Integrating Preventive Oral Health Measures Into HealthCare Practice

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Integrating Preventive Oral Health Measures Into
HealthCare Practice

• A Discussion of Oral Disease
• Department of Health and
• Family Services, Division of Public Health

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• Presented by
• Wisconsin Regional Oral Health Consultants

• Funded by
• The Federal Maternal and Child Health Block Grant
• Health Resources Services Administration
• Thank you to
• Nevada State Health Division Oral Health
  Initiatives for their cooperation and many
  resources
• Nancy Rublee, RDH, CDHC CDHC
• Price County Oral Health Coordinator

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Childhood Oral Health Program

• Early Childhood Oral Health

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Healthy Smiles for Wisconsin
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Introduction to Early Childhood Caries

• Definition of Early Childhood Caries
• Risk Factors
• Identification of White Spot Lesions
• Prevention of ECC--Anticipatory Guidance
• Review Fluoride Varnish Application Protocols

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Dental Caries Process

• Host -Tooth
• Agent - Bacteria
• Environment - pH
• Time - Frequency

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Dental Caries Multifactorial

• Enamel Developmental Defects
• Lack of Fluoride

• Early Infection
• with Strep Mutans

• Harmful
• Food Behaviors

Agent (bacteria)
Time
(frequency)
Host (teeth)
Environment (diet)

• Poor Oral Hygiene
• Access to Oral Health Services

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Early Childhood Caries/ECC

• Early Childhood Caries (ECC) describes cavities
  that children acquire in primary teeth.
• Early Childhood Caries, previously called Baby
  Bottle Tooth Decay/Nursing Caries, unique
  characteristics, pattern of decay affects the
  upper primary incisors followed by the primary
  molars.
• Caused by bacteria.
• Bacteria and fermentable carbohydrates in contact
  with the
• teeth over an extended period of time cause
  acids,
• de-mineralize teeth, causing tooth decay.

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Characteristics of ECC

• Early Childhood Caries Characteristics
• ECC is an infectious disease.
• Develops rapidly (occurs in six months or less).
• Generally affects the upper front teeth first
  (these teeth erupt at about 8 months of age).
• Primary molars, which erupt at about 12 months of
  age, are next to be affected.
• Lower front teeth are affected when the disease
• is severe.

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Infant/Child Dental Caries Risk Assessment
Checklist

• See Training Manual
• Tab 6

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Contributing Risk Factors

• Transmissibility
• Poor oral hygiene
• Diet high in sugar
• Improper bottle feeding
• Breast feeding at will throughout the night
• Pacifiers dipped in sugary substances
• Medications
• Parent/caregiver situations
• Children with special health needs

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Risk Factor 1 Transmissibility

• Salivary transmission of strep mutans.
• Evidence-based studies have shown that
  mothers/primary caregivers with untreated tooth
  decay have higher levels of strep mutans.
• Transmission occurs from mother/childs primary
  caregiver when sharing eating utensils, tasting
  foods and kissing.

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Transmission

• Untreated tooth decay
• has higher level of strep
• mutans.

• Sharing food can transmit
• cavity-causing bacteria.

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Risk Factor 2 Poor Oral Hygiene Care

• Poor oral hygiene care for the child.
• As soon as the first tooth erupts there should be
  daily oral hygiene care, cleaning the teeth.
• Use a small toothbrush or wipe teeth with a wet
  cloth.
• At least once daily a childs teeth should be
  cleaned by an adult (until age 4 or 5).

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Risk Factor 3 Diet High in Sugar and
Fermentable Carbohydrates

• Repeated exposure to fermentable carbohydrates
  over time allows bacteria to metabolize sugar.
• This creates an acidic environment.

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Sugar Exposures and Acid Levels
High Acid
Low Acid
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Risk Factor 4 Improper Bottle Feeding

• Bottles are often given to modify behavior.
• Results in frequent exposure to carbohydrates.

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Putting baby to bed with a bottle may lead to
Early Childhood Caries.
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Risk Factor 5 Breast Feeding at Will Throughout
the Night

• We recommend and support breast feeding.
• Breast-fed babies have a lower risk of ECC than
  bottle-fed babies.
• Once a child is receiving nutrition from sources
  other than solely breast milk, consult health
  care provider about nursing at will throughout
  the night.
• Breast milk by itself does not promote tooth
  decay, however consuming foods or liquids in
  addition to and in combination with breast milk
  will promote tooth decay.

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Risk Factor 6 Pacifiers Dipped in Sugary
Substances
Can contribute to early childhood caries
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Risk Factor 7 Medications

• Children with chronic illnesses or special health
  care needs may also be at increased risk of ECC.
• Medications may contain sugar.
• Certain medications may cause decreased salivary
  flow (example antihistamines).
• Saliva acts as a buffer for acids produced by
  strep mutans.
• Daily oral hygiene is very important.

