Contemporary Caries Management in Pediatric Dentistry

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Contemporary Caries ManagementinPediatric
Dentistry

• Jim Crall, DDS, ScD
• Professor Chair, UCLA Pediatric Dentistry
• Director, MCHB National Oral Health Policy Center
• OK AAPD HS DHI State Launch
• Oklahoma City, OK
• March 27, 2009

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Presentation Overview

• Dental caries distribution and trends in
  children, with an emphasis on early childhood
  caries
• Understanding caries as a common, chronic,
  complex, transmissible disease
• Understanding and applying caries risk assessment
  in practice and community settings
• Evidence on effective strategies for reducing
  caries in children myths vs. science
• Challenges and promising approaches for improving
  childrens oral health, with an emphasis on early
  childhood

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Dental CariesEarly Childhood Caries (ECC)
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A little pre-test . . .

• Whats this?
• How many think its caries?
• No! Its a hole!!! . . .
• Its a cavity!!! . . .
• A consequence
• of a disease
• called caries!!!

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What recent science tells us aboutdental caries
in young children

• Dental caries is an infectious, transmissible
  disease (though not a classical infection).
• The mother is usually the primary source of the
  transmission (can include caregivers).
• Cariogenic bacteria generally are transmitted
  from mother to child and colonize the teeth
  shortly after they erupt.

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Dental Caries a working definition

• Dental Caries is a COMPLEX (multi-factorial),
  CHRONIC DISEASE of teeth
• infectious and transmissible
• diet-dependent salivary-mediated
• dynamic and reversible (up to a threshold)
• highly prevalent
• ? a disease which may cause cavities in teeth
• ? and have significant consequences for general
  health and quality of life.

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Caries An infectious, transmissible disease
but also a chronic, complex disease.
Fejerskov O. Changing paradigms in concepts on
dental caries consequences for oral health care.
Caries Res 2004 38182-91.
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Caries is NOT

• A synonym for cavity
• Tooth decay is a synonym for caries
• The plural of carie
• Think of it as being similar to diabetes!!!
• A chronic disease ? progressive absent lifestyle
  changes
• Diet-related
• Causes damage to structures in the body
• A serious condition for many
• . . . Not the plural of diabete

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Caries Balance ? Chronic, Dynamic DiseaseAdapted
from Featherstone JDB JADA 131887-99, 2000

• Balance between
• Risk Factors Protective Factors

Risk factors Promote demineralization
Protective factors promote remineralization

• Fluorides
• Plaque control
• Saliva
• Antimicrobials

• Frequent exposure to refined sugars
• Cariogenic bacteria (S. mutans)
• Reduced salivary flow

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Healthy Caries Balance
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Caries Balance ? Chronic, Dynamic Disease
Adapted from Featherstone JDB JADA 131887-99,
2000

• Risk Factors Protective Factors ? Caries

Risk factors Promote demineralization
Protective factors Promote remineralization

• Fluorides
• Plaque control
• Saliva
• Antimicrobials

• Frequent exposure to refined sugars
• Cariogenic bacteria (S. mutans)
• Reduced salivary flow

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Dental Caries (Tooth Decay) Early Clinical
Stages
Enamel / White-Spot Lesions
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Dental Caries Advanced Clinical Stages(Early
Childhood Caries ECC)
Moderate
Severe
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Traditional Oral Health Dietary Guidance

• Do not fill bottles with sugar-containing
  liquids
• Start encouraging cup use at 6 - 8 months
• Limit sweet, starchy (sticky) snack foods
• Minimize sugar added to solid foods
• Limit liquids with high sugar content
• Avoid prolonged breast- and bottle-feeding
• especially at sleep times

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Fluoride Varnish An Alternative Form of Topical
Fluoride
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Fluoride Varnish Advantages
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Toothbrushing

• Children 2 yrs
• Staff should assist children with brushing 1x
  daily with small smear of fluoridated toothpaste
• Children 1-2 yrs
• Staff should actually brush childrens teeth 1x
  daily with small smear of fluoridated toothpaste
• Infants
• Staff must use gauze pad or soft cloth to gently
  wipe infants' gums.

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Savage MF, et al. Early Preventive Dental
Visits Effects on Subsequent Utilization and
Costs. Pediatrics, October, 2004.

