Epidemiology of ECC &

Effectiveness of Interventions

Oct 20, 2010

Ananda P. Dasanayake, BDS, MPH, Ph.D, FACE
Professor & Director, Graduate Program in Clinical Research
New York University College of Dentistry 1
Charge
Whats in a name?
ECC, S-ECC etc.,
How much of it is out there?
Prevalence & morbidity
How can we prevent/reduce it?
Summary of intervention approaches
Based on all of the above, now what?
Our priorities

2
 "What's in a name? That which we call a rose
by any other name.."
Over the last 5 decades, tooth decay that initially attack the
maxillary primary incisors have been referred to as :
Labial caries
Caries of the incisors
Rampant caries
Nursing bottle caries
Nursing caries
Baby bottle tooth decay
Maxillary anterior caries
Early childhood caries
Severe early childhood caries
Rampant infant and early childhood dental decay

3
ECC/S-ECC Definitions over
the years
One maxillary incisor with caries
At least one maxillary incisor with caries
Two or more primary upper front teeth with caries
Three decayed maxillary incisors with caries on
buccal surfaces and confirmed by childs eating
and feeding habits
Three or maxillary incisors with caries etc., etc.,

4
 Definition Concerns
Are we capturing the same disease with these
various definitions?
Are we or is our progress limited by our own
definitions?
Do we need a different metric to capture
the true essence?
A composite of number of lesions, age of onset
(induction/incubation), and rate of progression? Would
you add exposure to the disease definition?

5
 Current Definitions
ECC: At least 1 primary tooth surface that is either filled, missing
due to caries, or has a cavity or a non-cavitated lesion in a child who
is 71 months old or younger.

S-ECC: Any sign of smooth surface caries in 36-month old or

younger children.

S-ECC in 3-5 year olds: At least 1 primary maxillary anterior

smooth surface that is either cavitated, filled, or missing due to
caries or more than 4-6 decayed, missing, or filled surfaces in the
mouth.

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Potential challenges in using these definitions

Validity of non-cavitated lesion detection

Distinction between esthetic fillings and fillings due to caries
Determination of missing due to caries

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8
 Sharp Eyes and No Probes..
System Sensitivity Specificity

Explorer 60.5 87.4

Visual 65.0 82.5

(University)
Visual (Private 61.8 83.3
Practice)
Lussi, A. Caries Res 1991:25:296-303
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 Using these definitions, when we
say prevalence of ECC is x% in a
given population

is there a considerable
Before we look at ECC/ submerged part?
S-ECC prevalence

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 50
45.8
40 38

30

Mean
20

10
2.9 3.2 3.3 2.7
0
2-11 dfs 6-19 DMFS >=20 DMFS

88-94 99-02
11
N=2,663 2-5 year olds, Biased Sample, No Calibration
Average Caries Burden Over Time

14.6
11.1

Why? Are we capturing the true essence? 12

How is this compared to national
objectives?

13
Caries in AI/AN Children and HP2010

How can we move forward?

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15
ECC/S-ECC among AI/AN Children

Any child age 5 years or younger with decay

on their upper front teeth or six or more teeth with
decay is considered to have severe ECC.

(1999 IHS Survey Definition)

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ECC/S-ECC Prevalence IHS 1999

Approximately 6/10 children < 5 years of age

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Is ECC/S-ECC Also Changing Over Time?

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 Is ECC/S-ECC a Different Disease Entity?

AI/AN children acquire Hib earlier than the U.S. population

As a result, a second generation 4-dose vaccine given at 2, 4,
6, and 15 months did eliminate Hib in the general population
but not in the AI/AN children
A new vaccine that was immunogenic as early as 2 months
brought a 99% reduction in Hib meningitis in AI/AN children

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 Some Additional Questions

If the disease trend is on the up rise, why?

Is the estimate that 60% prevalence of ECC/S-
ECC in 2-5 year old AI/AN children similar to that
in the general AI/AN children population of
same age?
What proportion of children with ECC/S-ECC
receive care?
What proportion ends up in the OR?
Any other associated morbidities/mortalities?
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Number of Medicaid claims/1000 for children 24-35
months of age by state and race/ethnicity
900

800 Restoration

700 Crown
600
Pulp Tx
500
Extraction
400
Sedation
300

200

100

0
NHW AI/AN NHW AI/AN Hispanic NHW AI/AN Hispanic
AK NM OK

Junhie Oh & Dee Robertson 21

Burden of Inadequate Access
to Care
Can this be fatal?

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23
How can we do this?

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 ECC Prevention Strategies
Reducing the microbial burden
Increasing the resistance of teeth
Water fluoridation
Prenatal fluoride
Topical fluoride
Fluoride toothpaste
Reduce prenatal challenges that might lead to
hypoplasia?
Reducing the availability of refined
carbohydrates
Combination 25
 7
6 * *
5 *
log(10) M S

4
3
2
1
0
3T 6M 7M 12M 18M 24M 36M

* P < 0.05 Treatment Control

Mixed Model: Group x Time (p=0.0002)
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 The Effect of Chlorhexidine Varnish on
Caries Increment in Children
4 3.8 *NS
3.5
3
2.5
2.5
2
1.5
1
0.5
0
dfs

Treatment Control

Power, timing, agent, dose, and frequency, effect on

other cariogenic flora, target? MS is just one
member of the biofilm environment
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28
 Results

Glass half-full: Promising findings, Xylitol application can

be routine, yet 24-42% still got caries despite the treatment.
Intervention: (mean age 1.8 yrs)
All in a fluoridated community
All got counseling
Three arms:
4 applications of 0.1 mL
Duraphat per arch @ 0, 6,
12, & 18 months
2 applications @ 0 & 12
months
Counseling only
RCT in 0-5 year olds

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RCTs in 0-5 year olds

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 Now what?
We need to re-visit our current definitions
Using a new definition, we need to get a valid
estimate of the disease burden
Further understanding of the real causal factors
One-Size-Fits-All prevention approaches may not
work and there are no Silver Bullets
Solution? Culturally appropriate innovative
prevention strategies based on the population
specific patho-physiology and the common
risk factor approach?
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