Early Childhood CariesRedux

Burton L. Edelstein DDS MPHChair, Social & Behavioral Sciences

Columbia University School of Dental and Oral SurgeryFounding Director, Children’s Dental Health Project

What if ECC Were First Discovered Today – in Chicago?

Chicagoland TribuneChicagoland Tribune

New Disease Outbreak in Toddlers

Chicago 2/19/04

The Centers for Disease Control and Prevention in Atlanta yesterday reported the appearance of a devastating and rampant disease affecting young children in greater Chicagoland. The condition, provisionally termed “toddler brown tooth syndrome (TBTS)” was first reported by pediatrician Stew Lampiris who thought it to be a previously known defect in tooth development. But Lampiris was suspicious of a new disease entity because the stain appeared to be spreading and the child was reportedly “in pain, unable to sleep or eat well, and was showing particularly bad temper.” (continued page A4)

Chicagoland TribuneChicagoland Tribune

New Disease Outbreak in Toddlers(continued from page A1)

Lampiris stated that “the child’s acute distress was alarming and the extent of brown discoloration, especially on the front teeth, was greater than I had seen in other cases of dental malformation.”

CDC authorities likened the finding to initial reports of Chinese Avian Flu and stated that it’s experts will follow similar investigative procedures. CDC is today sending a team of epidemiologists, physicians, and medical scientists to study the extent, cause, management and control of this outbreak.

TV-113 News Special

In new developments today on the Toddler Brown Tooth Syndrome, CDC’s rapid response team epidemiologists reported “what we now know” about the outbreak.• The outbreak is much more extensive than previously thought. “Nearly one-fifth of the 2-4 year olds we have examined have clear visible evidence of TBTS”• Children in poverty have much higher rates of disease. “Poor children are more than twice as likely to have TBTS. Affected poor children have more than twice as many brown teeth as affected higher-income children.”

CDC experts estimate that if this condition spreads across the country, “nearly one and a half million preschoolers will have this new disease this year.”

TV 113 TBTS Fact of the DayTBTS 5X More Common Than Asthma!

TBTS Occurence Compared with Asthma Occurence in 2-4 Year Olds

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TV 113 TBTS Fact of the Day TBTS Hits 2X More Low-income Kids

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TV 113 TBTS Fact of the Day TBTS Hits More Minority Kids

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Chicago Tabloid DailyChicago Tabloid Daily

THE FACE OF TBTSArea Parents Live in Fear!!!

CDC Investigation Report

CDC scientists working in Chicago to discover the cause of TBTS made significant progress today with the finding that this devastating condition of toddlers may be infectious in origin.

CDC’s found that “all children affected with TBTS harbor a bacteria from the streptococcus family (a mutans variant).” Scientists note, however, that “not all children who have this bacterium in their mouths have TBTS.”

As scientists continue to investigate these apparently conflicting findings, they are seeking to discover the source of the bacterium and to determine why some infected children do not have TBTS.

Chicagoland TribuneChicagoland Tribune

New Report on TBTS Outbreak Cause

Chicago 3/2/04

The Centers for Disease Control and Prevention in Atlanta yesterday released further information on its TBTS investigation. Surprising discoveries include the finding that mothers of affected toddlers appear to be the primary source of the infection and that the responsible bacteria (“mutans streptococci”) appear to be conveyed to children through saliva. Women’s groups across Chicago responded with……

Channel 113 News Update

CDC continues to investigate the controversy over the cause of TBTS. CDC today released a technical advisory to US physicians that states:

“The family of bacteria, mutans streptococci, now appear to be a necessary but not sufficient cause of TBTS. We advise that precautions to limit transmission of these bacteria from mothers to their young children be implemented as a first step in controlling the outbreak. CDC continues to work to identify additional causative factors that may explain why only some infected children exhibit symptoms.”

Chicago Tabloid DailyChicago Tabloid Daily

TBTS Attacks Infant in CribBaby Begs for Relief!

Health Department Public Forum

At a public forum yesterday, the Health Commissioner called for public calm as scientists seek to understand and control TBTS. He released new information showing that:• Most severe cases are found in children who use bottles or sippy cups all day and at night.• Frequency of sugar exposure is suspected as a main cause.• First signs of TBTS may be white markings on the teeth. Parents are advised to check daily for these marks and report them to their physicians.• Children as young as 10 months may be affected but two year olds are most common.

TV 113 TBTS Fact of the Day TBTS Related to Harmful Feeding?

