Promising efforts to improve the oral health of Indigenous children

Dr. Tim K Thomas

Dr. Robert J Schroth

8th International Meeting on Indigenous Child Health

March 24, 2019

Calgary, Alberta

Faculty/Presenter Disclosure

• In the past 12 months, Tim Thomas and Robert Schroth have no relevant financial relationships with the manufacturer(s) of commercial services discussed in this CME activity

• We do not intend to discuss an unapproved/investigative use of a commercial product/device in our presentation.

Establishing an Oral Health Surveillance System in western Alaska using the

Electronic Dental Record

Timothy K. Thomas, MD

8th International Meeting on Indigenous Child Health

March 22-24, 2019 – Calgary, Alberta

Background• 2008 Yukon Kuskokwim Health

Corporation (YKHC) requested help to investigate pediatric dental caries

• Concern about high rates of Full Mouth Dental Rehabilitation• 400/yr in <6yrs

• $ 9,000 US

• Survey of 348 children age 4-15 yrs in 5 villages:• High rates of untreated decay

• Recommended establishing an ongoing surveillance system

Centers for Disease, C. and Prevention, Dental caries in rural Alaska Native children--Alaska, 2008.MMWR Morb Mortal Wkly Rep, 2011. 60(37): p. 1275-8.

Yukon Kuskokwim Health Corporation (YKHC)

• Provides comprehensive healthcare including dental

• 58 communities (pop: 25-1000)

• 75,000 square miles

(size of Oregon)

• Pop (2017): • Total = 23,500

• Age < 6 years = 2960

• YKHC has had an electronic dental record system since 2005

Objectives of Surveillance Project

• Adapt electronic dental software to provide information on the dental health of the YK Delta population

• Create an automated report of dental health for targeted age groups

Advantages of Ongoing Electronic Record Surveillance

• More timely and less expensive than intermittent surveys• IHS conducts surveys every 4 years (last done 2014)• 1083 Alaska Native children aged 1-5 years; few from YK• Paper based• Resource intensive

• Local or regional data

• Allows comparison across communities e.g. fluoridation, piped water status

• Allows assessment of interventions and across time

Limitations of Using Electronic Dental Record for Surveillance

• Reflects oral health of those who have interacted with the dental health care system• may be biased toward the children who have the

earliest and most severe disease.

Methods (dental records)

• Electronic dental record• date of service

• service codes (including comprehensive exam codes)

• status of each tooth (n= 20 primary teeth)• dft and dmft score established for each child

• Validated scores for 50 patients through chart review

• date of birth • Age reported as Age (years) at the end of the

calendar year

• community of residence

d = decayed

m = missing

f = filled

MethodsCommunity data

• Piped water status in year of exam• Piped ≥ 80% homes served• Un-piped ≤ 20% homes served

• Dental Health Aide Therapist (DHAT) status in year of exam• No DHAT, Itinerant or permanent

Population data

• State of Alaska Dept. of Labor and Statistics

• Census number by race, year, census designated borough and age

Results

• Focused initially on children less than 6 years of age with primary teeth only

Percent of AN Children < 6 yrs Receiving Any Dental Services and Percent Receiving Full Exams

2011-2015

5

39

64

8186 82

2

19

36 37 33 31

0

20

40

60

80

100

< 12mo 1 2 3 4 5

% YK Kids

Age (years)

Any dental service Full exam

Percentage of 3 and 5 year olds who received a comprehensive dental exam each year

2011-2015

24 23

3744

59

1722 24

41

49

0

10

20

30

40

50

60

70

80

90

100

2011 2012 2013 2014 2015

%

% 3 Year olds

% 5 Year oldsn=331

n=285

Oral Health Status of 3 year olds who received a comprehensive dental exam

2011-2015

YearNo. of children

n (% )Presence of any cavities

%

Mean decayed, missing, filled teeth score

(dmft) 2011 141 (24%) 87% 9.2

2012 132 (23%) 86% 8.2

2013 217 (37%) 92% 9.0

2014 248 (44%) 91% 9.4

2015 331 (59%) 91% 9.8

Oral Health Status of 3 and 5 year olds who received a comprehensive dental exam

2011-2015

Year3 year old

mean dmft 5 year old

mean dmft2011 9.2 10.1

2012 8.2 9.8

2013 9.0 9.3

2014 9.4 10.8

2015 9.8 10.8

Among U.S. all races, average dmft score for 5 year olds was 1.7

Percentage of 5 year olds receiving Comprehensive Exams in Communities with DHATs versus No DHATs

