1. How Fluoride Varnish Combats Early Childhood Caries Daniel Ravel, DDS Fayetteville, NC
For review purposes, Slides 7-19 review and summarize basic concepts from Smiles for Life Module 2: Child Oral Health. You may either hide or briefly review these slides based on how recently your learners have been exposed to this content.
This section addresses Objective 1: Discuss the etiology of ECC.

2. 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
Early childhood caries is an infectious and transmissible chronic disease that destroys tooth structure and leads to a loss of chewing function in children up to five years old. The term caries describes the process from initial enamel demineralization to frank cavities, which are the most obvious visible outcomes of caries. Previously called “baby bottle tooth decay”, it is now known to involve a number of variables in addition to feeding habits. Potentially severe consequences include pain, tooth loss, inflammation of the pulp (pulpitis), and pulp necrosis which can lead to dental abscess. 8

3. ECC Etiology Triad Caries
Oral bacteria (mutans strep) break down dietary sugars into acids which break down the tooth
Bacteria
Teeth
Caries
Dental caries occurs when the oral bacteria mutans streptococci interacts with dietary carbohydrates. Bacteria metabolize the sugars into acid which dissolves tooth enamel, especially in areas of existing enamel weakness. If oral bacterial load is reduced, or carbohydrates are ingested less frequently, less damage to the enamel will occur. This process is reviewed in greater depth in Smiles for Life Module 2: Child Oral Health.
Sugars 9

4. ECC Risk Assessment
This section addresses objective 2: Assess a child’s risk of developing ECC. 10

5. 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
Begin before or with first tooth (4-6 months)
Consider starting risk assessment at 4-6 months, based on expert opinion.
Press Release. Results of National Oral Health Survey. National Institute of Dental Research, National Institutes of Health, Department of Health and Human Services; March 11, 1996 11

6. Assessing Caries Risk High: Moderate: Low 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 (often in premature babies)
The boxes on this slide stratify children into low, moderate, and high caries risk based on the presence or absence of the risk factors listed. SES refers to socioeconomic status. Low risk refers to patients who are higher socioeconomic status (SES), have access to care and utilize care, and whose family members do not have caries. Moderate Risk factors include caries in family – particularly the mother. Dietary risks include drinks or eats sugar containing foods two or more times between meals, and sleeping with bottle or at breast. If a child has abnormal enamel or other developmental defects they are at increased risk, even if all other factors are negative. Another risk factors include children with special health care needs, especially those with craniofacial abnormalities. Moderate and High risk children will benefit from fluoride varnish.
A simple, non-validated, but useful, screen to determine if the child is moderate or high risk involves just three questions. Does the child have active or a history of caries, does the mother or siblings have active or a history of caries, and do they live on an non-fluoridated water system These three questions identify all moderate risk children.
Low 12

7. ECC Recognition
The section addresses Objective 3: Recognize the various stages of ECC on oral examination.
Photo shows white lines and a pit lesion at the gingival margin, both indicators of enamel demineralization in the early stages of Early Childhood Caries.
Photo: Joanna Douglass BDS DDS

8. Knee to Knee Oral Exam
1. Child is held facing care giver 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
Small children are best examined while lying down. For infants and toddlers, the knee to knee oral examination allows you to carefully examine the child’s teeth with assistance from a caregiver. Lift the lip. Look at all the teeth – front, back, sides. Note plaque, white spots, cavities, abscess, and damaged teeth. Palpate the floor of the mouth and gum lines. If the caregiver is obese and the legs don’t fit around, the child may sideways or diagonally on the lap. Adults can be examined while sitting on the exam table.
Photos: Mark Deutchman MD 14

9. Healthy Teeth
Healthy teeth should be a creamy white with no signs of deviation in color, roughness or other irregularities. If the clinician cannot determine if an abnormality in the tooth surface is a defect versus an early cavity it does not really matter. Any child with enamel abnormalities is at high risk for caries and should be referred to a dentist for further evaluation.
Photos: Joanna Douglass BDS DDS 15

