DentaQuest Institute

The Problem
Early Childhood Caries (ECC), or aggressive tooth decay in very young children, is a chronic, infectious dental disease. And like all dental disease, ECC is almost completely preventable.

When young children don’t get the preventive care they need and deserve early in life, many end up in hospital-based dental clinics where the only solution is to treat the disease surgically in the operating room. Early childhood caries is painful to the child, and if untreated, can impact the proper development of permanent teeth. The results are eating and speech problems, and negatively impacted learning in children.

The Need
Hospital-based dental clinics and dental safety net programs such as Federally Qualified Health Centers (FQHC) care for a disproportionate number of low-income and racial and ethnic minority children with early childhood caries. Many of the children end up being treated surgically, with months-long backlogs for expensive operating room care and a high rate of reoccurrence after treatment.

What We Did - Early Childhood Phase I
In 2008, the DentaQuest Institute, Children’s Hospital Boston, and St. Joseph Hospital for Specialty Care in Providence, Rhode Island developed a protocol to implement an evidence-based method of managing and preventing early childhood tooth decay in patients seeking treatment at hospital-based dental clinics. Since the fall of 2008, over 450 children were enrolled, treated and followed. 

The goal was to reduce the percentage of cavity recurrence in patients treated at the hospital dental clinics by 33%, reduce the percentage of patients who are treated in the operating room by 20%, and reduce the percentage of patients complaining of pain on their most recent visit by 50%.  Principal Investigators for Phase I were Dr. Man Wai Ng, Dentist-in-Chief at Children's Hospital Boston, and Dr. Dan Kane, Director of Dentistry at St. Joseph Hospital, Providence.

The ECC Initiative used an evidence- and risk-based disease management approach adapted from the concept of chronic care management of medical conditions.  Participating dental clinics used every point of intervention to engage and educate the child's guardians and then to make sure the child had access to reliable preventive and restorative care by connecting him/her with a dental home for ongoing support and coordination of follow up evaluations. In the process of meeting this objective, investigators also tracked the cost per case.

What We Found
Analysis of Phase I data showed very positive results.

What We're Doing - Early Childhood Phase II
In 2011, the DentaQuest Institute launched Phase II of the ECC Initiative.  Seven FQHC's and hospital based dental clinics began implementing and testing the disease management protocol with patients under 5 years old and presenting with at least one carious lesion.  Participating groups include Holyoke Health Center (Holyoke, MA), Children's Hospital Boston (Boston, MA), Nationwide Children's Hospital (Columbus, OH), Neighborcare Health (Seattle, WA), Native American Health Center (San Francisco, CA), St. Joseph's Health Services (Providence, RI), and University Pediatric Dentistry (Buffalo, NY).

Using a modified CAMBRA approach, teams at each site are collecting data monthly and quarterly about risk, pain due to untreated decay, and new cavitation.  Each test site is also focusing on individual system changes, such as hanging posters in exam rooms, engaging and educating front office staff in the importance of scheduling the recall visit within the recommended timeframe (1 month for high risk, 3 months for medium risk, and six months for low risk), and identifying self management goals with the patient's caregivers.

The Principal Investigator for Phase II is Dr. Man Wai Ng, Dentist-in-Chief at Children's Hospital Boston.  Phase II is also guided by an Expert Faculty Group that includes Dr. Jay Anderson, DentaQuest Institute; Dr. Man Wai Ng, Children's Hospital Boston; Dr. Richard Scoville, Quality Improvement Advisor; Dr. Marty Lieberman, Neighborcare Health; Dr. Francisco Romes-Gomez, UCLA; Dr. Jessica Lee, University of North Carolina; and Dr. Peter Maramaldi, Simmons School of Social Work and Harvard School of Dental Medicine.

What We're Finding
"The importance of having reliable delivery of care for these young and vulnerable patients is critical," explained Dr. Anderson, Director of Practice Improvement for the DentaQuest Institute.  "We are in the beginning stages of data collection but we are building a body of evidence that this protocol is an efficient and effective way of treating and controlling early childhood caries as a chronic disease.  We are also putting equal emphasis on education and that is helping to establish essential systems that will help these children avoid recurrence of the disease as they grow into adolescence."  To learn more, contact Cindy Hannon, Quality Improvement Manager at cindy.hannon@dentaquestinstitute.org.