Last Modified: July 2017€¦ · • Identification of high-risk patients for oral ... document the following components: •Risk Factors •Protective Factors •Clinical Findings

Third Edition June 2010www.smilesforlifeoralhealth.org

Copyright STFM 2005-2017Last Modified: July 2017

Course Steering Committee Authors and EditorsMichelle Dalal, M.D.

Dental ConsultantsRocio Quinonez, D.M.D, M.S., M.P.H.

Smiles for Life EditorMelinda Clark, M.D.

Funded ByThe 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• Review the prevalence, etiology, and consequences of early

childhood caries (ECC)• Perform an oral examination on young children• Use a Caries Risk Assessment Tool to:

– Identify specific risk factors and protective factors– Document clinical findings– Provide appropriate anticipatory guidance and timely dental referrals

• Discuss the effects, sources, and benefits of fluoride– Describe the benefits and indications for fluoride varnish – Demonstrate the application of fluoride varnish– Describe strategies for an effective office-based varnish program

• Advise families on strategies to prevent caries

Early Childhood Caries: A Brief Review

Chapter Objective• Review the prevalence, etiology,

and consequences of early childhood caries (ECC)

Image: Wojciech Gajda/Photos.com

What is ECC? 5

Etiology• > 1 decayed, missing, or filled primary

tooth surface between birth and 71 months of age

• Chronic disease that destroys tooth structure leading to difficulty chewing, pain, and infection

• 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

6ECC Prevalence• Affects 35% of 3-year-olds from low income families

• Dental caries rates in the primary teeth• ~ 23% of children aged 2–5 years• ~ 37% of children aged 2–8 years

• Untreated dental caries in primary teeth among children aged 2–8 is 2x the rate for Hispanic and non-Hispanic black children compared with non-Hispanic white children

Etiology: The Triad 7

What causes dental caries? • Caries is a multi-step process

resulting in destruction of the tooth structure

• Oral bacteria (including mutans streptococci and lactobacilli) metabolize the sugars from dietary carbohydrates into acid

• Acids demineralize the tooth enamel• If the cycle of acid production and

demineralization continues, the enamel will become weakened and break down into a cavity

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• Oral bacteria produce acids that persist for 20–40 minutes after sugar ingestion

• Oral acids lead to enamel demineralization• Remineralization occurs when acid is buffered by saliva• If sugars are consumed frequently, there is insufficient time for

remineralization to occur; tooth is subjected to continued demineralization and the caries process progresses

It’s not just WHAT, but HOW children eat

9ECC has Severe Consequences

Photo: Donald Greiner, DDS, MS Photo: Joanna Douglass, BDS, DDS Photo: Joanna Douglass, BDS, DDS

• Pain • Impaired chewing and nutrition• Infection• Increased caries in permanent

dentition• School/work absences• Students with dental pain are 3 times more likely to have poorer

school performance

• Difficulty sleeping• Poor self-esteem• Extensive and expensive

dental work which often must be completed under general anesthesia

ECC Recognition

Chapter Objectives• Perform an appropriate

oral examination on small children

• Recognize the various stages of ECC

Photo: Joanna Douglass, BDS, DDS

Knee-to-Knee Oral Exam 11

1. Child is held facing the caregiver in a straddle position

2. Child leans back onto examiner while caregiver holds child’s hands

3. Provider performs exam while caregiver holds child’s hands and legs

Photos: Mark Deutchman, MD

• Examine the soft tissues – tongue, lips, gums• Hard tissues – front, back, sides of all teeth for

plaque, white spots, cavities, & abscesses• Palpate for submucosal clefts

12Healthy Teeth Nature of Healthy Teeth • Creamy white with no signs of

deviation in color, roughness, or other irregularities

• Any child with enamel abnormalities (defect vs early cavity) is at high risk for caries and should be referred to a dentist for further evaluation

• Application of topical fluoride varnish may prevent caries


13Caries Progression


Order of Progression• Upper incisors (maxillary

anterior teeth)• First molars• Second molars

ECC affects the teeth that emerge early and are least protected by saliva (the upper central teeth)

Early ECC : White Spots 14

• White spots and lines are the first clinical signs of demineralized enamel

• Usually affects upper front teeth first and typically appear at the gingival margin


