1. 1 DRAFT Smiles for Life A National Oral Health Curriculum Second Edition STFM Group on Oral Health Module 6 Fluoride Varnish Date of release: July 2008 Copyright STFM 2005-2008

2. 2 Steering Committee  Alan B. Douglass, M.D. (Editor and Group Co-Chair)  Middlesex Hospital, University of Connecticut  Mark E. Deutchman, M.D.  University of Colorado  Wanda C. Gonsalves, M.D.  Medical University of South Carolina  Russell Maier, M.D. (Group Co-Chair)  University of Washington  Hugh Silk, M.D.  University of Massachusetts  James Tysinger, Ph.D.  University of Texas Medical Branch, San Antonio  A. Stevens Wrightson, M.D.  University of Kentucky

3. 3 Funders

4. 4 DRAFT Curriculum Overview  ACGME formatted educational objectives  6 annotated 50 minute PowerPoint modules 1. The relationship of oral to systemic health 2. Child oral health 3. Adult oral health 4. Dental emergencies 5. Oral health in pregnancy 6. Fluoride varnish  Test questions  Resources for further learning

5. 5 DRAFT Acknowledgements  The materials in this module were originally developed in part by:  Washington Interdisciplinary Oral Health Project (ICOHP)  UTHSC-San Antonio “Project Smile”  Washington Dental Services Foundation  University of Connecticut Schools of Medicine and Dental Medicine  Steering group editors for Module 6:  Russell Maier, M.D.  Wanda C. Gonsalves, M.D.  James Tysinger, Ph.D.  Dental Consultant  Joanna M. Douglass, B.D.S., D.D.S.  Smiles for Life Editor  Alan B. Douglass, M.D.

6. 6 DRAFT Educational Objectives  1. Discuss the etiology of early childhood caries (ECC)  2. Assess a child’s risk of developing ECC  3. Recognize the various stages of ECC on oral examination  4. Discuss the mechanism of action of topical fluoride  5. Describe the benefits and indications for fluoride varnish  6. Demonstrate the appropriate application of fluoride varnish

7. 7 DRAFT Early Childhood Caries A Brief Review

8. 8 DRAFT Early Childhood Caries (ECC)  Caries in primary dentition under age 5  Affects 35% of 3 year olds  Bacteria are the causative agent  Destroys tooth structure, often rapidly  Usually affects maxillary incisors first  Potentially severe consequences could include pain, tooth loss, pulpitis, pulp necrosis and dental abscess

9. 9 DRAFT ECC Etiology Triad Oral bacteria (mutans strep) break down dietary sugars into acids which break down the tooth Teeth Sugars Caries Bacteria

10. 10 ECC Risk Assessment

11. 11 Why is Risk Assessment Important?  80% of ECC occurs in 20% of children  Risk status determines:  Age of first dental visit  Use of fluoride  Depth of nutritional and hygiene counseling

12. 12 Assessing Caries Risk High: Multiple risk factors and:  Plaque on teeth  Presence of white spots or cavities  No systemic fluoride exposure Moderate: One of following risk factors:  Lower SES  Poor access to health care  Family members have cavities – particularly mother  Diet – drinks or eats sugar containing foods two or more times between meals  Diet - sleeping with bottle or at breast  Special health care needs  Developmental defects Low

13. 13 ECC Recognition Photo: Joanna Douglass BDS DDS

14. 14 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 Photos: Texas Project Smile

15. 15 DRAFT Healthy Teeth Photos: Joanna Douglass BDS DDS

16. 16 DRAFT White Spots: The Early Stage of ECC Photos: Joanna Douglass BDS DDS

17. 17 DRAFT White Spots Progress to Brown Areas Photos: Joanna Douglass BDS DDS

18. 18 DRAFT Early Aggressive ECC Photos: Joanna Douglass BDS DDS

19. 19 DRAFT Advanced ECC Photos: Joanna Douglass BDS DDS

20. 20 Fluoride

21. 21 Ongoing Balance No caries Caries Protective Factors Salivary flow Fluoride Pathologic Factors mutans strep Carbohydrates Reduced salivary flow

22. 22 Fluoride  Naturally occurring mineral present in water and food  Water supplementation reduces caries rates by 30%

23. 23 Mechanism of Action  Topical (greater effect)  Inhibits demineralization  Promotes remineralization  Produces anti-bacterial activity  Systemic (lesser effect)  Reduces enamel solubility by incorporation into its structure

24. 24 Sources of Fluoride  Systemic  Water fluoridation  Fluoride supplements  Topical  Fluoride toothpastes  Gels, foams, mouthwashes  Fluoride varnish

25. 25 Fluoride Use Low Risk Mod Risk High Risk Systemic Fluoride Fluoridated waterYes Fluoride tablets/drops ?Yes Topical Fluoride Toothpaste*Yes Fluoride VarnishNoYes OR AND * After age 2 all children should use fluoridated toothpaste