13%20% 17%

28%35%

16%21%

29%

54%

63%

0

10

20

30

40

50

60

70

80

90

100

2011 2012 2013 2014 2015

No DHAT DHAT

Mean dmft scores for 5 year olds by Community DHAT Status

Year

DHAT No DHAT

Total 5 year

old Pop

Dental Examn (%) dmft

Total 5 year old

Pop

Dental Examn (%) dmft p-value

2011-2015 1369 507 (37%) 10.5 811 184 (23%) 12.1 0.002

*2190 fewer decayed, missing, or filled teeth over 5 years

Full Mouth Dental Rehabilitation (FMDR), 2011-2015

• A total of 2333 AN children age 1-5 years were referred for FMDR• 1766 were completed

• 73% of children in the YK Delta underwent an FMDR by the time they were 6 years old

• Analysis of New York State Medicaid data, 1996-1999 showed 0.2% children <6yrs underwent FMDR

2008 Survey vs EDR surveillance (2011-2015): Proportion of 4-7 yr olds with given dft,

same 4 communities

0

5

10

15

20

25

30

35

40

45

50

0 1 to 6 7 to 12 13+

%o

f 4

-7 y

ro

lds

Number of teeth that were dft

2008 YKHC Survey (n=121) YKHC EDR Surveillance 2011-2015 (n=810) p=0.23

Use of these data for research

Vitamin D deficiency in Prenatal Women and Severe Early Childhood Cavities in their Infants

Rosalyn Singleton

Background: • Alaska Native prenatal women have low vitamin D levels leading to

risk for rickets in their infants. • Vitamin D is important in development of tooth enamel.• Some studies show an association between low prenatal vitamin D

and early childhood caries.

Objective:• Determine if there is an association between low vitamin D levels in

prenatal women, and early childhood caries in their children

Method:• We analyzed maternal vitamin D levels collected in the "Maternal

Organics Monitoring Study (MOMS)“ in prenatal and in cord blood. • We evaluated YKHC electronic dental records for decayed, missing,

filled, primary teeth (dmft) scores in MOMs infants at 12-60 months

Results: Association between Vitamin D and ECC

Age Mean dmft P-value

25(OH)D <12 ng/ml 25(OH)D >12 ng/ml

12-35 months (cord blood) 9.3 4.7 P=0.002

>36 months (cord blood) 10.9 8.7 P=0.140

Key Findings

• Children 12-35 months with deficient cord blood vitamin D level had a mean dmft

score twice as high as children who were not deficient.

• No difference in dmft score of children > 36 months who were deficient vs. non-

deficient.

Conclusions

• Vitamin D deficiency in prenatal women may contribute to early childhood caries.

ECC = early childhood caries; dmft = decayed missing and filled teeth; 25(OH)D – vitamin D concentrationJournal Dental Research, 2019.

Measures of a Surveillance System• Representative

• Increasing: 49% of 5 year olds in 2015• Larger number of 1-5 yr olds than IHS surveys• Similar distribution of disease (2007 survey vs electronic record)

• Timeliness• With EDR, available in real time• Can run report at any time (at least annually)

• Completeness• 100% concurrence on validity check

• Systematic• Some subjectivity in reporting condition of tooth

• Sustainability• YK staff in training; can run report with change of date

parameters

Summary

• Demonstrated the use of electronic dental record feasible for oral health surveillance

• While certain limitations exist:• Demonstrated increased proportion of children getting

comprehensive exams• Higher proportion in communities with DHATs

• Demonstrated persistence of extensive disease in a large proportion of children in this region• Children experience huge disease burden early in life

