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Systematic Review: Is there evidence-based research that evaluates the effectiveness of
the current recommendation that the first oral health visit occur six months after the
eruption of the first tooth or by age one?
by
Heather K. Blair, RDH
BS, Vermont Technical College, 2011
Thesis Submitted in Partial Fulfillment
of the Requirements for the
Master's Degree in Public Health
Concordia University
October 2015
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Abstract
This systematic review evaluates the effectiveness of the current recommendation that the
first oral health visit occur six months after the eruption of the first tooth or by age one.
Early childhood caries is defined as dental decay before age 6. Early childhood caries is
an epidemic, which is a public health concern due to the growing prevalence within the
United States. Approximately 28% in 2004, which was a 4% increase from 1994. This
study will evaluate whether the recommended preventive visit by age one helps to lessen
the incidence of early childhood caries, by addressing questions such as: the risk factors,
how parent/guardian education impacts preventive care appointments, the most common
barriers to accessing preventive dental care, what the incidence of dental surgeries area
associated with early childhood caries and what the history has indicated as the trend for
early childhood caries.
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Introduction to the Study
These days it is not uncommon to hear a colleague, friend, family member or
child complain about having to go to the dentist to have a filling. For many people their
six month routine preventative care (dental prophylaxis) visit, is not their only routine
appointment.
Problem Statement
Many people, especially children have an oral disease – Dental Caries (Tinanoff,
Kanellis, & Vargas, 2002). Dental caries affects 60 – 90% of children (Yokoyama et al.,
2013). In children ages 0 -5, this form of dental caries is referred to as early childhood
caries. Dental caries is the most common chronic infectious disease of childhood, it is
five times more prevalent than asthma and seven times more prevalent than hay fever
(Benjamin, 2010).
Early childhood caries is considered a serious public health problem in both
developing and industrialized countries (Colak, Dulgergil, Dalli & Hamidi, 2013). It can
have a long-term effect on those it touches, children may experience dental pain, tooth
loss, impaired growth, decreased weight gain, delayed speech, negative appearance and
self-esteem, decreased school performance, school absences, and a negative quality of
life (Chou, Cantor, Zakher, Mitchell & Pappas, 2013). It could ultimately result in the
potential for loss of life, if untreated infection progresses, as in the case of Deamonte
Driver (Gavett, 2012). Early childhood caries may predict future dental health, as the
biggest predictor for future oral disease is a history of oral disease. According to
Kagihara, Niederhauser & Stark (2009), there has been an increase of 15.2% in children
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aged 2-5 years old from 1994 and 2004, and in preschool children more than one in four
experienced early childhood caries.
In both the general public and the health industry there seems to be confusion
regarding the age of the first preventive dental appointment. There are many reasons for
this: lack of insurance or funding, oral health awareness of the parent/caregiver, no
referral from the pediatrician, lack of access to dental care or dentists not taking children
under a certain age, and no transportation. Many professional organizations recommend
the first dental visit at age one or six months after the eruption of the first tooth, these
include the American Dental Association, American Academy of Pediatrics Dentistry,
and the American Academy of Pediatrics.
The goal of my systematic review is to provide a summary of the evidence-based
research that evaluates the current recommendation that the first oral health visit occur
six months after the eruption of the first tooth or by age one.
Purpose Statement
The purpose of my systematic review is to provide a summary of the evidencebased research that evaluates the current recommendation that the first oral health visit
occur six months after the eruption of the first tooth or by age one. This review will
evaluate the prevalence, incidence of early childhood caries, along with the, benefits and
any drawbacks associated with this visit.
Research Questions and Associated Hypotheses

What are the risk factors associated with Early Childhood Caries?
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
How does education of the parent/guardian impact early preventive dental
care?

What are the barriers to obtaining early preventive dental care?

What is the incidence of dental surgeries for Early Childhood Caries?

What has the history shown for prevalence of Early Childhood Caries in
recent years?
These questions are designed to provide evidence to support the hypothesis that
early preventive dental visits will lessen the incidence of early childhood caries.
