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Prevalence of dental caries and dental care utilisation in preschool urban children enrolled in a comparative-effectiveness study.

Introduction

Dental caries remains the most common chronic childhood disease in the USA despite the fact that it can be prevented. Data from the 1988-1994 National Health and Nutritional Examination Survey (NHANES III, 1988-1994) show that the prevalence of dental caries in the primary dentition of 2 to 5 year old American children was 24% [CDC, 2005]. More recent NHANES data released in 2007 by the Centres for the Disease Control and Prevention (CDC) show that the prevalence of caries in the primary dentition of USA children is on the rise. Almost 28% of 2 to 5 year old of those children were classified as having caries experience in the primary dentition [Dye et al., 2007]. Dental care continues to be the most unmet health need among American children, especially among poor and minority children [Newacheck et al., 2000]. More than 70% of carious surfaces in the primary dentition of the 2-5 year old USA children remain untreated as presented in the 1999-2004 NHANES analysis [Dye et al., 2007].

Early childhood caries (ECC), as defined by the American Academy of Pediatric Dentistry (AAPD), is the presence of one or more decayed, missing, or filled tooth surfaces in a child 71 months of age or less [AAPD, 2004]. ECC has been related to failure to thrive, decreased capability to study, increased risk of caries development in the permanent dentition and an increase in the possibility of enamel defects on the successors of carious primary teeth [Gray et al., 1991; Acs et al., 1999; Broadbent et al., 2005]. Studies are warranted to examine different modalities that may reduce or eliminate barriers to optimal oral health and that improve oral health care utilisation by USA preschool children.

In our previous studies, we evaluated the sensitivity and specificity of teledentistry examinations vs. visual/tactile examinations and the feasibility of using this technology for dental screening of preschool children. We also assessed caries prevalence by means of teledentistry screening in preschool children. [Kopycka-Kedzierawski et al., 2007; Kopycka-Kedzierawski et al., 2008]. The sensitivity of the teledentistry examinations was 100% and specificity was 81% versus traditional oral dental exams. The kappa statistic between traditional oral dental examinations and teledentistry examinations was 61, suggesting a good agreement between the two examination modalities.

The mean dfs scores for the teledentistry images and the visual examinations were not statistically different, indicating that teledentistry would be a useful tool for dental screening of young children in childcare centres for early signs of caries activity, especially ECC.

The purpose of this study was to assess dental caries prevalence and dental care utilisation in 12-60 month old pre-school children enrolled in urban childcare in Rochester, New York who participated in a comparative-effectiveness study.

Materials and Methods

Study Population. A study sample of 234 preschool children, 12-60 months of age, was drawn from a cohort of nearly 600 children that were available in 2008-2009 and attended urban childcare centres located in the northeast quadrant of the city of Rochester, New York. The selection of the six childcare centres was based on their participation in health-e-access, a telemedicine project, conducted by the Department of Paediatrics, University of Rochester, School of Medicine and Dentistry.

Our sample size was limited to the children whose parents agreed to participate in the study, provided informed consent and completed the questionnaire. The majority of study participants were African-American and Hispanic children; only a few children were Caucasian or children of mixed race/ethnicity. Children enrolled in our study lived in the most impoverished areas of the city of Rochester, often referred to as the 'inner-city'. We powered the study based on whether or not each child had any utilisation of dental services from baseline to the 12th month of follow-up. A two tailed chi-square test for proportion was used to detect a 20% difference with 80% power and a p < 0.05 level of significance. The proportion that gave the largest sample size showed that 98 children per group were needed. After taking into account an estimated 30% attrition rate, 128 children per group were recruited.

Informed Consent. The University of Rochester Medical Center research subject review board (RSRB) approved the study prior to its initiation. Informed consent was obtained from parents of participating children prior to the study. Children older than one-year of age and younger than six years of age, regardless of gender, ethnic origin or race, were eligible to participate in the study. There were no other exclusion criteria.

