Early Childhood Caries in American Indians/Alaska Natives A Pediatric Infectious Disease with Dental Manifestations
Steve Holve, MD Chief Consultant in Pediatrics Indian Health Service “The remarkably low amount of caries among Indians is worthy of further study.”
• Survey of Navajo Nation in 1933 • Almost no cavities seen • Diet meat based
Journal of Dental Research vol 15(5) 1936 Caries in the Navajo Increased with Exposure to Anglo Diet • Survey of teenagers in 1958 • Children living in
remote camps had QuickTime™ and a decompressor are needed to see this picture. <1.0 DMF • Children attending boarding schools had 4.47 DMF
•Arch Oral Biology vol I 1959 The Inuit of Alaska and Canada
• With traditional diet <1% of children with caries QuickTime™ and a • Increased contact with decompressor trading posts lead to are needed to see this picture. increased caries • Inuit living in towns had caries rates >80%
J Dent Res vol 14 1934 The Diet Paradigm in ECC in AI/AN
“Caries have increased materially among the Eskimo since they have come into contact with civilization. And since their food habits are known to have changed there can be no doubt that diet is the predisposing factor for the increasing prevalence of dental caries.”
Amer J of Phys Anthro vol 16(4) 1932 The Infectious Disease Paradigm of ECC in AI/AN • The change from a traditional diet to a “modern” diet was a necessary but not sufficient factor • There is no evidence that the current diet in AI/AN is worse than the general US diet, merely the same • The cause of the disparity is the acquisition of Streptococcus mutans at an earlier age and at a higher load • We will not reduce the ECC disparity in AI/AN until we treat the infectious component Infectious Diseases in AI/AN Children • Occur at rates 2-10 times higher than the general US population • Occur at younger ages • The incidence is highest in Alaska and the Southwest • The regions with the highest rates of poverty and crowding are the regions with the highest rates of ECC Poverty Rate for Children
US Census 2000
Poverty Rate for Children < 5 years old
60 50 40 30 20 Percentage 10 0 Navajo All AI/AN US white Household Crowding
US Census 2000
Percent in crowded Housing > 1 person/room
70 60 50 40 30 20 Percentage 10 0 Navajo All AI/AN US all races Sanitation Services
US Census 2000
Homes Lacking Complete Plumbing
40 35 30 25 20
Percent 15 10 5 0 Navajo All AI/AN US allraces H. pylori Prevalence
Children Adults < 2 years US 3% 30%
Apaches 54% 77%
Canadian 67% NA Inuits
JClin Micro June 2003 Helicobacter 7(2) April 2002 Lower Respiratory Tract Infections: Annual Rate per 1,000 Children 1999-2001
Category Hospitalizations per 1,000 US < 1year 63
AIAN < 1 year 116
Alaska < 1 year 204
US 1-4 years 11
AIAN 1-4 years 14
Alaska 1-4 year 20
Peds IDJ 24(4) April 2005 Haemophilus Influenzae type b
Prevaccine Era Incidence per 100,000
US < 5 years 60
US NP Colonization 2%
US Peak age of onset of 6-12 months illness SW < 5 years 500
SW NP colonization 7%
SW Peak age of onset of 2-6 months illness
Amer J Pub Health 90(10) Oct 2000 Is Hib in AI/AN a Different Disease?
• Earlier onset of illness • Vaccines that were efficacious in the general population were not in the AI/AN population • Required a vaccine with earlier immunogenicity
QuickTime™ and a decompressor are needed to see this picture.
Peds 2006118 e421-429 Implications of the Infectious Disease Paradigm of ECC
• Increased risk of ECC in AI/AN related early acquisition of MS • Risk is socioeconomic, not genetic • Increased risk in other indigenous groups such as Maori and Aborigines who have no genetic relation to AI/AN Infectious Disease Paradigm of ECC
• May explain elevated risk for ECC in all groups in poverty
• ECC may become a worldwide problem as diets change in the developing world