Severe ECC: Cavitations

• Enamel destruction has exposed underlying dentin

• Lesions darken as they become stained with pigments from food

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16Severe ECC with Soft Tissue Involvement

• Multiple dark cavities appear in anterior and posterior teeth

• Abscesses and draining fistulae may be present

• Patients may experience pain, but young children may not be able to verbalize it


17Early Childhood Caries: Management


• Comprehensive dietary and oral hygiene counseling

• Fluoride varnish to arrest cavitated lesions and prevent development of new lesions

• Urgent dental referral for comprehensive treatment, which may include extractions, fillings and root canals

ECC: Caries Risk AssessmentChapter ObjectiveUse a Caries Risk Assessment Tool to:• Identify Specific Risk Factors and

Protective Factors• Document Clinical Findings • Provide Anticipatory Guidance and

Recommend Timely Dental Referrals


Risk Assessment Tool 19

• Oral Health Risk Assessments start at 6 months of age

• Should be completed at each well child visit or dental visit

• Several Caries Risk Assessment tools are available • AAP, ADA, AAPD• Reviews to date, including the

USPSTF, state there is no validated risk assessment tool available to primary care practitioners

• Why risk assessment?• Aids in documenting clinical findings

and guides counseling Risk Assessment Tool PDF available from the AAP Oral Health Home

Caries Risk Assessment Tool 20

The AAP and NIIOH collaborated to create a formal Oral Health Risk Assessment Tool piloted through QuIIN:• Over 80% of practices found the tool

easy to implement• Clinicians did not need to significantly

alter current practice to incorporate risk assessment

• Oral health recommendations can be implemented in just 2 minutes

• Identification of high-risk patients for oral health referral increased from 11% to over 87% with use of the tool

Risk Assessment Tool PDF available from the AAP Oral Health Home

AAP Risk Assessment Tool 21

Oral Health Risk Assessment tool should document the following components:

• Risk Factors• Protective Factors• Clinical Findings• Level of Caries Risk• Urgency of Dental Visit• Depth of nutritional and hygiene counseling

Instructions for use can be found at www2.aap.org/oralhealth/docs/RiskAssessmentTool.pdf Risk Assessment Tool PDF available

from the AAP Oral Health Home

Use the Tool: Identify Risk Factors22

Oral Health Risk Assessment toolshould document Risk Factors:

Questions marked YES with a yellow triangle means the child is at absolute high risk for caries

• Primary caregiver with active tooth decay• Primary caregiver does not have a dentist

For more complete description of each risk factor, see www2.aap.org/oralhealth/docs/RiskAssessmentTool.pdf

Use the Tool: Identify Protective factors23

Oral Health Risk Assessment tool should document Protective Factors:

• Protective factors decrease overall caries risk and include:

• Having a dental home• Tooth brushing• Fluoride use

• Toothpaste • Varnish• Supplements

For a more complete description of each protective factor, go to www2.aap.org/oralhealth/docs/RiskAssessmentTool.pdf

Use the Tool: Document Clinical Findings24

Oral Health Risk Assessment tool should document Clinical Findings:

• Yes answers to the following clinical findings places a child at increased caries risk• Plaque• Gingivitis• Brown or white spot lesions• Evidence of treated decay

For more complete description of clinical findings, go to www2.aap.org/oralhealth/docs/RiskAssessmentTool.pdf

Use the tool: Interpretation25

• Interpret risk based on Risk Factors, Clinical Findings, and Protective Factors balance

• Stratify the child as Low Risk or High Risk for caries to determine the need for routine vs. urgent referral and to create self management goals

Courtesy of Featherstone JD, 2004

FluorideChapter Objective

• Discuss the effects, sources, and benefits of fluoride– Describe the benefits and

indications for fluoride varnish – Demonstrate the application of

fluoride varnish– Describe strategies for an

effective office-based fluoride varnish program Image: Raoul Vernede/Photos.com

Effects and Sources of FluorideTopical 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 toothpaste

Fluoride varnishGels, foams, mouthwashes

• Systemic: Water fluoridationDietary fluoride supplements

27


Evidence for Fluoride UseRecommendations for Children Birth Through Age 5 (United States Preventive Services Task Force 1996, 2014)