10. Early Stage of ECC: White to Brown Spots
Demineralized area typically begin at the gingival margins that appear as white spots, white lines, and/or matt pale yellow areas are early stages of caries. If left to progress to the dentin, frank cavities develop that appear as cavitated brownish discoloration. At this point, pain may result from thermal stimulation, or sweet or sour foods or drinks.
Left upper photo: The left arrow indicates a typical white line. Right arrow indicates a pit-type carious lesion. Intervention at this stage typically involves dietary counseling, application of professional strength fluorides and increased use of fluorides at home.
Photo upper right: White and brown lines.
In the lower left photo: the brown areas represent areas where loss of overlying enamel has exposed underlying dentin. Intervention at this stage may still involve dietary counseling and use of fluorides. Some cavities may be restored using fluoride releasing restorative materials. At this stage these restorations can often be placed quickly and without the use of local anesthesia.
Lower right photo: illustrates enamel loss on the lingual tooth surfaces where it is easily overlooked.
Photos: Joanna Douglass BDS DDS 16

11. Early Aggressive ECC
The brown areas on the previous slide then progress to larger and deeper carious lesions that progressively destroy the tooth. The upper left picture shows exposed pulp (pulp polyp) in the right central incisor and carious lesions of the right lateral incisor. The left central and lateral incisors show carious lesions. The right upper slide show exposed dentin of the maxillary incisors with abscess formation above the right central incisor. The bottom right and left photos show carious lesions and demineralized areas.
Photos: Joanna Douglass BDS DDS 18

12. Fluoride
This section addresses Objective 4: Discuss the mechanism of action of topical fluoride. 20

13. Ongoing Balance Protective Factors Salivary flow Fluoride
Pathologic Factors
mutans strep
Carbohydrates
Reduced salivary flow
Caries is a dynamic process involving many more protective factors and pathologic factors including genetics, environment, lack or oral hygiene and other. Teeth are subjected to an ongoing cycle of demineralization and remineralization determined by the balance of these factors. When they are demineralized enamel is much more susceptible to the effects of bacterially generated acids. When fluoride supplementation is introduced it interacts with phosphate and calcium in a complex reaction that creates an enamel surface that is much less susceptible to demineralization.
No caries
Caries 21

14. Mechanism of Action Topical (greater effect) Systemic (lesser effect)
Inhibits demineralization
Promotes remineralization
Produces anti-bacterial activity
Systemic (lesser effect)
Reduces enamel solubility by incorporation into its structure
Fluoride is a naturally occurring mineral that was originally found in Colorado to be beneficial for preventing caries in areas where there were few caries and the water had naturally high content of fluoride.
Fluoride inhibits tooth demineralization by binding with minerals in enamel to create fluorapatite and fluoridated hydroxyapatite which are harder to demineralize. Fluoride enhances remineralization by repairing the tooth or early white spots and by precipitating calcium and phosphate. Fluoride inhibits bacterial metabolism and decreases acid production of bacteria. The most beneficial effect is this topical effect, primarily from fluoridated toothpaste and water. Systemic fluoride is secreted in saliva where it has its effect topically. 23

15. Sources of Fluoride Systemic Topical Water fluoridation
Fluoride supplements
Topical
Fluoride toothpastes
Gels, foams, mouthwashes
Fluoride varnish
Sources of fluoride other than varnish are addressed in Smile for Life Module 2: Child Oral Health. 24

16. Fluoride Use Recommendations
Low
Risk
Mod
Risk
High
Risk
Fluoridated water
Yes
Yes
Yes
Systemic
Fluoride
Fluoride tablets/drops ?
Yes
Yes
Self-explanatory.
Toothpaste *
Yes
Yes
Topical
Fluoride
Fluoride Varnish No
Yes
Yes
* After age 2 all children should use fluoridated toothpaste 25

