Early Childhood Caries (ECC) Collaborative

ECC Phase III teams are off and running!

Teams are currently testing changes, collecting data, and working with national clinical and quality improvement experts to implement the practices and protocols of disease management for early childhood caries.

ECC Phase III has almost 40 sites from across the United States working as part of a Breakthrough Series Collaborative. They are testing changes, collecting data, and working with nationally recognized clinical and quality improvement experts to implement the practices and protocols of disease management for early childhood caries. Teams started in August 2013; Phase III extends through February 2015.

The Problem
Early Childhood Caries (ECC), or tooth decay in very young children, is a chronic, infectious dental disease. Yet, ECC is almost completely preventable. Children with ECC may have pain, difficulty with eating, sleeping and speech and affect learning in the classroom. If left untreated, ECC can impact the proper development of permanent teeth.

Many children with ECC require surgical treatment at hospital-based dental clinics or with sedation or general anesthesia in the operating room. However, despite receiving such costly surgical treatment, high rates of children develop new and recurrent decay.

The Need
Hospital-based dental clinics and dental safety net programs such as Federally Qualified Health Centers (FQHC) and school-based programs care for a disproportionate number of low-income and racial and ethnic minority children with early childhood caries. Many of the children require surgical treatment. However, months-long backlogs for expensive operating room care and a high rate of relapse after treatment are common.

About 28% of preschoolers and 51% of 6 to 11 year olds have cavities.

What We Did - ECC Phase I
In 2008, the DentaQuest Institute, Children’s Hospital Boston, and St. Joseph's Health Services of RI 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. Over the next 24 months, more than 450 children were enrolled, received caries risk assessments, risk-based preventive and restorative care, and recall based on their caries risk.

The goal was to reduce the rate of new decay in patients treated by 33%, reduce the number of patients treated in the operating room by 20%, and reduce the number 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 Boston Children’s’ Hospital, and Dr. Dan Kane, Director of Dentistry at St. Joseph's Health Services of RI.

The ECC pilot used an evidence- and risk-based disease management approach adapted from the concept of chronic care management of medical conditions. The two hospital dental clinics evaluated and classified (low/moderate/high risk) each enrolled child between six and 60 months of age, and then used every follow-up appointment to engage and re-educate the guardians of the children. Finally, each child was introduced to a dental home, ensuring access to reliable preventive and restorative care for ongoing support and coordinated follow up evaluations. In the process of meeting this objective, investigators at Boston Children's Hospital also tracked the cost per case.

ECC Phase II

In 2011, the DentaQuest Institute launched Phase II with the ECC Collaborative. Seven FQHC's and hospital-based dental clinics began implementing and testing the disease management protocol with patients six months to 5 years old who presented with at least one caries lesion. Participating groups were Holyoke Health Center (Holyoke, MA), Boston Children's Hospital (Boston, MA), Nationwide Children's Hospital (Columbus, OH), NeighborCare Health (Seattle, WA), Native American Health Center (San Francisco, CA), St. Joseph's Health Services of RI (Providence, RI), and University Pediatric Dentistry (Buffalo, NY).

Using a modified CAMBRA approach, teams at each site followed the established protocol: evaluate and classify (low/moderate/high risk) each enrolled child between six and 60 months of age, provide oral health educational information to and engage caregivers to make changes in dietary and oral hygiene practices (through self-management care plans), and provide risk-based preventive and surgical care as needed and desired by the caregivers. In addition, teams collected monthly and quarterly data about risk, pain due to untreated decay, and new cavitation. Each test site focused 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.

Phase II sites successfully demonstrated that a disease management and prevention model in oral health care improves patient care delivery and improves patient outcomes. The data and evidence collected will lead to expanded adoption among oral health providers.

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

The work of the ECC collaborative and the results demonstrated have been reported in several national journals and publications, including the International Journal Dentistry, the Journal for Healthcare for the Poor and Underserved, the Dental Clinics of North America, the Boston Globe and the New York Times.

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

Phase II continued with positive results.

Results reflect a random sample of 438 children/families drawn from a total ECC Collaborative population of 3,030.

Where We Are Going
In Phase III, teams are working to re-design their care delivery systems, such that every child six months to five years of age receives a caries risk assessment, the parent receives an explanation of the caries process and an invitation to collaborate with the care provider to collaborate in preventing and managing their child’s disease and caries risk. Children determined to be medium and high risk return more frequently for caries risk assessments and to receive preventive care to improve their child’s caries risk.

"The importance of having reliable delivery of care for these young and vulnerable patients is critical," explained Dr. Rob Compton, Executive Director of the DentaQuest Institute. "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 about the Early Childhood Caries Collaborative, contact Cindy Hannon, Manager of Quality Improvement at cindy.hannon@dentaquestinstitute.org.