abcd pedodontia

A MANUAL FOR DENTAL PROVIDERS

By:

Department of Pediatric Dentistry Department of Dental Public Health Sciences

University of Washington

Division of Client Services Medical Assistance Administration

Department of Social and Health Services State of Washington

To Download a copy of this manual visit: http://www.dental.washington.edu/pedo

Visit the ABCD Web Site at: http://www.abcd-dental.org

February, 2001

i

ABCD A Manual for Dental Providers

Table of Contents

Section 1 Introduction

Section 2 Bright Futures in Practice: Oral Health

Oral Health Supervision Guidelines…………….……………………Prenatal…………………………………………………………………Infancy…………………………………………………………………. Early Childhood……………………………………………………….. Middle Childhood………………………………...……………………

2 6 8 13 18

Section 3 Examination of Infants and Toddlers

Examination of Infants and Toddlers………………………………..Management of the Very Young Child………………………………Coping with the Crying Child…………………………………………

24 26 27

Section 4 Family Oral Health Education

Family Oral Health Education………………………………………..Pacifiers and Sucking………………………………………………… Eruption Chart………………………………………………………… Diets of Infants and Toddlers………………….……………………..

29 35 36 37

Section 5 Prevention of Dental Disease

Topical Fluoride Varnishes…………………………………………...Fluoride Varnish Application………………………………………… Fluorides in Dentistry………………………………………………….Common Questions about Fluoride………………………………… Glass Ionomers as Sealants…………………………………………

41 49 50 56 57

Section 6 Glass Ionomer Restoration to Control Carious Lesions in Pre-cooperative Children

Glass Ionomer Restoration to Control Carious Lesions in Pre-cooperative Children…………………………………………

62

Section 7 Treatment of Pregnant Women Managing the Pregnant Dental Patient 66

ii

Section 8 Restorative Dentistry

Current Methods of Pulpal Therapy in Primary Dentition………… Space Maintainers…………………………………………………….

80 83

Section 9 Initial Assessment and Management of Infection and Trauma

Initial Assessment and Management of Infection and Trauma Recommended Treatment for Common Oral Lesions……………. Topical Anesthetics and Coating Agents for Primary Herpes Gingivostomatitis………………………………………………………

85 87 93

Section 10 How to Make a Referral

How to Make a Referral

95

Section 11 Appendix

ABCD Dental Program Benefits ABCD Dental Program Tips

Handouts for Parents

Your Baby's Teeth Fluoride Varnish

Suggested Reading

Milgrom P and Weinstein P. Early Childhood Caries. A Team Approach to Prevention and Treatment. Seattle: University of Washington School of Dentistry, 1999

iii

INTRODUCTION The aim of this manual is to provide a chair side guide for clinicians who intend to implement effective preventive and early intervention oral health therapies for infants and toddlers. Clearly, the interval from conception to three years is the most dramatic period of growth and development for the child. In nine months, a single cell, the fertilized egg, develops into a complex fully developed individual in utero. In subsequent months after birth the infant displays emotion, initiates language development, and rapidly develops gross and fine motor skills. By age three, the toddler is a walking, talking, bundle of curiosity and energy. By age three, the child usually has all 20 primary teeth erupted and has begun to develop enamel on 28 permanent teeth. Actually, enamel development on the four first permanent molars is usually completed by age two and one half to three years. For the majority of infants and toddlers in the U.S., dental development proceeds normally and the caries rate is very low. All toddlers are at risk for dental trauma as soon as they acquire their first tooth and a significant minority is also at risk for infant dental caries. A recent survey of 3rd grade children in Washington revealed that 20 percent of the children surveyed had experienced 84 percent of the caries. Clearly, there is a group of high risk for dental caries children in Washington State. We believe that this high risk group exists throughout all age groups and is manifested by the hundreds of children under four years of age who are treated for infant caries under general anesthesia in Washington's hospitals every year. With the successful implementation of comprehensive primary prevention programs for infants and toddlers, we anticipate a dramatic decrease in the prevalence and severity of caries in the primary dentition. We want to enlist your support and assistance in expanding access to preventive dental measures for all children under three years. Additional References Casamassimo P. Bright Futures in Practice: Oral Health. Arlington, VA: National Center for Education in Maternal and Child Health, 1996 Pinkham JR, senior editor: Pediatric Dentistry: Infancy through Adolescence. 2nd ed. Philadelphia, WB Saunders, 1994. Peterson DS and Davis JM: Pediatric Restorative Dentistry: A Computerized Instructional and Reference Program. University of Washington, 1995. Peterson DS and Davis JM: Pediatric Pulp Therapy: A Computerized Instructional and Reference Program. University of Washington, 1998

1

Bright Futures in Practice: Oral Health

2

BRIGHT FUTURES IN PRACTICE: ORAL HEALTH Adapted from Paul Casamassimo, 1996 Oral Heath Supervision Guidelines Oral health supervision involves regular, periodic health intervention by a dental professional. The dental professional performs a risk assessment, diagnoses existing conditions, and provides anticipatory guidance in order to promote oral health. Optimal oral health supervision occurs when there is a therapeutic alliance between the dental professional and the family—beginning between the dental professional and the parents during the prenatal period or early in the child's life, progressing between the dental professional and the growing child, and continuing to grow between the dental professional and the adolescent. Early in the alliance, parents assume responsibility for preventive and oral health procedures, but the child gradually assumes greater responsibility. This alliance creates a relationship based on familiarity, trust, and a shared history that supports health. Oral health supervision occurs over time. The frequency of intervention should be keyed to the individual's needs and developmental milestones. The interval between health supervision visits must be short enough to take advantage of change, because it is important to intercept incipient disease and to maximize opportunities for anticipatory guidance. Traditionally, a period of six months has been the interval for oral health supervision, but this guide strongly encourages assessing each child's individual risk, in order to address normal growth and development issues (such as nonnutritive sucking and the need for dental sealants) and to provide care more efficiently. Some children will need more frequent dental visits if they are at higher risk; children with low risk, stable environments, and demonstrated wellness habits may need less oral health supervision. Past experience and current oral health status may be a key to determining appropriate intervals for a child. The success of oral health supervision depends to a large degree on the relationship or alliance between the family, dental professional, and other health professionals. Successful oral health supervision also depends on the systematic assessment of risk; the prevalence of protective factors; the consideration of community, familial, economic, cultural, and social factors; and the integration of oral health with general health initiatives for the child. Components of Oral Health Supervision Family Preparation Just as the dental health professional prepares for oral health supervision, families need to prepare, too. Families can gather health information, prepare questions, and complete forms in anticipation of the health supervision visit. This step is an essential component of oral health supervision, and the dental professional should guide the family in how to prepare. Between health supervision visits, the child and the family might assess how well the child is complying with recommendations, and then determine how the self-assessment compares to the dental professional's assessment of the child's performance.

3

Periodicity and Services The periodicity of services included in these guidelines is based on what most infants, children, and adolescents need. The periodicity listed under the term ‘‘health professional" refers to the general preventive care the child or adolescent receives, usually from a nurse or physician. (The recommended periodicity listed in this guide is the same as that listed in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.) This periodicity is not meant to suggest supplemental visits to health professionals specifically for oral health; rather, within the context of health supervision visits with children and adolescents, health professionals can reinforce the oral health messages provided by a dental professional. All health professionals have an important role in educating and screening children to ensure that they are receiving the oral health care they need. The periodicity listed under "dental professional" refers to preventive and health promoting services provided by an appropriately trained dental professional. In addition to educating children and families, the dental professional examines the child or adolescent and uses oral health risk assessment to decide on appropriate interventions and guidance. The first dental visit is recommended by age one, with the aim of intervening early and providing appropriate counseling before the caries process develops. Health Supervision Interview The goal of the interview is to ascertain key issues that should be addressed in the health supervision visit. The interview needs to address information gleaned from previous health supervision visits, as well as issues specific to the age and development of the child. The dental professional needs to assess whether the child or family has assumed personal responsibility for oral health and demonstrates a sense of mastery and consistent use of preventive oral health care. As the child matures and becomes more responsible, the dental professional should discuss these issues directly with the child or adolescent. During the interview, it is important to listen to the family members in order to learn what they want and expect and how they view oral health. Do the parents believe it is realistic for their child to have a healthy mouth, free from dental caries? Do the parents feel empowered to teach their child good oral health practices? Does the child think it is possible to have healthy teeth with no decay? How does the adolescent feel about dental visits? About the appearance of her teeth and smile? Trigger questions, which address age-specific oral health issues and risk factors that are relevant to the child and family, can help guide the interview. Cultural, economic, social, and environmental factors influencing the family and child should be considered. Observation of Parent-Child Interaction Since parents are the child's primary teachers of healthy habits, interactions within the family can have a major impact on oral health. Watching parents with their children in the dental setting provides clues to learning strategies, potential behaviors, and

4

difficulties (and, in the extreme, parental child abuse and neglect situations). If children are clinging to the parents, especially at three to six years of age, their parents may need extra support to encourage independence. Detached and depressed children who are afraid of parental and other adult reactions may signal an abusive home situation. Observing how parents communicate with and motivate their child at early ages can indicate the strengths and difficulties parents may have in guiding oral hygiene efforts. Later, in middle childhood and adolescence, the dynamics between parent and adolescent when discussing habits and behaviors is also revealing. It can indicate difficulties or strengths in the relationship that will affect the adolescent's compliance with anticipatory guidance suggestions. Oral Exam and Diagnostic Procedures While physical risk factors can be noted during general screenings by other health professionals, an oral exam by a dentist is a vital part of health supervision because it provides evidence about the condition of the gums, teeth, and occlusion. It is an empirical way to measure oral health, the success of preventive interventions and treatments, and attainment of good oral health outcomes. Traditionally, the goal of the oral exam has been to identify disease. In the context of developmentally based health supervision, another critical goal is to identify risk factors. In addition to gaining information about the progress of disease, dentists should use the oral exam to thoroughly evaluate the child's or adolescent's physical risk factors and perform a risk assessment. Particularly with children under age three who may have no obvious disease, assessment of physical risk factors such as plaque can be done only with information gained through a thorough exam. In the adolescent, visual signs of tobacco use discovered in the oral exam can predict more serious problems later. Dentists may also need radiographs, if indicated, to assist in diagnosis, though radiographs are not used as a routine part of the exam. Other less common diagnostic procedures can include saliva tests or cultures of caries-causing bacteria, such as mutans streptococci. Risk Assessment Risk assessment provides the dental professional with the opportunity to tailor periodicity and oral health supervision to the individual's level of risk for specific diseases, conditions, and injuries. This assessment involves identifying risk factors that may negatively impact a child's oral health, and protective factors that promote oral health. Risk assessment allows health professionals to individualize intervention by focusing resources and education on specific components of oral health according to a child's risk and protective factors. The risk and protective factors are organized according to four major dental problems: dental caries, periodontal disease, malocclusion, and injury. The guidelines indicate which factors can be an issue for all ages of children, and which are most common at a particular developmental period.