Randomisation Procedures. After the parent or guardian signed the consent form, each child was randomly assigned to the control (clinical) or the experimental (teledentistry) arm. A computerised uniform random number generator was utilised to allocate children to the clinical or teledentistry arm.

Examination Procedures. The clinical oral exams were performed at the six childcare facilities selected for the study by a calibrated paediatric dentist. All examinations were conducted in an assigned examination room. Examinations were scheduled to fit each childcare centre's routine, usually after breakfast during playtime. Fibre optic lights, plane mirrors, and No 23 piano-wire explorers were used to conduct the clinical examinations. The explorer was used only to clean the tooth surface as necessary and was not used to probe the tooth or tooth surfaces. Radiographs were not used. As such, inter-proximal caries was assessed based on clinical examinations and teledentistry intra-oral images.

Teledentistry examinations were performed at the six childcare facilities selected for the study. A trained telehealth assistant (TA) conducted these examinations in the telemedicine examination room. The Dr. Camscope intra-oral camera (Sometech Inc, Seoul, South Korea) was used to provide images of the oral hard tissues. Six images of the labial/buccal and occlusal surfaces of each child's teeth were recorded, including two anterior and four posterior views. Additional views of the posterior buccal/facial surfaces and anterior/posterior lingual surfaces were obtained, as necessary. The images of the children's teeth were entered into the secure web database immediately after each screening was completed. The teledentistry dental examiner at the Eastman Institute for Oral Health, formally the Eastman Dental Centre (EDC) had password secure access to the images stored in the database. A dedicated computer at the remote site (EDC) with the appropriate software program was used to view the images. A general dentist who was calibrated in the same manner as the clinical caries examiner, i.e., by the gold standard caries examiner, scored the teledentistry images. To assess reliability of the clinical exams and teledentistry exams, kappa was calculated. The intra-observer agreement was assessed based on clinically re-examining a selected subsample (5%) of children and a blinded re-reading of a randomly selected subsample (5%) of the stored images. Both examiner's reliability scores were excellent (kappa statistic was 93% and 87% respectively).

The imaging protocol and the intra-oral camera specifications have been described elsewhere [Kopycka-Kedzierawski and Billings, 2006]. The TA assistants underwent training to learn the proper technique for obtaining intra-oral images. They practiced on a typodont first and subsequently on adult volunteers until they became proficient in obtaining intra-oral images. A powerpoint demonstration module was presented to the TA's to display healthy dentition, first signs of ECC and severe ECC. The telehealth assistants provided educational counselling to the parents of children in both the experimental and control arms along with providing referrals to parents of all participating children.

Referrals were generated immediately in both arms of the study; i.e. in the control group after completion of the examination and the experimental group after completion of the teledentistry examination. The TA's were also responsible for providing colour printouts of teeth with untreated caries to parents in the experimental arm.

Caries Measurement. Decayed and filled surfaces (dfs) were recorded on individualised pre-labelled caries exam forms. The most recent definition of ECC was used for this study [AAPD, 2004]. ECC was defined as the presence of a white spot lesion(s) and or cavitated lesion(s) on any primary tooth.

Questionnaires. The purpose of the questionnaires used in this study was to gather demographic information from the parents/guardians of participating children and to obtain information about dental and medical utilisation patterns. The following components were included in the questionnaire: demographics, including age, gender, race, ethnicity, education, employment, occupation, residence area (postal codes) and family income; dental and medical use survey, including past 12 months dental and emergency room care utilisation, difficulties in obtaining needed dental care, parents readiness to change with regard to dental care for their child or children, emergency dental and medical care utilisation, and parent' self-perceived dental treatment needs.

Data Analysis. Mean caries scores were calculated based on age, gender and ethnicity and the examination modality. Questionnaires were analysed using descriptive statistics. Bivariate analyses were conducted using the Fisher's exact test. The Wilcoxon Mann-Whitney test and the Kruskal-Wallis test were used to assess statistical differences (p was set at 0.05). Data were managed and processed by means of SAS statistical package, version 9.2 (SAS Institute Inc, Cary, NC).

