EARLY CHILDHOOD CARIES: ORAL HEALTH PROMOTION BEGINNING WITH MOM

transcript

Peter Milgrom, DDSNorthwest/Alaska Center to Reduce Oral Health

DisparitiesUniversity of Washington, Seattle

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

Patient Care Goals

• Healthy moms to reduce disease transmission

• Knowledgeable moms to increase utilization of preventive services

• Healthy children

NATURE OF THE PROBLEM

NORMAL PRIMARY DENTITION

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

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

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 19982. Kaste, et al., JDR, 1996

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

category

0102030405060708090

2-4 yrs 6-8 yrs 15 yrs

<100%100-199%>200%

PRIMARY CARE SOLUTIONS

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

ANTICIPATORY GUIDANCE

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

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

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.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

*American College of Obstetrics and Gynecology, 2000

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

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)

*JADA 129, September 1998: 1281-1286

• Short exposure to nitrous oxide safe (not classified by FDA)• Single dose of short acting benzodiazepine (FDA D) safe

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

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

0CONTROL CHX XYLITOL

n=33 n=28 n=103

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

Control

Xylitol

00 1 2 3 4 5 6

Baby teeth begin critical development at 3 mos gestation

ANTICIPATORY GUIDANCE

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

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

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

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

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

Toothpaste

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

SCREENINGAND

EARLY REFERRAL

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.

RECOGNIZING EARLY DECAY

WHITE SPOT LESIONS=

Subsurfacedemineralization

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.

TOOLS FOR THE PRIMARY CARE PROVIDER

Fluoride Varnish Application

•Safe for infants and toddlers

•Effective•Quickly completed

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

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

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

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

SUMMARY

• Primary care providers are key partners in improving oral health and preventing dental disease.

• Dental care is safe for pregnant women.• Children should see a dentist by age 1.

EARLY CHILDHOOD CARIES: ORAL HEALTH PROMOTION BEGINNING WITH MOM

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