5

Anticipatory Guidance Anticipatory guidance refers to the information provided to the child and family about the child's current oral health and what to expect as the child enters the next developmental phase. The guidance should be modified based on the risk assessment. The dental professional, for example, can not only remind an 11 year old and his family about the importance of wearing a mouth guard while playing soccer, but can also discuss how dental sealants will protect the second permanent molars, which should erupt in a year or two. Through advance discussion of dental sealants, the family learns about the procedure before the next dental visit, considers its benefits, and is better prepared to ask more informed questions of the dental professional. When providing anticipatory guidance, the dental professional is encouraged to discuss age-related risk and protective factors. The health professional can explain to families, for example, that inappropriate use of the baby bottle can produce baby bottle tooth decay (BBTD) in infancy and early childhood, increasing the risk of caries later in childhood. Discussing tobacco use as a risk factor for oral soft tissue problems becomes important to the middle-school child and the adolescent. It is also important for the dental professional to reinforce the key messages of anticipatory guidance in subsequent oral health supervision visits. Review As the need for accountability in health care increases, utilization review, outcomes assessment, and continuous quality improvement—new terms for many dental professionals—become more important. Additionally, individualized risk assessment, which requires more sophisticated tracking of individual progress and community risk profiles, needs automated and organized data. The review section suggests several sources of information that could indicate whether oral health supervision has been provided appropriately. This section, rather than being all-inclusive, describes the range of sources of information that can be adapted and used for utilization review, outcomes assessment, and continuous quality improvement. Outcome The success of oral health supervision can be measured by whether the child or adolescent has achieved certain outcomes. Measured outcomes will also help guide the dental professional in determining the necessary periodicity for subsequent visits, and in providing the appropriate anticipatory guidance. The guidelines include a list of general outcomes that are comprehensive, behavioral, and physical outcomes, since sustainable health promotion requires knowledge and effort as well as the ability to achieve a certain health status. The outcomes are keyed to developmental stages and thus represent clear and useful tools to determine intervals for oral health supervision, particularly when risk is low. These general outcomes can be refined for each child.

6

PRENATAL Family Preparation for Health Supervision Be prepared to discuss at your first visit:

• Your dental history • Dental history of baby's family • Questions about oral health aspects of pregnancy • Any other questions about oral health

Periodicity and Services Health or Dental Professional

• Oral health supervision can be reinforced at the prenatal visit (usually with the health professional):

• Education of the parents concerning fluoride supplementation, first-year oral development, nonnutritive sucking habits (sucking on thumb finger, or pacifier), breast feeding, bottle use, teething/tooth eruption, oral hygiene after tooth eruption

• Scheduling and provision of dental education and treatment for parents before infants birth

Interview: Trigger Questions To be used selectively by the health or dental professional. Discuss any issues or concerns of the family.

• What questions do you have for me today? • Do you have any problems with your teeth? • Does you family have any inherited problems/diseases affecting the teeth? • Do you know the fluoride status of your drinking water? • Are you brushing and flossing regularly? • When is the last time you saw a dentist? • Are you taking prenatal vitamins? • How do you plan to feed your baby? Breast feeding? Formula? Why? • As your child grows up, do you think you can help your child prevent dental

caries (the disease process that leads to "cavities")? What kinds of things do you want to do to protect your child's teeth?

Anticipatory Guidance

• Obtain a dental checkup and treatment for yourself before the birth of the baby. • Do not use baby walkers at any age. Tell family member not to give you one as a

gift. • If you plan to bottle feed: To avoid developing a habit that will harm the child's

teeth, do not put the baby to bed with a bottle, prop it in the baby's mouth, or allow the baby to feed "at will."

7

Review • Mother's prenatal record • Attendance • Appropriate screening/referral • Follow-up • Utilization review (appropriateness/quality of care) • Policies of health professional and dental professional regarding quality of care

Outcomes

• Parents are informed of issues relating to preventive dentistry and oral development

• Parents understand they should not put infant to bed with a bottle • Parents obtain dental information and individual treatment at appropriate

intervals before the baby's birth

8

INFANCY Family Preparation for Health Supervision Be prepared to give updates on the following at visits to a health or dental professional during infancy:

• Supplemental fluoride and vitamins • Changes in the source of the water used for drinking, cooking, or formula

preparation (bottled water, etc.) • Use of bottle, cup • Injuries to the mouth or teeth • Infections in the mouth • Medications, illnesses • Oral hygiene procedures (frequency, problems) • Changes in teeth present in the mouth • Thumb sucking or pacifier use

Periodicity and Services Dental Professional

• If indicated by the infant's needs and/or susceptibility to disease, at health professional's referral:

• Treatment for injury/dental disease • Recognition and reporting of suspected child abuse/neglect • Education and anticipatory guidance for parents concerning fluoride

supplementation, oral development, nonnutritive sucking habits (thumb or pacifier), bottle use, teething/tooth eruption, tooth cleaning, injury prevention, dietary habits

• Referral, as needed, to other health professionals Health Professional

• Health professionals can provide oral health supervision within the context of the health supervision visits during the first year— suggested at birth, 1 week, and 1, 2, 4, 6, and 9 months:

• Screening • Oral health risk assessment • Recognition and reporting of suspected child abuse/neglect • Education and anticipatory guidance for parents concerning fluoride

supplementation, oral development, nonnutritive sucking habits (thumb or pacifier), bottle use, teething/tooth eruption, tooth cleaning, injury prevention, dietary habits

• Referral as needed to other health professionals Interview: Trigger Questions

• To be used selectively by the health or dental professional. Discuss any issues or concerns of the family.

• How is feeding going?

9

• How well does Julia fall asleep? Do you give her a bottle in bed? • Is Hannah easy or difficult to console? • What drinking water do you give to Ana? • Does Nikita use a pacifier? Does she suck her thumb or finger? • Do you put Celeste in a safety seat when she rides in a car? • Are you brushing Alexander's teeth? How has this been going? • How much toothpaste do you use on baby's brush? • Do you have a family dentist? • Have you made an appointment for Carlos' one-year dental visit?

Observation of Parent-Child Interaction

• Are the parent and infant interested in and responsive to each other (i.e., sharing vocalizations, smiles, and facial expressions)?

• Is the parent aware of environmental risks, yet supportive of the infant's emerging autonomy and independence?

Oral Exam and Diagnostic Procedures As part of the complete oral exam, the following should be noted:

• Pathologic conditions • Developing dental anomalies • Risk factors

10

Risk Assessment: Dental Caries RISK FACTORS PROTECTIVE FACTORS All Ages: Examples

All Ages: Examples

Inadequate fluoride

Optimal systemic and/or topical fluoride

Inadequate oral hygiene

Good oral hygiene

Poor family oral health

Access to care and good oral hygiene

Poverty

Access to care

Frequent snacking

Reduction in snacking frequency

Special carbohydrate diet

Preventive intervention to minimize effects

Frequent intake of sugared medications

Alternative to minimize effects

Reduced saliva flow from medication or irradiation

Saliva substitutes

Variations in tooth enamel; deep pits and fissures; anatomically susceptible areas

Sealants (if possible) or observation

Special health needs


Previous caries experience

Increased frequency of supervision visits

Gastric reflux

Management of condition

High mutans streptococci count

Reduction of mutans streptococci

Infancy: Examples

Infancy: Examples

Bottle used at night for sleep or "at will" while awake

Prevention of bottle habit and weaning from bottle by 12 months

High parental levels of bacteria (mutans streptococci)

Good parental oral health and hygiene

History of baby bottle tooth decay

Increased frequency of supervision

11

Anticipatory Guidance Throughout Infancy:

• Use an infant safety seat that is properly secured at all times. • To avoid developing a habit that will harm the child's teeth, do not put the baby to

bed with a bottle, prop it in the baby's mouth, or allow the baby to feed "at will." • Most infants do not get their first teeth until after six months, and some will not do

so until after one year. Teethers may be irritable. • Familiarize yourself with the normal appearance of your baby's gums and teeth

so that you can identify problems if they occur. • Many babies need extra sucking. If the infant is receiving enough milk and

growing well, sucking a thumb or pacifier may help calm the infant and will not harm the teeth during infancy.

• Try to console the infant, but recognize that the infant may not always be consolable, regardless of your efforts. Accept support from your partner, family members, and friends. If you feel overwhelmed, discuss it with your health professional.

• Always keep one hand on the baby on high places such as changing tables, beds, sofas, or chairs.

• Keep all poisonous substances, medicines, cleaning agents, health and beauty aids, and paints and paint solvents locked in a safe place out of the baby's sight and reach.

