Fluoride Varnish Application Training: Early Childhood Dental Caries Grant Christensen, DDS State Dental Officer

Upper Peninsula Childrens Oral Health Summit

Erika J. Tyler R.D.H, D.D.SNorthern Michigan UniversityMay 17, 2014

Lecture GoalsArent they just baby teeth?Why should I care?What is a Pediatric Dentist?What is dental decay?What are some prevention ideas?

I was asked to include lots of gross pictures of stuff I see every day. Here goes2Arent they just baby teeth?Disease burdenSystemic infectionsGrowth problemsLow self esteemQuality of life

Speech problemsCompromised esthetics PainEconomic loss

Prevention is cheap. I saw a 5 y.o. girl last week that had been coming home from school crying about the kids teasing her about having a black tooth3Arent they just baby teeth?ER visits, Hospitalizations52 million school hours lost per year for dental problems

This baby is 18-19 months old, based on the upper canines are just now erupting. Both central incisors are abscessed and need to be extracted.4Public Health PointsOral disease is common and has consequences for overall healthMost oral disease is preventable

Public Health PointsA significant barrier to childrens access to dental care lies in the fact that approximately 90 percent of highest risk kids are enrolled in MedicaidMany dentists have expressed a reluctance to work with kids who are covered by Medicaid

80% of the disease burden are in 20% of the population. 6Disparities and Oral Health28% of all preschoolers between the ages of 2 and 5 suffer from tooth decayIn HS programs, decay rates range from 30 to 40% of 3-yr-olds and 50 to 60% of 4-yr-olds**AAPD Head Start Dental Home Initiative, http://www.aapd.org

Disparities and Oral HealthEthnically diverse populations have more oral diseaseCultural dimensions of eating, sleeping, child-rearing, healthbehaviors in relation to oralhealth

Disparities and Oral HealthDental caries (tooth decay) most common chronic disease of childhoodDental caries is 5x more common than asthma and 7x more common than hay-feverDental care most common unmet health need*

*Vargas et al, 1998; Newacheck et al, 2000a, 2000b, Mouradian, Wehr and Crall, 2000Disparities and Oral HealthDental insurance: children 2.5X more likely to lack dental coverage than medical coverage*Medicaid: only 1/5 children accessed dental care*50% of tooth decay in low income children goes untreated

*Vargas et al, 1998; Newacheck et al, 2000a, 2000b, Mouradian, Wehr and Crall, 2000

Now with the Affordable Health Care Act, children are guaranteed Dental Coverage. We have yet to see how this will play out10U.S. Dental Workforce IssuesNumber of dentists per capita declining (~200,000 in 2014)Few pediatric dentists (9300 in 2014)Acute shortagesin rural and underserved areas

4.6% of dentists are Peds11Gaps in Dental TrainingMost dentists and hygienists are not adequately trained in oral health care of infants and young children, or those with special needsMost medical education has limited dental education

Some wonderful general dentists are very comfortable and skilled in working with children. Many are not. Every day, I see children who have been traumatized by health care providers who just want to get it done.12Defining the Issue: Michigan~ 113,000 live births/year (2012) ~900K of Michigans 2.5 million kids are Medicaid eligible, (increasing)58% of Michigan 3rd Graders have caries

Decay rates are on the rise in pre-school kids (4% in last 10 years; CDC, 07)

And our #s are higher in vulnerable pop, low income, no Fl- , lower education, ethnic minority (Native Am), reduced lunch, etc

13Dentistry in Michigan: By the Numbers115 (2012) pediatric dentists, of which an estimated 84% (~96) see 1 year olds 5140 general dentists, (2012)Evidence suggests that pediatric dentists migrate to upper income communitiesThere are not enough pediatric dentists Most general dentists are not comfortable treating very young children

Addressing the Needs of Michigans InfantsCurrently: 113,000 live births =>981 new patients/pediatric dentist/year.

If all dentists accepted infants = ~22 infants/year. (If only half see infants = ~ 44 infants/year)Conclusion: This is possible!

I see on avg~ 550 NP/year15What is a Pediatric Dentist?Pediatric dentists are the pediatricians of dentistry. A pediatric dentist has two to three years of specialty training following dental school and limits his/her practice to treating children only.