• Fluoridated Toothpaste (I, A)

• Fluoride Varnish (B)

• Fluoride Supplements (B)

I: Indicates a recommendation based on evidence from properly constructed randomized controlled trialsA: Indicates a high certainty that net benefit is substantialB: Indicates high certainty that the net benefit is moderate or moderate certainty that the net benefit is moderate to substantial

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Fluoride Use Recommendations 29

Summary of Fluoride Modalities for Low‐ and High‐Risk Patients

Fluoride Modality Low Caries Risk High Caries Risk

Toothpaste Starting at tooth emergence Starting at tooth emergence

Fluoride varnish Every 3‐6 months starting at tooth emergence

Every 3‐6 months starting at tooth emergence

Over‐the‐counter mouth rinse

Not applicable Starting at age 6 if the child can reliably swish and spit

Community water fluoridation

Yes Yes

Dietary fluoride supplements Yes, if drinking water supply is not fluoridated

Yes, if drinking water supply is not fluoridated

Fluorosis 30

• Chronic excessive fluoride exposure to developing teeth can cause white mottling of the tooth surfaces• Mainly a cosmetic effect

• Reduce Fluorosis Risk:• Avoid duplicate fluoride prescriptions• Advise appropriate amount of fluoride

toothpaste use by age• Keep fluoride-containing products out of

the reach of small children• Determine drinking water fluoride content

prior to fluoride supplementation• Fluoride varnish is NOT a significant

risk factor for fluorosis when applied appropriately


Photo: John McDowell, DDS

Moderate Fluorosis

Severe Fluorosis

Fluoride Varnish Benefits 31

• Safe, inexpensive, and effective

• Not associated with treatment-related adverse events in young children

• Quickly and easily applied- Children can eat and drink after application

• Studies demonstrate 30-35% caries reduction

• Strengthens enamel and can stabilize and prevent progression of early caries (white spots) and slow enamel destruction in active ECC

Image: Jupiterimages/Photos.com

Fluoride Varnish: Standard of CareThe USPSTF in 2014 recommended that primary care clinicians apply fluoride varnish to the teeth of all infants and children, starting with the appearance of the first primary tooth through age 5, at least every 6 months.• Recommendation applies to ALL children; no longer a risk-

based recommendation• Assigned a “B” grade recommendation.• All children should receive a professional fluoride treatment

at least every 6 months in the primary care medical home. • Higher risk children should receive fluoride varnish

application every 3 months.

32

Reimbursement 33

Clinicians planning to apply fluoride varnish should consult with their state health department regarding coding requirements and reimbursement.

Medicaid reimburses for Medicaid eligible children in ALL states!

Preparation 34

Steps1. Assemble varnish, gauze and a

good light source2. Place child in knee-to-knee position3. Check child’s mouth:

− Hard tissue (tooth)− Developmental defects− White spots or cavities− Oral hygiene status

− Soft tissue pathology and submucosal cleft palate4. Child may cry during examination5. If child does not open mouth, slide finger in buccal

sulcus and apply gentle opening pressure6. Record findings

Photo: ICOHP

35Varnish Selection

Examples of Varnish Products

Guidelines• Unidose preparation recommended• Preschool children: 0.25ml 5% Na F (2.26% F)• Contains 5.6 mg fluoride• Cost: $1.00–$2.50 USD per unidose

ApplicationSteps 1. Use gauze to blot the teeth dry. Varnish does

not adhere well if teeth are wet.

2. Apply varnish to dried teeth, starting in posterior. Apply a thin layer to all tooth surfaces with a brush.

3. Apply varnish to anterior teeth last. This is the ideal order that may need to be modified if the child is active and uncooperative to ensure the high-risk anterior teeth are not missed.

