Upper Peninsula Children’s
Oral Health Summit
Erika J.Tyler R.D.H,
D.D.S
Northern Michigan
University
May 17, 2014
Lecture Goals
Aren’t they “just baby teeth?”
 Why should I care?
 What is a Pediatric Dentist?
 What is dental decay?
 What are some prevention ideas?

Aren’t they “just baby teeth?”





Disease burden
Systemic infections
Growth problems
Low self esteem
Quality of life
Speech problems
 Compromised
esthetics
 Pain
 Economic loss

Aren’t they “just baby teeth?”
ER visits, Hospitalizations
 52 million school hours lost per year for
dental problems

Public Health Points
Oral disease is
common and has
consequences for
overall health
 Most oral disease is
preventable

Public Health Points


A significant barrier to
children’s access to dental
care lies in the fact that
approximately 90 percent
of highest risk kids are
enrolled in Medicaid
Many dentists have
expressed a reluctance to
work with kids who are
covered by Medicaid
Disparities and Oral Health
28% of all preschoolers between the ages
of 2 and 5 suffer from tooth decay
 In HS programs, decay rates range from 30
to 40% of 3-yr-olds and 50 to 60% of 4-yrolds**AAPD Head Start Dental Home Initiative,

http://www.aapd.org
Disparities and Oral Health
Ethnically diverse populations have more
oral disease
 Cultural dimensions of eating, sleeping,
childrearing, health
behaviors in
relation to oral
health

Disparities and Oral Health
Dental caries (tooth decay) most
common chronic disease of childhood
 Dental caries is 5x more common than
asthma and 7x more common than hayfever
 Dental care most common unmet health
need*

*Vargas et al, 1998; Newacheck et al, 2000a, 2000b, Mouradian, Wehr and Crall,
2000
Disparities and Oral Health
Dental 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
U.S. Dental Workforce Issues
Number of dentists per capita declining
(~200,000 in 2014)
 Few pediatric dentists (9300 in 2014)
 Acute
shortages
in rural and
underserved
areas

Gaps in Dental Training
Most dentists and hygienists are not
adequately trained in oral health care of
infants and young children, or those with
special needs
 Most medical
education
has limited
dental
education

Defining the Issue: Michigan
~ 113,000 live
births/year (2012)
 ~900K of Michigan’s
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)
Dentistry in Michigan: By the
Numbers





115 (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 communities
There are not enough
pediatric dentists
Most general dentists are
not comfortable treating
very young children
Addressing the Needs of
Michigan’s Infants

Currently: 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!

What 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.

What is a Pediatric Dentist?

Pediatric dentists are primary and specialty
oral care providers for infants and children
through adolescence, including those with
special health needs
Children are not just
smaller versions of adults
 Kid’s 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 exam
 Pediatric dentists examine and treat
children in ways that make them
comfortable
 Pediatric dentists use
specially designed
equipment in offices
that
are arranged and
decorated with children’s
development in mind

Pediatric Dentistry’s Role in
Oral Health






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Anticipatory guidance and counseling
Education of parent, child and community
Caries risk assessment
Oral screening exam
Applying fluoride varnish,
as
needed
Appropriate treatment,
as
needed
Establishing a Dental
Home
Making Oral Health FUN!
Pediatric Dentistry’s Role in
Oral Health
Management of dental emergencies and
simple trauma
 Oral-systemic health interactions,
especially for CSHCN, and patients with
chronic illnesses
 Identify and
manage
developmental
and
growth
issues

Dental Decay – Infectious,
Transmittable Disease

The cariogenic bacteria of primary
caregiver can be transferred to child by:
◦ Wetting pacifier
with saliva
◦ Pre-chewing
the child’s food
◦ Tasting the child’s
food
◦ Kissing child on
the lips
What is Dental Decay???
Biofilm (‘plaque’) is a living community of
bacteria
 Bacteria ferment carbohydrates and
produce acid
 Over time acid demineralizes enamel
(white spot lesion)
 REVERSIBLE!
 The end result is
caries
which is non
reversible

Early Childhood Caries
Dental decay in primary teeth, kids < age
6 years old
 Formerly known as “Baby bottle” tooth
decay or Nursing/bottle caries

Early Childhood Caries
A transmissible infection caused by
Streptococcus Mutans
 Diet dependent – fermentable
carbohydrates with frequent exposure
 Occurs on erupted susceptible teeth
 Causes cavities to develop over time
 ECC affected children are at higher risk
for decay as adolescents and adults

Dental Venn Diagrams
Dental Venn Diagrams
AAPD Guidelines for Caries Risk
Caries 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 child’s age
• numerous white spot lesions
• high levels of mutans streptococci
• low socioeconomic status
• high caries rate in siblings/parents
• diet high in sugar
• and/or presence of dental appliances
Food Lesson - Eating Frequency
Ongoing Balance

No Caries
◦ Protective Factors
◦ Salivary flow
◦ Fluoride

Caries
◦ Pathologic Factors
◦ + + Strep Mutans
◦ Fermentable
carbohydrates
◦ Reduced salivary
flow
Early Childhood Caries Maternal Transmission
Window of infectivity: 6 – 30 months
 Transmission is a natural process
 Don’t suggest mother
decrease contact with
infant
 Help mother meet
her oral health care
needs
 Suggest other
preventive measures

