Microsoft Word - Rea 40 April 30.docx   Vol  3,  No  1  (2015)   ISSN  2167-­‐8677  (online)   DOI  10.5195/d3000.2015.40           http://dentistry3000.pitt.edu     New  articles  in  this  journal  are  licensed  under  a  Creative  Commons  Attribution  4.0  United  States  License.     This  journal  is  published  by  the  University  Library  System,  University  of  Pittsburgh  as  part  of  its  D-­‐Scribe  Digital  Publishing  Program  and  is  cosponored   by  the  University  of  Pittsburgh  Press.     Haitian  orphan  population  and  protective  factors  against  caries   Madelyn  Rea1     1  University  of  Pi.sburgh  School  of  Dental  Medicine,  Pi.sburgh  PA,  USA Abstract   Objec&ve  In  Hai',  families  were  torn  apart  and  children  were  le6  orphans  a6er  the  2010  earthquake.   In  the  a(ermath  of  this  natural  disaster  many  children  were  relocated  to  orphanages  across  the  coun-­‐ try  and  adopted  interna,onally.  Years  later  these  children  find  themselves  catching  up  in  growth  physi-­‐ cally,  mentally  and  emo-onally  a.er  an  extremely  trauma-c  event  during  a  crucial  -me  in  their  health   development.  Another  important  marker  of  development  is  the  primary  den55on  and  the  presence  of   caries.    We  report  es(mates  of  early  childhood  caries  (ECC)  frequency,  risk  factors  and  quality  of  health   among  Hai)an  children.  Methods  Medical  and  dental  professionals  conducted  a  descrip1ve  cross  sec-­‐ !onal   study   through   the   Pi2sburgh   Kids   Founda!on   and   their   partnership   with   IDADEE   children’s   home,  EBAC  orphanage  and  New  Vision  Children’s  home.  Vital  signs  were  taken  and  recorded  to  create   a   health/growth   history   for   each   child.   Brief   dental   screenings   were   conducted   and   topical   fluoride   treatments  were  administered.  Risk   factors  and  quality  of  health   informa6on  was  obtained  from  dis-­‐ cussions  with   the   caregivers  present.   The   children  and  caregivers  were  given  oral  hygiene  educa6on   and  supplies  (i.e.  toothbrushes,  toothpaste,  floss).    Results  Physical  exams  and  dental  screenings  were   conducted  on  the  40  children  ages  3-­‐10  years  of  age  living  in  the  IDADEE  children’s  home.  Two  children   had  cavitated  teeth.  Eight  children  had  teeth  that  were  stained.  Four  children  had  evidence  of  dental   trauma.  26  out  of  the  40  children  had  otherwise  healthy  den//on.  Conclusion  The  IDADEE  children’s   home   and   New   Vision   Children’s   home   have   hopes   to   expand   their   capacity  with   new   construc9on   scheduled   to   be   finished   in   2016.   As  more   children   enter   these   homes   ac8on   is   needed   to   educate   caregivers  on  ways  to  iden0fy  high-­‐risk  children  to  prevent  ECC  and  ways  they  can  be  treated  before  ir-­‐ reversible  damage  is  done  to  the  developing  permanent  den22on.     Cita%on:  Rea  M.  (2016)  Hai$an  orphan  popula-­‐ !on  and  protec!ve  factors  against  caries.  Den-­‐ !stry  3000.  1:a001  doi:10.5195/d3000.2015.40   Received:  April  2,  2016   Accepted:    April  8,  2016   Published:    May  10,  2016   Copyright:  ©2016  Rea,  M.  This  is  an  open  access   ar!cle   licensed   under   a   Crea-ve   Commons   A!ribu!on  Work  4.0  United  States  License.   Email:  mar262@pi).edu   Introduction   In  Cap-­‐Haïtien,  a  city  in  northern   Haiti,  multiple  orphanages  are  the   home  to  children  who  found   themselves  orphans  after  the  2010   earthquake  that  hit  the  southern   capital  city  Port  au  Prince.  As  in   any  natural  disaster  aid,  clean  up   and  rebuilding  can  be  a  long  pain   staking  process  and  many  children   when  found  were  fighting  to  hang   on  for  their  lives.  