Transcribed by Albert Cheng 9/5/14

[DOD Cariology] [Lecture 27/28 Caries in a Pediatric Population I & II by Dr. Herman]

Slide 1 Dental Decay and Caries Management in the Pediatric Population[Dr. Herman] Nice to see you again. Welcome back. Im Neal Herman. I think weve met a few times. Today, we will be talking about dental caries in children. This is a part of Dr. Allens course. Let me apologize in advance. I did not post this yet; I just recently got back from a trip abroad.

Slide 2 Tanzania August 2014I was with Dr. Fernandez. A group of dentists did a mission in Tanzania. Anyways, I just got back and Im a little under the weather as well. Ill do my best and cover the material. I promise you that Dr. Allen will post this. Just sit back and enjoy it. One of the great things about being in dental academia and public health, we have the opportunity to go to East Africa to a dental outreach mission. We were there for 2.5 weeks.

Slide 3 Pictures of his outreachThis is some of my photos. Ive been there before 5 years ago. We went to the south of Tanzania which nobody in their right mind goes. The tourist stuff that you would like to see in Tanzania is to the North. We were in the deep south (Songea) by the Mozambique water which not much is there, lots of needy and poor people in the villages. Just some interesting tidbits of village life. You see the bus terminalObama/Barack Expresstheyre very enamored with President Obama. Its very interesting if youve never been to that part of the world before.

Slide 4 Pictures of him and other dentists working on childrenThe main reason we were there was to provide some oral health care to some children. Thats me up there with my custom made scrubs ($7). We were in schools to provide these children their first experience with some of them with toothbrush and how to take care of themselves. This is a dental clinic here, which is built on 150 acres plot of land right outside of town by this foundation called Miracle Corners of the World. We worked with 6 dental therapy students from the village of Mbyea. They came and worked with us. I had the opportunity to work with them. As you can see, we did a little morning session and I actually did some treatment myself. Professor Hernandez applying fluoride varnish to the kids. Same kinds of things we do on the outreaches here to educate not only the children but also the schoolteacher and try to make this a sustainable project. Having the dental therapy students there was wonderful because talk about sustainability, we only come occasionally there, but theyre there all the time. They learn very little about preventive care and theyre basically extracting teeth and even restorative care is a new experience for them. So we introduce them to new dental materials.

Slide 5 Slides of elephants/zebra/giraffe etcWe worked 9 days in the clinic. And on the way home, we managed to squeeze in a Safari and this is a general dentist and he actually went to school herehis name is Clint Timmerman (not sure)hes practicing out in Colorado Springs in Denver. These were my photos. We actually saw these animals.

Slide 6 The search for a CURE for, or at least a way to MANAGE, dental caries has been ongoing for many yearsLets talk about dental caries. Im going to give you the pediatric version. I dont think its all that different. Although, one of things we do in pediatric dentistry more than on the clinic floor for adults is that we practice what we preach. We talk about doing conservative therapy, therapeutic intervention and leaving the decay behind. Those of you who have the opportunities to come to our clinic see that we actually do it. We dont expose pulp if the tooth is capable of reversing itself and healing. We manage deep caries very differently than you would in the adult clinic. Im going to talk to you about that todaywhy we do thatwhat the benefits are etc. As you can see from the dates here, this is not something new. I was a pediatric resident over 40 years ago here. We were leaving decay behind and doing pulp therapy 40 years ago. Its not new. I mentioned this to you. The literature goes back to the 70s. This is just how long it takes to get this into practice. Theres many reasons why it takes so long and well get into that later but its been very frustrating watching this evolutionwhich hasnt really been an evolution but it should be a part of practice and hopefully you guys will be the ones carrying it forwardthats why it takes generations. People in my generation, who are out in practice, many of them are practicing the way they were in dental school and thats unfortunate with all the wonderful changes weve hadthe material, technology, and research. Youve all heard the attempt to find a vaccinesome way of curing dental caries. Something that can be universally applied. The closest thing weve achieved to that is water fluoridation. Even that to this day is a controversial issue. Some of you may have just read that a few countries, the last one being Israel, have just banned water fluoridation. This is how powerful the anti-fluoridation lobby is around the world. People who are not of the scientific mind, who do not know how to properly read the literature, feed into the natural human fears about adding things to our environmental water. Its playing out that countries such as the Czech Republiceven Sweden which is a pretty sophisticated scientifically oriented country has banned community water fluoridation. As I said just last week, Israel had pass legislation there too. So this cure for caries has not happenedwill not happen. So what were looking for is a way to manage as best we can this disease call dental caries. Youll have these slides available to you. Ill skip over some stuff but I also include references. I try to give you evidence based stuff. But there have been many attempts over the yearsback in the 1800syouve all maybe heard of silver nitrate but you wont learn much about it unless its from me, its having a resurgence now. It was pretty popular about 50-60 years ago, definitely popular during the turn of the last century. Its a proven therapeutic agent that arrests decay but has an unfortunate side effect of turning the decay black. And in this days and age of cosmetics, thats a no-no. But it does has its place maybe not in your average Manhattan practice but certainly in places like Tanzania in the middle nowherein certain communities its very appropriate as a caries control measure. Some dentists have come up with a sort of scheme to reduce caries. I dont know if you know about 100 years ago here in NYC and the US, dental caries was a huge problem. The numbers now of caries-free children are enormous. If you look at the national statistics, Ill show you in a few minutes. Virtually every child (~98-99%) at the turn of the 1900s had cavities. Anybody know how many children are caries-free today in this country? Its 65% and its pretty impressive. Most of that has been attributed to water fluoridation because 75% of the population does get fluoridated water. But there are still problems because 80% of the dental caries we do find are found in only 25% of the population. Thats the population were involved with here at the school and out on your outreach locations in under-served areas where you do the find the population with high caries rate. So while caries is being reduced nationally, were not really doing a good job in certain populations. And again, well talk about that in a few minutes

