Speaker Notes. Module 2 Child Oral Health. Smiles for Life, 3rd Edition. Slide 1

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1 Slide 1 Image: Wojciech Gajda/Photos.com Image: Jupiterimages/Photos.com Image: Christoph Hähnel/Photos.com Image: Getty Copyright STFM Third Edition June Last Modified: March, 2015 Speaker Notes Module 2 Child Oral Health Smiles for Life, 3rd Edition Copyright STFM

2 Slide 2 Course Steering Committee Authors Jonathan Bowser, M.S., PA-C James Tysinger, Ph.D Russell Maier, M.D. Dental Consultant Joanna M. Douglass, B.D.S., D.D.S. Rocio Quinonez, D.M.S., M.S., M.P.H. Smiles for Life Editor Melinda Clark, M.D. Funded By The images in this presentation are not to be reproduced/downloaded for purposes other than personal use. Republication, retransmission, reproduction, or other use of the Licensed Material is prohibited. Welcome to the Child Oral Health Course This course addresses the prevalence, etiology, and consequences of early childhood caries (ECC). Clinicians will learn to assess risk factors, recognize the various stages of ECC, and counsel patients on preventative techniques. Additionally, this module will discuss common oral developmental issues in children such as teething, eruption hematomas, and non-nutritive sucking. Acknowledgements: Course Steering Committee Editors Jonathan Bowser, M.S., PA-C James Tysinger, Ph.D. Russell Maier, M.D. Dental Consultant Joanna M. Douglass, B.D.S., D.D.S. Rocio Quinonez, D.M.S., M.S., M.P.H. Smiles for Life Editor Melinda Clark, M.D. Last Modified: March, 2015

3 Slide 3 Educational Objectives Discuss the prevalence, etiology, and consequences of Early Childhood Caries (ECC) Recognize the various stages of ECC on oral examination Assess a child's risk of developing ECC Implement prevention of ECC through use of fluoride, proper hygiene, diet, and appropriate dental referral Discuss common dental development issues in children and adolescents Offer appropriate anticipatory guidance regarding developmental issues Educational Objectives Discuss the prevalence, etiology, and consequences of Early Childhood Caries (ECC). Recognize the various stages of ECC on oral examination. Assess a child's risk of developing ECC. Implement prevention of ECC through use of fluoride, proper hygiene, diet, and appropriate dental referral. Discuss common dental development issues in children and adolescents. Offer appropriate anticipatory guidance regarding developmental issues.

4 Slide 4 Early Childhood Caries (ECC) Chapter Objectives Discuss the prevalence, etiology, and consequences of ECC Recognize the various stages of ECC during an oral examination Image: Wojciech Gajda/Photos.com Learning objectives targeted in this chapter: Discuss the prevalence, etiology, and consequences of early childhood caries (ECC). Recognize the various stages of ECC during an oral examination.

5 Slide 5 What is ECC? 5 Etiology Infectious, chronic disease that destroys tooth structure leading to loss of chewing function, pain, and infection Now the disease is called ECC as a variety of feeding habits are implicated Affects 35% of 3-year-olds from low income families Progression Upper front teeth that are least protected by saliva are affected first Disease moves posteriorly as teeth emerge Photos: Joanna Douglass, BDS, DDS What is ECC? Early Childhood Caries is an infectious and chronic disease that destroys tooth structure leading to loss of chewing function, pain, and infection in children up to five years of age. Etiology ECC was once called "nursing caries" or "baby bottle tooth decay." Now the disease is called ECC as a variety of feeding habits are implicated. Other known variables include socioeconomic status, access to dental care, fluoride exposure, and family caries experience. Progression Upper front teeth that are least protected by saliva are affected first. Disease moves posteriorly as teeth emerge. Reference Tinanoff N, Kanellis MJ, Vargas CM. Current understanding of the epidemiology, mechanisms, and prevention of dental caries in preschool children. Pediatr Dent. 2002;24(6):

6 Slide 6 Prevalence 6 ECC is the most common chronic disease in children and is 5 times more common than asthma 30 to 50% of low income children have ECC ECC prevalence in children 2 to 5 years old increased from 24% in to 28% in % of dental caries occurs in 20% of children Up to 70% of Native American children may have ECC Photos: Joanna Douglass, BDS, DDS Prevalence ECC is a public health crisis and the most common chronic disease in children. Consider the following statistics: ECC is five times more common than asthma. 30% to 50% of low income children have ECC. ECC appears to be increasing. The prevalence of ECC in children two to five years old increased from 24% in to 28% in % of dental caries occurs in 20% of children. Up to 70% of Native American children may have ECC. Many cases of ECC are undiagnosed, usually because parents or caregivers do not seek dental care at an early age for their children. Clinicians can play a major role in preventing ECC and initiating early treatment. References US Department of Health and Human Services. Oral health in America. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; B.A. Dye, S. Tan and V. Smith et al., Trends in oral health status: United States, and National Center for Health Statistics, Vital Health Stat 11 (2007), p Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. Am J Public Health. Impact of poor oral health on children's school attendance and performance. Am J Public Health 2011.

7 Slide 7 Etiology: The Triad 7 What causes dental caries? Caries is a multi-step process that results in destruction of the tooth structure. Oral bacteria (mutans streptococci) metabolize the sugars from dietary carbohydrates into acid The acid demineralizes the tooth enamel If the cycle of acid production and demineralization continues, the enamel will become weakened and break down into a cavity What Causes Dental Caries? Caries is a multi-step process that results in destruction of the tooth structure. Oral bacteria (mutans streptococci) metabolize the sugars from dietary carbohydrates into acid. The acid demineralizes the tooth enamel. If the cycle of acid production and demineralization continues, the enamel will become weakened and break down into a cavity. References Fisher-Owens SA, Gansky SA, Platt LJ et al. Influences on Children's Oral Health: A Conceptual Model. Pediatrics Vol. 120(3): pp. e510 -e520. Colak H, Dülgergil CT, Dalli M, Hamidi MM. Early childhood caries update: A review of causes, diagnoses, and treatments. J Nat Sci Biol Med. 2013;4(1):29-38.