The  original  mis-­‐ sion  of  the  IDADEE  childrens’   home  was  in  fact  not  to  be  a  home   at  all,  but  rather  a  place  for  mere   infants  and  toddlers  to  respectful-­‐ ly  die.  Many  of  these  children  ini-­‐ tially  exhibited  failure  to  thrive,  [1]   and  some  continue  to  show  these   symptoms,  however  the  vast  ma-­‐ jority  have  experienced  catch  up   growth  and  are  developing  within   normal  limits  for  their  sex  and  age   [2].  This  can  be  in  large  attributed   to  the  organizational  set  up  of  the   IDADEE  children’s  home.  The  chil-­‐ dren  of  IDADEE  find  themselves  in   a  very  unique  situation  in  which   they  are  divided  and  assigned  to  1   of  8  different  house  “mothers”   who  permanently  live  at  IDADEE   cooking,  cleaning  and  caring  for   the  basic  needs  of  the  children   under  their  care,  just  as  any  par-­‐ ent  does.  The  house  “mothers”   are  also  the  ones  brushing  the   children’s  teeth  or  supervising   them  brushing  their  own  teeth.      Hai$an  orphan  popula$on  and  protec$ve  factors  against  caries   Vol  3,  No  1  (2015)        DOI  10.5195/d3000.2015.40    http://dentistry3000.pitt.edu   2   The  IDADEE  children’s  home  is  no-­‐ tably  located  in  a  more  rural  por-­‐ tion  of  Cap  Haitien  known  as   Mourne  Rouge,  however  it  is   unique  in  that  the  home  is  located   on  a  rather  large  compound  that   includes  the  IDADEE  school  and   the  Joshua  House  Retreat  Center.   The  Joshua  House  Retreat  Center   is  open  all  year  long,  accommodat-­‐ ing  church,  business  and  medical   missions.  The  IDADEE  house   “mothers”  are  very  aware  of  the   presence  of  medical  personnel   that  frequent  the  center  and  they   use  that  as  their  main  source  of   medical  attention  for  the  children.   When  our  specific  medical  group   was  there,  the  “mothers”  were   ready  and  prepared  to  express   their  concerns  both  medically  and   dentally  for  many  of  the  children   [3].  In  this  report,  we  describe  the   preliminary  findings  related  to  oral   health  of  children  that  survived   the  Haitian  2010  earthquake.   Subjects  and  Methods   Physical  exams  were  conducted  on   the  IDADEE  compound.  IDADEE   staff  was  given  notification  in  the   weeks  prior  to  the  visit  and  con-­‐ sent  was  given  and  arrangements   were  made  for  the  physicals.  Vital   signs  were  measured  and  record-­‐ ed  for  height,  weight,  occipital   frontal  circumference  (OFC),  blood   pressure,  and  heart  rate.  These   records  are  then  filed  in  the  per-­‐ sonal  records  being  kept  for  each   child  to  track  growth  patterns.   Additionally  the  children  under-­‐ went  a  limited  oral  exam  screen-­‐ ing  for  decay,  trauma,  staining  and   oral  hygiene.  They  were  then  giv-­‐ en  brief  oral  hygiene  education   and  had  their  teeth  brushed  by   the  dental  and  medical  volunteers   (Figures  1  and  2).  Once  superficial   plaque  removal  was  achieved   PreviDent  Varnish  (5%  NaF)  was   applied  and  the  caregivers  and  the   children  were  given  instruction  to   not  brush  their  teeth  until  the  next   day.  Questions  about  diet,  oral   hygiene,  previous  medical  and   dental  history  answered  by  care-­‐ givers  via  and  interpreter.   Results   Table  1  summarizes  the  oral   health  outcomes  found.  Table  2   describes  the  contents  of  the  chil-­‐ dren  weekly  diet  and  oral  hygiene   habits  as  reported  by  the  chil-­‐ dren’s  caregivers.   