Year results of a collaborative school-based oral health program in a remote First Nations community

Introduction: Surveys of dental health among Aboriginal children in Canada, using scales such as the Decayed, Missing, and Filled Teeth (DMFT) score, indicate that Aboriginal children have 2 to 3 times poorer oral health compared with other populations. A remote First Nations community approached requested assistance in addressing the health of their children. The objective was to work with the community to improve oral health and knowledge among school children. The hypothesis formulated was that after 3 years of the program there would be a significant decrease in dmft/DMFT (primary /permanent) score. Methods: This was a cross-sectional study of all school-aged children in a small, remote First Nations community. Preand postintervention evaluation of oral health was conducted by a dentist not involved in the study. The intervention consisted of a schoolbased program with daily brush-ins, fluoride application, educational presentations, and a recognition/incentive scheme. Results: Twenty-six children were assessed prior to the intervention, representing 45% of the 58 children then in the community. All 40 children in the community were assessed following the intervention. Prior to the intervention, 8% of children were cavity free. Following 3 years of the intervention, 32% were cavity free. Among the 13 children assessed both preand post-intervention, dmfs/DMFS improved significantly (p <0.005). The visiting hygienist noted increased knowledge about oral health.


Introduction
Surveys of dental health among Aboriginal children in Canada, using scales such as the Decayed, Missing, and Filled Teeth (DMFT) score, indicate that Aboriginal children have 2 to 3 times poorer oral health compared with other populations [1][2][3] .A Health Canada report from August 2000 indicates that dental decay rates range from 3 to 5 times greater than in the non-Aboriginal Canadian population 4 .
Statistics from the USA indicate similar discrepancies, with 1999 data showing an incidence of decayed or filled teeth 5 to 6 times greater among Aboriginal Americans compared with non-Aboriginal Americans 5 .Recent statistics from British Columbia (BC) First Nations children are equally troubling.Causes include giving bottles of milk or apple juice to babies to soothe them, high-sugar diets, and poor or irregular access to dental care.Similar observations of poor dental hygiene and high consumption of sugar-sweetened drinks and food are reported among Aboriginal children living in remote communities in Australia 6 .Poor oral health is of particular concern now that evidence exists that this chronic inflammatory process may predispose individuals to a higher incidence of diabetes, coronary artery disease and even premature labor 7 .This makes the issue of oral health all the more pressing in Aboriginal children.We hypothesized that after 3 years of the program there would be a significant decrease in dmft/DMFT (primary teeth/permanent teeth) score in a cross-sectional study, and that pre-post evaluation of individuals would reveal significant improvement in 'cavity free' status.

Methods
The program was approved by the University of British of the school population), all of whom were available in the community at the time of the follow-up dental examination.
The primary outcome measures were: • dmfs/DMFS score, where molars and premolars have five surfaces each, and the remaining teeth have four surfaces each for a possible total score of 128 for 28 teeth, and where a score of 0 indicates no decayed, missing or filled surfaces.dmfs/DMFS score tends to increase with age.
• 'Cavity-free/caries free' status as determined by a dentist not involved in the study, as a better reflection of current rather than long-term oral health than the dmfs/DMFS score.
Additional process outcomes were:

Results
Twenty-six children were assessed prior to the intervention.
This was 45% of the 58 children then in the community.All 40 children in the community were assessed following the intervention.Initial data and follow-up data for all children are presented (Table 1).There were 13 children who were assessed both at the beginning and at the end of the study.
Data for these children are presented (Table 2).Children assessed both before and after the intervention, had significant improvement in dmfs/DMFS (p <0.005) and dmft/DMFT (p <0.05) scores.Data from the questionnaire are presented (Table 3).