8 Slide 8 Etiology: Bacteria 8 Etiology Cariogenic bacteria are vertically transmitted from the primary caregiver, typically the mother Transfer is thought to occur via saliva contact The higher the bacteria level in the caregiver s mouth, the more likely the child will become colonized Caregivers can decrease the risk of passing bacteria to children by: Receiving regular comprehensive dental care Limiting the frequency of sugar in the diet Maintaining excellent oral hygiene and using a fluoride containing toothpaste Using preventive agents such as topical fluorides, antibacterial mouth rinses, and xylitol containing gums in appropriate age groups Cariogenic bacteria are vertically transmitted from the primary caregiver, typically the mother. It is thought that transfer occurs via saliva contact. The higher the bacteria level in the caregiver's mouth, the more likely the child will become colonized with mutans streptococci. Caregivers with high bacteria levels usually have: A high frequency of sugar intake Poor oral hygiene High levels of dental caries There is promising evidence showing that caregivers can decrease their risk of passing on mutans streptococci to their children by decreasing their own caries levels. Strategies include: Receiving regular comprehensive dental care Limiting the frequency of sugar in the diet Maintaining excellent oral hygiene and using a fluoride containing toothpaste Using preventive agents, in appropriate age groups, such as : Topical fluorides Anti-bacterial mouthrinses such as chlorhexidene Xylitol containing gums References Kozai K, Nakayama R et al. Intrafamilial distribution of mutans streptococci in Japanese families and possibility of father-to-child transmission. Microbiol Immunol. 1999;43(2): Köhler B, Lundberg AB, Birkhed D, Papapanou PN. Longitudinal study of intrafamilial mutans streptococci ribotypes. Eur J Oral Sci Oct;111(5): Weintraub JA et al. Mothers' caries increases odds of children's caries. J Dent Res. 2010; 89(9):954-8.

9 Slide 9 Etiology: Sugars 9 It s not just WHAT, but HOW children eat Oral bacteria produce acids that persist for minutes after sugar ingestion Oral acids lead to enamel demineralization Remineralization occurs when acid is buffered by saliva If sugars are consumed frequently, there is insufficient time for remineralization to occur; tooth is subjected to continued demineralization and the caries process progresses It's not just WHAT, but HOW, children eat: Oral bacteria produce acids that persist for minutes after sugar ingestion. Oral acids lead to enamel demineralization. Remineralization occurs when acid is buffered by saliva. If sugars are consumed frequently, there is insufficient time for the remineralization process to occur. The tooth is subjected to continued demineralization and the caries process progresses. If sugars are consumed infrequently, teeth are able to fully remineralize and the caries process halts.

10 Slide 10 Etiology: Teeth 10 Nature of enamel defects 20 to 40% of children have enamel defects Defects may appear as changes in translucency, color, or texture It may be difficult to distinguish enamel defects from early clinical signs of caries (bottom photo) though this does not affect management. Enamel defects are associated with substantially increased risk of ECC. Increased incidence of enamel defects is associated with: Lower socioeconomic status (SES) Children who were born prematurely Children who have certain congenital diseases Photos: Joanna Douglass, BDS, DDS The cells that manufacture enamel are very sensitive to systemic insults. Disruption in the production of enamel will result in a defect which may be microscopic or macroscopic. Nature of Enamel Defects Twenty to forty percent of children have enamel defects. Defects may appear as changes in translucency, color, or texture. It may be difficult to distinguish enamel defects from early clinical signs of caries though this does not affect management. Enamel defects are associated with substantially increased risk of ECC. Increased incidence of enamel defects is associated with: Lower socioeconomic status (SES) Children who were born prematurely Children who have certain congenital diseases References Oliveira AF, Chaves AM, Rosenblatt A. The influence of enamel defects on the development of early childhood caries in a population with low socioeconomic status: a longitudinal study. Caries Res. 2006;40(4): Weerheijm KL. Molar incisor hypomineralization (MIH): clinical presentation, etiology and management. Dent Update Jan-Feb;31(1):9-12. Seow WK. Enamel hypoplasia in the primary dentition: a review. ASDC J Dent Child 1991;58: Jacobsen PE, Haubek D, Henriksen TB, et al. Developmental enamel defects in children born preterm: a systematic review. Eur J Oral Sci. 2014; 122(1):7-14.

11 Slide 11 Healthy Teeth 11 Nature of healthy teeth Creamy white with no signs of deviation in color, roughness, or other irregularities If the clinician cannot determine whether an abnormality in the tooth surface is a defect versus an early cavity, this will not alter management Any child with enamel abnormalities is at high risk for caries and should be referred to a dentist for further evaluation Topical fluoride varnish to prevent decay Photos: Joanna Douglass, BDS, DDS Healthy teeth should be a creamy white with no signs of deviation in color, roughness, or other irregularities. If the clinician cannot determine whether an abnormality in the tooth surface is a defect versus an early cavity, this will not alter management. Any child with enamel abnormalities is at high risk for caries and should be referred to a dentist for further evaluation. Topical fluoride varnish to prevent decay

