Oral Health and Primary Care

Lessons from the Tooth Fairy

Suzanne Boulter, MD

South Carolina Chapter Meeting

July 23, 2011

Disclosures

• No disclosures of financial nature

• Will mention off label use

of product (fluoride varnish)

Goals for Today

• Review the importance of caries

• Discuss etiology of early childhood caries

• Learn about Bright Futures and AAP recommendations for oral health screening in your office

Tooth Fairy Consultation

• Four questions

• Six lessons

Question 1

• Most children can start brushing their own teeth without supervision at what age:– 2 years– 4 years– 6 years– 8 years

Question 2

• Both the AAP and AAPD policy statements recommend that all children have their first dental visit by the following age:– 6 months– 1 year– 2 years– 3 years

Question 3

• Early childhood caries requires which bacteria to develop:– Staph aureus– Strep mutans– Hemophilus influenzae– Lactobacillus species

Question 4

• CDC recently updated its recommendation for public drinking water fluoridation to which of the following– 0.3 ppm– 0.7 ppm– 1.2 ppm

Tooth Fairy Lesson 1

Overview of Early Childhood Caries – Prevalence and Significance

Early Childhood Caries – What Is It?

• A severe, rapidly progressing form of tooth decay in infants and young children

• Affects teeth that erupt first, and are least protected by saliva

Prevalence

Dental caries is:

• 5 times more common than asthma

• 7 times more common than hay fever

Children and Tooth Decay

• 28% of US children age 2-5 have dental caries, increased from 24% in prior survey*

• Possible factors– Parents too busy to supervise brushing– Changes in diet (more sugar)– Use of bottled water without added fluoride

*“Trends in Oral Health Status: United States, 1994-1998 and 1999-2004”

Significance of Caries

• What is the importance of oral disease in the population?

Oral Disease is Consequential

• Missed work/school – 51 million school hours lost per year

• Low income children missed 12 times more days than children from more affluent families

• Distraction from normal activities including learning

• Speech and eating dysfunction

• Growth delay

• Loss of wages and potential loss of job

Oral Disease is Consequential

•Pain & infection – cellulitis, abscess

•High cost of surgery for severe ECC ($12,000/case)

•Hospitalization, surgical intervention, death(Deamonte Driver)

•Emergency room visits; antibiotics; pain medications; “See your dentist in the morning” ($400-$500/visit)

Tooth Fairy Lesson 2

Pathophysiology of Caries

Three Factors Needed for Caries

• Bacteria

• Teeth

• Carbohydrates

Factors Necessary for Caries

Bacterial Biofilm (plaque)

• Dental plaque, loaded with bacteria, covers tooth surfaces

• Most mouth flora are benign; about 500 types of bacteria are present with about 25 potential pathogens

• Microbiological shifts in the biofilm (plaque) can inhibit or promote caries

• Caries is an infection initiated by the pathogenic bacteria – mainly Streptococcus mutans

•Selwitz.R ,Ismail. N, Pitts.B: Dental Caries.Lancet Vol. 369 Jan 6, 2007

Oral Flora: How Does Infection Occur?

• Bacteria are transmitted mainly from mother or primary caregiver to infant

• Window of infectivity is first 2 years of life

• The earlier a child is colonized, the higher the risk of caries

Factors Necessary for Caries

Tooth

• Pathogenic bacterial colonization does not start until the eruption of teeth

Primary Teeth Eruption

Factors Necessary for Caries

Substrate: You Are What You Eat

• Caries development is promoted by carbohydrates which break down to acid

• Acid causes demineralization of enamel

You Are What You Drink - Sugar in 12 Ounce Can of Soda Pop

Soda Pop: Sugar: (in teaspoons)

• Orange Slice 11.9• Minute Maid Orange 11.2• Mountain Dew 11.0• Barq’s Root Beer 10.7• Pepsi 9.8• Dr. Pepper 9.5• Coca-Cola 9.3• Sprite 9.0

Not Just What You Eat,But How Often

• Acids produced by bacteria after sugar intake persist for 20-40 minutes

• Frequency of sugar ingestion is more important than quantity

Safe zone

Dangerzone

pH

6 7 8 9 10 11 12 1Bottle Breakfast Snack Sippy-cup Sippy-cup Lunch

Breastmilk as a Substrate

• Unclear evidence whether breastmilk is cariogenic• Cautions on frequent night-time and on-demand

breastfeeding after tooth eruption

• Potential for early childhood caries (ECC)

• exists with extended and repetitive feeding times without appropriate oral hygiene

