EARLY CHILDHOOD CARIES: ORAL HEALTH PROMOTION BEGINNING WITH MOM

1. EARLY CHILDHOOD CARIES: ORAL HEALTH PROMOTION BEGINNING WITH MOM Peter Milgrom, DDS Northwest/Alaska Center to Reduce Oral Health Disparities University of Washington, Seattle

2. OUTLINE • Nature of the Problem • Early childhood caries • Oral health disparities • Primary Care Solutions • Appropriate dental care during pregnancy • Well child care, anticipatory guidance • Screening and referral • Topical fluorides in toothpaste and varnish

3. Patient Care Goals • Healthy moms to reduce disease transmission • Knowledgeable moms to increase utilization of preventive services • Healthy children

4. NATURE OF THE PROBLEM

5. NORMAL PRIMARY DENTITION

9. EARLY CHILDHOOD CARIES (ECC) • Bacteria grow in a biofilm and are largely resistant to bodily defenses • Baby bottle tooth decay and nursing bottle caries are subtypes

10. EARLY CHILDHOOD CARIES • Usually first affects maxillary incisors • Other patterns can affect posterior teeth first • Lesions progress rapidly as enamel of primary teeth is thin

14. ORAL HEALTH DISPARITIES • Substantial disparities exist for oral health status and access to dental care • Low-income children have 5 times more untreated dental decay compared to higher income children1 • 80% of untreated dental disease occurs in 25% of the population, with low-income children bearing the greatest burden2 1. Vargas, et al.,JADA, September 1998 2. Kaste, et al., JDR, 1996

15. Percent of children with one or more cavities by age and federal poverty category

16. PRIMARY CARE SOLUTIONS

17. THE ROLE OF THE PRIMARY CARE PROVIDER IN ORAL HEALTH Assessment of the oral health of the pregnant woman and timely referral for dental care • Prescription of chlorhexidine, fluoride, and xylitol • Provision of anticipatory guidance, • Assessment, prompt referral of children at high risk or with early signs of decay • Application of a caries control therapy such as toothpaste and fluoride varnish

18. ANTICIPATORY GUIDANCE

19. ANTICIPATORY GUIDANCE • Oral health important to overall health • Importance of mother’s oral health • Dental Care for Pregnant Mothers • Transmissibility of Strep mutans • Tooth eruption • Lift the Lip/looking for decay

20. Oral health is important to overall health • Periodontal infections are associated with poor pregnancy outcomes. • ECC has been associated with failure to thrive. • Low-income children suffer 12 times the number of restricted activity days due to dental problems compared to more affluent children.* *Lewis, et al., Pediatrics, December 6, 2000

21. Dental Care During Pregnancy • Dental treatment can be rendered safely any time during pregnancy.* • Elective treatment should be carried out in the 2nd and early 3rd trimesters. *American College of Obstetrics and Gynecology, 2000

24. Dental Care During Pregnancy • Oral hygiene to promote healthy gums • Chlorhexidine (0.12%) rinses 2x daily for 2 weeks during the last 6-8 weeks of pregnancy (FDA class B) • The Daily use of topical fluoride • Prenatal fluoride unproven

25. Dental Care During Pregnancy • X-ray exposure safe with lead apron which includes a thyroid collar • Lidocaine (FDA B) • Amoxicillin, Cephalexin, Clindamycin, Erythromycin, Metronidzole,Penicillin V-K (FDA B) • Short exposure to nitrous oxide safe (not classified by FDA) • Single dose of short acting benzodiazepine (FDA D) safe *JADA 129, September 1998: 1281-1286

26. Xylitol gum--impact of preventing transmission Xylitol is a naturally occurring sugar alcohol with 1/3 less calories than sucrose. FDA approved food additive. Safe for diabetics Effective dose 4-6 mg/day in gum or mints

27. Mutans streptococci of the 2-year-old children(Söderling, et al.,JDR 2000) • The child’s risk of having salivary mutans streptococci colonization in the dentition was 5-fold in the F group and 3-fold in the CHX group as compared to the Xylitol group

28. Caries occurrence in children(Isokangas, et al., JDR 2000) • At the age of 5 years ,the need of restorative treatment was 71-75% lower in the Xylitol group as compared to the F and CHX groups • The occurrence of caries and early mutans streptococci colonization were in agreement

29. Baby teeth begin critical development at 3 mos gestation

30. ANTICIPATORY GUIDANCE • Fluoride needs • Tooth brushing with fluoridated toothpaste • No bottle at bedtime or nap time • Diet

31. Chlorhexidine Mouthwash • For mothers with tooth decay problems • Useful in conjunction with dental treatment • Reduces strep mutans levels in mouth • Available 0.12% oral rinse by prescription • Use 2x daily for 30 sec for 1 week/month or 2 weeks/3-4 months • Spit and do not rinse

32. Should I prescribe fluoride supplements? • Originated before fluoridated toothpaste and water • No evidence for efficacy from clinical trials • Significant risk of fluorosis • Little compliance *Lewis, C. W., and Milgrom, P. “Fluoride.” Pediatr Rev 2003 Oct. 24(10):327–336

33. AAP recommended dosing • In areas with <0.3 mg/l F in drinking water • Birth to 6 mo. - NONE • 6-36 mo. - 0.25 mg/day • 36-72 mo. - 0.50 mg/day • >72 mo. - 1.0 mg/day

34. Fluoridated Toothpaste • 74 studies, >42,000 children • Prevented fraction 24% (95% CI 21-28%) in permanent teeth • Little data on primary teeth • Effect increases with greater use and supervision • Home distribution reduces tooth decay *Cochrane Database Syst Rev, 2003 (1):CD002278

35. Toothpaste A small pea-sized amount of toothpaste weighs 0.4 gm = 0.6 mg Fluoride

37. SCREENINGAND EARLY REFERRAL

38. Caries Risk Analysis • There is a history of decay in the family. • There is visible plaque on the teeth. • The child is on Medicaid • The child is low birthweight or premature.

39. RECOGNIZING EARLY DECAY WHITE SPOT LESIONS = Subsurface demineralization

43. REFERRAL • AAP and AAPD recommend that the first dental visit should occur at 1 year of age. • Children at high risk for decay or with visible signs of decay should be referred to a dentist.

44. TOOLS FOR THE PRIMARY CARE PROVIDER Fluoride Varnish Application

45. Fluoride Varnish Application • Safe for infants and toddlers • Effective • Quickly completed

46. EFFICACY • Meta-analysis of Duraphat trials reveals 33% caries reductions in 2-per-year applications* • 14% greater inhibitory effect than other topical fluorides** • Fluoride effects are frequency related. Varnish tied to well baby visits being studied. *Helfenstein and Steiner, Community Dentistry and Oral Epidemiology, 1994 **Cochrane Library, Issue 4, 2003

47. Basic varnish formula • Ethyl alcohol anhydrous USP 38.58% • Shellac powder 16.92% • Rosin USP 29.61% • Copal 9.31% • Sodium fluoride USP 4.23% • Sodium saccharin USP 0.04% • Flavorings, cetostearyl alcohol

48. Wide margin of safety • Dose from 5 to 8 mg Fluoride • Toxic dose 5 mg/kg • Very limited evidence of allergy • Previous concerns about asthma unfounded • Does not cause fluorosis

49. Fluoride Varnish • 40-80 applications per 10 mL tube with disposable brush • Or single use with brush attached • No refrigeration required. Shelf life ~2 years