Insights in Public Health

Background

Significance: 10 Million US Children, and 100,000 Hawai‘i Children Have Untreated Caries

Caries is a preventable Gram-positive microaerophilic bacterial infection. Yet, 10 million (>29%) US children have untreated dental decay. This is five-times the prevalence of asthma. Caries is, according to the US Surgeon General, a silent, preventable, epidemic.¹

Caries has profound disparities by geographic location, race, and socio-economic status.^1,2 In Hawai‘i, untreated caries rates are almost twice the national average and affect approximately 100,000 (>50%) 5–9 year old children. Untreated caries are significantly more prevalent among Native Hawaiians, Pacific Islanders, and children living outside of Honolulu.³

Untreated tooth decay can have multiple significant negative effects for children. For example, it impairs classroom learning—children with an acute toothache have trouble paying attention in school, exhibit increased school absenteeism, and do not keep up with their peers academically.⁴ Even worse, 5% of children with untreated decay develop sepsis.⁵

Effective Prevention Programs are Available

Fortunately, evidence-based caries preventive interventions with proven effectiveness are available, as are evidence-based guidelines for school-based implementation (Table 1).^6–9 These guidelines were developed through a collaborative effort of participants from the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatric Dentistry (AAPD), and the American Dental Association (ADA), along with academic experts. These evidence-based guidelines now set national, if not international, standards.

Table 1.

Evidence-Based Oral Health Interventions

General Guideline Recommendations
Diagnosis	Visual examination after cleaning and drying the tooth is sufficient to detect early noncavitated lesions in pits and fissures.
	The use of explorers is not necessary for the detection of early lesions, and forceful use of a sharp explorer can damage tooth surfaces.8
	The clinician should not obtain radiographs for the sole purpose of placing sealants.
Primary Prevention	Sealants should be placed on pits and fissures of children's primary and permanent teeth when it is determined that the tooth, or the patient, is at risk of experiencing caries
Secondary Prevention	Sealants should be placed on early (noncavitated) carious lesions, to reduce the percentage of lesions that progress.
Follow up	Provide sealants to children even if follow-up examinations for every child cannot be guaranteed
Additional School-based Program Recommendations
Diagnosis	Unaided visual assessment is appropriate and adequate.
	Radiographs and other diagnostic techniques are unnecessary for sealant placement.
Primary Prevention	Seal teeth of children even if follow-up cannot be ensured.

Hawai‘i Underutilizes Prevention Programs

Sealants are recommended by the CDC because they are safe and effectively prevent decay. Unfortunately, in Hawai‘i, school-based delivery of this effective caries prevention measure is under-utilized. Dental hygienists in Hawai'i are trained and licensed to provide sealants. However, state laws present substantial hurdles to doing this by requiring: (1) an examination by a dentist prior to sealant placement, and (2) the presence of a dentist when a sealant is placed. As indicated in the previous paragraphs, these requirements do not reflect the scientific evidence or current guidelines, and advanced diagnostic skills or tools are not required to determine the need for sealants. To address the need for sealants, currently, a few community health centers have school-based prevention programs to serve schools in their community. However, these efforts are localized, and there are no state-wide programs available.

As a direct consequence of Hawai'i's lack of adequate programs for children's oral health, three sequential Pew Trusts Oral Health Reports have given Hawai‘i an “F” grade. The 2013 report was based on four indicators of an effective prevention strategy:¹⁰

1. Having sealant programs in high-need schools,

2. Allowing hygienists to place sealants in school-based programs without requiring a dentist's exam,

3. Collecting data regularly about the dental health of school-children and submitting it to a national oral health database, and

4. Meeting a national health objective (Healthy People 2010) on sealants.¹⁰ The Healthy People goal calls for sealants to be applied to the molars of 50 percent of children, and it also says there should be no disparities among children based on income and other factors.

2013 Hawai‘i Senate Bill 343, House Bill 658: Improving Children's Oral Health

To address the oral health needs of Hawai‘i's children, the 2013 Hawai‘i Senate Bill 343 and House Bill 658 both supported increased access to and improved oral health care. Both bills proposed aligning Hawai‘i's public oral health care programs with the CDC's and ADA's evidence-based guidelines in the following ways:

• Require the Department of Health to participate in the National Oral Health Surveillance System, a national database managed by the federal Centers for Disease Control and Prevention and the Association of State and Territorial Dental Directors;

• Permit dental hygienists to apply preventive sealants in a school-based dental sealant program;

• Require the Department of Health to establish and administer a school-based dental sealant program in high-need demonstration schools;

• Require the Department of Health to report to the legislature about the department's efforts to prioritize prevention of tooth decay amongst the State's children; and

• Appropriate funds to establish and administer a school-based dental sealant program in a high-need demonstration school, including plans to implement the program on a statewide level.

