1. 1 Smiles for Life A National Oral Health Curriculum for Family Medicine STFM Group on Oral Health Module 2 Child Oral Health

2. 2 Funders

3. 3 Overall Curriculum  Educational objectives  Four annotated 50 minute PowerPoint lecture modules  The relationship of oral to systemic health  Child oral health  Adult oral health  Dental emergencies  Test questions  Resources for further learning

4. 4 Acknowledgements  The materials in this module were originally developed in part by: University of Connecticut Physician Oral Health Education in Kentucky Texas Project Smile Washington Interdisciplinary Child Oral Health Project  Steering group editors for Module 2: James Tysinger, Ph.D. Russell Maier, M.D.

5. 5 Educational Objectives  Define Early Childhood Caries (ECC)  Discuss the etiology and consequences of ECC  List the risk factors for developing ECC  Recognize ECC in its various stages  Implement prevention of ECC  Perform a knee-to-knee oral screening examination  Discuss common developmental issues and oral pathology in children

6. 6 Early Childhood Caries and its Consequences

7. 7 Early Childhood Caries  Early Childhood Caries (ECC)  Infectious and transmissible  Destroys tooth structure  Affects children under 5  Previously called “Nursing Caries” and “Baby Bottle Tooth Decay”

8. 8 ECC: A Public Health Crisis  Prevalence:  5% of all U.S. children  30-50% of low income children  As high as 70% in Native American populations  80% of decay occurs in 20% of children  Most common chronic disease in children  5 times more common than asthma  7 times more common than hay fever

9. 9 ECC: Consequences  Pain  Infection  Increased caries in permanent dentition  Impaired chewing and nutrition  Below average weight gain  Poor self esteem  School/work absences  Extensive and expensive dental work

10. 10 Early Childhood Caries: Etiology

11. 11 The Etiology Triad Oral bacteria (Mutans Strep) break down dietary sugars into acids which eat away the tooth Teeth Sugars Caries Bacteria

12. 12 Etiology: Bacteria  Mutans Streptococci is vertically transmitted from primary caregiver (usually mother)  Caregivers with high bacteria levels usually have:  High levels of decay  Poor oral hygiene  High frequency of sugar intake  Both bacteria and dietary habits are passed to child

13. 13  It’s not just WHAT, but HOW, children eat  Enamel demineralizes in response to oral acids, then remineralizes as acid is buffered  Oral bacteria produce acids that persist for 20- 40 minutes after sugar ingestion  How often sugar is ingested is more important than how much sugar is eaten at once  If sugar intake is frequent demineralization predominates and teeth are at risk Etiology: Sugars

14. 14 Mouth Acidity

15. 15 Etiology: Teeth  Enamel protects tooth from acids  Enamel defects increase risk of ECC  20-40% of children have defects  Increased incidence with lower SES and prematurity

16. 16 Early Childhood Caries: Risk Factors

17. 17 ECC Risk Factors  SES and cultural factors  Caries in child, siblings or caretakers  Frequent feeding/snacks  Enamel defects  Chronic medical conditions and/or medications  Inadequate fluoride

18. 18 Early Childhood Caries: Recognition

19. 19 This is our goal!

20. 20 Caries Progression  ECC affects the teeth that erupt first and are least protected by saliva Upper incisors First molars Second molars  ECC can begin when teeth first erupt  ECC rarely affects the lower incisors

21. 21 White Spots  White spots indicate acids have demineralized enamel  First clinical signs of caries  White spots place a child at high risk for developing cavities  Indication for dental referral

22. 22 Early Caries

23. 23 Moderate Caries

24. 24 Severe Caries

25. 25 Early Childhood Caries: Prevention

26. 26 Preventing ECC  The role of the family physician  Tooth brushing  Fluoride  Dental sealants  Dietary counseling  Knee to knee screening exam  Age 1 dental visit

27. 27 Why Family Physicians?  Most children have access to primary care physicians (PCPs):  89% of poor children have a usual source of care  74% of poor children 19-35 months of age receive all their vaccines  PCP’s have regular, consistent contact through well child visits

28. 28 Tooth Brushing  Brush twice daily  Bedtime most critical  Caregiver should brush child’s teeth until age six  Child should stand in front of caregiver or lie face up in lap  Spit out not rinse after brushing

