Top ten facts a pediatric dentist would like pediatricians to know

1. Top ten facts a pediatric dentist would like pediatricians to know Yasmi O. Crystal DMD

2. 10. Prevalence Dental Caries is the most prevalent chronic disease of childhood, more than asthma or hay fever. Successes - Prevalence and severity trends have changed • 75% of kids have only 25% of the disease Challenges • 25% of children have 80% of the disease • 28 percent of 2-5 year-olds had experienced tooth decay. This represents a significant 15 percent increase compared to the same age group of children during 1988-1994.8 Tooth decay can progress with age if risk factors are not addressed: 11 percent of two year-olds have tooth decay and by age five, 44 percent have tooth decay.9

3. Severe late clinical stages of ECC Overall impact of the underlying disease on general health and quality of life

4. 9. Higher caries experience is associated with: • Mothers who have high caries experience • Lower socio-economic status • Ethnicity • Parental education level However, • Poverty alone (or being on medicaid) is not an indicator of high risk • Belonging to a racial minority or being a recent immigrant does not automatically place a child

5. 8. Caries a disease Cavities consequence or a sequelae of the disease

6. 7.Dental caries is an infectious, transmissible disease Modified by dietary carbohydrates and critically regulated by saliva. Complex and Multifactorial

7. INFECTIOUS Dental caries is an , transmissible disease Modified by dietary carbohydrates and critically regulated by saliva. Caused by specific bacteria • mutans streptococci strep mutans sterp sobrinus • lactobacilli complex and different than regular infections

8. SEM of Plaque on a tooth surface Acid producing bacteria are usually less than 1 percent of the total flora in the plaque

9. TRANSMISSABLE Dental caries is an infectious, disease Modified by dietary carbohydrates and critically regulated by saliva. • Primarily Vertical Transmission cariogenic bacteria are transmitted via saliva from mother or caretaker to child before teeth erupt and colonize the teeth shortly after their eruption • Horizontal transmission seems to be more common than previously thought in early childhood and pre-school age children Parental caries status is critical

10. Modified by dietary carbohydrates • Diet related sugars and carbohydrates (especially refined) promote bacterial growth. Frequency of exposure is critical. (Vipeholm Study) • Lifestyle dependent home care and hygiene practices limit the action of diet on bacteria because it is a time dependent process. Dental caries is an infectious, transmissible disease and critically regulated by saliva.

11. Streptococcus mutans culture showing active cell division.Sucrose leads to extracellular polysaccharides that stick the plaque together

12. CRITICALLY REGULATED BY SALIVA Dental caries is an infectious, transmissible disease modified by dietary carbohydrates and • Saliva’s flow and composition alter the caries process on the tooth surface • Has a major impact on biofilm, plaque and bacterial colonization

13. 6. Caries is a dynamic process and reversible up to a specific point The Caries Balance • Protective Factors • Saliva flow and components • Fluoride - remineralization • Antibacterials:- • chlorhexidine, xylitol, new? • Pathological Factors • Acid-producing bacteria • Frequent eating/drinking of • fermentable carbohydrates • Sub-normal saliva flow and • function Caries No Caries JDB Feathersone

14. When protective factors prevail the result is remineralization When harmful factors prevail the result is further demineralization that quickly progresses into cavitation which is irreversible

15. Fluoride varnish works to strengthen teeth before there are cavitated lesions

16. 5. Once the enamel breaks, the process is irreversible and progressive

17. cavities only get larger, and fast

18. Treatment gets progressively more invasive, expensive….

19. …and complicated

20. 4. It is important to control the disease process early because: • About half of ECC patients treated with restorations under GA relapse, experiencing tooth decay within the first year after dental surgery. (Berkowitz RJ, CDAJ 2003/ Amin MS et al, European Arch of Ped Dent, Dec 2010) • Children having tooth decay in their primary teeth are three timesmore likely to develop decay in their permanent teeth. (Li Y, Wang W, J Dent Res 2002)

21. Caries is an entirely preventable disease • Incorporate oral risk assessments to well child visits • Recognize early signs of dental decay • Promote Fluoride Varnish Applications when indicated • Refer early AAAAAANNNNNDDDDDD………

22. 3. Dental Caries is Entirely Preventable Fight risk factors: • Instruct parents about vertical transmission • Discourage frequent snacking • Discourage frequent consumption of sweet drinks. Bottle, sippy cup? Not only for caries obesity/diabetes

23. 2. Dental Caries is Entirely Preventable • Promote Protective Factors: • Encourage supervised brushing with fluoride toothpaste • Encourage drinking of fluoridated water • Recommend healthy snacks • 8 oz bottles contain aprox. .20 mg F ion

24. Fluoride toothpaste should be used twice daily as a primary preventive procedure. Twice daily use has benefits greater than once daily. Parents should be counseled on their child’s caries Risk, dispensing an appropriate volume of toothpaste onto a soft, age-appro priate sized toothbrush, frequency of brushing, and performing/assisting brushing on young children. A “smear” of fluoridated toothpaste for children less than 2 years of age A “pea-size” amount for children ages 2 to 5 http://www.aapd.org/media/Policies_ Guidelines/G_FluorideTherapy.pdf

25. 1. Refer to a Dental Home AAP Oral Health Policy. May, 2003 Infants at risk for caries should have a dental home by age 1 or at the eruption of the first tooth.

