Abstract
Early Childhood Caries (ECC) is the most common chronic disease affecting children younger than six years of age (CDA, 2010). Indigenous children, children whose families do not have a high level of education, and those whose reside in rural areas all have a greater prevalence of ECC (Health Canada, 2010). One in three day surgeries at pediatric hospitals are for treatment of ECC, which also affects the socioeconomically disadvantaged at a disproportionate rate (CDA, 2010; CIHI, 2013). The negative impacts on both the primary and permanent dentition can lead to lifelong quality of life impacts (WHO, 2019). Several Canadian, and international oral health/pediatric health associations recommend a multidisciplinary approach to preventing ECC. Specifically, primary healthcare workers are in an optimal position to educate caregivers on oral health and facilitate referrals for early establishment of a dental home (CDA 2017). A review of current literature reveals limited research in this topic, majority of which is from the United States, where oral healthcare funding differs of that within Nova Scotia. Current research displays that there is a lack of knowledge, and infrequent referral rates of preventative measures to control ECC. This study aims to evaluate current practice, attitude, and knowledge level within primary healthcare practitioners regarding the prevention of early childhood caries within Nova Scotia.
Keywords/Search Terms: Early childhood caries, primary healthcare practitioner, prevention of ECC, interprofessional collaboration, children’s oral health
Evaluation of Primary Healthcare’s Role in the Prevention of Early Childhood Caries
Early childhood caries (ECC) is defined as decay affecting primary teeth. ECC is a complex, multifactorial and largely preventable disease that is influenced by biomedical factors, and the social determinants of health (CDA, 2010). It can begin immediately after tooth eruption and progress rapidly, possibly requiring in hospital treatment (WHO, 2019; CDA, 2017). ECC affects both primary and permanent dentition which leads to lifelong quality of life impacts (WHO, 2019). The prevention of ECC begins by children establishing a dental home early (CDA, 2017). At these early visits dental practitioners can provide families with strategies to prevent decay from developing; how to clean children’s teeth, when to use fluoride, and healthy eating. Early visits, and early detection of caries results in less invasive treatments which can be completed in community rather than hospital setting.
Primary healthcare practitioners are often the first and consistent point of care for infants, children, and their caregivers. These early visits are an optimal time to discuss the importance of oral health and recommend referral for initiation of a dental home early in life (CDA, 2017). Much of the literature discusses the importance of early education, and the essential role of primary healthcare in prevention of ECC. Several studies completed in the United States looking at primary healthcare practitioners and their knowledge, attitudes, and referral rates for prevention of ECC. To date no research has been completed in Nova Scotia, where children’s dental care is publicly funded, which varies from that of the coverage within the United States (Nova Scotia Government, 2019). For this reason, it is important to investigate the role the primary healthcare plays in ECC prevention in Nova Scotia.
Referral for ECC Prevention within Primary Healthcare
Definition
Early Childhood Caries (ECC) is defined as the presence of one or more decayed, missing, or filled tooth surfaces in any primary teeth in a child less than six years of age. It is a complex and multifactorial chronic disease that is influenced by biomedical factors, such as diet, bacteria, and the social determinants of health (CDA, 2010). Dental caries are caused by cariogenic bacteria that digest dietary carbohydrates and produce acids leading to tooth demineralization and formation of caries (CIHI, 2013). In its early stages ECC typically begins as white-spot lesions in the upper incisors along the margin of the gingiva, only affecting the enamel. If the disease continues it leads to destruction of the tooth's crown, and inner layers of the tooth. Treatment of caries once they pass through the first enamel layer into the second dentin layer involves restoration, or removal of the tooth (Anil & Anand, 2017; CIHI, 2013).
Prevalence
More than 530 million children globally have dental caries within primary teeth (WHO, 2019). Within Canada, ECC is the most common chronic disease affecting children younger than six years of age (CDA, 2010). Health Canada (2010) reports that 47.8% of children under the age of eleven have at least one tooth affected by caries. ECC is significantly prevalent in aboriginal children (83.9%), children living in families with only public dental insurance (60.9%) and families whose highest level of education is less than a degree/diploma (60.1%).
