1
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
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.
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 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?
· 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, 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 “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, 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 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 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 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.