Results

Of 234 children examined, 66 (approximately 28%) had caries experience in the primary dentition. The mean dfs score for all the children was 1.56 (SD [+ or -] 4.15) with a range of 0-34 carious surfaces. The mean dfs score for the children examined by means of teledentistry (n=108) was 1.75 (SD [+ or -] 4.25) and for the children examined by means of the traditional visual/tactile method (n=126), the mean dfs was 1.40 (SD [+ or -] 4.07); the means between the two groups were not significantly different (Wilcoxon Mann- Whitney test, p>0.05). Approximately 27% of the children were classified as having caries experience by means of the visual/tactile exams and 29% of the children were classified as having caries experience by means of teledentistry exams.

Overall, African-American children (n=153) had the highest mean dfs score of 1.86, followed by Hispanic children (n=42, dfs=1.64), Caucasian children (n=19, dfs=0.53) and children of mixed race/ethnicity (n=20, dfs= 0.15); the means among the different ethnic groups were not statistically significant (Kruskal-Wallis test, p-value>0.05). Females had a higher mean dfs score (n=121, dfs=1.97, SD [+ or -] 5.20) than males (n=113, dfs=1.13, SD [+ or -] 2.54); the means between girls and boys were not significantly different, (Wilcoxon Mann- Whitney test, p>0.05).

As would be expected, children 5 years of age were found to have the highest mean caries scores followed by children 4 years of age, 3 years of age, 2 years of age and 1 year of age (Table 1). Differences based on age were statistically significant (Kruskal-Wallis test, p-value <0.0001).

Twenty-six children (approximately 39%) out of 66 children with caries experience showed evidence of being treated for caries.

Results of the questionnaires are presented in Tables 2 and 3. The majority of respondents were females (93%). Seventy six percent of respondents identified themselves as African-Americans, 21% as Whites and 3% as Native Americans; 27% were found to be Hispanic and 73% non-Hispanic. Based on the bivariate analyses, conducted using the Fisher's exact test, more parents in the clinical arm identified themselves as Hispanic than parents in the teledentistry arm, (p=0.03, Fisher's exact test).

Self-reported oral health status of parents in the clinical arm was statistically significantly different from parents in the teledentistry arm (p=0.04, Fisher's exact test). As presented in Table 2, the remaining variables, as reported by parents in the teledentistry and clinical arms, were not significantly different. Approximately 64% of respondents were currently employed. Only 15% of the parents were married, 74% were single, 9% were divorced or separated and 2% identified themselves as 'other'. Seventy percent of respondents stated that their yearly family income was less than $20,000, suggesting that the majority of children who were enrolled in the study live in an economically disadvantaged home environment. About 45% of adults stated in the questionnaire that they had not had a routine dental visit in the past 12 months. Interestingly, 88.6% of the respondents had dental insurance and of these, 53% reported that they currently need dental treatment.

Parents/guardians also answered questions about their children's dental status, current and past dental utilisation and future dental appointments. According to the parental responses 97% of the children had dental insurance; 68% had Medicaid, 12% had Child Health Plus and 17% of the children had other types of dental insurance. Medicaid is a USA government insurance program for children under the age of 19 years who are eligible for Medicaid coverage, based on their family's income. There is no cost or monthly insurance premium to the parents. Child Health Plus is a State insurance program for children under the age of 19 years whose family income exceeds the eligibility level for Medicaid. Depending on family income, there may be a small monthly insurance premium.

About 36% of the children had not had a dental visit in the past 12 months and 39% of the children had not had a routine check-up in the last 12 months. Although a majority of parents (92%) did not perceive accessing dental care for their children as a problem, almost 32% of the children had never visited a dentist. Variables that were significantly associated with having caries experience in the primary dentition were: having a problem to get care for your child (p=0.003); timing of the last dental check-up (p=0.04) and any dental work needed for a child (p=0.004) as presented in Table 3.

