1. EARLY CHILDHOOD CARIES (ECC) PREVENTION AND ORAL HEALTH PROMOTION Pacific Islands Continuing Clinical Education Program (PICCEP) The following presentation was adopted by me to use in American Samoa and Palu in the Pacific Islands. The program was designed and implemented by Dr. Peter Milgrom a professor at the University of Washington and has been used in much of Micronesia with great success

2. EARLY CHILDHOOD CARIES (ECC) PREVENTION AND ORAL HEALTH PROMOTION Pacific Islands Continuing Clinical Education Program (PICCEP) Fred Quarnstrom, DDS FICD, FASDA, FAGD Department of Dental Public Health Sciences University of Washington, Private Practice, Seattle WA Palau 2003

3. We have a problem

4. ECC in American Samoa James B. Quartey, DDS, MPH, Dental Department, LBJ Tropical Medical Center, Pago Pago, AS. Lepetia Aga-Letuli, BS, Department of Health, American Samoa Government, Pago Pago, AS 208 children 3 y. o.37% 4 y. o.58% 5 y. o.75% had 5 or more decayed, missing or filled dmf teeth 1% had 20 or more dmf teeth Average 6.4 dmf teeth 13% were caries free

5. ECC on Ofu Fred Quarnstrom, DDS, University of Washington, Dept. Public Health Sciences 5/8/02 1 was caries free 93% had caries Study was visual exam with no x-rays 38 children 4 y. o. 100% had decay av. 6.7 decayed n=12 5 y. o. 93% had decay av 5.4 decayed n= 14 6 y. o 100% had decay av. 5.4.decayed n=6

6. Dentistry on Ofu and Olosega 40 children had 250 teeth that needed treatment. Fluoride varnish took less than 3 minutes per child. Projection (realizing that projections can be inaccurate) A population of 400 has 2,500 teeth needing treatment If 7 patients had 3 teeth treated per day - a very optimistic schedule. It would take 125 dentist days to take care of basic needs. 200 days if you include cleanings and exams. A full time dentist with an assistant is needed at the Ofu clinic.. Another dentist and assistant is needed at the clinic on Ta’u. Multiply this need by 100 to 150 for all of American Samoa. You can not possibly provide this much service. Prevention is the only solution

7. We have a problem It is an epidemic.

8. We have a problem It is an epidemic. It is bacterial.

9. We have a problem It is an epidemic. 90% of 6 year olds are infected.

10. We have a problem It is an epidemic. It causes many children to have severe pain on a regular basis.

11. It is an epidemic. If they were adults, they would not put up with the pain. We have a problem

12. It is passed to the children by their mothers.

13. We have a problem If it were an STD like Clamydia, mothers would be treated prior to giving birth.

14. We have a problem We treat it by amputating tissue and providing prosthesis.

15. We have a problem If we treated diabetes this way, rather then controlling blood sugar, we would amputate feet.

16. We have a problem It costs 10 times as much to treat as it does to prevent.

17. We have a problem It is much easier and less costly to prevent than it is to treat.

18. NORMAL PRIMARY DENTITION

19. We have a problem It is early childhood caries (decay), ECC.

20. Who are “WE” We are American migrant workers. We are American Indians. We are recent American immigrants. We are from Siapan, Northern Marshal Islands, Guam, Pohnhpei, Yap, Palau, Chuuk and American Samoa. We are Children.

21. What we know about dental disease: Dental caries is an infectious disease. The mother is usually the primary source of the infection. The infectious bacteria is easily transmitted from mother-to-child prior to tooth eruption.

22. 13.8% had hypoplasia ECC in Saipan

23. Strep. Mutans vs Decay

24. 66.7% of 6-12 mo olds were colonized on teeth or tongue. Concepts of a later “window of infectivity” do not appear to apply to this population. S. mutans was found in 25% (4/16) children who had no erupted teeth raising questions about the validity of previous arguments.

25. ECC prevalence in other areas? RMI (Majuro) 50% in 2-3 y.o.; nearly 100% by age 5 Yap 93% by age 3-4 Other places?? Virtually all the disease goes untreated.