Slide 7 The Global PerspectiveLets take a quick look at the global perspective

Slide 8 The burden of oral diseases and conditionsThe global perspective is pretty much like this. This is WHO stuff. They have a wonderful website by the way which you might want to look at on your own time. So they talk about these oral conditions of which dental caries lead the list. Again, Im not going to go through everything but some things you dont know a lot about like thiswhich in certain parts of the worldNoma is a degenerative diseasea skin-eating disease similar to some of the pictures youve seen like Ebola. A big problemnot in the USbut certain part of the world. If youre interested in public health or global perspective, hopefully youll learn more about that but you wont learn any more about it in dental school. I dont even think they mention it in Oral Pathology or even general pathology

Slide 9 Global trends in oral health Developed countriesSo the trendsin public healthwe talk about the developed countries which are westernized countries including North America, Europe mostly, parts of Asia (not that many parts). And then we talk about developing countries. These are the global trends in developed countries and youll see a decline in dental caries in the western world. Adults are keeping their teeth longer. As the economic conditions get better and the quality of life gets better, people start becoming more interested and involved with their oral health. The use of tobacco and alcohol is down compared to the developing world. And most of the burden falls in the under-served and disadvantaged populations

Slide 10 Global trends in oral health Developing countriesIn the developing countries, often the dental caries is low. Why? Because their diet is generally more an endemic diet. Its not westernizedall the sugar and processed food. Problems that we experience here, as a major part of dental caries, is not present in that part of the world. But whats happening with globalization is that more and more of these developing countries are being exposed to western products. Even in Tanzania, people are living on small amounts of money, high unemployment, and living a very basic life-style. But if you go to any of the shops there, youll see candy bars and soda. Theyre being inundated with these Western products. While dental caries is initially low, the more civilize they become, dental caries becomes more and more of a problem because in addition to all that, the dental infrastructure is non-existent. There are either no dentists or the people cant afford to go to the dentists. And theres very little dental awareness in these countries. If you put the two together, you find an increasing trend towards dental decay.

Slide 11 World map on dental caries (DMFT), 35-44 yearsSo this is looking at DMFT indices to show you, which countries are very low and which countries are very high. The US is considered moderate. Many parts of Africa are considered quite low. This is changing over the year. Again this is ADULTS not children.

Slide 12- World map on dental caries (DMFT), 12 yearsChildren are hereat least the 12 year olds. This is consistent. The US does pretty well in the pediatric population. But again, dental caries isnt a disease of childhood; it affects adults as well especially after adolescence.

Slide 13 Graph Here it is in a graph form. Youll see the developed countries; theres been a decrease in DMF scores. Here youll see the total around the world is relatively stable. Its been on the increase in developing countries.

Slide 14 Epidemiology of Dental Caries in the United StatesSo what about the U.S

Slide 15 Some Data to ConsiderHeres some data on the US. The NHANES study is done every 10 years. Here is some of the last statistics we saw. And you can see as the children get olderat age 5, almost the children have dental diseaseat least 1 cavitated lesions. Heres that statistic I threw at you earlier. 65% of the population as a whole seems to be caries free up to the age of 12. How do you make sense of all that?

Slide 16 Increased Access to Care?Here are some of the reasons why. Issues such as dental insurance. People with dental insurance access dental care more frequently than people without dental coverage. Here are some things about public dental coverage versus private dental coverage. Dental utilization, which means you can have dental insurance but if you dont go to the dentist, youre not using it. So utilization is how often people go the dentist and seek care even if its preventative care. So look this over and you can see here some interesting numbers about the public sector. The children havethis is Medicaid mostlythe different forms of public assistance has actually increase the access to dental care for the under-served. Privateits a different story

Slide 17 1999-2004 NNHANES findingsSo heres the interesting thing we found in that last NNHANES study that while for all age groups the dental caries has continued to decline, the younger age group (2-5 year olds)theres actually an increase4% increase from 24%-28%. This really threw the pediatric and public health community for a loop because nobody really understood what was going on. Why in this particular age group was this happening?

Slide 18 Supposed increase in incidence of dental caries in 2-5 year oldsSo theres been a lot of debate and analysis of this phenomenon. And again without going a lot into details, as you know its not easy reconciling datadifferent people can take the same data and analyze it differently and come to different conclusions about why. And thats sort of whats happened here. I still havent heard of any good explanation as to why this is happening. Some people believe that it was a statistical glitch. In fact, its possible that the caries has continued to decline but what this basically says here is that the number of filled teeththe F part of the DMFT has actually skewed the data in a way that makes it seem like caries has risen. In fact, what it means is that more and more children are actually getting to a dentist to get treatment. Im not sure if thats clear. It is kind of complicated. They think it has to do with the fact that access to care has increased and that more teeth are being treated and filled. Its not that cariesthe untreated part of the diseasethe decay part may have decreased. [student question inaudible] No they use DMFTits just notated differently. Children under 5 do get teeth extracted so missing is an appropriate usage. Ill look into that for you but Im not quite sure

Slide 19 caries increase between NHANES III and 99-04 reported bySo again, these explanations may help a little about how its analyzed. Im not a statistician so I dont really understand a whole lot of this stuff but they talk about aggregated versus disaggregated data. As I said, its complicated. Most of us meaning pediatric dentist and public health people do believe that its still open to debate whether this has actually increase. We will be getting a new NHANES shortly. I guess well see if it works itself out in the next one.