Future• Expansion to other Tribal health

organizations • Use different EDR systems

• Assess impact of interventions • Improving access

• Initiating exams at early age (6 mo)

• Prenatal vitamin D supplementation

• Reducing soda consumption

• Expanding DHAT

• Installing piped water

• Expanding communities with fluoridation

Acknowledgements

• Richard Baum (CDC)

• Dana Bruden (CDC)

• Tom Hennessy (CDC)

• Joseph Klejka (YKHC)

• Brian Hollander (YKHC)

• Ros Singleton (ANTHC)

Evaluating First Nations and Inuit Health’s Children’s Oral Health Initiative (COHI)

• COHI started in the Fall 2004 in some Canadian First Nation and Inuit communities.

• Shift focus from treating disease to prevention and less invasive treatment.

• Program activities

• Screening

• 1-1 oral health information sessions

• Fluoride varnish

• Sealants and ART

• Target groups:

• Pregnant women and parents and caregivers

• Children 0-4 years (preschool)

• Children 5-7 years (school age)

GOAL of COHI: Over time COHI will result in significant improvement of the oral health in First Nations and Inuit children.

Schroth RJ, McNally M, Martin H, Edwards J, Hai-Santiago, Kinew KA, Bertone M, Brownell M, Lavoie J, Moffatt ME, Star L, McNabW, Nickel N, Dufour L, Hayes A, Tait-Neufeld H

Children’s Oral Health Initiative (COHI) Interventions

• Screening of eligible children by dental therapists and dental hygienists.

• Fluoride varnish application.

• Dental sealants.

• Stabilize active dental caries with glass ionomer.

• COHI aide community oral health worker:• Community oral health champion.

• Provides caries preventive instruction to children, parents and caregivers, and pregnant women.

Findings from Auditor General of Canada’s Report 4 – Oral Health Programs for First Nations and Inuit – Health Canada

• Assessing COHI and the effects of its services is necessary to determine how the program can be improved.

• Recommendation: Health Canada should improve its analysis of data, including the information that is collected and recorded in its dental database, so that its information on COHI is accurate and comprehensive.

Mixed methods evaluation of COHI. Does it lead to improved health for young First Nations and Inuit Children?

COHI Evaluation Research

Evaluate the relevance and impact of the program for

children and families in First Nations and Inuit communities in

different regions of Canada

Rate of Dental Surgery in Manitoba

Whether communities with COHI have a lower rate than those without and

whether rates have declined since 2004

Data from COHI database

Impact COHI having on First Nations and Inuit

children in Atlantic Canada, Saskatchewan

and Ontario

Community perspectives

Discover attitudes, beliefs and values

of COHI in communities and

the impact on children’s oral

health

27 of 63 ManitobaFirst Nations have COHI

Birdtail SiouxBrokenheadChemahawinCross LakeDakota PlainsFairfordFisher RiverFort AlexanderGarden HillGrand RapidsKeeseekooweninLittle Black RiverLong PlainMoose Lake

Nelson HouseNorway HouseOak LakePeguisPukatawaganRoseau RiverSandy BaySioux ValleySt. Theresa PointSwan LakeThe PasValley RiverWaywayseecappo

Methods:

Rates of Pediatric Dental Surgery to Treat S-ECC in MB

5.38(5.14-5.63)

8.65(8.34-8.97)

12.04(11.69-12.41)

12.08(11.76-12.42)

5.28(4.80-5.80)

9.56(8.88-10.29)

12.32(11.51-13.20)

12.82(12.02-13.68)

5.36(8.53-9.11)

8.82(8.53-9.11)

12.08(11.75-12.42)

12.19(11.88-12.51)

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

1994/95-1998/99 1999/00-2003/04 2005/06-2009/10 2010/11-2014/15

COHI No-COHI Overall

0

2

4

6

8

10

12

14

1994/95-1998/99 1999/00-2003/04 2005/06-2009/10 2010/11-2014/15

Den

tal S

urg

erie

s p

er 1

00

ch

ildre

n

Cases of Dental Surgery by COHI Participation Over Time

COHI No COHI Overall

11.6

11.8

12

12.2

12.4

12.6

12.8

13

2005/06-2009/10 2010/11-2014/15

Time Trend

Preliminary Conclusions

• Rates have increased over time in ALL First Nations communities in Manitoba.