Potential Significance
As previously discussed, early childhood caries is the most common chronic
multifactorial infectious disease of childhood that affects many children. This is at the
cost of the child’s oral health, emotional health, possibly systemic health and potentially
future oral health. However, there is a monetary cost associated with these interventions,
according to the Burden of Oral Disease in Vermont 2013, Expenditures for dental
services in the United States in 2003 were $74.3 billion, 4.4 percent of the total spent on
health care that year. In Vermont, 2010 health care expenditures totaled $4.93 billion;
dental services accounted for 4.3 percent of the total, or $214 million. Medicaid claims
for restorations (fillings), extractions, and endodontic treatment (root canal) for children
ages 0 – 5 in 2009, totaled 2,201. The total cost to the Medicaid program was 2.2 million
dollars, with an average per child cost of $1004 for restorative care and the maximum
cost for an individual child totaling $10,126. This is just a small sampling of what the
cost of oral health care can be. This is an indication that in addition to the physical,
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emotional and mental toll that oral disease can take on a child and family, it can also have
a significant financial impact. Which makes the early preventive dental visit worthy of
evaluation.
Background Literature Review
Search Strategy
A comprehensive literature search was conducted using PubMed, American
Dental Association, Academic Search Premier and CINHAL to identify relevant
published studies. The search terms/phrases that were used included: oral health, dentists
treating young children, age one dental visit, infant oral health, effects of early dental
visits, early preventive dental visit, and age one dental visit. There was a limit place on
language – English only. No limit was placed on country, however most articles were
from the United States. The dates included studies within the last 15 years. The
inclusion criteria focused on a study population of children ages 0 – 6 years old, dental or
medical appointments in which oral health was discussed, oral health interventions for
young children, and study outcomes – relating to oral health. The exclusion criteria was
limited to studies in other languages.
Theoretical Foundation
Health Belief Model
The Health Belief Model (HBM) will be used to exam and encourage people to
develop a routine of early preventive dental visits to lessen the incidence of early
childhood caries. DiClemente, Salazar & Crosby (2013), discuss the Health Belief
Model noting that it has been part of the public health practice for over 50 years and was
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“initially used to identify determinants of being screened for tuberculosis” (p. 86). The
HBM was developed in the 1950s in response to people failing to adopt disease
prevention strategies with the emphasis on these six areas: perceived susceptibility,
perceived severity, perceived benefits, perceived barriers, cue to action, and self-efficacy
(BUSPH, 2013). The HBM is successful when a person feels that a negative health
consequence can be avoid is a positive action is taken (an early preventive dental visit)
(ReCAPP, 2015). This is a value-expectancy model in which people must feel that
adopting the new behavior will out weight the negative risk or perceived threat of not
adopting the behavior or the perceived barrier to the risk (Riverside Community Health
Foundation, n.d.). Health belief theories allow for insight into the multiple factors that
influence health behaviors, whether they are negative behaviors or positive changes to
improve personal or community health.
Applying the Health Belief Model to the question (How does early preventive
dental care impact the incidence of early childhood caries?) a qualitative study comes to
mind to assess parental knowledge regarding the benefits of preventive oral health care at
a young age. If parents knew that early childhood caries is an infectious disease that has
the potential to being when teeth begin to erupt and is the most common chronic
childhood disease, which can lead to pain, interfere with ability learn, and could
potentially lead to death if left untreated with an acute infection (AAPD, n.d.). Then they
may be more apt to take their children for preventive care, as they would not want them
to develop caries – have acute tooth pain, affect their ability to learn and potentially set
them up for life long oral health problems (Chou, Cantor, Zakher, Mitchell & Pappas,
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2013). Early childhood caries is not a normal part of childhood, the HBM is a
mechanism to have people weight the risk of not having early preventive dental visits.
With education, support from their healthcare providers and method of payment (private
insurance, Medicaid, or private pay) then parents may increase their likelihood of
scheduling that early appointment.