12 Slide 12 White Spots 12 Appearance & Symptoms White spots and lines are the first clinical signs of demineralized enamel Typically begins at the gingival margin If the disease process is not managed, lesions will progress to cavities that are initially yellow Treatment Immediate dental referral Dietary and oral hygiene counseling Topical fluoride varnish to reverse or arrest lesions Photos: Joanna Douglass, BDS, DDS White Spots: The Early Stage of ECC White spots and lines are demineralized areas of enamel and represent the first clinical signs of caries. Appearance & Symptoms Caries typically affects the teeth that emerge first and are least protected by saliva, e.g., the upper incisors. White spots/white lines typically begin at the gingival margin. If the disease process is not managed, the lesions will progress and the demineralized enamel will break down to frank cavities that initially appear pale yellow. In time, they will progress to larger brown cavities. Treatment & Referral Immediate dental referral should be arranged. It does not matter if the clinician cannot determine whether an enamel lesion represents hypoplasia or early caries. In either case, the child is at high risk for ECC and requires referral. Dietary and oral hygiene counseling should be given. Use topical fluoride varnish to reverse or arrest lesions.

13 Slide 13 Brown Cavitations Appearance & Symptoms Brown cavitations represent areas where loss of enamel has exposed underlying dentin Lesions darken as they become stained with pigments from food Treatment Immediate dental referral Lesions are small enough that techniques not requiring local anesthesia or handpieces (drills) can be used to stabilize their progression. Dietary and oral hygiene counseling Topical fluoride to arrest lesions not requiring restorations Photos: Joanna Douglass, BDS, DDS 13 White Spots Progress to Brown Cavitations Brown cavitations represent areas where loss of enamel has exposed underlying dentin. Appearance & Symptoms Anterior upper incisors are most typically first affected as posterior teeth have not yet emerged. Lesions are initially pale yellow and become progressively darker as they become stained with pigments from food. Teeth may be sensitive to thermal changes and sweet or sour foods or drinks. Most children are too young to articulate symptoms. Treatment & Referral Immediate dental referral should be arranged. Some cavities may need to be restored using fluoride releasing restorative materials. Lesions are small enough that simplified restorative techniques not requiring local anesthesia or high speed drills can be used to stabilize their progression. Provide dietary and oral hygiene counseling. Use fluoride to arrest lesions not requiring restoration.

14 Slide 14 Early Aggressive ECC 14 Appearance & Symptoms Abscesses and fistulae may be present Patient may experience pain, but children may be too young to accurately verbalize it Treatment Urgent dental referral for comprehensive treatment including extractions and/or silver crowns Dietary and oral hygiene counseling Topical fluoride to prevent development of new lesions 10 month old 18 month old Photos: Joanna Douglass, BDS, DDS If left untreated, brown cavitations then progress, often quite rapidly, to larger and deeper carious lesions that progressively destroy the tooth. Parents may tell you that "the teeth grew in looking like this." Appearance & Symptoms Multiple dark cavities appear in predominantly anterior teeth Abscesses and fistulae may be present Patient may experience pain, but children may be too young to accurately verbalize it Treatment & Referral Urgent dental referral for comprehensive treatment including extractions and/or silver crowns Dietary and oral hygiene counseling Use of fluoride to prevent development of new lesions

15 Slide 15 Advanced ECC 15 Appearance & Symptoms Multiple dark cavities appear in anterior and posterior teeth Possible for abscesses and draining fistulae to be present Patients may experience pain Treatment Urgent dental referral for comprehensive treatment including extractions and/or silver crowns Dietary and oral hygiene counseling Use of fluoride to prevent development of new lesions Photos: Joanna Douglass, BDS, DDS These patients require extensive dental treatment. Cooperative four-year-olds with this kind of decay may be able to have the work done in the dental chair under the care of a dentist skilled in behavior guidance and treatment of ECC. It is likely younger and less cooperative children will need oral sedation in the dental office or general anesthesia in the operating room, both of which can be costly. Appearance & Symptoms Multiple dark cavities appear in anterior and posterior teeth. Possible for abscesses and draining fistulae to be present. Patients may experience pain. Typically ECC progresses in the following order: Upper incisors (maxillary anterior teeth) First molars (mandibular primary molars) Second molars (maxillary primary molars) Mandibular incisors, although they emerge first, are generally not affected because they are protected by the tongue and pooling of saliva in that area Treatment & Referral Urgent dental referral for comprehensive treatment including extractions and/or silver crowns Dietary and oral hygiene counseling Use of fluoride to prevent development of new lesions

16 Slide 16 Caries Progression 16 ECC affects the teeth that emerge early and are least protected by saliva. Order of Progression Upper incisors (maxillary anterior teeth) First molars (mandibular primary molars) Second molars (maxillary primary molars) Photos: Joanna Douglass, BDS, DDS ECC affects the teeth that erupt early and are least protected by saliva. Visualize a child sucking a bottle. With the child's tongue thrust forward, the maxillary incisors get maximal sugar exposure. Typically ECC progresses in the following order: Upper incisors (maxillary anterior teeth) First molars (mandibular primary molars) Second molars (maxillary primary molars) Mandibular incisors, although they emerge first, are generally not affected because they are protected by the tongue and pooling of saliva in that area.

