning about this problem is the potential for the current situation to worsen. As reported by the Centers for Disease Control, when caries rates of children aged two to five years are compared in the United States between 1988 to 1994 and 1999 to 2004, there appears an increase from 24 to 28 percent.
It is easy to get caught up in the statistics of this disease and forget that behind these numbers are real children and their families. Unfortunately, many will find themselves in hospitals for treatment by paediatric dentists. Dr. Ross Anderson is one of these paediatric dentists. He is the Chief of Dentistry at the IWK Health Centre, a children's hospital in the Maritimes and has had many experiences treating ECC. He recalls one day in an operating room at the children's hospital in Halifax:
"My first case of the day was a 4-year-old autistic boy who would bang his head against the fridge until his mom gave him apple juice which he would sip all day. The bacterial plaque on his teeth was so thick that his teeth looked like petri dishes.
The next two children I saw were 18 and 24 months old and both were sippy cup juice junkies. They had no major medical comorbidities, but were sick from their abscessed baby teeth. One parent knew something wasn't right when they noticed chalky areas on the front baby teeth that were quickly turning brown. They told me that they had called several dental offices, but were told 'we do not see children until age three.' The parents then went to their family doctor who recognized the problem and referred the child to the hospital.
My last case of the day involved placing eight stainless steel crowns on a 3-year-old Aboriginal boy with Severe Early Childhood Caries (S-ECC).
It is frustrating having to do damage control on children who have suffered pain and infection, knowing that this disease is mostly preventable.
This story is not unique; it is occurring every day in dental offices and operating rooms across Canada. Preliminary data from the National Wait List study is showing that paediatric dentistry has some of the longest wait lists in Canada. This dismal reality leaves many children in pain due to infection and can cause unnecessary tooth loss and spacing issues, much less, the as of yet unmeasured economic burden on the health care system and on Canadian society.
It is surprising that in spite of its successes, our dental care system is largely unprepared to deal with ECC. The simplest reason is that the disease tends to develop well in advance of a child's first dental visit. To be sure, the current system works for many Canadians and their families. For example, approximately 70% of Canadians visit the dentist every year and almost 85% of Canadians report their oral health as good to excellent. In addition, about 85% of Canadians access the services through employment based insurance or personal financing, and another 74% report that they can afford the dental care that they need.
Yet despite of these positives, there remains an estimated 10 to 20% of Canadians where the situation is difficult. So in effect, in addition to having higher levels of dental disease, many Canadian children are left with limited or no access to oral health care as well.
Clearly, we need to think "outside the box" if we are to try to address this problem. There are many opportunities to address ECC from a public policy perspective. There are examples where the public financing and delivery of dental care for children is legislated through health protection and general health insurance Acts (i. e., Ontario and Quebec). In addition, both Federal and Provincial/Territorial Governments in partnership with providers, clients and other stakeholders have attempted to focus their efforts on a health promotion/disease prevention approach. Health Canada, for example, has worked closely with First Nations organizations to introduce the Children's Oral Health Initiative which emphasises early screenings, fluoride varnish applications, sealants and promotion of positive health practices. Use of non-dental service providers (e. g., Community Health Representatives) supported by dental professionals also occurs in many isolated and non-isolated communities.
In the US, some interesting examples exist as to how already stretched dental human resources are using other health care providers to assist in addressing the problem. In a collaborative association between the American Academy of Paediatrics (AAP) and paediatric dentists in a southern US State, a program provided by nurses in paediatrician's offices involving assessment, fluoride varnish, health promotion and referral to a dental home when appropriate has resulted in a 40 percent reduction in anterior caries in some locations. Each patient is assigned a dental home and referral from the paediatrician occurs upon agreement between the paediatrician and a dentist. Dental caries has now been added as an infectious disease in the AAP Handbook, and along with immunization, obesity and mental health, oral health has been identified as a top priority of the AAP. In Canada, although our paediatricians are already overstretched, primary care providers such as general practice physicians, nurses, pharmacists and others could act as agents of awareness, prevention and referral.
As a dental profession, we have a responsibility to help each child reach their full potential in life. We need to learn how to apply the American Academy of Paediatric Dentistry's Caries Risk Assessment tool to positively predict and identify those children at one year of age who will have ECC by three. We need to promote lines of communication between the dental and medical communities. Children need us as their advocates and we can assist their parents to make choices that can prevent this disease from developing. As an individual practitioner, please ask yourself what you and your primary health care team can do to help reverse the trend? As a dental student, please take the time to learn about ECC and its effect on children. As a member of the dental profession, please ask yourself how we can move forward to improve the lives of many Canadian children and their families?
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Images courtesy of Dr. Ross D. Anderson.
Ross D. Anderson, DDS, D. Paed., MSc., FRCD(C) Chief of Dentistry IWK Health Centre Assistant Professor and Head, Division of Paediatric Dentistry, Faculty of Dentistry, Dalhousie University.
Peter Cooney, BDS, LDM, DDPH, MSc, FRCD(C) Chief Dental Officer, Canada Office of the Chief Dental Officer Health Canada.
Carlos R. Quiñonez DMD MSc., Doctoral and Specialty Candidate (Dental Public Health) Canada Graduate Scholar (Social Science & Humanities Research Council of Canada), Community Dental Health Services Research Unit Faculty of Dentistry, University of Toronto.
Oral Health welcomes this original article.
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ECC is
the most common infectious disease in children