Slide 20 I ask everyone to consider that this may reflect the possibility ofThese are some quotes from a dental public list serv, which I subscribe to which if any of you are interested in public health pediatric, I highly recommend you look at it. A lot of the real experts in the field chime in on certain issues that I think are pretty important. This is something thats important to me. Theyre talking about the increased access to care for children and the whole issue of drilling and filling teeth. The concept basically youve all heard is that you cannot drill away dental caries. You will not solve the dental caries problem by just increasing people going to the dentist. You have to manage and have people understand, this is a disease and you have to treat the disease not the symptoms of the disease. Every time youre filling the tooth, youre treating a symptom of dental caries. Youre not treating dental caries, youre filling a tooth which is a symptom of dental caries. So this is the essence of conservative and preventive dentistry. This talk about the monetization of our professionthat we earn our living by filling the teeththe more fillings you do the more money you make. Unfortunately, thats one of the reality of not just dentistry but health care in general. Many well intention people as you can see from reading this dont always make the right decisions for the right reasons. And what were trying to do is to focus on the evidence and best practices to figure out a way to make this thing work. In the 20th century, there was no solution. We had dental amalgam. We had no understanding about the role of fluoride. We had no materials that we have now like glass ionomers and bonding material that could offer us any alternative to drilling and filling. We do have them now. We also have the knowledge and research to show us now. When I was in dental school, we were taught that hard tissue cannot remineralize. We know now that thats absolutely not true. Not only can bone regenerate but you can remineralize early lesionslesions that have not cavitated. We have tools and materials available to us that allow us to overcome our history and practice more like we ought to be practicing now.

Slide 21 The National Survey of Childrens Health 2003Again, Im not going to go over these. Just some more statistics about the under-served, the young children

Slide 22 The National Survey of Childrens Health 2003This is the federal poverty level showing that the poorer children are less likely to receive preventive care. It gets higher as the family earns more money. Not a surprise, the more educatedthe more money you make.

Slide 24 This is consistent with the statementThis is the number I threw at you earlier. Statisticsstatistics[starts skipping through slides] about the different ethnic groupsutilization dataIll let you look at this yourself.

Slide 29 Summary of IssuesIm not gonna spend a lot of time because Ive mentioned most of these. But these are the kind of issues that as pediatric and public health people, we are concerned with. That gap between access to care for the underservedthats a big onehow do people get the care that they needthat theres this clash of social, monetary and professional values. There are too few providers for the safety net. Very few people open practices in the underserved areas. Try to find a pediatric dentist in the community health center in this country. Its a rarity because pediatric practice is lucrative and thats where everyone goes. Our own residents do the same thing. We try to encourage them to come back, teach and do something. This whole issue of a safety net is a big problem in a country such as ours, which focuses on the private practices system.

Slide 30 Summary of Issues contThese are issues that you probably wont hear much of because its not really technical based in doing the dentistry. But as people who are entering the profession, I think you ought to be aware of. You know what Head Start isthe only program in the country that has oral health standards. Thats another problem. Most public schools and children who go to school do not have oral health requirements. They all have medical requirement but oral health is not considered in them. If they are, its often voluntary not mandatory. So we have a long way to go. There are other parts of the world that do have these requirements.

Slide 31 Suggested Short-Term Strategies Much of Europe and Scandinaviayes they have socialized systems that are in placethey have better safety nets than we have, but their awareness is greater. They understand the concept that you have to get to children early and you have to educate their parent to understand how do you prevent these problems before they began. We dont do such a good job with that. We spend a lot of effort trying to educate the people to do it but the economic system we operate in doesnt reward that. It rewards actions/treatment. It doesnt reward prevention unfortunately. That is gradually changing I believe but not fast enough. Heres some strategies you can look at. Some of the things that we public health people talk about to try to get some of this stuff into law.

Slide 32 Suggested Long Term Challenge Winds of Change for the profession Just as an example. The latest Affordable Care Act (Obamacare)the intentions were goodthe Children Dental Project out in D.C. was lobbying strongly to get pediatric dentistry included in that and it was initially successful and as the politics worked out and as it was implemented gradually nowas some of you may knowit is not a mandated service anymore, it was included as an optional add-on which again most people who arethe 40 million people who are going to benefit from the ACA, many of them have benefitted but not the kind of people who are going to opt to pay for additional oral healthcare. Thats a big disappointment. So I mentioned this paradigm changeback to dental caries. Were looking at the medical versus the surgical model. I am going to be talking to you starting in November for the D2 pediatric series but Im going to give you a little insight as to what that means. Its the concept of treating dental caries as an infectious disease and focusing on diagnosis rather than drill and fit and treating those symptoms. Treating caries as a transmissible infectious disease. Promoting a therapeutic approach and conservative therapies, not drill and fill.

