Prevalence of Early Childhood Caries among Children at Two Community Health Centers in Hawaii

Research Article

J Dent & Oral Disord. 2017; 3(5): 1072.

Prevalence of Early Childhood Caries among Children at Two Community Health Centers in Hawaii

Logigian JL¹* and Okuji DM²

¹NYU Lutheran Advanced Education in Pediatric Dentistry-Hawaii, USA

²NYU Langone Health System, New York, USA

*Corresponding author: Jennifer L. Logigian, NYU Lutheran Advanced Education in Pediatric Dentistry- Hawaii, USA

Received: June 28, 2017; Accepted: August 03, 2017; Published: August 10, 2017


Purpose: The purpose of this cross-sectional study was to compare the prevalence of Early Childhood Caries (ECC) among children under age 6 in two Federally Qualified Community Health Centers (FQHC) in Hawaii, one urban and one rural.

Methods: Thirty-seven children who met inclusion criteria received a clinical examination and had their Decayed, Missing and Filled Teeth Index (DMFT) score recorded. The parent of each child filled out a self-administered ten-question survey regarding caries risk factors, oral health practices and demographic information.

Results: The average number of decayed teeth per child was 5.6, with the urban average being lower (4.2) than the rural (7.5) DMFT scores were not normally distributed so Wilcoxon-Mann-Whitney and Kruskal Wallis tests were performed to test for differences between mean values of scores; the data showed slight difference in prevalence of ECC between sex, race and among children born outside of the United States, but these were not statistically significant. The hypothesis that children in the rural FQHC would have higher median DMFT scores than those in the urban FQHC was supported by the data (p=0.03).

Conclusion: Children in the rural FQHC had a higher prevalence of DMFT than children in the urban FQHC. Parent-reported habits and home care practices did not seem to accurately correspond to patients’ DMFT score and clinical presentation, indicating that many parents may have inaccurately reported on the self-administered questionnaire.

Keywords: Early childhood caries; Community health; Dental


ECC: Early Childhood Caries; S-ECC: Severe Early Childhood Caries; FQHC: Federally Qualified Community Health Centers; KKV: Kokua Kalihi Valley Comprehensive Family Services; LCHC: Lanai Community Health Center; DMFT: Decayed, Missing, Filled Teeth; AAPD: American Academy of Pediatric Dentistry


The state of Hawaii is unique both in its population make-up and its geographic location. While many think of Hawaii as simply a vacation destination, there are over1.4 million residents who call the islands home, and close to 22% of these residents are children under the age of 18 [1]. Data from the 2010-2014 United State Census indicates that Native Hawaiians, Asians and Pacific Islanders make up the majority of the population of the Hawaiian Islands; this is in contrast to population and demographic data from the other 49 states, of which non-Hispanic whites, non-Hispanic blacks, and Hispanics or Latinos compromise the racial majorities [1,2]. The number of Native Hawaiians living in Hawaii has continued to increase over the past century as well [3]. Likewise, the geography of Hawaii is particularly distinct from other states, in that it is comprised of eight main islands, seven of which are inhabited. Each island has a different racial/ethnic makeup as well as varying degrees of access to medical and dental care.

Unfortunately, Hawaii has continued to rank among the worst performing states in terms of oral health. In 2015 Hawaii was one of only three states to receive a score of “F” on its oral health report card published by The Pew Center on the States, marking the fifth year in a row it received the lowest possible grade [4]. A 2015 report on oral health issued by the Hawaii State Department of Health: Family Health Services Division found that adults living outside of Honolulu County were less likely to have seen a dentist in the past year than those living within Honolulu County. In order to access dental services, residents often have to travel between islands to find providers and specialists who can provide needed care. In 2009 3,633 people were transported from their home island to Honolulu for dental services, at a cost of $1.2 million; of these, 87% (3,153) were children [5].

Clearly, there is a need for improved oral health education and access to care in Hawaii, however it is also essential to take into consideration that the racial and ethnic background of the population varies significantly from the rest of the country. It might then be inferred that oral health habits as well as childhood caries prevalence may vary significantly from island to island, depending upon cultural factors and resources available. Understanding these attitudes and challenges can allow us to better tailor preventative and early education programs to the different populations in Hawaii.

In addition, there is quite a bit of existing literature that has demonstrated a link between geographic location – as well as access to dental care – and the prevalence of Early Childhood Caries (ECC). Similar research has been conducted in India, Africa and Australia that has found a greater prevalence of ECC among children in rural areas where access to dental services is often limited.