• Use safety locks on cabinets. • Install gates at the top and bottom of stairs, and place safety devices on

windows. • Lower the crib mattress. • Avoid dangling electrical and drapery cords. Ensure that appliances are out of

reach. • Keep pet food and dishes out of reach. Do not permit the baby to approach the

pet while it is eating. • Do not use an infant walker at any age. • Always use a safety belt or infant seat when placing the infant in a shopping cart.

At six months:

• Begin to offer a cup for water or juice. • Clean the infant's teeth with a soft brush, beginning with the eruption of the first

tooth. • Give the infant fluoride supplements only as recommended by the health

professional, based on the level of fluoride in the infant's drinking water. At nine months:

• Encourage the infant to drink from a cup. If bottle-feeding, begin weaning from the bottle.

12

Review • Chart with assessment of child's oral health. • Appropriate screening/referral. • Follow-up. • Utilization review (appropriateness/quality of care). • Policies of health professional and dental professional regarding quality of care.

Outcomes

• Parents are informed of oral development and teething issues. • Parents are informed of and practice preventive oral health care, including

brushing infant's teeth with pea-size amount of fluoridated toothpaste. • Infant rides in car safety seat. • Infant's environment is safeguarded to protect against oral facial injuries. • Infant receives appropriate fluoride supplementation. • Infant has no active carious lesions. • Infant has healthy oral soft tissues

13

EARLY CHILDHOOD Family Preparation for Health Supervision Be prepared to give updates on the following at the visits during early childhood:

• Supplemental fluoride and vitamins • Changes in the source of the water used for drinking or cooking (bottled water,

etc.) • Use of bottle, cup • Eating habits • Injuries to the mouth or teeth • Infections in the mouth • Medications, illnesses • Oral hygiene procedures (frequency, problems) • Changes in teeth present in the mouth • Thumb sucking or pacifier use

Periodicity and Services Dental Professional

• Every 6 months, or as indicated by the child's needs or susceptibility to disease, as determined by a primary care dentist:

• Examination • Oral health risk assessment • Recognition and reporting of suspected child abuse/neglect • Education and anticipatory guidance for parents concerning fluoride

supplementation, appropriate use of dental sealants, oral development, nonnutritive sucking habits (thumb or pacifier), bottle use, tooth eruption, tooth cleaning, injury prevention, dietary habits

• Preventive dental procedures • Guidance of developing occlusion • Treatment of injury/dental disease • Referral, as needed, to other health professionals

Health Professional

• Health professionals can reinforce oral health supervision within the context of other health supervision visits— suggested at 12, 15, and 18 months, and 2, 3, and 4 years:

• Screening • Oral health risk assessment • Recognition and reporting of suspected child abuse/neglect • Education and anticipatory guidance for parents concerning fluoride


• Referral, as needed, to dental professional

14

Interview: Trigger Questions • To be used selectively by the dental or health professional. Discuss any issues or

concerns of the family. • Do you help Lynne with brushing her teeth? How has this been going? • Does Brittany's brother have fillings? Have you had any problems with your own

teeth? • Are you using fluoridated toothpaste on Bassam's teeth? • Do you know about dental sealants? • What would you do if JoAnne knocked out one of her teeth? • Does Benita drink from a cup? Does she take a bottle? • How often does Marie snack? What does she usually eat? • Does Marcos use a pacifier? Does he suck his thumb or finger? • Have you taken Michael for regular dental checkups? • When did Lee have his last checkup with a nurse or doctor? • When did he last get immunizations?


• Is the parent positive and supportive during the dental visit, helping to reduce anxiety?

• How does the parent help to relieve the child's anxiety? • Does the parent seem concerned about the oral health of the child?

Oral Exam and Diagnostic Procedures As a part of the complete oral exam, the following should be noted: Tooth eruption Caries Plaque accumulation Baby bottle tooth decay Dental injuries Pathologic conditions Developmental dental Risk factors At two-year exam, the professional should also check for: Malocclusion

15

Risk Assessment: Dental Caries

RISK FACTORS PROTECTIVE FACTORS All Ages: Examples All Ages: Examples Inadequate fluoride

Optimal systemic and/or topical fluoride

Inadequate oral hygiene

Good oral hygiene



Poverty

Access to care

Frequent snacking

Reduction in snacking frequency

Special carbohydrate diet


Frequent intake of sugared medications

Alternative to minimize effects

Reduced saliva flow from medication or irradiation

Saliva substitutes

Variations in tooth enamel; deep pits and fissures; anatomically susceptible areas

Sealants (if possible) or observation



Previous caries experience


Gastric reflux

Management of condition

High mutans streptococci count

Reduction of mutans streptococci

Early Childhood: Examples Early Childhood: Examples Bottle used at night for sleep or "at will" while awake

Prevention of bottle habit and weaning from bottle by 12 months

High parental levels of bacteria (mutans streptococci)

Good parental oral health and hygiene

History of baby bottle tooth decay


16

Anticipatory Guidance Throughout early childhood:

• Use a car safety seat that is properly secured at all times. • Give the child fluoride supplements only as recommended by the health

professional, based on the level of fluoride in the child's drinking water. • After the one-year visit, schedule the next dental appointment for the child

according to the schedule recommended by the dental professional, based on the child's individual needs and/or susceptibility to disease.

• Familiarize yourself with the normal appearance of your child's gums and teeth • Keep all poisonous substances, medicines, cleaning agents, health and beauty

aids, and paints and paint solvents locked in a safe place out of the child's sight and reach.

• Use safety locks on cabinets. • Always use a safety belt or child safety seat when the child rides in a shopping

cart. • Continue to use gates at the top and bottom of stairs and safety devices on

windows. • Supervise closely when the child is on stairs. • Ensure that the child wears a bicycle helmet when riding in a seat on an adult's

bicycle, on a tricycle, or on a bicycle with training wheels. Wear a helmet yourself.

• Teach the child to use caution when approaching dogs, especially if the dogs are unknown or are eating.

• Ask any questions you have about how to prevent dental injuries and how to handle dental emergencies, especially the loss or fracture of a tooth.

• Provide the child's caregivers with the dentist's emergency phone contacts and ensure that the caregivers are familiar with how to handle oral health emergencies.

At 12 months:

• Begin brushing the toddler's teeth with a pea-size amount of fluoridated toothpaste.

• Make an appointment for the toddler's first dental examination and risk assessment.

• To protect the child's teeth, do not put the child to bed with a bottle, prop it in the child's mouth, or allow the child to feed "at will."

• Continue to encourage the toddler to drink from a cup. Wean the toddler from the bottle.

At 15 and 18 months:

• Continue to brush the toddler's teeth with a pea-size amount of fluoridated toothpaste.

• Children under four to five years of age will continue to need help since they do not have the manual dexterity to clean their own teeth adequately.

• Schedule the toddler's first dental visit if it has not already taken place.

17

At three years:

• Begin teaching the child to brush teeth with a small amount (just a smear) of fluoridated toothpaste.

• At four years: • Ensure that the child brushes her teeth twice a day with a pea-size amount of

fluoridated toothpaste. Regularly supervise the tooth brushing. • If the child regularly sucks a pacifier or fingers or thumb, begin to intervene to

help the child discontinue the habit. • Review: • Chart with assessment of child's oral health • Appropriate screening/referral • Follow-up • Utilization review (appropriateness/quality of care) • Policies of dental professional and health professional regarding quality of care • Outcomes: • Parents are informed of oral development issues • Parents and child are informed of and practice preventive oral health care • Child receives appropriate fluoride supplementation • Child uses car safety seat or safety belt • Child wears appropriate play and athletic protective gear • Child is under the care of a dentist • Child has no active carious lesions • Child has healthy oral soft tissues • Child has functional occlusion

Review:

• Chart with assessment of child's oral health • Appropriate screening/referral • Follow-up • Utilization review (appropriateness/quality of care) • Policies of dental professional and health professional regarding quality of

care

Outcomes: • Parents are informed of oral development issues • Parents and child are informed of and practice preventive oral health care • Child receives appropriate fluoride supplementation • Child uses car safety seat or safety belt • Child wears appropriate play and athletic protective gear • Child is under the care of a dentist • Child has no active carious lesions • Child has healthy oral soft tissues • Child has functional occlusion

18

MIDDLE CHILDHOOD Family Preparation for Health Supervision Be prepared to ask for updates on the following at the visits during middle childhood:

• Supplemental fluoride and vitamins • Changes in the source of the water used for drinking or cooking (bottled water,

etc.) • Current sports and activities • Eating habits • Injuries to the mouth or teeth • Infections in the mouth • Medications, illnesses • Oral hygiene procedures (frequency, problems) • Changes in teeth present in the mouth • Thumb sucking • Use of substances (tobacco, other drugs)

Periodicity and Services Dental Professional Every 6 months, or as indicated by the child's needs or susceptibility to disease, as determined by a primary care dentist:

• Examination • Oral health risk assessment • Recognition and reporting of suspected child abuse/neglect • Education and anticipatory guidance for parents concerning fluoride

supplementation, appropriate use of dental sealants, oral development, nonnutritive sucking habits (thumb), tooth eruption, tooth cleaning, injury prevention, dietary habits, use of tobacco and other drugs

• Preventive dental procedures • Guidance of developing occlusion • Treatment of injury/dental disease • Referral, as needed, to other health professionals

Health Professional Health professionals can reinforce oral health supervision within the context of other health supervision visits— suggested at 5, 6, 8, and 10 years:

• Screening • Oral risk assessment • Recognition and reporting of suspected child abuse/neglect • Education and anticipatory guidance for parents concerning fluoride


• Referral, as needed, to dental professional

19

Interview: Trigger Questions To be used selectively by the dental or health professional. Discuss any issues or concerns of the family. As the child grows, ask the child questions directly. To parent:

• Are you familiar with dental sealants? Do you have any questions about them? • Do you understand what to do if Elisa knocks out one of her teeth? • Is Jee brushing and flossing his teeth without being reminded? • Do you have any special problems with brushing because of Perry's other

medical issues? • Do you and your family members wear safety belts in the car? • Does Selena ever comment about her teeth and how they look?