• Communities with COHI may not have significantly lower rates of dental surgery than non-COHI communities.

• The current trajectory of rates are increasing more sharply in non COHI communities.

• Controlling for community variables will offer further insight into time trend outcomes.

• Further investigation into why rates are increasing would be helpful.

• Community feedback (Focus Groups) may help interpret findings.

At least 1 screen per year

0

10

20

30

40

50

60

70

80

90

100

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Saskatchewan Ontario Atlantic

At least 1 Fluoride varnish application

0

20

40

60

80

100

120

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Saskatchewan Ontario Atlantic Canada

2 Fluoride varnish applications

0

10

20

30

40

50

60

70

80

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Saskatchewan Ontario Atlantic

COHI Preliminary Data

At least 1 sealant application

0

2

4

6

8

10

12

14

16

18

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Saskatchewan Ontario Atlantic

% of children receiving 1 ART/IST application

0102030405060708090

100

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Saskatchewan Ontario Atlantic

Preliminary Conclusions

• Preliminary review of data from Saskatchewan, Ontario, and Atlantic Canada suggest that children are consistently receiving dental screenings and at least one fluoride varnish application.

• There are some obvious regional differences with respect to other preventive services, including sealants, two fluoride varnish applications, and interim therapeutic restorations.

ADA Evidence-Based Clinical Practice Guideline on Nonrestorative Treatments for Carious Lesions

• Advanced cavitated lesions on any coronal tooth surface:

• Arresting advanced cavitated carious lesions on any coronal surface of primary teeth – RECOMMENDS: prioritize use of 38% SDF (biannual application) over 5% NaF varnish (1/week for 3 weeks) [Moderate-certainty evidence, strong recommendation].

37

Silver Diamine Fluoride (SDF)as a Nonrestorative Treatment for Caries Lesions

OBJECTIVES

1. To determine the caries arrest rate when SDF is applied to cavitated caries lesions in young children.

2. To determine the association with OHRQoL after SDF is used to treat caries lesions in young children.

METHODS

• Prospective cohort pilot feasibility trial (University of Manitoba HREB approved).

• SDF applied to lesions meeting ICDAS 5 or 6 criteria.

• Caries lesions considered to be successfully arrested when the dentin is HARD and BLACK in color, with no signs of irreversible pulpitis or infection.• Hardness: Very soft, Medium, Very hard• Color: Yellow, Brown, Black

The Effectiveness of Silver Diamine Fluoride when used to Arrest Caries in Children

R. Sihra*, M. Bertone, L. Dufour, H. Martin, B. Patterson, B. Mittermuller, V. Lee, Dr. M.E. Moffatt, J. Edwards, Dr. P. Dahl, Dr. G. ‘t Jong, Dr. M. Fontana, Dr. K. Hai-Santiago, Dr. B. Klus, Dr. L. Robertson, Dr. R.J. Schroth

Pre-treatment vs. Post-treatment

Results – Caries Arrest Rates

18 (45%)22

(55%)

SEX (n=40)

Boys Girls

Arrest Rates for Maxillary and Mandibular Teeth

Conclusion

1. SDF is an effective strategy for treating ECC and may have a significant role in shifting the paradigm from surgical intervention to disease management, particularly for high-risk groups who face challenges in obtaining conventional care.

2. Two applications of SDF is more effective than one application and children must be reassessed at regular intervals.

HEALTHY SMILE HAPPY CHILD: Goals and Objectives

• To promote the initiative and gain community awareness and acceptance of the importance of early childhood oral health.

• To build on existing programs that target young children to deliver oral health promotion and ECC prevention activities.

• To recruit and train natural leaders, including service providers, to assist in program development and to deliver prevention programs in an ongoing basis.

• To scale-up capacity within existing programs and communities to assist in the sustainability of the promotional and educational program.

• To determine the impact this would have on preschool oral health, parental knowledge and attitudes regarding ECC, and knowledge of existing services and health care providers regarding the importance of prevention.