Literature Review
The next three paragraphs will briefly review outcomes of interest, the
interventions or exposures and relationships among studies.
As previously noted Early Childhood Caries is the most common, chronic,
infectious disease in childhood and there are many interventions that have been
introduced to help combat this disease. One suggested intervention would be to have
primary care providers develop a strong foundation for the dental caries process, which
would include both enamel demineralization/remineralization, as well as how to prevent,
identify and refer for early intervention (Kagihara, Niederhauser & Stark, 2008).
Another intervention could be to introduce motivational interviewing with mothers of
young children to evaluate whether or not there would be a decrease in early childhood
caries and an increase in early preventive dental visits (Manchanda, Sampath & De
Sarkar, 2014). Lastly, a final intervention could be a computer simulation model which
identifies by geographic area which areas to focus on based on surveys from parents and
Medicaid insurance claims (Hirsch, Edelstein, Frosh & Anselmo, 2012). The potential
interventions could have a positive impact on the oral health of the children in the
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communities that are served. These interventions and others have noted both positive and
negative results in their outcomes in lessening the incidence of early childhood caries.
Interventions and exposures are a method to let the study investigators know
whether or not the outcome made a positive impact or not. A study by Plutzer & Keirse
(2014), found that providing first-time mothers with instruction on the prevention of early
childhood caries had a positive effect by increasing personal oral health and decreasing
dental service expenditures over time. A surprising outcome in a systematic review by
Chou, Cantor, Zakher, Mitchell & Pappas (2013), revealed that there was no conclusive
evidence that primary care providers that were doing oral health screenings had an effect
on the reduction of early childhood caries, although they did find a correlation between
topical fluoride application and lessened dental caries. In the final study that reviewed
outcomes, it focused on the small town of Chelsea, MA and found that there were many
factors that facilitated early childhood preventive visits and that there were some
significant barriers that influence the perceived inability to make and attend these
appointments. Within all these studies there are both positive results noted and negative
results that help to further develop more interventions that could be studied. These
outcomes will help
begin the discussion on the relationships between programs and
their outcomes.
The relationships or correlations that are recognized as a result of a good study
can be very beneficial to shaping the future of early childhood caries. There are times
when it is not the desired health response that is the most motivating part of a study,
rather it is a benefit that is a result of the desired health response, such as a noted
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reduction in the cost of dental care for children due to early preventive care (Savage, Lee,
Kotch & Vann, 2004). In North Carolina, there was an oral health program developed to
focus on preschool aged children which was integrated into primary care medical offices
and was successful in the reduction of dental caries in the targeted vulnerable population,
indicating that oral health could be addressed in a medical setting with a specific program
to target a specific population (Achembong, Kranz, & Rozier, 2014). In a systematic
review with a focus on the importance of early preventive dental visits from a young age,
found that there was a positive relationship noted for visits under age 3, however they
could not find significant evidence to support the age 1 visit, but further recommended
that more research is warranted (Bhaskar, McGraw & Divaris, 2014). These studies all
show a correlation with their topic of study and a decrease in the incidence of early
childhood caries. The relationships that are developed during the span of the studies and
correlation with lessening, maintaining or increasing early childhood caries have the
potential to change the standard of recommended oral health care.
Methods
This systematic review will be conducted in a manner to determine the whether
there is an oral health benefit in children attending early preventive dental. The use of a
systematic review will be to provide a comprehensive review of current literature on
early preventive dental visits and their impact on oral heath in an effort to answer the
proposed research questions, by combining the results of the reviewed studies. The
review of current literature will determine the answer for the hypothesis: If children are
exposed to early preventive dental visits, they will have better oral health. The null
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hypothesis would then be that early preventive dental visits have no effect on the oral
health of children.
Inclusion and exclusion criteria
Please refer to Table 1 for a list of inclusion and exclusion criteria.
