Dental Health Screening and Fluoride Varnish Application „

Dr. Amos Deinard, MD, MPH and Suzanne Tessier, RDH, CDHC

pretest „

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Dental caries is __ times more common than asthma __ school hours are lost each year due to dental caries A child of a mother with active caries will have caries

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The average cost of dental care under general anes is___ ___% of decay in children of low socioeconomic status goes untreated Fluoride varnish is difficult to apply

Introduction and Overview

Surgeon General Report 2000 „

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Childhood caries is the most chronic infectious disease in children 5 times more common than asthma 7 times more common than hayfever

Population Considerations

‘Minority children’ are more likely to have untreated tooth decay

(regardless of family income) Percent of children `

White

Ethnic groups African American

Mexican American

50 40 30 20 10 0 2-5 years

6-12 years

Primary dentition

6-14 years

15-18 years

Permanent dentition

Percent of Children with Decayed and Filled Primary Teeth by Household Income Level (% of Federal Poverty Level) 50 40

0-100% 101-200%

30

201-300%

20

301%+

10 0 Decayed 2-5 year olds

Decayed 6-12 year olds

Filled 2-5 year olds

Filled 6-12 year olds

Sad Realities 50% of Tooth Decay in Low Income Children Goes Untreated

Enormous Costs „ „ „

Lost School Days Loss of Wages High Cost of Hospital Outpatient Surgeries 6,000-12,000 dollars total per case.

Responding to Changing Paradigms for Dealing with Dental Caries Old Paradigm --> Surgical / ‘Drill and Fill’ (deal with the consequences of the disease) ⇓ „ Later Paradigm: Prevention!!! (but generally “one size fits all”) ⇓ „ “Current” Paradigm: Early Intervention, Risk Assessment, Anticipatory Guidance, Individualized Prevention and Disease Management (why this approach?) „

Etiology

What Causes Caries? „

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Dental caries is an infectious disease caused by bacteria (that are usually passed from high-risk caregiver to child through saliva). Avoid things that transfer salivaprechewing food, licking pacifiers

Dental Plaque Dental Plaque contains: Bacteria Food debris Dead mucosal cells Salivary components

Tooth Decay „

Plaque + sugars = acid that etch the enamel of the teeth which results in tooth decay.

Soda - Pop Do You Know How Much Sugar?

Sugar in 12 ounce can of pop Soda Pop: „ „ „ „ „ „ „ „

Sugar: (in teaspoons) Orange Slice 11.9 Minute Maid Orange 11.2 Mountain Dew 11.0 Barq’s Root Beer 10.7 Pepsi 9.8 Dr. Pepper 9.5 Coca-Cola 9.3 Sprite 9.0

Sugars in other beverages Beverage

Sugar in teaspoons

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Powerade (32 oz)

15

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Sunny Delight

9

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Gatorade

8

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Capri Sun

6

Etiology and Prevention of Dental Caries

What can we do?

Prevention is key „

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Early, consistent dental health screenings Prevention education

Tooth decay can be prevented

Anticipatory Guidance 0-6 months „ Assess and counsel with regard to proper feeding „ Assess need for fluoride supplements „ Assess and counsel with regard to risk for dental decay „ Do a screening for decay and other dental diseases and conditions „ Help identify a “dental home”

Anticipatory Guidance

7 months and older „ Assess and counsel with regard to proper feeding „

Assess need for and prescribe fluoride supplements

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Provide oral hygiene instructions

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Ensure regular dental visits from age one year

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Assess and counsel with regard to risk for dental decay Do a screening for decay and other dental diseases and conditions

Oral Risk Assessment

Caries Risk* „

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"Caries Risk" is a term to indicate what will happen in the future - will there be demineralizations, will new cavities occur? It is understood that the evaluation is made for a certain period of time, for example for the coming year.

* - Department of Cariology, Malmö University http://www.db.od.mah.se/car/data/riskprincip.html

Oral Risk Assessment „

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Be done at every well-child visit for every child Anticipatory guidance offered to the caregivers of all children Behavior modifications discussed with caregivers of identified high risk children

Predictors of Risk „

Past caries experience

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Past caries experience of primary caregiver

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Past caries experience of siblings

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Inadequate exposure to fluoride

Predictors of Risk: „

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Inability to maintain good oral hygiene Continual exposure to fermentable carbohydrates and medications

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Infrequency of regular dental care

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Xerostomia (Dry Mouth)

AAPD Caries Risk Assessment Tool (CAT)

Caries Risk Indicators

Low Risk

Moderate Risk

High Risk

Clinical Conditions

•No

carious teeth in past 24 months •No enamel demineralization (enamel caries “white spot lesions) •No visible plaque; no gingivitis

•Carious

teeth in the past 24 months •1 area of enamel demineralization (enamel caries “white spot lesions) •Gingivitis