Unfortunately, in marked contrast from the available evidence and CDC guidelines, SB 343 did not pass due to a “language discussion” on the need for “direct” supervision by a dentist while a dental hygienist places a sealant in public health setting.

Testimony for and Against the House and Senate bills

Testimony for and against the House and Senate bills revealed that Hawai‘i's Dental Hygiene Association supported the bill, while Hawai‘i's Dental Association appeared to be against the bill. In documented testimony, both professional organizations claimed to be primarily concerned about patient safety and the efficacy of prevention programs. Yet, neither testimony identified the evidence-based guidelines or the national standards. The outcome of the deliberations was that the bill died in conference. When the legislature, professional associations, and the public begin to reconsider these bills, and their potential implementation, it will be important that they also consider the larger legal and scientific context. As clinical evidence becomes more widely available, standards of care are quickly being adapted more widely, progressing from local to national to international. Thus, in a public health setting, by not passing and implementing public health measures with documented safety and efficacy, Hawai'i may be inadvertently opening itself for potential legal liability.¹¹

The Mino‘aka (Smile) Pilot Program, Delivering School-based Caries Prevention

Despite legislative setbacks, Hawai‘i is engaged in efforts to increase oral health care in public settings. One example to address children's oral health needs in Hawai‘i is the Mino‘aka (smile) Program. This pilot program is a community-based collaborative effort among Kama‘aina Kids, YMCA, and the University of Hawai‘i at Manoa, supported by the US National Institutes of Health. The long-term goal is to increase access to oral health care and improve the oral health of Hawai‘i's children. The immediate goal is to develop and implement a model afterschool-based caries prevention program that meets the precepts and standards of the CDC and ADA guidelines, and adheres to all state and federal regulations.

The pilot study has 3 segments:

Segment 1

Identify locations for the pilot program. Due to pre-existing relationships we elected to collaborate with after-school programs of Kama‘aina Kids and YMCA. As part of the site selection process, afterschool site coordinators (N=125) completed a survey examining a social network analysis and oral health attitudes.

Social Network Analysis (SNA) is a study of how people connect and influence each other. We examined how oral health can be promoted by after-school program site coordinators. We hypothesized that site-coordinators who are well connected with each other would help other site coordinators to promote the importance of oral health care to children. The SNA (Figure 1) identified multiple social networks that divided people both within and between programs. In these figures, the high connected site coordinators are near the center of the network, while low connected site coordinators are on the periphery. We also carried out a school-based oral health program attitude and behavioral intent assessment to evaluate if the site coordinator's attitude on oral health care would affect the promotion of oral health care for children in the after-school program. The assessment divided responders into two categories: High oral health attitude; and low oral health attitude. The two components, attitude and SNA, were integrated and factored in for the selection of site coordinators Table 2 shows the integration of connectedness and attitude.

Figure 1.

A social network analysis of after-school site coordinators in Kama‘aina Kids and YMCA. The networks indicate that the site coordinators largely form networks among their peer (networks are single colors), with some site coordinators being more central, and others being peripheral to the network.

Table 2.

Pilot Study Design. The 2x2 table illustrates the conceptual experimental design of the pilot program.

	High Social Network Connectedness + High Oral Health Attitude	Low Social Network Connectedness + Low Oral Health Attitude
Behavioral Intervention using Motivational Interview (Experimental)	1 Kama‘aina Kids site 1 YMCA site (Expect high informed consent)	1 Kama‘aina Kids site 1 YMCA site
No Behavioral Intervention (Control)	1 Kama‘aina Kids site 1 YMCA site	1 Kama‘aina Kids site 1 YMCA site (Expect low informed consent)

