Oral Health Promotion: Knowledge, Confidence, and Practices in Preventing Early-Severe Childhood Caries of Virginia WIC Program Personnel

Severe–Early Childhood Caries

The Centers for Disease Control (CDC) uses the term early childhood caries (ECC) or severe-early childhood caries (S-ECC) for the occurrence of rampant decay in infants and toddlers.¹⁷ S-ECC is the most common chronic, preventable dental disease affecting smooth surfaces of primary teeth (Figure 1).¹⁸ The American Academy of Pediatric Dentistry (AAPD) defines S-ECC as the presence of 1 or more decayed noncavitated or cavitated decayed lesions, missing teeth, or filled tooth surfaces in any primary tooth in a child 71 months of age or younger, or any sign of smooth-surface decay in children younger than 3 years of age.¹⁹

S-ECC is caused by a complex interaction among cariogenic microorganisms, fermentable carbohydrates and susceptible teeth.^20-22 Using selective detection, Tanner et al identified Scardovia wiggsiae in the mouths of children with severe ECC when other pathogens were not detected.²³ Microorganisms play a major role in tooth demineralization and vertical transmission of caries from a mother or caregiver to child through close contact, shared food utensils and saliva.^24-27 The earlier the microorganism colonizes the primary teeth, the more likely the demineralization process begins.²⁷

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Figure 1:

Clinical Signs of Severe–Early Childhood Caries¹⁷

Li and Caufield's²⁷ longitudinal study of 34 mother-infant pairs determined how infants acquire pathogenic bacteria.⁶ Bacterial samples were obtained at 3-month intervals from mothers and their infants to approximately 3 years of age. Almost 71% of infants and toddlers showed DNA patterns harboring genotypes of bacterial microflora identical to those of mothers. Female infants were 6-times more likely to match their mother's genotypes. Male infants and toddlers were 13-times more likely to exhibit dental decay and the MS strain than female children, even though male infants usually have later tooth eruption. This finding remains unexplained until future immunology research is conducted. Researchers strongly suggest that mothers are the major source of MS transmission to their infants and toddlers and recommended future immunology studies.^23-27

Palmer et al found food frequency, cariogenicity and bacterial pathogenesis to be associated with S-ECC and caries recurrence.²⁶ Bacteria metabolize carbohydrates or liquids, initiating acid demineralization of tooth enamel. A combination of bacteria, saliva, defective tooth about the transmission of bacteria enamel, parental behaviors and attitudes increases S-ECC risk.²⁶

Oral Health Promotion

Caries control should start prenatally with screening and treating the mother. Following birth, the infant should be screened and parent and child provided with continued preventive care throughout childhood.^24-26 First dental care visits for infants and toddlers should occur by 12 months of age or when the first tooth erupts.^19,20,25 To monitor the caries balance, infant's knee to lap examinations are recommended biannually by the American Academy of Pediatrics (AAP).²⁸ Periodic fluoride varnish therapy, parental counseling and establishing a relationship with a dental provider has been shown to be effective in reducing S-ECC.^28-31 Fluoride varnish frequency is recommended every 6 months for children at high risk for dental caries, according to the Medicaid Early and Periodic Screening, Diagnosis, and Treatment Benefits Program (EPSDT).³¹ Varnish therapy can also be applied up to 4 times annually.

According to Bandura's Social Learning Theory, human behavior is acquired through observation, experience, modeling, self-efficacy, confidence and positive reinforcement.³² Self-efficacy and self-confidence are qualities for promoting behavioral change.33 Positive reinforcement of oral health concepts and behavior by WIC educators and parents results in positive behavioral and clinical outcomes for children and parents.^33-34 Oral health education aimed at parents or caregivers in the WIC program can improve children's dental and overall health.^35-39

Schick and Rozier conducted a 1 year study of North Carolina nutritionists' effectiveness in oral health promotion among WIC participants.⁴⁰ Researchers found nutritionists with a greater sense of self-efficacy and outcome expectancy were more confident in oral health promotion. The nutritionists were more likely to perform oral risk assessments, counsel parents and make dental referrals than those who lacked confidence.⁴⁰ One study revealed nurses and dental hygienists were more likely to discuss oral health promotion if they were more confident in oral health practices.⁴¹ Pediatricians with greater confidence in oral health screening for dental decay were more likely to make referrals of Head Start children than those with lower self-confidence.⁴² Physicians' confidence in ability to screen for risky health behaviors was positively related with the promotion of disease preventive practices.⁴³ WIC nutritionists often see children before they see a dental health professional.^37-41 Therefore, WIC nutritionists' ability to examine for caries, promote oral health practices, and make referrals is important in preventing S-ECC in low-income populations.