To child:

• How often do you brush your teeth? Floss? Do you think it helps? • Do you always wear a safety belt in the car? • What sports do you play? Do you wear a mouth guard? Other protective gear? • Are you familiar with dental sealants? • Do you have any questions about them? • Do you think your teeth look okay? • Do you snack at school? After school? What do you eat?


• Is the child comfortable separating from the parent during the dental visit? • Does the child ask questions? • Does the parent support the professional's recommendations to the child? • Does the parent seem interested in oral health?

Oral Exam and Diagnostic Procedures

• As a part of the complete oral exam, the following should be noted: • Caries • Developmental dental anomalies • Malocclusion • Pathologic conditions • Dental injuries • Risk factors

20

Risk Assessment: Dental Caries RISK FACTORS PROTECTIVE FACTORS All Ages: Examples All Ages: Examples Inadequate oral hygiene Good oral hygiene

Unrestored caries Restoration of carious lesions



Poverty

Access to care


Prevention intervention to minimize effects

Nutritional deficiency (e.g., vitamin C)

Healthy eating habits

Infectious disease (e.g., HIV/AIDS)

Treatment of disease or preventive intervention to minimize effects

Medications (e.g., Dilantin)


Metabolic disease (e.g., diabetes, hypophosphatasia)

Treatment of disease

Neoplastic disease (e.g., leukemia and its treatment)

Treatment of disease and preventive intervention to minimize effects

Genetic predisposition (e.g., Down or Papillon Lefevre syndrome)


Poor-quality restorations

Properly contoured and finished restorations

Mouthbreathing

Management of mouthbreathing

Injury Use of age-appropriate safety measures and treatment of injury

Middle Childhood: Examples

Middle Childhood: Examples

Malpositioned and crowed teeth

Orthodontic care

Puberty

Preventive measures to address oral effects

Tobacco use Tobacco cessation

Anatomical variations (e.g., frenum) Surgical correction

21

Anticipatory Guidance Throughout middle childhood:

• Ensure that the child wears a safety belt in the car at all times • Ensure that the child brushes her teeth twice a day with a pea-size amount of

fluoridated toothpaste. Regularly supervise the tooth brushing. • Give the child fluoride in the child's drinking water • Ensure that the child wears a helmet when riding a bicycle • Ask questions you have about how to prevent dental injuries and handle dental

emergencies, especially in the loss or fracture of a tooth • Provide the child's caregivers with the dentist's emergency phone contacts and

ensure that the caregivers know how to handle oral health emergencies • Familiarize yourself with the normal appearance of your child's gums and teeth

so that you can identify problems if they occur • Schedule the next dental appointment for the child according to the schedule

recommended by the dental professional, based on the child's individual needs and/or susceptibility to disease

At 6 years: Teach the child about sports safety, including the need to wear protective sports gear such as a mouth guard and a face protector If the child regularly sucks fingers or thumb, begin to intervene gently to help the child stop At 8 years: Teach the child how to floss. Teach the child how to handle dental emergencies, especially the loss or fracture of a tooth. Teach the child not to smoke or use spit tobacco At 10 years: Help the child understand the dangers of smoking, spit tobacco, and other drugs Review

• Chart with assessment of child's oral health • Appropriate screening/referral • Follow-up • Utilization review (appropriateness/quality of care) • Policies of dental professional and health professional regarding quality of care

Outcomes

• Parents are informed of oral development issues • Parents and child are informed of and practice preventive oral health care • Child wears safety belt • Child wears appropriate play and athletic protective gear • Child does not suck fingers or thumb

22

• Child does not use tobacco or other drugs • Child receives appropriate fluoride supplementation • Child has been assessed for dental sealants • Child is under the care of a dentist • Child has no active carious lesions • Child has healthy oral soft tissues • Child has functional occlusion

23

Examination of Infants and Toddlers

24

Examination of Infants and Toddlers Peter K. Domoto, DDS, Department of Pediatric Dentistry and Donna Oberg, RD, MPH, Public Health Nutritionist Seattle-King Department of Public Health Objectives

• Introduction to dentistry. The infant and toddler's introduction to dentistry should occur in an environment, which is perceived by the child and caretaker as a safe and pleasant one. The dental team should exude caring and confidence as it introduces the family to pediatric dentistry. The "golden rule" and the principle of "do no harm" should prevail. Both the child and the caretaker(s) should be treated with kindness and respect. This introduction will serve as the foundation for the development of positive attitudes and responsible relationships with members of the dental health profession in the future.

• Prevention. The value and effectiveness of preventive dentistry is a major

emphasis of the infant and toddler dental examination. Preventive dialogue should include discussions of diet and feeding practices, tooth cleaning procedures, and optimal fluoride use - both systemic and topical.

• Assessment. This objective is achieved through the process of evaluation and

synthesis of information from a variety of sources. Demographic data from the patients' record, including information from other agencies and providers provide important descriptions of the child and family's status. Observations of the child and caretaker(s) as they interact, both in the dental setting and elsewhere provide useful information regarding the child's developmental status and "readiness" for a dental examination. Finally, an evaluation of the child's head and neck region and oral cavity will be used to detect the presence of trauma, infection, and/or signs of infant caries, including white spot lesions.

• Pre-appointment Assessment in WIC:

WIC certifiers conduct a health history, current health status and dietary assessment to determine client eligibility for the program. In order to qualify for WIC, infants and children up to age five (and pregnant and breastfeeding women) must meet income requirements and have a medical or nutritional risk. One of the qualifying risk criteria is a severe dental problem which is defined as: "A child with a diagnosis of baby bottle tooth decay, rampant caries or needing dental treatment for 3 or more caries in the last six months." (WA State WIC Manual page 76). Certifiers across Washington State have been offered oral screening training at statewide WIC conferences for the past three years to assist them in determining eligibility for WIC. In 1994 disposable mouth mirrors (funded by the Washington Dental Service Foundation) were distributed to all WIC agencies in Washington to improve the ability to conduct the visual oral screening. Monthly WIC computer reports are available, which describe the total number of children in each clinic on WIC with severe dental problems (#14). When

25

interpreting this data and comparing different months, remember that each month some children are added to WIC and some move or are no longer eligible due to a variety of reasons. Therefore, the data for #14 reflects all children currently on WIC at a clinic who have been identified with "severe dental problems" according to the above definition.

Interview The interview occurs prior to the dental examination. The following issues are addressed during the interview:

• Build rapport with the family. Focus on the comfort of the client. Demonstrate effective nonverbal skills and position yourself appropriately during the interview. Use open-ended questions and address the client's concerns in an empathic and courteous manner. Attend to the clients' need for appropriate words and in the case where English is not the primary language, speak slowly and clearly. Where an interpreter is required, allow adequate time for translation and clarification with both the interpreter and the clients.

• Specific concerns of the parents are elicited. "Why are you here today?" • Confirm pre appointment information. • Assess the family's current dental prevention practices:

1. Family history of dental disease 2. Fluoride inventory 3. Tooth cleaning procedures 4. Diet history and feeding pattern

The examination procedure The dental exam should not proceed until the clinician has had a chance to establish some contact and rapport with the child. An effective way to achieve this is to give a toothbrush to the child and briefly observe. Often the child will place the brush in his/her mouth and the examiner can effectively catch a glimpse of the teeth as well as observe the child's behavior with the toothbrush and the interaction with the caretaker. Armamentarium Mouth mirror Infant size toothbrush Procedure Give the child a toothbrush. Position the child on the examining table or assume the "knee to knee" posture and have the caretaker lower the child's head onto your lap. Use the child's toothbrush and quickly assess the child's oral condition. Use a dental mirror and continue to assess the child's oral condition. Record findings. Advise caretaker of oral findings and recommendations for follow-up

26

MANAGEMENT OF THE VERY YOUNG CHILD Philip Weinstein, PhD, Professor, Department of Dental Public Health Sciences, Adjunct Departments of Pediatric Dentistry and Psychology Goal The aim of this early intervention program for infants and toddlers is that the children return for subsequent care and monitoring. What is accomplished at a given appointment is secondary to continuity of care and maintaining an effective relationship with the child and caretaker(s). Essentials of successful management Rapport and trust with the caretaker and child are essential to the success of the program and the health of the child. Learning about the caretaker and child and showing genuine interest in their welfare is necessary. The environment in the waiting room and even the operatory should reflect concern for the comfort of the caretaker and child. It is very helpful to play with the child when you first meet him or her. It can be fun. While few toys are really needed, they help structure the initial interaction. A range of age-appropriate toys and games are suggested. Role of the caretaker Competent caretakers tend to be very useful during the dental team's interaction with the infant or toddler. Give caretakers detailed instructions on how to hold the child during the exam or treatment. Practice a few times. Moreover, parents can be taught to coach or distract the child. Caretaker tolerance of crying should be discussed. Teaching coping Even very young children can do a breathing exercise (blow) with a pinwheel, party noisemaker (blower), or make sounds like a leaky balloon or tire. Imagery you provide (birthday parties, rides, etc.) can be hypnotic. Distraction, especially when expecting danger, is another useful strategy. Toys, coloring, reading books, especially those that are interactive, and games are all possible adjuncts to building rapport and comfort. Gifts Gifts are a common way to reward the child. It may be best to provide the gift to the child at the beginning of the appointment. A gift for the caretaker is also a good idea.

