how fluoride varnish combats early childhood caries daniel ravel dds fayetteville nc l.
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How Fluoride Varnish Combats Early Childhood Caries Daniel Ravel, DDS Fayetteville, NC. Early Childhood Caries (ECC). Caries in primary dentition under age 5 Affects 35% of 3 year olds Bacteria are the causative agent Destroys tooth structure, often rapidly

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early childhood caries ecc
Early Childhood Caries (ECC)

Caries in primary dentition under age 5

Affects 35% of 3 year olds

Bacteria are the causative agent

Destroys tooth structure, often rapidly

Usually affects maxillary incisors first

Potentially severe consequences could include pain, tooth loss, pulpitis, pulp necrosis and dental abscess

8

ecc etiology triad
ECC Etiology Triad

Teeth

Bacteria

Caries

Sugars

Oral bacteria (mutans strep) break down dietary sugars into acids which break down the tooth

9

why is risk assessment important
Why is Risk Assessment Important?
  • 80% of ECC occurs in 20% of children
  • Risk status determines:
    • Age of first dental visit
    • Use of fluoride
    • Depth of nutritional and hygiene counseling
    • Begin before or with first tooth (4-6 months)

11

assessing caries risk
Assessing Caries Risk
  • High:
  • Multiple risk factors and:
    • Plaque on teeth
    • Presence of white spots or cavities
    • No systemic fluoride exposure
  • Moderate:
  • One of following risk factors:
    • Lower SES
    • Poor access to health care
    • Family members have cavities – particularly mother
    • Diet – drinks or eats sugar containing foods two or more times between meals
    • Diet - sleeping with bottle or at breast
    • Special health care needs
    • Developmental defects (often in premature babies)

Low

12

ecc recognition

ECC Recognition

Photo: Joanna Douglass BDS DDS

knee to knee oral exam
Knee to Knee Oral Exam

1. Child is held facing care giver in a straddle position

2. Child leans back onto examiner while caregiver holds child’s hands

3. Provider performs exam while caregiver holds child’s hands and legs

Photos: Mark Deutchman MD

14

healthy teeth
Healthy Teeth

Photos: Joanna Douglass BDS DDS

15

early stage of ecc white to brown spots
Early Stage of ECC: White to Brown Spots

Photos: Joanna Douglass BDS DDS

16

early aggressive ecc
Early Aggressive ECC

Photos: Joanna Douglass BDS DDS

18

ongoing balance
Ongoing Balance

Protective Factors

Salivary flow

Fluoride

Pathologic Factors

mutans strep

Carbohydrates

Reduced salivary flow

Caries

No caries

21

mechanism of action
Topical (greater effect)

Inhibits demineralization

Promotes remineralization

Produces anti-bacterial activity

Systemic (lesser effect)

Reduces enamel solubility by incorporation into its structure

Mechanism of Action

23

sources of fluoride
Sources of Fluoride

Systemic

  • Water fluoridation
  • Fluoride supplements

Topical

  • Fluoride toothpastes
  • Gels, foams, mouthwashes
  • Fluoride varnish

24

slide16

Fluoride Use Recommendations

Low

Risk

Mod

Risk

High

Risk

Fluoridated water

Yes

Yes

Yes

Systemic

Fluoride

Fluoride tablets/drops

Yes

Yes

?

*

Yes

Yes

Toothpaste

Topical

Fluoride

Fluoride Varnish

No

Yes

Yes

* After age 2 all children should use fluoridated toothpaste

25

evidence of benefit for fluoride
General Population

(USPSTF 1989, 1996)

Fluoridated toothpaste (I, A)

High Risk Populations

(MMWR 2001)

Water supplementation reduces caries by 30%

Fluoride supplement if water <.3ppm (6-12 yr-olds)(I,A)

Topical fluoride gels (I, A)

Fluoride varnishes on permanent teeth (I, A)

Fluoride varnish on high risk infants (I, A)

Evidence of Benefit for Fluoride

26

benefits
Benefits

Can be quickly and easily applied

Application does not have to be done by a physician

Dry tooth surface facilitates fluoride uptake

Sets on contact with moisture

Taste is tolerable

Can reverse early decay (“white spots”) and slow enamel destruction in active ECC

28

indications
Indications

Moderate and high risk children without caries

Children with “white spots”

Children with caries

Generally applied twice per year beginning when teeth erupt

Varnish is not a replacement for appropriate diet, regular brushing, indicated systemic fluoride supplements, or routine dental care!

