The Oral Health of Preschool Children of Refugee and Immigrant Families in Manitoba

Early childhood caries (ECC) is a particularly damaging form of tooth decay observed in the toddler and preschool population.¹ Preventing early caries development is important, as those with ECC are at increased risk of developing future decay during childhood and adolescence.² Over the last 20 years, North American trends show a significant increase in the prevalence of ECC.³ Several groups in Canada are at high risk, including Indigenous children, refugees and other newcomers, those experiencing poverty and those living in rural regions of the country where there is reduced access to care.^4-8 The term “newcomer” encompasses both refugees and immigrants.⁹ In fact, there are 3 categories of newcomers to Canada: family (to reunify families), economic and refugee class immigrants.¹⁰

Newcomers face unique challenges, including maintaining health and accessing health services,⁶ as a result of many factors, such as language barriers, cultural differences, lack of awareness, limited family finances and restrictive government policy.^6,9,11,12 Because of these barriers, newcomer children, especially refugees, are considered to be at higher risk of dental caries.⁶ In recent revisions of the American Academy of Pediatric Dentistry’s Caries-Risk Assessment tool,¹³ a question about recent immigrant status has been included, confirming that children from these groups are considered to be at moderate to high risk for caries.

Studies suggest that awareness of the importance of early childhood oral health among some new immigrant parents to Canada is low and that they are less likely to seek preventive dental care.^14,15 In addition, Canadian surveys report that children from disadvantaged groups, including newcomers, have higher rates of caries and lower rates of dental visits than Canadian-born children.^11,15

In 2014, 16 222 newcomers arrived in Manitoba, the highest number in a single year.¹⁰ That same year, the province also witnessed its greatest influx of refugees (1439) along with the largest number of refugees per capita in Canada.¹⁰ Nearly 6 out of every 10 government-sponsored refugees came from Somalia, Iraq, Democratic Republic of Congo (DRC) and Eritrea, whereas 92% of privately sponsored refugees came from Eritrea, Somalia, Ethiopia and the DRC.¹⁰ Over 80% of newcomers to Manitoba settled in Winnipeg.¹⁰

No current evidence has been published on the prevalence and burden of ECC among preschool children from newcomer groups to Manitoba, although the province has one of the highest rates of immigration in Canada. In addition, the greatest proportion of newcomers are women in their childbearing years followed by young children, including those under 5 years of age.^16,17 Previous newcomers to Winnipeg have identified that oral health is a significant health concern and that barriers to care affecting their oral health include not only the cost, but also lack of knowledge.^16-18

The purpose of this study was to investigate the oral health of preschool children from newcomer families in Winnipeg, Canada. Discovering the oral health status of these children can provide important information that can help inform early childhood oral health and preventive dental services for newcomer families.

Methods

In keeping with the recognized case definition of ECC, eligibility for this cross-sectional study was restricted to children 12–71 months of age and their parent(s) or primary caregiver(s).^1,19 The study team visited newcomer settlement agency sites, community dental clinics and Healthy Start for Mom & Me locations in the Winnipeg region. All eligible children and their parent or primary caregiver were invited to participate.

All parents and primary caregivers provided written informed consent and completed a short questionnaire with the assistance of a team member. Each participating child received a small honorarium. Interpreters were used when available. However, as trained interpreters were not always present during study visits, we ensured that the questions were simple enough so that participants could respond.

The questionnaire posed simple questions related to the child and parent: e.g., country of origin, language spoken, type of dental insurance (e.g., Interim Federal Health [IFH], Employment and Income Assistance, private insurance, no insurance) and whether the child had already received dental care in Winnipeg. For our statistical analyses, “recent newcomers” were defined as people living in Manitoba for ≤ 24 months. Government-sponsored refugees were those with IFH dental benefits. Countries of origin were categorized into World Health Organization regions (Americas, Africa, Eastern Mediterranean, Europe, Southeast Asia and Western Pacific).

Two experienced dentists served as the examiners and reviewed the examination criteria together to ensure that each was recording oral health conditions consistently (e.g., plaque levels, gingivitis, caries and enamel hypoplasia). Examinations were performed at the participating site using a mirror and explorer. When possible, examinations were performed in a knee-to-knee position. No additional light sources were used during the dental screening examinations and no radiographs were obtained.

Caries was diagnosed beginning with cavitated enamel. Both caries prevalence and scores involving the primary dentition were determined. ECC and severe-ECC (S-ECC) were defined according to established case definitions.^1,19 Dental caries scores were determined via decayed, missing and filled teeth (dmft) and decayed, missing, filled surfaces (dmfs) indices, which indicate the child’s current and past caries experience. The significant caries (SIC) index was also reported, i.e., the average score among the third of the study population with the highest dmft and dmfs scores. The simplified oral hygiene index²⁰ was used to assess the amount of debris on primary teeth. Developmental defects of enamel (DDE), which include enamel hypoplasia and opacities, were assessed using the DDE index.²¹

Children’s dental screening results were combined with questionnaire responses. Data were entered into a spreadsheet and analyzed using Number Cruncher Statistical Software version 9 (NCSS, Kaysville, Utah). Descriptive statistics included frequencies and means ± standard deviation (SD). Bivariate analyses included χ² analysis, t tests, Mann-Whitney-Wilcoxon test, analysis of variance (ANOVA) and correlation. Multiple logistic regression for ECC and S-ECC was performed and included those variables that were significantly associated with these main outcomes of interest or had a p value < 0.10 at the bivariate level; p ≤ 0.05 was considered significant.

This study was approved by the University of Manitoba’s Health Research Ethics Board (H2014:190).

