Caries Risk Assessment and Disease Prevention

1. Caries Risk Assessment andDisease Prevention Thuan Le, DDS, PhD Associate Professor of Clinical Pediatric Dentistry University of California, San Francisco

2. Objectives • Inspire medical and dental personnel to evaluate oral health status in infants and young children. • Be able to assess caries risk and to individualize interventions and recall. • Demonstrate key elements addressed in the knee-to-knee encounter. • Promote the use of fluorides and dental sealants. • Understand and promote the use of early intervention techniques. • Understand motivational interviewing and goal setting. • Promote healthy daily family behaviors for optimal oral health.

3. You too can see young children and learn to do a Caries Risk Assessment!

4. Early Childhood Caries (ECC) Any tooth decay, including extractions and fillings from previous decay, in the primary dentition.

5. Severe Early Childhood Caries (S-ECC) • Distinctive pattern of tooth decay that begins on upper primary teeth. • Rapidly progressing to other teeth as they erupt.

6. Early Childhood Caries (ECC) in California • California’s children fall well below the nation in oral health. • About 1/3 of preschoolers and almost 70% of children in grades K-3 have experienced tooth decay. Data from the 2006 California Smile Survey

7. Treatment of ECC • 40-50% of children treated with severe ECC have new decay within 4-12 months. • Restorations alone do not solve the problem. We must treat the infection!

8. Primary teeth are important! Eating and Nutrition Holding Space Talking Smiling!

9. White Spot Lesions • The first visible sign of tooth decay is decalcification. • Reversible!

10. ECC can be prevented. • Interventions with pregnant women and mothers of infants. • Interventions with babies and young children.

11. Ways to Prevent ECC • Water Fluoridation • Application of Fluoride Varnish • Sealants on primary teeth • Daily brushing with fluoride toothpaste • Dietary changes

12. Fluoride Varnish • Easily applied topical fluoride treatment • Safe for babies and young children

13. Dental Sealants

14. Dietary Counseling • Limit sugary foods and drinks. • Limit simple carbohydrates like white crackers. • Need to limit both frequency and total sugar intake. • Encourage drinking water and fresh fruit and vegetable snacks.

15. Limit Total Sugar Intake • Dentistry does not practice in a vacuum. • Increased obesity and diabetes type II among children requires limiting both frequency and total sugar intake.

16. Weaning • Recommend using a cup at 6 months of age. • Consider weaning at 12-14 months of age. • Don’t let baby sleep with the bottle or walk around with a bottle or sippy cup all day.

17. Oral Health Assessment andCaries Risk Assessment (CRA) for Babies and Young Children

18. Supply List • 2X2 gauze • Direct light source • Baby/child toothbrush • Fluoride Varnish • Vinyl/latex gloves • Plastic mirror/tongue blades • Floss

19. Step 1: Begin assessing risk factors and protective factors • Family history of caries • Bottle use and other dietary habits • Developmental disabilities or special needs • Assess water fluoridation/systemic fluoride supplements • Home care and use of fluoride toothpaste • Dental Home

20. Building Rapport • Play and talk with child • Use toys or a baby toothbrush for distraction • Use staff to occupy child during the interview

21. Step 2: Knee-to-Knee Position

22. Expect Crying • Bad News: Child is crying. • Good News: You can see the teeth clearly.

23. Tips for Behavior Management • Focus on the nature of the cry • Use distraction techniques • Tell, show, do Above all, stay calm!

24. Step 3: Toothbrush Prophy • Remove plaque so you can see teeth clearly • Discuss home care • Reinforce the use of a small smear of fluoride toothpaste

25. Cleaning the Teeth at Home • Begins when first tooth erupts • Let older children and caregivers practice while you watch

26. Step 4: Clinical aspects of CRA • Presence of thick plaque • Chalky white spots, brown spots, or obvious dental caries • Tooth defects • Visually inadequate saliva flow

27. White Spots or Gingival Inflammation

28. Mild, Moderate and SevereEarly Childhood Caries

29. Lift the Lip • Show caregivers any signs of tooth decay • Teach them to “lift the lip” monthly to check for chalky white spots or brown spots

30. Caries Risk Assessment High risk = Active disease or recent disease activity • White spot lesions • Carious lesions in previous 12 months • Active caries in caregiver Moderate risk = Presence of risk indicator but no active disease • Visible plaque • Frequent carbohydrate exposure • No carious lesions in previous 12 months Low risk = Absence of factors in either category

31. Step 5: Apply Fluoride Varnish

32. Fluoride Varnish Procedure • Dry teeth lightly with a gauze square • Open the packet of varnish • Stir with applicator • “Paint” the varnish on the child’s teeth • “Less is More”

33. Fluoride Varnish Procedure • Begin with lower teeth. Do the outsides of all teeth and then the insides. • Repeat with upper arch. • Develop a pattern that works for you.

34. Fluoride Varnish Procedure • When in doubt, follow the manufacturer’s instructions

35. Parent Instructions • Mild yellow or brownish tint that will disappear when the teeth are brushed. • Don’t brush until the next day for optimal benefit.

36. All done! • Raise the child back into their caregiver’s arms for comforting. • Most children stop crying at this point. • Give them a toothbrush or toy to play with while you talk with the caregiver.

37. Motivational Interviewing

38. Step 6: Summary and Goal-Setting • Summarize findings, follow-up, and home care. • Discuss risk. • Set goals.

39. Small Steps • Choose 1-2 key messages • Non-judgmental and friendly • Culturally sensitive • Remain positive!

40. Multiple Triggers Over Time • Changes in health behavior do not happen overnight. • It often takes many triggers, delivered over a period of time, in combination with a person’s own experiences and values to change health behavior.

41. Documentation

42. Disease Management • Interim Therapeutic Restorations (ITRs) using fluoride-releasing glass ionomer • Silver Diamine Fluoride

43. Interim Therapeutic Restorations • Minimal cavity preparation, no injections, no drilling • Fluoride releasing glass ionomer • Be sure to inform the family: • That this stops the disease for the time-being • That these fillings will be recharged with fluoride when the child drinks fluoridated water or brushes with fluoride toothpaste • Continued check-ups are important

44. Silver Diamine Fluoride • Silver’s antibacterial properties; fluoride’s remineralization properties. • Interim Caries Arresting Medicament • CDT Code 1354 • FDA approved for tooth sensitivity; off label use for caries arrest.

45. Risk-Based Recall Consider: • High risk = 4x/year • Moderate risk = 3x/year • Low risk = 1-2x/year

46. Reinforce Home Care It’s what families do at home that really counts!

47. Follow-Up Visits Children who have received infant caries risk assessments often make excellent future dental patients.

48. 6 Steps • Interview • Position the child • Toothbrush Prophy • CRA • Fluoride Varnish Treatment • Summary and Goal Setting

49. Healthy Smiles for California’s Children