FLUORIDE VARNISH PROGRAM IN PRIMARY

CARE

Maria Cordero, DMD, MSAssistant Professor of Pediatric Dentistry

Stony Brook UniversitySchool of Dental Medicine

Why are we here?

Outline

Dental Caries Risk Assessment Behavioral Health Fluoride Varnish Appointment Flow

DENTAL CARIES IS…

The most prevalent chronic illness in our nation’s children

5 times more common than Asthma

An infectious disease that is PREVENTABLE

15% increase in primary tooth decay in the last decade1

12-month old with

decayed incisors

1 CDC MMWR August 20052 Newacheck et al from NHANES III 1999-2002

DENTAL CARIES ETIOLOGY

TOOTHage, fluorides, morphologynutrition, carbonate level

SUBSTRATEoral clearanceoral hygienesaliva stimulantsfrequency of eatingcarbohydrate type

FLORAStrep mutans(oral hygiene and fluoride in plaque) TOOTH

SUBSTRATE

FLORA

CARIES

Children can get cavities as soon as they get teeth

Cavities begin as white lines (demineralization)

The enamel will breakdown and caries will progress into brown spots

The Good The Bad The Ugly

white lines caries

THE CARIES PROCESS

Risk Assessment

Fosters the treatment of the disease process instead of treating the outcome of the disease Understanding the disease factors Individualize preventive discussions

American Academy of Pediatric Dentistry Caries-risk Assessment Tool (AAPD CAT) Biological, Protective, Clinical Findings

1. Biological

Mother/primary caregiver has active caries High  

Parent/caregiver has low socioeconomic status High  

Child has >3 between meal sugar-containing snacks or beverages per day

High  

Child is put to bed with a bottle containing natural or added sugar High  

Child has special health care needs   Moderat

e

Child is a recent immigrant   Moderate

TRANSMISSABLE

Vertical transmission of caries causing bacteria (Streptococcus Mutans) typically occurs between mothers and infants

– direct salivary exchange from feeding, playing, kissing

– Occurs before age 2 yrs

If mother has cavities or gum disease the child will often have poor oral health

Infant acquiring nutrition and

mutans

1. Biological

Mother/primary caregiver has active caries High  

Parent/caregiver has low socioeconomic status High  

Child has >3 between meal sugar-containing snacks or beverages per day

High  

Child is put to bed with a bottle containing natural or added sugar High  

Child has special health care needs   Moderat

e

Child is a recent immigrant   Moderate

Plaque pH

1944- Stephan

7.0

4.0

5.0

6.0

DANGER ZONE

20 405 MINUTES

pH

The Reality of the Problem

Grazers, picky eaters, snackers, and sippers

1. Biological

Mother/primary caregiver has active caries High  

Parent/caregiver has low socioeconomic status High  

Child has >3 between meal sugar-containing snacks or beverages per day

High  

Child is put to bed with a bottle containing natural or added sugar High  

Child has special health care needs   Moderat

e

Child is a recent immigrant   Moderate

BREASTFEEDING &BOTTLEFEEDING

the bottle, sippy cup or other cup should only have WATER in it BEFORE BED OR NAP TIME

=JUICESODAMILK

Poor feeding practice alone will not cause cavities hence

* baby bottle tooth decay * bottle mouth * nursing decay are misleading terms

2. Protective

Child receives optimally-fluoridated drinking water or supplements

Protective

Child has teeth brushed daily with fluoridated toothpaste

Protective

Child receives topical fluoride from health professional

Protective

Fluoride

1901 Dr. McKay moves to Colorado, notices “brown stained teeth”

1945 first city to fluoridate Grand Rapids, Michigan

1950s Fluoride marketed in toothpaste

ADA guidelines on Fluoride supplementation

Age Fluoride Ion Level in Drinking Water (ppm)*

  <0.3 ppm 0.3-0.6 ppm >0.6 ppm

Birth-6 months None None None

6 months-3 years 0.25 mg/day** None None

3-6 years 0.50 mg/day 0.25 mg/day None

6-16 years 1.0 mg/day 0.50 mg/day None

* 1.0 ppm = 1 mg/liter** 2.2 mg sodium fluoride contains 1 mg fluoride ion.