26. Bright Futures Implementation Project Oral Health Risk Assessment February 17 and 23, 2011 Suzanne Boulter, MD

27. Bright Futures Recommendations Oral health risk assessment performed Anticipatory guidance given Fluoride modalities addressed Referral to dental home

28. Measures for This Project OHRA at 6 and 9 months; longer if a dental home cannot be established Referral to a dental home at 12 months

29. 1) Oral Health Risk Assessment Done

30. 2) Anticipatory Guidance Given Brushing Flossing Diet Education about caries etiology

31. Brushing Toothpaste - • 1,000-1500 ppm fluoridePea sized dose = 0.25 mg • Available OTC • Lower F content toothpaste available in Europe for children but none being developed in US

32. Toothpaste Brushing increases the level of F in saliva then low concentrations remain for 2 to 6 hours Excess fluoride ingestion from swallowing is risk factor for fluorosis! Amounts of toothpaste used and ability to spit out determine risk

33. Toothpaste Evidence Cochrane Reviews – 2003 “Children aged 5-16 who used F toothpaste had fewer decayed, missing and filed permanent teeth after three years regardless of whether their drinking water was fluoridated.” Studies showed average of 24% caries reduction

34. When Should Toothbrushing Begin? As soon as first tooth erupts Under direct supervision of caregiver until age 6

35. What Should be on Toothbrush? New recommendation from AAPD: Grain of rice amount of paste from 0-2! Pea sized amount over age 2 pea size amount of toothpaste weighs 0.4 gms and contains 0.6 mg fluoride - equal to the daily recommended intake for a child less than age 2. Lewis C, Milgrom,P. Fluoride. Pediatrics in Review 2003;24(10)

36. Toothpaste Issues

37. Flossing - When 2 Teeth Touch

38. Diet Limit foods and drinks with added sugar Avoid sticky foods Discuss pre tasting of food Recommend no bottle in bed with anything except water Advise stopping bottle by first birthday

39. Not Just What You Eat,But How Often Acids produced by bacteria after carbohydrate intake persist for 20-40 minutes lowering pH Frequency of sugar ingestion is more important than quantity • pH • Safe zone • Danger • zone • 6 7 8 9 10 11 12 1 • Bottle Breakfast Snack Sippy-cup Sippy-cup Lunch

40. Education About Caries Discuss balance between diet, oral hygiene and bacteria Use AAP or other handouts

41. 3) Fluoride Issues Discussed Community water fluoridation Filters Topical fluoride Systemic supplements

42. Community Water Fluoridation Provides both topical and systemic benefits Frequent exposure to small amounts over lifespan gives ongoing protection Cost effective – every $1 invested in water fluoridation saves $38 in dental costs Cost of fluoridation ranges from 0.50 to $3.00 per person in community Use of bottled water and some home filter systems negate effectiveness Universal access – income level no barrier! No need for individual behavior change

43. Local Water Fluoridation Facts www.cdc.gov/fluoridation Does your water system supply fluoridated water?

44. Fluoride Removal Systems Activated charcoal Cellulose filters Reverse osmosis – all F removed Distillation – all F removed

45. Filtration System Examples • Brita Systems • No fluoride removal • Relatively inexpensive • Faucet system • Pitcher • Reverse Osmosis • Fluoride removed • Expensive!

46. Formula Issues ADA published interim study October 2009 suggesting mixing powdered formula with fluoridated water might be risk factor for fluorosis JADA 2009;140(10):1228-1236 October 2010 study concluded that although mild fluorosis could result from mixing with F water the caries preventive benefit of F outweighed the small risk JADA 2010;141(10):1190-1201 Evidence based guideline published January 2011 JADA 2011;142;79-87

47. Systemic F - Prescription Supplements Available from physician or dentist Determine water fluoride level before writing prescription! Multiple sources of F make prescribing challenging! Recommended for patients at high risk who have no F in tap water starting at 6 months JADA 2010;141;1480-1489

48. Fluoride Varnish Offer to patients at high risk Evidence for up to 35% decreased caries Apply and bill per your state Medicaid guidelines Give information sheet about what to do after application

49. Office Tools for OHRA and Varnish Application

50. Medicaid Codes and Reimbursement Fluoride varnish D 1206 $12 - $53 Oral evaluation new pt D 0145 $29 - $56 Oral evaluation est pt D 0120 $20 - $27 Age limit – varies; ages 6 months to 5 years Number of varnish applications reimbursed annually – 2- 4 Training required – varies; state specific Delegation of procedure (NP, RN, LPN, CMA) about 2/3 of states allow