Discussion    According  to  the  AAPD  (American   Association  of  Pediatric  Dentis-­‐ try)  caries-­‐risk  assessment  this   population  of  children  would   all  be  classified  as  high  risk  for   early  childhood  caries  (ECC)   due  to  the  factors  of  having  a   low  SES  status,  non-­‐ fluoridated  drinking  water,  lit-­‐ tle  availability  of  oral  hygiene   products  (i.e.  toothbrushes   and  fluoridated  tooth  paste,   minimal  access  to  or  regular   dental  care  [4].  The  results  of   our  oral  exam  findings  howev-­‐ er  only  report  5%  of  these  children   presenting  with  tooth  decay.  This   is  a  relatively  large  difference  in   comparison  to  the  42%  of  children   affected  with  tooth  decay  in  the   United  States.  The  children  in  our   sample  that  presented  with  such   extensive  decay  that  their  DMF   score  (Decayed  Missing  Filled)  for   their  age  further  classified  as  hav-­‐ ing  severe  early  childhood  carried   (S-­‐ECC).  S-­‐ECC  is  defined  as  having   a  DMF  score  of  greater  than  or   equal  to  4  surfaces  at  age  3,   greater  than  or  equal  to  5  surfaces   at  age  4  or  greater  than  equal  to  6   surfaces  at  age  5  [4].  Among  the   children  with  staining,  no  further   classifications  of  ECC  or  S-­‐ECC   were  made  because  the  staining   appeared  to  be  mainly  external  or   confined  to  the  pits  and  fissures  of   the  teeth.  It  was  suspected  that   much  of  this  external  staining   would  have  been  able  to  be  re-­‐ moved  with  a  proper  dental   prophylaxis.  Additionally  it  was   suspected  that  the  pit  and  fissure   staining  was  the  sign  of  an  arrest-­‐ ed  caries  process  and  that  appro-­‐ priate  treatment  for  this  would   have  been  the  placement  of  seal-­‐ ants  or  a  preventive  resin  restora-­‐ tion  (PRR)  confined  to  these  af-­‐ fected  pits  and  fissures  [5].     The  results  of  the  diet  his-­‐ tory  given  by  the  caregivers  nota-­‐ bly  report  a  diet  that  would  be   considered  relatively  low  caries   risk.  The  children  have  essentially   no  processed  sugar  intake  and   Table  1.  Frequency  of  dental  operations.   Finding   N   Percent   (%)   Staining   8   20   Cavitations   2   5   Trauma   4   10   Normal  Dentition   26   65     40   100      Hai$an  orphan  popula$on  and  protec$ve  factors  against  caries   Vol  3,  No  1  (2015)        DOI  10.5195/d3000.2015.40    http://dentistry3000.pitt.edu   3   their  consumption  of  fruits  is   mainly  in  the  form  of  whole  fruits.   In  the  case  of  whole  fruits  there  is   little  evidence  to  show  causality  of   caries.  Fiber  rich  fruits  such  as   mangos  and  bananas  require  more   chewing,  therefore  stimulate  more   saliva  flow  potentially  acting  as  a   protective  mechanism  against  car-­‐ ies  [6].    Children  that  these  organi-­‐ zations  are  seeking  to  bring  into   their  programs  are  those  that  are   physically,  mentally  and  emotion-­‐ ally  delayed.  Action  is  needed  to   educate  these  caregivers  regard-­‐ ing  the  specialized  care  required   by  these  children  to  prevent  as   many  permanent  complications  as   possible.  The  organizational  set  up   of  dividing  the  children  among  in-­‐ dividual  “  house”  mothers  has  in-­‐ creased  individual  attention  that   children  receive  and  has  arguably   allowed  these  children  to  over-­‐ come  developmental  obstacles   early  on  in  life.  Additionally  it  can   be  argued  that  oral  hygiene  pro-­‐ vided  under  the  supervision  of   these  “mothers”  has  resulted  in   prevention  of  early  childhood  car-­‐ ies  for  the  vast  majority  of  these   children.    