Early Childhood Caries Redux

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					   Early Childhood Caries
         Burton L. Edelstein DDS MPH
        Chair, Social & Behavioral Sciences
Columbia University School of Dental and Oral Surgery
 Founding Director, Children’s Dental Health Project
    What if ECC Were First
Discovered Today – in Chicago?
                  Chicagoland Tribune
             New Disease Outbreak in Toddlers
Chicago 2/19/04
   The Centers for Disease Control and Prevention in Atlanta
   yesterday reported the appearance of a devastating and
   rampant disease affecting young children in greater
   The condition, provisionally termed “toddler brown tooth
   syndrome (TBTS)” was first reported by pediatrician Stew
   Lampiris who thought it to be a previously known defect in
   tooth development.
   But Lampiris was suspicious of a new disease entity because
   the stain appeared to be spreading and the child was reportedly
   “in pain, unable to sleep or eat well, and was showing
   particularly bad temper.” (continued page A4)
                Chicagoland Tribune
         New Disease Outbreak in Toddlers
(continued from page A1)
   Lampiris stated that “the child’s acute distress was alarming
   and the extent of brown discoloration, especially on the front
   teeth, was greater than I had seen in other cases of dental
   CDC authorities likened the finding to initial reports of
   Chinese Avian Flu and stated that it’s experts will follow
   similar investigative procedures. CDC is today sending a team
   of epidemiologists, physicians, and medical scientists to study
   the extent, cause, management and control of this outbreak.
           TV-113 News Special
In new developments today on the Toddler Brown Tooth
Syndrome, CDC’s rapid response team epidemiologists
reported “what we now know” about the outbreak.
• The outbreak is much more extensive than previously
thought. “Nearly one-fifth of the 2-4 year olds we have
examined have clear visible evidence of TBTS”
• Children in poverty have much higher rates of disease.
“Poor children are more than twice as likely to have TBTS.
Affected poor children have more than twice as many
brown teeth as affected higher-income children.”
CDC experts estimate that if this condition spreads across
the country, “nearly one and a half million preschoolers will
have this new disease this year.”
 TV 113 TBTS Fact of the Day
TBTS 5X More Common Than Asthma!
      TBTS Occurence Compared with Asthma
           Occurence in 2-4 Year Olds





             Asthma              TBTS
  TV 113 TBTS Fact of the Day
TBTS Hits 2X More Low-income Kids

   decayed teeth (dft) x 5






                                    Overall      0-   101-200% 201-300%   >300%
                                              100%FPL    FPL      FPL      FPL
TV 113 TBTS Fact of the Day
 TBTS Hits More Minority Kids
decayed teeth (dft) x 5

                                 Overall   White   Black   Hispanic
  Chicago Tabloid Daily

Live in
        CDC Investigation Report
        CDC scientists working in Chicago to discover the
cause of TBTS made significant progress today with the
finding that this devastating condition of toddlers may be
infectious in origin.
        CDC’s found that “all children affected with TBTS
harbor a bacteria from the streptococcus family (a mutans
variant).” Scientists note, however, that “not all children
who have this bacterium in their mouths have TBTS.”
        As scientists continue to investigate these
apparently conflicting findings, they are seeking to discover
the source of the bacterium and to determine why some
infected children do not have TBTS.
             Chicagoland Tribune
 New Report on TBTS Outbreak Cause
Chicago 3/2/04
  The Centers for Disease Control and Prevention in
  Atlanta yesterday released further information on its
  TBTS investigation. Surprising discoveries include
  the finding that mothers of affected toddlers appear to
  be the primary source of the infection and that the
  responsible bacteria (“mutans streptococci”) appear to
  be conveyed to children through saliva. Women’s
  groups across Chicago responded with……
     Channel 113 News Update
CDC continues to investigate the controversy over the
cause of TBTS. CDC today released a technical advisory to
US physicians that states:

“The family of bacteria, mutans streptococci, now appear to
be a necessary but not sufficient cause of TBTS. We
advise that precautions to limit transmission of these
bacteria from mothers to their young children be
implemented as a first step in controlling the outbreak.
CDC continues to work to identify additional causative
factors that may explain why only some infected children
exhibit symptoms.”
   Chicago Tabloid Daily

Infant in
Baby Begs
for Relief!
Health Department Public Forum
At a public forum yesterday, the Health Commissioner
called for public calm as scientists seek to
understand and control TBTS. He released new
information showing that:
• Most severe cases are found in children who use
bottles or sippy cups all day and at night.
• Frequency of sugar exposure is suspected as a
main cause.
• First signs of TBTS may be white markings on the
teeth. Parents are advised to check daily for these
marks and report them to their physicians.
• Children as young as 10 months may be affected
but two year olds are most common.
 TV 113 TBTS Fact of the Day
TBTS Related to Harmful Feeding?
            % Preschoolers Exposed to
             Harmful Feeding Practices