17 Slide 17 Consequences ECC has severe consequences Pain Impaired chewing and nutrition Infection Increased caries in permanent dentition School/work absences Difficulty sleeping Poor self-esteem Extensive and expensive dental work which often must be completed under general anesthesia Students with dental pain are almost 4 times more likely to have a low grade point average 17 Photo: Donald Greiner, DDS, MS Photo: Joanna Douglass, BDS, DDS Photo: Joanna Douglass, BDS, DDS ECC is the most common chronic childhood disease and has many potentially severe consequences, such as: Pain Impaired chewing and nutrition Infection Increased caries in permanent dentition School/work absences Students with dental pain are almost four times more likely to have a low grade point average Difficulty sleeping Poor self-esteem Extensive and expensive dental work which often must be completed under general anesthesia References The Catalyst Institute. The Oral Health of Massachusetts' Children. January 2008 Available from: port.pdf (Accessed April 16, 2010). Jackson SL et al. Impact of Poor Oral Health on Children's School Attendance and Performance. Am J Public Health ;101(10): Seirawan H, Faust S, Mulligan R. The impact of oral health on the academic performance of disadvantaged children. Am J Public Health (9): Martins-Júnior PA, Vieira-Andrade RG, Corrêa-Faria P et al. Impact of early childhood caries on the oral health-related quality of life of preschool children and their parents. Caries Res. 2013;47(3):211-8.

18 Slide 18 Ongoing Balance 18 Preventing or reversing the caries process is possible by enhancing protective factors and reducing pathologic factors. Preventive strategies enhance protective factors and reduce pathologic factors. Disease can be halted and early lesions remineralized. Caries & Demineralization Caries is a dynamic process involving many protective factors and pathologic factors Teeth are subjected to an ongoing cycle of demineralization and remineralization. To help prevent or reverse the caries process and tip the balance towards no caries, we can: Delay colonization with cariogenic bacteria by providing preventive care and treatment for mothers. Limit the number of times teeth are demineralized by decreasing the frequency of consumption of dietary carbohydrates Make teeth more resistant to acid through the use of fluoride Enhance remineralization through the use of fluoride Reference Featherstone JD, Adair SM, Anderson MH et al., Caries management by risk assessment: Consensus statement, April J Calif Dent Assoc. 2003;31(3);

19 Slide 19 ECC Risk Assessment Chapter Objective Assess a child s risk of developing ECC Understand formal ECC risk assessment tool use in clinical practice Image: Getty Learning objective targeted in this chapter: Assess a child s risk of developing ECC Understand formal ECC risk assessment tool use in clinical practice.

20 Slide 20 Why Is Risk Assessment Important? 20 80% of ECC occurs in 20% of children. Oral health risk assessments should begin around 4 to 6 months of age, just before the first tooth emerges. Risk assessment determines the depth of nutritional and hygiene counseling Many practitioners find that, especially when starting to perform risk assessments, using a formal risk assessment tool aids in both oral health risk determination and in documentation. Keep in mind that 80% of ECC occurs in 20% of children. Oral health risk assessment should begin around 4-6 months of age, just before the first tooth emerges. Risk assessment determines the depth of nutritional and hygiene counseling. In areas where dental access is limited, higher risk children should be referred earlier for establishment of a dental home. References 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, American Academy of Pediatric Dentistry: Council on Clinical Affairs. Guideline on Caries-risk assessment and Management for Infants, Children, and Adolescents. Revised REFERENCE MANUAL V 35 (6): Krol D. Maintaining and Improving the Oral Health of Young Children. Section on Oral Health Policy Statement. Pediatrics. 2014;134:

21 Slide 21 Assessing Caries Risk 21 Moderate Risk One of the 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 Special health care needs Developmental enamel defects High Risk Multiple moderate risk factors and one of the following: Plaque on teeth Presence of white spots or cavities No systemic fluoride exposure Stratification of children into low, moderate, and high caries risk based on the presence of risk factors. 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 High: Multiple moderate risk factors and one of the following: Plaque on teeth Presence of white spots or cavities No systemic fluoride exposure Low: Refers to patients who: Higher socioeconomic status (SES) Regularly receive dental care Have fluoridated water Have families with no caries

22 Slide 22 Risk Assessment Tool 22 Oral Health Risk Assessment tools should document the following components: Caries risk and protective factors. Clinical findings. Anticipatory guidance provided. Referral to a dental home. The AAP and NIIOH have collaborated to create a formal Oral Health Risk Assessment Tool piloted through the QuIIN: Over 80% of practices found the tool easy to implement Clinicians did not need to significantly alter current practice to incorporate risk assessment Bright Futures oral health recommendations can be implemented in just 2 minutes during the well child visit Identification of high-risk patients for oral health referral increased from 11% to over 87% with use of the tool A PDF of the Risk Assessment Tool is available for download at Oral Health Risk Assessment tools should document the following components: Caries risk and protective factors. Clinical findings. Anticipatory guidance provided. Referral to a dental home. The AAP and National Interprofessional Initiative on Oral Health (NIIOH) have collaborated to create a formal Oral Health Risk Assessment Tool piloted through the Quality Improvement Innovation Network (QuIIN): Over 80% of practices found the tool easy to implement. Clinicians did not need to significantly alter current practice to incorporate risk assessment. Bright Futures oral health recommendations can be implemented in just 2 minutes during the well child visit. Identification of high-risk patients for oral health referral increased from 11% to over 87% with use of the tool. References American Academy of Pediatrics. Oral Health Initiative. Oral health risk assessment: training for pediatricians and other child health professionals. Unpublished data Brightening Oral Health: Teaching and Implementing Oral Health Risk Assessments in Pediatric Care project. Brightening Oral Health Workgroup and Quality Improvement Innovation Networks, American Academy of Pediatrics.

23 Slide 23 ECC Prevention Chapter Objective Implement prevention of ECC through use of fluoride, proper hygiene, diet, and appropriate dental referral Image: Jupiterimages/Photos.com Learning objective targeted in this chapter: Implement prevention of ECC through use of fluoride, proper hygiene, a diet, and appropriate dental referral.