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These medications contain sugar.
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Risk Factor 8 Parent or Caregiver Situations

• Single parent or caregiver with an overload of
  responsibilities
• Those with limited exposure to education about
  healthier choices for their children
• Those in abusive relationships
• Families with a pattern of substance abuse
• Parents of children with special health care
  needs (added responsibilities)

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Evidence-based Caries Prevention Strategies
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Prevention Strategies

• School Fluoride Mouthrinse Programs
• Dietary Fluoride Supplements
• Community Water Fluoridation
• Fluoride Varnish Application Programs
• Dental Sealant Programs
• Early MCH Intervention

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Children with Special Health Care Needs

• Link with Regional CSHCN Centers (children with
  special health care needs)
• Northeastern Region St Vincent Hospital in
  Green Bay with Childrens Hospital of Wisconsin
• Northern Region Family Connection, Department
  of Sacred Heart / St. Marys Hospital Rhinelander
• Southeast Region Childrens Hospital of
  Wisconsin in Milwaukee
• Southern Region Board of Regents, University of
  Wisconsin System at the Waisman Center in Madison
• Western Region Chippewa County Department of
  Public Health in Chippewa Falls

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Identification of White Spot Lesions
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White Spot Lesions

• Appear as white spots on the tooth enamel
• Begin along the gumline of the upper front
  teeth
• Can encircle the affected teeth
• Undetected, can eventually affect the primary
  molars

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Development and Location

• Eruption pattern of the teeth
• Bottle and tongue position in the mouth
• Decreased saliva flow while sleeping

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Healthy Primary Teeth
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Early Tooth Decay
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Moderate Tooth Decay
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Later Tooth Decay
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Advanced Tooth Decay
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Enamel DemineralizationandEnamel
Remineralization
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Early Childhood Caries Prevention

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Early Childhood Caries Prevention

• 1. Screening / Lift the Lip
• 2. Anticipatory Guidance
• 3. Fluoride Varnish Placement
• 4. Referral

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Basic Screening Survey (BSS)

• Standardized screening
• Developed by the Association of State and
  Territorial Dental Directors
• Adults, School-Aged and Preschool Children
• Used across the country in public health for data
  collection
• Used for Wisconsins Make Your Smile Count Data
  Collection and Seal a Smile programs

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Preschool Basic Screening Form

• See Training Manual
• Tab 6

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EARLY CHILDHOOD SCREENING
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Early Childhood Oral Screening

• Untreated caries
• Caries experience
• Early childhood caries
• Treatment urgency

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1. Untreated Caries

• Code 0No untreated caries
• Code 1Untreated caries

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Code 0 De-mineralization Precavitated White
Spot Lesions
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Code 1 Untreated CariesPit and Fissure Caries
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Code 1 Untreated caries Smooth Surface Caries
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2. Caries Experience

• 0No caries experience
• 1Caries experience

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2. Code 1 Caries Experience
Composite
Amalgam
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3. Early Childhood Caries

• Also referred to as baby bottle tooth decay or
  nursing caries
• Defined in the ASTDD Basic Screening Survey as
  any child three or under found to have one of his
  or her six upper front teeth missing due to
  caries (code 1)

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Early Childhood Caries
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Early Childhood Caries
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4. Treatment Urgency

• Code 2 Urgent or emergency need for dental care
  (within 24 hours)
• Pain or infection, swelling or soft tissue
  ulceration of more that 2 weeks duration
• Overriding accompanying signs (multiple decay)
• Code 1 Early dental care is needed (within
  several weeks)
• Code 0 No obvious problems (next regular
  checkup)

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Code 2 Urgent
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Code 2 Urgent Large Untreated Caries in the
absence of symptoms
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Code 2 Urgent
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Code 1 Early Dental Care No accompanying signs
or symptoms
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Code 0 No Obvious Problems
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Special Health Care Needs

• 0No
• 1Yes
• Specify Needs

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Comments

• Use this box to identify any other dental
  problems that are noted, such as fractures,
  parulis, pain or swelling.

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What else could you see?

• Malocclusion
• Underbite
• Crowding
• Fillings (amalgam and composite)
• Periodontal disease
• Sealants
• Abscess
• Injury

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Malocclusion
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Underbite
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Crowding
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Crowding
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Dental Abscess
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Fractured Tooth
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Vertical Fracture
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Anticipatory Guidance

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Infant and Toddler Oral HealthAnticipatory
Guidance Schedule

• 9 Months
• Discuss and demonstrate the appropriate brushing
  of infant teeth.
• Instruct the parent to conduct "Lift the Lip"
  procedures.
• Continue to monitor progress in weaning infant
  from bottle to cup.
• Offer appropriate guidance in limiting juice in
  sippy cup.

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Anticipatory Guidance 12 Months

• Conduct Lift the Lip screening and complete Basic
  Screening Survey on infant.
• Discuss complete weaning from bottle to cup.
• Discuss importance of routine dental care with
  oral health provider.
• Offer guidance and referral to establish a
  regular dental home.
• Review intake of dietary fluoride supplements.