The Dynamic Balance

Saliva + Fl, Ca,

Antibacterials

Bacteria + Sugar+ Reduced Saliva Flow

GOAL = Balance between remineralizingand demineralizing factors

Tooth Fairy Lesson 3

Demographics of Caries Risk

High-Risk Groups for Dental Caries

• Children with special health care needs

• Children whose caregivers and/or siblings have caries

• Children with poor dietary and feeding habits

High Risk for Dental Caries

• Children with sub optimal exposure to topical or systemic fluoride

• Children who are exposed to cigarette smoke at home (JAMA.2003;289:1258-1264)

• Children eligible for Medicaid

Common Issues Among CSHCN

• Children with asthma and allergies are often on medications that dry salivary secretion increasing risk of caries

• Children who are pre-term or Low Birth Weight (LBW) have a much higher rate of enamel defects and are at increased risk of caries

• Children with congenital heart disease are at risk for systemic infection from untreated oral disease

0

10

20

30

40

50

Obj. 21-1a

Children 2-4 Years Who Have Ever Had Caries in Primary Teeth, 1988-94 and 1999-2000

Source: National Health and Nutrition Examination Survey, NCHS, CDC.

Total Black MexicanAmerican

White MaleFemale

2010 Target

1988-94 1999-2000Percent

Tooth Fairy Lesson 4

Oral Health Risk Assessment

AAP Recommendations for an Oral Health Risk Assessment

• Assess mother/caregivers oral health

• Assess oral health risk of infants and children

• Recognize signs and symptoms of caries

• Assess child’s exposure to fluoride

• Provide anticipatory guidance and oral hygiene instructions (brush/ floss)

• Make timely referral to a dental home

Bright Futures 3rd Edition Themes

Child Development Family Support Mental Health and

Emotional Well-Being Nutritional Health Physical Activity Healthy Weight

Oral Health Healthy Sexuality Safety and Injury

Prevention Community

Relationships and Resources

Bright Futures Recommendations

• Oral health risk assessment performed

• Anticipatory guidance given

• Fluoride modalities addressed

• Referral to dental home

RISK FACTORSPROTECTIVE

FACTORSCLINICAL FACTORS

Has mother or primary caregiver had active decay in the past 12 months? Yes □ No □ Does mother have a dentist? Yes □ No □ Other Risk Factors: Yes No□ □ Continual bottle/sippy cup use with fluid other than water□ □ Frequent snacking □ □ Special health care needs□ □ Low SES or health literacy/Medicaideligible

Yes No□ □ Existing dental home□ □ Drinks fluoridated water or takes F supplements□ □ F varnish in the last 6 months□ □ Child has teeth brushed daily   

□ White spots or visible decalcifications

□ Obvious decay□ Restorations present□ Visible plaque

accumulation□ Gingivitis

(swollen/bleeding gums)

□ None □ No Teeth Present 

Caries Risk: Low High

Completed: Anticipatory Guidance Fluoride Varnish Referral to_________________

Goals: 

Assess Caretakers Risk Factors

• Screen for dental home of parent/caretaker

• History of parental decay in prior year

• Refer caregiver to dental home

Assess Child’s Risk Factors

• Continual bottle/sippy cup use with any liquid other than water

• Frequent snacking

• Special health care needs

• Medicaid eligible/low health literacy level

Assess Clinical Factors

• Lift the lip to inspect soft tissue and teeth

• Assess for:

– Presence of plaque

– Presence of white spots or dental decay– Presence of enamel

defects

– Presence of dental crowding

Child Assessment Position

• Position child in caregiver’s lap facing caregiver

• Sit with knees touching knees of caregiver

• Lower the child’s head onto your lap

Use gentle downward finger pressure behind lower lip on lower incisors to open the child’s mouthIf child has a lot of plaque present, brush or wipe with gauze

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

Assess for Fluoride

• Systemic – Water fluoridation– Prescription supplements

• Topical – Toothpaste– Varnish– Mouth rinse

Systemic Fluoride

Supplements and Tap water

Public Water Fluoridation Stats

• United States as a whole– 72.4%

• South Carolina– 94.4%

• Rank – 9th best!!!