27

COPING WITH THE CRYING CHILD Philip Weinstein, PhD, Professor, Department of Dental Public Health Sciences, Adjunct Departments of Pediatric Dentistry and Psychology Background This section presents information about crying in young children. Crying is believed to have a purpose; it has a social/communicative function and facilitates parental recognition. Research has identified and differentiated among a variety of cries. Tempo, pitch and melody are the important variables. Most studies have been conducted with neonates and infants less than six months. Crying itself has positive and negative physiological consequences for the child Tolerance to crying Crying is an aversive stimulus that leads the listener to react. The desired response is to reduce discomfort; unintended responses by the listener include avoidance and abuse. Perceived averseness of crying is influenced by cry characteristics and the characteristics and experiences of the listener. Parents and caregivers have increased tolerance. Information i.e., knowledge that the baby is sick, alters tolerance. Research also shows that focus on discriminating different types of cries makes them more tolerable. Coping with crying Emotional upset and stress decrease tolerance to many aversive stimuli. Therefore strategies that decrease upset or stress will increase tolerance. It may be best to use multiple strategies. Medical personnel have learned not to allow themselves to engage their emotions when working on a cadaver. They focus on the technical aspects of the task at hand. This ability to "dissociate" is helpful in tolerating crying. Self-talk can be useful in controlling negative cognitions that reduce tolerance. Breathing exercises and practice are also recommended. If you are "losing it", it is important to take a rest break (a breather) and to begin again when you are no longer upset.

28

Family Oral Health Education

29

Family Oral Health Education Philip Weinstein, PhD, Professor, Department of Dental Public Health Sciences, Adjunct Departments of Pediatric Dentistry and Psychology Prenatal Counseling The participants in the ABCD Program have an exciting and important opportunity to provide an essential resource for existing programs in the community which serve clients who access prenatal counseling and care, e.g. WIC, Maternal and Child Health Programs like First Steps. Regardless of where the program is conducted, close collaboration among members of the various health professionals and community support groups is essential. Research in both education and health promotion supports the emphasis of specific information introduced prenatally and reinforced often both prenatally and postnatally. Family Oral Health Education is a benefit in this program. It is allowed twice per year for a family. It needs to be documented in the chart. Objectives:

1. Establish/maintain trust so that caretaker will return 2. Choose more than one strategy that will help prevent the disease from

getting started 3. Choose more than one strategy that will help stop the disease process,

once started 4. Establish / maintain rapport and trust with caretaker(s) so that

caretaker(s) and child return. • Demonstrate concern for child and caretaker • Play with the child • Affectionate, culturally-appropriate touch • Discuss caretaker’s experience in obtaining dental care for child and self • Access / barriers • Quality / satisfaction • Fear / avoidance and distrust • Do not talk of the benefits of dental health, especially at initial appointment • Do not criticize caretaker in any manner • Be empathic with the difficulties and stresses in low income families • Discuss developmental issues that are relevant • Assess and discuss risk for infant/toddler caries • Debrief at end of appointment

Risk for Infant/Toddler Caries (Nowak & Crall, 1988)

• Family history moderate-to-severe dental disease • Hereditary / congenital defects / anomalies • High-risk pregnancy or complicated delivery • No systemic fluoride received

30

Assessing Family History Do siblings have dental disease? Do caretaker(s) have dental disease? Strategies That Will Help Prevent Disease from Getting Started Teach caretakers how to “lift the lip” Caretaker cleaning Enhanced access to fluoride Nutritional / diet counseling Strategies that will help stop the disease process, once started Teach caregivers to 'Lift the Lip" Flip chart or video and practice with feedback Use of mirror Handout Frequency of exam Caries control measures: frequent application of fluoride varnish; glass ionomer restorations Caretaker Cleaning

• While encouraging toddler use of brush, caretaker must clean; usually until age 5 or so

• No access to toothpaste for infants / toddlers without caretaker present • Clean high-risk surfaces

- Maxillary incisors - Any decalcified / hypoplastic or cavitated toot - Special attention to places where no spaces between teeth

• Developmental differences

0 - 9 months - Stimulate gingiva around where teeth will be coming in. Cold

teething ring afterwards - Clean erupting tooth, especially in maxilla with cold, wet washcloth - Cleaning 1 x a day

10 - 48 months - Continue cleaning erupting teeth and other high-risk surfaces

• Brushes - Massage brush, washcloth / gauze - Triple-headed toothbrush - Very small-headed brush

• Make it a habit

- Same time every day - Before bath, before bedtime story

31

• Technique - Position so can see - Smear layer of toothpaste only

Enhanced Access to Fluoride

• Limited transfer of fluoride from human milk (only 2% of a high dose of fluoride—11.25 mg) given to lactating mother was transferred to infant (Ekstrand, 1984)

• H2O fluoridated? Critical question • The use of fluoride-containing toothpaste • A pea-size amount (Pang & Vann, 1992) • Only provided by caretaker, no unsupervised access to toothpaste • The use of fluoride supplements • “In areas with inadequate water fluoridation (< 0.3 ppm), all infants, breast-fed

and formula-fed, should be given fluoride supplements (0.25 mg/d) beginning at 6 months of life” (ADA Council on Dental Therapeutics 1994).

Topical and systemic effects: Problems Solution: let caretaker and child try it out right now Cues, Premack Principle Continued contact with enthusiastic and dedicated staff makes a big difference (Newbrun, 1978)

An infant’s daily fluoride intake is determined by the amount of fluoride in the breast milk, formula, and water source (Clarkson, 1991)

• At relatively high concentrations (71 ppm) fluoride reduces the acidogenic potential of pathogenic bacteria

• At lower concentration effects remineralization/demineralization of hard tissue Feeding Practices to Avoid

• No juice or other sugar product in bottle • No bottle while sleeping • Control snacking for toddlers • Set time • Reduce number of snacks

32

Feeding Practices to Follow • Sugary liquids from cup only -- begin cup as young as 6 - 7 months • Begin cup as soon as possible- introduce juice • Begin adding solids 4 - 6 months -- see WIC personnel • Counseling concerning given strategy • Counseling - giving information • Listen • Ask questions • Mention possibilities • List • Summarize verbally • Write down the plan • Review progress - by phone and at next appointment

What are some bottle elimination options? “Cold turkey” vs. gradual elimination Water down; reduce volume Change one feeding at a time Sleep-related problem? Introduce the Cup as Early as Possible Recommend that the bottle not be used as a pacifier Pacifiers are readily available No sweets on pacifiers If bottle used as pacifier, put water in it Relevant Developmental Issues Teething and how to help the child Use and selection of a pacifier What to do if there is a dental emergency Prevention of oral injuries What Caretaker Can Do for Teething Rubbing pressure Clean the area Teething toy, ring Home Care The prevention of dental diseases is a personal responsibility, which initially falls to the parents or caretaker and must be eventually adopted by the child. As has been previously mentioned, learning preventive behaviors should begin prenatally. Attention to a balanced diet and reasonable feeding practices, optimal use of systemic and topical fluorides, and effective home care are the foundation for building life long personal preventive practices to ensure oral health. Plaque removal is often a neglected part of the preventive regimen suggested by health care professionals for infants. It should be understood that plaque begins to form as soon as baby's first tooth has begun to erupt.

33

The plaque harbors bacteria, many of which cause carious infections. Some plaque bacteria cause gingival infections. Daily disruption and removal of plaque will reduce the numbers and the virulence of the bacteria in the infant’s mouth thus leading to a reduced risk for caries and gingivitis. Recently, Caulfield has demonstrated that children of mothers with high levels of S. mutans tend to become infected with these bacteria between 19 and 28 months of age. While transmission does not occur from mother to child in all cases, it is clear that there is a period of time when the baby is highly susceptible to being infected with caries producing bacteria. This period of time, probably between 12 to 30 months, is an interval when the child is actively erupting teeth. These newly erupted teeth are vulnerable to rapid demineralization because the enamel has not had an opportunity to mature. If the plaque is allowed to accumulate and the infant's diet and feeding pattern provide exposure to fermentable carbohydrates frequently or for a long duration, the acid produced in the plaque will be sufficient to produce demineralization and eventual cavitation of the tooth surface. Daily removal of plaque with a wet, soft bristled brush will enhance both caries prevention and will prevent gingivitis. The parent or caretaker must, of course, take responsibility for this activity. A goal is to have the child take more and more responsibility over the years but initially plaque removal is an adult caregiver’s responsibility. Initially, the baby only has a few anterior teeth that are erupted and naturally likes to put anything and everything into her/his mouth. A perfect time to introduce a small toothbrush! Positioning of the baby is the first step in efficient and effective plaque removal for the youngster. The two people, knee-to-knee technique that was demonstrated during the section on the infant dental examination is an ideal method of performing tooth brushing for the baby. If it is not possible to have another person assist, the baby should be reclining when the brushing is performed. Perhaps an appropriate setting is one that is similar or identical to the area that is used for changing diapers. The main difference would be that the brushing should be done from behind the baby or to the side. Regular, effective plaque removal takes skill and persistence on the part of the caretaker. The caretaker's enthusiasm and willingness to tolerate some resistance on the part of the child will go far in establishing lifetime habits for the child. Teething There is a general pattern in the eruption of teeth, with wide variation. The first teeth to come in are lower central incisors, followed by upper central incisors. Babies may vary by several months. Once the central incisors begin to erupt at about 8 months, the child will be teething for the next 2 years or so. Around 10 months, the upper incisors begin to erupt. At about 16 months, the upper first molars begin to come in, leaving a gap filled at about 20 months by the canines. See the eruption chart on page 36.

34

Teething frequently is believed to result in feverish, fussy, cranky babies who whine, drool, and put objects into their mouths. Clearly, there are other causes of such behavior. Teething is a normal physiologic process. If a child has fever, nausea, or congestion, it is important not to assume the cause is teething. Have the caretaker check with a pediatrician. Do not cut gingival tissues to help the primary teeth erupt. A wide variety of remedies for teething are available; some folk remedies caretakers use actually work. We recommend rubbing and cleaning the area where the teeth are erupting and giving the baby something safe to bite on—for example, a teething ring; cool spoon; or a cold, wet washcloth.

