Evaluation of an Oral Health Intervention Program for Children With Congenital Heart Defects

This was a prospective longitudinal design study, including four cohorts of children with CHD (born 2008-2011) who required lifelong follow-up for their CHD. Parents, who did not respond to the initial letter of invitation for their child, received a reminder by mail two months later. All children in the intervention group were recruited before three years of age. A total of 119 children (66 girls) were invited to participate and receive an oral health intervention; at baseline (below three years), at first follow-up (three years) and at second follow-up (five years). Because parents were responsible for their young children's oral health, we found no reason to exclude children with co-morbidities such as Down's syndrome, Di George syndrome, Noonan syndrome, Cornelia de Lange syndrome, Williams's syndrome and autism. According to their CHD, the children were divided in three groups; i) left-to-right shunts, e.g. atrial septal defect and ventricular septal defect, ii) obstructions, e.g. coarctation of the aorta, aortic stenosis, and pulmonary stenosis, and iii) complex heart defects, e.g. tetralogy of Fallots, transposition of the great arteries and hypoplastic left or right heart syndromes. At five years, data on oral health and oral health related background factors were compared with corresponding published data of 5-year-old children with CHD, also from Western Norway (n=67, born 2005-2007). The latter group served as controls. These children were recruited at the age of five years and had not been offered the intensive oral health intervention program received by children in the intervention group. The control group had been followed in the PDS in line with the general population of children, who are offered the first oral examination from three years of age.

The caries prevalence (at dentine level) of five year olds in the control group had previously been compared with the corresponding prevalence of five year olds in the general population from the national health register "KOSTRA" (Municipality-State-Report of 2010, 2011 and 2012 in three counties in Western Norway, n = 18,974). Likewise the caries prevalence at age five years of the present intervention group were compared with the general population (Municipality-State-Report of 2013, 2014, 2015, 2016, n=26161). Possible time trends in caries epidemiology of five year olds during 2010-2016 were assessed.

Children's clinical oral examinations:

At baseline (below three years of age) a simplified oral examination was performed. Children were examined sitting on their parents' laps in the dental chair or on a regular chair examined by the "lap to lap" method. At the first follow-up examination at three years old, the children sat either on parents' laps or alone in the dental chair. Procedures for the oral health examination of the intervention and of the control group at five years of age were the same. Examinations were performed using a mouth mirror and a dental probe under good lighting conditions. Caries and DDE were registered for all dental surfaces while index teeth were used for dental erosion, dental plaque and gingival bleeding. Bitewing radiographs (BW) were only taken in five year olds, when there were molar contacts. Parents with immigrant background were offered interpreting services if desired. All oral health examinations were conducted by the same two dentists who previously had collected the published inter- and intra-observer reliability data of the control group.

Criteria for the various diagnostic systems were as follows: For caries, a five-graded diagnostic system was used,where enamel lesions were characterised as grades 1 or 2, and dentine lesions as grades 3, 4, or 5. Secondary caries, filled and extracted (due to caries only) teeth and the care index (a fraction with filled teeth as numerator and d3-5mft count as denominator). For dental erosion, a four graded diagnostic system was applied on buccal and palatal surfaces of the primary maxillary anterior teeth (53-63) and the occlusal surfaces of all primary molars. Erosion grade 3 was considered severe and grade 4 very severe. A modified DDE index was selected for DDE registration in which demarcated opacities were coded 1, diffuse opacities 2, demarcated and diffuse opacities 3, hypoplasia 4, hypoplasia and opacities 5, post-eruptive breakdown of enamel 6, and atypical fillings 7. Finally, for dental plaque and gingival bleeding, the PI and GBI were reported around the marker teeth 55, 51, 65, 75, 71, and 85. The presence of plaque in the four amelo-gingival areas was assessed with a dental probe and absence of debris was recorded as score 0 and presence as score 1. Gingival bleeding was recorded by probing cautiously using a WHO periodontal probe with a 0.5-mm ball tip on six surfaces; mesio-buccal, in the middle of the buccal surface, disto-buccal, mesio-lingual, in the middle of the lingual surface and, disto-lingual. If bleeding occurred within 10 seconds in at least one of the places, the tooth was scored 1 (bleeding), otherwise the tooth was scored 0.