30. ECC Risk Increases... 7x from 12 -24 mo 18x from 12-36 mo 5x from high S. mutans 10x from hypoplasia 8x from frequent high sugar snacks

31. How can transmission be prevented?

32. PRIMARY SOLUTION Define oral health for mothers as part of peri-natal care. Moms must get priority for treatment.

33. How can transmission be prevented? Antimicrobial applications to reduce cavity- causing bacteria in mothers: causing bacteria in mothers: Peri-natal: Chlorhexidine gluconate (0.12%) rinses twice daily Peri-natal: Xylitol chewing gum 4-5 times daily Dental care for the expectant mother

34. Kohler program for mothers with infants until age 3 Dietary counseling Professional tooth cleaning & oral hygiene instruction Topical fluoride treatment Treatment of dental caries 1% chlorhexidine gel, 1x day, 2 wks; repeated after 2-3 mo.

35. Chlorhexidine gluconate 0.12% rinse Many dental professionals are not aware of the use of chlorhexidine for caries Safe in pregnancy Safe for nursing mothers

36. Chlorhexidine gluconate 0.12% rinse for pregnant women and mothers with infants Rinse twice daily with 1/2 capful for 30 sec and expectorate. Do not rinse with water or eat or drink afterwards for 30 min

37. Xylitol Gum and Mints Each stick/pellet is 1 gram Use 4 or more grams/day Up to 10-12 grams Chew for 5 minutes Safe for pregnant or nursing moms

38. Maternal consumption of xylitol gum 2 or 3 times a day beginning at 3 months after childbirth was associated with reduced mother-child transmissions of MS. Solderling,Isokangas, Pienihakkien &tenovuo, 2000

39. PRIMARY CARE SOLUTION Define oral health as part of well baby care If we stop decay in these kids, we do not have to treat decay later.

40. THE PRIMARY CARE PROVIDER MCH workers have regular and consistent contact with young children at well-child care/immunization visits Control of ECC cannot be confined to the dental clinic

41. PRIMARY CARE PROVIDER IN ORAL HEALTH Role could include: provision of dietary & oral hygiene guidance dispensing of fluoridated toothpaste application of a caries control therapy such as fluoride varnish assessment, prompt referral of children at high risk

42. ANTICIPATORY GUIDANCE Oral health important to overall health Importance of care provider’s oral health Dental Care for Pregnant Mothers Transmissability of Strep mutans Tooth eruption Lift the Lip/looking for decay

43. RECOGNIZING EARLY DECAY WHITE SPOT LESIONS = Subsurface demineralization

45. Decay

47. Dietary Guidance: - Dental disease is exacerbated by diet. - Avoid prolonged breast- and bottle-feeding, especially at sleep times. Do not fill bottle with a sugar-containing product. Do not add sugar to solid foods. Encourage cup use at 6 - 8 months. Limit sweet, starchy snack foods.

48. Oral Hygiene: New moms need training in cleaning kids’ teeth Wipe infant’s gums with a wet cloth or gauze after each feeding.) Brush baby teeth as soon as the first tooth erupts. (~ 6 months in age) Children do not brush their own teeth effectively Use a small amount of fluoridated toothpaste on the toothbrush. If you cannot brush smear some fluoride toothpaste on their teeth with your finger.

49. FLUORIDE MECHANISMS OF ACTION Reduces enamel solubility Promotes remineralization of enamel Some anti-bacterial activity

50. CHARACTERISTICS Dry tooth facilitates fluoride uptake Sets on contact with moisture No prophy required Taste is tolerable Can reverse early decay and can arrest active lesions

51. Fluoride Varnish More than 25 years of use and research in Europe Available in Canada for many years Currently, more than 90% of all professionally applied topical fluorides in Scandinavia are varnishes

52. EFFICACY Meta-analysis of Duraphat trials reveals 38% caries reduction* More frequent application yields better results Fluoride varnish and Acidulated Phosphate Fluoride ( APF) have comparable efficacy *Helfenstein and Steiner, Community Dentistry and Oral Epidemiology, 1994

53. Comparison of FV to Other Topical Fluorides: APF Gel - APF Gel - similar clinical effect as FV. inappropriate for young children - they will swallow. lengthy application time potential for excessive ingestion – adverse effects.