4. Saliva contamination after application is expected and varnish sets on contact with saliva.

36

Photo: ICOHP


Follow-up 37

Inform the caregiver• Child's teeth may be discolored for 24–

48 hours (only with yellow products), will be removed by thorough brushing

• No brushing until the next morning• Children can eat and drink immediately

after application• Avoid sticky, hot, and very hard foods

(choose soft foods same day)

Photo: ICOHP

Provide Anticipatory Guidance• Emphasize importance of regular oral hygiene practices• Offer dietary counseling regarding carbohydrate intake • Provide systemic fluoride prescription if appropriate• Arrange referral to dental home

Application Video 38

STFM Smiles for Life 2 Fluoride Varnish Video 7-17-08.wmv

Click here to the launch YouTube video version

Implementation Tips • Educate all staff, including front desk personnel, on caries risk

assessment and the value of fluoride varnish• Train all clinicians on application procedure• Identify a varnish champion who can answer questions, understand

billing issues, assign tasks, order varnish, and maintain supplies• Store supplies in exam rooms or a portable kit • Use a one-page/screen documentation form with check boxes for risk

history, consent, varnish documentation, advice, and referral• Update billing forms with varnish code(s)

• CPT code effective January 2015 for fluoride varnish application is 99188. It is suggested to append a Z modifier for preventive services (e.g. Prophylatic fluoride administration Z41.8)

• Stock educational handouts for parents

39

Implementation: Oral Health Delivery FrameworkFive actions primary care teams can take to protect and promote their

patients’ oral health. Within the scope of practice for primary care, possible to implement in diverse practice settings.

Courtesy of: Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care. Seattle, WA: Qualis Health; June 2015

Resources for Oral Health Integration 41

See SFL website Resources >> Tools >> Office Integration Tools

Other Prevention StrategiesChapter Objective• Advise families on strategies

to prevent caries– Diet– Toothbrushing and Flossing– Toothpaste– Fluoride Supplementation– Dental Home Establishment

Image: Ron Chapple studios/Photos.com

43Diet Advice: 0 – 12 Months Recommendations• Strongly encourage breast feeding

• Hold infant for bottle feeding

• Avoid giving bottles at bedtime or naptime

• Don’t offer sweetened pacifiers

• Introduce cup at 6 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

44Diet Advice: 1 – 5 Years 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 sugar

• 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 2 snacks between meals

• Limit soft drinks, candy, and sweets

Tooth Brushing and FlossingGuidelines• Brush twice daily starting when first tooth

emergesₒ Lift lip and brush along the gum line

• Caregiver should brush child's teeth until age 8 or 9 ₒ Caregiver should stand or sit behind the

child• Child should spit out, not rinse, after

brushing to maximize topical fluoride exposure

• Floss once daily between teeth that touch

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46Toothpaste: How much?

Small smear (grain of rice size): Less than 3 years of age

Pea sized: 3 years & over, regardless of caries risk

Guidelines• Most preschool children swallow much of the toothpaste placed

on the brush. These guidelines account for this by limiting toothpaste to amounts safe to swallow, though spitting out should always be encouraged

• Keep toothpaste tubes out of reach of small children

Photos: Rocio Quiñonez DMD, MPH

Fluoride Supplementation 47

Guidelines• Prescribe dietary fluoride supplements to all children who lack access

to optimally fluoridated water, not based on risk assessment• Determine your patient's source of water and its fluoride content before

prescribing fluoride supplements • Test well water before prescribing systemic fluoride

Dietary Fluoride Supplementation for Children Ages 6 months to 16 years

Establish a Dental Home by Age One48

The American Academy of Pediatric Dentistry and the American Academy of Pediatrics both recommend establishment of a dental home by the first birthday.Dentist will provide• Enhanced preventive services • Comprehensive evaluation and diagnosis of oral disease • Evaluation of growth and development • Counseling on oral habits and interceptive orthodontic treatment as

needed • Fluoride varnish and cleanings • Dental x-rays when indicated • Sealants to molars as child grows• Dental trauma management

Take Home Messages• ECC is a significant health problem for children • As a primary care clinician, you can play a key

role in preventing ECC• Fluoride varnish is one part of a comprehensive

approach to a child's oral health • Fluoride varnish is safe and effective • You can apply fluoride varnish to a child's teeth

as a part of a routine health care

Questions?

Image: PhotoObjects.net/Photos.com

Documents

Last Modified: July 2017€¦ · • Identification of high-risk patients for oral ... document the following components: •Risk Factors •Protective Factors •Clinical Findings