Table 1
Inclusion/Exclusion Criteria
Inclusion Criteria
Population: Children under age 6
English language articles
Full text available
Peer reviewed study articles
Articles written in years 2010-2015
Human studies
Exclusion Criteria
Non-English language articles
Study articles written prior to 2010
Please refer to Table 2 for the results of the electronic search
Table 2
Electronic Search Results
Search Engine
Used
Search Terms
Academic Search
Premier
Boolen/Phrase
Early
Childhood
Preventive
Dental Visit
And age one
PeerReviewed
Full Text
CINAHL
Boolen/Phrase
Early
Childhood
Preventive
Dental Visit
Number of
Studies
identified
9
Number of
Studies
Excluded
6
Exclusion
Criteria Used
2
0
Not Animal
English Only
Prior to 2000
Not Animal
English Only
Prior to 2000
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And age one
PeerReviewed
Full Text
PubMed
Boolen/Phrase
Early
Preventive
Dental Visit
And age one
PeerReviewed
Full Text
18
12
Not Animal
English Only
Prior to 2000
Number of
duplicate articles:
2
Data analysis plan
At the completion of performing a literature review, there were twenty-nine
articles using the electronic search using three different search engines. After removing
two articles that were duplications between the three search engines, there were twentyseven left to screen. Of these articles, eighteen were then excluded, as they did not fit the
search guidelines and were article that had results for adults or for other diseases, some
just focused on pregnant mothers prior to birth and others only looked at older children.
Please refer to Figure 1 for the results of inclusion and exclusion criteria.
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Records identified through
database searching (n = 29)
Additional records identified
through other sources (n = 1)
Records after duplicates removed
(n = 2)
Records screened
(n = 28)
Records excluded
(n = 19)
Full-text articles
assessed for eligibility (n
= 9)
Full-text articles
excluded, with reasons
(n = 0)
Studies included in
systematic review (n =9)
Qualitative Studies (n=1)
(n1)11)
Quantitative Studies (n=8 )
Figure 1. Results of Inclusion and Exclusion Criteria.
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Table 3 (A demonstration of how results will be presented)
Included Studies and Effects
Author(s)
and Year
Research
Design
Main
Argument/
Hypothesis
Key concepts/
assumptions
Results
Bhaskar,
McGraw,
Divaris,
2014
Systematic
Review
Review of the
early preventive
dental visits and
whether there is
a correlation
with less dental
disease.
Dental caries is
the most
common
chronic
childhood
disease. The
standard of
care is a visit
by age 1.
The recommendation for
the year 1 visit is weak.
Recommends more
research.
There are benefits noted of
an exam before age 3 for
children at high risk.
There is a link between
early preventive dental
visits, being associated
with more preventive
visits and may be
associated with reduced
restorative visits, lessening
expenditures.
Some studies
have shown an
increase in
restorative care
that is
associated with
early
preventive
dental visits.
Other studies
show a
decrease in the
amount spent
on restorative
care and an
increase spent
on preventive
The results of the study
found that children that
had early preventive visits
had less nonpreventive
dental visits and more
preventive dental visits.
There is a feeling that this
improves the quality of
life, due to less oral health
problems.
The study also found a
need for continued
research in this area.
Early
Bisakha,
Econometric preventive
Blackburn, Cohort
dental visits are
Morrisey,
Study
considered
Kilgore,
important there
Becker,
is little
Caldwell,
information
Menachemi,
available to
2015
support this.
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Savage,
Lee, Kotch,
Vann, 2004
Determine how
early preventive
Longitudinal dental visits
cohort study impacted the
costs of dental
services among
pre-school aged
children
care for those
that have had
early
preventive
visits.
There is
evidence that
supports the
reassessment
of strategies
for high-risk
preschool aged
children. Early
childhood
caries is a
disease that is
on the rise and
with it are the
rise costs
associated with
the restoration
of the teeth
affected.
Medicaid children that
utilized the early
preventive dental visit
model were associated
with less cost for oral
health care and had more
preventive care
appointments. Although it
was noted that children
from minorities had
greater difficulty in
finding a dental home and
those in counties with
fewer dentists had
difficulty accessing care.
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