• The age at the first preventive dental visit had
  a significant positive effect on dentally related
  expenditures.
• 1st dental visit / Total cost
• Before age 1 262
• Age 1-2 339
• Age 2-3 449
• Age 3-4 492
• Age 4-5 546

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Preschoolers Caries Experience
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Percent of Children with Decayed and Filled
Primary Teeth by Household Income Level ( of
Federal Poverty Level)
50
0-100
40
101-200
30
201-300
20
301
10
0
Decayed
Decayed
Filled 2-5
Filled 6-12 year olds
2-5 year olds
6-12
year
year
olds
olds
Vargas, Crall, Schneider. Analysis of NHANES III
data. JADA, 1998.
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Minority children are more likely to have
untreated tooth decay(regardless of family
income)
Percent of children

Ethnic groups
White
African American
Mexican American
50
40
30
20
10
0
2-5 years
6
-12 years
6-14 years
15-18 years

Permanent dentition
Primary dentition
Vargas, Crall, Schneider JADA
19981291229-1238.
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Treatment Urgency Data California Needs
Assessment - 1993-94
Source The Oral Health of Californias Children
A Neglected Epidemic. The Dental Health
Foundation, 1997.
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Dental Caries in Californias School Children
2005

• Decay Experience
• 54 by Kindergarten
• 71 by 3rd Grade

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High-risk PreschoolersResults of a MD State-wide
Survey of Head Start Children

• 52 of children in Head Start centers had
  untreated tooth decay
• 43 of 3 year-olds
• 62 of 4 year-olds
• Over 5 decayed tooth surfaces per child with decay

Vargas CM, Monajemy N, Khurana P, Tinanoff N.
Oral health status of preschool children
attending Head Start in Maryland, 2000.Pediatr
Dent 2002 May-Jun24(3)257-63.
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Significance of ECCCaries Prevalence in U.S.
Children
                                                  
                                                  

Source National Center for Health Statistics,
CDC. Third National Health and Nutrition
Examination Survey, 1988-1994
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Its about much more than baby teeth

• This facial cellulitis resulted from a
  cavity in a primary tooth. This child is in
  pain, cant eat and is suffering. If she is not
  treated, her ability to breathe could be
  compromised and she may lose the sight in her eye.

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Its about much more than baby teeth

• What might a PET scan of this childs brain
• look like?
• Whats the likely
• impact of his dental problems on his
• ability to concentrate?
• to learn?

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Caries A Preventable Disease???What do we
mean by prevention?

• Prevention the act of preventing
• Prevent to keep from happening /existing to
  hold back / stop
• Prevent taking advance measures against
  something possible/ probable
• Immunity a condition of being able to resist a
  particular disease, especially through preventing
  the development of a pathogenic microorganism or
  by countering the effect of its products
• N.B. In biological contexts, Immune and
  Immunity generally involves the immune system
  or an immune response that produces a reaction to
  an antigen that induces formation of antibodies
  and lymphocytes ? conditions that generally do
  not apply to counteracting the effects of dental
  caries.

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Prevention???50 show effects of caries by age
5!80 have evidence of caries by age 17!!
                                                  
                                                  

Source National Center for Health Statistics,
CDC. Third National Health and Nutrition
Examination Survey, 1988-1994
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Dental CariesA Highly Prevalent Disease

• Tooth decay is the most common chronic disease of
  childhood in America.
• 56 of Grade 1 children have evidence of caries
  (NIDR, 1995)
• 85 of Grade 12 children have decayed or restored
  teeth (NIDR, 1995)
• Primary tooth decay is NOT declining 14
  increase in ECC in the past decade (MMWR, August
  26, 2005)

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Caries A transmissible disease but also a
chronic, complex disease.
Fejerskov O. Changing paradigms in concepts
on dental caries consequences for oral health
care. Caries Res 2004 38182-91.
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Keys to Good Oral Health

• Good eating snacking practices
• Regular self-care practices
• daily brushing with F toothpaste
• Access to dental homes
• regular, ongoing source of dental care
• diagnostic, preventive treatment services

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MCHB ECC ForumServices for Families

• Oral health self-care instructions
• Appropriate for ages/developmental stages
• Health literacy considerations
• Distribution of oral health materials
• Toothbrushes fluoride toothpaste for children
  (as appropriate) and caregivers floss for
  caregivers
• Risk assessment training for caregivers
• E.g., lift-the-lip technique for infants

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MCHB ECC ForumServices for Families (continued)

• Incorporation of oral health assessment and
  counseling into home visitation programs (e.g.,
  those conducted by nurses)
• Care coordination programs
• Assist with benefits enrollment
• Help arrange appointments
• Assist in patient-provider communications
• Follow-up to ensure needed care is completed

