Don t Delay; Prevent Decay! Fluoride varnish and paediatric oral health

Don t Delay; Prevent Decay! Fluoride varnish and paediatric oral health Family Medicine Forum, Vancouver, BC November 12, 2016 Presenters: Dr..James.Taylor,.Chief Dental Officer,.Public Health Agency of Canada Dr. Elizabeth Shaw, MD CCFP FCFP Professor of Family Medicine, Faculty of Health Sciences. McMaster University Dr. Leslie Rourke, MD, CCFP, MClinSc(FM), FCFP, FRRMS, Professor Emerita of Family Medicine; Faculty of Medicine, Memorial University of Newfoundland Dr. Andrea Feller, MD MS FAAP FACPM, Associate Medical Officer of Health, Niagara Region Public Health http://www.nidcr.nih.gov/oralhealth/oralhealthinformation/childrensoralhealth/toothdecayprocess.htm

Disclaimer There are no real or apparent conflicts of interest for any of the presenters that may have a direct bearing on the subject matter of the program. 2

Objectives At the conclusion of this activity, participants will be able to: Assess a child s risk of developing early childhood caries (ECC) Perform an oral examination, recognize the stages of ECC, and appropriately refer patients Provide effective counseling/anticipatory guidance to caregivers to prevent ECC Apply topical fluoride varnish in their practices 3

Outline Scope of the Issue Smiles for Life Module Primary Care Pilots and Interventions in Ontario Demonstration Questions A dental assistant demonstrates the application of fluoride varnish. Luke Hendry / Postmedia 4 http://news.nationalpost.com/news/canada/edmonton-kids-have-better-teeth-than-those-in-calgary-because-of-fluoridated-water-study-says

Children's Oral Health in Canada: Scope of the Issue Family Medicine Forum Vancouver, BC November 12, 2016 Dr. James Taylor Chief Dental Officer

Canadian Oral Health Status Source: Canadian Health Measures Survey, 2007-2009 6

Indigenous Children 3-5 Years of Age Indicator Canadian 6+ (CHMS) First Nations On Reserve Inuit Decay Prevalence n/a 86% 85% Mean dmft n/a 7.62 8.22 Untreated caries: n/a Prevalence Severity d/dmft 35.2% 2.68 49% 4.06 Sources: First Nations Oral Health Survey, 2009-2010 Inuit Oral Health Survey, 2008-2009 7

WHO/FDI Objective WHO/FDI Objectives for the year 2000: 50 % children entering school with no cavities National Inuit First Nations 53.4% 13.9% 7.6% Source: FDI/WHO Global Goals for Oral Health by the Year 2000, 1981 Canadian Health Measures Survey 2007-2009 8

CIHI Report on Day Surgery Leading cause of day surgery for children age 1 to younger than 5 19,000 day surgery operations per year $21.2 million per year (excluding costs associated with care providers and travel to care) Source: CIHI Treatment of Preventable Dental Cavities in Preschoolers: A Focus on Day Surgery under General Anesthesia, 2013 9

CIHI Report on Day Surgery 8.6 times more surgeries on children from neighbourhoods with high Aboriginal populations 3.9 times more surgeries on children from the least affluent neighbourhoods 3.1 times more surgeries on children from rural neighbourhoods Source: CIHI Treatment of Preventable Dental Cavities in Preschoolers: A Focus on Day Surgery under General Anesthesia, 2013 10

Dental Home Number of children who see a dentist: Less than 1% of children aged 1 Less than 2% of children aged 2 40% of children by age 4 Medical Home CDA recommendation: within 6 months of the eruption of the first tooth or by 12 months of age 96% of children aged 0-2 have a usual place of health care and children have been seen at least 8 times before they reach school entry. Source: Darmawikarta et al. Factors Associated With Dental Care Utilization in Early Childhood. Pediatrics Volume 133, Number 6, June 2014 11

Image: Wojciech Gajda/Photos.com Image: Jupiterimages/Photos.com Image: Christoph Hähnel/Photos.com Image: Getty Copyright STFM 2005-2016 Third Edition June 2010 www.smilesforlifeoralhealth.org Last Modified: December, 2015

Course Steering Committee Authors Andrea Feller, M.D., and the Niagara Region Public Health Staff Anne Rowan-Legg, M.D. Jonathan Bowser, M.S., PA-C Dental Consultant (U.S. Version)* 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.

