Preventing Caries in American Indian Children: Lost Battle or New Hope?

We explore the perplexing and often distressing results of efforts to prevent dental caries among American Indian children, using the results of an ongoing program of clinical trials to illustrate the challenge and suggest opportunities to develop promising approaches to prevention. Although theoretically preventable, early childhood caries is a critical health issue among high-risk populations, and ethnic minority children from lower income families and communities are disproportionately affected. Data from American Indian (AI) children reflect some of the highest prevalence and severity figures seen anywhere in the world. In one of the tribes studied, 89% of the children had experienced caries by the age of 3. A culturally-tailored prevention program delivered by tribal members for Head Start enrollees and their parents in a Southwestern tribe resulted in no reduction in caries progression. Parent participation was low, however, and a further analysis indicated that caries increases were reduced when parents participated. Moreover, examination of baseline data showed that parents of the 11% of children who were caries-free when they entered the program had higher internal locus of control, higher health literacy, and greater sense of coherence; these parents also perceived their children as less susceptible, perceived fewer barriers to prevention, and viewed oral healthy as important. Finally, they reported experiencing less personal distress and community-related stress. More recent data provide some support for the role of parent knowledge, attitudes, and behaviors in mitigating the progress of disease, as well as the initial onset. We conclude that prevention programs for American Indian children must begin even younger than 3 and describe a second clinical trial that is working with new AI mothers using a motivational interviewing approach. Alternative explanations for the high rates of caries in AI children are discussed, and although most support earlier intervention, the concept of “inverse case law” offers a different perspective on addressing the prevention challenge. This theory suggests that those who most need prevention are least likely to benefit and vice versa. This is because those with less need may be so because they have resources – personal, economic, or social, that allow them to recognize and address the health problem. Those with greater need often lack such resources. Our clinical trials data provide context for this model and suggest the need for prevention programs that address the underlying problems of ability to benefit.