The Diet and Early Childhood Caries (DECC) Study: Validation of a Novel ECC Risk Assessment Tool and Investigation of Diet-Related ECC Risk Factors Christie L. Custodio-Lumsden Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Under the Executive Committee of the Graduate School of Arts and Sciences COLUMBIA UNIVERSITY 2013 ©2013 Christie L. Custodio-Lumsden All rights reserved ABSTRACT The Diet and Early Childhood Caries (DECC) Study: Validation of a Novel ECC Risk Assessment Tool and Investigation of Diet-Related ECC Risk Factors Christie Custodio-Lumsden Early Childhood Caries (ECC) is a highly prevalent disease afflicting approximately 28 percent of children in the U.S. under the age of 6 years (Bruce A Dye et al., 2007). ECC is a serious condition that can have profound health implications, including altered physical appearance, impaired ability to chew and speak, diminished quality of life, and increased risk for both oral and systemic health conditions (Colares & Feitosa, 2003; B. L. Edelstein, Vargas, & D, 2006; Norman Tinanoff & Reisine, 2009). Early identification of risk and prompt, targeted intervention is essential to overcoming the rising rates of ECC. The Diet and Early Childhood Caries (DECC) study was designed to evaluate a novel risk assessment tool, MySmileBuddy (MSB), in a predominantly Spanish speaking, low income, urban population. MSB serves as an interactive platform for education and goal setting for ECC prevention and a comprehensive ECC risk assessment tool that incorporates questions evaluating diet, feeding practices, general attitudes and beliefs, fluoride use, and family history. A large component of the MSB tool is devoted to the assessment of dietary risk factors related to ECC via inclusion of a modified 24-hour dietary recall. A primary aim of the DECC study was to establish concurrent criterion validity by evaluating if MSB diet and comprehensive scores were associated with physical evidence of risk (i.e., oral mutans levels, decalcifications, visible plaque, and ECC status). Additionally the DECC study aimed to examine associations between physical evidence of caries risk and overall frequency of oral exposures, length of exposure time, and body mass index-for-age (BMI/age). Lastly, the DECC study was designed to assess the preliminary impact of the MSB intervention on recollection of stated goals and progress toward achievement of targeted ECC-related behavior changes one month post-intervention. In 108 parent/child (caregiver/child) dyads, the MSB diet risk scores were found to be significantly associated with early stage indicators of caries risk, specifically oral mutans levels (p < 0.05), and borderline associated (p < 0.1) with visible plaque levels. The MSB comprehensive risk score was also found to be significantly associated with both oral mutans and visible plaque (p < 0.05). Children with high MSB risk scores (diet and comprehensive) were more likely to have higher levels of oral mutans, and more likely to have higher levels of visible plaque compared to children with lower scores. Physical indicators of caries risk were not associated with other factors included in the DECC study (i.e., frequency of oral exposures and intake of individual food/beverage categories, length of oral exposure time, and BMI/age weight status). Preliminary data from the one-month follow-up suggests that the majority of parents/caregivers were able to recall their MSB goal and were beginning to initiate diet- and other dental-related changes at home. Overall, these findings suggest that the MSB tool may be a valid tool for predicting known physical precursors to caries and may be an effective avenue for behavior change. While these preliminary findings are encouraging, larger and longer-term studies will be necessary to determine the ultimate utility of MSB in predicting the ECC experience in children. TABLE OF CONTENTS PAGE CHAPTER 1: Introduction 1.1 - Introduction ................................................................................................................ 1 1.2 – Rationale ................................................................................................................... 6 1.3 – Purpose ...................................................................................................................... 10 1.4 – Research Questions and Hypotheses ......................................................................... 11 1.5 – Significance ............................................................................................................... 13 1.6 – Scope and Delimitations ........................................................................................... 15 1.7 – Definition of Key Terms ........................................................................................... 17 CHAPTER 2: Literature Review 2.1 – Oral Health Impact and Consequences ..................................................................... 20 2.1.1 – Systemic Health Consequences ......................................................................... 21 2.1.2 – Impact on Nutrition Status ................................................................................ 23 2.1.3 – Quality of Life ................................................................................................... 25 2.1.4 – Academic Achievement .................................................................................... 27 2.1.5 – Economic Impact ............................................................................................... 28 2.2 – Early Childhood Caries Prevalence .......................................................................... 35 i TABLE OF CONTENTS PAGE 2.3 – Oral Health Disparities ............................................................................................... 37 2.3.1 – Race/Ethnicity and Immigration Status ............................................................. 38 2.3.2 – Socioeconomic Status ....................................................................................... 44 2.4 – Early Childhood Caries Etiology .............................................................................. 47 2.4.1 – Bacteria .............................................................................................................. 48 2.4.2 – pH Balance ........................................................................................................ 51 2.4.3 – Diet .................................................................................................................... 53 2.4.4 – Oral Self-Care ................................................................................................... 54 2.4.5 – Conceptual Models ............................................................................................ 55 2.5 – Diet and Early Childhood Caries .............................................................................. 59 2.5.1 – Cariogenicity of Foods and Beverages .............................................................. 60 2.5.2 – Intake Patterns, Oral Exposure Time, and Dental Caries .................................. 66 2.6 – Early Childhood Caries Treatment and Interventions ............................................... 72 2.6.1 – Traditional Treatment Methods ......................................................................... 75 2.6.2 – Disease Prevention ............................................................................................ 77 2.7 – Diet and Oral Health Recommendations for Children .............................................. 89 ii TABLE OF CONTENTS PAGE 2.7.1 – USDA Dietary Guidelines ................................................................................. 89 2.7.2 – Oral Health Recommendations ......................................................................... 91 2.8 – Early Childhood Caries Risk Assessment Tools ....................................................... 100 2.9 – Development of MySmileBuddy .............................................................................. 111 2.9.1 – Model and Theoretical Framework ................................................................... 112 2.9.2 – Dietary Risk Assessment ................................................................................... 115 2.9.3 – Comprehensive Risk Evaluation ....................................................................... 117 2.9.4 – Education and Goal Setting ............................................................................... 118 2.10 – Study Rationale ....................................................................................................... 119 CHAPTER 3: Methods 3.1 – Overview of Study and Study Design ....................................................................... 121 3.1.1 – Research Questions and Hypotheses ................................................................. 122 3.2 – Informed Consent ...................................................................................................... 124 3.3 – Study Setting ............................................................................................................. 125 3.4 – Study Participants ..................................................................................................... 125 iii TABLE OF CONTENTS PAGE 3.4.1 – Sample ............................................................................................................... 125 3.4.2 – Recruitment Procedures ...................................................................................