ECC is generally preventable and with early detection can be treated less invasively within community settings. In cases the disease progresses substantially, children require general anesthesia and day surgery. Within most Canadian pediatric hospitals’ treatment of ECC is the most common surgical procedure, accounting for approximately one-third of all surgeries performed on children one to four years of age (CDA, 2017; Pierce et al., 2019). Similar to prevalence of caries, the rates for children who require day surgery for treatment is more prevalent for aboriginal children (93.1%), low-income children (27.2%), and those from rural areas (31.7%) (CIHI, 2013).
Risk Factors
ECC is largely preventable, with almost all risk factors being modifiable. Its cause and prevention are strongly determined by the social determinants of health such as behavioural (WHO, 2019). Anil & Anand (2017) divided the risk factors of ECC into four broad groups. Dietary impacts which can include factors such as a high level of fermentable carbohydrates, feeding practices (nocturnal bottle/breastfeeding). Environmental factors include poor parental education on oral hygiene and low family socioeconomic status. Microorganisms play an enormous role in caries development, especially if not routinely and adequately removed with oral hygiene. The last factor, teeth, includes genetic factors, possible enamel defects, and a lack of fluoride exposure.
Both high education and income have a positive correlation with the rate of visiting the dentist; children who are least likely to visit the dentist are the most likely to have dental caries (Health Canada, 2010; Bader et al, 2004). In contrast, neither education nor income had any association with visiting a primary care practitioner (Health Canada, 2010).
Overall Health Effects
ECC affects both primary and permanent teeth. This can affect quality of life across the entire lifespan leading to self-esteem issues, communication, and socialization skills (WHO, 2019; CIHI, 2013). The primary dentition is necessary for proper mastication, esthetics, phonetics and maintaining space for the permanent dentition (Anil & Anand, 2017). Untreated dental caries in primary or permanent teeth can lead to pain and abscess, which may compromise the ability to eat, sleep and restrict life activities. Dental abscesses and infection can progress becoming life-threatening if left untreated for extended periods (WHO, 2019; Nicolae et al., 2018).
Recommendations for Prevention
The world health organization defines health promotion as “the process of enabling people to increase control over, and to improve, their health” (WHO, 1998). In keeping with this definition, preventative education, not only treatment is crucial in preventing of ECC. Combined efforts, including early establishment of a dental home, timely risk assessment, appropriate therapeutic interventions and preventative education of caregivers, is essential (CDA, 2010).
The Canadian Dental Association (CDA), Canadian Pediatric Society (CPS), Canadian Association for Pediatric Dentistry (CAPD), American Dental Association (ADA), American Academy of Pediatric Dentistry (AAPD), American Association of Public Health Dentistry (AAPHD), and American Association of Pediatrics (AAP) all recommend that children establish a dental home by 12 months of age (CDA, 2010; Herndon et al., 2010; Rowan-Legg, A., 2013). The AAPD (2020) defines a dental home as the “ongoing relationship between the dentist and the patient, inclusive of aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centred way”.
The CDA, CPS, and WHO recommend a multidisciplinary approach to control ECC. Children and their caregivers are seen by primary healthcare teams more often than oral health professionals (CDA, 2010; WHO, 2019). These routine visits provide an ideal opportunity for education regarding the importance of early dental visits, establishment of a dental home, as well as reinforcing the relation between oral health and overall health (Nicolae Et al., 2018). A position statement released by the CDA board of directors (2010) recommends that oral health be included as an integral component of early childhood development, and to expectant mothers.
The Cost of Children’s Dental Care
Within Canada, approximately 6% of dental care is publicly funded (Health Canada, 2010). Specifically in Nova Scotia, the children’s oral health program funds individuals under the age of fifteen are eligible to receive each year preventative services such as a routine dental exam, fluoride application, two routine x-rays, and an educational/debridement session (Nova Scotia Government, 2019).