Slide 33 What is the latest thinking regarding caries management, dental education and licensure?A little bit of editorializing about some of the ways this kind of infiltrates into our practices. Heres a little bit about dental licensure and how some of this affectsyou will know when you take your boards. This is again the last holdout in this country about conservative therapy. Theyre still requiring complete caries removal or else you dont pass your boards. This is insulting in a way. Heres a statement I think you should all read and think about carefully. In the latest Cochrane study, the highest-level meta-analysis of critical analysis of research, leaving decay at the base actually gives better outcomes than caries removal. So what does that mean? It means when you look at the longevity of the tooth thats been treated in that manner, and when you at the fact that when you remove all the decayhow many pulps you expose which then require further RCT or possible extraction. When you measure the outcomes from a patients POV, you keep more teeth in the mouth and you keep them healthier by actually being conservative and letting the tooth heal from within, getting a good seal on the tooth and moving on from there. Theres extensive literature on that. This is not new. This has been around a long time. Theyre not integrated into our education enough certainly not integrated into board exams so this is just something thats an issue for the future. Hopefully, it may change when you take the NERBs in 3 years. The dental board examiners in this country are the last holdout and so far theyre doing a good job.

Slide 34 Controversies that proved to be trueI just have this slide on to make a point and that is a lot of the stuff youre hearing from people who advocate newer or innovative type of thinking/therapy. Here are some examples of some things that were considered controversial in my lifetime. But we know now that indirect pulp caps not only work but are superior to removing decay. Dental sealants were once considered controversial and in fact are still by some dentists who do not believe that sealing over decay will arrest the lesion. Again, its an effective conservative therapeutic approach that works. People are still fighting this concept that you cannot reverse or arrest caries. Fluoride is superior to CaOH as a pulp liner. I do believe there are still parts in the dental school that use CaOH under restorations. Big problem with that in my book. Extensive literatures showing CaOH while equally effective as fluoride in promoting pulp healing, CaOH has other major side effects that fluoride does not have such as internal resorption and pulp remineralization. Think twice before you put a liner in with CaOH because it MAY have not always some detrimental reactions by the pulp while fluoride has neither of those reactions. That a tooth that is traumatized or avulsed that has a pulpotomy in it after trauma that you absolutely must do RCT after thatjust not true. There are number of studies and I have some personal experience with this, where often the tooth heals by itself. So a lot of the traditional values that have been promoted for decades or longer in the dental profession have been gradually proven to not hold up to scrutiny as far as statistically. Another example that I just thought ofprophylactic 3rd molar extractionoral surgeon earn half of their income on thatremoving 3rd molar in teenagers because orthodontists are afraid its going to crowd up their anterior teeth after they do their orthodontics. No evidence for that, never been shown to be true. We do stainless steel crowns in pediatric dentistry all the time. We dont get a good seal on them right. We think thered be secondary decay under them sometimes right. Never happenswere not sure whywe think it has to do with the chemistry in the crevice and gingival sulcuswere not really sure but no one has ever seen secondary decay under stainless steel crowns, which means that were getting some sort of a seal in there. So even on a badly decayed primary tooth that you need a crown on, you can still do indirect pulp therapy even though one of the critical components to being successful is getting a good sealit works with stainless steel crown. And of course the whole issue of how does fluoride work? When I was a dental student, we were all learning it works by ingesting it and coming back and incorporating itself into the tooth structure and we now know pretty clearly at least the present thinking right nowwhich may change again as more research is donebut its the topical nature of fluoride that prevents decay not systemically.

Slide 35 Disease Management (Therapeutic vs. Surgical)So this whole thing about leaving decay and doing conservative therapynot drilling and fillingwell its controversial nowI think as you guys mature and progress in your career, its going to become more and more the standard of care. Thats going to involve major changes in the way we get reimbursed, the way insurance companies deal with payments etc.

Slide 36 Another promising therapy we will NOT discussThere are many agents we use, the major one being fluoride. I mentioned already fluoride varnish. You will be applying fluoride varnish when you head out to outreaches. That is still the major agent we use nowadays for prevention and other interventions such as remineralization and arresting decay. Any of you heard of silver diamine fluoride. This is a product that is a version of varnish but its got that silver ion that I mentioned to you earlier in silver nitrate. This has just been approved by the FDA about 3 weeks ago. It has never been available in the US. Its been used worldwide for decades as was fluoride varnish by the waywell its never been approved here. It was approved here as a sensitivity agent not as an anti-caries agent. We use it off label. Interesting right, thats never been approved as an effective anti-caries agent yet its the standard of care for prevention. Silver Diamine fluoride is used similarly to fluoride varnish but its been actually shown to be a little more effective. Again, we have this issue again as we do with silver nitrate. Its the silver ion that becomes a compound that turns the decayed dentin black. Theres actually research going on right now to counteract that by potassium iodide being applied on top of that to remove that. Once that happens, I think you will find that this is going to be the new agent that everyone going to be talking about. So even better, maybe theyll find a way to combine the two into one agent. The big objection is not the effectiveness. We all know its extremely effective. Its that darkening/black color that stains the dentin, thats the objection to using it

Slide 37 Two teeth treated with silver diamine fluorideHeres what it looks like. Here are two teeth that were treated with silver diamine fluoride. Here we see a cavitated lesion where you can see by the color and its hardthis is what arrested decay looks like. And this one was never cavitated. This is not just staining. This was actually what applying a silver compound to a non-cavitated fissure or pit would look like. Not particularly objectionable. Many people have natural staining like that thats hard to remove anyway. This makes these fissures less permeable and less incline to become carious and a lot easier to do than a sealantand you dont have retention issues. Something to think about and something I think youll be seeing a lot more of in the future

Slide 38 Another Therapy We Will NOT DiscussAgain, stuff were not going to spend a lot of time on because as this emerges into a product, you will hear more details. Heres some preliminary readings about how its used and applied

Slide 39 Fluoride Varnish and ApplicationHere are some of the traditional therapeutic agents we use now. All of these are varnishes. Heres how theyre applied. Usually we use the brush but sometime you can use a cotton applicator or even the tip of an explorer if you really want to get into grooves and fissures.