35

Pacifiers and Sucking Nature provides great pacifiers - the thumb and fingers. Artificial pacifiers are purchased in stores. Babies have the inborn desire to suck on anything near their mouth. This reflex should not be discouraged. Some babies get enough sucking actually by nursing or using a bottle with a proper nipple (non-free-flow-up type). Others seem to want more sucking. Sucking habits by children prior to eruption of permanent incisors (about age 6 or 7) is not a serious problem. The only advantage to the pacifier is that it is likely to be “lost” and at some future date the habit will be more easily terminated. Pacifiers may be useful when the child wants to suck, but is adequately fed; it may replace reliance on the bottle in some circumstances and, thereby, reduce risk of dental disease. As the child grows older and the risk of dental disease decreases, reliance on the use of a pacifier can be decreased to reduce risk of misalignment of permanent teeth. Moss (1993) recommends stopping the use of artificial / natural pacifiers by 4 years (if it can be easily accomplished). Most children give up pacifiers by themselves by ages 3 to 4. Safe Use of Pacifiers Recommend that the caretaker:

• NOT hang the pacifier around the baby’s neck; this has resulted in a number of deaths!

• Find a sturdy pacifier with one-piece construction, made of non-toxic, flexible material with an easily grasped handle.

• Find a pacifier with a shield or mouth guard that can separate from nipple, two ventilating holes, and that is too large to be swallowed.

• Find a pacifier where the nipple is intact. Caretaker should pull on nipple and replace when it shows signs of wear.

36

Eruption Chart Tooth

Eruption Age in months (+ Range)

Mandible Central 8 (6-10) Lateral 13 (10-16) Canine 20 (17-23) First Molar 16 (14-18) Second Molar 27 (23-31) Maxilla Central 10 (8-12) Lateral 11 (9-13) Canine 19 (16-22) First Molar 16 (13-19) Second Molar 29 (25-33) Teeth that erupt earlier are at greater risk!

37

DIETS OF INFANTS AND TODDLERS Donna Oberg RD, MPH , Public Health Nutritionist, Seattle-King County, Department of Public Health Infant Feeding Normal infants triple their birth weight by one year of age and require adequate nutrition to obtain optimal growth and development. Breast feeding or infant formula is recommended for the entire first year of life, especially for low-income infants. During the first four to six months solely breast-feeding or iron-fortified infant formula is recommended. Introduction of solid foods begins with infant cereal offered by spoon (adding infant cereal to the baby bottle is not normally recommended with the exception of esophageal reflex) between four and six months, depending upon the infant's developmental readiness. At six months of age infants can begin drinking juice from a cup with assistance from a caregiver. Breast or bottle-feeding often occurs at bedtime. However, it is recommended to hold the infant while feeding and then lay them down with the a favorite stuffed animal, blanket or something comforting rather than a baby bottle containing any sweetened liquid (milk, formula, juice, Kool-aid, etc.) which can contribute to dental disease. Water is the only dentally safe liquid. Offering pureed fruits or vegetables is recommended next and by about eight months some easily chewable protein foods should be introduced. Gradually more and more bite-size table foods are added to an infant's diet depending upon their readiness. Feeding Toddlers At one year of age, toddlers can easily get a balanced diet if offered a variety of foods. From 1 -2 years of age a child's daily intake should be: 1 ounce of protein; 2 cups of whole milk; approximately 3/4 cup of fruits and vegetables; and 6-11 servings of grain products (servings = 1/4 slice of bread; 1/8 cup hot cereal, rice, or pasta). Toddlers who continue using baby bottles may over consume milk and/or juice and may not eat a balanced diet required for optimal growth. By introducing the baby cup early and providing adequate practice toddlers can easily use a cup to obtain the recommended 2 cups of milk/ day (1/2 cup of milk with each meal and with one snack). Eating habits begin developing early and can be greatly influenced by caregivers. Changing bad habits is much more difficult than learning good eating habits. For example, when a caregiver uses food to control a child's behavior like providing a favorite treat for good behavior and the child learns that foods are rewards. When a child goes to sleep each night sucking on a beverage from their bottle, they are learning how to comfort themselves with food. Instead of eating to satisfy a hunger cue, eating satisfies emotional needs like fussiness or boredom and this feeding pattern can establish life-long eating patterns that may contribute to overweight and possibly poor eating habits.

38

Picky eating is a common trait of two-year-old children. Food is one of the few things they can control in their life and they often will show their independence by refusing to eat certain foods. It is the caregiver's responsibility to offer healthy foods, but it is the child's responsibility to choose what and how much to eat. It is not recommended to force anyone to eat, especially a toddler. The caregiver may win the battle but will most likely lose the war. Treating children's food preference respectfully is highly recommended. Snacking habits are especially important to toddler-aged children because they have small appetites at mealtime due to their stomach's limited capacity. Therefore, three small snacks are recommended between meals, but not too close to mealtime. Ideally snacks should contribute to getting a balanced diet, such as a vegetable or fruit. (See handout: Snacks for Tots) Frequent snacking on sweet, sticky or starchy foods (containing fermentable carbohydrates) can contribute to dental caries. Many caregivers use crackers or baby bottles of sweetened beverages as a continuous snack/pacifier for their toddler that will reduce their appetite at mealtime and may contribute to caries. Snacking habits have been implicated by recent research as contributing to baby bottle tooth decay. Good snacking choices will benefit toddler's oral health and total health and will contribute to establishing better eating habits. BBTD Prevention Project in WIC For the past three years the Washington state WIC Program (Special Supplemental Nutrition Program for Women, Infants, and Children) has conducted a BBTD Prevention Project. The Washington Association of Local WIC Agencies (WALWICA) and the Seattle-King County Department of Public Health have coordinated this successful project. The project has been funded by the Washington Dental Service Foundation to provide baby cups when infants are six months of age and a disposable mouth mirror for oral screening and early identification of infant caries. For more details see appendix. WIC is a federally funded nutrition program serving 95,000 low-income children under age five and pregnant or breastfeeding women in Washington at approximately 250 clinics throughout Washington. A nutritional or medical risk must be diagnosed in addition to meeting low-income requirements. This unique program combines free nutritious foods (eggs, milk/cheese, juice, cereal, peanut butter/dried beans, infant formula and infant cereal) with nutrition education and healthcare referrals. Studies indicate WIC is effective in improving pregnancy outcomes by reducing the number of low birth weight infants and producing a significant savings in health care dollars. Additional Reading: R.C. Burgess: Diet and Dental Caries, National Institute of Nutrition, Vol. 4:No2; 1989, Supplement, pages 1-4. W.J. Loesche: Nutrition and dental decay in infants, American Journal of Clinical Nutrition, Vol. 41: 1985, pages 423-435.

39

G. Acs: Effect of nursing caries on body weight in pediatric population, Pediatric Dentistry, Vol. 14:No5, 1992, pages 302-305. J.M. Navia, Caries Prevention in Infants and Young Children: Which Etiologic Factors Should We Address?, Journal of Public Health Dentistry, Vol. 54:No 4, 1994, pages 195-196. E. Satter, How to Get Your Kids to Eat...But Not Too Much, Bull Publishing Co. 1987. P.L. Pipes, Nutrition in Infancy and Childhood, Times Mirror/Mosby, 1989.

40

Prevention of Dental Disease

41

TOPICAL FLUORIDE VARNISHES Introduction The last half-century in the US has demonstrated dramatic reductions in decay rates. While the causes of this reduction are multifactorial, it is clear that enormous benefits in caries reductions must be attributed to both systemic and topical mechanisms of fluoride ion. The efficacy of topical fluoride, both home and professional applications, is well established.1 In recent years as caries rates have gone down there has been a rise of mild to moderate dental fluorosis in permanent teeth.1,2 Thus there are concerns regarding excessive ingestion of fluoride especially in children under the age of 3 years.3-7. At the same time, both national data and small area data indicate that some 20% of the population experiences 80% of the decay.8,9 Clearly, the benefits of fluoride are essential for this high risk for caries group. The challenge for further reductions in caries lies in reducing the rates in these high-risk groups. Fluoride varnishes are a type of topical fluoride and have extensive evidence of efficacy as a caries preventive agent in Europe over the past three decades.10-17 Fluoride varnishes appear to be comparable in efficacy to traditional fluoride gels currently used in dental practice. In spite of approval by the FDA as a device, fluoride varnishes are not used extensively in this country. The purpose of this paper is to suggest a rationale for the "off-label" use of fluoride varnish as a professionally applied topical for caries prevention. The FDA and Federal Law The US Food and Drug Administration (FDA) administers the Federal Food, Drug and Cosmetic Act which requires manufacturers to demonstrate safety and effectiveness of all new drugs for their indications i.e., (the new drug) "will have the effect it purports or is represented to have under the conditions or use prescribed, recommended or suggested in the proposed labeling".18 The FDA requires substantial evidence from adequate and well-controlled investigations in order to approve a new drug for marketing.18,19 Fluoride varnishes became available in the United States in 1991 when the FDA approved Duraflor. FluorProtector and Duraphat are also currently approved. Duraflor, Duraphat and FluorProtector have FDA approval as root desensitizers or cavity varnishes, but not as a therapeutic topical fluoride. These three varnishes are considered by the FDA to fall into a category of drugs and devices that "present minimal risk and is (are) subject to the lowest level of regulation".20 The FDA will not accept the extensive findings from European investigations as adequate evidence for approval for labeling as a caries preventive agent, primarily because European research compares the active drug to no treatment and not to a placebo.

