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CAN DO: Center to Address Disparities in Children's Oral Health

Media: The Inside Scoop

May 2009

Smiling 5-year-old childIn 2001, the NIDCR began supporting the Center to Address Disparities in Children’s Oral Health at the University of California at San Francisco.  After seven productive years, the center recently received NIDCR support for another seven years.  Known by its acronym CAN DO, the center is one of three NIDCR-supported centers with a primary focus on early childhood caries, a serious form of tooth decay.  In this case, CAN DO scientists are developing better ways to prevent childhood caries in California, one of the nation’s most culturally and socio-economically diverse states.  As CAN DO scientists often note, the lessons learned in California will be of benefit to public health programs throughout the country.  In fact, they already have.  To tell us more about the CAN DO center and its research, past and present, we spoke with Jane Weintraub, DDS, MPH, a researcher at the University of California at San Francisco and the center’s principal investigator and director.

Your center goes by the acronym CAN DO.  What is it that you and your colleagues can do over the next seven years?

CAN DO center logoOur mission is to understand, prevent, and reduce oral health disparities among young children in California.  Our particular focus is early childhood tooth decay, or caries, a disease that affects all races and ethnicities but is more prevalent among vulnerable populations.  As one of the nation’s most diverse states, California serves as a unique, 160,000-square-mile laboratory to develop practical, low-cost, culturally sensitive strategies to fight childhood caries.  What we learn here certainly will be of benefit to other states and even nations.

How prevalent is tooth decay in California?

Early childhood caries remains a significant public health problem, particularly among the state’s low-income ethnic and racial populations.  When our center was launched eight years ago, a statewide oral health needs assessment survey had just been released that was based on data collected in 1993 and 1994.  The survey found the prevalence of early childhood caries was 14 percent among all California preschool children.  But in low-income preschool children of certain races and ethnicities, the prevalence was much higher. 

How much higher?

Let me give you two examples.  In young Asian and Latino children, specifically low-income kids enrolled in Head Start programs, the prevalence was 44 and 39 percent, respectively.  But, more recently, Dr. Francisco Ramos-Gomez, a former UCSF-based colleague who is now at UCLA, found in a study of over 2,000 young Hispanic children who lived near the California-Mexico border, the early childhood caries prevalence was 58 percent.  By contrast, the latest NHANES figures (1999-2004) show the prevalence of early childhood caries has been increasing nationally in the two-to-five age group – preschool aged children was the only age group to show an increase.  Almost three out of every ten children in this age group have already experienced dental caries.

And yet, early childhood caries is largely preventable. 

That’s right.  It just breaks your heart to see these kids with rampant decay.  Their most basic oral health needs have been largely unmet, and it’s also difficult for their parents.  That’s important to remember, too.  We conducted a study in California’s Central Valley, a heavily agricultural area, and a lot of parents can’t take time off from working in the fields to bring a child to a dentist.  What’s more, there isn’t a pediatric dentist within 50 miles of their community.  They have to go to Fresno.  We even heard stories about parents losing their jobs because they took too much time off from work to take their kids to the dentist.  The situation is complex. With our hard economic times right now, I think the situation has the potential to grow worse.  The problem is, unless dental problems are treated, they don’t go away.  They just get worse. 

And that’s where the CAN DO center enters the picture.

Yes and no.  We provide the science that feeds into the front end of the public health system.  In other words, we’re trying to build the best scientifically validated toolbox possible to help parents and practitioners reduce early childhood caries.  But the broader public distribution of this toolbox is a matter to be determined largely in statehouses across the country.  As we just touched on, fiscal times are tough.  So, I think it’s important to take the longer view right now.  High quality science will endure; economic downturns won’t.

But the center and its science already have had an impact on public health in California and really around the country.  I’m referring to your group’s work with fluoride varnish.  What is fluoride varnish?

Fluoride varnish is a lacquer made from a clear resinous base that contains about 5 percent sodium fluoride.  As the word “lacquer” implies, you brush the varnish onto the teeth much like applying nail polish to your fingernails.  The varnish contains a high concentration of fluoride that remains directly on the tooth and can get incorporated into the enamel.  The Europeans have used fluoride varnish for quite a while to prevent the decay of permanent teeth.  When we formed the center in 2001, the data were inconsistent on its effectiveness in primary teeth, especially to prevent early childhood caries.  We were intrigued by the inconsistencies, saw a scientific opportunity, and launched a clinical study at two health centers serving vulnerable populations here in San Francisco.  One center was in Chinatown; the other provided care primarily for a Hispanic population. 