30

slide21

Available Preparations0.25ml unidose 5% NaF (2.26% F)

CavityShield

OMNII

$1.00 per dose

Enamel Pro Varnish

Primier

$1.60 per dose

Duraflor

Medicom

$1.00 per dose

All Solutions

Dentsply

$1.60 per dose

Flor-Opal

Ultradent

$2.00 per dose

31

follow up
Follow-up
  • After application of topical fluoride:
    • Offer caries preventive advice
    • Assess need for fluoride supplements
    • Plan next visit to the medical home
    • Refer to dental home (if needed)
  • If a child has active caries
    • Intensive counseling and preventive measures
    • Urgent definitive dental referral

33

hygiene advice tooth brushing
Hygiene Advice: Tooth Brushing

Start when teeth erupt

Brush twice daily

Bedtime most critical

Caregiver brushes until age 6

Child can stand in front of caregiver or lie face up in lap

Spit after brushing, not rinse

Use rice size or smear of fluoridated toothpaste

Lift lip; brush behind teeth

Photos: Joanna Douglass BDS DDS

23

high risk eating pattern advice
High Risk Eating Pattern Advice

Eating Pattern

Frequent snacking – 2 +times between meals

Sticky, retentive snacks, slow dissolving carbohydrates

Sequence of eating & time

Examples

Candy, sippy cup of juice or soft drink, graham crackers, cookies

Raisins, dried fruit, fruit rolls, bananas, caramels, jelly beans, peanut butter/jelly sandwich

Chewable vitamins at end of meal, food or drink after brushing and before bed

24

healthy snacks advice
Healthy Snacks Advice

Happy Foods

Fruit

Veggies

Cheese

Crackers

Pretzels

Popcorn

Nuts

Peanut Butter

Cheese Crackers

Sugar Free Gum

Milk

Water

100% pure fruit juice (only 4 oz per day)

Sad Foods

Fruit Roll-ups

Fruit by the Foot

Fruit Wrinkles

Gummy Bears

Cookies

Cupcakes

Sugared Cereals

Granola Bars

Pop Tarts

Soda, Gatorade, Ice Tea

Donuts

Sugar drinks

25

fluoride supplementation advice
Fluoride Supplementation Advice

Water Fluoride Concentration

Child’s Age

< 0.3 ppm 0.3 – 0.6 > 0.6 ppm

ppm

6 mos – 3 yrs 0.25 mg None None

3 yrs – 6 yrs 0.50 mg 0.25 mg None

> 6 years 1.00 mg 0.50 mg None

Dosages are in milligrams F/day

26

age 1 dental visit referral
Age 1 Dental Visit Referral

The American Academy of Pediatric Dentistry recommends a dental evaluation by the 1st birthday

The American Academy of Pediatrics recommends establishment of a dental home by the 1st birthday for children at high risk

If limited dental access, clinician assumes responsibility for screening and guidance

27

applying fluoride varnish step 2
Visually inspect all the child’s teeth and document any white spots and/or cavities for future follow-up

Hints

Use the knee-to-knee exam

Show the toothbrush to prompt opening of the mouth

Applying Fluoride Varnish: Step 2

Photos: ICOHP

37

applying fluoride varnish step 4
Apply varnish to all the surfaces of the dry teeth

Note: The varnish will not adhere if it is applied to wet teeth, but saliva contamination after the application is fine

Applying Fluoride Varnish: Step 4

Photos: ICOHP

39

applying fluoride varnish step 5
Tell the caregiver:

The child’s teeth will be discolored for 24-48 hours

Do not brush the child’s teeth for 12-24 hours

Avoid giving the child hot, sticky or hard foods for 24 hours

Applying Fluoride Varnish: Step 5

Photo: ICOHP

40

fluorosis
Discoloration of teeth due to chronic excessive exposure to Fluoride while teeth are developing

Risk greatest at intake of greater than 0.06 mg/kg/day

Prevalence of Fluorosis: 0.2% - 27%

Fluorosis

Photos: John McDowell DDS, Joanna M. Douglass BDS DDS

42

reducing the risk of fluorosis
Determine the fluoride content of the child’s drinking water

Consult with the child’s dentist to avoid duplicating fluoride prescriptions

Follow current dosage schedules for systemic fluoride supplementation

Tell the child’s caregiver to place only a rice-grain size dab of fluoridated toothpaste on the child’s toothbrush

Keep fluoride containing products out of the reach of small children

Reducing the Risk of Fluorosis

43

safety of fluoride varnish
5% NaF varnish = 26,000 ppm fluoride

A 0.5 milliliter application of fluoride varnish contains < 6 milligrams of fluoride

Negligible fluoridelevels are detected in blood and urine

Fluoride varnish is as safe as other topical fluoride applications via toothpastes, rinses, and gels

Safety of Fluoride Varnish

44

take home messages
ECC is a significant health problem for children

As a medical clinician, you can play a key role in preventing ECC

Fluoride varnish is one part of a comprehensive approach to a child’s oral health

Fluoride varnish is safe and effective

You can apply fluoride varnish to a child’s teeth as a part of a routine visit

You can minimize the risk of fluorosis by educating the child’s caregivers

Take Home Messages

46