Oral Health and Primary Care

1. Oral Health and Primary Care Lessons from the Tooth Fairy Suzanne Boulter, MD South Carolina Chapter Meeting July 23, 2011

2. Disclosures • No disclosures of financial nature • Will mention off label use of product (fluoride varnish)

3. Goals for Today • Review the importance of caries • Discuss etiology of early childhood caries • Learn about Bright Futures and AAP recommendations for oral health screening in your office

4. Tooth Fairy Consultation • Four questions • Six lessons

5. Question 1 • Most children can start brushing their own teeth without supervision at what age: • 2 years • 4 years • 6 years • 8 years

6. Question 2 • Both the AAP and AAPD policy statements recommend that all children have their first dental visit by the following age: • 6 months • 1 year • 2 years • 3 years

7. Question 3 • Early childhood caries requires which bacteria to develop: • Staph aureus • Strep mutans • Hemophilus influenzae • Lactobacillus species

8. Question 4 • CDC recently updated its recommendation for public drinking water fluoridation to which of the following • 0.3 ppm • 0.7 ppm • 1.2 ppm

9. Tooth Fairy Lesson 1 Overview of Early Childhood Caries – Prevalence and Significance

10. Early Childhood Caries – What Is It? • A severe, rapidly progressing form of tooth decay in infants and young children • Affects teeth that erupt first, and are least protected by saliva

11. Prevalence Dental caries is: • 5 times more common than asthma • 7 times more common than hay fever

12. Children and Tooth Decay • 28% of US children age 2-5 have dental caries, increased from 24% in prior survey* • Possible factors • Parents too busy to supervise brushing • Changes in diet (more sugar) • Use of bottled water without added fluoride *“Trends in Oral Health Status: United States, 1994-1998 and 1999-2004”

13. Significance of Caries • What is the importance of oral disease in the population?

14. Oral Disease is Consequential • Missed work/school – 51 million school hours lost per year • Low income children missed 12 times more days than children from more affluent families • Distraction from normal activities including learning • Speech and eating dysfunction • Growth delay • Loss of wages and potential loss of job

15. Oral Disease is Consequential • Pain & infection – cellulitis, abscess • High cost of surgery for severe ECC ($12,000/case) • Hospitalization, surgical intervention, death (Deamonte Driver) • Emergency room visits; antibiotics; pain medications; “See your dentist in the morning” ($400-$500/visit)

16. Tooth Fairy Lesson 2 Pathophysiology of Caries

17. Three Factors Needed for Caries • Bacteria • Teeth • Carbohydrates

18. Factors Necessary for Caries

19. Bacterial Biofilm (plaque) • Dental plaque, loaded with bacteria, covers tooth surfaces • Most mouth flora are benign; about 500 types of bacteria are present with about 25 potential pathogens • Microbiological shifts in the biofilm (plaque) can inhibit or promote caries • Caries is an infection initiated by the pathogenic bacteria – mainly Streptococcusmutans • Selwitz.R ,Ismail. N, Pitts.B: Dental Caries.Lancet Vol. 369 Jan 6, 2007

20. Oral Flora: How Does Infection Occur? • Bacteria are transmitted mainly from mother or primary caregiver to infant • Window of infectivity is first 2 years of life • The earlier a child is colonized, the higher the risk of caries

21. Factors Necessary for Caries

22. Tooth • Pathogenic bacterial colonization does not start until the eruption of teeth

23. Primary Teeth Eruption

24. Factors Necessary for Caries

25. Substrate: You Are What You Eat • Caries development is promoted by carbohydrates which break down to acid • Acid causes demineralization of enamel

26. You Are What You Drink - Sugar in 12 Ounce Can of Soda Pop Soda Pop: Sugar: (in teaspoons) • Orange Slice 11.9 • Minute Maid Orange 11.2 • Mountain Dew 11.0 • Barq’s Root Beer 10.7 • Pepsi 9.8 • Dr. Pepper 9.5 • Coca-Cola 9.3 • Sprite 9.0