Slide 40 Adjunctive products to assist in remineralizing or arresting carious lesionsHere are some of the other products. OTC fluoride rinses. Any child with any caries risk should be on this in my opinion. Its cheap, no prescription required, a daily rinse in addition to twice a day brushing will increase the likelihood that any incipient lesions developing in the child will either stabilize or remineralize rather than progress. Heres a form of ReCaldent, calcium and phosphate ions that are delivered right to the teeth by wiping on the teeth. This is MI paste. We use this in our clinic as well. This is a prescription toothpaste with 5x the fluoride of normal toothpaste. Instead of a 1000ppm, we have 5000ppm. This again we prescribe to high-risk children. Children who are likely to get decay or already have had dental caries.

Slide 41 The Medical Model of CareThats our repertoire of agents that we use when were trying to use this medical model care. Again, I will talk to you more extensively about this in November. This is the paperModern Management of Dental Cariesas you can see its already 20 years oldMax Anderson was the authorwonderful thing about this paper, it did not appear in the pediatric journal, it appeared in the Journal of the American Dental Association as you can see which meant everybody was reading it. You dont have to read it but you benefit by reading it. He gives you what all of us love to have. A cookbook approach to how do you do this. Whats the regimen, how do you do it, when do you do it, why do you do it. Why does this work better than traditional drill and fill dentistry. So again well talk more about the details of it but this is what he talks aboutthat were being pretty ineffective with our present surgical model and that while open lesionsand these are terms he usessequestering of the infection are vital to success, the therapeutic intervention mostly fluoride really ensures us that this is going to work. The trick is getting patient to comply with that. And therefore not only do we have to buy into it; the patients have to buy into it. We dont do such a good job with that as dentists

Slide 42 The Key is Diagnosisand Risk AssessmentWere spending more time worrying about billing those Class II and crowns than we are spending time working on the patients for prevention. So the key is diagnosis not how many fillings they need and its a disease intervention model focused on diagnosing and treating the bacterial infectionnot the lesionsthe lesions are not the disease. Its very interesting. You go to professional meetings and many of your lecturers are going to stand up here and talk to you about caries on the tooth. Its not correct. Dental caries is not something you can see. Its the disease. You can see the cavity and cavitation. You can see the result of dental caries. If you have diabetes, you cannot see a diabete. You have a disease called diabetes, there is no lesions right. Even in the profession among very educated people, its misunderstood and not used properly. So Im a stickler for terminology but I think as professionals, its a little embarrassing when it happens.

Slide 43 Effectiveness of Fluoride VarnishSo a little bit about fluoride varnish. Again, we talk about this in D1. I know I gave you a very early lecture on the different types of fluoride we use. Very successful in reducing caries in permanent teeth

Slide 44 Fluoride Varnish: Therapy of choice for preventing, controlling or reducingIts the therapy of choice right now because of all these great advantages. Its safe for childrenno ingestion. Thats always a problem that the anti-fluoridation is concerned aboutswallowing too much fluoride. It has extended contact with enamel. These are all the nice things. It dries under moisture; you dont have to keep it totally dry. All the benefits, why we use it universally pretty much these days.

Slide 45 Hypothesis: Intensive fluoride regimens can arrest decay in cavitated lesionsGels are gone. All the other modalities of delivering it are gone. Its pretty much varnish varnish varnish. Heres our hypothesis based on this conservative approachthat intensive fluoride can arrest decay in cavitated lesions and remineralize teeth with non-cavitated, incipient carious lesions. Heres some study that talk about that

Slide 46 Therapeutic Remineralization (14 year old)Heres some proof. I have other radiographs to show you. Here are some examples from my own patients where we actually documented some of these things. Heres a 14 year old over a period of a year which showed on the initial radiograph a E2 lesion and here it is a year laterIm not sure which regimen this child was on but my guess is we added the OTC rinse in addition to the 2x a day brushing right before bedtime, rinse with one minute the OTC (0.5%) rinse and after 1 yearpretty impressivenot only have they not progressed, they look a little more mineralize to me. Normally I can assure you when I was in dental school, this was a MO/DO here. This is evidence of a few things. One, that weve come a long way. Two, now we have products that can remineralize. And yes hard tissue can definitely be remineralized.

Slide 47 Arrested CariesSo as far as arresting caries, this is what arrested caries look like. Here it is in primary molars. There is arrested decay here. Even teeth like this, probably not going to cause any problems. As dentists, were just dying to pick up that hand piece and put stainless steel crowns on those teeth. I can tell you honestly from my experience if you just left these teeth alone and did nothing, the decay cannot progressed because this decay has arrested. Once decay arrests, it does not un-arrest and it does not continue to progress. These are arrested and theyll stay like this for the life of the child. They have a characteristic appearance.

Slide 48 So, what is this process weve come to know as ARRESTED DECAYIf you look at a radiograph, it has a horizontal nature rather than a vertical nature. It doesnt barrel its way towards the pulp. It just flattens out and the pulp gradually recedes from it. Youll never get a clinical exposure. Theyre darker in color, harder in texture, and slow in progression. Sometime, they dont progress at all depending whether theyre fully arrested or on their way. Heres some pretty crummy mouth. But again, a child like thismy guess is this child treated with intensive fluoride which Im going to talk about in a minutethe teeth were not restoredand these teeth would normally exfoliate around 6.5 to 7.5 years of ageif this child was 4 nowcould go all that time without worrying about it. The only reason for restoring this is for cosmetics. As far as disease progression or treatment of disease, theres really no reason to be doing that anymore

Slide 49 Histological DifferencesThis is a big change because of not covering decay still irritates most dentists including many of my colleagues in pediatric dentistry. This is a little piece I picked out. I was trying to read up a little bit about what is arrested decay. I dont really have a good definition for you. This talks a little bit about some of the zones that you find. So Ill let you look it over. I couldnt really find a good definition of what arrested decay was. I would love to see any references about what exactly is arrested decay and the nature of it

Slide 50 Risk Factors (Individual)You all know about risk factors. Im not going to spend a lot of time on that. We talk about in public healthindividual risk factors and we talk about community risk factors...theyre very differentjust like epidemiologic research versus individual research.