Messages for Parents
◦
◦
◦
◦
◦
Oral health - important to overall health
Primary teeth matter
Caries can start as soon as teeth erupt
Strep Mutans is transmissible
Stress importance of
caretaker’s
oral health
◦ Advise pregnant moms
to
receive dental care
◦ Avoid frequent intake
of
carbohydrates
Evidence Based Prevention
Recommendations

Personal:
◦ Brush with fluoridated toothpaste
◦ Limit sipping/snacking
◦ Visit dentist regularly

Professional:
◦ Sealants
◦ Fl- varnishes
◦ Fluoride supps
◦ Dietary counseling
Sources of Fluoride

Systemic
◦ Water fluoridation
◦ Fluoride supplements

Topical
◦ Fluoride toothpastes
◦ Gels
◦ Fluoride varnish
Fluoride Can Prevent and/or
Reverse White Spot Lesions

Mechanisms of action:
◦
◦
◦
◦
Reduces enamel solubility
Promotes re-mineralization of enamel
Anti-bacterial activity in higher
concentrations
Action is topical, in saliva
Fluoride
Community water fluoridation should
have 0.7-1.2 ppm fluoride to be effective
 Fluoride supplements should be
prescribed if the water supply does not
have adequate fluoridation (naturally; lack
of public fluoridation; home filters).

Fluoride
Infants younger than
six months do not
require fluoride
supplements
 Infants six months
and older who are
breast-fed may have
the greatest need for
dietary fluoride
supplements

U.S. Fluoride Supplement
Schedule, 1994
Age
>0.6ppm
Community Fluoridation Level
<0.3ppm 0.3-0.6ppm
0 mos.- 6 mos. 0
6 mos.- 3 yrs. 0.25mg
3 yrs. - 6 yrs.
0.50mg
6 yrs. - 16 yrs. 1.0 mg
0
0
0.25mg
0.50mg
0
0
0
0
ADA, AAP, AAPD
Caries Risk Assessment

HIGH RISK if by history:
◦
◦
◦
◦
Previous or current caries
Siblings or mom with caries
No fluoride in water
Chronic health condition
and/or medication use
◦ SES, cultural factors
◦ CSHCN
◦ Adapted, Bright Futures in Practice, Oral
Health, 1996
Age One Dental Visit

All children
◦ Dental evaluation – by age 1
Anticipatory guidance earlier
 Prioritize dental needs: visible disease or
high risk for disease
 Pregnant women, mothers with disease
need timely treatment
 All children need a regular source of
dental care (“dental home”)

Often accompanied by bleeding
Follows contour of gum-line
Pre-Cavity Lesions:
White Spot Lesions
Brown Spots - Advancing
decay 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?



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Effective in preventing tooth decay in both
the primary and permanent dentition
Fluoride varnish is a liquid coating that
adheres to the dental
Enamel forms a depot from which fluoride is
slowly released
Fluoride varnish was first introduced in
Germany in 1964
Over 30 years of clinical studies in Europe
report 25- 45% caries reduction
What is fluoride varnish?
More recent studies in the United States
also support these findings
 Introduced to United States in 1991
 FDA approved in the 1990’s as a
desensitizing agent – Used “off label” for
caries reduction
 American 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 Oral
Epidemiol 1979, 7:241-5.
225 Swedish 3-year-olds
 Semiannual application of fluoride varnish
 44% caries reduction after two years

Fluoride Varnish
Protective coating that is painted on the
surfaces of teeth to prevent new cavities
from forming and to help stop cavities
that have already started
 Prevents caries on both smooth surface
and pit and fissure sites
 Minimal chance of ingestion
 Protective effect of the fluoride varnish
will continue to work for several months

Fluoride Varnish
Fluoride varnish is very easy to apply
 Fluoride varnish adheres to the teeth so
potential ingestion of fluoride is low
 Fluoride 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
position

Remove plaque and debris with
gauze sponge
Varnish Application
Varnish Application
Post Application Instructions
Varnish will set on
contact with saliva
 The applied fluoride
varnish will leave a
yellow film that will
remain on teeth
(Vanish Varnish is
white)

Advantages to Fluoride
Application
Child-friendly flavors, easily tolerated
 Easily applied in less than three minutes
 Teeth need not be cleaned first or even dried
completely
 Is safe and very
little, if any, ingestion
 Does not require the
use of any dental
equipment

Brown Spots - Arrested
decay process after 3 mos
Public Health Advocacy
Monitor children’s health in community
 Mobilize community partnerships
 Help develop policies/actions at
community level
 Water fluoridation
 School based programs
 Problem solving with local dental societies
 Link families to needed care

Caring for our poorest and most
vulnerable
Children seen early are less costly to care for
over time
 With 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

Summary

Dental decay is a
◦ significant health
◦ problem for children





Anticipatory
guidance
Oral exam by age 1
Primary care providers have key role
Fluoride varnish – safe and effective
Collaborate with other health care
providers to improve oral health and access
to care