Caries Challenge in Native American Children

During a research project several years ago, I visited an American Indian reservation to train examiners to diagnose dental caries in young children. Prior to this visit, I had examined hundreds of children in schools, Head Start programs, and Women, Infants, and Children (WIC) programs for other studies, during which I had witnessed all levels and patterns of decay. Moreover, I was aware of the high prevalence and severity of this disease among American Indian communities. Thus, I felt prepared for what I was likely to see on the reservation. Instead, I found caries in the American Indian population to be an altogether different disease, with nearly every child having rampant and severe decay, often with multiple abscesses.

Unfortunately, my experience is typical of American Indian and Alaska Native (AI/AN) communities, where dental caries has long plagued the population. This paper documents the problem, likely causes and contributing factors, and possible solutions.

Dental caries affects a large percentage of AI/AN children before they begin school, and at levels of severity that surpass other population groups. As reported in the Indian Health Service’s (IHS) 2010 Survey of Preschool Children, 62.3% of AI/AN children ages 2 to 5 had decay experience, with a mean of 4.2 teeth affected per child.¹ In comparison, a recent National Health and Nutrition Examination Survey (NHANES) reported that 22.7% of general-population children ages 2 to 5 had caries experience, with a mean of 1.2 teeth affected (Figure 1).²

Although data on American Indian children’s dental caries prevalence and severity prior to the 1960s are scarce, available evidence suggests that caries was uncommon in this population in the first half of the 20th century.³ By the 1960s, however, caries in American Indian children had become rampant.>sup>4,5 Indeed, despite general population declines in caries prevalence and severity over the past 50 years,^6,7 this has not been the case for American Indian children.^8–10

Studies in the 1990s reported high prevalence of caries and high levels of decayed, missing, or filled (dmf) teeth among children in the state of Washington,¹¹ as well as children in the Navajo community,¹² Alaska Head Start,¹³ Arizona Head Start and Arizona WIC programs.¹⁴ The first two studies^11,12 suggested that inappropriate bottle feeding was strongly associated with caries. The latter studies^13,14 documented that caries prevalence and severity (i.e., dmf) among AI/AN children were much higher than other groups of children attending the same programs. A more recent longitudinal study of American Indian children in a Northern Plains tribal community reported that 80% of children had caries experience by age 3. Additionally, the study found that caries was strongly associated with the following factors: consumption of sugarsweetened beverages, young mothers, mothers with increased caries rates, and a high number of individuals living in the same household.¹⁵

POVERTY

Dental caries is a disease closely related to poverty, with data from NHANES showing that children living at or below the U.S. federal poverty level have substantially higher rates of caries than those not living in poverty.⁷ Income also appears to be a contributing factor to caries in the AI/AN population, as many reservations — particularly those in the plains and West — are situated in some of the most impoverished counties in the U.S.¹⁶ There is considerable variation in the prevalence and severity of caries within the American Indian population,¹⁰ with higher prevalence reported among groups living in the poorest counties. Associations between poverty and high caries prevalence and severity are not fully understood, but it appears that poor diet, lack of self-care, and limited access to preventive and treatment services play key roles.

CARIOGENIC DIETS

A fundamental cause of dental caries is sugar consumption.¹⁷ Recent studies of early childhood caries have found that sugar consumption, often in the form of sugar-sweetened beverages (such as soda), is associated with both high caries prevalence^18–21 and increased severity.^21,22 As mentioned, a recent longitudinal study found sugar-sweetened beverages were associated with caries among 3-year-old American Indian children,¹⁵ suggesting that consuming sugar-sweetened beverages is a risk factor in this community.^18–22

Addressing the dietary shortcomings of AI/AN groups is made especially difficult by the geographic isolation of many tribal communities. Reservations are typically served by small grocery stores that, to stay profitable, focus on products with relatively long shelf lives and high profit margins. As a result, processed foods and sugar-sweetened beverages are common, while healthy food choices, such as fresh fruits or vegetables, are limited.²³ The availability of cheap, highsugar foods, combined with high poverty rates, can lead to cariogenic diets. Moreover, with limited food choices available — or affordable — efforts to improve dietary practices have little chance for success.