27. pH Safe zone Danger zone 6 7 8 9 10 11 12 1 Bottle Breakfast Snack Sippy-cup Sippy-cup Lunch Not Just What You Eat,But How Often • Acids produced by bacteria after sugar intake persist for 20-40 minutes • Frequency of sugar ingestion is more important than quantity

28. Breastmilk as a Substrate • Unclear evidence whether breastmilk is cariogenic • Cautions on frequent night-time and on-demand breastfeeding after tooth eruption • Potential for early childhood caries (ECC) • exists with extended and repetitive feeding times without appropriate oral hygiene

29. The Dynamic Balance Bacteria + Sugar + Reduced Saliva Flow Saliva + Fl, Ca, Antibacterials GOAL = Balance between remineralizing and demineralizing factors

30. Tooth Fairy Lesson 3 Demographics of Caries Risk

31. High-Risk Groups for Dental Caries • Children with special health care needs • Children whose caregivers and/or siblings have caries • Children with poor dietary and feeding habits

32. High Risk for Dental Caries • Children with sub optimal exposure to topical or systemic fluoride • Children who are exposed to cigarette smoke at home (JAMA.2003;289:1258-1264) • Children eligible for Medicaid

33. Common Issues Among CSHCN • Children with asthma and allergies are often on medications that dry salivary secretion increasing risk of caries • Children who are pre-term or Low Birth Weight (LBW) have a much higher rate of enamel defects and are at increased risk of caries • Children with congenital heart disease are at risk for systemic infection from untreated oral disease

34. Children 2-4 Years Who Have Ever Had Caries in Primary Teeth, 1988-94 and 1999-2000 Percent 1999-2000 1988-94 2010 Target Female Male Total White Black Mexican American Obj. 21-1a Source: National Health and Nutrition Examination Survey, NCHS, CDC.

35. Tooth Fairy Lesson 4 Oral Health Risk Assessment

36. AAP Recommendations for an Oral Health Risk Assessment • Assess mother/caregivers oral health • Assess oral health risk of infants and children • Recognize signs and symptoms of caries • Assess child’s exposure to fluoride • Provide anticipatory guidance and oral hygiene instructions (brush/ floss) • Make timely referral to a dental home

37. Bright Futures 3rd Edition Themes • Oral Health • Healthy Sexuality • Safety and Injury Prevention • Community Relationships and Resources • Child Development • Family Support • Mental Health and Emotional Well-Being • Nutritional Health • Physical Activity • Healthy Weight

38. Bright Futures Recommendations • Oral health risk assessment performed • Anticipatory guidance given • Fluoride modalities addressed • Referral to dental home

40. Assess Caretakers Risk Factors • Screen for dental home of parent/caretaker • History of parental decay in prior year • Refer caregiver to dental home

41. Assess Child’s Risk Factors • Continual bottle/sippy cup use with any liquid other than water • Frequent snacking • Special health care needs • Medicaid eligible/low health literacy level

42. Assess Clinical Factors • Lift the lip to inspect soft tissue and teeth • Assess for: • Presence of plaque • Presence of white spots or dental decay • Presence of enamel defects • Presence of dental crowding

43. Child Assessment Position • Position child in caregiver’s lap facing caregiver • Sit with knees touching knees of caregiver • Lower the child’s head onto your lap

44. Use gentle downward finger pressure behind lower lip on lower incisors to open the child’s mouth If child has a lot of plaque present, brush or wipe with gauze

45. Check for Normal Healthy Teeth

46. Check for Early Signs of Decay:White Spots

47. Check for Later Signs of Decay:Brown Spots

48. Check for Advanced /Severe Decay

49. Assess for Fluoride • Systemic • Water fluoridation • Prescription supplements • Topical • Toothpaste • Varnish • Mouth rinse

50. Systemic Fluoride Supplements and Tap water