• www.cdc.gov/fluoridation/statistics/2008stats

Community Water Fluoridation

• Provides both topical and systemic benefits• Universal access – income level no barrier!• No need for individual behavior change• Frequent exposure to small amounts over lifespan

gives ongoing protection• Cost effective – every $1 invested in water

fluoridation saves $38 in dental costs• Cost of fluoridation ranges from 0.50 to $3.00 per

person in community

Facts on Fluoridated Tap Water• HHS recommends 0.7 ppm fluoridation

– HHS and EPA recommendation; Federal Register/Vol.76, No.9, January 13, 2011

• 8 ounces of fluoridated tap water provides 0.25 mg F

• 4 glasses water per day sufficient to supply daily needs (over age 6)

• Use of bottled water and some home filter systems negate effectiveness

• Halo effect of F incorporated in foods

Formula and Fluoride

• ADA published interim study October 2009 suggesting mixing powdered formula with fluoridated water might be risk factor for fluorosis

– JADA 2009;140(10):1228-1236

• October 2010 study concluded that although mild fluorosis could result from mixing with F water the caries preventive benefit of F outweighed the small risk

– JADA 2010;141(10):1190-1201

• Evidence based guideline published January 2011• JADA 2011;142;79-87

Systemic - Prescription Supplements

• Determine water fluoride level before writing prescription!

• Multiple sources of F make prescribing challenging!

• Results both topical and systemic

• Issues with compliance

• Dr Paul Hletko will discuss S.Carolina data…

CDC 2001 Recommendations

None0.50 mg/day1.0 mg/day6 yrs-16 yrs

None0.25 mg/day0.50 mg/day3 yrs-6 yrs

NoneNone0.25 mg/day6 mo-3 yrs

NoneNoneNone0-6 months

>0.6 ppm0.3-0.6 ppm<0.3 ppmAge

Fluoride Concentration in Community Drinking Water

Evidence for Supplements

• US Preventive Services Task Force gives B* level recommendation to F supplements for preschool children over age 6 months

*B level – clinicians provide the service to eligible patients. USPSTF found at least fair evidence that the service improves important health outcomes and concludes that benefits outweigh harms.

Topical Fluoride Sources

• Toothpaste

• Varnish

• Rinse

• 1,000-1500 ppm– Pea sized dose = 0.25

mg

• 22,600 ppm (NaF)– 0.2 ml = 4.4 mg

• 230 ppm (0.05%NaF)– 5 ml = 2.5 mg

Topical F - Toothpaste

• Available OTC

• Children under age 2 at high risk for caries should use a smear bid

• Children over age 2 should use pea sized amount bid

• Lower F content toothpaste available in Europe for children but none being developed in US

Toothpaste Evidence

Cochrane Reviews – 2003• “Children aged 5-16 who used F toothpaste had

fewer decayed, missing and filed permanent teeth after three years regardless of whether their drinking water was fluoridated.”

• Studies showed average of 24% caries reduction

Toothpaste

• Brushing increases the level of F in saliva then low concentrations remain for 2 to 6 hours

• Excess fluoride ingestion from swallowing is risk factor for fluorosis!

• Amounts of toothpaste used and ability to spit out determine risk

When Should Toothbrushing Begin?

• As soon as first tooth erupts

• Under direct supervision of caregiver until age 6

What Should be on Toothbrush?New recommendation from AAPD:

– Grain of rice amount of paste from 0-2!

– Pea sized amount over age 2pea size amount of toothpaste weighs 0.4 gms and contains 0.6 mg fluoride - equal to the daily recommended intake for a child less than age 2.

Lewis C, Milgrom,P. Fluoride. Pediatrics in Review 2003;24(10)

Topical Fluoride -Varnish

Fluoride Varnish What Is the Evidence?

• USPSTF 2009 recommends varnish as effective vehicle for caries reduction

• Cochrane Review 2005 recommends varnish 2-4 times per year

• Canadian Dental Association recommends varnish application 2 times a year

Azarpazhooh A, Main P.Fluoride varnish in the prevention of dental caries in children and adolescents: a systematic review. JCDA 2008 74 (1) 73-79

American Dental Association Recommendations –

Under Age 6 Low risk patients may not benefit from varnish

applications, especially if they have adequate fluoridated water and toothpaste

Moderate risk patients should receive varnish applications every 6 months (1a)

High risk patients should receive fluoride varnish applications every 3-6 months (1a)

JADA, Vol. 137, August 2006

Evidence-based Recommendation for Professionally Applied Topical Fluoride

ADA, 2006

Risk Category <6 6-18 18+

Low None None None

Moderate Varnish or Foam at 6 month intervals

Varnish or Gel at 6 month intervals

Varnish or Gel at 6 month intervals

High Varnish or Foam at 3 or 6 month

intervals

Varnish or Gel at 3 or 6 month

intervals

Varnish or Gel at 3 or 6 month

intervals

Age Age

Supplies

• Microbrush applicators

• 2 x 2 gauze squares

• Gloves

• Disposable mirror

• Direct light source

• Toothbrush (optional)

Applying Fluoride Varnish

•Step One: Drop of varnish in small dish or on gloved hand (multidose tube) or from unit dose container

Applying Fluoride VarnishStep Two: Dry quadrant of teeth with gauze square

Step Three: Apply a thin layer of varnish to all tooth surfaces in dried quadrant. Do not wipe again.