17. Evidence of Benefit for Fluoride
General Population
(USPSTF 1989, 1996)
Fluoridated toothpaste (I, A)
High Risk Populations
(MMWR 2001)
Water supplementation reduces caries by 30%
Fluoride supplement if water <.3ppm (6-12 yr-olds)(I,A)
Topical fluoride gels (I, A)
Fluoride varnishes on permanent teeth (I, A)
Fluoride varnish on high risk infants (I, A)
The benefit of public water fluoridation has been somewhat variable. In some communities when fluoridation was introduced caries rates decreased by as much as 50-70%. In communities with higher socioeconomic status and lower caries prevalence the decrease was around 20%.
There is strong evidence supporting many dental interventions that can be implemented in primary care.
US Preventive Services Task Force. Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 interventions. Baltimore, MD: Williams & Wilkins; 1989
US Preventive Services Task Force, Guide to Clinical Preventive Services, 2nd edition, Available at:
Centers for Disease Control and Prevention Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States. MMWR Aug 17, 2001/50 (RR14); Available at:
Centers for Disease Control and Prevention (1999) Achievements in public health, 1990–1999: fluoridation of drinking water to prevent dental caries. MMWR Morb Mortal Wkly Rep 48:933–940.
Source: Essential Evidence + (formerly Inforetriever)
article.cfm?resource=T&article=10199 (accessed ) 26

18. Fluoride Varnish
This section addresses Objective 5: Describe the benefits and indications for fluoride varnish. 27

19. 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 in active ECC
Self explanatory. 28

20. 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!
Self explanatory. It should be noted that fluoride varnish application is NOT a substitute for a dentally healthy diet, regular brushing, systemic fluoride supplementation (if indicated), and regular dental care. Fluoride varnish is typically applied twice per year, but in extremely high risk children it can be applied up to four times per year.
Hutter JW, Chan JT, Featherstone JDB, et al. Professionally Applied Topical Fluoride: Evidence Based Clinical Recommendations. American Dental Association, Council on Scientific Affairs, May 2006. 30

21. Available Preparations 0.25ml unidose 5% NaF (2.26% F)
CavityShield
OMNII
$1.00 per dose
Enamel Pro Varnish
Primier
$1.60 per dose
Duraflor
Medicom
$1.00 per dose
Five 0.25 ml 5% NaF unidose fluoride varnish preparations commercially were available in the United States as of May Pricing information is based on average costs when purchased through distributors and is subject to variation and may be less when purchased in bulk. Each product and applicator system have their own unique advantages and disadvantages, and taste may vary. Some products are clear and some are brownish in color. The Smiles for Life authors, Editor, and the Society of Teachers of Family Medicine do not endorse any particular product.
All Solutions
Dentsply
$1.60 per dose
Flor-Opal
Ultradent
$2.00 per dose 31

22. Follow-up After application of topical fluoride:
Offer caries preventive advice
Assess need for fluoride supplements
Plan next visit to the medical home
Refer to dental home (if needed)
If a child has active caries
Intensive counseling and preventive measures
Urgent definitive dental referral
If teeth are varnished, there needs to be follow-up. The follow-up interval should be determined by a child’s caries risk status and whether they have been able to establish a dental home. There must be a record in the medical chart documenting the application. If the varnish is done for white spots or active decay, there needs to be an immediate action plan. Intensive counseling (see Smiles for Life Module 2: Child Oral Health) on oral health care including diet and brushing, systemic fluoride prescription, a one month follow-up would be typical. If active caries is present the goal is to get established in a dental home as soon as possible. 33