•Carious

Environmental Characteristics

•Optimal

•Suboptimal systemic fluoride exposure with optimal topical exposure •Occasional (ie, 11-2) betweenbetween-meal exposures to simple sugars or foods strongly associated with caries •MidMid-level caregiver socioeconomic status (ie eligible for school lunch program or SCHIP) •Irregular use of dental services

•Suboptimal

General Health Conditions

systemic and topical fluoride exposure •Consumption of simple sugars or foods strongly associated with caries initiation primarily at mealtimes •High caregiver socioeconomic status •Regular use of dental care in an established dental home

teeth in the past 12 months •More than 1 area of enamel demineralization (enamel caries “white – spot lesions” lesions” •Visible plaque on anterior (front) teeth •Radiographic enamel caries •High titers of mutans streptococci •Wearing dental or orthodontic appliances •Enamel hypoplasia

topical fluoride exposure •Frequent (ie, 3 or more) betweenbetween-meal exposures to simple sugars or foods strongly associated with caries •LowLow-level caregiver socioeconomic status (ie, eligible for Medicaid) •No usual source of dental care •Active caries present in the mother

•Children

with special health care needs impairing saliva composition/flow

•Conditions

Complete AAPD Policy Statement with CAT available at: http://www.aapd.org/pdf/policycariesriskassessmenttool.pdf

Caries Balance Æ chronic, dynamic disease

Adapted from Featherstone JDB: JADA 131:88799, 2000

Balance between Risk Factors & Protective Factors

Risk factors:

Protective factors:

Promote demineralization

promote remineralization

¾ Frequent exposure to refined sugars ¾ Cariogenic bacteria (S. mutans) ¾ Reduced salivary flow

¾ Fluorides ¾ Plaque control ¾ Saliva ¾ Antimicrobials

Value of Caries Risk Assessment ¾ Makes prevention strategies cost -effective cost-effective ¾ Strongest correlations with caries prevalence/incidence and mutans strep. ¾ Serves as a guide for selecting preventive and restorative procedures ¾ Helps one understand prognosis ¾ Broadens the understanding of the disease process ¾ Fosters treatment of caries instead of cavities

Strategies For Prevention

Remember?

What Causes Caries? „

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Dental caries is an infectious disease caused by bacteria (that are usually passed from high-risk caregiver to child through saliva). Avoid things that transfer salivaprechewing food, licking pacifiers

Caregiver „

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Ideally, assess mother’s prenatal oral health status Siblings? Greatest educational opportunity Greatest potential to decrease bacterial load in mother

Adapted Adapted from from Alaluusua Alaluusua and and Malmivirta, Malmivirta, Comm Comm Dent Dent Oral Oral Epi Epi 22: 22: 273-276, 273-276, 1994 1994 Variable

Category

Mean dt at 36 months

Mother’s DMFT

low

0.3

high

1.3

low

0.5

high

1.2

no

0.1

yes

1.4

no

0.1

yes

2.8

Mother’s mutans strep *

Use of nursing bottle (19 months) *

Presence of plaque (19 months old)

Dental Decay is an infectious transmittable disease „

The cariogenic bacteria in primary caregiver can be transferred to child by: Wetting pacifier Prechewing the child’s food Tasting the child’s food Kissing child on the lips

Litt et al. Public Health Reports 110: 607-617, 1995

HISTORICAL HISTORICAL

PRESENT PRESENT

FUTURE FUTURE

psychological psychological factors factors baby baby bottle bottle usage usage

sucrose sucrose consumption consumption

race/ethnicity race/ethnicity

parent’s parent’s dental dental knowledge knowledge

mutans mutans strep. strep. levels levels

Δ Δ CARIES CARIES CARIES CARIES

How to reduce cariogenic bacteria „

Brushing

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Flossing

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Nutrition

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Routine dental visits

Fluoride: What does it do „

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It inhibits the process by which cariogenic bacteria metabolize carbohydrates to produce acid It remineralizes the enamel of the tooth Community water fluoridation should have 0.7-1.2 ppm fluoride to be effective

Fluoride „

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Fluoride supplements should be prescribed if the water supply does not have adequate fluoridation. Infants less than six months do not require fluoride supplements Infants six months and older who are breast-fed may have the greatest need for dietary fluoride supplements

Fluoride Supplement

Schedule

Fluoride Concentration in Community Drinking Water

Age

0.6 ppm

0–6 months

None

None

None

6 mo–3 yrs

0.25 mg/day

None

None

3 yrs–6 yrs

0.50 mg/day

0.25 mg/day

None

6 yrs–16 yrs

1.0 mg/day

0.50 mg/day

None

MMWR: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the US: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.

Fluoride varnish „

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protective coating that is painted on the surfaces of teeth to prevent new cavities from forming and to help stop cavities that have already started fluoride varnish can be used on babies' teeth. Minimal chance of ingestion The protective effect of the fluoride varnish will continue to work for several months

Evidence-based Recommendation for Professionally Applied Topical Fluoride ADA, 2006 Age Risk Category