       Overall          Minority         Low Education
Health Department Public Forum

 Early-Stage TBTS   Advanced TBTS
         Head Start TBTS Report
US Head Start officials released new data on TBTS among
   low-income preschoolers in Head Start showing:

1.   Head Start Directors reveal that 60% of children show
     signs of TBTS
2.   One Director claimed that “Dental pain in our low-
     income preschool kids exists and is coming at us like a
     tidal wave.”
3.   Another Director reported that “This disease is tragic
     for the development of our children. How can children
     learn, grow, and mature when they are in constant
     pain and have draining pus flowing into their mouths?”
 TV 113 TBTS Fact of the Day
TBTS Causing Pain – Especially in
         Minority Kids
          Children with Dental Pain

         White                        Non-White
             Chicagoland Tribune
     Breaking Research on TBTS Symptoms
Researchers at the University of Michigan School of Dentistry
today released a study on how TBTS impacts toddlers “quality of
Researchers asked questions about the child’s ability to bite, eat
sweet foods, and eat hot and cold foods. They also asked about
the child’s ability to sleep through the night and whether the child
complains about his or her teeth.
Comparing 69 children struck with TBTS with 43 who have been
spared, researchers found that “children with TBTS have
significantly lower… quality of life than children without TBTS.”

                              (Pediatric Dentistry 25/5:431, Filstrup et al)
               Chicagoland Tribune
               Congress Takes Up TBTS
The House of Representatives Subcommittee on Health today
convened a special hearing on TBTS which has now been
discovered in every state and the District of Columbia. Official
witnesses included the Director of CDC, Administrator of the
Maternal and Child Health Bureau, Director of the National
Institute for Dental and Craniofacial Research, and the US
Surgeon General.
The witness who garnered greatest attention was not a public
official but Mrs. Wilma Carothers, mother of 23 month old Sam
who suffers from TBTS. Mrs. Carothers, wife of IL99th District
Representative Mark Carothers, put a human face on this new
acute disease of young children – describing his pain, inability….
          NIDCR Update on TBTS
NIDCR’s leading dental scientists today reported that:
• Vaccines are ineffective against TBTS because the
  mutans bacteria are not typical pathogens and cannot
  be reached in their location on the teeth.
• Reducing mutans by tooth brushing has been found to
  be modestly effective in slowing the progression of
• Fluorides applied to the teeth appear to slow and even
  reverse TBTS.
• Traditional dental repair has little impact on TBTS
  progression and recurrence rates are high.
• TBTS appears to be a multifactorial disease that will
  require behavioral interventions.

    What if ECC Were First
Discovered Today – in Chicago?

Its understanding, management,
treatment, and prevention would
be based on observations about
 its nature, rather than on dental
      traditions tied to repair.
      The Nature of ECC (TBTS)
1. Caries is a disease
2. Caries is infectious
3. Cariogenic bacteria are transmissible within families
    when children are infants or toddlers
4. Caries is diet dependent
5. Caries is fluoride mediated
6. Caries is progressive and destructive but reversible
7. Caries is consequential to children’s & families’ lives
8. Caries is highly prevalent among toddlers
9. Caries is inequitably distributed
10. Caries is little affected by dental repair
    Implications of Understanding
      the Nature of ECC (TBTS)
1. Infectious and transmissible: Caries would be
   managed as an infectious disease by limiting early
   transmission of cariogenic bacteria and suppressing
   bacteria once established
2. Diet dependent: Caries would be managed as a
   dietary disease by controlling the frequency of
   cariogenic exposures
3. Fluoride mediated: Caries would be managed as a
   reversible disease by increasing host resistance and
4. Inequitably distributed: Disease management
   resources would be focused on highest risk groups
     Implications of Understanding
       the Nature of ECC (TBTS)
5.   Inequitably distributed: Children and families would be
     assessed for risk level before disease onset.
6.   First seen as white spots: Early diagnosis and
     management would be routine.
7.   Early onset: Medical primary care providers would play
     a dominant role in disease prevention. Dental visits
     would begin by age one.
8.   Intervention: Dental repair would be considered
     prosthetic and would only be initiated after the disease
     was controlled. Materials that are bioactive would be
9.   Progressive: Disease would be “staged” and treated
     according to stage
    Implications of Understanding
      the Nature of ECC (TBTS)
•  Policymakers would develop funded programs for its
•  Press would keep the issue in front of the public
•  Parents would seek information and learn how to
   prevent and control it
•  Advocates would campaign against its continuance
•  Professionals would convene meetings and promote
•  Groceries and pharmacies would hold free screening
            …….Until it was eradicated!
Raw Potential -- But Vulnerable
   How Things Would Be Different
            TBTS                         ECC
First visit age: prenatal,   First visit age: 3 years
  then 3-6 months              or symptoms
Prevention: limit            Prevention: hygiene,
  transmission                 diet, fluoride
  (primary)                    (secondary)
Primary therapy:             Primary therapy:
  disease management           restorations
Interventions:               Interventions:
  risk-based                   symptoms-based