Slide 51 Risk Factors (Community)These are certain risk factors when we look at a community.

Slide 52 Application FrequencySo one of the important parts, if youre going to talk about therapeutic, one of the very important things is to know what youre doing and why youre doing it. Unfortunately, theres very little data on this. But the application frequency is what really makes this work. One fluoride varnish application is not going to suddenly arrest dental caries or the results of dental caries. Its not going to result in a cavitated lesion arresting. But multiple might. Also agents like silver nitrateone or two applicationsthe literature is not always clear on thatIve seen some literature where it says only one applicationsome of it Ill show you it at the end, they recommend a pretty intensive regiment. So a lot of this stuff is just emerging as far as the disease management approach but to be effective with non-cavitated lesions, you must have multiple applications. Thats why the rinseits the beauty of the rinse. The child is getting it every night over and over again. Youve all heard of constant low-dose fluoride is the way to go in terms as far as prevention and remineralization. So here you see some data about how it works and that you get significant caries reduction in these studies.

Slide 53 Application Frequency (There is no single protocol)No single protocol seems to be the standard. Different people seem to do different things. The ADA recommends one thing. The US Navy recommends another. So different practitioners have different versions of this. What we do have in common is were all wiling to try it and were all pretty successful at it. So one of these days when we get some good data, we will have an actual standardized regimen for doing this

Slide 54 Onset of ECC Early Demineralization Lets look at some examples. So heres a 10-month-old babywalks into your office and this is whats in their mouth? Whats going on here? We have the early signs of demineralization. You may be beginning to see the edges start chipping. Soon you may start seeing some cavitation either on the facial or possibly interproximally. You just dont know how this is going to progress. But already at 10 months, were a little late. Wouldnt it have been nice to educate the parents and have them avoid this? When we talk about early intervention, we mean really early intervention. Sometimes pre-natal is the best time. This is why the Academy of Pediatric Dentistry recommends a dental visit by the first year but often even that can be a little late. First year or the eruption of the first tooth. I recommend as soon as the baby is born, the parent should be in the mouth with a piece of gauze wiping the gums. Why? To get them use to itlet the kid know. You see these parents come into our clinic with their 3 year old and look like theyve never had a toothbrush on their teeth. You have to get in early. The children when youre in their mouth early, it becomes a routine.

Slide 55 - How about this case?Heres a 1 year old. Hes got his 4 upper and lower anteriors and yet you already got some problems here. No this is not tetracycline staining/hypoplasia. This is demineralization. You can see it by the texture and quality of the gingival tissue. This is a child probably sucking on a bottle at nightbeing stuff with sorts of snack food/chip whatever. No semblance of oral health careno tooth brushingno wiping with gauzeprobably no supplemental fluoride being given either

Slide 57 An older childSo heres an example of wherewhat do you do when you see thatthe first thing a dentist does is put a composite in therethats not solving the problem. You want to teach the parent about why this happens so it doesnt continue happening. You know you do get a 2nd chance in life at least with your teeth. The earlier you start the better. They should know what this is caused bywhat they can do to avoid it and then put them on a therapeutic program. First, see if they can follow some directions and arrest the decay somehow and then worry about the cosmetic part of it. So heres an example where after a few months, theyve gone from here to here [left to right]. But this is definitely a little darker and harder in texture.

Slide 58 How would you handle this? What are your priorities?Same thing here. We didnt do anything here as far as restorationsthat will come later if they want it. This is on the lingual of the upper incisorsno one can see them anyways. Were more concern about controlling the disease and keeping it under control. Kid is not even 2 yet. What are you gonna do? You think theyll sit in the dental chair and let you treat them. Again these are all done lap-to-lap, knee-to-knee. You need something you can do quickly yet effective and thats where the fluoride varnish comes in

Slide 59 3 months of intensive Fl- varnish and Prevident 5000%...Heres a little more dramatic. Same case. You can seenot even a year old11 months old and in a few months, weve gotten this. We used 3 months of intensive varnish and Prevident 5000 for the second brushing. One brushing with regular toothpaste and nighttime brushing with Prevident.

Slide 60 So, what are the protocols for therapeutic intervention to combat dental caries?So what are the protocols? What do we recommend to you if youre going to practice this way?

Slide 61 The following regimens are:First, my disclaimer. Again, I try to only give you evidence based stuff. Unfortunately, for some of this, there is no evidence. These regimens are not only based on my personal experience but also the experience of many of our faculties and many pediatric dentists around the world. A lot of it is anecdotal and empirical except for the preventive regimensthat we do have as youll see.