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 oral concerns

What is ECC? 15 Etiology 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 Progression Upper front teeth that are least protected by saliva are affected first Disease moves posteriorly as teeth emerge Photos: Joanna Douglass, BDS, DDS

Prevalence of Caries 16 Dental caries is the number one chronic disease of childhood 57% of Canadian children aged 6-11 years have had a cavity Average 2.5 teeth affected Caries rates are increasing among children two to four years of age 27% of oral day surgeries are preschoolers from the least affluent neighbourhoods in Canada ECC prevalence exceeds 90% in some disadvantaged indigenous communities Photos: Joanna Douglass, BDS, DDS

Etiology: The Triad 17 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 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

Social Determinants of Oral Health 18 More than just the triad Child, family, community level characteristics all influence oral health outcomes of children Oral health inequities are largely influenced by community level influences rather than individual level factors An integrated approach of policy and individual influences can promote the greatest impact on health inequities, including oral health Health care teams have a critical role in promoting oral health equity for patients and the community

Etiology: Bacteria 19 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

Healthy Teeth 20 Nature of healthy teeth Creamy white with no signs of deviation in color, roughness, or other irregularities If the clinician cannot determine whether an tooth surface abnormality is a defect or an early cavity, the child should be considered high risk for caries and be referred to a dentist for further evaluation Discuss improved nutrition, proper hygiene, and topical fluoride to prevent decay Photos: Joanna Douglass, BDS, DDS

Etiology: Teeth 21 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 with certain congenital diseases Enamel Defects Dental Caries Photos: Joanna Douglass, BDS, DDS

White Spots 22 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 may be able to reverse or arrest lesions Photos: Joanna Douglass, BDS, DDS

Brown Cavitations 23 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 may be small enough not to require local anesthesia or handpieces (drills) stabilize their progression; other techniques may be used Dietary and oral hygiene counseling Topical fluoride may be indicated for other lesions not requiring restorations Photos: Joanna Douglass, BDS, DDS

Early Aggressive ECC 24 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 stainless steel crowns Dietary and oral hygiene counseling Topical fluoride may prevent development of new lesions 10 month old 18 month old Photos: Joanna Douglass, BDS, DDS

Advanced ECC 25 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 stainless steel crowns Dietary and oral hygiene counseling Use of fluoride to prevent development of new lesions Photos: Joanna Douglass, BDS, DDS

Caries Progression 26 ECC primarily affects the teeth that emerge early and are least protected by saliva. Order of Progression Upper incisors (maxillary anterior teeth) First molars Second molars Photos: Joanna Douglass, BDS, DDS

Consequences of ECC 27 Pain Impaired chewing and nutrition Infection Increased caries in permanent dentition School/work absences Difficulty sleeping Poor self-esteem Extensive and expensive dental treatment which often must be completed under general anesthesia Students with dental pain are almost 4 times more likely to have poorer school performance Leading cause of day surgery (31%) among children ages 1-5 years performed at Canadian paediatric hospitals Photo: Donald Greiner, DDS, MS Photo: Joanna Douglass, BDS, DDS

Ongoing Balance 28 Preventing or reversing the caries process is possible by enhancing protective factors and reducing pathologic factors. Diagram Credit: Featherstone JD, Caries management by risk assessment. 2003.

Assessing Caries Risk 29 Moderate Risk One of the following risk factors: Lower SES Poor access to health care Family members have cavities particularly mother Diet snacking more than 2 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

ECC Prevention Chapter Objective Implement prevention of ECC through use of fluoride, proper hygiene, diet, and appropriate dental referral Image: Jupiterimages/Photos.com

Pediatric Dental Visits 31 Canadian Dental Association, Canadian Paediatric Society, and Canadian Academy of Pediatric Dentistry all recommend children see a dentist by one year of age or within 6 months of eruption of first tooth. Rates of dental access in Canada: <1% of healthy urban children in a PCP see a dentist by age 1 1.9% by 2 years of age 40% by 4 years of age Dental disease burden disproportionately represented by: Families of lower socio-economic status Aboriginal communities New immigrants to Canada Children with complex special health care needs

Canadian Dental Reimbursement 32 Canadians pay for dental care 3 different ways: Private dental insurance, employment-related or independently purchased (62%) Under-insurance often results in out-of-pocket payment Out-of-pocket payment; no insurance (32%) Government-subsidized programs (6%) Most publicly delivered dental programs in Canada include only emergency or basic treatment, with limited care for recipients of financial assistance or for children in low-income families Program comprehensiveness differs significantly among provinces and territories