24 Slide 24 Why Primary Care Clinicians? 24 Primary care clinicians are well positioned to promote oral health: 96% of children have access a usual source of primary medical care Primary care clinicians have regular, consistent contact through well-child visits 63.4% of poor children months of age receive all their vaccines Clinicians see children for well and acute care a minimum of 8 times by age 2, and frequently thereafter Few preschool children from low-income families receive regular dental care Most children have access to primary medical care. Primary care clinicians have regular, consistent contact through well-child visits. Consider the following: 63.4 % of low-income children months of age have completed all the primary vaccine series. 96% of children in the United States had a usual place of health care. Clinicians see children for well and acute care a minimum of eight times by age two, and frequently thereafter. In contrast, few preschool children from low-income families regularly receive dental care. References Centers for Disease Control and Prevention. National, State, and Local Area Vaccination Coverage Among Children Aged Months United States, MMWR September 13, 2013 / 62(36); Centers for Disease Control and Prevention: Vital and Health Statistics, Summary Health Statistics for U.S. Children: National Health Interview Survey, August, 2013.

25 Slide 25 Effects and Sources of Fluoride 25 Topical Mechanisms (main effect) Inhibiting tooth demineralization Enhancing remineralization Inhibiting bacterial metabolism Systemic Mechanisms (lesser effect) Reducing enamel solubility through incorporation into its structure during tooth development Fluoride Sources Topical: Fluoride toothpastes Gels, foams, mouthwashes Fluoride varnish Dietary: Water fluoridation Dietary fluoride supplements Photos: Joanna Douglass, BDS, DDS The use of fluoride, both through dietary and topical applications, has led to dramatic drops in caries rates. How Does Fluoride Help Prevent Dental Caries? Through topical mechanisms, the main effect, fluoride works by Inhibiting tooth demineralization Enhancing remineralization Inhibiting bacterial metabolism Through systemic mechanisms, the lesser effect, fluoride works by Reducing enamel solubility through incorporation into its structure during tooth development What are the Primary Sources of Fluoride? Systemic fluoride is obtained through: Water fluoridation Dietary fluoride supplements Topical Fluoride is the most beneficial and is obtained through: Fluoride toothpastes Gels, foams, mouthwashes Fluoride varnish Reference Weyant RJ, Tracy SL, Anselmo TT et al. Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review. American Dental Association Council on Scientific Affairs Expert Panel on Topical Fluoride Caries Preventive Agents. J Am Dent Assoc (11):

26 Slide 26 Systemic Fluoride 26 Guidelines All children should receive fluoride through systemic water fluoridation or dietary supplements Children who drink optimally fluoridated water should NOT receive supplements Optimal water fluoridation is 0.7 ppm Determine patient s water source and fluoride content Public water supply (Local health department or water company can provide fluoridation levels) Bottled water (variable fluoride levels) Well water (variable fluoride levels, requires testing) Guidelines All children should receive fluoride through systemic water fluoridation or dietary supplements. Children who drink optimally fluoridated water should NOT receive supplements. Optimal water fluoridation is 0.7 ppm Steps to Take Before Considering Prescribing Supplements Determine the source of your patient's water, which may be: Fluoridated city water Nonfluoridated city water Bottled water (variable fluoride levels) Well water (variable fluoride levels) Determine the fluoride content: Public water supply: Contact local health departments or water company for fluoride levels Well water: Test the well water for fluoride level. Local health departments can provide resources for water testing. Additional factors affecting fluoride content: Water filters: Most filters are charcoal based and do not remove fluoride. Only reverse osmosis water filters (very costly to install) remove fluoride. Bottled water: If companies add fluoride, this must be listed on the bottle. The fluoride content of most bottled water is unknown as natural water may or may not contain naturally occurring fluoride. Reference March 18, 2014).

27 Rozier RG, Steven Adair S, Graham S, Lafolla T. et al. Evidence-Based Clinical Recommendations on the Prescription of Dietary Fluoride Supplements for Caries Prevention. Journal of the American Dental Association. 2010; 141 (12): U.S. Preventive Services Task Force Recommendation Statement. Prevention of Dental Caries in Children from Birth Through Age 5 Years. May Clark MB, Slayton RL; AAP Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics Sep;134(3):

28 Slide 27 Dietary Fluoride Supplementation 27 Guidelines Dosages are in milligrams F/day If fluoride content of water cannot be determined, do not prescribe In optimally fluoridated communities where children drink bottled water, supplements should not be prescribed due to halo effect Supplements are not recommended for infants until age six months All prescriptions for fluoride should specify a sugar-free prescription Dietary fluoride supplementation by prescription for children at high caries risk 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. The United States Preventive Services Taskforce (USPSTF) and the American Academy of Pediatrics (AAP) recommend primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for ALL children whose water supply is deficient in fluoride, not based on risk assessment. Dietary fluoride supplementation by prescription for children at high caries risk who do not have access to optimally fluoridated water is recommended by the American Academy of Pediatric Dentistry and the American Dental Association (ADA). Guidelines If the fluoride content of the main water used for cooking and drinking cannot be determined, then supplemental fluoride should NOT be prescribed. In optimally fluoridated communities where children drink bottled water, supplements should NOT be prescribed due to halo effect. Supplementation is not recommended for breast feeding infants or formula fed infants until age six months. All prescriptions for fluoride should specify a sugar-free preparation. References Adair S, Graham F, et al. Evidence-Based Clinical Recommendations on the Prescription of Dietary Fluoride Supplements for Caries Prevention. A Report of the American Dental Association Council on Scientific Affairs. JADA. December 2010 vol. 141(12):

29 (accessed April 17, 2010). 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): (accessed April 17, 2010). U.S. Preventive Services Task Force Recommendation Statement. Prevention of Dental Caries in Children from Birth Through Age 5 Years. May Clark MB, Slayton RL; AAP Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics Sep;134(3):

