CHS 483 Lecture 3

By Dr. Ebtisam Fetohy

Objectives of the lectureObjectives of the lecture• At the of lecture the students will be able to:At the of lecture the students will be able to:1. Identify Early Signs of Decay: White Spots and

Brown Spots2. Identify Advanced/Severe Decay3. List the methods to minimize Risk for oral Infection4. Identify Dietary and Feeding Habits that lead to dental

caries5. Demonstrate how to educate mothers for Tooth brushing

and Flossing

6. List American Academy of Pediatric Dentistry (AAPD) Caries Risk Assessment Tool (CAT)

7. List Recommended Fluoride Supplement Schedule

8. Identify signs of Fluorosis

Physical: Oral Health AssessmentPhysical: Oral Health Assessment

This section addresses the following topics:This section addresses the following topics:• Maternal Primary Caregiver Screening

• Child Oral Health Assessment

• Positioning Child for Oral Examination

• Primary Teeth Eruption

• What to Look ForWhat to Look For

1. Check for Normal Healthy Teeth

2. Check for Early Signs of Decay: White Spots

3. Check for Early Signs of Decay: Brown Spots

4. Check for Advanced/Severe Decay

5. AAPD Caries Risk Assessment Tool (CAT)

Fluoride Exposure• Determine fluoride exposure: systemic versus topicalsystemic versus topical

• Fluoridated water– 58% of total population

– Optimal level is 0.7 to1.2 ppm

– Significant state variability

– CDC fluoridation map

Maternal/Primary Caregiver ScreeningMaternal/Primary Caregiver Screening

• Assess mother’s/caregiver’s oral history.

• Document involved quadrants.

• Refer to dental home if untreated oral health disease.

Maternal/Primary Caregiver Screening/2Maternal/Primary Caregiver Screening/2

• Although child health professionals may not be used to assessing maternal health issues, they routinely take a health history when assessing medical conditions that are heritable or transmissible.

• Because cariogenic bacteria can be Because cariogenic bacteria can be transmitted from primary caregiver to child, transmitted from primary caregiver to child, an oral health history provides an opportunityan oral health history provides an opportunity for:

A. The child health professional to better understand a child’s risk for early colonization and also provides

B. Educating the caregiver about caries prevention.

Maternal/Primary Caregiver Screening/3Maternal/Primary Caregiver Screening/3A mother’s/caregiver’s oral assessment does not mother’s/caregiver’s oral assessment does not

need to involve a physical examination, but can be need to involve a physical examination, but can be donedone by asking key questions such as: by asking key questions such as:

• How are your teeth? • Have you had a lot of cavities? • Do you have a regular dentist? • When was your last visit to the

dentist? • Have you ever had a tooth filled? • Have you had a lot of dental work

done?

Primary Teeth Eruption

What to Look ForWhat to Look For• Lift the lip to inspect soft tissue and

teeth

• Assess forAssess for

- Presence of plaqueplaque or debrisdebris on teeth (oral hygieneoral hygiene)- Presence of white spotswhite spots or dental dental decaydecay- Presence of tooth defectstooth defects (enamel)

- Presence of dentaldental crowdingcrowding

• Provide education on brushingbrushing using the appropriate-sized toothbrush and diet during diet during examination.examination.

Check for Normal Healthy Teeth

Check for Early Signs of Decay: White Spots

Check for Later Signs of Decay: Brown Spots

Check for Advanced/Severe Decay

AAPDAAPD Caries Risk AssessmentAssessment Tool (CAT)C

aries Risk In

dicato

rs

Low RiskLow RiskModerate Moderate RiskRisk

High RiskHigh Risk

Clinical Clinical ConditionsConditions

- NoNo carious teeth in past 24 months

-NoNo enamel demineralization (enamel caries “white- spot lesions”)-NoNo visible plaque; -NoNo gingivitis

- CariousCarious teeth in the past 24 24 months

- 11 areaarea of enamel demineralization (enamel caries “white-spot lesions”)

- GingivitisGingivitis

- CariousCarious teeth in the past 1212 months

- More than 1 areaMore than 1 area of enamel demineralization (enamel caries “white- spot lesions”)

- Visible plaque on anterior (front) teeth

- Radiographic enamel cariesRadiographic enamel caries

-High titers of mutans streptococci

-Wearing dental or orthodontic Wearing dental or orthodontic appliancesappliances

- Enamel hypoplasia

AAPD Caries Risk Assessment Tool (CAT)AAPD Caries Risk Assessment Tool (CAT)C

aries Risk In

dicato

rs

Low RiskLow RiskModerate RiskModerate RiskHigh RiskHigh RiskEnvironmentalEnvironmental

