A Review of ECC: Dissemination of a Standardized Case Definition

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A Review of ECC Dissemination of a Standardized
Case Definition

• Julie S. Maniate, DMD
• Pediatric Dentistry
• Yale New-Haven Hospital
• April 26, 2007
• In collaboration with
• R. J. Schroth, DMD, MSc
• Faculty of Dentistry
• University of Manitoba

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Introduction

• Dental caries (Surgeon General, 2000)
• most common chronic childhood disease
• 5x more common than asthma
• 7x more common than hay fever
• Prevalence (Curzon Preston, 2004)
• 1.0 to 86.5
• ? over past 2 decades in developing countries

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Risk Factors/Etiology

• Identify and assess risk factors by
• - AAPD Caries Risk Assessment Tool (CAT)
• - aid in predicting children at high risk for
  developing caries
• (Ped Dent, Oral Health Policies, 2006-07)

• Caries triad influenced by
• Social
• Behavioral
• Microbiological
• Environmental
• Clinical

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Caries in the Young (lt72 mo)

• Previously termed
• nursing caries
• nursing bottle syndrome
• rampant caries
• baby-bottle tooth decay
• Attributed to inappropriate feeding practices
• Bedtime bottle use research both supports and
  contradicts
• Breastfeeding insufficient evidence to link with
  the increase prevalence of caries activity,
  possibly protect against ECC
• (Valaitis et al, 2000)

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Dental Caries in the Young

• Multi-factorial nature
• No single predominant risk factor
• Emergence of term
• Early Childhood Caries or ECC

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Inconsistencies Limitations

• Challenges Comparing ECC Studies
• Differing case definitions
• Differing diagnostic criteria for caries
• Cavitated vs. non-cavitated
• Varying ages of subjects
• Different sampling methodology
• Examiner differences

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Examples

• Differing Case Definitions
• 1 decayed primary maxillary incisor
• (Huntington et al 2002)
• 2 incisors with decay (Matee et al 1994)
• 2 decayed labial/palatal surfaces of maxillary
  incisors (Roberts et al 1994)
• 3 or more decayed primary maxillary incisors
• (Kelly Bruerd 1987, Currier Glinka 1977,
  Schroth et al 2005)

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ECC Definition

• AAPD and ECC
• the presence of at least one primary tooth
  affected by caries in children under 72 months of
  age.
• Affected
• Decayed non-cavitated or cavitated
• Missing due to caries
• Filled surface

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Severe Early Childhood Caries

• SECC is a subgroup of ECC (Drury et al 1999, AAPD
  2004)

Age (months) SECC
lt12 1 or more smooth dmf surfaces
12-23 1 or more smooth dmf surfaces
24-35 1 or more smooth dmf surfaces
36-47 dmfs score 4 OR 1 or more smooth dmf surfaces in the primary maxillary anteriors
48-59 dmfs score 5 OR 1 or more smooth dmf surfaces in the primary maxillary anteriors
60-71 dmfs score 6 OR 1 or more smooth dmf surfaces in the primary maxillary anteriors
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Purpose

• To determine the extent to which the current case
  definition for ECC is disseminated in the
  literature.

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Methods Search Strategy

• Medline
• MeSH, key terms
• bottle feeding adverse effects
• early childhood caries
• nursing caries
• nursing bottle syndrome
• baby bottle tooth decay
• labial caries

• nursing bottle mouth
• milk bottle caries
• nursing bottle caries
• bottle propping caries
• bottle mouth caries

• Review formal search strategy
• experienced librarian

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Methods Inclusion Criteria

• Studies from January 1, 1996 to July 6, 2006.
• No language restrictions were imposed.
• Studies using a definition of ECC or studies
  comparing cohorts with caries with those free
  from any caries (deft ?1, defs ? 1, dmft ? 1,
  dmfs ? 1 vs. deft 0, defs 0, dmft 0, dmfs
  0).
• Various study design types.
• e.g. cross sectional, case-control,
  longitudinal/ prospective, interventional trials
• Studies where participants were exclusively
  children under 6 years of age (lt 72 months), or
  where data for children under 6 years of age
  could be extracted from the text of the
  publication.

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Methods Exclusion Criteria

• All non-dental studies.
• Studies that did not assess/mention caries in the
  abstract.
• Studies that did not use the current definition
  for ECC or did not compare a group of children
  less than 72 months of age with caries against a
  caries free group.
• In addition, studies using differing definitions
  of nursing caries or BBTD based upon specific
  patterns of decay in the primary maxillary
  incisors were excluded if there was no assurance
  that the groups without nursing caries of baby
  bottle tooth decay were truly caries free (deft
  0, defs 0, dmft 0, dmfs 0).
• Review articles, case series or case reports,
  letters or editorials.
• Studies involving non-healthy patients.
• Studies that only report mean deft (dmft) or defs
  (dmfs) rates
• rather than the presence or absence of decay.