I have been asked to define for you what is a pediatric dentist16What is a Pediatric Dentist?Pediatric dentists are primary and specialty oral care providers for infants and children through adolescence, including those with special health needsChildren are not just smaller versions of adultsKids teeth and mouths are not just smaller versions of adult teeth and mouths

What is a Pediatric Dentist?Kids are not always able to be patient and cooperative during a dental examPediatric dentists examine and treat children in ways that make them comfortablePediatric dentists use specially designed equipment in offices that are arranged and decorated with childrens development in mind

let alone during treatment! This is the kid I see every day! 18

Pediatric Dentistrys Role in Oral HealthAnticipatory guidance and counselingEducation of parent, child and communityCaries risk assessmentOral screening examApplying fluoride varnish, as neededAppropriate treatment, as needed Establishing a Dental HomeMaking Oral Health FUN!

My goal as a pediatric dentist is to NEVER fix another tooth again. I want every child to come see me for happy, fun visits and be able to pick out a prize for being a good helper. This establishes a lifetime of good memories about visiting the dentist. Pediatric Dentistry is NOT about holding the kid down and freaking them out. Unfortunately, many of you in this room, have likely had that happen to you and have suffered your whole life for it.20Pediatric Dentistrys Role in Oral HealthManagement of dental emergencies and simple traumaOral-systemic health interactions, especially for CSHCN, and patients with chronic illnessesIdentify and manage developmental and growth issues

Dental Decay Infectious, Transmittable DiseaseThe cariogenic bacteria of primary caregiver can be transferred to child by:Wetting pacifierwith salivaPre-chewing the childs foodTasting the childsfoodKissing child on the lips

What is Dental Decay???Biofilm (plaque) is a living community of bacteriaBacteria ferment carbohydrates and produce acidOver time acid demineralizes enamel (white spot lesion)REVERSIBLE! The end result is caries which is non reversible

You know when you go camping for the weekend and you forgot your toothbrush? When you come home, your teeth feel like they have sweaters?23Early Childhood CariesDental decay in primary teeth, kids < age 6 years oldFormerly known as Baby bottle tooth decay or Nursing/bottle caries

Nursing is the best thing Mommas can do for their babies, we never would want to discourage nursing. However, at will, frequent nursers are at higher risk of 24Early Childhood CariesA transmissible infection caused by Streptococcus MutansDiet dependent fermentable carbohydrates with frequent exposureOccurs on erupted susceptible teethCauses cavities to develop over timeECC affected children are at higher risk for decay as adolescents and adultsDental Venn Diagrams

Dental Venn Diagrams

AAPD Guidelines for Caries RiskCaries risk is greater for children who are poor, rural, or minority or who have limited access to care. Factors for high caries risk include:dmfs > the childs agenumerous white spot lesionshigh levels of mutans streptococcilow socioeconomic statushigh caries rate in siblings/parentsdiet high in sugarand/or presence of dental appliances

Food Lesson - Eating Frequency

Stephan curve29Ongoing BalanceNo CariesProtective Factors Salivary flowFluorideCariesPathologic Factors+ + Strep MutansFermentable carbohydratesReduced salivary flow

Protective factors (3 meals a day with only water b/t, brushing 2x/d, nicely aligned teeth). Pathologic factors (sipping and snacking all day, brushing 2x/week, crowded teeth)30Early Childhood Caries - Maternal TransmissionWindow of infectivity: 6 30 monthsTransmission is a natural processDont suggest mother decrease contact with infantHelp mother meet her oral health careneedsSuggest other preventive measures

All of us humans have strep mutans. It depends on what kind of bug we have and we do with it31Messages for ParentsOral health - important to overall healthPrimary teeth matterCaries can start as soon as teeth eruptStrep Mutans is transmissibleStress importance of caretakers oral healthAdvise pregnant moms to receive dental care Avoid frequent intake of carbohydrates

Evidence Based Prevention RecommendationsPersonal:Brush with fluoridated toothpasteLimit sipping/snackingVisit dentist regularlyProfessional:SealantsFl- varnishesFluoride suppsDietary counseling

Sources of FluorideSystemicWater fluoridationFluoride supplementsTopicalFluoride toothpastesGelsFluoride varnish