Discussion

Several risk factors have been identified for ECC, including dietary factors, excessive bottle use, poor oral hygiene, previous caries experience, microbiologic factors, socio-economic status, psychosocial factors, socio-cultural factors and utilisation factors [Broadbent et al, 2005; Tinanoff and Reisine, 2009]. In our study, approximately 28% of the children had caries experience in the primary dentition; these results are consistent with the NHANES 1999-2004 data on caries prevalence among 2-5 year old children, as almost 28% of 2-5 year old USA children were classified as having caries experience in the primary dentition [Dye et al., 2007].

Tomar and Reeves examined the improvement in US children's oral health and dental public health infrastructure since the Healthy People 2010 oral health objectives were issued [Tomar and Reeves, 2009]. According to their report, progress toward improving oral health in the USA during the last decade has been mixed. Although the oral health status of most American children improved in the last ten years, the prevalence of dental caries in the primary dentition of preschool children increased greatly [Dye et al., 2007; Tomar and Reeves, 2009]. Furthermore, the use of preventive dental services by low-income children stayed far below the 2010 target; it was estimated that only about 31% of low income children and adolescents received any preventive dental services in 2004.

Data from the parental questionnaires suggest that approximately 32% of the preschool children enrolled in this study had never visited a dentist. Almost 40% of the parents stated in the questionnaire that their children did not have a routine dental visit in the past 12 months and about 36% of the parents stated that their children did not have a dental appointment in the last 12 months. Although the majority of the parents did not report difficulties in accessing dental care for their children, more than 60% of the children with caries did not receive needed dental treatment.

Rochester is considered fortunate in the availability of dental resources for inner-city children. The EDC division of Paediatric Dentistry has a centrally located paediatric clinic located at EDC and the division of community dentistry has one school based clinic as well as three mobile clinics (Smilemobiles) that travel to several inner-city elementary schools during the school year. The Community Dentistry Clinics are mostly staffed by paediatric dentists and residents; yet urban preschool children enrolled in this study had a high proportion of untreated caries in the primary dentition. Based on the questionnaires, about 45% of parents enrolled children had not had a routine dental visit in the past 12 months and about 47% stated that their children needed dental treatment. About 44% of parents stated that their child's dental status was excellent and 33% of parents believed that it was very good. These facts are consistent with our clinical data, as approximately 28% of children had caries experience in the primary dentition. About 70% of the respondents stated that their yearly family income was less than $20,000. Based on the USA census, 42.8% of families in the northeast area of the City of Rochester live below the Government poverty level (postal codes 14605 and 14621) [USA census, 2010]. The national average of families living below the Government poverty level is 9.2%. Rochester ranks 12th per capita in child poverty nationwide, and has the second highest per capita poverty rate among all 720 school districts in New York State.

Our cross-sectional data suggest that new strategies are needed to improve utilisation of dental services among young, poor, inner-city children. As the children in this study will be re-examined 6 and 12 months after baseline, we plan to perform explanatory analyses to measure the relationship of utilisation of dental services by preschool children. Families with socio-economic and demographic factors, utilisation of medical services and perceived and actual need for dental treatment will be addressed. At baseline examinations the TA provided educational counselling to the parents of all participating children along with providing referrals for dental care as necessary or appropriate.

Two examination modalities were used in this study to assess caries prevalence and mean caries scores in the primary dentition of preschool, urban children: visual/tactile clinical examinations and teledentistry examinations. Our results indicate that both examination methods were comparable in caries diagnosis for both caries severity and caries prevalence. This suggests that screening young children for dental caries by means of teledentistry is as good as visual/tactile examinations. In a previous study, we evaluated the sensitivity and specificity of teledentistry examinations versus visual/ tactile examinations [Kopycka-Kedzierawski et al., 2007]. The sensitivity of the teledentistry examinations was 100% and specificity was 81%.