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Methods Data Handling Extraction

• Application of Search strategy
• 2 reviewers
• Elimination of non-dental studies
• based on abstract and/or title
• Application of Inclusion/Exclusion criteria
• Identification of studies into 1 of 4 categories
• 1. Used AAPD defn for ECC
• 2. Did not use AAPD defn for ECC but reported
  caries prevalence/ caries-free
• 3. Did not report caries using either method
• 4. (Used AAPD defn for SECC)

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Statistics (Results Pending)

• Frequencies will be tabulated for the of
  studies falling into the different categories.
• Analyses will be employed to assess the
  relationships between year of publication and use
  of the ECC definition.
• Chi Square analysis, Spearman rank correlation
  coefficient
• assess the association between the number of
  papers conforming to the AAPD definition and the
  year of publication.
• Data to be analyzed using SPSS version 15.0 (SPSS
  Inc., Chicago, IL).
• A p value of .05 will denote statistical
  significance.

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FIGURE 1 Summary of studies resulting from
search strategy.
Non-dental 196 excluded
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TABLE 1 Summary of the 468 studies in agreement
with inclusion and exclusion criteria

• 12 studies included in both categories as they
  evaluate both ECC and S-ECC.

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Discussion

• 468 articles all considered primary caries in
  young children
• 37 studies specifically applied standardized
  AAPD definition of ECC
• delayed acceptance or awareness of the definition
• delay in studies reaching publication status
• studies prior to the adoption of the AAPD
  definition, thus not available to standardize
  their reporting.

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FIGURE 2 Division of the 468 studies based on
year of publication from January 1, 1996 to July
6, 2006 for categories 1, 2 and 3
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Discussion

• 344 studies did not use AAPD defn for ECC but
  did report prevalence with primary caries
• comparing cohorts with caries against those free
  from any
• these studies in fact comply with the case
  definition
• children gt72 months studies separately reported
  prevalence and/or caries-free values for each age
  group
• small number of studies used the term ECC in
  title and/or intros but no definition for the
  term.
• (The true number of studies complying with the
  AAPD definition should include those papers
  falling into this grouping).

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FIGURE 3 Division of the 468 studies based on
year of publication from Jan.1, 1996 to July 6,
2006 for categories 1 and 2 (combined) and 3
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Discussion

• 83 studies did not use the AAPD defn for ECC, nor
  reported prevalence with primary caries
• majority reported results for children gt72 months
  with no separation of ages
• reporting prevalence of caries only in mothers
• reporting levels of salivary MS and/or
  lactobacilli
• no indication of the age of participants

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Discussion

• 14 studies applied the AAPD defn for SECC in
  reporting of caries prevalence
• 2 of these studies solely considered SECC, while
  12 reported both ECC and SECC values

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FIGURE 4 Division of the 14 studies based on
year of publication from January 1, 1996 to July
6, 2006 for category 4
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Discussion

• Overall
• only a limited number of published reports
  address the issue of ECC and even fewer that have
  considered SECC.
• more researchers in recent publications have
  chosen to apply the AAPD defn of ECC in their
  reporting of caries prevalence in preschool
  children.

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FIGURE 5 Division of the 468 studies based on
year of publication from January 1, 1996 to July
6, 2006 for categories 1, 2 and 3
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Discussion other considerations

• Other areas of investigation
• look at type of journal (specialty vs. g.p.)
• country of publication, language of publication
• journal editors awareness
• Role on achieving a consensus statement--especiall
  y among journals which are pediatric focused or
  dental public health in nature
• clinical caries assessment
• affects/influences prevalence rates of ECC in the
  literature
• setting and lighting in which screenings take
  place
• age of children screened (younger vs. older)
• diagnosed (cavitations vs. white spots)
• examiner variability, clinical etc.

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Conclusion

• Noticeable deficiency in standardized reporting
  of ECC despite the existence of an accepted
  definition.
• Over time, there seems to have been better
  penetration of the definition in the literature.
• ECC is a significant public health issue.
• as severe forms of ECC require treatment by
  pediatric dentists in hospital, under general
  anesthesia.

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Conclusion

• Acceptance of the AAPD definition of ECC in
  future reports will be essential to facilitate
  the comparison of caries prevalence results.
• enable researchers, clinicians and public health
  advocates to target and manage young children who
  have this progressive dental condition
• impacts the child well beyond the preschool period

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Questions?

• Special Thanks to
• University of Manitoba
• Faculty of Dentistry Endowment Fund