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If It’s Broke, Fix It: Evolving the Approach to Early Childhood Caries by Brian Nový, DDS, FADI, FACD

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Header: If It's Broke, Fix It
by Brian Novy, DDS, FADI, FACD

More than 20 years have passed since the term "early childhood caries" (ECC) was first coined at a workshop sponsored by the Centers for Disease Control and Prevention.1

Since then, the treatment for ECC has evolved in response to what some now consider a public health crisis. Defined as the presence of one or more decayed, missing or filled tooth surfaces in any primary tooth in children ages 0-6, ECC is one of the most prevalent chronic diseases in young children.2 Nearly a quarter of children ages 2-5 have experienced tooth decay.3 In underserved populations, the impact is even more alarming. The Children's Dental Health Project reports that 75 percent of American Indian/Alaska Native children have experienced caries by the age of 5.3

While progress has been made, ECC continues to be an Achilles' heel for the dental profession. But as dentistry transitions toward oral health care, dentists are beginning to change their approach to managing this chronic condition and to dental caries in general.

Dentists are building upon the inherent connection between oral health and overall health, creating an opportunity to integrate key strategies used in chronic care management of medical conditions like diabetes and cardiovascular disease to turn the tide of ECC. But that also requires a new way of thinking as oral health professionals.

Misconception:
ECC is solely a pediatric concern
One of the greatest challenges in managing and preventing ECC is that providers must work closely with the patient's caregivers, and not just the patient. This means coordinating and partnering with them on immediate treatment plans and how to change behaviors that increase the risk for continued disease. From a young age, children's actions are guided by adults' behavior, so it's essential when caring for pediatric patients that dentists address the caregivers' understanding of, and attitudes toward, oral health to ensure long-term success.

Yet, even those who aren't treating pediatric patients can make a difference in ECC disease management. When caring for pregnant women or new parents, it's essential to assess their understanding of ECC and to take advantage of opportunities to educate the new parent.

Without knowing that harmful bacteria can be transmitted, many parents and caregivers may not realize the impact that their own oral health can have on a child's oral and systemic health. Plus, by raising awareness of the condition, general dentists can begin key conversations early on to ensure parents are taking the necessary steps to maintain or improve their child's oral health.

By shifting the belief that ECC is "a child's disease" to the understanding that it requires a family's commitment, providers can more effectively engage caregivers in making a measurable difference.

Misconception:
Treating caries means drilling and filling
Historically, the dogma of restorative dentistry dictates that dental caries is treated through surgical interventions—the drilling and filling mentality common among even the most well-intentioned practitioners. While this approach may remove the physical caries lesion, it fails to treat the underlying infection that caused the lesion, and that may lead to ongoing issues. In fact, an estimated 23-57 percent of caries lesions recur within six to 24 months.2

A significant shift in this ideology first occurred in the early 2000s when the concept of caries management through risk assessment, intervention and prevention was introduced.4 Developed by a group of key educators from dental schools,5 the Caries Management by Risk Assessment (CAMBRA) philosophy—and subsequently published protocols—has served as a foundation for the medical management of dental caries disease.

Building upon this new approach to manage dental caries more effectively, the DentaQuest Institute explored methodologies that prioritized managing the infection ahead of any restorative and surgical interventions. In 2008, the DentaQuest Institute launched the ECC Collaborative,6 a national initiative to help increase the adoption of a disease management strategy developed by Dr. Man Wai Ng, the dentist-in-chief at Boston Children's Hospital.

In three different phases, the collaborative has worked with federally qualified health centers, hospital-based dental clinics, dental schools and private practices across the country to implement this novel approach. The collaborative has shown initial improvement in care—including reduced new cavitation and fewer referrals to the operating room—in Phases 1 and 2, with full results from Phase 3 forthcoming.2

Like the CAMBRA philosophy, the ECC Collaborative seeks to replace the stand-alone operative approach to treating dental caries with one of comprehensive management. This includes caries risk assessment, remineralization, recare intervals based on caries risk, self-management goals, caries lesion charting by tooth surface and activity, effective communication, and treatment based on patient's clinical needs and caregiver or parental wishes.

Most importantly, it centers on the premise that a patient's caries risk status is dynamic and can change over time.

The emergence of new treatment methods, such as silver diamine fluoride, also could be integrated into disease management and further expand the approach to care. Altogether, these different efforts and tools 7 demonstrate a serious shift from the traditional definition of ECC treatment, as each innovation seems to propel dentistry toward oral health care.

Misconception:
Dentistry alone is the answer
Another key step may require approaching ECC more holistically, by thinking outside the realm of surgical dentistry and into the world of psychology. Today, many dentists are familiar with the concept of risk assessment and can complete a caries risk assessment,8 but the true value of the tool lies in using it to identify why a child has ECC, then effectively communicating and engaging with caregivers and patients to address the risky behaviors.