Slide 62 Preventive RegimenThe 2006 Weintraub study, a definitive study that validated fluoride varnish as the most effective way to prevent dental caries. A terrific study done by very top-notch people. This has become the standardthe reference that everybody says now we have the literature for it. They got pretty impressive results. Reductions ranging from 53-93%. What they did was follow groups up to 3 year. They started applying twice a year varnish on 1 year old and of course had a control group. The difference on the control group was up to almost twice fewer caries than the control group

Slide 63 Preventive Regimen (cont)So the preventive regimen recommended is pretty surprising. It brings up another point about overtreatment. Even in our own pediatric clinic, when you bring in a patient for recall, pretty much whether theyre decay free or have extensive decay, they get a fluoride treatment. Notice that the recommended regimen for a child who is caries free or really low risk really does not need fluoride. What its telling you is that theyre getting enough fluoride and theyre probably going to stay that way. Does it hurt to do the varnish? Probably not, its extremely safe, its low-cost. If it were my child, Id do it anyways, similarly with sealant but theres not a lot of evidence showing that youre getting better outcomes on those children. Frankly, dealing with the underserved population, I think its proven to actually do it even though the recommendation is that these kids dont need it. Some of these pediatric practices from Long Island to Manhattanits like the day the child comes in at 1 or 2 up to until theyre teenagers, they never had a cavity in their mouth yet every 4-6 months, theyre getting fluoride varnish during their checkup. I think thats a little over treating. Its benefitting the dentist more than the child. This is in the area of controversypractice patternseffectiveness of the agents. We could talk for weeks about that but this is the recommendation from that study. Moderate or high risk patients 2 4 a year. Two for the moderate reallythe child shows some risk factors but up to 4 times a year. Even Medicaid pays for 4 times a year in New York. For high-risk caries, you should be getting them every few months but of course the key is what they do at home. Without a doubt, the one evidence based strategy about avoiding and preventing caries is that twice a day brushing with the fluoride toothpaste, not just the brushing. We learn that as a dental student, you break up the plaque and it forms every 24 hoursno plaque no decay. The evidence says only with the fluoride toothpaste are you reducing decay. These are the references for the recommendation

Slide 64 Regimen for RemineralizationSo heres the new stuff. Heres the regimen for remineralizing. If you want to remineralize a tooth even if it has a lesion, instead of worrying about filling it, you want to get the disease under control first. Heres what you do. You apply FV intensively (3 applications in 3 weeks). Now you cant send fluoride varnish home with the parents. Its too concentrated and not considered acceptable. Frankly, I dont see the big harm in doing that but its just not done. We let parents do other things at home just not varnish. What this means is that theyve got to come back to the office every week for 3 weeks. Usually, you can frighten the parent when they walk in with a child like that and hold up an advanced ECCheres whats gonna happen. Its all true. Its not like youre telling them a lie or anything but they need to get right on top of this thing. They do seem to come back. Whats critical is reinforcing and accelerating that strategy at homekeeping those teeth brushed with fluoride toothpaste and thennow you cant give a 1 or 2 year old OTC fluoride rinse because theyre gonna swallow it so we use other modalities such as Prevident as the toothpaste for the 2nd brushing or we use MI paste ReCaldent which is something you can just rub on with your fingers 2x a day. That works very well too. What we started doing lately is you have them buy the OTC rinse and we have them apply it with a cotton tip applicator and just swab it around the mouth. No evidence that that really works but how can it hurt. So frequent application of low dosage fluoride. Thats the regimen for remineralization

Slide 65 Therapeutic Remineralization (6 year old)Here are a couple more examples of where you have clear incipient lesions that have been since remineralized over a period of 6 months from July to Jan.

Slide 66 Remineralization using Prevident 5000+ (4-5 year old)Heres another one over a little longer period (1.5 years). Of course, its nice looking at the longer ones because you might ask yourself does it really last? And they do last. Whats different about remineralization and arrestingI mentioned once you arrest they stay arrestedthats not necessarily true for remineralization. Remineralization needs an ongoing therapy that youre doing. So a sudden stop may cause reoccurrence because the bacteria is going to come back

Slide 67 Regimens to Arrest CariesOne of the other thing fluoride does besides strengthen the tooth crystal itself, it keeps the bacterial count down. When I was a dental student, we didnt know that. It was not known that fluoride suppress the microbes. Its only since the 80s that we know that. So in addition to acting on the hard structurehelping with that remineralizationit also keeps the bacterial count low. The regimen to arrest caries is a little more intensive than the remineralization. It starts out the same with the 3 initial applications but the we need the patient to re present themselves to the office for the next 4 monthsonce a month for 4 months. Thats where we run into problems with compliance and we lose people along the way. Thats something thats gotta be worked on but unfortunately, it takes a whileremember the remineralization while youre giving those 3 intensive applications in the officewhat youre really counting on is the extra compliance at home, but it seems to be critical for the remineralization. In the arresting part, you should see at the end of the 5 months, you should actually see clinical arresting of decay physically. While all this is important, that they maintain this, its mostly for prevention of future lesions. Again youre not going to unarrest what youve already arrested.

Slide 68 Arresting caries with intensive Fl- varnish (4 months)Heres just some examples of lesionagain I showed you earlier onesthese are a littleI mean look at whats on the teethits still on the teethit gets darker and harder. This is a 2-year-old child

Slide 69 In progress, treatment w/ intensive Fl- varnish (2.5 months)Here are some examples of arresting decay. Heres what the radiographs look like. You can see these large radiolucency here. No infection which makes it amenable to this. If they were infected, you would probably want to extract them or doing some RCT therapy

Slide 70 Silver NitrateThats pretty much it. Just a final word about silver nitrate. Silver nitrate is sort of in a comeback phase particularly for certain applications such as remote locations and underserved populationsvery effective as I mentioned beforejust like the silver diamine fluoride, this is something youre going to be reading about in the next couple of years.

