PedsCases- Oral Health for Total Health Script

Developed by Sara Markovic and Dr. Anne Rowan-Legg for PedsCases.com. January 28, 2021.

Oral Health for Total Health – CPS Podcast Developed by Sara Markovic and Dr. Anne Rowan-Legg for PedsCases.com. January 28, 2021. Introduction Hi, my name is Sara Markovic, and I am a final year medical student at McMaster University. This PedsCases podcast aims to provide an introduction to pediatric oral care, while reviewing components of the Canadian Pediatric Society Position Statement on “Oral health care – a call to action”. This podcast was created under the supervision of the CPS statement lead author, Dr. Anne Rowan-Legg, a Pediatrician at CHEO and Associate Professor with the Department of Pediatric Medicine at the University of Ottawa. Oral health is an integral part of overall health in children. It can affect the functional, psychological and social dimensions of a child’s well-being.1,2 Tooth decay was identified by the CDC as the most common disease of childhood in children aged 5-17 years old, five times more common than asthma.3 Despite the importance of oral health and its impact on children, almost 80% and 90% of pediatricians and family doctors, respectively, said they received <3 hours of oral health care training in medical school or residency!4,5 As such, the learning objectives for today are as follows: Learning Objectives

1. Review the basics of the oral health assessment by pediatricians 2. Discuss Early Childhood Caries, or ECCs: the pathophysiology, presentation,

complications and importance of preventative care 3. Identify the existing disparities in access to oral health care 4. Recognize areas where advocacy for children’s oral health is most needed

Canada’s Dental Delivery System Canada has always curiously considered dental health separate from other health, so it is not covered under the basic principles of the Canada Health Act: public

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administration, universality, accessibility, portability, and comprehensiveness. Canadians are largely responsible for financing their own dental care, which they pay for in four different ways: through third-party insurance; private dental insurance; directly out-of-pocket; or through government-subsidized programs (eg, First Nations Non-insured Health Benefits [NIHB] or Veterans’ Affairs). Currently, most publicly delivered paediatric dental programs in Canada include only emergency or basic treatment, and cover only limited care for recipients of financial assistance or for children in low-income families. The comprehensiveness of these programs differs significantly among provinces and territories.6

Case Jay, a four year old boy, presents with his mother to your Emergency Department with a 1 week history of worsening, throbbing jaw pain that occasionally wakes him from sleep, and difficulty chewing. His mom also notes that he has felt warm to touch for the last 24 hours.

Dental Health Assessment Primary dentition is composed of 20 teeth, while permanent dentition involves 32 teeth. An infant should have their first primary tooth at approximately 7 months of age, but a large range of timing exists..7 If a child has had no tooth eruption by 1 year, it is worth noting and considering. There should be a symmetrical eruption pattern, starting with the central incisors, lateral incisors, first molars, canine, then secondary molars.8 Remember, the sequence is more important than the timing! When taking a dental history, the following questions may be of importance:

- Timing of eruption of primary and permanent teeth - Brushing & flossing frequency - Dietary habits

o Frequency of bottle-feeding and breast-feeding in infancy o Being put to bed with a bottle o Frequency of carb intake

- Current source of dental care & frequency of visits - Current Symptoms: oral pain, redness, swelling, drainage, headaches and

abdominal pain - Problems with bite: over/underbite, occlusion - History of dental problems and/or orofacial trauma - Family history of dental issues or disorders


Let’s go back to our case! You ask Jay and his Mom these questions. Some pertinent points include that he drinks 2-3 cups of apple juice a day, was given a bedtime bottle until 3 years of age, and has never been to a dentist. He has full primary dentition. You note some swelling around his left jaw, and Jay says he has had a bad headache that has kept him from preschool the last week. Many of the questions asked in a pediatric dental health assessment are designed to assess the risk factors for the development of early childhood caries, or ECCs.9