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MCHB ECC ForumTraining for Clinical Providers
Serving Young Children Their Families

• Behavior management and positioning
• Caries risk assessment, anticipatory guidance,
  counseling, preventive restorative services for
  general dentists
• Oral health / caries risk assessments and
  counseling for primary care providers
• fluoride varnish applications in some programs
• Electronic databases PDAs to transmit data

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MCHB ECC ForumTraining for Non-Clinical
Providers Serving Young Children and Families

• Head Start, WIC other community-based family
  support service providers
• Trusted sources for information referrals to
  dental homes
• Training in oral health / caries risk assessments
  and counseling

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Risk Assessment Risk-based Approaches for
Reducing Cariesin Children
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Caries Risk Assessment Tools
Source American Academy of Pediatric Dentistry
Reference Manual. Available at www.aapd.org.
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Risk-based Management of Initial Carious Lesions
Low caries-risk patients
High caries-risk patients
Recall appointments extended over time
More frequent recall appointments tailored to
progression of disease
Chlorhexidine products Fluoride products
Sealant on fissues (when indicated)
No treatment
Sealant Fissures White spots
Fluoride products
LOW
HIGH
S. mutans count
-

Disease progression
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Responding to Changing Paradigms for Dealing
with Dental Caries

• Old Paradigm -- Surgical / Drill and Fill
• (deal with the consequences of the disease)
• ?
• Later Paradigm Prevention!!!
• (but generally one size fits all)
• ?
• Current Paradigm Early Intervention, Risk
  Assessment, Anticipatory Guidance, Individualized
  Prevention and Disease Management

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See Crall JJ. Ped Dent 200527323-330.
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Emerging Challenges

• Increasing diversity
• Language / communications
• Cultural differences
• Beliefs
• Nutrition
• Self-care routines
• Care-seeking behaviors
• Provider cultural competency

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Increases in Low-Income, Racial/Ethnic Minority
Children

• 65 of Latino children under age 6 3.1
  millionlive in low-income families.
• 64 of African American children millionlive in low-income families.
• 29 of White children under age 6 3.8
  millionlive in low-income families.
• 23 of Asian children under age 6 0.2
  millionlive in low-income families.

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Children of Low-Income Recent Immigrants

• 45 of children of low-income, recent immigrants
  live with parents who do not hold a high school
  degree, compared to 18 of children of
  low-income, native-born parents.
• Children of low-income, recent immigrants in the
  West are particularly likely to have parents with
  low education levels.
• Almost half of children of low-income, recent
  immigrants are under age 6.

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Promising Approaches for Improving Oral Health
for At-risk Preschoolers
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Klamath County, OREarly Childhood Caries
Prevention ProgramPeter Milgrom, DDS, et al.
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Program Goals

• 100 of 2-year old children on Medicaid will have
  no cavities.
• A sustainable program that grows and changes over
  time to meet the needs of the community

Slide courtesy of Dr. Peter Milgrom
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Key Objectives of the Klamath Program

• Develop community-supported strategies to stop
  (reduce? / delay?) S. mutans transmission from
  mothers to children.
• Prevent caries expression in kids through parent
  education about risks and periodic application of
  fluoride varnish on erupting teeth (Goal
  Cavity-free 2-year-olds).
• Provide a dental home for moms and kids at risk,
  ensuring success by utilizing a case management
  model for both clients and providers.

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Klamath Program Research-based Components

• Home visits
• Parent education on dental disease
  transmission/ECC
• Follow-up at WIC
• Tool Kits
• Case management to reduce barriers to dental care
• Fluoride toothpaste provided to mother and child
  with instructions to apply to teeth daily from
  1st tooth
• Every pregnant woman and newborn assigned a
  dental home for necessary treatment
• Chlorhexidine rinses during pregnancy and xylitol
  gum for the new mother. Fluoride varnish for
  children based on risk.