42

Off-label Use of Approved Drugs in Medicine Use of approved fluoride varnishes for caries prevention therefore is an unapproved use or more commonly, "off-label" use, of an approved drug. Such use is not considered unlawful; indeed, the use of drugs off-label is common practice in medicine. Three fourths of the prescription drugs currently marketed in the US lack full pediatric approval.18 Quoting from the recommendations of the Committee on Drugs of the American Academy of Pediatrics: "Unapproved use does not imply an illegal use. The word unapproved is used merely to indicate lack of approval, not to imply disapproval or contraindication based on positive evidence of a lack of safety or efficacy." (Committee on Drugs, American Academy of Pediatrics 1996)18 The labeling of many drugs, "old and new", contain pediatric disclaimers and are being used extensively "off-label". The following are a few examples of commonly used "off-label" drugs with pediatric disclaimers:19

• Albuterol (Ventolin) • Meperidine hydrochloride (Demerol) injection (PCA) • Ketorolac tromethamine (Toradol) • Morphine (PCA) • Midazolam hydrochloride (Versed)

In addition, some drugs are used off-label when the drugs labeling do not cover their use. Some examples are as follows:22

• Finasteride for benign prostatic hyperplasia. Off-label: male pattern baldness • Fluoxethine (Prozac) for depression. Off-label uses: Anorexia nervosa,

alcoholism, ADHD • Mexiletine for refractory ventricular arrhythmias. Off-label: Paresthesia

associated with diabetic neuropathy • Triprolidine and Pseudoephedrine (Actifed) for bronchodilation. Off-label: Otitis

Media Both physicians and dentists assume the responsibility for justifying off-label use of approved drugs. If one considers that the application of topical fluoride for a patient who is at risk for caries is the standard of dental practice for his/her community then the selection of an approved fluoride varnish is a reasonable choice. Purpose of Topical Fluorides The purpose of applying topical fluoride to the exterior of teeth is to retard, arrest, and reverse the caries process. As was noted earlier topical benefits of fluoride are derived from water, dentifrices, over the counter rinses, prescription rinses and gels, and professionally applied products.

43

Topical Fluoride Enhanced Benefit The fluoride benefit in the ABCD Program is the application of fluoride varnish three times in a year for each eligible child. There is no set time interval between fluoride varnish treatments in the program. Safety of Fluoride Varnish Despite Duraphat's high fluoride concentration, Ekstrand et al.23 found no toxic effect on fluoride plasma levels or renal function in pre-school children and school children treated with Duraphat. This is as would be expected considering the material's fast setting, its slow release of the fluoride and the small amount of varnish required for an application. In Ekstrand's investigation all teeth of the children were coated with varnish. An average of 0.3 to 0.5 ml of varnish was used which would contain a maximum of 12 mg fluoride. In applying varnish to the infant or toddlers four maxillary incisors, no more than two drops of Duraflor are dispensed and thus less than 0.3 ml of the varnish would be applied which would result in a maximum of a little over 7 mg of fluoride. Rationale and Efficacy Duraflor (Pharmascience Inc., New Jersey) Duraphat (Colgate-Hoyt) appear to be particularly suitable topical fluorides for infants and toddlers when professionally applied. This fluoride containing varnish was first introduced in Germany in 1964 under the trade name Duraphat.24 Duraflor contains 5% by weight NaF or 2.26% by weight fluoride in a neutral colophonium base. Duraflor is usually applied with a brush. Upon contact with saliva or water the material sets quickly as a yellow-brown coating. During the last 25 years a number of laboratory investigations and clinical investigations have shown that varnishes supply fluoride more efficiently than other topical agents. Caries reductions have been shown to be in the range of 40% to 70% which is comparable to APF.10-17 A recent clinical investigation conducted by the University of Washington among high risk toddlers it appeared that an every 6 months application of Duraflor was particularly useful in enhancing remineralization of affected teeth15. In high risk groups it is generally recommended that Duraflor be applied at intervals of 3-6 months. (Petersson et al. reported that three consecutive applications of Duraphat within a 10 day period, once a year for three years obtained better results than with two applications per year.13) The principle of the varnish delivery system is based on contact of topical fluoride with the teeth over a sustained period of time. By the mid '70's the benefits of fluoride varnishes were accepted by the European dental community and were being used extensively. Fluoride varnish does not appear to be inactivated by dental plaque25 and this may be applied without any previous prophylaxis. However, de Bruyn and Arends12 recommended normal tooth brushing followed by drying prior to the varnish application. Koch et al.26 found that dry tooth surface facilitates fluoride uptake in enamel. Helfenstein and Steiner14 recently reviewed the methodology and findings of investigations of Duraphat over the last 20 years.

44

No serious side effects have been reported from the use of Duraphat or Duraflor. However, it should not be applied to bleeding gingival tissue in order to avoid risk of developing a contact allergy to the colophonium base. Duraflor does not have a strong flavor and appears to be reasonably well tolerated by young taste buds. It is recommended that all providers perform a "taste test" prior to initiating the use of Duraflor with patients as experience has taught us that providers who are uninformed may unnecessarily bias children and/or caretakers against the flavor. Justification for Off-label Use of Fluoride Varnish: Application of varnish is safe, effective, quick and easy. Fluoride varnish is safe. FluorProtector is 0.9% fluor silane that yields a fluoride concentration approximately one half of conventional acidulated phosphate fluoride (APF). The fluoride concentration of Duraphat and Duraflor varnishes is twice that of APF gels, at 5% NaF, but the amount used per treatment is ten times less. For applications in the primary dentition 0.1 ml to 0.3 ml are utilized (2.3 to 6.8 mg of fluoride ion).23 The toxic dose of fluoride varnish is reached with 10 times the normal dose. The toxic dose of APF gel is reached with about double the normal dose. In essence, we do not have any alternatives for use of a topical fluoride on very young children. Fluoride varnishes offer the safest topical fluoride available for the young, at risk child. An additional advantage of fluoride varnish is its slow release over time. APF gel is swallowed as a bolus, but varnish sets on the teeth and is swallowed over many hours. Professionally applied topical fluorides actually present little risk for fluorosis. Burt found that dietary supplements, inadvertent swallowing of fluoride toothpaste, and increased fluoride in food and beverages are the most likely sources of increased fluoride ingestion.27 In addition, Burt states that "...there is no evidence that swallowing of fluoride gels has been a factor in the increase in fluorosis among North American children". Since the amount of fluoride that is applied in the application of fluoride varnish is small and the varnish sticks to the tooth surface the risk for fluorosis is almost negligible.23 Clark and Berkowitz in a longitudinal study of dental fluorosis in three Canadian communities concluded that while the prevalence of esthetic problems resulting from fluorosis is low in these communities, children's risk for esthetic problems increases when fluoride dentifrices, fluoride supplements, and fluoridated water are used in the third year of life.28 Fluoride varnish is effective. Caries reductions have been shown to be in the range of 40% that is comparable to APF.10-17 The principle of the varnish delivery system is based on contact of topical fluoride with the teeth over a sustained period of time. By the mid '70's the benefits of fluoride varnishes were accepted by the European dental community and were being used extensively. By the early '90's almost 93% of all professionally applied topical fluorides in Scandinavia were varnishes.29 In addition, there is some evidence that varnishes are more effective than other topical fluorides in reducing caries on fissured surfaces.30

45

Fluoride varnishes offer several advantages over traditional topical fluoride such as speed and ease of application and a greater range of applications. Varnish can be safely and effectively applied to infants and toddlers, developmentally disabled patients, and patients with active gag reflexes. Varnish can be applied to at risk surfaces in a matter of seconds. An effective application is quick and easy. In addition, high risk for caries patients including adults with root caries and/or xerostomia benefit greatly from regular application of fluoride varnish. Conclusions Fluoride varnish provides a useful and effective means of delivering topical fluoride to the teeth of patients. As with any topical fluoride, the at-risk-for-caries patient will benefit the most from periodic applications of this material. The fact that fluoride varnish as a caries preventive measure currently must be used "off-label" should not be a barrier to its use in clinical practice. The benefits of fluoride application far outweigh the risk for fluorosis in the at-risk-for-caries patient. If a patient requires a professionally applied topical fluoride and is too young, too uncooperative or too medically compromised for a four minute (or even one minute) APF treatment, fluoride varnish offers an efficacious and safe alternative. Fluoride supplementation is not a substitute for topical fluorides in the child less than three years of age. Supplementation is prescribed for the infant and toddler in the form of drops or other liquid medium. Since the caries preventive effect of supplements is primarily posteruptive it is reasonable to encourage a chewable tablet as soon as possible in order to exploit these topical benefits.31 There is no evidence that the high risk for caries child would receive any meaningful topical effect from this systemic method of fluoride supplementation. The "off-label" use of drugs is a practice that is common in medicine with a number drugs that have multiple efficacious therapeutic uses. The literature is clear that the major benefit of the fluoride varnishes is their caries preventive properties.10-17,30 The FDA requirements for substantial evidence from well-controlled investigations should be met as soon as possible. Colleagues at the University of Washington are currently conducting controlled investigations designed to provide efficacy data on the use of a fluoride varnish in children less than five years of age. An approved status from the FDA for one or more fluoride varnish products will greatly facilitate the use of effective caries preventive measures in both public and private programs. Varnish is currently classified as a "device" but the FDA has ruled that it is a drug if it is used for caries prevention. There are, unfortunately, significant cost barriers for companies to support the investigations for full approval as a therapeutic agent. Full approval for new FDA labeling is a costly endeavor. It has been estimated that it would require at least half a million dollars for a company to fund the investigations necessary to meet the FDA requirements for new labeling. Dentistry is a small industry and an analysis of potential markets may not justify funded investigations in the minds of the

46

fluoride varnish manufacturers. The reality is that dentistry may have to choose to use fluoride varnishes "off-label" for an extended time. The Early Childhood Caries (ECC) Conference held on the NIH Campus in October 1997 addressed the etiology, implications and prevention of ECC.32 It is clear that ECC is of epidemic proportions in many US minority populations. Unfortunately, an effective preventive regimen for high risk for ECC patients has not been developed. Much work remains to develop successful office and community based approaches to the prevention of ECC. In spite of the dearth of well-controlled trials in the prevention of ECC, current knowledge of caries and its prevention yields some obvious guidance. The key to an effective primary prevention program with infants and toddlers is to deliver topical fluoride early and often to children at risk. At risk children include those with existing caries (including white spot lesions), family histories of moderate to severe dental disease, and congenital enamel defects. Other risk factors include high-risk pregnancy or complicated delivery and no systemic fluoride received. Dental care providers and policy makers are encouraged to carefully review the existing data and practices involving the use of fluoride varnishes. A thorough assessment of the caries status of their patients and the potential risks and benefits of fluoride varnish application should result in the adoption of varnishes as a valid means of delivering fluoride to their patients' teeth. Fluoride varnishes are safe, effective, and easily incorporated into both public and private programs of caries prevention. REFERENCES

1. Ripa LW: A critique of topical fluoride methods in an era of decreased caries and increased fluorosis prevalence. J Public Health Dent 51:23-41, 1991.