Early Childhood Caries Definition ECCs are defined as the presence of one or more decayed, missing (due to caries) or filled tooth surfaces in any primary tooth in a preschool-aged child.10 It is a multifactorial, chronic disease influenced by biomedical factors (diet, bacteria, host) and by the social determinants of health.11 Etiology/Pathophysiology ECCs are caused by the interaction of acid-producing pathogens, mainly S. mutans and Streptococcus sobrinus, with sugary foods on tooth enamel. The main way that S. mutans is acquired is through vertical transmission, or spread from caregiver to baby during infancy.12,13 These bacteria break down fermentable carbohydrates like sucrose, fructose and glucose, creating an acidic environment in the mouth that results in demineralization of tooth enamel.14,15 Caries initially start as reversible white spot lesions around the gingiva, but as subsurface demineralization occurs beneath the dental plaque, decay and cavitation develop.16,17 Increasing the time per day that teeth are exposed to sugar is the most significant risk factor in shifting the equilibrium towards demineralization. Prolonged and nocturnal breastfeeding, as well as use of a baby bottle at night when there is reduced salivary flow, is associated with an increased risk of occurrence and severity of ECC.18,19 Epidemiology Caries rates are increasing among children 2-4 years of age. ECCs are the leading cause of day surgery for Canadian children, according to a study by the Canadian Institute for Health Information.20 In urban areas of Canada, the prevalence of ECC in


preschool children is 6-8%, but in some Indigenous communities, the prevalence of decay exceeds 90%.21 Much of the burden of dental disease is greatest in marginalized populations including low-income families, Indigenous children, new immigrants, and children with special health care needs.22-23 Like general health, oral health is strongly influenced by socioeconomic status.24 One study showed children from the lowest income families had decay rates four times that of children from higher income families. The ‘working poor’ are especially vulnerable because their employment status often renders them ineligible for dental care under publicly funded programs, while the jobs they hold seldom offer employment-related health insurance. Working people with constrained incomes have competing needs, such as food, clothing and housing, and may regard dental visits as a luxury.25-27 However, access to oral care is only a component. The oral health of Canadian Indigenous children is a public health crisis.28 Indigenous populations in Canada face financial, geographical, and sociocultural barriers to obtaining care. Prevalence and rates of caries are substantially higher than the general pediatric population, with ECC rates in the 50-97% range.29 First Nations children in northern communities have inordinately high rates of surgical restoration therapy, and annual dental visits are often difficult to obtain due to lack of dental specialists in many communities.30 Several studies have confirmed the disparities between immigrant children and their Canadian-born peers with regards to dental care. On arrival to Canada, immigrants encounter language and cultural barriers, an unfamiliar health care system, and lack of financial resources can further impede access to appropriate dental care.31,32 Finally, poor oral health is common among children with special health care needs, due to the dependency for oral care, increased prevalence of acid reflux, and risk of aspiration pneumonia in tube-fed children.33 Access for this population may be precluded by cost, distance from tertiary pediatric centres, and shortage of pediatric dentists trained in the care of medically complex children.23,34 Diagnosis ECCs are initially recognized as dull, white de-mineralized enamel along gingival margin, with decay generally first seen on primary maxillary incisors and four maxillary anterior teeth often involved concurrently.35,36 The caries may be located on labial or lingual surface of teeth.37 Consequences Poor dental health can impair language development, socialization and self-esteem.1 ECCs are also associated with reduced weight gain and poor nutrition due to insufficient food consumption from difficulty chewing. The burden of disease is very high - ECCs leading to dental restoration surgery (ie. extraction) is the most common


procedure performed at Canadian pediatric hospitals. Spread of infection and abscesses are other complications of untreated ECCs.38-41

Meanwhile… You examine Jay and note he has swelling around his left primary molar, which is erythematous with a fluctuant mass just adjacent to it. When you palpate it, you note blood seeping. There is no regional lymphadenopathy. You note two other chalky white and yellow spots on his anterior maxillary incisors. You discuss with Mom the clinical impression of a dental abscess secondary to untreated dental caries. You suggest that, while he will be started on antibiotics in the ED, he should be urgently seen by a dentist. The Mom shares that they are financially quite constrained, and doesn’t know how she will afford a dentist visit. After some discussion, you recognize that she is supported by the Ontario Disability Support Program (ODSP), and Jay, as a dependent child, is covered under the Dental Special Care Plan. How can we prevent situations like Jay’s?