% Preschoolers Exposed to Harmful Feeding Practices

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Overall Minority Low EducationMothers

Health Department Public Forum

Early-Stage TBTS Advanced TBTS

Head Start TBTS Report

US Head Start officials released new data on TBTS among low-income preschoolers in Head Start showing:

1. Head Start Directors reveal that 60% of children show signs of TBTS

2. One Director claimed that “Dental pain in our low-income preschool kids exists and is coming at us like a tidal wave.”

3. Another Director reported that “This disease is tragic for the development of our children. How can children learn, grow, and mature when they are in constant pain and have draining pus flowing into their mouths?”

TV 113 TBTS Fact of the Day TBTS Causing Pain – Especially in

Minority KidsChildren with Dental Pain

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Chicagoland Tribune

Breaking Research on TBTS SymptomsResearchers at the University of Michigan School of Dentistry today released a study on how TBTS impacts toddlers “quality of life.” Researchers asked questions about the child’s ability to bite, eat sweet foods, and eat hot and cold foods. They also asked about the child’s ability to sleep through the night and whether the child complains about his or her teeth. Comparing 69 children struck with TBTS with 43 who have been spared, researchers found that “children with TBTS have significantly lower… quality of life than children without TBTS.”

(Pediatric Dentistry 25/5:431, Filstrup et al)

Chicagoland Tribune

Congress Takes Up TBTS

The House of Representatives Subcommittee on Health today convened a special hearing on TBTS which has now been discovered in every state and the District of Columbia. Official witnesses included the Director of CDC, Administrator of the Maternal and Child Health Bureau, Director of the National Institute for Dental and Craniofacial Research, and the US Surgeon General.

The witness who garnered greatest attention was not a public official but Mrs. Wilma Carothers, mother of 23 month old Sam who suffers from TBTS. Mrs. Carothers, wife of IL99th District Representative Mark Carothers, put a human face on this new acute disease of young children – describing his pain, inability….

NIDCR NIDCR Update on TBTS on TBTS

NIDCR’s leading dental scientists today reported that:• Vaccines are ineffective against TBTS because the

mutans bacteria are not typical pathogens and cannot be reached in their location on the teeth.

• Reducing mutans by tooth brushing has been found to be modestly effective in slowing the progression of TBTS.

• Fluorides applied to the teeth appear to slow and even reverse TBTS.

• Traditional dental repair has little impact on TBTS progression and recurrence rates are high.

• TBTS appears to be a multifactorial disease that will require behavioral interventions.

Question:

What if ECC Were First Discovered Today – in Chicago?

Answer:

Its understanding, management, treatment, and prevention would be based on observations about its nature, rather than on dental

traditions tied to repair.

The Nature of ECC (TBTS) 1. Caries is a disease

2. Caries is infectious

3. Cariogenic bacteria are transmissible within families when children are infants or toddlers

4. Caries is diet dependent

5. Caries is fluoride mediated

6. Caries is progressive and destructive but reversible

7. Caries is consequential to children’s & families’ lives

8. Caries is highly prevalent among toddlers

9. Caries is inequitably distributed

10. Caries is little affected by dental repair

Implications of Understanding the Nature of ECC (TBTS)

1. Infectious and transmissible: Caries would be managed as an infectious disease by limiting early transmission of cariogenic bacteria and suppressing bacteria once established

2. Diet dependent: Caries would be managed as a dietary disease by controlling the frequency of cariogenic exposures

3. Fluoride mediated: Caries would be managed as a reversible disease by increasing host resistance and repair

4. Inequitably distributed: Disease management resources would be focused on highest risk groups

Implications of Understanding the Nature of ECC (TBTS)

5. Inequitably distributed: Children and families would be assessed for risk level before disease onset.

6. First seen as white spots: Early diagnosis and management would be routine.

7. Early onset: Medical primary care providers would play a dominant role in disease prevention. Dental visits would begin by age one.

8. Intervention: Dental repair would be considered prosthetic and would only be initiated after the disease was controlled. Materials that are bioactive would be preferred.

9. Progressive: Disease would be “staged” and treated according to stage

Implications of Understanding the Nature of ECC (TBTS)

And…• Policymakers would develop funded programs for its

eradication• Press would keep the issue in front of the public• Parents would seek information and learn how to

prevent and control it• Advocates would campaign against its continuance • Professionals would convene meetings and promote

action• Groceries and pharmacies would hold free screening

clinics…….Until it was eradicated!

Raw Potential -- But Vulnerable

How Things Would Be Different

ECCFirst visit age: 3 years

or symptomsPrevention: hygiene,

diet, fluoride (secondary)

Primary therapy: restorations

Interventions: symptoms-based

TBTSFirst visit age: prenatal,

then 3-6 monthsPrevention: limit

transmission (primary)

Primary therapy: disease management

Interventions: risk-based