30 Slide 28 Fluorosis 28 Appearance and Significance White mottling of teeth due to chronic excessive exposure to fluoride during tooth development Cosmetic issue that does not affect systemic health Risk Reduction Determine fluoride content of drinking water before prescribing current dosage schedules Avoid duplicate fluoride prescriptions Place only a smear (under two years) or pea size dab (children over age 3 or when the child can spit effectively) of fluoridated toothpaste on the child's toothbrush Fluoride varnish presents a low risk for fluorosis Moderate Fluorosis Photo: Joanna Douglass, BDS, DDS Severe Fluorosis Photo: John McDowell, DDS Fluoride is a very safe and effective agent, but care needs to be taken to minimize the risk of fluorosis. Fluorosis is a discoloration of the teeth due to chronic excessive exposure to fluoride during tooth development. It is a cosmetic issue that does NOT affect systemic health. Clinical Appearance Usually consists of white mottling. Prevalence & Risk Factors Prevalence of fluorosis (mostly mild or very mild) in the United States is 23% and rising. The risk of developing fluorosis is greatest at an intake of more than 0.06 milligram per kilogram of body weight per day. Varnish is not a major risk factor for fluorosis as it is an irregular source of fluoride when applied as recommended two to four times per year. Risk Reduction Determine the fluoride content of the child's drinking water before prescribing supplements. Avoid duplicating fluoride prescriptions. Follow current dosage schedules for systemic fluoride supplementation. Advise appropriate amount of fluoride toothpaste use by age. Keep fluoride-containing products out of the reach of small children. References 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): Skotowski MC, Hunt RJ, Levy SM. Risk factors for dental fluorosis in pediatric dental patients. J Public Health Dent Summer;55(3):154-9.

31 Do LG, Spencer AJ. Risk-benefit balance in the use of fluoride among young children. J Dent Res Aug;86(8): Chankanka O, Levy SM, Warren JJ, Chalmers JM. A literature review of aesthetic perceptions of dental fluorosis and relationships with psychosocial aspects / oral health-related quality of life. Community Dent Oral Epidemiol Wright JT, Hanson N, Ristic H et al. Fluoride toothpaste efficacy and safety in children younger than 6 years: A systematic review. JADA (2): American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy REFERENCE MANUAL. 36(6): American Dental Association Council on Scientific Affairs. Fluoride toothpaste use for young children. JADA 2014;145(2):

32 Slide 29 Hygiene: Tooth Brushing 29 Guidelines Brush twice daily beginning as soon as teeth emerge Bedtime is most critical due to decreased salivary flow at night Caregiver should brush child's teeth until age 8 or 9 Young children have difficulty brushing all areas Parents should continue to intermittently supervise brushing after children assume independence Caregiver should stand or sit behind child Lift the lip and brush along the gum line Child should spit out, not rinse, after brushing to increase topical fluoride exposure Photos: Joanna Douglass, BDS, DDS Regular tooth brushing is important to remove plaque and food debris, and most importantly for distributing the fluoridated toothpaste. Brushing Guidelines Brush twice daily beginning as soon as teeth emerge. Bedtime is most critical due to decreased salivary flow. Caregiver should brush child's teeth until age 8 or 9, at least until they have developed the manual dexterity to write in cursive and tie their own shoes. Children will not reliably spit and may swallow flavored toothpaste. Young children have difficulty adequately brushing all areas. Parents should continue to intermittently supervise brushing after children assume independence. Caregiver should stand or sit behind child. Child should spit out, not rinse, after brushing to increase topical fluoride exposure. Reference 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):

33 Slide 30 How Much Toothpaste? Guidelines Most preschool children swallow much of the toothpaste placed on the brush. These guidelines take this into account and these amounts are safe to swallow, but spitting out should always be encouraged Parents should keep toothpaste tubes out of reach of small children Small smear: Less than 3 years of age Pea sized: 3 years & over, regardless of caries risk 30 Photos: Joanna Douglass, BDS, DDS Excessive ingestion of toothpaste can cause fluorosis which is a minor cosmetic problem, relative to losing teeth to caries. In rare situations, such as consuming a large portion of a family sized tube, systemic toxicity including electrolyte abnormalities can result in a medical emergency. Guidelines Use a small smear for children less than 3 years old (size of a grain of rice). Apply a pea-sized amount of toothpaste for children three years and older regardless of caries risk status. Most preschool children swallow much of the toothpaste placed on the brush. These guidelines take this into account and these amounts are safe to swallow, but spitting out should always be encouraged. Parents should keep toothpaste tubes out of reach of small children. References Shulman JD, Wells LM. Acute fluoride toxicity from ingesting home-use dental products in children, birth to 6 years of age. J Public Health Dent 1997;57: Douglass JM, Douglass AB, Silk H. A Practical Guide to Infant Oral Health at the Well Child Visit. American Family Physician 2004;70: , American Dental Association Council on Scientific Affairs. Fluoride toothpaste use for young children. JADA 2014;145(2): Krol D. Maintaining and Improving the Oral Health of Young Children. Section on Oral Health Policy Statement. Pediatrics. 2014;134:

34 Slide 31 Brushing Techniques 31 Guidelines Caregiver should stand or sit behind the child Lift lip to allow proper visualization Brush along the gum line, both on the outside (buccal) and inside (lingual) of the tooth Brush the top or chewing surface (occlusal) Use small backwards and forwards brushing movements or small circles Spit out toothpaste and don't rinse after brushing No food or drink after brushing Begin flossing daily once teeth touch Encourage use of electric toothbrush beginning at age 4 years Lift the lip Brush behind teeth Photos: Joanna Douglass, BDS, DDS Often families receive no formal instruction in correct brushing, and if the clinician does not provide it no one else will. Encourage patients to follow these guidelines: The caregiver should stand or sit behind the child and brush the exposed surfaces of each tooth. Lift lip to allow proper visualization. Brush along the gum line where caries commonly begins, both on the outside (buccal) and inside (lingual) of the tooth. Brush the top or chewing surface (occlusal). Use small backwards and forwards brushing movements or small circles. Spit out toothpaste and don't rinse after brushing. No food or drink after brushing. Begin flossing daily once teeth touch. Encourage use of electric toothbrush beginning at age 4 years. Make Toothbrushing Fun Sing a song that lasts 2 minutes and brush until done. Sing the alphabet and brush each quadrant until done. Brush in front of mirror Use an electric toothbrush featuring timers, lights, or favorite characters. PLAY VIDEO NOW

35 Slide 32 Cariogenicity of Foods 32 Low Risk Snacks Fruit Veggies Cheese Crackers Pretzels Popcorn Nuts Sugar free gum Plain milk Cheese & whole wheat crackers Water High Risk Snacks Fruit Roll-ups Gummy bears Cookies Cupcakes Donuts Granola bars Pop tarts Sugared Cereals Soda, Iced tea Sugared drinks Raisins Images: Photos.com Images: Photos.com 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 other refined, processed carbohydrate snacks can be broken down into simple sugars which allow the bacteria to ferment the sugars into acids. Frequent consumption of these foods can lead to caries. Encourage caregivers to offer sugar free, dentally appropriate snacks.

36 Slide 33 Avoid High Risk Eating Patterns 33 Follow these tips to lower caries risk Avoid frequent snacking (two or more times between meals) especially on foods like Juice or soft drinks Candy, cookies, or sweetened breakfast cereals Refrain from eating sticky, retentive snacks and slow dissolving carbohydrates, such as Raisins, dried fruit, fruit rolls, bananas, caramels, jelly beans, or peanut butter and jelly sandwiches Do not eat or drink before bed after tooth brushing No bottle use in bed Salivary ph remains low between meals which makes frequent snacking inadvisable. Maximizing the interval between food intake allows time for teeth to remineralize after exposure to acids. Follow these tips to lower caries risk: Avoid frequent snacking (2 or more times between meals), especially on foods like: Juice or soft drinks Candy, cookies, or sweetened breakfast cereals Refrain from eating sticky, retentive snacks and slow dissolving : Raisins, dried fruit, fruit rolls, bananas, caramels, jelly beans, peanut butter and jelly sandwich Establish bedtime routines that include brushing after feedings. Do not eat or drink before bed after toothbrushing No bottle use in bed

37 Slide 34 Diet Advice: 0 12 Months Recommendations 34 Strongly encourage breast feeding Hold infant for bottle feeding Avoid giving bottles at bedtime or naptime Don t use sweetened pacifiers Introduce cup at 6 months Wean bottle by 12 months Avoid ad lib use of sippy cup unless it contains water Recommend no juice in the first year of life Snacks should contain no added sugar Recommendations Strongly encourage breast feeding. Hold infant for bottle feeding. Avoid giving bottles at bedtime or naptime. Don't use sweetened pacifiers. Introduce cup at six months. Wean bottle by 12 months. Avoid ad lib use of sippy cup unless it contains water. Recommend no juice in the first year of life. Snacks should contain no added sugar.

38 Slide 35 Diet Advice: 1 5 Years 35 Recommendations Discontinue bottle by 12 months Limit juice to 4 oz. per day and serve with meals only Avoid carbonated beverages and juice drinks containing sweeteners Choose fresh fruits, vegetables, or sugar free whole grain snacks Only drink milk or water between meals Limit eating occasions to 3 meals a day with 1 snack in between Reserve soda, candy, and sweets for special occasions, preferably with meals Recommendations Discontinue bottle by 12 months. Limit juice to four ounces per day and serve with meals only. Avoid carbonated beverages and juice drinks containing sweeteners. Choose fresh fruits, vegetables, or sugar free whole grain snacks. Only drink milk or water between meals. Limit eating occasions to three meals a day with one snack in between. Reserve soda, candy, and sweets for special occasions, preferably with meals.

39 Slide 36 Establish a Dental Home 36 The American Academy of Pediatric Dentistry and the American Academy of Pediatrics both recommend establishment of a dental home by the first birthday. Dentist will provide Enhanced preventative services Comprehensive evaluation and diagnosis of oral disease Evaluation of growth and development Counseling on oral habits and interceptive orthodontic treatment as needed Fluoride varnish and cleanings Dental x-rays when indicated Sealants to permanent molars as child grows Dental trauma management The American Academy of Pediatric Dentistry and the American Academy of Pediatrics both recommend establishment of a dental home by the 1st birthday. Dentists will provide: Enhanced preventative services Comprehensive evaluation and diagnosis of oral disease Evaluation of growth and development and provide counseling on oral habits and interceptive orthodontic treatment as needed Fluoride varnish and cleanings Dental x-rays when indicated Sealants to permanent molars as child ages Dental trauma management Communities with Limited Dental Access In many communities, those with no insurance or insured through Medicaid have limited or no access to dental care. If limited dental access, the primary care clinician may need to: Stratify the risk of the child. Strive to assist children at moderate or high risk or with active disease in accessing the dental system in a timely manner. Apply fluoride varnish to the teeth of all infants and children in the medical office, regardless of risk level. Follow low risk children in the medical office:. Ensure appropriate anticipatory guidance is given. Assess need for systemic fluoride supplementation and prescribe appropriately. Regularly assess oral health and provide dental referral when necessary and no later than age three years. References AAP Section on Pediatric Dentistry. Preventive Oral health Intervention for Pediatricians. Pediatrics 2008;122: Savage MF LJ, Vann WF. Does Age Matter? Examination of the first preventive dental visit. Pediatric Dentistry 2003;25(2):181.American Academy of Pediatric Dentistry. Policy on the Dental Home. Revised Reference Manual 35 (6):

40 Slide 37 Developmental Issues Chapter Objective Review common developmental issues in children and offer appropriate guidance to parents Discuss and counsel adolescents regarding the risks associated with oral piercings and grills Image: Maurizio Milanesio /Photos.com Learning objective targeted in this chapter: Review common developmental issues in children and offer appropriate guidance to parents. Discuss and counsel adolescents regarding the risks associated with oral piercings and grills.