When ECC progresses children often need day surgery and general anesthesia to restore affected teeth. The Canadian Institute for Health Information (2013) reported that the average cost per day surgery for ECC treatment is $1657. Alternatively in the Nova Scotia fee guide, a recall oral exam (for the primary dentition) is $32.00, two radiographs are $24.00, and a fluoride treatment is $19.00, totalling $75.00 (Nova Scotia Dental Association 2020). These would be typical preventative services completed in a general dental office, which are also all publicly funded within the Children’s Oral Health Program (Nova Scotia Government, 2019).
A study completed in 2014 (Nowak et al.) found that children who began preventative dental care at a younger age (four years or younger) had fewer restorative treatments (restorations, crowns, pulpotomies, and extractions) compared to those who began dental care later. Preventative dental care includes aspects of care such as caregiver education on oral habits, oral hygiene aids, dietary impacts, sealants, and the application of topical fluoride within the dental setting. This prevention translates into less dental care expenditure, both for families and for the healthcare system as a whole.
Gaps Within Current Practice of Primary Healthcare
A survey completed by Herndon et al. (2010) involved a questionnaire survey of 421 family physicians and pediatricians within Florida assessing knowledge, confidence, previous oral health training and practice characteristics. The survey found that less than 20% of both groups reported counselling caregivers on bringing their child for a dentist visit before one year of age. An interesting observation was that only 43% of respondents correctly answered a knowledge-based Likert scale question “white spots on the teeth may indicate early tooth decay”. However, 77% of family physicians, and 95% of pediatricians reported being somewhat, or very confident in evaluating the risk of tooth decay in infants and toddlers, and 81% of respondents report examining patients for tooth decay.
A study completed in 2000 (Lewis et al.,) involving a randomly selected national sample of pediatricians in the United States investigated the role of prevention of ECC in pediatrician’s regular care. More than 90% of pediatricians surveyed believed that dental assessments and preventative counselling should be a part of well-child visits. However, only 14.6% of participants agreed with the current recommendations by the AAPD regarding referral to a dentist by 12 months of age. 55% of participants reported that they had difficulty achieving dental referrals for uninsured patients, and 38% with Medicaid patients. When asked simple AAPD recommendation knowledge-based questions, only 9% correctly answered all four questions. While this study was completed in 2000, its findings are still relevant to the importance, and lack of early dental intervention referrals performed by primary healthcare.
A study completed in the United States by Shimpi et al (2016) investigated the overall knowledge, attitude, and practice behaviours of both Physicians and Nurses in regard to oral health of all ages, not focused on children. The most relevant results of the study found that the rate of dental referrals was 32% ‘frequently’, and 68% ‘infrequently’. With these low referral rates it is possible that primary healthcare practitioners who self-report referrals to dental practitioners, are not referring them for general preventative care, instead only for specific patient concerns. Only 16% reported what they felt adequate coverage of oral/dental health topics in their medical training. One of the knowledge-based questions was a T/F response - ‘children should have their first dental visit no later than 1 year of age’, only 31% of respondents answered this correctly. The study acknowledged the need of education regarding early childhood dental intervention, also noting that primary healthcare provides care for children seven times more frequently that dental practitioners before the age of two, therefore can provide oral health education and recommendations (Shimpi et al., 2016).
A qualitative interview study was completed in Ontario in 2020 (Silva et al.) with the intention to understand the perspectives of stakeholders (primary care, dental personnel, and public health advocates) regarding the initiation of a routine children’s fluoride varnish application program within primary care practice. Participants in this study acknowledged the importance of an interdisciplinary approach to ECC prevention, and most recognized that involving primary care practitioners would lead to an increased number of dental visits at age one year. One participant stated that “I think [a] real key to this program would be for physicians to start routinely looking into the mouth and making referrals. The physician’s office being the starting point for establishing a dental home.” The article also stated that change within health care is a complex issue, with many associated practice and policy barriers. Several participants demonstrated concern for cost, and the necessity of creating government reimbursement for application of fluoride varnish. Overall participants recognized the importance of children’s oral health but were concerned with the barriers faced in creation of a fluoride varnish program.