Results

We recruited 211 children and their parent or primary caregiver (Table 1). The average age was 40.2 ± 15.4 months and more than half the participants (51.7%) were recent newcomers to Canada. The largest proportion were from Africa (43.6%). Few parents reported that their child had visited a dentist in Winnipeg (27.3%); however, 35.1% believed that their child had a dental problem.

ECC was identified in 96 children (45.5%), while the prevalence of S-ECC was 31.8% (67 of the 211 children). Overall, this revealed that 69.8% (67) of children with ECC had this more rampant subtype of caries (Table 2). The mean dmft score was 2.2 ± 3.8 while the mean dmfs score was 4.8 ± 11.0. In addition, the SIC indexes of the third of children with the highest dmft and dmfs scores were 6.2 and 13.8, respectively. Most of the children had untreated caries, as shown by the dt score, which was 78.6% of the dmft score, and the ds score, which was 62.5% of the dmfs score.

The prevalence of developmental defects of enamel (DDE) was 11.6% (23 of 198 children); 6.6% had enamel hypoplasia (13 children) and 7.6% had enamel opacities (15 children). Of interest, 6 children (2.8%) had been affected by infant dental mutilation (i.e., enucleation). The mean debris score was 0.67 ± 0.71 (range 0–6).

Children affected by ECC were significantly older than caries-free children (49 ± 14.0 months vs. 37.1 ± 14.9 months) (Table 3). Significantly more children who visited a dentist in Winnipeg had ECC than children who had not yet done so (66.7% vs. 37.5%) and more children of parents who reported that their child had a dental problem had ECC than those who reported their child was free from dental problems. The presence of enamel hypoplasia was significantly associated with ECC (p = 0.007). Children with ECC also had significantly higher debris scores than caries-free children (p < 0.001).

There was no significant difference in the proportion of boys and girls with S-ECC and, unlike the findings for ECC, there was no difference in the mean age between children with and without S-ECC (Table 4). Children with enamel hypoplasia were significantly more likely to have S-ECC than those without (61.5% vs. 29.7%). Those with S-ECC were also found to have significantly higher debris scores. The prevalence of S-ECC was significantly higher among children whose parents reported that their child had a dental problem than those who reported their child did not have any dental problems.

Canadian-born children had significantly lower dmft scores than those born outside Canada (p = 0.040) (Table 5). A statistically significant association was found between mean dmft scores and region of origin of families. Tukey’s analysis revealed that children from the Western Pacific had scores significantly higher than children from Africa (5.1 ± 6.5 vs. 1.6 ± 3.0). Children who were reported to have visited a dentist in Winnipeg had significantly higher dmft scores than those who did not (3.8 ± 4.9 vs. 1.6 ± 3.1, p = 0.003). Significantly higher scores were found among children whose parents reported that their child had a dental problem compared with those who did not (4.6 ± 4.8 vs. 0.9 ± 2.2, p < 0.001).

It was surprising that boys had significantly higher dmfs scores than girls (p = 0.031) (Table 5). ANOVA revealed that mean dmfs scores significantly differed by region of origin. Tukey’s analysis indicated that children from the Western Pacific had significantly greater dmfs scores than those from Africa (13.2 ± 19.7 vs. 2.8 ± 7.5). Findings of significant associations between dmfs score and the history of dental visits in Winnipeg and parents’ beliefs that their child had dental problems mirrored those reported for mean dmft scores.

Logistic regression analyses showed that increasing age, the presence of debris on teeth, parents believing their child had dental problems and the presence of enamel hypoplasia were significantly and independently associated with ECC (Table 6). Those with enamel hypoplasia were 6.1 times more likely to have ECC, and those whose parents thought they had a dental problem were 5.5 times more likely to have ECC. Similarly, the presence of debris on teeth, parental reporting that their child had a dental problem and enamel hypoplasia were significantly and independently associated with S-ECC (Table 7).

• Children, dental caries, pediatrics, pediatrics. public health

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Table 4: Association between severe early childhood caries (S-ECC) and covariables of interest in our study group of newcomer children in Winnipeg (
n = 211).

Variable	No S-ECC, no. (% by variable)*	S-ECC, no. (% by variable)*	p
Note: SD = standard deviation. *Except where other units given.
Sex
Female	72 (74.2)	25 (25.8)	0.085
Male	72 (63.2)	42 (36.8)
Responding parent
Father	17 (65.4)	9 (34.6)	0.74
Mother	127 (68.7)	58 (31.3)
Child’s mean age, months ± SD	39.5 ± 15.4	41.8 ± 15.5	0.30
Region
Africa	69 (75.0)	23 (25.0)
Americas	3 (75.0)	1 (25.0)
Eastern Mediterranean	43 (65.1)	23 (34.9)	0.14
Europe	4 (100.0)	0 (0.0)
Southeast Asia	18 (60.0)	12 (40.0)
Western Pacific	7 (46.7)	8 (53.3)
Recent newcomer (≤ 24 months)
Yes	71 (65.1)	29 (34,9)	0.32
No	73 (71.6)	38 (28.4)
Government-sponsored refugee
Yes	15 (62.5)	9 (37.5)	0.52
No	129 (69.0)	58 (31.0)
Recent refugee
Yes	55 (64.0)	31 (36.0)	0.19
No	85 (72.7)	32 (27.3)
Child ever visited dentist in Winnipeg
Yes	30 (52.6)	27 (47.4)	0.003
No	113 (74.3)	39 (25.7)
Dental Insurance
Yes	65 (61.9)	40 (38.1)	0.049
No/unsure	79 (74.5)	27 (25.5)
Parent thinks child has dental problem