These  women  are  the   common  denominator  in  control-­‐ ling  crucial  environmental  factors   such  as  hygiene,  nutrition  and  ac-­‐ cess  to  healthcare.     These  women  are  also  a   common  denominator  as  a  reser-­‐ voir  for  Streptococcus  mutans,  the   prime  organism  involved  in  caries   initiation  and  progression.  In  bio-­‐ logic  mothers  and  children  the   levels  of  Streptococcus  mutans  are   highly  associated  due  to  their  con-­‐ tact  normally  being  most  intimate,   of  highest  frequency  and  duration.   Additionally,  immunological  fac-­‐ tors  are  shared  between  mother   and  child,  a  phenomenon  known   as  vertical  transmission.  Although,   the  children  of  IDADEE  no  longer   are  in  contact  with  their  biologic   mothers  they  still  have  their  im-­‐ munological  factors  that  were  ac-­‐ quired  in  utero  or  potentially  via   breastfeeding.  In  the  case  of  these   women,  while  their  contact  with   these  children  can  also  be  de-­‐ scribed  as  intimate,  in  high  fre-­‐ quency  and  duration,  their  immu-­‐ nological  factors  are  not  being   conferred  to  these  children.  This   type  of  transmission  is  known  as   horizontal  transmission.  Other   children  in  IDADEE  also  serve  as  a   reservoir  of  Streptococcus  mutans   and  contact  with  each  other  is  an-­‐ other  form  of  horizontal  transmis-­‐ sion  [7].     With  so  many  of  these  envi-­‐ ronmental  factors  kept  constant   from  child  to  child  in  IDADEE,  the   major  difference  in  these  children   is  their  genetics  and  their  past  envi-­‐ ronmental  exposures.     Caries  is  defined  as  a  multi-­‐ factorial  infectious  disease  caused   by  an  imbalance  between  protec-­‐ tive  and  risk  factors  [8].  Keeping  in   mind  the  multifactorial  nature  of   this  disease  it  can  be  proposed   that  the  genetic  mode  of  inher-­‐ itance  would  best  be  described  as   being  polygenic.  Genes  of  interest   when  investigating  cariology  in-­‐ clude  dentition,  salivary,  immuno-­‐ logical,  and  gustation  genes  [9].  In   some  children  the  protective  ef-­‐ fect  of  some  of  these  genes  is   great  enough  to  outweigh  many  of   the  established  environmental  fac-­‐ tors  such  as  diet,  oral  hygiene,  and   SES  that  place  children  at  high  risk.   In  the  case  of  the  children  at   IDADEE  it  can  be  argued  that  the   75%  of  children  with  healthy  den-­‐ tition  and  history  of  dental  trauma   have  genes  that  in  fact  do  provide   that  protection  against  the  caries   process.  In  the  5%  of  children  with   ECC  we  can  argue  that  their  genes   are  not  providing  adequate  pro-­‐ tection  against  the  caries  process   and  are  being  heavily  outweighed   by  known  risk  factors.  In  the  20%   of  children  with  staining,  the  exact   nature  of  the  staining  would  be   further  characterized  as  either  ex-­‐ ternal  or  pit  and  fissure.  In  the   case  of  pit  and  fissure  staining  the   staining  could  be  the  result  of  an   arrested  caries  process.  If  this  is  in   fact  the  case,  an  argument  can  be   made  that  while  the  balance  at   some  point  was  in  favor  of  risk  fac-­‐ tors  and  the  progression  of  the   caries  process,  it  has  now  been   tipped  to  the  other  direction  and   protective  genetic  factors  could  be   predominating.        Hai$an  orphan  popula$on  and  protec$ve  factors  against  caries   Vol  3,  No  1  (2015)        DOI  10.5195/d3000.2015.40    http://dentistry3000.pitt.edu   4   Follow-­‐up  is  definitely  indicated  in   this  sample,  with  potential  re-­‐ search  expanding  to  the  other  as-­‐ sociated  orphanages  that  were  in   place  before  the  earthquake.   