41 Slide 38 Teething 38 Concerns Teething does not cause fever, upper respiratory infection, ear infection, or diarrhea Teething may cause fussiness Drooling is developmentally common at this age Anticipatory Guidance Apply cold teething ring or cloth to gums Photo: ICOHP Provide acetaminophen or ibuprofen if necessary Avoid teething gels Eruption Hematoma Tooth emergence may be preceded by a hematoma no treatment is needed in primary dentition Concerns Teething does not cause fever, upper respiratory infection, ear infection, or diarrhea. Teething may cause fussiness. Drooling is developmentally common at this age. Anticipatory Guidance Apply cold teething ring or cloth to gums. Provide acetaminophen or ibuprofen if necessary. Avoid teething gels they are not effective and contain high doses of topic anesthetics which can be dangerous in infants. Remember tooth emergence may be preceded by a hematoma no treatment is needed in primary dentition. Reference Wake M, Hesketh K, Lucas J. Teething and tooth eruption in infants: A cohort study. Pediatrics. 2000;106(6):

42 Slide 39 Nonnutritive Sucking 39 Etiology Satisfies a psychological need and decreases as the child ages Increases risk of anterior open bite and delayed speech development if habit persists Anticipatory Guidance Intervene to stop habit by 36 months, especially if changes to occlusion are noted Breaking the habit: Restrict to limited situations Cover hands at night with mittens Provide alternative comfort object such as stuffed animal Pacifier use is preferable to digit sucking Recommend never to dip pacifier in honey or other sweetened food Nonnutritive sucking satisfies a psychological need and decreases as the child ages; most stop at two to four years. It increases the risk of anterior open bite and delayed speech development if the habit persists. Anticipatory Guidance Intervene to stop habit by 36 months, especially if changes to occlusion are noted. Offer positive reinforcement, such as a star chart or stickers. Restrict to limited situations. Cover hands at night with mittens. Provide stuffed animal or other comfort object. In general, pacifier use is preferable to digit sucking as it is less likely to cause a problem and the habit is easier to break (the pacifier can be removed). Recommend never to dip pacifier in honey or other sweetened foods. Reference Nowak AJ and Warren JJ. Infant oral health and oral habits. Pediatric Clinics of North America 2000;47(5):

43 Slide 40 Adolescence - Oral Piercings 40 Procedure-related Risks Swelling most common symptom post-piercing Prolonged bleeding, nerve damage Infection Skin or oral tissues Hepatitis B,C,D,G and tetanus Endocarditis Jewelry-Related Complications Injury to the gums and dental fractures, scarring Interference with oral hygiene, speech, chewing and swallowing Allergic/hypersensitivity reaction to metal Aspiration or ingestion if jewelry is loose The American Academy of Pediatric Dentistry (AAPD) "strongly opposes" the the practice of piercing perioral and intraoral tissues and use of jewelry on these tissues. Photos by Rebecca Slayton DDS, PhD Oral piercings are increasingly popular, but there are significant risks. Procedure-related risks: Swelling most common symptom post-piercing Prolonged bleeding Nerve damage Jewelry-Related Complications: Injury to the gums and dental fractures, scarring Interference with oral hygiene, speech, chewing and swallowing Allergic/hypersensitivity reaction to metal Aspiration or ingestion if jewelry becomes loose For treatment information, see "Oral piercing complications Course 4: Acute Dental Problems". The American Academy of Pediatric Dentistry (AAPD) "strongly opposes" the practice of piercing perioral and intraoral tissues use of jewelry on these tissues. Reference American Academy of Pediatric Dentistry. Council on Clinical Affairs. Policy on Intraoral and Perioral Piercing (6):

44 Slide 41 Adolescence - Grills 41 Grills on the teeth can increase the risk of developing caries and trigger allergic reactions to the metal. Counsel grill-wearers to Remove the grill to eat and sleep Brush and floss regularly Limit amount of time the grill is worn Photos by Scott Eidson DDS Grills on the teeth can increase the risk of developing caries and trigger allergic reactions to the metal. Counsel grill-wearers to: Remove the grill to eat and sleep Brush and floss regularly Limit amount of time the grill is worn Reference American Academy of Pediatric Dentistry. Council on Clinical Affairs. Policy on Intraoral and Perioral Piercing (6):

45 Slide 42 Take Home Messages ECC develops through the interaction of bacteria, dietary sugars, and teeth Assess teeth and risk factors Prevention by clinicians targeting: Hygiene Fluoride Diet Establish a dental home by age one for all children where possible These are the key messages to take away from this course: ECC develops through the interaction of bacteria, dietary sugars, and teeth. Assess teeth and risk factors. Prevention by clinicians targeting: Hygiene Fluoride Diet Establish a Dental Home by age 1 for all children where possible.

46 Slide 43 Questions? Image: Jupiterimages/Photos.com The End