CharacteristicsCharacteristicstopical fluoride topical fluoride exposureexposure

- Consumption of simple sugar or simple sugar or foods strongly foods strongly associated with associated with caries initiation caries initiation primarily at primarily at mealtimesmealtimes

- Regular use of dental care in the established dental home

Suboptimal systemic Suboptimal systemic fluoride exposure with fluoride exposure with optimal topical optimal topical exposureexposure

- Occasional between Occasional between meal exposures to meal exposures to simple sugar or foods simple sugar or foods strongly associated strongly associated with carieswith caries

- Mid-level caregiver socioeconomic status (i.e., eligibleمؤهل for school lunch program)

- Irregular Irregular use of dental services

- Suboptimal topicalSuboptimal topical fluoride exposure

- Frequent (i.e., 3 or Frequent (i.e., 3 or more) between-meal more) between-meal exposuresexposures to simple sugars or foods associated strongly with caries

- Low-level caregiver Low-level caregiver socioeconomic statussocioeconomic status (i.e, eligible for Medicaidمساعدة طبية - No usual sourceNo usual source of dental care

- Active caries present Active caries present in the motherin the mother

AAPD Caries Risk Assessment Tool (CAT)AAPD Caries Risk Assessment Tool (CAT)

Caries

Caries

risk indicatorsrisk indicators

Low Low RiskRisk

Moderate Moderate RiskRisk

High RiskHigh Risk

General Health General Health ConditionsConditions

- Children with special health care needs

- Conditions impairing saliva composition/flow

Anticipatory GuidanceAnticipatory GuidanceThis section addresses the following This section addresses the following

topicstopics:

•Anticipatoryتوقعي Guidance•Minimize Risk for Infection•Xylitol for Mothers•SubstrateSubstrate: Contributing Dietary and Feeding Habits•Tooth brushing Recommendations•Toothpaste and Children•Toothpaste•Optimizing Oral Hygiene: Flossing

Minimize Risk for InfectionMinimize Risk for Infection• Address active oral health

disease in mother/caregiver.

• Educate mother/caregiver about the mechanism of cariogenic

bacteria transmission.

• Mother/caregiver should model positive oral hygiene behaviors for their children.

• Recommend xylitol chewing gum to mothers/caregiver.

Anticipatory GuidanceAnticipatory Guidance

• Minimize risk of infection.

• Optimize oral hygiene.

• Reduce dietary sugars.

• Remove existing dental decay.

• Administer fluorides

judiciouslyبتعقل .

Xylitol for MothersXylitol for MothersXylitol gum or mints used 4 times a

day may prevent transmission of cariogenic bacteria to infants.

• Helps reduce the development of dental caries

• A “sugar” that bacteria can’t use easily

• Resists fermentation by mouth bacteria

• Reduces plaque formation

• Increases salivary flow to aid in the repair of damaged tooth enamel

Substrate: Contributing Dietary and Feeding HabitsSubstrate: Contributing Dietary and Feeding Habits• Frequent consumption of

carbohydrates, especially sippy cups/bottles with fruit juice, soft drinks, powdered sweetened drinks, formula, or milk

• Sticky foods like raisinsزبيب/fruit leather (roll-ups لفة مثل قمر الدين), hard candies , and chewy vitamins

• Bottles at bedtime or nap time not containing water

• Dipping pacifier in sugary substances

Substrate: Contributing Dietary and Feeding Substrate: Contributing Dietary and Feeding Habits/2Habits/2

• If a bottle is given at nap time or bedtime, parents should use a cloth to wipe the baby’s mouth prior to lying the infant down.

• Due to the decreased salivary flow, any food or drink that is in the baby’s mouth during sleeping periods stays there for many hours and promotes the caries process.

Substrate: Contributing Dietary and Feeding Substrate: Contributing Dietary and Feeding Habits/3Habits/3

• Because there is an increased risk for the development of caries for children who sleep with bottles containing liquid with natural or added sugars, and

• Because children who drink bottles while lying down may be more prone to getting ear infections, the AAP suggests that children not be put to bed with bottles.

Substrate: Contributing Dietary and Feeding Substrate: Contributing Dietary and Feeding Habits/4Habits/4

• Parents should also be reminded that pacifiers should not be dipped in sweet liquids.