Prevention Prevention is best accomplished by the timely identification of risk factors and appropriate intervention. Screening The Canadian Dentistry Association encourages dental assessments of infants within 6 months of eruption of the first tooth, and no later than 12 months of age.There is evidence supporting the establishment of the “dental home” by one year of age.11 The rationale focuses on early professional intervention to provide examination, risk assessment and anticipatory guidance for parents, so that disease can be prevented. Professional intervention beginning later has not been successful in preventing early oral bacterial colonization or its cariogenic effects.42 Since contact with a family physician or paediatrician typically occurs earlier than a child’s first visit to a dentist, primary care providers play a critical role in promoting oral health in children. A Canadian caries risk assessment tool has been developed by Dr. Robert Schroth’s team at the University of Manitoba, and allows non-dental primary health care providers to assess the risk of tooth decay for children under 6 years old by asking about feeding practices, fluoride exposure, and oral hygiene practices. The tool provides concrete action items depending on the risk score, and has been endorsed by the Canadian Pediatric Society, Canadian Academy of Pediatric Dentistry, and Public


Health Agency of Canada, and is being considered for inclusion in the Rourke baby record.43 The healthcare professional should also provide guidance to the parents regarding modification of infant diet and feeding habits. Feeding Behaviours Caries-promoting feeding behaviours should be avoided, such as the following:

- Infants should not be put to sleep with a bottle containing fermentable carbohydrates

- Parents should be encouraged to have infants drink from a cup as they approach their first birthday.

- Prolonged exposures to sweetened juices should be avoided.44,45,46 Fluoride The single most cost-effective measure for reducing dental caries is fluoridation of public water supplies.47 Fluoride strengthens enamel, prevents remineralization of carious lesions and exerts a bacteriostatic effect. While water fluoridation is a major, cost-effective public health achievement, only 45.1% of community water supplies in Canada are fluoridated.48,49 Evidence based guidelines recommend a biannual fluoride varnish application regimen for high risk populations, including Indigenous children, as well as brushing twice daily with a fluoridated toothpaste.50-52 Suppression of Oral Bacteria Minimizing saliva-sharing activities between children and parents/caregivers avoids inoculation of oral flora.13 Examples include avoiding the sharing of utensils, food, and drinks, and avoiding orally cleaning pacifiers.53,54 Treatment Caries management with restorative therapy (eg, fillings) is the preferred therapeutic approach in many countries. However, tooth extraction is a common and necessary treatment for advanced caries. Premature loss of molars is likely to result in future orthodontic problems.55 Areas for Advocacy Dental care, like health care, is an essential service, and all levels of government must commit to providing quality dental care for every young Canadian. The group most


marginalized by the current dental care system are the lowest income families. This population has the least access to dental care and bears the greatest burden of untreated disease.56 Paediatricians are ideally positioned to advocate for programs and services to reduce disparities and promote better oral health. While dental health is one of the most costly diseases in Canada, public financing is disproportionately low.1As per the CPS statement on enhancing access to oral care, the five most pressing targets for policy development are to:

1. Ensure leadership in paediatric oral health policy development at provincial/territorial and federal levels.

2. Assure provision of dental services under the Canada Health Act tenets, with special attention on marginalized populations.

3. Compile (and maintain) current data on the dental health status of children and youth.

4. Extend dental policy and programs based on evidence-based practices. 5. Ensure proper evaluation of existing programs.2

In summary, let’s review our key learning points: • ECCs are a common, infectious, transmissible, diet-dependent and chronic

disease heavily influenced by biomedical factors (diet, bacteria, and host) and by social determinants of health, with many long term health and developmental consequences if left untreated

• It is crucial for primary care health providers to recognize risk factors, provide oral health education as preventative guidance, and encourage the early establishment of a dental home

• Due to the disparities in oral health and access to dental care, the burden of disease is greatest in marginalized populations including Indigenous peoples, new immigrants, children with special health care needs, and low income families.

• Evidence-based prevention strategies involve suppressing oral bacteria through reduction of saliva-sharing activities with caregivers, modifying feeding behaviours, and optimizing fluoride exposure

• Future oral health policy development should focus on ensuring equitable access to dental care with focus on marginalized populations, expansion and evaluation of evidence-based surveillance programs, and maintaining current data on dental health status of children & youth.


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PedsCases- Oral Health for Total Health Script

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