What was the outcome?

The outcome was very beneficial.  Most children were just under two years old at the start of the study, and we followed them for two years.  At that point, we determined the odds of developing caries were four times higher in children randomized for their parents to receive oral health counseling only compared to kids randomized to obtain fluoride varnish treatment twice a year and parental counseling.  The odds were two times higher in the counseling-only group compared to children randomized to receive the fluoride varnish only once a year in addition to counseling.  So we had a very dramatic dose-response effect. 

How did you move from interesting data to journal article to public health policy?

A key piece was that we subsequently developed a policy brief.  It included some additional analyses, done by my colleague Dr. Stuart Gansky, that showed even one application of fluoride varnish over two years was better than none.   That’s critical information for staff at a community health center.  They don’t always know whether – or when - a child will come back for a second visit.  But they can apply the initial treatment with confidence that they’re helping the child.  Stuart later presented the policy brief and findings to California legislative aides in Sacramento to get the message out to policymakers.  We also distributed this policy brief to the more than 1,000 federally qualified health centers in California.  That is, they receive the federally qualified health center benefit under Medicaid.

What happened?

The California Medicaid program introduced a new fluoride varnish benefit for children.  The other big piece was physicians got the legal okay to apply the fluoride varnish.  In addition, if the attending physician delegated the procedure and established the protocol, nurses and medical personnel were allowed to fill in.  This meant that both dental and medical offices now could apply fluoride varnish and get reimbursed from the Medicaid program.  This benefit is for children under age six. 

That must have been really exciting to watch your research progress from A to Z?

Oh, it was.  Around this time, the American Dental Association’s Council on Scientific Affairs issued recommendations that included fluoride varnish for young children at moderate or high caries risk.  Meanwhile, the American Association of Public Health Dentistry came out with a resolution on fluoride varnish for caries prevention.  The point being, this research can – and will – make a difference for tens of thousands of young children nationwide, and that’s a wonderful thing.

You and your colleagues also have focused quite a bit on cultural issues and barriers to care.  What have you learned?

First of all, a lot of parents from vulnerable, underserved populations don’t recognize the importance of baby teeth.  That’s a big one.  Baby teeth are important for chewing, speaking, and, of course, self esteem.  Perhaps the biggest is that caries is an infectious disease with bacteria playing a significant role.  We’ve also found a lot of cultural differences about dental care, particularly preventive practices. 

Such as?

For example, let’s go back to the fluoride varnish study that we conducted in Hispanics and Asian populations.  Among the Hispanic population, some parents dip the pacifier in honey.   We didn’t find that in some other groups.  In the Chinese population, compared to other groups, there was a lot less emphasis on prevention.  In other studies, we’ve found that Hispanic populations consume bottled water rather than fluoridated tap water in part for cultural reasons stemming from not trusting water sources in their home country, as well as not trusting old pipes in sometimes older, urban housing.  In another study, medical anthropologist colleague Dr. Judith Barker found Hispanic parents indicated that oral hygiene was an important preventive activity, but thought their children didn’t need to start brushing until they ate adult food - and then, only after all of the teeth had come in. 

So, the benefits of a low-cost, easy-to-do, daily home care practice – brushing – are much delayed or reduced.  There’s also a lot of misunderstanding about the disease process.  Many parents don’t know caries is an infectious bacterial disease that can be transmitted from parent to child.  Not knowing this means they might not take preventive hygienic measures to prevent parent-to-child transmission of oral bacteria associated with decay.  Some parents got the message that nighttime bottle feeding with milk or juice was bad for the teeth.  But they thought it was due more to the bottle’s nipple than the fluid content. There are a lot of misunderstandings out there, and a lot of educational work to be done.  

What about taking their kids to the dentist?

That’s interesting, too.  Many parents didn’t know when to take their children to the dentist.  Some parents waited until the children complained of pain and a tooth looked dark or damaged.  Discolored teeth without accompanying pain did not always result in a trip to the dentist. Interestingly, they didn’t tell this to the dentists.  They confided in our medical anthropologists.  The anthropologist found while accompanying Latino families to the dental office, some parents would mention what they called “stains” on their children’s teeth.  They thought the teeth just needed cleaning.  They’d get to the dentist’s office, find out that their child had five cavities, and they’d be shocked.  

