ABSTRACT
Purpose: This study aimed to assess if the American Academy of Pediatric Dentistry’s (AAPD) recommendation that the First Dental Visit (FDV) to occur before age 12 months is being complied and what are the affecting factors.
Methods: A cross-sectional sample of 606 young children (consisted of 2001-2006 Caries Free (CF) Sample and 2001-2006 & 1997-2001 Early Childhood Caries (ECC) Samples) was obtained consecutively in a pediatric practice in Vancouver and Burnaby, BC. Upon the first time that a child visited our practice, the subject was tallied according to age. Parental interviews provided the child’s birth place and mother tongue, parent’s belief on the age of the FDV, and awareness of ECC.
Results and Conclusions: About 10% of the two ECC Samples (N=261 & 190) had visits at age 13-24 months; the visits became three times more by age 25-36 months. Therefore the AAPD’s recommendation to see a child before 1 year is valid.
The compliance of the AAPD’s recommendation is extremely low because the visits before age 12 months occurred in only 5% of the CF sample (N=155), which amounted to 1.3% of the entire sample (N=606).
An acceptable and opportune time for the FDV to be before age 24 months is supported by the following data. Thirty-four percent of the CF Sample had visits at age 13-24 months, whereas that for the two ECC Samples was slightly over 10%. Sixty-three percent of the CF Sample believed that the FDV should be by age 24 months. Over 40% of the two ECC Samples believed that the FDV should occur by 24 months.
Parental adherence to the traditional third year FDV is strong since parents in the two ECC Samples believed that the FDV should be 3+ years was three times that of the first year.
About 90% of the entire sample was Canadian born; 80% mother tongue was not English. Over 50% of the CF Sample and the 2001-2006 ECC Sample had not heard of ECC. These data illustrate that promotion of infant oral health education should be multilingual and multicultural.
Dental caries is the most common chronic disease among North American children.1 The often quoted statistic is that 20% to 25% of children experience 80% of total childhood caries.2 One recent study indicates that for children two to five years, 75% of caries is found in 8% of the population.3 Early Childhood Caries (ECC), which concentrates among children of low income and minority families, may have a lasting detrimental impact on the development and well-being of the child.1 Nevertheless, given appropriate interventions at the right time, ECC is entirely preventable.4 When is this “right time” that the dentist has recommended to the parents to act? By recording the age of 606 patients upon their initial visit to our pediatric practice, and interviewing their parents, the current study aimed to assess the extent that this recommendation was being received and complied by the parents, as well as what factors might have affected the compliance.
ECC is defined as the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger.5 ECC is mainly caused by the frequent and prolonged use of a bottle containing milk or sugary liquids as a pacifier or putting the child to sleep at night or at naptime. With poor oral hygiene the decay can start before 12 months of age on the upper incisors and spread to the molars which, unless intervened, would be lost long before their normal exfoliation at 10 to 12 years.6 Since 1986 the American Academy of Pediatric Dentistry (AAPD) has recommended that the First Dental Visit (FDV) should occur within 6 months of eruption of the first tooth and no later than 12 months of age.7 In the mid-1990’s, the concept of the Anticipatory Guidance was introduced,8 and in 2003 the AAPD adopted the policy of the Dental Home.9 The Editorial of Oral Health, January 2006, states that it is the role of the dental practitioners to empower the parents to provide infant preventive oral care and to anticipate the oral health needs of the growing child (Anticipatory Guidance). This is being carried through the Dental Home which forms an on-going relationship between the dentist and child to provide preventive, treatment, and referral services.10 Nevertheless, a recent report from the Centers for Disease Control and Prevention found that between 1988 to 1994 and 1999 to 2002, there was an increase in 15.2% of cavities among 2 to 5 year old American children.11
METHODS
Determination of whether or not the recommendation for the FDV to occur no later than 12 months of age is followed by parents, the age of the child was tallied upon their initial visit to our pediatric offices in Vancouver and Burnaby, BC between 1997 and 2006. Parents were interviewed to obtain the child’s birthplace and mother tongue. Parental belief on when should be the age for the FDV as well as whether or not they have heard about ECC were determined.
RESULTS
Table 1 & Chart 1. Demography of the cross-sectional data of caries free (cf) sample and early childhood caries (ecc) samples
A CF Sample consisted of 155 children with mean age 31 months, range nine to 59 months, 92% were Canadian born, 89% mother tongue was not English, was collected between 2001 and 2006. An ECC Sample of 261 children with mean age 40 months, range 13 to 60 months, 87% were Canadian born, 86% mother tongue was not English, was collected between 2001 and 2006. Another ECC Sample of 190 children with mean age 38 months, range 13 to 59 months, 94% were Canadian born, 77% mother tongue was not English, was collected between 1997 and 2001.
Chart 2. Prevalence of dental visits occurred at age groups of the caries free and early childhood caries samples
Eight cases in the 2001-2006 CF Sample (N=155) had their FDV between ages 1-12 months, constituting 5% of the sample. Thirty-four percent of the CF Sample (N=155), 10% of the 2001-2006 ECC Sample (N=261), and 13% of the 1997-2001 ECC Sample (N=190) had their initial dental visit to our practice between ages 13-24 months. Between 25 and 36 months, 30% of the CF Sample, 33% of the 2001-2006 ECC Sample, and 38% of the 1997-2001 ECC Sample had their dental visit. Between 37 and 48 months, 17% of the CF Sample, 30% of the 2001-2006 ECC Sample, and 25% of the 1997-2001 ECC Sample had their dental visit.