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Anticipatory Guidance

• 18 Months
• Review healthy eating habits and scheduled
  snacking for toddler.
• 24 Months
• Establish the healthy behaviors that have been
  implemented.
• Continue to screen for Early Childhood Caries.
• Discuss and evaluate the toddlers ability to
  begin to use fluoridated toothpaste.

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Lift the Lip

• Purpose
• Train parent/guardian to detect signs of
  childhood caries
• Facilitate prevention and early intervention
  through referral

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Lift the Lip

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Lift the Lip Parents Position
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Knee to Knee Position

Knee to Knee position can be taught to parents to
aid them in checking their child's teeth.
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Check the Facial (outside) and Lingual (inside)
of the Teeth

• A mouth mirror can help view the inside of
  the front teeth.

Lift the Lip to view the teeth for white spot
lesions" along the gum line.
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Fluoride Varnish

• Does not require special dental equipment.
• Material costs from .77 to 4 per application.
• Does not require a professional dental cleaning
  prior to application.
• Easy to apply.
• Dries immediately upon contact with saliva.
• Minimally ingested during and after application.
• Enhances re-mineralization of the tooth surface.
• Is safe, and taste is well tolerated by infants,
  young children, and individuals with special
  needs.

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Fluoride Varnish Introduction

• 5 sodium or 22,600 PPM fluoride resin
• Applied as a thin coating to protect from decay
• According to FDA, fluoride varnish falls under
  the category of drugs and devices that present
  minimal risk and are subject to the lowest level
  of regulation
• FDA approved as a cavity liner and is used
  off-label for dental caries prevention

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Purpose

• The purpose of applying fluoride varnish is to
  retard, arrest, and reverse the process of cavity
  formation (remineralization).

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Indications for Fluoride Varnish

• An infant or child at moderate or high risk of
  caries
• Transmissibility
• Poor Oral Hygiene
• Diet High in Carbohydrates
• Improper Bottle Use
• Breast-feeds on Demand at Night
• Pacifier Dipped in Sugary Substance
• Medication
• Parent/Guardian/Child Situation

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Contraindications for Fluoride Varnish

• Ulcerative gingivitis and stomatitis
• Known colophony (colophonium) allergy

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Fluoride Varnish Protocol

• The applications can be given in a variety of
  time schedules.
• Repeat the application once every three months
  for children at risk of early childhood caries.
• Studies show three applications of fluoride
  varnish help prevent ECC.

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Pre-application Instructions

• Advise parent/guardian
• Child should eat and drink something before
  coming to receive a fluoride application.
• Childs teeth may become discolored temporarily
  as fluoride varnish has an orange-brown tinge.
• Varnish can be brushed off the following day.

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Fluoride Application Materials

• Infant-sized toothbrush or infant safety brush
  (to take home)
• Disposable gloves
• Disposable mask
• Eye protection
• Gauze sponges (2 x 2)
• Fluoride varnish - one to two drops/unit dosed
• Small disposable fluoride applicator (if not
  included with the varnish)
• Paper towels or disposable bibs to place under
  the childs head (optional)

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Positions

• For an infant
• Knee to knee
• Exam table
• For a young child
• Sitting position
• Exam table

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Knee to Knee Position

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Application of Fluoride Varnish

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Application of Fluoride Varnish

• Using gentle finger pressure, open the childs
  mouth.
• Gently remove excess saliva or plaque with a
  gauze sponge.
• Use your fingers and sponges to isolate the dry
  teeth and keep them dry.
• Isolate a quadrant of teeth at a time, or a few
  teeth at a time. (Infants have only anterior
  teeth.)
• Apply a thin layer of the varnish to all surfaces
  of the teeth.
• Avoid applying varnish on large open cavities.
• Once the varnish is applied, you need not worry
  about moisture (saliva) contamination. The
  varnish sets quickly.

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Post-application Instructions

• Soft diet for the rest of the day.
• Do not brush or floss the child's teeth until the
  next morning.
• It is normal for the teeth to appear dull and
  yellow until they are brushed.
• Remember
• Even though the child may fuss, the varnish
  application is not unpleasant.
• Tell the parent that the teeth will not be white
• and shiny until the next day.

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PharmaceuticalRecommendations Include

• Discontinue use of supplements for several days
  following treatments.
• Discontinue other prescriptive fluoride
  preparation (gels/rinses) for 24 hours after
  application of varnish.

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Adverse Reactions

• Edema (swelling) has been reported rarely
  following application of extensive surfaces.
• Nausea can occur in patients with known sensitive
  digestive systems following extensive
  applications.
• Do not use on individuals with known colophony
  (colophonium) allergy.

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Referral

• Establish a dental home whenever possible.
• Early Dental Care
• Urgent Dental Care

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Thank You
Questions?