While,  the  resilient  nature  of  the   IDADEE  children  is  more  than  evi-­‐ dent  the  synergistic  effect  of  their   resilience  and  the  diligence  of  the   “house”  mothers  to  provide  ex-­‐ ceptional  care  to  an  otherwise   marginalized  population  has  re-­‐ sulted  in  better  than  expected  oral   health.  It  would  be  very  valuable   future  research  to  collect  saliva   samples  and  identify  the  exact   markers  expressed  in  the  children   with  S-­‐ECC.  Additionally,  this   would  be  a  very  interesting  sam-­‐ ple  population  to  study  longitudi-­‐ nally  caries  and  other  oral  health   outcomes.  Overall,  this  is  an  ex-­‐ traordinarily  unique  group  of  chil-­‐ children  that  can  teach  us  the   power  of  environment  on  genet-­‐ ics.     Acknowledgements   The  Pittsburgh  Kids  Foundation   provided  funding  and  support.     References   1.  McLean  HS,  Price  DT.  Failure  to   thrive.  In:  Kliegman  RM,  Stanton   BF,  St.  Geme  JW  III,  et  al.,  eds.   Nelson  Textbook  of  Pediatrics.   19th  ed.  Philadelphia,  Pa:  Elsevier   Saunders;  2011:chap  38.   2.  Growth  Charts  -­‐  Homepage.   Cdcgov.  2016.  Available  at:   http://www.cdc.gov/growthchart s.  Accessed  March  14,  2016.   3.  Pittsburgh  Kids  Foundation  -­‐   HAITI.  Pittsburghkidsfounda-­‐ tionorg.  2016.  Available  at:   http://www.pittsburghkidsfounda tion.org/haiti/.  Accessed  March   14,  2016.   4.  Nowak  AJ,  Casamassimo  PS.   The  Handbook  of  Pediatric  Den-­‐ tistry.  American  Academy  of  Pe-­‐ diatric  Dentistry,  2011   5.  Dean  J,  McDonald  R,  Avery  D.   Mcdonald  And  Avery's  Dentistry   For  The  Child  And  Adolescent.  St.   Louis,  Missouri:  Elsevier;  2016.   6.  Dental  caries  in  pre-­‐school  chil-­‐ dren:  associations  with  social   class,  toothbrushing  habit  and   consumption  of  sugars  and  sugar-­‐ Table  2.  Interveiw  responses  obtained  from  caregivers  in  regards  to  diet  and   oral  health.   Diet     Protein   Chicken,  fish,  beans,  peanut  butter   Carbohydrates   Rice,  white  bread,  oatmeal   Vegetables   Plantains   Fruits   Mango,  oranges,  pineapple,  bananas   Water   Bagged     Juice   Occasionally  Tampico  (orange  and  other  fruit  juices)   Soda   Rarely   Sugar/Sweets   Rarely;  have  somewhat  of  an  aversion   Dental  Health  Behav-­‐ iors     Brushing  frequency   2x  a  day;  by  caregiver  some  of  the  older  children  can   brush  on  their  own   Fluoride  sources   Toothpaste  when  available   Varnish  ~1-­‐2x  a  year   Water  non-­‐fluoridated   History  of  pain     2  children  with  severely  cavitated  teeth,  cry  a  lot  at   night,  won’t  open  their  mouths      Hai$an  orphan  popula$on  and  protec$ve  factors  against  caries   Vol  3,  No  1  (2015)        DOI  10.5195/d3000.2015.40    http://dentistry3000.pitt.edu   5   containing  foods.  Further  analysis   of  data  from  the  National  Diet  and   Nutrition  Survey  of  children  aged   1.5-­‐4.5  years.  Gibson  S,  William  S.   Caries  Res.  1999;33(2):101-­‐13.   PMID:  9892777   7.  An  investigation  into  the  use  of   restriction  endonuclease  analysis   for  the  study  of  transmission  of   mutans  streptococci.  Kulkarni  GV,   Chan  KH,  Sandham  HJ.  J  Dent  Res.   1989;68(7):1155–61.  PMID:   2632600   8.  Early  childhood  caries  is  associ-­‐ ated  with  genetic  variants  in   enamel  formation  and  immune   response  genes.  Abbasoğlu  Z,   Tanboğa  İ,  Küchler  EC,  Deeley  K,   Weber  M,  Kaspar  C,  Korachi  M,   Vieira  AR.  Caries  Res.   2015;49(1):70-­‐7.  PMID:  25531160   9.  Vieira,  Alexandre  R  (January   2016)  Genetic  Influences  on  Den-­‐ tal  Caries.  In:  eLS.  Wiley  &  Sons,   Ltd:  Chichester.   DOI:10.1002/9780470015802.a00 24258