23. Hygiene Advice: Tooth Brushing
Start when teeth erupt
Brush twice daily
Bedtime most critical
Caregiver brushes until age 6
Child can stand in front of caregiver or lie face up in lap
Spit after brushing, not rinse
Use rice size or smear of fluoridated toothpaste
Lift lip; brush behind teeth
Regular tooth brushing is important to remove plaque and food debris, and most important for distributing the fluoridated toothpaste. Brushing at nighttime is most important as salivary flow is decreased. Caregivers need to supervise the brushing of children under age 6 as they do not reliably spit, and will often swallow children’s flavored toothpaste. This additional Fluoride exposure increases the risk of fluorosis. Young children have difficulty carefully brushing all areas – tops and sides – and in particularly behind teeth and all the way to the rear of the mouth. Appropriate positioning is shown above.
Chestnutt IG, Schafer F, Jacobson AP, Stephen KW. The influence of tooth brushing frequency and post-brushing rinsing on caries experience in a caries clinical trial. Community Dentistry & Oral Epidemiology. 1998;26(6):
Photos: Joanna Douglass BDS DDS 23

24. High Risk Eating Pattern Advice
Frequent snacking – 2 +times between meals
Sticky, retentive snacks, slow dissolving carbohydrates
Sequence of eating & time
Examples
Candy, sippy cup of juice or soft drink, graham crackers, cookies
Raisins, dried fruit, fruit rolls, bananas, caramels, jelly beans, peanut butter/jelly sandwich
Chewable vitamins at end of meal, food or drink after brushing and before bed
This slide reviews eating patterns that present high caries risk. Recall the salivary pH remains low between meals with frequent snacking (see slide 14). Maximizing the interval between food intake allows time for teeth to re-mineralize after exposure to acids. 24

25. Healthy Snacks Advice Happy Foods Sad Foods Fruit Fruit Roll-ups
Veggies
Cheese
Crackers
Pretzels
Popcorn
Nuts
Peanut Butter
Cheese Crackers
Sugar Free Gum
Milk
Water
100% pure fruit juice (only 4 oz per day)
Sad Foods
Fruit Roll-ups
Fruit by the Foot
Fruit Wrinkles
Gummy Bears
Cookies
Cupcakes
Sugared Cereals
Granola Bars
Pop Tarts
Soda, Gatorade, Ice Tea
Donuts
Sugar drinks
Here are some suggestions for healthy and not so-healthy snacks. In addition to avoiding the frequent use of juice and soda, caretakers must be mindful of seemingly “innocent” products, such as “sport drinks” and processed fruit products. Potato chips and similar snacks are high carbohydrates foods that break down into simple sugars which allow the bacteria to ferment the sugars into acids. Frequent consumption of these foods can also lead to caries.
We thank Man Wai Ng, DDS, MPH, Boston University, School of Dental Medicine, Department of Pediatric Dentistry, for allowing us to use the content of this slide. 25 25

26. Fluoride Supplementation Advice
6 mos – 3 yrs 0.25 mg None None
3 yrs – 6 yrs 0.50 mg 0.25 mg None
> 6 years 1.00 mg 0.50 mg None
< 0.3 ppm 0.3 – 0.6 > 0.6 ppm
ppm
Water Fluoride Concentration
Child’s Age
Systemic fluoride supplementation by prescription for children who do not have access to optimally fluoridated water is recommended by the American Academy of Pediatrics, the American Academy of Pediatric Dentistry, and the Centers for Disease Control and Prevention. Appropriate dosing is shown in the table above. This has traditionally been an area of poor compliance with prescribing guidelines by clinicians, so attention to detail is important. Fluoride supplements should never be prescribed unless the clinician obtains clear documentation of the fluoride content of a child’s water source. In optimally fluoridated communities where children drink bottled water supplements should NOT be prescribed. Supplementation is not recommended for breast feeding infants or formula fed infants until age 6 months. No study specifically quantifies what is too much or too little fluoridated water to drink.
(accessed 5/14/08, site reference last updated 2007)
Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention. MMWR Recomm Rep 2001;50(RR-14):1-42.
Dosages are in milligrams F/day 26