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Challenge

• Keep in contact with new moms and get the babies
  in to the dental home

Solution Staff training, motivational
interviewing, better contact information
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Challenge Fluoride Toothpaste Toddlers

• Topical application of fluoride at home
• Concerns about fluorosis

Solution Educate the professional community on
benefits and risks the alternative is caries!
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Framework for SC More Smiling Faces Project
Combining Resources for Improved Oral Health for
Children

• Integrated Network
• Dental
• Medical
• CHCs
• Churches/Faith Groups
• School/Preschool
• Programs

Community Education Consistent OH Messages

• System Linkage
• Patient navigator links
• Link medical homes with dental providers
• Link patients to resources
• Screen for Medicaid or insurance eligibility
• Arrange transportation for target population

Local Advisory Committee

• Pediatric OH
• Training
• Medical providers
• Dental providers

Outreach to Medical Home Integrate OH promotion
and disease prevention into the medical home
Slide courtesy of Christine Veschusio
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SC More Smiling Faces Lessons Learned

• Pediatric Oral Health Training
• Medical providers want to refer children oral health providers in their community
• Multiple barriers exist between medical and
  pediatric dental providers in implementing urgent
  need plans
• Physicians welcome working with patient
  navigators
• Physicians welcome development of stronger
  relationships with local dental community

Slide courtesy of Christine Veschusio
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Considerations for Primary Care Delivery

• Medical Home Dental Home Linkages
• MI Points of Light Program
• Identify community dentists willing to provide
  dental care for children beginning at an early
  age
• Provide lists to primary medical care providers
  to facilitate referrals
• Community-based Care Coordination
• ABCD Program (WA et al.)
• Patient Navigators (CA, SC)
• Primary Care Case Management (AL)
• New models (Community Oral Health Coordinator)

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Key Elements Challenges for Improving Oral
Health in At-risk Preschoolers
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Key ElementsOral Health in Childhood Beyond

• Healthy Habits
• What and how often we eat drink
• Daily self-care (e.g., brushing with fluoride
  toothpaste)
• Early, Ongoing Sources of Care
• Savage MF, Lee JY, Kotch JB, Vann WF Jr. Early
  preventive dental visits effects on subsequent
  utilization and costs. Pediatrics
  2004114418-23.
• Risk-based, Targeted Interventions
• Jokela J, Pienihakkinen K. Economic evaluation of
  a risk-based caries prevention program in
  preschool children. Acta Odontol Scand
  200361(2)110-4.

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• What Can We (You)
• Do About Childhood Caries?

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Step 1 Understand the DiseaseChanging
Paradigms

• Old concepts of caries/prevention
  (simplistic/mechanical)
• bacteria sugar -- acid teeth -- cavities
• Recent concepts of caries (dynamic disease
  process)
• subsurface lesions / demineralization /
  remineralization
• transmissible, infectious disease / chronic
  disease
• Current concepts of prevention / disease mgt
  (multi-faceted)
• prevent / delay transmission of Strep. mutans
• alter dynamics of demineralization
  remineralization
• risk assessment and individualized prevention
  and/or disease management strategies
• importance of multiple, reinforcing strategies
• awareness of environmental / cultural influences

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Step 2 Reduce the Incidence and Severity of
Dental Caries

• Caretakers ? Daily self-care (home / HS)
• Dietary guidance
• Plaque control (oral hygiene)
• Fluoride toothpaste
• Health Care Providers ?Early/risk-based care
• Dental Homes
• Topical fluoride
• e.g., fluoride varnish, APF
• Sealants

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Compelling Arguments
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Earlier Interventions ? Lower CostsSavage MF, et
al. Early Preventive Dental Visits Effects on
Subsequent Utilization and Costs. Pediatrics
October, 2004.

• The age at the first preventive dental visit had
  a significant positive effect on dentally related
  expenditures.
• 1st dental visit / Total cost
• Before age 1 262
• Age 1-2 339
• Age 2-3 449
• Age 3-4 492
• Age 4-5 546

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Spill Over Into Medical Sector Costs The
effects of a dental infection are wide-ranging
and long-lasting.

• A week or more of pain and sleeplessness, her
  parents lost work days and productivity, her own
  missed schooling, a futile and expensive use of a
  hospital emergency room, and a life-long external
  scar are among the ripple effects of this
  preventable infection.

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Consequences of Limited Oral Health Access
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Creating a Foundation for a Lifetime of Oral
Health for Children Depends on Success in 3
Strategic Areas

• Developing and implementing effective oral health
  promotion activities within communities
• to instill habits that promote oral health
  reduce caries risk
• Educating and motivating parents/caregivers to
  take an active role in their childrens ( their
  own) oral health to reinforce and extend
  oral health promotion activities to the home
  environment
• Creating effective partnerships within
  communities to ensure that children and families
  have access to quality, comprehensive, culturally
  competent care (dental homes) that fully meets
  their oral health needs.

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Healthy Teeth Healthy Development for All Kids!