54. How does FV work? The lacquer-based product adheres to the dental enamel forming a deposit from which fluoride is slowly released.

55. Fluoride Varnish Application Have everything ready Position the child Quick visual inspection Dry teeth with cotton gauze Apply fluoride varnish with disposable applicator Have a drink of water No brushing until tomorrow

56. white spots holes missing structure QUICK VISUAL INSPECTION

57. Fluoride Varnish 40-80 applications per 10 mL tube Use a brush

67. Contraindications and Adverse Reactions w/ FV Contraindications: Contact allergy may occur in those hypersensitive to colophony (skin- sensitizing resin). Ulcerative gingivitis and stomatitis. Adverse Reactions: Nausea

68. Dyspnea (in patients w/ asthma): Although listed as an adverse reaction on the product insert - There are no known reports from the literature or the FDA concerning this reaction.

69. Fluoride Varnish Application Safe Effective Quickly completed

70. TOOLS FOR CONTROL OF ECC Fluoride varnish Silver Fluoride Application Glass ionomer sealants Scoop and fill - ART

71. Ag Fl vs. Na Fl V All preschool children 375 children for 18 months Guangzhou in Southern China Mean base line 4.73 dmf (anteriors) Brushed with fluoride toothpaste - 73% 38% once a day 17% twice a day Ag Fl was applied every 12 months Na Fl was applied every 3 months Water for the control group

72. Ag Fl vs. Na Fl V techniqueExcavate decay New decayArrested surfaces Ag Fl yes 0.44 2.84 Ag Fl Na Fl V Control

73. Ag Fl vs. Na Fl V techniqueExcavate decay New decayArrested surfaces Ag Fl yes 0.44 2.84 Ag Fl no 0.42 2.99 Na Fl V Control

74. Ag Fl vs. Na Fl V techniqueExcavate decay New decayArrested surfaces Ag Fl yes 0.44 2.84 Ag Fl no 0.42 2.99 Na Fl V yes 0.84 1.69 Na Fl V Control

75. Ag Fl vs. Na Fl V techniqueExcavate decay New decayArrested surfaces Ag Fl yes 0.44 2.84 Ag Fl no 0.42 2.99 Na Fl V yes 0.84 1.69 Na Fl V no 0.63 1.50 Control

76. Ag Fl vs. Na Fl V techniqueExcavate decay New decayArrested surfaces Ag Fl yes 0.44 2.84 Ag Fl no 0.42 2.99 Na Fl V yes 0.84 1.69 Na Fl V no 0.63 1.50 Control 1.22 0.99

77. TOOLS FOR CONTROL OF ECC Silver Fluoride Application

78. Silver fluoride Available as a 3.8% silver diamide fluoride solution from Japan (Safloride) 40% aqueous Silver fluoride solution in Australia

79. Chinese trial of Safloride Prevents new lesions from developing in other surfaces

80. Silver fluoride safety Application to all the primary teeth, if done carefully, should be equivalent to taking 2 mg F orally. Fluoride should be confined to the lesion to avoid over exposure Over exposure could result in fluorosis

81. Silver fluoride application Dry teeth with cotton gauze Apply to open lesion with small brush. Keep it off the gingiva OK to eat/drink after 1 hour Stains clothes, fingers

82. TOOLS FOR CONTROL OF ECC Glass ionomer sealants ART

84. Use glass ionomer (Ketac, Fuji 9) as sealants because they tolerate some moisture during placement.

85. SUMMARY Redefine perinatal care to include oral health. Redefine well baby care to include oral health. Much of this work must occur outside of the dental clinic and involve others. Effective tools are available. Fluoride varnish, silver fluoride Chlorhexidine Xylitol gum Dental Care and Oral Hygiene Glass ionomer sealants and ART We have an epidemic!

86. It is for the children

87. The children are the key

88. Prevent decay in the children and you will not need the dentist.