2. Protective

Child receives optimally-fluoridated drinking water or supplements

Protective

Child has teeth brushed daily with fluoridated toothpaste

Protective

Child receives topical fluoride from health professional

Protective

Toothbrush with Fluoride Toothpaste

Amount of toothpaste: 0-2 year old: smear (.1mg) 2-5 year old: pea (.2mg)

2. Protective

Child receives optimally-fluoridated drinking water or supplements

Protective

Child has teeth brushed daily with fluoridated toothpaste

Protective

Child receives topical fluoride from health professional

Protective

FIRST DENTAL VISIT

Risk assessment of dental disease

Diet Anticipatory

Guidance Oral hygiene

instruction Delay of

colonization Mother’s oral

health Oral health Plan

3. Clinical Findings

Child has white spot lesions or enamel defects High  

Child has visible cavities or fillings High  

Child has plaque on teeth   Moderate

Gauze Test Wrap gloved index

finger with gauze Wipe teeth and show

caregiver This is plaque……..

Plaque infection makes acid from sugars and starches causing caries.

FLUORIDE - FAQSWhat Parents Want to Know

Is it safe?

Probable toxic dose is 5 mg/kg

Average weight of a 1 year old is 10 kg

PTD = 50 mg .25 mL per unit dose

(Duraflor) 12.5mg per dose .4 mL per unit dose (Vanish) 40 mg per dose

What do I do if my child swallows too much fluoride?

Abdominal pain, convulsions, diarrhea, vomiting

Call National Poison Control Center May give Calcium or Milk Gastric Lavage Possible Monitor Vital signs

Any Allergies?

Two cases of contact allergy to Duraphat varnish have been reported. Dermatitis in a dental

assistant’s hand Stomatitis in a patient

Related to the colophony (tree nuts)

Duraphat claims that the use of varnish in patients with ulcerative gingivitis and stomatitis is contraindicated.

Isaksson M, Bruze M, Björkner B, Niklasson B. Contact allergy to Duraphat. Scand J Dent Res 1993;101:49-51.

What about that website…

Fluoride has been accused of causing lower IQs, Autism, osteosarcomas, and kidney disease

The only known risk in therapeutic doses is fluorosis Caused by unmonitored

consumption of fluoride in children 8 years or younger

Appointment – Step 1

Caries Risk Assessment Determines

Indications Opportunity for

Counseling

Appointment – Step 2

Knee-to-Knee Screening Examination

Appointment – Step 3

Fluoride Application Use gauze to dry the teeth

as much as possible. Varnish will not adhere if teeth are wet.

Apply varnish to dried teeth, starting in posterior.

Apply varnish to anterior teeth last.

Saliva contamination after the application is fine as varnish sets in contact with saliva.

Protocol

1. Diet Counseling

2. Oral Hygiene Instruction3. Fluoride Application

4. Referral to Dentist

6 month

Reinforcement1. Diet update

2. Oral Hygiene

9 month

1. Diet Counseling

2. Oral Hygiene Instruction3. Fluoride Application

4. Referral to Dentist-

troubleshoot

12 month

Reinforcement1. Diet update

2. Oral Hygiene

3. Oral Habits

15-18 months

Repeat Fluoride application and counseling cycle until a dental home is established.

Additional Resources

AAPD Reference Manual http://www.aapd.org/policies/

Additional Resources

Additional Resources

http://www2.aap.org/oralhealth/SmilesForLife.html

Stony Brook Dental Associates

Comprehensive Oral Health for Children

Maria Cordero, DMD, MSHechang Huang, DDS, MS, PhD

Fred Ferguson, DDSStephanos Kyrkanides, DDS, MS, PhD

Maria Ryan, DDS, PhDDenise Trochesset, DDS

Allan Kucine, DDS

Sullivan HallStony Brook, NY 11794-8705

631-632-8971