Teledentistry screenings may serve as an alternative screening modality in urban and rural areas where dental access is limited. Parents of children who were enrolled in the experimental (teledentistry) arm received colour printouts of their children's carious teeth with the referral form; our premise is that colour printouts will serve as a motivational instrument for parents of children examined by teledentistry and will change parents' readiness to take their child to the dentist. The follow-up examinations are currently being conducted to assess the full extent of teledentistry screening capability to enhance dental care utilisation, especially in families with evidence of limited oral health care utilisation. Subsequently, we will examine the cost-effectiveness of teledentistry for its utility as a potential screening tool by means of a cost-effectiveness analysis.

Conclusions

The data show that 28% of the children had caries and, of these, 61% had never been treated for caries, thus indicating that continued efforts are needed to improve oral health care utilisation by inner-city preschool children.

Acknowledgements

The study was supported by NIH/NIDCR K23 DE 017230.

References

Acs G, Shulman R, Ng MW et al. The effect of dental rehabilitation on the body weight of children with early childhood caries. Pediatr Dent 1999; 21:109-113.

American Academy of Pediatric Dentistry, Definition of Early Childhood Caries (ECC). In: Reference Manual Pediatric Dentistry 2004; 26: 13.

Broadbent JM, Thomson WM, Williams SM. Does caries in primary teeth predict enamel defects in permanent teeth? A longitudinal study. J Dent Res 2005; 84:260-264.

Centers for disease Control and Prevention (CDC). Surveillance for Dental

Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis-United States, 1988-1994 and 1999-2002. MMWR Surveillance Summaries Aug 26, 2005; 54:1-44.

Dye BA, Tan S, Smith V et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. National Center for Health Statistics. Vital Health Stat 2007; 11(248).

Gray MM, Marchment MD, Anderson RJ. The relationship between caries experience in deciduous molars at 5 years and in the first permanent molars of the same child at 7 years. Comm Dent Health 1991;8:3-7.

Kopycka-Kedzierawski DT, Billings RJ. Teledentistry in inner-city childcare centers. J Telemed Telecare 2006; 12: 176-181.

Kopycka-Kedzierawski DT, Billings RJ, McConnochie KM. Dental screening of preschool children using teledentistry: a feasibility study. Pediatr Dent 2007; 29:209-213.

Kopycka-Kedzierawski DT, Bell CH, Billings RJ. Prevalence of Dental Caries in early Head Start Children as Diagnosed Using Teledentistry. Pediatr Dent 2008; 30: 211-215.

Newacheck PW, Hughes DC, Hung YY et al. The Unmet Health Needs of America's Children. Pediatrics 2000; 105:989-997.

Tinanoff N, Reisine S. Update on Early Childhood Caries Since the Surgeon General's Report. Acad Pediatr 2009; 9:396-403.

Tomar SL, Reeves AF. Changes in the Oral Health of US Children and Adolescents and Dental Public Health Infrastructure Since the Release of the Healthy People 2010 Objectives. Acad Pediatr 2009; 9:388-395.

USA census.www.census.gov Accessed 10/13/2010.

D.T. Kopycka-Kedzierawski and R.J. Billings

Eastman Institute for Oral Health, University of Rochester, NY, USA

Postal address: Dr. D. T. Kopycka-Kedzierawski, University of Rochester, Eastman Institute for Oral Health, 625 Elmwood Ave, Box 683, Rochester, NY 14620, USA.