Canada and the United States are similar in many aspects. However, the United States does not have equivalent public funding for children’s dental care as is present in Nova Scotia’s unique publicly funded system. The United States does have a program called EPSDT (Early and Periodic Screening, Diagnostic and Treatment services) which states it provides a comprehensive dental treatment for low-income infants, children and adolescents under 21. (Department of Health and Human Services, 2014). Without delving into this program, the coverage is much less than that of what is publicly funded here in Nova Scotia (Nova Scotia Government, 2019). For many of the primary healthcare practitioners surveyed, they may be children’s front, and only line, caregiver for dental care.
Throughout the literature ECC has been identified many times as a significant health problem within Canada, and throughout the world. A significant portion of the focus up to this point has been on downstream treatment. This treatment paradigm drastically needs to shift to an upstream preventative approach. Some stakeholders, such as the dental community, have shifted to strengthen preventative measures such as encouraging first visit first tooth, advocating for public funding, etc. However, more needs to be done in terms of both advocacy and implementation from all stakeholders for adequate prevention. One of the initial contacts and stakeholders for children and their caregivers is the primary healthcare team. Current research displays that there is limited evidence surrounding current practice, attitudes, and knowledge of primary healthcare practitioners in relation to ECC. This is especially necessary in areas where dental care is publicly funded, such as in Nova Scotia. In theory, preventative coverage should translate to greater prevention of ECC, increased rates of early intervention, and greater referral of services by all stakeholders including primary health. By conducting a survey questionnaire of primary healthcare practitioners in Nova Scotia, it will reveal how children’s oral health preventative services are understood, emphasized, and referred within primary healthcare practitioners. This knowledge, attitude, and referral rate is something that can be strengthen through education (at all levels of primary healthcare training) reimbursement (through MSI), and personal attitude shift.
Methods
Participants will complete a short (5-10 minute) self-administered questionnaire surrounding current practice, personal attitudes/beliefs and knowledge-based questions regarding children’s oral health. This questionnaire was developed from previously validated questionnaires regarding children’s oral health in relation to primary healthcare. A questionnaire format allows access to the most prospective participants, also allowing flexibility to complete within participants own time & schedule. This survey will be distributed through family physician’s, pediatrician’s, and nurse practitioner’s respective college/professional body. The survey will be administered within a secure online website.
Participants
Individuals who are fully licensed as a family physician, pediatrician, or nurse practitioner within Nova Scotia will be invited to participate in this study. All practice settings & roles within these job titles will be included. All genders, ethnicities and ages will be included. Inclusion Criteria
Those included within the study will be any medical practitioner fully licensed within Nova Scotia as a family physician, pediatrician, or nurse practitioner. Participants are required to have access to the email associated with their respective licensing body and access to the internet to complete the questionnaire within an online webpage. To fully consent participants must speak, read, and fully understand English.
Exclusion Criteria
Individuals who are in training within an educational program, or in a residency/fellowship program are not eligible to participate. Those who are not fully licensed to practice within Nova Scotia are not able to participate, which includes those on a restricted, academic, or temporary license.
Proposed Sample Size
With all survey research, a low response rate is typical. Reliable and valid questionnaire research requires a minimum response rate of 40%, which is the response rate this questionnaire will strive to achieve (Story & Tait 2019). According to the College of Physicians and Surgeons of Nova Scotia (CPSNS), there are currently 1075 family physicians and 162 pediatricians licensed within Nova Scotia (2021). According to the Nova Scotia College of Nurses there are 238 nurse practitioners licensed within Nova Scotia (2020). This creates a sampling frame of 1475 participants. To achieve a response rate greater than 40%, a minimum of 590 participants is required.
Sample Frames/Procedures
Family physicians, pediatricians, and nurse practitioners will be included within this study. Participants will be recruited through each respective licensing body/college. To ensure eligibility, within the demographic section participants will ask participants their job title. They will be able to select from Family physician, pediatrician, Nurse practitioner, and other. If a participant selects ‘other’ their submission will be assessed to ensure eligibility and questionnaire results removed if they do not fit within the sample parameters.