Chart 3. Prevalence of parental belief on the age of the first dental visit, and their awareness of early childhood caries in the caries free and early childhood caries samples
Of the parents who believed that the FDV should be by one year of age, they were 33% in the 2001-2006 CF Sample, 21% in the 2001-2006, and 18% in the 1997-2001 ECC Samples. The percentages of the parents believing that the FDV should be by two years were quite similar to the percentages for the one year. Parents who believed that the FDV should be at 3+ years or upon problems were 37% for the CF Sample, 54% for 2001-2006 and 60% for 1997-2001 ECC Samples.
Forty-six percent of the parents in the 2001-2006 CF Sample and 57% of the 2001-2006 ECC Sample reported that they had not heard of ECC.
DISCUSSION
The goal of early assessment of oral health no later than 12 months of age is to timely deliver educational information to parents and care-providers in order to avoid extensive intervention. The recommendation for the First Dental Visit to occur before one year of age is provided by the American Academy of Pediatric Dentistry, American Dental Association, and Canadian Dental Association. The validity of this recommendation, versus the traditional third year for the First Dental Visit, is supported by the current study. Chart 2 shows that the visits of the Early Childhood Caries Samples were slightly above 10% by age 13 to 24 months. By age 25 to 36 months, however, the visits of the Early Childhood Caries Samples bec
ame three times that of 13-24 months. It is clear that for the high-risk population the First Dental Visit by age three year is too late.
To date, few studies have assessed the compliance of parents with the AAPD’s recommendation. In a longitudinal study published in 2002, Slayton et al. obtained reports from parental questionnaires that 2% of children in Iowa had a dental visit by age one year. This increased to 11% by age 2 and 26% by age 3.12 One Australian study showed that 9% of children five – 12 months old had their First Dental Visit.13 Another study showed that 12% of 2 year olds in Australia had seen a dentist.14 In 2004, Savage et al. reported a North Carolina longitudinal study. They reported that 23 children (0.24%) had their first preventive dental visit before one year of age, 2.7% between 1-2 years, 5.1% between two-three years, and 9.9% between three-four years.15 In the current study of the cross-sectional data, Chart 2 reveals that among the 606 cases only eight cases from the Caries Free Sample had visited our offices at an age younger than 12 months. This constituted 5% of the 2001-2006 Caries Free Sample (N=155), or 1.3% of the entire sample taken between 1997 and 2006 (N=606). These data indicate that parents coming to our pediatric practice had rarely complied with the AAPD’s First Dental Visit recommendation. It becomes evident that, in spite of the differences in cross-sectional or longitudinal data, sample sizes, recording by clinicians or retrospective reporting by parents, the results obtained from different studies have shown that the recommendation of the First Dental Visit before 12 months is seldom complied.
Some research has addressed factors that affect early dental visit by young children. Chart 3 reveals that the belief of the parents of the Caries Free Sample on the age of the First Dental Visit was about evenly distributed at 1, 2, and 3+ years. The belief of the two Early Childhood Caries Samples on the age of the First Dental Visit at age 1 and 2 were quite similar. However, the number of parents in the Early Childhood Caries Samples believed that the First Dental Visit should be by the third year, beyond third year, or upon problems was over 3 times that by the first year. The current data confirm that the traditional concept of having the First Dental Visit by the third year or upon problems is still a factor strongly entrenched among parents. Chart 3 also shows that about 50% of the parents in the 2001-2006 Caries Free Sample as well as the 2001-2006 Early Childhood Caries Sample had not heard of ECC. As shown in Chart 1, about 90% of the children were Canadian born, and about 80% their mother tongue was not English. It may therefore be suggested that, in multicultural Canada, the lack of English language facility is another factor hindering parents to be informed.
Upon the publication of the study on the 1997-2001 Early Childhood Caries Sample,6 Dr. Gordon Thompson suggested the collection of a Caries Free Sample (clinically no caries) for comparative studies. Chart 2 discloses that the visits of the Caries Free Sample rose steadily to 34% until age 24 months, and maintained at 30% by 36 months. In contrast, the Early Childhood Caries Samples reached slightly over 10% upon 24 months, but climbed rapidly to over 30% from 25 to 36 months. These data demonstrate that parents of the caries-free children were in tune with the principle of early intervention, and had visits at an opportune time before the age of 2 years. The parents having children with caries, however, visited the dentist in full force between ages 25-36 months in response to the rapid progress of caries. Chart 3 reveals that 63% and over 40% of the parents in the caries-free and the caries groups, respectively, believed that the First Dental Visit should be before age 24 months. In order to provide this much needed parental education, it would be an easy proposition to the parents of the caries-free group to set the First Dental Visit to be before age two years. As to the parents of the caries groups, this middle-of-the-road approach may be acceptable provided that they are informed that Early Childhood Caries can start before age 2 and progress rapidly. It is the responsibility of the dental practitioners to inform and motivate parents to prevent Early Childhood Caries.10,16,17
CONCLUSIONS
The data of this study lend support to the following conclusions:
1. The AAPD’s recommendation on the First Dental Visit before 12 months of age is valid in providing education on early intervention to parents.
2. The compliance of parents with the First Dental Visit before 12 months of age is extremely low.
3. An acceptable and opportune time for the First Dental Visit would be before age 24 months.
4. Parental adherence to the traditional third year First Dental Visit is a factor delaying infant’s First Dental Visit.
5. Promotion of infant oral health education should be multilingual and multicultural.
Dr. George C. Ng, a native of Hong Kong, obtained his dental education at the University of Toronto. He is a pediatric specialist in Vancouver and Burnaby, BC. georgengdds@hotmail.com
Dr. Carter K. Ng is a dental graduate of the University of the Pacific. He is in practice with George Ng. He is a part-time instructor at the Faculty of Dentistry, University of BC, and Course Director of Pharmacology at the Vancouver College of Dental Hygiene. carterng@hotmail.com
Oral Health welcomes this original article.
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