Slide 71 Reportedly used as early as the 1840sA little more about the background. You can read this for yourself. But basically, its been used as early as the 1840s. It seems to be very effective. We know it works. It fell into disfavor in the latter half of the century. There were some suspicions that it also had adverse effects on the pulp. That has not ever been proven to be true. Others have since concluded that it penetrates the dentin. It has a mild, self-limiting, localized effects on the pulp. Again I have never heard of anybody de-vitalizing the tooth with silver nitrate. If it is, it was probably a carious lesion that was probably to progressed to begin with and already had some impact on the pulp.

Slide 72 A major disadvantageHeres another example of what it looks like. You dont need even to make a prep or open the tooth. Many of the remote locations for example where we were in Tanzania, there were nice dental chairs but they didnt even work so we had to do a lot of ART/IPC/IPT (indirect pulp caps/therapy, alternative restorative treatment). They all mean the same thing. You are just basically opening it up, scooping it out along the walls, and placing some restoration (like glass ionomers) thats going to give you a good seal and youre going to arrest whats in there and its going to heal from the inside. We did tons of that and these are the types of teeth youd be doing it on. Once you get something like this, theres really no crown left. These teeth are arrested. These are teeth I would be more incline to not do the ART or IPC and worry about putting a restoration in there. These would be perfect teeth to be treated with silver nitrate where you just paint it on and if youre not sure that theyre fully arrested, its kind of going to guaranteed that they are

Slide 73 Recommended RegimenThis is how we use it. I mentioned that if you read the literature, some people advocate only 1 application is enough which is very heartening if youre in a remote area in the world, you may not be coming back againyou may actually be benefitting the people by using it for the 1 application but Steve Duffin whos out in Oregon, hes the major advocate for silver nitrate here in the US. He has what you called the Duffin regimen. He does it at 2,4,8 and 12 weeks and he finds 90%+ of the decay arrest following that protocol. He doesnt talk about what happens if you only do it twice. Ive never seen numbers from him on that. Theres not a whole lot of good research on that stuff. This is his quote. Silver nitrate to arrest carieshe adds it to fluoride varnish which is the interesting thing... is the most cost effective treatment I have ever encountered. One drop of silver nitrate to fluoride varnish cost only pennies. Arrest of early to moderate lesions may eliminate the need to restore the tooth or allow for less invasive atraumatic restorative treatmentthats the old terminologyits now called alternative restorative treatment. His experience over the last 6 years with this protocoland this is the big thing in pediatric dentistrykeeping kids out of the hospital for general anesthesia. You get a 2-3 year old with ECC. Theres not much you can do with them. They require this 10k hospital experience after you pay for the dentistry and the operating room and the anesthesiologist and the recovery room and most of that is paid by your tax dollars. This has been a big effort particularly in NYS to reduce the number of children who get general anesthesia in the hospital. We have almost a 6 months waiting list to Bellevue. We do 4-5 cases a week. We have a 6 month backup of cases waiting to get into the OR and there are 15 other pediatric programs in the city and they have similar backups. The problem is that there are too few of them and its costing everybody lots of money. So hes interested in reducing the morbidity, the disease prevalence. Hes interested in controlling it and keeping the kid out of pain whereas the dental profession has always been more concerned about other things such as whos going to pay for it and whats it going to look like. When you speak to parents, theyre very interested in a therapy that is simple, quick, easy and practically free that is going to keep their kid out of pain. There has been this disconnect between our standards and desires and what the public really wants. Again, another reason I think youre going to be hearing a lot more about this.

Slide 74 Contact InformationThats all I have to say. Id be happy to answer any questions? [Student question] Whats the best way to detect arrested caries? You got to develop an eye for it I think. If you see it, you know it kind of thing. It takes a little bit of experience. It comes not that hard. I think our resident having seen a number of patients even by their mid 1st year, theyre pretty good at it. I think the problem in dental school, you dont get to see a lot of this. For example, if you come to our pediatric clinic as a pre-doc, these kids will all be in post-doc just because of the magnitude of the case. Its a little overwhelming for you at this point to treat that. But I certainly welcome you and invite you to come up. Our residents are wonderful. They will talk to you. They will clue you in. Watch how they work, theyre fabulousnot only how to manage kids but we really practice what we preach there. [Student question] Why dont we use fluoride for pulp capping? You mean right on the pulp? We dont ever do direct pulp capsactually the success rate of that is fairly low. Generally, when you expose a pulp, particularly in the primary tooth, you do pulpotomy. [Student question] We do use fluoride, thats the point. Our department does not have CaOH anymore for many years. The reason is as Ive mentioned, the traditional approach to a restoration thats more than halfway into dentin is to CaOH. We now know because of the 2 major side effects, the mineralizing of the pulp and the internal resorption that may be triggered and premature resorption of the primary tooth, fluoride does not have either of those 2 yet has the same ability for the odontoblasts to realign, pull back, and then lay down secondary reparative dentin. So you get the same biological response without the side effects. Both of them can be put on the pulp directly, but none of them gives you a long-term result. Usually you get a chronic inflammatory response that kind of blows up. So in pediatric dentistry what we do is we either do a Cvek pulpotomypartial pulpotomy where we only remove the area immediate around the exposure and not the whole chamberor a traditional pulpotomy where you take out all the pulp in the chamber. Theyre both pretty successful. Pulpotomy are much more successful than a direct pulp capping. A direct pulp cap is a last ditch effort to avoid RCT. In all fairness, it does work in 30-35% of the time if you look at the 5-year results but thats not very high. We like to see more 80 to 95% which pulpotomies are.