Sampling Procedures
Participants will be recruited via email distributed by each respective college. The College of Physicians of Nova Scotia, and the Nova Scotia College of Nurses will be contacted and provided with a description of the study, its benefits and possible risks. Embedded within the email will be a link to the consent form, and then participate in the study. A reminder email will be sent out two weeks after the initial invitation, reminding all prospective participants. The survey will remain live and accepting responses for one month prior to initial recruitment.
Data Collection Measures
A self administered questionnaire was chosen for this study for several reasons. A questionnaire allows participants to complete at their own leisure, the ability to reach a significant number of potential participants. The initial page of this questionnaire will be an informed consent page, discussing ethics approval, goals of the research, any endorsements/funding, reassurance of confidentiality, and how to contact researchers if any questions/concerns arise. Questions will include true/false, agree/disagree, as well as Likert scale responses. A draft questionnaire was adapted from previous research tools developed to assess primary healthcare’s knowledge on children’s oral health status (Lewis et al., 2000; Shimpi et al., 2016; Herndon et al., 2010). This questionnaire includes four main sections: participant demographics, knowledge based questions, current clinical practice, and attitudes/beliefs toward children’s oral health. A draft questionnaire can be found within the Appendix.
1) Participant demographics includes information regarding age of participant, their job title, years in practice, and practice location.
2) Knowledge based questions were derived from information accessed within the CDA’s First Tooth First Visit webpage (Canadian Dental Association, 2017).
3) Current clinical practice includes asking the participants to rate the frequency that they would perform oral health related actions within their current practice. This includes information such as frequency of dental problem assessment, referral to a dentist at/before 12 months of age, counselling on the prevention of dental caries, and application of fluoride varnish.
4) Attitudes and beliefs towards children’s oral health assesses the likelihood of change within primary healthcare to better promote oral health. This will include question such as how significant of a role primary healthcare plays in promotion of oral health, what primary healthcare should be doing to increase oral health (fluoride varnish, counselling of families).
Strengths & Weaknesses
In general, there are several strengths and weakness to questionnaire research. The most significant strength is that participants can respond at a time convenient to them. In theory this translates to a higher response rate, as well as honest, considerate responses. However, response rates are often low in survey research which can greatly affect the result’s external validity. Strategies utilized to increase external validity will include ensuring the survey takes only 5-10 minutes to complete, its benefits to overall healthcare being clear, as well as a reminder to complete the survey being sent to participants midway through the questionnaire response period. Selection bias is inherent, as those who take the time to participate in questionnaires are often those that are passionate about the topic. This may be true for those within primary healthcare who currently do place an emphasis on children’s oral health within their practice. By reinforcing the importance of the results for children’s healthcare, as well as a short survey completion time participants will hopefully be more inclined to participate. Social desirability bias is also a concern, as participants may be reluctant to admit if that they are not familiar with the significance of children’s oral health within primary health care, and do not emphasize it within their practice. Care must be taken to reinforce confidentiality to ensure that participants answer truthfully, and accurately. Questionnaire wording & ordering will be carefully created to ensure participants are answering questions honestly, this will be pretested with a sample population.