27. Age 1 Dental Visit Referral
The American Academy of Pediatric Dentistry recommends a dental evaluation by the 1st birthday
The American Academy of Pediatrics recommends establishment of a dental home by the 1st birthday for children at high risk
If limited dental access, clinician assumes responsibility for screening and guidance
It is recommended that clinicians refer children to a general or pediatric dentist by the child’s first birthday to ensure the early establishment of a dental home. However, in many communities those with no insurance or on Medicaid have limited or no access. In these setting it is important to stratify the risk of the child, and make sure that children at high risk or with disease present can access the dental system. Children at lower risk can be screened by the clinician, but he/she must take responsibility for ensuring that appropriate anticipatory guidance and fluoride prescription is provided.
For those patients with access to a dentist, he/she can reinforce our message, when indicated can provide dental x-rays, and as the child ages can provide sealants to permanent molars.
Hale KJ, American Academy of Pediatrics Section on Pediatric D. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003;111(5 Pt 1):
Savage MF LJ, Vann WF. Does Age Matter? Examination of the first preventive dental visit. Pediatric Dentistry 2003;25(2):181.
Policy on the dental home. In: American Academy of Pediatric Dentistry. Oral health policies. Pediatr Dent 2002;24(7 suppl):10-42. 27

28. Applying Fluoride Varnish
This section addresses Objective 6: Demonstrate the appropriate application of fluoride varnish. 34 28

29. Applying Fluoride Varnish: Step 1
Assemble the required supplies:
Varnish
Toothbrush
Gauze
Gather supplies as listed. Mix the varnish well before applying, but do not open the packet until you are ready to use it as it may dry out prematurely. 36 29

30. 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
Self explanatory.
Photos: ICOHP 37 30

31. Applying Fluoride Varnish: Step 3
Use a 4x4 gauze pad to dry the child’s teeth and remove gross plaque
Self explanatory.
Photo: ICOHP 38 31

32. 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
Self explanatory.
Photos: ICOHP 39 32

33. Applying Fluoride Varnish: Step 5
Tell the caregiver:
The child’s teeth will be discolored for hours
Do not brush the child’s teeth for hours
Avoid giving the child hot, sticky or hard foods for 24 hours
Self explanatory.
Photo: ICOHP 40 33

34. Fluorosis and the Safety of Fluoride Varnish
Section title slide. 41 34

35. 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%
Fluorosis is tooth discoloration that can be quite variable, but usually consists of white mottling. Children can develop Fluorosis if they have chronic excessive exposure to Fluoride while their teeth are developing. The risk of developing Fluorosis is greatest at an intake of more than 0.06 milligram per kilogram of body weight per day. Fluorosis in only a cosmetic issue. It does NOT affect systemic health. The prevalence of fluorosis has been cited as anywhere from 0.2% to 27% in the United States children, and is rising. Varnish is not a major risk factor for fluorosis as it is an irregular source of fluoride rather than a daily one. Using too much fluoridated toothpaste is often cited as a major contributor to fluorosis.
Photos shows moderately severe Fluorosis.
Pendrys DG. Risk of enamel fluorosis in nonfluoridated and optimally fluoridated populations: considerations for the dental professional. Journal of the American Dental Association. 2000;131(6):
Photos: John McDowell DDS, Joanna M. Douglass BDS DDS 42 35

36. 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
Self explanatory.
Skotowski MC, Hunt RJ, Levy SM. Risk factors for dental fluorosis in pediatric dental patients. J Public Health Dent Summer;55(3):154-9.
Do LG, Spencer AJ. Risk-benefit balance in the use of fluoride among young children. J Dent Res Aug;86(8):723-8. 43 36

37. 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
5% sodium fluoride varnish has 26,000 parts per million fluoride. This concentration is relatively high. However, a single application of 0.5 milliliter represents less than 6 milligrams of Fluoride. With this level of application, negligible Fluoride levels have been detected in blood and urine, and the amount of Fluoride in the urine is comparable to that found in the urine of a child who swallowed toothpaste while brushing. Fluoride varnish is as safe as other topical fluoride applications such as toothpastes, rinses, and gels. 44 37

38. 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
These are the key points that we hope you will take away from this talk. 46 38