Email: Dorota_KopyckaKedzierawski@URMC.Rochester.edu
Table 1. Decayed and filled surfaces (dfs) for 234 children enrolled
in the study by age in Rochester (NY, USA)

Age           N    Mean   Std    Min   Max   95%     95%
                   dfs    Dev                LCL     UCL

1 year olds   37   0.03   0.16   0     1     -0.03   0.08
2 year olds   67   0.70   2.03   0     11    0.21    1.20
3 year olds   52   1.25   3.36   0     20    0.31    2.19
4 year olds   70   3.21   6.23   0     34    1.73    4.70
5 year olds   8    3.50   4.04   0     12    0.13    6.87

Kruskal-Wallis test, p<0.0001

Table 2. Parents-guardians demographics and dental-medical status
from the baseline questionnaire. Fisher's exact test: NS-non
significant in bivariate comparison with teledentistry and
clinical exam group; * statistically significant in bivariate
comparison with teledentistry and clinical exam group, P<0.05

Parents/Guardians                                   Clinical vs.
                                                    Teledentistry
                                                    Group. Bivariate
                                                    comparisons using
                                                    Fisher's exact test

Mean Age        27.6 years of age                   NS
                (SD [+ or -] 6.28) Min-Max 16-50

Mean of         2.35 (SD [+ or -] 1.41) Min-Max     NS
children        1-11

Gender          7% Male                             NS
                93% Female

Race/           76% A-American                      * P=0.03
Ethnicity *     27% Hispanic *
                21% White
                73% Non-Hispanic *
                3% American/Indian

Work Status     64% Currently employed              NS
                36% Currently unemployed

Education       5% Middle school                    NS
                41% High School
                22% More than High School
                29% College level
                3% Post graduate level

Marital         15% Married                         NS
status          74% Single
                9% Separated or Divorced
                2% Other

Income          70% $0-19.999                       NS
                21% $20,000-29,999
                9% $30,000-50,000+

Dental          61.1% Medicaid                      NS
insurance       27.5% Other
                11.4% No dental Insurance

Medical         63.1% Medicaid                      NS
insurance       31.6% Other
                5.3% No medical Insurance

Emergency       14% Yes                             NS
room visit in   86% No
the last 12
months

Routine         55% Yes                             NS
dental visit    45% No
in the past
12 months

Do you          53% Yes                             NS
currently       47% No
need any
dental work?

Your dental     13% Excellent                       P=0.04
health          22.5% Very good
status *        45% Good
                13% Fair
                6.5% Poor

Residency       90% City of Rochester               NS
status          9% Suburbs of Rochester
                1% Other

Table 3. Children's demographics and dental/medical status from
the baseline questionnaire.

Children                                       Bivariate
                                               comparisons with
                                               dfs variable using
                                               Fisher's exact test

Dental insurance       68% Medicaid            NS
                       12% Child Health Plus
                       17% Other
                       3% None

Medical                66% Medicaid            NS
insurance              14% Child Health Plus
                       19% Other
                       1% None

Emergency room         23% Yes                 NS
visit in the last 12   77% No
months

Dental                 64% Yes                 NS
appointment            36% No
in the last 12
months

Routine dental         61% Yes                 NS
visit in the past      39% No
12 months

Are you thinking       88% yes                 NS
of taking your         12% No
child to see a
dentist in the
next 6 months?

Did you make an        52% Yes                 NS
appointment for        48% No
your child to see
a dentist in the
next 6 months?

In the last year       3% A big problem        P=0.003
how much of a          5% A small problem
problem was it to      92% Not a problem
get care for your
child that you
or your dentist
believed was
necessary? *

Last dental            64% Past 12 months      P=0.04
check-up of your       4% 1-2 Years ago
child *                0.5% More than 2
                       years ago
                       31.5% Never

Does your child        12% Yes                 P=0.004
currently need         88% No
any dental
work? *

Your child's           44% Excellent           NS
dental health          33% Very Good
status                 21% Good
                       1.4% Fair
                       1.5% Poor

Fisher's exact test: NS-non significant in bivariate comparison
with dfs; * Statistically significant in bivariate comparison
with dfs in P<0.05
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Author:Kopycka-Kedzierawski, D.T.; Billings, R.J.
Publication:European Archives of Paediatric Dentistry
Article Type:Report
Geographic Code:1USA
Date:Jun 1, 2011
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