SELF-CARE PRACTICES

A growing body of literature suggests family and social factors — including parental stress — can impact parents’ oral self-care practices, and in turn, the oral health of their children.^24–26 While there is limited evidence of this phenomenon in AI/AN communities, studies suggest that AI/AN parents have sufficient oral health knowledge, but may find it difficult to perform appropriate health behaviors.^27,28 In light of social problems in AI/AN communities — including substance abuse and domestic violence, particularly affecting women — it is not surprising that AI/AN parents may struggle to implement optimal oral health behaviors on behalf of their children.^27,29,30 Additionally, many AI/AN children are not consuming optimally fluoridated water^8,31 or using fluoride toothpaste.²⁸

LACK OF ACCESS TO DENTAL CARE

As discussed by Phipps et al,¹ a severe dental access problem exists in AI/AN communities. Simply put, there are not enough dental providers to meet the needs of these communities. While many dental clinics, whether operated by IHS or tribal communities, are modern facilities, the remoteness of many AI/AN communities makes it difficult to recruit and retain dentists and other oral health professionals.¹ As a result, 15% to 20% of dentist positions remain consistently vacant within IHS.^1,10 The dental professionals who are employed by IHS or tribal communities are sometimes overwhelmed by emergency needs, leaving insufficient time to provide routine care or focus on prevention. Moreover, there is a shortage of pediatric dentists in tribal communities. As such, appropriate care may only be available offsite (e.g., hospital settings) for the numerous children who have extensive oral health care needs. In addition to these challenges, adequate housing is often difficult to find in or near tribal communities, and there may be limited employment opportunities for dentists’ family members.

ADDITIONAL FACTORS

Compared to other populations, studies suggest that tooth eruption in children from AI/AN communities tends to occur earlier for both primary³² and permanent³³ dentitions. It has been hypothesized these early erupting teeth may be less well-developed and more prone to hypoplasia, a condition associated with a high caries rate.³⁴ In addition, early eruption may contribute to the early onset of caries.

Finally, there is limited evidence to suggest that microbiota profiles in AI/AN children may differ from other populations. One study found that Northern Plains tribal children harbored an abundance of highly cariogenic Streptococcus sobrinus, in addition to typical caries-causative bacteria, such as Streptococcus mutans.³⁵

In summary, while there is limited evidence regarding the specific causes of rampant caries in AI/AN populations, many factors common to these communities have been associated with caries in other populations. These include poverty, high-sugar diets, limited exposure to fluoride, lack of self-care, and poor access to professional dental services. In addition, AI/AN children may face other risk factors, including early tooth eruption and increased exposure to cariogenic microorganisms.

POTENTIAL SOLUTIONS

A common finding in studies of caries in AI/AN children is that severe disease often occurs at a very young age.^{1,8–12,15,36}Thus, preventive and mitigative efforts must begin early and should likely include oral health education and behavioral modification by expectant mothers. Unfortunately, while numerous efforts have been attempted over the years, these have typically met with little success. Thus, any proposed solutions to this problem must be recognized as speculative.

As suggested here, oral health education and behavioral modification aimed at new and expectant mothers appear to be key elements of any solution, especially in light of the early onset of caries in AI/AN children. Such efforts should be based on theoretical frameworks that use proven tools, including motivational interviewing and interventions based on the self-determination theory — both of which have been shown to improve parental oral health behaviors (Table 1).^37–42

Another potential solution is to use a health management approach to provide early screening and referral for caries prevention and treatment. Under this approach, dental hygienists, nurses or other licensed clinicians perform oral health screenings to determine how urgently an individual needs professional dental care. If treatment is needed, dental care options are provided based on location, availability of appointments, and the type of care required. The care coordinator assists in arranging transportation to dental offices, finding child care, and communicating appointment reminders to patients to help ensure scheduled dental visits occur. The care coordinator might also provide direct preventive care, including fluoride varnish application, in a variety of dental and nondental settings.

Finally, traditional dental preventive strategies — including the use of fluoride toothpaste, frequent application of fluoride varnish, and use of new anticaries products, such as silver diamine fluoride (SDF) — should be considered. It has been suggested that fluoride toothpaste is used less frequently than recommended in AI/AN populations,²⁸ which may be related to the high rates of poverty in these communities. As such, one possible solution would be to provide fluoride toothpaste and instructions for use to parents/caregivers of young AI/AN children. Similarly, although biannual application of fluoride varnish has been shown to be effective in some populations,⁴³ evidence is lacking as to whether monthly or quarterly applications would offer increased levels of prevention in disease-prone AI/AN communities.

Recently, SDF has become available to U.S. clinicians, which may aid in the primary and secondary prevention of caries in young children.⁴⁴ At least two clinical trials outside of the U.S. have demonstrated that, compared with placeboes or traditional fluoride applications, SDF provides significant preventive effects and better arrests existing lesions.^45,46 Projects to test and demonstrate the effectiveness of silver products (such as SDF and silver nitrate) in AI/AN communities are underway, and preliminary results are promising.⁴⁷ Although it is premature to suggest that meaningful progress has been made in addressing the problem of rampant caries in AI/AN children, the use of SDF and other approaches offers reason for hope.

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Featured Photo Courtesy of ND1939/ISTOCK/ THINKSTOCK

From Decisions in Dentistry. November 2016; 2(11):42-45.