Compared to other health problems of young children living in the United States, caries in the primary dentition is extremely common, with about 23% of 2-to 5-year-old children having had caries experience. However, it has a low severity for most of the children affected, and often does not result in any significant decrease in their quality of life. In contrast, in some populations—especially young American Indian and Alaska Native (AI/AN) children—the prevalence is almost universal. In 2015, Warren et al reported that 95% of 36-month-old children in a Northern Plains American Indian community already had caries experience, which was similar to the prevalence found in an unsuccessful intervention investigation of Navajo children in 2016. Worse still, a large proportion of these children experience severe caries, which causes pain and disability, often culminating in the need for multiple restorations and extractions under general anesthesia (GA). The reasons for this are manifold and not fully understood.

Despite the decades of efforts by the Indian Health Service (IHS) and tribal groups to incorporate all the recommended primary prevention strategies, until recently there was no evidence of sustained reduction in the prevalence or severity of dental caries among this population. In 2013, Dr. Frank Mendoza, a career IHS pediatric dentist with 30 years of experience, decided on a different approach: When primary prevention failed, he began to offer parents the option of medical management of their child’s non-symptomatic carious teeth using a series of applications of 25% silver nitrate followed by fluoride varnish (SN/FV) over a 3-month period. At that time, this secondary prevention protocol was anecdotally being reported to be safe and efficacious by a small number of dentists in the surrounding region of Oregon. Unfortunately, none of them had any credible data to support this claim. As he was the first IHS dentist to employ this protocol, Dr. Mendoza felt it essential that he carefully document and monitor all aspects of this new approach even though it was done as a clinical practice based on his expert opinion and not as research. To do this, he used a customized database and tracking system that captured (a) all inputs (medications); (b) clinical outcomes (surface-specific exams at 3-month intervals); (c) procedures, if required (restorations or extractions); and in particular the number of children who required treatment under GA.

Clinical Outcomes

The project was initiated in September 2013, and soon showed clear evidence of success in both the clinical outcomes and acceptance by the community, which have both continued to the present. This protocol has been extremely safe, with no reported adverse events in more than 1000 children treated. In contrast to the usual pattern, with each successive visit even the youngest children are consistently more cooperative because they learn the visits will not be painful. To date (October 2016) the 238 children managed this way have ranged from 1.5 to 10 years (mean = 3.8) at the start of the protocol, and on average have had extensive dental caries: mean (range) dmft: 7.5 (1-20); mean (range) dmfs = 16.2 (1-69). Almost 85% of the children younger than 6 years old at the baseline exam score at the highest level of severity according to a recently published caries severity staging system.

  • Although comparable baseline data are not available for all clinical outcomes from the years immediately prior to implementing this approach, Dr. Mendoza has found dramatic reductions in the number and extensiveness of invasive procedures required; less than 5% of children have required stainless steel crowns (SSC).
  • Less than 10% of children have had either SSCs, amalgam, or resin restorations.
  • Only 11 (<5%) of children in the protocol have required treatment under GA, which is approximately an 85% reduction compared to the 3 years prior to this.

Telling the Full Story

Although there has been a great reduction in the need for treatment under GA for children receiving this protocol, this constitutes a decrease of only approximately 50% for all children within the community. Despite the ready availability of this safe, effective, feasible, and acceptable approach to managing caries in young children, many of the children who continue to come to the dental clinic for the first time who already have symptomatic caries (eg, pulpitis, ulceration, fistula or abscess). Also, a small number of children who started the protocol have failed follow-up visits, and returned many months later with symptomatic caries. Dr. Mendoza is viewing these cases as systems failures rather than failures of his dental clinic or failures of the parents. It is highly likely that in this small community these children could have been identified earlier through a more formalized collaboration with the medical clinic in the same facility or with the local Early Head Start and Head Start. Efforts have recently been initiated to implement just such a Medical-Dental Collaboration utilizing a caseworker to ensure better case finding, tracking, and communication between the different entities providing health care services to the children of this community.

Conclusion

This caries control strategy is notable for several reasons:

  • It has produced the first ever credible data showing a substantial and sustained reduction in (a) the severity of dental caries in young AI/AN children, (b) the overall disease burden from the disease and invasive treatment of the disease, and (3) the astronomical health disparity for AI/AN children receiving treatment for caries under general anesthesia.
  • It is sustainable because it is not dependent on high-cost personnel, facilities, or procedures; nor does it require a high level of organizational structure and support.
  • It has been extremely well-accepted by the children, parents, and staff.
  • In the words of Dr. Mendoza, “I like it. The parents like it. And the kids love it!”

Despite all the positive aspects of the Warm Springs Model, it still can achieve much better outcomes at a very modest cost by (a) doing a careful analysis of the systems failures that are still the cause of a lot of children developing a severe level of dental caries at a young age, (b) designing and implementing remedies to these failures, and (c) doing on-going Q/A and quality improvement to ensure the maximum benefit to the children. Dr. Mendoza has received on-going support from the non-profit organization QUEST for all of this since well before the first child was treated, including providing the database and tracking system he has used, assistance with data analyses, and currently leading the effort to identify the systems failures that are impeding further progress as well as finding feasible and efficacious remedies to these failures.

L. D. Robertson, MD, MPH

President, QUEST

Note: A fuller exposition of the above report is in press.

Resources

Factors associated with dental caries in a group of American Indian children at age 36 months.

Warren JJ, Blanchette D, Dawson DV, Marshall TA, Phipps KR, Starr D, Drake DR.
Community Dent Oral Epidemiol. 2016 Apr;44(2):154-61. doi: 10.1111/cdoe.12200. Epub 2015 Nov 6.