This cross-sectional study was undertaken to investigate the prevalence of untreated caries in north central Kentucky, USA and to examine the relationships between the available demographic variables and untreated caries. One third of the children had untreated caries reported by the dentists who performed the oral screening examinations in the schools. Children were significantly more likely to have caries if they lived in the metropolitan area, had not seen a dentist for 3 years or were uninsured.
Our finding that children residing in a metropolitan area were more likely to have caries is consistent with results reported by Maserejian and colleagues who reported that children living in the metropolitan area of Boston, Massachusetts, USA had significantly more caries than children from the rural setting of Farmington, Maine, USA, even after controlling sociodemographic factors. Similarly, Weyant and colleagues reported that children living in the metropolitan areas of Philadelphia and Pittsburg had the highest unfilled caries rate in permanent teeth than anywhere else in the state of Pennsylvania, USA.
Our finding differs from the North Carolina, USA study reported by Rozier and King who that found children residing in non-metropolitan areas adjacent to a metropolitan area to have higher rates of caries than children from metropolitan areas who had a lower caries rate. Their data was obtained from the Behavioral Risk Factor Surveillance System (BRFSS) and the Child Health Assessment and Monitoring Program (CHAMP) which may have used a different definition of metropolitan and non-metropolitan which could account for the difference in findings.
The 33% overall caries prevalence in our study suggests that there may have been little change in the prevalence of childhood caries since the 2001 Kentucky survey for the National Oral Health Surveillance System (NOHSS) which reported 34.6% caries prevalence. Although the children in our study ranged in age from 5 to 13 years, the mean age was 9 years which is approximately the age of the children screened for the NOHSS. The results are concerning given the fact that there is a dental school located in downtown Louisville, Kentucky along with numerous private and public dental practices located in all the study areas. In addition, programs to improve access to dental care such as SmileKentucky! have been ongoing for almost a decade in this part of Kentucky.
The fact that only one-half of the uninsured children who had untreated caries noted during the screening examination later received dental treatment is also of concern. Smile Kentucky! eliminated structural obstacles to dental care by providing free transportation and free treatment in the University of Louisville pediatric dental clinic. Over 500 uninsured children were invited to receive treatment and parents provided consent for 350 of these children. On the SmileKentucky! treatment days in February 2009, only 236 uninsured children were transported and received comprehensive dental care in the pediatric dental clinic.
Anecdotal reports suggest that some parents did not want their child to be treated without them being present, the parents may have had poor functional literacy which prevented them from understanding the written invitation to receive free transportation and dental treatment, or they already had a dental home for their child. The reasons for failure to consent and/or failure to show up for dental care should be further investigated to determine what psychosocial factors may have prevented so many children from receiving treatment.
More focused preventive efforts may be required to reduce caries in disadvantaged children including home-based and/or school-based interventions. There is a clear need to reduce the development of childhood caries in addition to getting children to the dentist for cleanings, fillings and extractions. Not only will this improve children’s oral health in the short and long term, but may also be more cost effective. Public health policy makers may need to consider programs where the most at-risk children are identified and are provided preventive interventions at the family and/or community level.
There is some evidence that a dental care coordinator can improve oral health outcomes for disadvantaged children. The American Dental Association supports the Community Dental Health Coordinator (CDHC) pilot program which trains students from urban, rural and Native American communities to provide brief oral assessments, oral health education, preventive dental services and assistance in accessing and obtaining dental treatment. The CDHCs are community health workers with dental skills focusing on education and prevention and are “part social worker and part dental assistant who, under the supervision of a dentist, can help people navigate the public health system to get the dental care they need.” The CDHCs are trained to work in the community’s schools, clinics, senior citizen centers, Head Start Programs and other public health settings under the supervision of a dentist.
Attention may also need to be again directed at effective caries prevention initiatives including school based educational, needs-related caries preventive, sealant and fluoride mouth rinse programs. Improving nutrition in public schools by reducing carbohydrates in meals and vending machines may also lead to reduced caries and have the added benefit of helping to reduce childhood obesity. Programs to educate pediatricians, primary care physicians and nurses in assessment of children’s oral health, counselling, referral for dental care, and application of fluoride varnish may also reduce caries development.
This study may have limitations due to the use of a convenience sample of children residing in counties in north-central Kentucky but the study’s large sample size of 3,488 children and data available for each child allowed for significant analyses of factors associated with untreated caries. The demographic information and dental history reported by parents was valuable but having more individualized information, such as actual household income, would have been beneficial. Another limitation was the lack of calibration of the almost 100 volunteer dental professionals who performed the oral screening exams. Although Smile Kentucky! is a community service program and calibration would have been difficult, future studies should include assessment of the reliability of the dental screening procedures across examiners. The study was also limited because the oral screening examinations were performed in the schools without the use of radiographs and as a result the untreated caries estimates may have been lower or higher than what truly existed[26, 27].