Repeat procedure until all quadrants have been varnished

Applying Fluoride Varnish

Once the varnish is applied:

• It sets quickly

• You need NOT worry about moisture contamination

Topical Fluoride - Rinses

• Not recommended under age 6 – risk factor for fluorosis when swallowed

• Up to 24% caries reduction in school children*

• OTC rinses available OTC – 230 ppm F

• Dentist can rx higher concentration – 920 ppm – for supervised usage

*Cochrane Reviews 2003

Risk of Fluorosis

• Mild to moderate increase in US; cosmetic issue

• Does not affect primary dentition (baby teeth) as these teeth mineralize in utero

• Highest period of fluorosis risk for permanent dentition ages 20-30 months

• No risk of fluorosis after age 8

Tooth Fairy Lesson 5

Anticipatory Guidance

Education About Caries

• Discuss balance between diet,

oral hygiene and bacteria

• Use AAP or other handouts

Dietary Advice

• Limit foods and drinks with added sugar• Limit sippy cups, bottles with fruit juice, soft

drinks, “sports” drinks, powdered sweetened drinks• Avoid sticky foods• Discuss pre tasting of food• Recommend no bottle in bed with anything except

water• Advise stopping bottle by first birthday

Optimize Oral Hygiene: Brushing and Flossing

When to Use Floss

Once/day (preferably at night)

When 2 teeth touch

Tooth Brushing Recommendations

AgeTooth Brushing

Recommendations (MMWR/CDC.Gov, 2001 1A evidence for

caries prevention)

< 1 year

~ clean teeth with soft cloth or toothbrush

1-2 year

s

~ parent performs brushing with smear of toothpaste

2 - 6 year

s

~ pea-sized amount of fluoride- containing toothpaste 2x/day

~ parent performs or supervises

> 6 year

s

~ brush with fluoridated toothpaste 2x/day

Tooth Fairy Lesson 6

Recommendations and Referral

Referral to Dental Home

• First dental visit should take place at 1 year; earlier if patient is at high risk

• Develop list of dentists who will accept patients this age

• Include office phone numbers and addresses

• Refer Medicaid patients to state web site or phone line if no access

Dental Network Tips

• Find specialists (pediatric dentist, general dentist seeing children)

• Call yourself to schedule appointment while patient is in room (a call from an MD will be answered!)

• Gather contact information and develop list if feedback is positive

• Adapted from Dr Eve Kimball

Summary of Goals for Today

• Reviewed the importance of caries

• Discussed etiology of early childhood caries

• Learned about Bright Futures and AAP recommendations for oral health screening in your office

You Can Make a Difference!

• Institute oral health risk assessments into well-child visits

• Provide patient education regarding oral health

• Provide appropriate prevention interventions (eg, feeding practices, hygiene, fluoride)

You Can Make a Difference!

• Document findings and follow-up

• Train office staff in oral health assessment

• Investigate fluoride content in area water supply

• Develop relationships with local dentists for referral to a dental home

• Use oral health risk assessment as a QI project (more on QI in this afternoon’s session!!)

Question 1

• Most children can start brushing their own teeth without supervision at what age:– 2 years– 4 years– 6 years– 8 years

Question 2

• Both the AAP and AAPD policy statements recommend that all children have their first dental visit by the following age:– 6 months– 1 year– 2 years– 3 years

Question 3

• Early childhood caries requires which bacteria to develop:– Staph aureus– Strep mutans– Hemophilus influenzae– Lactobacillus species

Question 4

• CDC recently updated its recommendation for public drinking water fluoridation to which of the following– 0.3 ppm– 0.7 ppm– 1.2 ppm

Medicaid Codes and Reimbursement

• Fluoride varnish D 1206 $12 - $53• Oral evaluation new pt D 0145 $29 - $56• Oral evaluation est pt D 0120 $20 - $27• Age limit – varies; ages 6 months to 5 years• Number of varnish applications reimbursed annually

– 2- 4• Training required – varies; state specific• Delegation of procedure (NP, RN, LPN, CMA) about

2/3 of states allow