By using effective communication techniques from our colleagues in psychology, such as motivational interviewing,9 practitioners can help patients and caregivers establish healthy behaviors in a meaningful way. That could mean shifting the way dentists highlight and discuss unhealthy behaviors. (Instead of saying, "You need to brush your teeth before you go to bed," try asking, "Do you have time to brush your teeth before bed?" or "Are you aware that before bed is the most important time to brush your teeth?") This allows the provider, caregiver and patient to set manageable, attainable goals that improve the likelihood of true behavior change over time.

Prioritizing effective patient engagement must be a practice-wide effort. From the moment a patient steps into a dental office, each member of the care team—from the front desk to the hygienist to the dentist—is responsible for learning more about the patient's well-being, providing encouragement and identifying roadblocks that are preventing him or her from meeting key goals.

Misconception:
The one-size-fits-all
visit interval model
An ongoing challenge with ECC isn't just the increasing incidence of disease. If the patient has a cavity, the practitioner has already lost precious time needed to manage the condition. In the ECC Collaborative, recare intervals are determined by risk.

While frequent in-office visits may be difficult to implement for offices and caregivers both financially and logistically, practitioners can explore new methods for staying up to date on their patients' oral health. Phone calls or text messages can provide more convenient touchpoints. Even checking on a patient during appointment scheduling is an example of making every interaction an opportunity for recare.

Outside of the dental office, efforts to integrate community health workers, school nurses and even primary-care providers into oral health care could help identify issues early on and develop referral networks, so children at risk for ECC are receiving individualized care earlier.

With all members of the care team aligned and committed to maximizing these interactions, we're more capable of providing the ongoing, frequent care needed to properly manage ECC.

New way forward
The Dr. Samuel D. Harris National Museum of Dentistry in Baltimore features a quote by Dr. Greene Vardiman Black from the late 1800s: "The day is surely coming … when we will be engaged in practicing preventive rather than reparative dentistry." The father of modern dentistry's prophetic statement remains a strong call to action today, especially in relation to ECC.

Clinicians have a great responsibility to these young patients. We know that poor oral health early on can lead to a lifetime of dental and other health issues. The need is not solely to fill cavities, but ultimately to improve the health of the child. By working together to develop the new skills required to meet this charge, practitioners will empower themselves as care providers and, in turn, their patients and caregivers.

References
  1. Çolak H, Dülgergil ÇT, Dalli M, Hamidi MM. Early childhood caries update: a review of causes, diagnoses, and treatments. J of Nat Sci, Biol, and Med. 2013;4(1):29-38. doi:10.4103/0976-9668.107257.
  2. Richman A, Hannon C, Scoville R, Ng MW. Not just drilling and filling: adopting a disease management approach to manage early childhood caries. Poster presented at: American Public Health Association (APHA) Annual Meeting; November 2, 2015; Chicago, IL. https://www.dentaquestinstitute.org/sites/default/files/DentaQuest%20APHA%20Poster%20Final_Handout.pdf.
  3. The state of dental health: pregnancy and early childhood. Children's Dental Health Project website. https://www.cdhp.org/state-of-dental-health/pregnancy-early-childhood. Accessed April 16, 2016.
  4. Featherstone JDB, Roth JR. Cariology in the new world order: moving from restoration toward prevention. J of the California Dent Assoc. 2003;31(2): 123-124. http://www.cda.org/Portals/0/journal/journal_022003.pdf. Accessed April 16, 2016.
  5. History. CAMBRA Coalition website. http://www.cambracoalition.org/history. Accessed April 26, 2016.
  6. Early childhood caries (ECC) collaborative. DentaQuest Institute website. https://www.dentaquestinstitute.org/learn/quality-improvement-initiatives/early-childhood-caries-ecc-collaborative. Accessed April 16, 2016
  7. DentaQuest disease management series. DentaQuest Institute website. https://www.dentaquestinstitute.org/learn/online-learning-center/online-courseware/dentaquest-disease-management-series. Accessed April 28, 2016.
  8. Caries risk assessment appropriate for the age 1 visit (infants and toddlers): CAMBRA for dental providers (0-5) assessment tool. J of the California Dent Assoc. 2007;35(10):689-690. http://www.cda.org/Portals/0/journal/journal_102007.pdf. Accessed April 28, 2016.
  9. Britt E, Hudson SM, Blampied NM. Motivational interviewing in health settings: a review. Patient Education and Counseling. 2004;53(2)147-155.




Dr. Brian Novy Brian Novy, DDS, FADI, FACD, is the director of practice improvement at the DentaQuest Institute, and an international thought leader in the science of dental caries management. He is an adjunct associate professor at Loma Linda University, and his private practice was the first to receive the title, "American Dental Association Adult Preventive Care Practice of the Year." He maintains a clinical practice at the DentaQuest Oral Health Center in Massachusetts.



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