• In addition, because bacteria are transmitted through the saliva,

A. pre-tasting, B. pre-chewing, and C. sharing of utensils should be avoided.

Tooth brushing Recommendations

Tooth brushing Recommendations (CDC, 2001)

< 1 year~ Clean teeth with soft toothbrush

1–2 years~ Parent performs brushing

2–6 years~ Pea-sized amount of fluoride- containing toothpaste or gel 2x/day

~ Parent performs or supervises

> 6 years ~ Brush with fluoridated toothpaste 2x/day

Toothpaste and Children• Children ingest substantial amounts

of toothpaste because of immature swallowing reflex.

• Early use of fluoride toothpaste may be associated with increased risk of fluorosis.

• Once permanent teeth have mineralized (around 6-8 years of age), dental fluorosis is no longer a concern.

ToothpasteToothpaste

A small pea-sized amount of toothpaste weighs 0.4 mg to 0.6 mg fluoride, which is equal to the daily recommended intake for children younger than 2 years.

Optimizing Oral Hygiene: FlossingOptimizing Oral Hygiene: Flossing

When to Use Floss

• Once a day (preferably at night)

• Whenever any 2 teeth touch commonly around 2 to 2 ½ years of age.

• Some children may only need a few back teeth flossed and

• Others may need flossing between all their tight teeth, depending on the child’s dental spacing.

Treatment and ReferralTreatment and ReferralThis section addresses the following This section addresses the following

topics:topics:• Recommended Fluoride

Supplement Schedule• Example of Fluorosis• Fluoride Varnish• Applying Fluoride Varnish• Remove Existing Dental Decay:

Treating an Infection• Referral: Establishmentمؤسسة of

Dental Home• Community Systems of Care

Recommended Fluoride Supplement ScheduleRecommended Fluoride Supplement Schedule

Fluoride Concentration in Community Drinking Fluoride Concentration in Community Drinking WaterWater

Age<0.3 ppm0.3–0.6 ppm<0.6 ppm

0–6 monthsNoneNoneNone

6 mo–3 yrs0.25 mg/dayNoneNone

3 yrs–6 yrs0.50 mg/day0.25 mg/dayNone

6 yrs–16 yrs1.0 mg/day0.50 mg/dayNone

Example of FluorosisExample of Fluorosis

Mild Fluorosis Severe Fluorosis

Fluoride VarnishFluoride Varnish• 5% sodium fluoride or 2.26% fluoride in a viscous

base in an alcoholic suspension راتنجيةresinous لزجwith flavoring agent (e.g., bubble gum)

• Has not been associated with fluorosis

• Application does not replace the dental home nor is it equivalent to comprehensive dental care

How to apply fluoride varnishHow to apply fluoride varnish

1. Dry all the teeth with a 2 x 2 gauze.

2. Paint fluoride varnish on all tooth surfaces.

3. Instructions to Parents

Applying Fluoride VarnishApplying Fluoride Varnish

Remove Existing Dental Decay: Remove Existing Dental Decay: Treating an InfectionTreating an Infection

• One of the things that child health professionals do best is treat infections!

• However, it is important to remember this is an active dental infection that must be treated.

• The child should be referred to a pediatric dentist or general dentist for appropriate treatment.

Remove Existing Dental Decay: Remove Existing Dental Decay: Treating an Infection/2Treating an Infection/2

• The child in this photo has 4 severely decayed upper incisors. Both central incisors are abscessed. Note the parulus above each incisor. The abscessed central incisors need to be extracted as soon as possible to avoid development of facial cellulitis with potential orbital involvement. The lateral incisors may be salvageable with dental restorations or crowns depending on radiographic evaluation.

Referral: Establishment of Dental HomeReferral: Establishment of Dental Home

What is a dental home?What is a dental home?

When to refer?When to refer?

• Refer high-risk children by 6 months.

• Refer all children within 6 months after the first tooth erupts or by 1 year of age, whichever is earlier.

Community Systems of CareCommunity Systems of Care

• Identify dental care professionals in your community.

• Develop partnerships.

This section addresses the This section addresses the following topics:following topics:

• You Can Make a Difference!

• Continuing Medical Education (CME) Credit

ConclusionConclusion

You Can Make a DifferenceYou Can Make a Difference!!• Institute oral health risk

assessments into well-child visits.

• Provide patient education regarding oral health.

• Provide appropriate prevention interventions (e.g., feeding practices, hygiene).

• Document findings and follow-up.

• Train office staff in oral health assessment.

You Can Make a Difference!/2You Can Make a Difference!/2

• Identify dentists (pediatric/general) in your area who accept new patients/Medicaid patients.

• Take a dentist to lunch to establish a referral relationship.

• Investigate fluoride content in area water supply.