Another common theme was dental fear.  Many parents reported negative experiences as children while receiving dental care.  Some parents used that as motivation to find what they considered a “good” dentist for their child.  Others just avoided dental care for their children.  They didn’t want to expose them to the same bad experience. 

Let’s take a look ahead.  The NIDCR has renewed its support of the CAN DO center for seven years.  Where do you go from here?

We want to continue disseminating our previous findings on fluoride varnish.  But we don’t yet have a good handle on how to most efficiently and efficaciously reach susceptible children.  So, one of the center’s two main research projects is now directly exploring this issue.  The project directed by Dr. Margaret Walsh will consist of two strata:  primary care clinics and Women, Infants, and Children (WIC) Program sites.  The participating primary care clinics will be randomized either to provide fluoride varnish on site to the children – meaning, we’ll train medical providers, nurses, aides, and their staff to apply the fluoride varnish to children in the clinic – or to refer the families to a dentist to get fluoride varnish. 

What about the WIC sites?

The participating WIC sites will also be randomized.  In California, we have a category of provider called a registered dental hygienist in alternative practice.  They practice quite independently primarily in public health settings, including WIC sites.  They’ll apply the fluoride varnish to kids at some WIC sites.  At the other WIC sites, parents will receive educational information and will be referred to dentists to get fluoride varnish.  We’ll compare the effectiveness of these four approaches.

What is the other main project?

Well, there’s actually a backstory that highlights the tremendous synergy that’s possible with community-based research.  We previously conducted a randomized clinical study, directed by Dr. Francisco Ramos-Gomez, at the San Ysidro Health Center, which is near the California-Mexico border.  Unlike the aforementioned fluoride varnish trial, which started with children almost two years old, we began the study by providing oral health counseling to pregnant women. 

Why pregnant women?

I feel strongly that you can’t consider the child in isolation.  You must consider the influence of the child’s family and environment, too, and the research is clear that bacteria get transmitted from the mom to the baby.  So ideally, you want the mother to have good oral health before the babies are born. 

We easily met our recruitment goals, and that helped us move smoothly into the oral health-counseling component.  After their babies were delivered, the women were randomly assigned to a treatment arm.  In the intervention group, mothers were placed on a chlorhexidine mouth rinse regimen to reduce the bacteria in their mouths.  Once their kids had their teeth, the kids received fluoride varnish treatments twice a year.  The children were followed initially until they reached age three.  We don’t have the results from that study yet.  We’ve finished data collection and are busy analyzing the data. 

And will this study continue?

Yes, the parents wanted to continue participating in the research.  This next study will involve the same health center and another center in San Diego County.  It will focus on the oral health needs of three to six year olds.  This study will be a traditional randomized clinical trial in that the children will be assigned to one of four different treatment arms.  In all groups the parents will receive oral health counseling.  In one group the children will also get fluoride varnish applications.  Another group will also get a relatively new material called a glass ionomer dental sealant, which is applied to the teeth to prevent decay.  The advantage of this material is that it’s not technique sensitive like existing resin-based dental sealants.  Those sealants require very dry environments, and dental professionals really must control the saliva, i.e., moisture, in the child’s mouth.  That’s tough when you have a squirming three year old in the chair.  This new dental sealant is not moisture sensitive, and it also releases fluoride.  A third group will get a combination of fluoride varnish and the glass ionomer sealant, while the fourth group will initially receive only the counseling and later therapeutic varnish treatment if white spots, early reversible signs of decay, are detected.

I realize this is just a broad overview, but it sounds like the next several years will be busy and productive.

That’s certainly the goal.  We also want to give parents and other healthcare providers tools to help improve the oral health of children. The dental profession can’t do it alone.  There just aren’t enough pediatric dentists to go around or dentists treating one year olds and Medicaid-eligible kids. In a lot of these rural or inner-city areas, low-income families don’t have access to the dental care that they need.  To get the job done, we need to engage people outside the dental profession.

And the CAN DO center helps to forge those outside relationships.

That’s right.  I’m a public health dentist.  I feel strongly about prevention.  It’s a lot easier to prevent problems than treat them later on.  So, we’re focused a lot on prevention and education for the caregivers as well as a range of health professionals who often do not have much knowledge about oral health. As you say, we’re building networks and trying to get a better understanding of the problem at the child, family, community and system levels. Our overall goal is to improve the health and oral health of children.

Thanks for your time.



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This page last updated: February 26, 2014