References
American Academy of Pediatric Dentistry. (2020). Definition of a Dental Home. The Reference Manual of Pediatric Dentistry. https://www.aapd.org/research/oral-health-policies--recommendations/Dental-Home/
Anil, S., & Anand, P. (2017). Early Childhood Caries: Prevalence, Risk Factors, and Prevention. Frontiers in Pediatrics. 5:157. doi:10.3389/fped.2017.00157
Bader, J.D., Rozier R.G., Lohr K.N., Frame P.S. (2004) Physicians’ roles in preventing dental caries in preschool children: a summary of the evidence for the U.S. Preventive Services Task Force. American Journal of Preventative Medicine. 26(4):315-25. doi:10.1016/j.amepre.2003.12.001
Canadian Dental Association (2010). Early Childhood Caries. https://www.cda-adc.ca/en/about/position_statements/ecc/
Canadian Dental Association. (2017). First Visit, First tooth. https://www.firstvisitfirsttooth.ca
CDA Board of Directors. (2010). Position Paper on the Access to Oral Health Care for Canadians. http://www.cda-adc.ca/_files/position_statements/accessToCarePaper.pdf
Canadian institute for Health Information. (2013). Treatment of Preventable Dental Cavities in Preschoolers. https://cdn.ymaws.com/www.alphaweb.org/resource/collection/822EC60D-0D03-413E-B590-AFE1AA8620A9/CIHI_Caries_Surgery_2013.pdf
College of Physicians & Surgeons of Nova Scotia (2021). https://cpsns.ns.ca
Department of Health and Human Services USA. (2014). EPSDT – A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-Treatment.html
Health Canada. (2010). Report on the Findings of the Oral Health Component of the Canadian Health Measures Survey: 2007-2009. https://www.caphd.ca/sites/default/files/CHMS-E-tech.pdf
Herndon, J.B., Tomar, S.L., Lossius, M.N., Catalanotto, F.A. (2010). Preventive Oral Health Care in Early Childhood: Knowledge, Confidence, and Practices of Pediatricians and Family Physicians in Florida. The Journal of Pediatrics. 157(6):1018-1024. 10.1016/j/peds/2010.05.045
Lewis, C.W., Grossman, D.C., Domoto, P.K., Deyo, R.A., (2000). The Role of the Pediatrician in the Oral health of Children: A National Survey. Pediatrics. 106(6). https://doi.org/10.1542/peds.106.6.e8
Nicolae, A., Levin, L., Wong, P.D., Dave, M.G., Taras, J., Misty, C., Ford-Jones, E.L., Wong, M., Schroth, R. (2018). Identification of early childhood caries in primary care settings. Paediatrics & Child Health. 23:2 (111-115). doi:10.1093/pch/pxx155
Nowak, A.J., Casamassimo, P.S., Scott, J., Moulton, R., (2014) Do Early Dental Visits Reduce Treatment and Treatment Costs for Children? Journal of Pediatric Dentistry. 36(7).
Nova Scotia Dental Association (2020). Abbreviated Fee Guide. https://nsdental.org/wp-content/uploads/2020/02/2020-Abbreviated-Fee-guide.pdf
Nova Scotia Government. (2019). Nova Scotia Children’s Oral Health Program. https://novascotia.ca/dhw/children-dental/
Nova Scotia College of Nurses. (2020). Annual Report 2020: Excellence for All. https://cdn1.nscn.ca/sites/default/files/documents/AnnualReport2020.pdf
Pierce, A., Singh, S., Lee, J., Grant, C., Cruz de Jesus, V., & Schroth, R. J. (2019). The Burden of Early Childhood Caries in Canadian Children and Associated Risk Factors. Frontiers in Public Health. 7, 328. https://doi.org/10.3389/fpubh.2019.00328
Rowan-Legg, A. (2013). Position statement: Oral health care for children – a call to action. Paediatrics & Child Health. 18(1):37-43. https://doi.org/10.1093/pch/18.1.37
Silva, K.D., Daniel, I., Singhal, S., Feller, A., Quinonez, C. (2020). The Use of Fluoride Varnish in Primary Care in Ontario: A qualitative Study. Canadian Dental Association Journal. 86:k6
Shimpi, N., Schroeder, Kilsdonk, J., Chyou, P., Glurich, I., Penniman, E., Acharya, A. (2016). Medical Providers’ Oral Health Knowledgeability, Attitudes, and Practice Behaviours: An Opportunity for Interprofessional Collaboration. The Journal of Evidence-Based Dental Practice. 16(1)19-29. Doi:10.1016j.jedpd.2016.01.002
Story, D.A., & Tait, A. R. (2019). Readers Toolbox: Understanding Research Methods. Survey Research. American Society of Anesthesiology. 130:192-202.
World Health Organization. (2019). Ending Childhood Dental Caries. WHO Implementation Manual.https://apps.who.int/iris/rest/bitstreams/1266137/retrieve
World Health Organization. (1998). Health Promotions Glossary. https://www.who.int/healthpromotion/about/HPG/en/
Comments