Fluoride Can Prevent and/or Reverse White Spot LesionsMechanisms of action:Reduces enamel solubilityPromotes re-mineralization of enamelAnti-bacterial activity in higher concentrationsAction is topical, in saliva

FluorideCommunity water fluoridation should have 0.7-1.2 ppm fluoride to be effectiveFluoride supplements should be prescribed if the water supply does not have adequate fluoridation (naturally; lack of public fluoridation; home filters).FluorideInfants younger than six months do not require fluoride supplementsInfants six months and older who are breast-fed may have the greatest need for dietary fluoride supplements

U.S. Fluoride Supplement Schedule, 1994Community Fluoridation LevelAge 0.6ppm

0 mos.- 6 mos. 0 0 06 mos.- 3 yrs.0.25mg 0 03 yrs. - 6 yrs.0.50mg 0.25mg 06 yrs. - 16 yrs.1.0 mg 0.50mg 0 ADA, AAP, AAPDCaries Risk AssessmentHIGH RISK if by history:Previous or current cariesSiblings or mom with cariesNo fluoride in waterChronic health condition and/or medication useSES, cultural factorsCSHCNAdapted, Bright Futures in Practice, Oral Health, 1996

Age One Dental VisitAll childrenDental evaluation by age 1Anticipatory guidance earlierPrioritize dental needs: visible disease or high risk for diseasePregnant women, mothers with disease need timely treatmentAll children need a regular source of dental care (dental home)

Pre-Cavity Lesions: White Spot LesionsOften accompanied by bleedingFollows contour of gum-line

44Brown Spots - Advancingdecay process

Risk Assessment

Do this:1. Apply fluoride varnish.2. Make referral to dentist.3. Explain the importance of regular tooth brushing with fluoride toothpaste.4. Emphasize early decay can be reversed.

What is fluoride varnish?Effective in preventing tooth decay in both the primary and permanent dentitionFluoride varnish is a liquid coating that adheres to the dentalEnamel forms a depot from which fluoride is slowly releasedFluoride varnish was first introduced in Germany in 1964Over 30 years of clinical studies in Europe report 25- 45% caries reduction47What is fluoride varnish?More recent studies in the United States also support these findingsIntroduced to United States in 1991FDA approved in the 1990s as a desensitizing agent Used off label for caries reductionAmerican Dental Association (ADA) endorses the use of fluoride varnish for caries prevention in May 2006

Holm AK. Effect of a fluoride varnish (Duraphat) in preschool children. Community Dent OralEpidemiol 1979, 7:241-5.225 Swedish 3-year-oldsSemiannual application of fluoride varnish44% caries reduction after two yearsFluoride VarnishProtective coating that is painted on the surfaces of teeth to prevent new cavities from forming and to help stop cavities that have already startedPrevents caries on both smooth surface and pit and fissure sitesMinimal chance of ingestionProtective effect of the fluoride varnish will continue to work for several monthsFluoride VarnishFluoride varnish is very easy to applyFluoride varnish adheres to the teeth so potential ingestion of fluoride is lowFluoride varnish has a yellow color to it when it sets up (Vanish Varnish (Omnii) is white)Parent can be involved by assisting in holding the child in the knee-to-knee positionRemove plaque and debris with gauze sponge

Varnish Application

Varnish Application

Post Application Instructions

Varnish will set on contact with salivaThe applied fluoride varnish will leave a yellow film that will remain on teeth (Vanish Varnish is white)

Advantages to Fluoride ApplicationChild-friendly flavors, easily toleratedEasily applied in less than three minutesTeeth need not be cleaned first or even dried completelyIs safe and verylittle, if any, ingestionDoes not require theuse of any dental equipment

Brown Spots - Arresteddecay process after 3 mos

Public Health AdvocacyMonitor childrens health in communityMobilize community partnershipsHelp develop policies/actions at community levelWater fluoridationSchool based programsProblem solving with local dental societiesLink families to needed care

Caring for our poorest and most vulnerableChildren seen early are less costly to care for over timeWith very young patients, preventing decay is far easier than restoring teeth

Children with less complex restorative needs are less likely to require referral to a pediatric dentist

SummaryDental decay is asignificant health problem for childrenAnticipatory guidanceOral exam by age 1Primary care providers have key roleFluoride varnish safe and effectiveCollaborate with other health care providers to improve oral health and access to care