Discussion
The community-and university-   The fact that the partnership has thrived and expanded is due in large part to the success and popularity of its central component, the oral health program.This choice to address oral health was driven by identified community need and also provided a realistic and achievable goal.This supports the philosophy that achieving a small success and then building on it will promote trust and open other avenues of collaboration.
It was evident at the recent international conference on Inuit and Native American Child Health held jointly with the 2005 17th Annual IHS Research Conference that to date in North America, success in the area of caries reduction in aboriginal children has been elusive.Our program may be the first to document efficacy.
One additional element for the program that we will be proposing to the community is chlorhexidine varnish for new mothers, since this simple process has been shown by others to significantly reduce early childhood caries 13 .
In partnership with Makarere University in Kampala, we An opportunity arose for the Pediatric Residency Program at the University of British Columbia to establish a partnership with the people of Hartley Bay, a remote First Nations community with a population of 200-300.In return for addressing the caommunity's concerns about their children's health, the university's trainees would gain practical experience of First Nations and remote community health issues by being invited into the community.Following several meetings with the elders of the community and the community health staff, oral health was identified as a problem with the potential to show positive results in a relatively short period of time, and have a significant impact on a wide range of First Nations issues -from self-esteem to long-term cardiac health.A variety of possible interventions that could be implemented in the community were identified and presented to the Health Director and Band Council in the community.These included: • use of traditional soothing methods (eg cradle songs) for infants • fluoridation of the water • school-based instruction to improve knowledge and practices around oral health using brush-ins and topical fluoride varnish and/or rinses • measures to address dietary deficiencies and life style practices in the community as a whole.The option of a school-based program was selected, and the process and method of delivery were determined by consultation with the community.The rationale was that this was a project involving children, and therefore the program delivery should be school-based and include all children of school age in the community.The school principal and teachers were involved in the design of the program.

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Assessment of oral hygiene and 'time required to treat' evaluations by the Health Canada dental hygienist Response of community to ongoing presence of university-based team members • Response of university trainees to experience in a remote First Nations community.The Program The Pediatric Residency program provided teams consisting of two medical residents and a faculty supervisor.Residents were given instruction in oral health, attended a dental clinic, and were provided with information on working with First Nations communities prior to their first visits.Teams visited the community for 3 days approximately every 6 to 8 weeks, providing well-child clinics at the invitation of the community, and implementing and supporting the oral health program.The team worked with the nurses, the school, and the council to maintain the program, and the residents gave health promotion, injury prevention, science career and general interest presentations to the school, the parents, and the elders.The oral health program consisted of a:• daily school-based brush-ins after lunch each day, supervised by teachers and/or the community health director, with small rewards weekly for daily participation, and larger prizes for 100% participation for a month• weekly fluoride rinse• fluoride varnish applications three times in 10 days every 4 months for those under 9 years of age• dental health anticipatory guidance by the pediatric residents during well-baby and well-child visits• classroom presentations by the pediatric residents about a variety of health topics, including oral health.The community was invited to become a clinical teaching facility of the Faculty of Medicine.Primary care physicians and other health care providers (eg dentists) who usually attend the band members were sent a letter describing the project and assuring them that there was no intent to decrease the utilization of their services or interfere in their relationship with their patients.Data collected were dmfs/DMFS scores, cavity free status, decay-free status, and a brief questionnaire concerning oral health habits.Wilcoxon signed-rank test and Chi-square test were used to test the hypotheses.
photographs of children who are caries free as a measure of their success.
have also taken the Brighter Smiles program to Uganda, where over 1100 children were enrolled in four remote communities.The Brighter Smiles Africa program includes annual visits by multidisciplinary UBC-based teams, including such disciplines as medical, dental, economics, engineering, and culture.

ConclusionA
community-and university-supported, school-based, collaborative oral health program improved oral health among children in a remote First Nations community.

Table 1 : Mean dmft/DMFT (primary/permanent) scores at initial and follow-up assessments (by F-test)
DMFT, Decayed, missing, and filled teeth score; ds, decayed surfaces primary teeth; DS, decayed surfaces permanent teeth; fs, filled surfaces primary teeth; FS, filled surfaces permanent teeth; ms, missing surfaces primary teeth; MS, missing surfaces permanent teeth; NS, not significant.

Table 3 : Results of a brief questionnaire on oral health behaviours
11,12er11,12.The oral health program has led to community requests for other initiatives, notably a nutrition survey and an immunization program that now has 100% of the children fully immunized.