Yost and Li suggested that nurses apply anticipatory oral health guidance for infants and children.²⁴ For example, this guidance includes teaching caregivers to use a damp, warm washcloth to clean infant's gums after eating and before bedtime, putting an infant to bed with a bottle containing water rather than one with fermentable carbohydrates, and avoid on-demand breastfeeding during night. After tooth eruption, caregivers should clean their infant's mouth with a washcloth and slowly progress to a soft child toothbrush. A pea-size or smear of toothpaste should be introduced at approximately 18 to 24 months of age and hands-on parental or caregiver toothbrush instruction should be taught and reinforced.²⁵ Researchers emphasize the importance of making the first dental visit within 6 months of tooth eruption or by 12 months of age.^19,25,28

Weinstein, Harrison and Benton demonstrated that motivational interviewing (MI) techniques are helpful in reducing or preventing S-ECC by counseling mothers during the first year following the birth of a child.³⁴ MI is a collaborative, client-centered form of guiding to elicit and strengthen motivation for change.^33,34,36 MI focuses on skills to educate and motivate others in making health-promoting behaviors based on a client's stage of readiness.^34,35 Children in the MI group exhibited significantly less new caries. The guardians and/or parents of 2 year olds displayed greater compliance with recommended fluoride varnish treatment regimens than the control group without the MI. Weinstein and associates concluded that MI intervention improves health-promoting behaviors of mothers and their young children at high risk for dental caries.³⁴

Freudenthal and Bowen examined MI techniques to decrease parental risk-related behaviors for S-ECC.³⁶ Positive changes in valuing oral health, permissiveness, change difficulty and openness to health information were studied in a population of WIC mothers in Southeast Idaho using a pre- and post-test questionnaire. Avoidance of sharing utensils during feeding and number of times per week mothers brushed or cleaned their child's teeth significantly increased in the group of mothers exposed to the MI counseling techniques. Researchers concluded that using MI with diverse populations at WIC sites would most likely have a positive impact on oral health practices.³⁶

Oral Health Confidence

Oral health confidence among WIC providers studied by Butani et al found those with some oral health training are more likely to counsel mothers and their children about dental disease prevention than WIC providers void of confidence and oral health training.³⁷ Nurses were most likely to discuss oral health issues with WIC clients when compared to other WIC providers. Furthermore, the researchers observed that providing appropriate oral health training to WIC providers increases their confidence and encourages discussion of oral health issues and S-ECC prevention with clients.³⁷ Researchers recommend oral health training for WIC personnel so that they are comfortable with current dental concepts for improving the oral health status of their WIC clients.³⁷

Nurko et al compared the prevalence of caries in children (n=120) of parents or caregivers who had participated in the WIC Infant Oral Health Educational Program (IOHEP) to children of parents who never participated.³⁸ Participants were mostly of Hispanic descent, ages 1 to 5. Parents at the WIC program received counseling and participated in a survey and children in both groups had their decayed and filled teeth (DFT) scores evaluated by pediatric dental faculty and pre- and post-doctoral students. Findings revealed that children whose parents participated in an IOHEP experienced significantly fewer overall caries from 57 to 39% following a 5 year IOHEP community-based program. Findings support oral health promotion by WIC personnel on oral hygiene instructions, proper diet and nutrition, and periodic fluoride applications aimed at reducing the incidence of S-ECC.^37-39

Underserved preschool-aged children rarely visit a dentist, and often receive their first oral screening and dental referral through a public health program such as WIC or Head Start. Virginia Division of Dental Health implemented a Maternal and Early Childhood Oral Health Program called Bright Smiles For Babies.⁴⁴ This program followed the structure used by North Carolina's Into the Mouths of Babes program.^39,40,44,45 Virginia's's Bright Smiles For Babies program offers oral health training to non-dental personnel in occupations who legally can apply fluoride varnish and bill Medicaid, i.e., physicians, physician assistants, pediatric nurse practitioners, family nurse practitioners and registered nurses.⁴⁴ Effective July 2008, the Pharmacy Act allows dentists or physicians to provide standing orders for dental hygienists or nurses to place fluoride varnish on the teeth of children 6 months to 3 years of age at home visits, pediatric and immunization clinics, WIC clinics, and other health district programs.⁴⁵ To operationalize the Pharmacy Act, WIC personnel should first be trained on the demineralization-remineralization process, caries risk and protective factors, oral health risk assessment and screening, oral health information documentation, and prevention guidance to WIC children and families.⁴⁵

Bright Smiles For Babies training is comparable to the Open Wide training for health professionals available through the National Maternal and Child Oral Health Resource Center.^44,46 In 2009, Virginia's Division of Dental Health began a pilot project allowing dental hygienists who hold a Virginia license issued by Virginia Board of Dentistry (Sec.54.1-2722) under a remote oral health care model to provide educational and preventive dental care in designated dental professional shortage areas.⁴⁵

California has the nation's largest number of WIC sites (n=82). In 2001, WIC began First Smiles with dental services provided once a week using portable dental equipment. After 2005, the application of fluoride varnish was introduced. First Smiles' goal is to significantly reduce the incidence of dental decay in young children. Dental and medical providers are trained to increase the number of dental visits for at-risk 1 year olds. Since few dentists treat low-income one year olds, California WIC programs collaborate with dental providers to treat the WIC participants at selected WIC sites.¹⁵

Lee and Rozier compared dental services among children enrolled at WIC to those not enrolled at WIC.³⁹ Children participating in WIC programs are more likely to use preventive and restorative services and less likely to use emergency services than non-WIC participants. Since WIC program participants fall below the 185% Federal Poverty Level, all are considered high risk for dental decay.