Community Engagement

and Development

Knowledge Exchange

Research, Evaluation, &

Quality Improvement

ECOH

Promotion

&

ECC

Prevention

Lift the Lip Video

• Link: https://www.youtube.com/watch?v=05QLGBWJFwE

Type of Toothpaste Matters

• Teeth are less resistant to caries when they first erupt into the mouth and become more resistant over time (Pitts et al. Dental caries. Nature Review 2017).

• Therefore, Fluoride toothpaste is a good thing.

• Be aware of training toothpastes or Fluoride-free toothpastes.

SCALING UP Healthy Smile Happy Child:Intent

To work with First Nations and Metis partners in the spirit of

Reconciliation to:

1. Listen and support traditional teachings regarding oral

health.

2. Identify policies and practices in Indigenous children’s oral

health which need changing and recommend new ones.

3. Adapt and assess the effectiveness and scalability of the

Healthy Smile Happy Child initiative.

Schroth RJ, DeMaré D, Edwards J, Lavoie J, Sanguins J, Pinsonneault L, Bertone M, Moffatt ME, Dahl P, Carter S, McNab Fontaine W, Kyoon-Achan G, Chartrand F, Hai-Santiago K, Dufour L, Campbell R, Chief T, Flatfoot T, Batson K, Monti D, Taylor J, O'Keefe J, Star L, Pharand L, Kostyniuk S, Melina Sturym, Rosteski M, Martin H, Gilroy K, Patterson B, Dhaliwal T, Levesque J, Lee J

SCALING UP:Timeline and Project Phases

SCALING UP:Outcomes and Data Analysis

We will:

• Compare community knowledge, attitudes, and behaviors relating to ECOH and ECC at the end of the third

stage to those at baseline.

• Measure changes in oral health status and oral health-related quality of life (OHRQL) by comparing baseline

and follow-up study ECOHIS scores.

• Compare the prevalence of ECC and S-ECC, caries scores, and age-adjusted rates of dental surgery under

general anesthesia at baseline and then again at the end of the intervention period.

• Attempt to determine the average age of a child at the time of their first dental visit in each community at

baseline and again post-intervention.

• Review the data, project highlights and findings, and consider the changes in policy and practice needed to

improve young Indigenous children’s oral health.

• Create new resources highlighting what we have learned from participants.

SCALING UP:Potential Enhancements

Anticipated enhancements and adaptations to HSHC:

• Promoting traditional ways to feed (i.e. breastfeeding) and comfort infants and toddlers.

• Promoting and encouraging breastfeeding, traditional foods, and diets.

• Promoting prenatal and infant dental visits.

• Improving access to early dental visits and oral health screenings by 12 months of age.

• Engaging non-dental health providers to apply fluoride varnish to children.

• Utilizing cultural teachings on oral health and wellness by grandparents and Elders.

• Partnering with existing maternal-child health programs in communities.

• Promoting oral health at community gatherings and feasts.

• Improving access to toothbrushes and toothpaste for infants, toddlers, and preschool children.

• Making people aware of the use of Silver Diamine Fluoride, which may keep children from going to the operating room.

Thank you to the many partnerships, collaborators, and funding agencies that support these projects…

Funders:

University of Manitoba

Children’s Hospital Research Institute of Manitoba

Canadian Institutes of Health Research

Manitoba Health, Seniors and Active Living

Public Health Agency of Canada

Partners:

Healthy Smile Happy Child initiative partners

Health Canada, First Nations Inuit Health Branch

Public Health Agency of Canada

Winnipeg Regional Health Authority and other Manitoba RHAs

Manitoba Health, Seniors and Active Living

Nanaandawewigamig

Manitoba Métis Federation

Canadian Dental Association

Duck Bay, Camperville, and Pine Creek First Nation

Research Team: Daniella DeMare, Betty-Anne Mittermuller, Heather Martin,

Melina Sturym, Kelsey Mann, Brayden Patterson, Tiffany Dhaliwal, Josh Levesque, Victor Lee, Andrew Pierce, Ju Hae Lee, Grace

Kyoon-Achan, and many others,