The purpose of this cross-sectional study was to compare the prevalence of ECC among children under age 6 in two Federally Qualified Community Health Centers (FQHC) in Hawaii, one urban and one rural.

Materials and Methods

The Institutional Review Board of NYU Lutheran Medical Center as well as the executive directors of Kokua Kalihi Valley Comprehensive Family Services (KKV) and Lanai Community Health Center (LCHC) approved the survey and informed consent protocol.

KKV is a health center located in urban Honolulu on the island of Oahu, the most populous island in Hawaii (almost 1 million residents); LCHC is the only community health center on rural Lanai Island, the second least populated island (just over 3,000 residents) and the second smallest island of the inhabited islands of Hawaii. Study participants were selected on the basis of location and had to be patients of one of two federally qualified health centers either KKV or LCHC. Participants were also selected on the basis of age and had to be 71 months or younger at the time the survey was completed, in accordance with the American Academy of Pediatric Dentistry definition of early childhood caries [6]. Children of both sexes and from all ethnic backgrounds were eligible to participate in this study. Exclusion criteria were limited to children who were not patients of either KKV or LCHC and who were older than 71 months of age. No attempts were made to seek out participants who met the inclusion criteria; rather patients who presented for regularly scheduled exams were screened at the time of check-in for eligibility to participate in the study.

Data was collected at KKV over the course of 6 weeks in February- March 2016 and at LCHC over the course of 4 weeks in April 2016.


A questionnaire was created that sought to address issues related to maternal understanding of oral health, children’s home care habits and diet and past dental history [7,8]. Much literature exists to support a strong relationship between high caries risk in children and low educational attainment in the parent as well as low socioeconomic status [9-11]. Published studies conducted to assess correlation between caries prevalence and risk factors among children were referenced [12-20]. The questionnaire also utilized questions that were adapted from existing published studies that had been previously standardized and/or validated or from existing caries risk indicators [21-24].

Verbal and written consent was obtained from the parent(s) at the time of the exam. In the instance that a parent was not fluent in English, an on-site interpreter was available. This was only necessary in one of the thirty-seven cases; the preferred language was Chuukese and a native speaker was utilized to verbally interpret the consent and the survey for the parent.

The questionnaire was distributed to the parent of each study participant and was self-administered.


The criteria for Early Childhood Caries (ECC) and Severe Early Childhood Caries (S-ECC) were taken from The American Academy of Pediatric Dentistry (AAPD).ECC is defined as, “…the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger.” S-ECC is any sign of smooth-surface caries in a child younger than 3 or, “From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of =4 (age 3), =5 (age 4), or =6 (age 5) surface” [6].

A clinical examination was completed on participants who presented to the clinics for scheduled examinations (ADA dental codes: D0145, D0120, D0150). Findings were based only on visual examination and using the decayed, missing, filled index according to the process outlined by the World Health Organization [21,25]. Identification of carious and white-spot lesions was completed using the evidenced-based recommendations published by an expert panel convened by the American Dental Association Council on Scientific Affairs in 2008 [26]. Visual examination was completed after cleaning and drying the teeth. Additional criteria for identifying carious lesions were taken from the Association of State and Territorial Dental Directors and the textbook Pediatric Dentistry: Infancy through Adolescence [8,27]. No invasive or irreversible procedures were completed as part of the examination. A Single Licensed Dentist (JLL) completed all examinations.


A total of thirty-seven children were included in the study, 60% (n=22) of these children were from the urban (KKV) clinic and 40% (n=15) from the rural (LCHC) clinic. The mean age was 3.16 years old, with a younger mean age at KKV (2.7) than at LCHC (3.8). While the gender distribution was relatively even overall (46% female, 53% male), and was somewhat similarly represented at KKV (59% female, 41% male), LCHC had a much different gender distribution and males were better represented in the study sample than females (27% female, 73% male). The majority of children identified as Filipino (30%), Native Hawaiian (27%) or Other Pacific Islander (24%), though there was a greater percentage of Filipino (36%) and Other Pacific Islander (36%) patients at KKV than at LCHC, where the majority (60%) were Native Hawaiian. At both clinics the vast majority of children (n=35, 95%) were born in the US. There were a much higher number of parents with graduate-level education at KKV (45.5% compared with 13% at LCHC); this may be due to study wording and is discussed in the limitations section below (Figure 1.).

Citation:Logigian JL and Okuji DM. Prevalence of Early Childhood Caries among Children at Two Community Health Centers in Hawaii. J Dent & Oral Disord. 2017; 3(5): 1072. ISSN:2572-7710