26. 26 Fluoride Varnish

27. 27 Benefits  Can be quickly and easily applied  Application does not have to be done by a physician  Dry tooth surface facilitates fluoride uptake  Sets on contact with moisture  Taste is tolerable  Can reverse early decay (“white spots”) and slow enamel destruction by active ECC

28. 28 Efficacy in Preschool Children StudyCountry% Caries Decrease Holm 1979Sweden44 Grodzka et al. 1982Poland10 Clark et al. 1985Canada9 Petersson et al. 1998Sweden7 Frostell et al. 1991Sweden37 Twetman et al. 1996Sweden30 Weintraub et al 2006US50

29. 29 Indications  Moderate and high risk children without caries  Children with “white spots”  Children with caries  Generally applied twice per year beginning when teeth erupt  Varnish is not a replacement for appropriate diet, regular brushing, indicated systemic fluoride supplements, or routine dental care!

30. 30 Available Preparations 0.25ml unidose 5% NaF (2.26% F) CavityShield OMNII $1.00 per dose Duraflor Medicom $1.00 per dose Enamel Pro Varnish Primier $1.60 per dose

31. 31 Available Preparations 0.25ml unidose 5% NaF (2.26% F) All Solutions Dentsply $1.60 per dose Flor-Opal Ultradent $2.00 per dose

32. 32 Follow-up  Application of Topical Fluoride initiates a follow-up  Either back to the medical home OR  Referral to a dental home  If a child has active caries  Intensive counseling and preventive measures  Urgent definitive dental referral

33. 33 Applying Fluoride Varnish

34. 34 Clinical Case  Melissa is 3 years old and new to your un- fluoridated community. At a well child visit Mom tells you that a dentist has never examined Melissa’s teeth and she daughter does not take fluoride supplements. On exam you note 2 small “white spots.” You decide to apply fluoride varnish. What do you do next?

35. 35 Applying Fluoride Varnish: Step 1  Assemble the required supplies:  Varnish  Toothbrush  Gauze

36. 36 Applying Fluoride Varnish: Step 2  Visually inspect all the child’s teeth and document any white spots and/or cavities for future follow-up  Hints Use the knee-to-knee exam Show the toothbrush to prompt opening of the mouth Photos: ICOHP

37. 37 Applying Fluoride Varnish: Step 3  Use a 4x4 gauze pad to dry the child’s teeth and remove gross plaque Photo: ICOHP

38. 38 Applying Fluoride Varnish: Step 4  Apply varnish to all the surfaces of the dry teeth  Note: The varnish will not adhere if it is applied to wet teeth, but saliva contamination after the application is fine Photos: ICOHP

39. 39 Applying Fluoride Varnish: Step 5  Tell the caregiver:  The child’s teeth will be discolored for 24-48 hours  Do not brush the child’s teeth for 24 hours  Avoid giving the child hot or hard foods for 24 hours Photo: ICOHP

40. 40 Fluorosis and the Safety of Fluoride Varnish

41. 41 Fluorosis  Discoloration of teeth due to chronic excessive exposure to Fluoride while teeth are developing  Risk greatest at intake of greater than 0.06 mg/kg/day  Prevalence of Fluorosis: 0.2% - 27% Photo: Source???

42. 42 Reducing the Risk of Fluorosis  Determine the fluoride content of the child’s drinking water  Consult with the child’s dentist to avoid duplicating Fluoride prescriptions  Follow current dosage schedules for systemic Fluoride supplementation  Tell the child’s caregiver to place only a rice-grain size dab of fluoridated toothpaste on the child’s toothbrush  Keep fluoride containing products out of the reach of small children

43. 43 Safety of Fluoride Varnish  5% NaF varnish = 26,000 ppm Fluoride  A 0.5 milliliter application of fluoride varnish contains < 6 milligrams of Fluoride  Negligible Fluoride levels are detected in blood and urine  Fluoride varnish is as safe as other topical fluoride applications via toothpastes, rinses, and gels

44. 44 = In certain circumstances States with Medicaid Funding for Physician Oral Health Screening and Fluoride Varnish = Medicaid coverage approved = Considering Source AAP

45. 45 Take Home Messages  ECC is a significant health problem for children  As a medical clinician, you can play a key role in preventing ECC  Fluoride varnish is one part of a comprehensive approach to a child’s oral health  Fluoride varnish is safe and effective  You can apply fluoride varnish to a child’s teeth as a part of a routine visit  You can minimize the risk of fluorosis by educating the child’s caregivers

46. 46 Questions?

47. 47 Post-Module Assessment 1.What is the etiology of ECC? 2.What factors impact a child’s risk of developing ECC? 3.What does ECC look like? 4.How would you assess a child’s ability to benefit from an application of Fluoride varnish? 5.What is topical Fluoride’s mechanism of action? 6.What steps are used to apply Fluoride varnish? 7.What is Fluorosis, and what prevent it?