29. 29 How much toothpaste? Appropriate amount of toothpaste

30. 30 Brushing Technique Lift the lip Brush behind teeth

31. 31 Fluoride Mechanism  Inhibits demineralization  Enhances remineralization  Inhibits bacterial metabolism  Decreases bacterial acid production  Has both systemic and topical mechanisms of action

32. 32 Water Fluoridation  Optimal fluoridation is 1 ppm  Wells contain variable levels of fluoride and must be tested  Fluoride is added to some community water supplies- determine your patient’s source  Filters and bottled water are modifying variables

33. 33 Systemic Fluoride Supplementation Child’s Age Water Fluoride Concentration <0.3 ppm0.3-0.6 ppm >0.6 ppm 6 mos-3 yrs 3 yrs – 6 yrs > 6 years 0.25 mg 0.50 mg 1.00 mg None 0.25 mg 0.50 mg None Dosages are in milligrams F/day

34. 34 Professionally Applied Topical Fluorides

35. 35 Fluorosis  Excessive levels of fluoride, even naturally occurring, can discolor teeth  Most cases mild  Does not harm tooth or increase caries

36. 36 Fluorosis Prevention  Use rice or pea size toothpaste for children  Determine fluoride content of patient’s drinking water before prescribing supplements  Avoid duplicate fluoride prescriptions  Follow recommended dosage schedules  Use professionally applied fluoride appropriately  Keep toothpaste out of reach of small children

37. 37 Dental Sealants  A plastic material typically applied to the chewing surface of permanent molars  Provides a physical barrier to bacterial invasion of pits and fissures  Typically applied in children at high risk of caries at age 6  Sealants do NOT replace fluoride supplementation

38. 38 Cariogenicity Of Foods

39. 39 High Risk Eating Patterns

40. 40 Diet and Feeding Advice: 0-12 months  Hold infant for bottle and breast feedings  No bottles at bedtime or nap  No sweetened pacifiers  Introduce cup at 6 months, wean bottle by 12 months  Avoid ad lib use of sippy cup unless it contains water  Avoid cariogenic snacks between meals

41. 41 Diet and Feeding Advice: 1-2 years  Discontinue bottle by 12 months  Avoid ad lib use of sippy cup unless it contains water  Avoid excessive juice  Limit cariogenic snacks between meals  Reserve soda, candy and sweets for special occasions

42. 42 Diet And Feeding Advice: 2-5 years  Avoid excessive juice  Choose fresh fruits, vegetables, or whole grain snacks  Limit cariogenic snacks between meals  Reserve soda, candy and sweets for special occasions

43. 43 Age 1 Dental Visit  AAPD recommends all children see dentist at age 1  AAP recommends age 1 visit for children at caries risk  If no dental access FP assumes responsibility for screening and guidance

44. 44 The Knee-to-Knee Screening Exam

45. 45 Oral Exam Goals  Identify existing problems for early referral  Tooth eruption sequence  Developmental defects  Caries  Oral Hygiene  Assess risk of potential problems  Provide anticipatory guidance to parents

46. 46 Knee to Knee Oral Exam 1: Child is held facing caregiver 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

47. 47 Common Behavioral Issues

48. 48 Teething  Teething concerns many caregivers  Does not cause URI, fever, ear infection, or diarrhea  May cause fussiness  Drooling developmentally common at this age  Anticipatory guidance:  Apply cold teething ring or cloth to gums  Acetaminophen or ibuprofen if necessary  Avoid teething gels

49. 49 Eruption Hematoma  Tooth eruption may be preceded by hematoma  Anticipatory guidance:  Reassurance  No treatment needed in primary dentition  In secondary dentition watch for infection

50. 50 Non-nutritive Sucking  Satisfies psychological need  Decrease as the child ages; most stop at 2-4 years  Increases risk of anterior open bite if persists  Intervene:  Pacifier age 2  Thumb age 4-6  Anticipatory guidance when child ready:  Positive reinforcement- start chart, stickers  Cover hands at night with mittens  Stuffed animal or other comfort object

51. 51 Take Home Messages  Dental caries develops in the presence of teeth, bacteria and sugars.  Prevention by non-dental professionals targets:  Feeding practices  Oral hygiene  Systemic fluoride  Assessment of risk factors  Dental screening by non-dental professionals must occur at every well child visit  First dental visit by first birthday for high risk children

52. 52 Questions?

53. 53 Photo Credits  Texas Project Smile  Joanna Douglass B.D.S., D.D.S.  Donald Greiner D.D.S.