A Multi-Pronged Approach for Improving Mother and Child Oral Health in Indigenous Communities

Led by Professor Herenia Lawrence, a Learning Circle was held in May that brought together a team of key partners who are working on the Nishtam Niwiipitan Study, or My First Teeth. It was an important opportunity to learn and share ideas about how to improve the oral health of young Indigenous children.

“The customary use of general anesthesia for treating decay in baby teeth has become the norm rather than the exception among Indigenous children living in remote, isolated communities in northern Canada,” said Dr. Lawrence.

Early Childhood Caries (ECC), or tooth decay in children’s primary teeth, is a complicated disease with a range of social outcomes. ECC has become a serious and prevalent burden on Aboriginal communities across Canada, where many cases are severe enough to require surgical or restorative treatment under general anesthesia (GA). This is complicated for the child’s early development and for the family. To treat complications from ECC, families must seek specialty treatment in hospitals, which will often require a plane flight away from their communities.

“Prevention is really key to solving this problem,” said Dr. Lawrence. “Preventive dental care is clearly needed to catch early childhood caries in its early stages or prevent its onset altogether as restorative dental care alone will never be able to make a significant dent in the numbers of Indigenous children requiring emergency dental treatment under GA.”

The primary aim of the study is to work collaboratively with on- and off-reserve Aboriginal communities, in Ontario and Manitoba to strengthen the effectiveness of a multi-pronged intervention. “In the Nishtam Niwiipitan Study we are building on the 2017 Baby Teeth Talk Study preventive and behavioural interventions by creating enhancements that combine Indigenous ways of knowing and Western approaches to oral health and dental care,” said Dr. Lawrence. With culturally appropriate preventive interventions, the goal of the study is to be an effective and cost-effective method in reducing ECC and the need for expensive dental treatment under GA.

The three main elements of the intervention are: Oral Health Anticipatory Guidance (AG), a counselling approach for First Nations and Métis mothers, delivered by trained community-based researchers, that focuses on the needs of their children at specific life stages; Motivational Interviewing (MI), a collaborative conversation style for strengthening a person’s motivation and commitment to change; and, fluoride varnish treatments, a proven caries preventive measure among Indigenous children.

Topical fluoride varnish is applied twice yearly to the teeth of infants/toddlers by the community-based researchers. The study will use a mixed methods design, incorporating a community-based participatory research approach and an Indigenous analytic framework.

The preliminary Learning Circles in these communities have suggested the use of digital storytelling and the incorporation of a family-centred approach into the AG/MI interventions.

“We want to integrate Digital Storytelling into oral health Motivational Interviewing. Storytelling as a research methodology is not new in Indigenous community-based research, but Digital Storytelling has recently emerged as a participatory visual method that is an effective strategy for promoting health and well-being,” said Dr. Lawrence. “In using Digital Storytelling, mothers will share their stories with prenatal mothers, and at the same time, the long tradition of Aboriginal storytelling will be honoured via new media,”

The final phase of the study will report on how the new culturally tailored components enhanced the workability, effectiveness, appropriateness and accessibility of the existing multipronged approach. Participating communities include Sioux Lookout Zone First Nations, Moose Factory, Six Nations of the Grand River and Fort William First Nation in Ontario, and Norway House Cree Nation in Manitoba. Urban First Nations and Métis participants will be recruited from the City of Winnipeg and the City of Toronto through the community partners in each location.

An intervention based on this strong foundation can lead to community relevant outcomes, such as a reduction in referrals and wait times for dental care, and move Aboriginal peoples beyond (oral) health equity to wellness. The May event discussed the fact that there have been significant caries reduction at age two for children residing on reserve in the intervention group during the Baby Teeth Talk Study, and the intervention reduced referral rates for dental care and the need for dental treatment under GA for those on reserve.

A further intervention enhancement discussed at the May event is Silver Diamine Fluoride (SDF). There has been unprecedented interest in the use of Silver Diamine Fluoride in dentistry ever since it has become available in the United States in 2015 and in Canada in 2017, according to Dr. Lawrence.

“This minimally invasive treatment can arrest carious lesions and reduce anxieties related to dental office visits. SDF can be used alongside fluoride varnish for maximum caries prevention and in turn, reduce the risks to children by eliminating sedation and general anesthesia. It also represents a significant cost savings for the patient, family, and the government,” noted Dr. Lawrence. The side effect of SDF, however, is the blackening of carious lesions, probably affecting patients’ and parents’ acceptance of the treatment; something that was also part of the discussions at the two-day meeting.

Lawrence added that “A growing amount of scientific literature has shown that SDF is very effective in combating dental caries. The number of randomized clinical trials is increasing exponentially. However, we don’t know what Indigenous parents will think of their child’s dental appearance after SDF therapy, although studies show that many parents accepted SDF treatment to avoid the alternative treatments under sedation or general anesthesia.”

Why is the study so important?

It is important because there are profound oral health inequalities between Indigenous children and their non-Indigenous counterparts in Canada. For example, dental caries in First Nations children is 2 to 3 times that of the rest of Canada, according to national oral health surveys conducted in the past decade. Prevention is really key to solving this problem because restorative dental care alone will never be able to bring down the high rates of oral disease among Indigenous children to manageable levels. Working in partnership with First Nations communities in Ontario and Manitoba, we are scaling up a multi-pronged preventive and behavioural intervention for improving mother and child oral health with funding support from the CIHR Pathways Initiative.

What were the conclusions of the Learning Circle?

The participants in the Circle agreed to move forward with the intervention enhancements discussed at the gathering, meaning the creation of Digital Stories about child oral health and care practices and investigating the parental acceptance of silver diamine fluoride as a new therapy to arrest the progression of early childhood caries among Indigenous children.

What are the next steps?

The next steps are to gain approval for, and then conduct Learning Circles with families with young children and with other child oral healthcare stakeholders in Sioux Lookout, Fort William First Nation, Moose Factory and Six Nations of the Grand River. During these circles we will be introducing the Digital Storytelling workshops and discussing the use of silver diamine fluoride in these communities. Ms. Eleeyah Uri, a summer student of Dr. Lawrence, will be leading the Digital Storytelling workshops.

Who attended the Learning Circle?

Main community partners:

• Janet Gordon – Chief Operating Officer, Sioux Lookout First Nations Health Authority, Sioux Lookout, Ontario
• James Queskekapow – Acting Director of Health Services, Norway House Cree Nation Health Division, Norway House Cree Nation, Manitoba
• Rupinder Brar – Past Director of Health Services, Norway House Cree Nation Health Division, Norway House Cree Nation, Manitoba

Representatives from new community partners:

• Douglas Crane – DDS, Six Nations Health Services, Six Nations of the Grand River, Ontario
• Desiree Morriseau-Shields – Registered Dental Hygienist (RDH), Manager of Anishinabek Dental Hygiene Clinic, Fort William First Nation, Ontario
• Sarah Harney – CIHR Pathways Partner for Engagement and Knowledge Exchange (PEKE) Project Coordinator, Native Women's Association of Canada
• Lisette Dufour – RDH/HD, Senior Oral Health Advisor, Office of the Chief Dental Officer, Health Promotion & Chronic Disease Prevention Branch, Public Health Agency of Canada