A Review of ECC: Dissemination of a Standardized Case
Definition
Julie S. Maniate, DMDPediatric Dentistry
Yale New-Haven HospitalApril 26, 2007
In collaboration with:R. J. Schroth, DMD, MSc
Faculty of DentistryUniversity of Manitoba
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
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:SocialBehavioralMicrobiologicalEnvironmentalClinical
Caries in the Young (<72 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)
Dental Caries in the Young
Multi-factorial natureNo single predominant risk factor
Emergence of term:“Early Childhood Caries” or ECC
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
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)
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
Severe Early Childhood Caries
SECC is a subgroup of ECC (Drury et al 1999, AAPD 2004)
Age (months) SECC
<12 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
Purpose
• To determine the extent to which the current case definition for ECC is disseminated in the literature.
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
Methods: Inclusion Criteria
1. Studies from January 1, 1996 to July 6, 2006.
2. No language restrictions were imposed.
3. 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).
4. Various study design types.e.g. cross sectional, case-control, longitudinal/ prospective, interventional trials
5. Studies where participants were exclusively children under 6 years of age (< 72 months), or where data for children under 6 years of age could be extracted from the text of the publication.
Methods: Exclusion Criteria
1. All non-dental studies.2. Studies that did not assess/mention caries in the abstract.
3. 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).
4. Review articles, case series or case reports, letters or editorials.5. Studies involving “non-healthy” patients.
6. Studies that only report mean deft (dmft) or defs (dmfs) rates rather than the presence or absence of decay.
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 ECC2. Did not use AAPD defn for ECC but reported caries prevalence/
caries-free3. Did not report caries using either method4. (Used AAPD defn for SECC)
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.
Full search 1876 studies
Dental 1680 studies
All other 1179 studies
Children <6yr
1151 studies
Accepted studies
468 studies
Children 6 years 28 studies
Excluded 504 studies
No caries mentioned 683 studies
Non-dental196
excluded
FIGURE 1: Summary of studies resulting from search strategy.
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.
Category Description N % of Total 1 Used AAPD definition for ECC
*37 7.9
2 Did not use AAPD definition for ECC, but reported prevalence/caries-free
344 73.5
3 Did not use AAPD definition for ECC, and did not report prevalence/caries-free
85 18.1
4 Used AAPD definition for S-ECC
*14 3.0
Total
468
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.
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
0
5
10
15
20
25
30
35
40
45
50
Year of study publication
# o
f st
udie
s publish
ed
Exclusively used AAPDdefinition for ECC
Reported only cariesprevalence/caries-free
Did not report cariesprevalence/caries-free
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 >72 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).
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
0
10
20
30
40
50
60
Year of study publication
# of
stu
dies
pub
lishe
d Used ECC definition/reportprevalence or caries-free
Did not use ECCdefinition/report prevalence orcaries-free
Discussion
• 83 studies did not use the AAPD defn for ECC, nor reported prevalence with primary caries
– majority reported results for children >72 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
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
FIGURE 4: Division of the 14 studies based on year of publication from January 1, 1996 to July 6, 2006 for category 4
0
1
2
3
4
5
6
Year of study publication
# o
f st
udie
s publish
ed
Used AAPD definition for SECC
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.
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
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Year of publication
% o
f stu
die
s p
ublished
Used SECC definition
Excluded
Reported Prevalence/Caries Free
Used ECC definition
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--especially 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.
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.
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
Questions?
Special Thanks to:
University of ManitobaFaculty of Dentistry Endowment Fund
