Maria Cordero, DMD, MS Assistant Professor of Pediatric Dentistry Stony Brook University School of Dental Medicine

 Dental Caries  Risk Assessment  Behavioral Health  Fluoride Varnish  Appointment Flow

The most prevalent chronic illness in our nation’s children The most prevalent chronic illness in our nation’s children 5 times more common than Asthma 5 times more common than Asthma An infectious disease that is PREVENTABLE An infectious disease that is PREVENTABLE 15% increase in primary tooth decay in the last decade 1 15% increase in primary tooth decay in the last decade 1 12-month old with decayed incisors 1 CDC MMWR August Newacheck et al from NHANES III

TOOTH age, fluorides, morphology nutrition, carbonate level SUBSTRATE oral clearance oral hygiene saliva stimulants frequency of eating carbohydrate type FLORA Strep mutans (oral hygiene and fluoride in plaque) TOOTH SUBSTRATE FLORA CARIES

 Children can get cavities as soon as they get teeth  Cavities begin as white lines (demineralization)  The enamel will breakdown and caries will progress into brown spots The Good The Bad The Ugly white lines caries

 Fosters the treatment of the disease process instead of treating the outcome of the disease  Understanding the disease factors  Individualize preventive discussions  American Academy of Pediatric Dentistry Caries-risk Assessment Tool (AAPD CAT)  Biological, Protective, Clinical Findings

Mother/primary caregiver has active caries High Parent/caregiver has low socioeconomic status High Child has >3 between meal sugar- containing snacks or beverages per day High Child is put to bed with a bottle containing natural or added sugar High Child has special health care needs Moderate Child is a recent immigrant Moderate

TRANSMISSABLE Vertical transmission of caries causing bacteria (Streptococcus Mutans) typically occurs between mothers and infants – direct salivary exchange from feeding, playing, kissing – Occurs before age 2 yrs If mother has cavities or gum disease the child will often have poor oral health Infant acquiring nutrition and mutans

Mother/primary caregiver has active caries High Parent/caregiver has low socioeconomic status High Child has >3 between meal sugar- containing snacks or beverages per day High Child is put to bed with a bottle containing natural or added sugar High Child has special health care needs Moderate Child is a recent immigrant Moderate

1944- Stephan DANGER ZONE MINUTES pH

 Grazers, picky eaters, snackers, and sippers

Mother/primary caregiver has active caries High Parent/caregiver has low socioeconomic status High Child has >3 between meal sugar- containing snacks or beverages per day High Child is put to bed with a bottle containing natural or added sugar High Child has special health care needs Moderate Child is a recent immigrant Moderate

BREASTFEEDING & BOTTLEFEEDING  the bottle, sippy cup or other cup should only have WATER in it BEFORE BED OR NAP TIME = JUICE SODA MILK Poor feeding practice alone will not cause cavities hence * baby bottle tooth decay * bottle mouth * nursing decay are misleading terms

Child receives optimally-fluoridated drinking water or supplements Protective Child has teeth brushed daily with fluoridated toothpaste Protective Child receives topical fluoride from health professional Protective

1901 Dr. McKay moves to Colorado, notices “brown stained teeth” 1945 first city to fluoridate Grand Rapids, Michigan 1950s Fluoride marketed in toothpaste

Age Fluoride Ion Level in Drinking Water (ppm)* <0.3 ppm ppm>0.6 ppm Birth-6 monthsNone 6 months-3 years0.25 mg/day**None 3-6 years0.50 mg/day0.25 mg/dayNone 6-16 years1.0 mg/day0.50 mg/dayNone * 1.0 ppm = 1 mg/liter ** 2.2 mg sodium fluoride contains 1 mg fluoride ion.

Child receives optimally-fluoridated drinking water or supplements Protective Child has teeth brushed daily with fluoridated toothpaste Protective Child receives topical fluoride from health professional Protective

 Amount of toothpaste:  0-2 year old: smear (.1mg)  2-5 year old: pea (.2mg)

Child receives optimally-fluoridated drinking water or supplements Protective Child has teeth brushed daily with fluoridated toothpaste Protective Child receives topical fluoride from health professional Protective

 Risk assessment of dental disease  Diet  Anticipatory Guidance  Oral hygiene instruction  Delay of colonization  Mother’s oral health  Oral health Plan

Child has white spot lesions or enamel defects High Child has visible cavities or fillingsHigh Child has plaque on teeth Moderate

 Wrap gloved index finger with gauze  Wipe teeth and show caregiver  This is plaque…….. Plaque infection makes acid from sugars and starches causing caries.

What Parents Want to Know

 Probable toxic dose is 5 mg/kg  Average weight of a 1 year old is 10 kg  PTD = 50 mg .25 mL per unit dose (Duraflor) 12.5mg per dose .4 mL per unit dose (Vanish) 40 mg per dose

 Abdominal pain, convulsions, diarrhea, vomiting  Call National Poison Control Center  May give Calcium or Milk  Gastric Lavage Possible  Monitor Vital signs

 Two cases of contact allergy to Duraphat varnish have been reported.  Dermatitis in a dental assistant’s hand  Stomatitis in a patient  Related to the colophony (tree nuts)  Duraphat claims that the use of varnish in patients with ulcerative gingivitis and stomatitis is contraindicated. Isaksson M, Bruze M, Björkner B, Niklasson B. Contact allergy to Duraphat. Scand J Dent Res 1993;101:49-51.

 Fluoride has been accused of causing lower IQs, Autism, osteosarcomas, and kidney disease  The only known risk in therapeutic doses is fluorosis  Caused by unmonitored consumption of fluoride in children 8 years or younger

 Caries Risk Assessment  Determines Indications  Opportunity for Counseling

 Knee-to-Knee Screening Examination

 Fluoride Application  Use gauze to dry the teeth as much as possible. Varnish will not adhere if teeth are wet.  Apply varnish to dried teeth, starting in posterior.  Apply varnish to anterior teeth last.  Saliva contamination after the application is fine as varnish sets in contact with saliva.

1. Diet Counseling 2. Oral Hygiene Instruction 3. Fluoride Application 4. Referral to Dentist 6 month Reinforcement 1. Diet update 2. Oral Hygiene 9 month 1. Diet Counseling 2. Oral Hygiene Instruction 3. Fluoride Application 4. Referral to Dentist- troubleshoot 12 month Reinforcement 1. Diet update 2. Oral Hygiene 3. Oral Habits months Repeat Fluoride application and counseling cycle until a dental home is established.

 AAPD Reference Manual 

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Stony Brook Dental Associates Comprehensive Oral Health for Children Maria Cordero, DMD, MS Hechang Huang, DDS, MS, PhD Fred Ferguson, DDS Stephanos Kyrkanides, DDS, MS, PhD Maria Ryan, DDS, PhD Denise Trochesset, DDS Allan Kucine, DDS Sullivan Hall Stony Brook, NY