Segment 2

From the four cells of the table we randomly selected 1 control school and 1 intervention school from each cell (8 schools total) to participate in the pilot study. The control schools' site coordinators (n=4) received information about the caries prevention program, were given parental informed consent forms, and were asked to distribute and collect them from 3^rd graders parents/guardians. The experimental schools' site coordinators (n=4) also received information about the caries prevention program, were given parental informed consent forms, and received a brief motivational interviewing (MI) training prior to distributing and collecting the consent form from 3rd graders parents/guardians. The brief MI training (lasting about 1-hour) included: (1) empowering and encouraging autonomy of the site coordinators to come up with their own way of maximizing consent form return rates; (2) developing discrepancy (helping participants recognize that their present situation does not necessarily fit their values and envision what they would like in the future); (3) rolling with resistance (allowing participants to explore their views, and avoid arguing for change; and not directly opposing resistance so as to avoid a communication breakdown); (4) expressing empathy (showing acceptance to increase the chance of developing a rapport with participants); (5) supporting self-efficacy (allowing the participants to realize the belief that they have the ability and power to change); (6) and employing reflective listening (acknowledging, confirming and rephrasing what the participants are saying).¹² We hypothesized that the brief MI would increase child and parental consent rates (participation).

Segment 3

Upon return of informed consent the clinical team provided preventive care to children with consent. Care included a dental examination by a dentist, a cleaning, sealants with glass ionomer, interim restorations with glass ionomer when applicable (eg, sealing cavities to prevent progression), oral hygiene instruction, and the provision of a care package including a tooth brush, tooth paste, fluoride varnish, and an interactive booklet including crosswords, coloring, and activities promoting oral health behaviors.

Outcomes

The primary outcome variable is program impact, defined as the product of its reach and its effectiveness. Reach is defined as the number and percent of participants with returned informed consent forms. Effectiveness is defined as change in the number and percent of children with untreated decay or acute abscess, assessed based on data collected during the initial care, and in follow-up care.

Summary of Project's Current Status

The research team completed the afterschool site coordinators (N=125) social network and oral health attitudes survey, and the sites were selected. In April 2013, the clinical team completed both rounds of prevention (initial and follow-up care), as described in segment 3. The collected data will be analyzed and will provide information needed to enable a power calculation and evaluate the feasibility of conducting a larger trial.

Program Benefits and Barriers to Care

The benefit of the program is that all children in the participating after-school programs with informed consent can obtain free comprehensive caries prevention that meets current national and international standards. The program, however, has two significant barriers to care. The first barrier to care is the limited time frame for after-school programs of 2–3 hours, which significantly restricts the program's reach. A preventive visit typically takes 15–30 minutes; as a result, only 4–6 children can be seen in an afternoon. Being limited to late-afternoon programs is also costly in terms of disrupting a clinician's day, and substantially lengthening the travel time to and from the school. This barrier to care could be obviated by allowing preventive care to be delivered during school hours, as recommended by national guidelines and as occurs in 40 states.⁹ Children could also be bused en masse to a dental clinic with multiple chairs and where the intervention is administered. That would allow several patients to be seen at a time and minimize time away from work for the dental health professionals. The argument against utilizing school-time for dental care is that it would take time out of class. On the other hand, the argument for utilizing school-time is that it (a) significantly increases access, and (b) actually reduces time out of class if one considers a typical dental office visit requiring a parent and child to be absent from work and school for one-half day. The second barrier to care is the requirement that a dentist deliver care, and that a dental examination must be completed prior to treatment. This significantly increases the cost of care with no measurable clinical benefit. As indicated in the CDC and ADA evidence-based guidelines⁹ and the Pew Trust report,¹⁰ and recommended by the CDC¹³ and the US Association of State and Territorial Dental Directors,¹⁴ comprehensive caries prevention can be safely and effectively delivered by dental hygienists without a prior examination by a dentist. Conversely, dentists function at their optimal level and are more clinically effective when they deliver surgical care in their offices; furthermore, the approach of utilizing dental hygienists to provide primary dental care is also more cost effective.

Conclusions: An Opportunity for the Community to Control a Silent Epidemic

It is clear from evidence-based guidelines that the incidence and prevalence of dental cavities can be significantly reduced by comprehensive prevention that includes fluoride varnish, brushing instruction/cleaning, high viscosity glass ionomer sealants, and interim restorations. Children receiving dental sealants in school-based programs have 60% less new decay in the pit and fissure surfaces of back teeth (90% of decay occurs in pits and fissures)¹⁷. Further, increasing the percentage of children at high risk for tooth decay who participate in school sealant programs to 50% would prevent more than half of the caries that these children would otherwise have and save public health dollars.¹⁷ These studies also indicate that these preventive measures are safe as well as clinically effective and cost-effective.

Creating a state-wide prevention program seems to be a logical way to increase access to care and to decrease oral health care disparities among Hawai‘i's children. Policies that reflect evidence-based guidelines and support a sustainable dental care delivery system must be designed and be in place.

Conflict of Interest

None of the authors identify a conflict of interest.