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

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 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

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

 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 9. Higher caries experience is associated with:

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

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

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

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

Dental caries is an infectious, disease Modified by dietary carbohydrates and critically regulated by saliva. TRANSMISSABLE  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 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 in early childhood and pre-school age children Parental caries status is critical Parental caries status is critical

Dental caries is an infectious, transmissible disease and critically regulated by saliva. Modified by dietary carbohydrates  Diet related sugars and carbohydrates (especially refined) promote bacterial growth. Frequency of exposure is critical. (Vipeholm Study) 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.

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

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

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

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

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

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

cavities only get larger, and fast

Treatment gets progressively more invasive, expensive….

…and complicated

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 times more likely to develop decay in their permanent teeth. (Li Y, Wang W, J Dent Res 2002)  Children having tooth decay in their primary teeth are three times more likely to develop decay in their permanent teeth. (Li Y, Wang W, J Dent Res 2002)

Caries is an entirely preventable disease 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………

3. Dental Caries is Entirely Preventable Fight risk factors: 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

2. Dental Caries is Entirely Preventable Promote Protective Factors: 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

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 Guidelines/G_FluorideTherapy.pdf

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.

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

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

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

1) Oral Health Risk Assessment Done

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

Brushing Toothpaste - 1, ppm fluoride Pea sized dose = 0.25 mg 1, ppm fluoride Pea sized dose = 0.25 mg Available OTC Available OTC Lower F content toothpaste available in Europe for children but none being developed in US Lower F content toothpaste available in Europe for children but none being developed in US

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

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

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

What Should be on Toothbrush? New recommendation from AAPD: Grain of rice amount of paste from 0-2! Grain of rice amount of paste from 0-2! Pea sized amount over age 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)

Toothpaste Issues

Flossing - When 2 Teeth Touch

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

Not Just What You Eat, But How Often  Acids produced by bacteria after carbohydrate intake persist for minutes lowering pH  Frequency of sugar ingestion is more important than quantity Safe zone Dang er zone p H Bottle Breakfast Snack Sippy-cup Sippy-cup Lunch

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

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

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

Local Water Fluoridation Facts Does your water system supply fluoridated water?

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

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

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): JADA 2009;140(10):  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): JADA 2010;141(10):  Evidence based guideline published January 2011 JADA 2011;142;79-87JADA 2011;142;79-87

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; JADA 2010;141;

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

Office Tools for OHRA and Varnish Application

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

4) Referral to Dental Home  First dental visit should take place at 1 year; earlier if patient is at high risk  Develop list of dentists who will accept patients this age  Include office phone numbers and addresses  Refer Medicaid patients to state web site or phone line if no access

Dental Network Tips  Find specialists (pediatric dentist, general dentist seeing children)  Call yourself to schedule appointment while patient is in room (a call from an MD will be answered!)  Gather contact information and develop list if feedback is positive Adapted from Dr Eve KimballAdapted from Dr Eve Kimball

Brightening Oral Health Bright Futures Implementation Project 2010 Funded by Proctor & Gamble

Project Details  Initial QUINN practice pilot done  10 sites chosen to test OHRA tool as part of QI Brightening Oral Health project  Pre test survey of practices  Post project survey of data completed

Clinician Agreement on Oral Health

Practice Has a System to Document OHRA  Our practice has a system in place to document oral health risk assessment.

Practice Has a System and Can Identify High Risk Patients  My practice has a system to identify high risk patients for an oral health referral

System to Apply Fluoride Varnish

Easily Accessible Dental Referral List in my Office

Responsible for Regularly Updating Someone responsible for regularly updating practice’s oral health list

Brightening Oral Health Study Conclusions  Practice teams employing a system to document oral health risk assessments increased significantly  Practice teams utilizing a system to identify high risk patients for an oral health referral increased significantly

Summary Tips  Bright Futures recommends: OHRA OHRA Anticipatory guidance Anticipatory guidance Assessment of fluoride modalities Assessment of fluoride modalities Referral to dental home Referral to dental home Your data will help determine feasibility in a busy practice setting!!!