Why Primary Care Clinicians? 33 Primary care clinicians are well positioned to promote oral health: Primary care providers see children > 8 times before age 5 for growth assessments, developmental surveillance, and immunizations 96% of children have access to a usual source of primary medical care Opportunities to provide oral health anticipatory guidance and preventive intervention to parents and children

Rourke Baby Record Oral Health 34 Counsel and assess teething, dental cleaning and fluoride starting between 2 and 6 months Discuss first dental visit between 9 and 15 months

Effects and Sources of Fluoride 35 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 (in dental or medical home or community program) Systemic: Water fluoridation Dietary fluoride supplements Photos: Joanna Douglass, BDS, DDS

Fluorosis 36 Appearance and Significance White mottling of teeth due to chronic excessive fluoride exposure during tooth development Mainly a 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 grain of rice-sized (under 3 years if high caries risk) or pea sized dab (children ages 3+) of fluoridated toothpaste on the brush Fluoride varnish presents a very low risk for fluorosis Moderate Fluorosis Severe Fluorosis

Hygiene: Brushing & Flossing 37 Guidelines Brush twice daily beginning at teeth emergence Important to brush to remove food and plaque mechanically even if not using toothpaste Bedtime most critical: salivary flow decreases at night Lift the lip and brush along the gum line Caregiver should brush child's until they develop the manual dexterity to do this alone Typically age 8 or 9 years until they can write in cursive and tie their own shoes Parents should continue to intermittently supervise brushing after children assume independence Caregiver should stand or sit behind child Child should spit, but not rinse, after brushing to increase topical fluoride exposure Photos: Joanna Douglass, BDS, DDS

How Much Toothpaste? 38 Guidelines Under age 3 recommend: Children at high caries risk: Grain of rice-sized amount of fluoride toothpaste twice daily Children at low caries risk: No toothpaste (moisten brush with water) or fluoride-free toothpaste All children > 3 years of age should use a pea-sized amount of fluoride toothpaste twice daily Keep toothpaste out of reach of small children Grain of rice-sized Pea-sized Photos: Joanna Douglass, BDS, DDS

Cariogenicity of Foods 39 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 Soft drinks, Sweet iced tea Sugared drinks Raisins Images: Photos.com Images: Photos.com

Avoid High Risk Eating Patterns 40 Follow these tips to lower caries risk Avoid frequent snacking (more than 2 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

Diet Advice: 0 12 Months 41 Recommendations Strongly encourage breast feeding Hold infant for bottle feeding Avoid giving bottles at bedtime or naptime Don t use sweetened pacifiers Introduce open cup at 6 to 9 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

Diet Advice: 1 5 Years 42 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 soft drinks, candy, and sweets for special occasions, preferably with meals

Establish a Dental Home 43 Canadian Dental Association, Canadian Paediatric Society, American Academy of Pediatric Dentistry, and the American Academy of Pediatrics all recommend establishment of a dental home 6 months after eruption of the first tooth or by 12 months of age, whichever comes first. Dentist will provide: Enhanced preventive services Comprehensive evaluation, diagnosis, and treatment of oral disease Evaluation of growth and development Counseling on oral habits and interceptive orthodontic treatment Fluoride varnish and cleanings Dental x-rays when indicated Sealants on molars Dental trauma management

Primary Care Pilots and Interventions in Ontario 44 2016 Special Benefits Insurance Services Agency Incorporated.

WHY me? 45

US Preventive Services Task Force The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B recommendation) May 2014 46

VITAMIN for the teeth 47

In collaboration with the following dentists and doctors: U of T Dental public health: Carlos Quinonez McMaster, Niagara campus: Karl Stobbe Thought Leaders group: James Taylor Leslie Rourke Peter Cooney Karl Stobbe Joseph Telch David Price Elizabeth Shaw Anne Rowan-Legg Andrea Feller 48

Progress in Ontario Health Units Providing Fluoride Varnish 10% 5% 11% Healthy Smiles Ontario only Health Unit - preschool/ school/ daycare Primary Care 16% 58% Pilot with Primary Care Interested/ Exploring Primary Care FV 49

Pilot Details The Windsor Essex Fluoride Varnish Pilot Project (WEFVPP) 9 participating sites February to October 2016 As of June 2016, 101 children had received one application of Fluoride Varnish 50

Pilot Findings 100% 90% 80% 70% 60% 79% 74% 50% 40% 50% 30% 20% 32% 10% 0% Not seen a dentist Have dental insurance Brush teeth twice per day Used fluoride toothpaste 51

Requirements 53