2. Pendrys DG and Stamm JW: Relationship of total fluoride intake to beneficial effects and enamel fluorosis. J Dent Res 69 (Spec Iss):529-538, 1990.

3. Pang DT and Vann WF, Jr.: The use of fluoride-containing toothpastes in young children: The scientific evidence for recommending a small quantity. Pediatr Dent 14:384-387, 1992.

4. Levy SM, Maurice TJ and Jakobsen JR: A pilot study of preschoolers' use of regular-flavored dentifrices and those flavored for children. Pediatr Dent 14:388-391, 1992.

5. Levy SM, Maurice TJ and Jakobsen JR: Dentifrice use among preschool children. J Am Dent Assoc 124:57-60, 1993.

6. Stookey GK: Review of fluorosis risk of self-applied topical fluorides: dentifrices, mouthrinses and gels. Community Dent oral Epidemiol 22:282-286, 1994

7. Skotowski MC, Hunt RJ and Levy SM: Risk factors for dental fluorosis in pediatric dental patients. J Public Health Dent 55:154-159, 1995.

8. NIDR National survey of oral health in US school children 1986-87. Bethesda, MD: National Institute of Dental Research, 1992.

9. Leroux B, Maynard R, Domoto P, Zhu C, Milgrom P: The estimation of caries prevalence in small areas. J Dent Res 75:1947-1956, 1996.

47

10. Petersson LG: On topical application of fluorides and its inhibiting effect on caries; thesis University of Lund. Odont Rev 26(suppl 34) 1975.

11. Seppa L: Fluoride varnishes and enamel caries; thesis University of Groningen, 1987.

12. de Bruyn H and Arends J: Fluoride varnishes. J Biol Buccale 15:71-82, 1987. 13. Petersson LG, Arthursson L, ÷sterberg C, Jonsson G and Gleerup A: Caries-

inhibiting effects of different modes of Duraphat varnish reapplication: A 3 year radiographic study. Caries 25:70-73, 1991.

14. Helfenstein U, Steiner M: Fluoride varnishes (Duraphat): A meta-analysis. Community Dent Oral Epidemiol 22:1-5, 1994.

15. Weinstein P, Domoto P, Koday M, and Leroux B: Results of a promising open trial to prevent baby bottle tooth decay: a fluoride varnish study. J Dent Child 61:338-341, 1994.

16. Twetman S, Petersson LG and Pakhomov GN: Caries incidence in relation to salivary mutans streptococci and fluoride varnish applications in preschool children from low- and optimal-fluoride areas. Caries Res30:347-353, 1996.

17. Twetman S and Petersson LG: Prediction of caries in pre-school children in relation to fluoride exposure. Eur J Oral Sci 104:523-528, 1996.

18. Committee on Drugs (Berlin CM, Jr., Chair) American Academy of Pediatrics. Unapproved uses of approved drugs: The physician, the package insert, and the Food and Drug Administration: Subject review. Pediatrics 98:143-145, 1996.

19. Coté CJ, Kauffman RE, Troendale GJ and Lambert GH: Is the "Therapeutic Orphan" about to be adopted? Pediatrics 98:118-123, 1996.

20. Code of the Federal Registry Part 130. Legal status of approved labeling for prescription drugs; prescribing for uses unproved by the Food and Drug Administration. Aug. 15, 1972.

21. Hom L: Off-label use of approved drugs. Pharmacy Newsletter 15:17-18, 1997.

22. Ekstrand J, Koch G, Petersson LG: Plasma fluoride concentration and urinary fluoride excretion in children following application of the fluoride containing varnish Duraphat. Caries Res 1980;14:185-189.

23. Schmidt HIM: Ein neus Touchierungsmittle mit besonders lang anhaltendem intesivem Fluoridierungseffect. Stoma 17:14-20,1964.Sepp‰ L and Hanhijarvi H: Fluoride concentrations in whole and parotid saliva after application of fluoride varnishes. Caries Res 17:476-480, 1983.

24. Seppa L: Effect of dental plaque in fluoride uptake by enamel from a sodium fluoride vanish in vivo. Caries Res17:71-75, 1983.

25. Koch G, Hakeberg M, Petersson LG: Fluoride uptake on dry versus water-saliva wetted human enamel surfaces in vitro after topical application of a varnish (Duraphat) containing fluoride. Swed Dent J 12:221-225, 1988.

26. Burt BA: The changing patterns of systemic fluoride intake: J Dent Res 71(Spec Iss):1228-1237, 1992.

27. Clark CD and Berkowitz J: The influence of various fluoride exposures on the prevalence of esthetic problems resulting from dental fluorosis. J Pub Health Dent 57:0144-149, 1997.

48

28. Moran R. and Saemundsson, S: Fluoride Varnish: An alternative to traditional topical fluoride therapy. Department of Pediatric Dentistry, University of North Carolina 1996.

29. Bravo M, Baca P, Llodra JC and Osorio E: A 24-month study comparing sealant and fluoride varnish in caries reduction on different permanent first molar surfaces. J Public Health Dent 57:184-186, 1997.

30. Clark CD: Appropriate use of fluorides in the 1990s. J Canad Dent Assoc 59:272-279, 1993.

31. Tinanoff N and O'Sullivan DM: Early childhood caries: Overview and recent findings. Pediatric Dent 19:12-15, 1997.

49

FLUORIDE VARNISH APPLICATION Armamentarium • Mouth mirror • 2x2 gauze sponges • Infant size toothbrush • Disposable brush • Disposable dampen dish • Two (2) drops fluoride varnish Procedure

1. Give the child a toothbrush.

2. Position the child in the "knee to knee" posture and have the caretaker lower the child's head onto your lap.

3. Use the child's toothbrush and quickly brush the child's teeth.

4. Dry the teeth with 2x2 gauze sponges and apply fluoride varnish with the

disposable brush to all surfaces of the teeth.

5. Continue to “wipe and paint” until all the teeth have been treated. The varnish will set upon contact with saliva.

6. Advise caretaker that the varnish is slightly yellow and that it may be visible for a few hours. Request that the caretaker not resume brushing until tomorrow in order to preserve the varnish coating as long as possible.

7. Fluoride varnish should be applied every two or three months on the at-risk-for- caries child.

50

FLUORIDES IN DENTISTRY Rationale The rationale for the use of fluoride to prevent caries is based on both systemic and topical effects of fluoride. Both pre-eruptive (systemic) and post-eruptive (topical) benefits are apparent in extensive research findings and clinical practice. The following mechanisms are considered to be the primary methods for caries prevention and are assumed to operate simultaneously

• Reduction in enamel solubility • Remineralization • Interference with plaque microorganism metabolism • Modification of tooth morphology i.e. enhancing the completion of

development in pits and fissures • Increased rate of post-eruptive maturation

Community water fluoridation is the method of choice to provide reliable and effective caries for the children of a community. Water fluoridation has been long recognized as the classical public health measure. Water fluoridation is safe, effective, low cost, and non-discriminatory and should be the cornerstone of all caries preventive programs. Metabolism of Fluoride t is essential that dentists, dental hygienists, other dental team members, as well as other health care workers understand the process of fluoride metabolism. All forms of fluoride intended for human use, whether designed for systemic or topical use, should be evaluated for efficacy and safety. It is well known that substances that are designed as topical agents, including dentifrices, mouthwashes, and professionally applied topicals, are usually swallowed in varying amounts by individuals. Water is the most efficient source of systemic fluoride since 82 to 97% of the fluoride is absorbed from ingested water. Milk can be used as a vehicle for fluoride but there is much less absorption of fluoride in the first hour after ingestion since calcium fluoride, a relatively insoluble compound, is formed. After the first hour fluoride ion continues to be absorbed and eventually the level of absorption is comparable to the levels absorbed from water. Excretion of fluoride is accomplished through the gut, kidney, and skin. The kidney is the chief organ of excretion for fluoride; approximately half of all ingested fluoride is excreted in the urine. Fluoride has a great affinity for bone and teeth. Ninety-seven percent of the fluoride that is stored in the body is stored in bone and teeth. Osteoporosis and Fluorides Osteoporosis is a condition characterized by a reduced bone mass and a high frequency of bone fractures. Claims have been made that water fluoridation is associated with osteoporosis. Experts in the field of epidemiology have clearly

51

demonstrated that there is no relationship between water fluoridation and increased risk for osteoporosis. Fluoride Transfer by Placenta Fluoride readily crosses the mother's placenta to the fetus. Developing primary teeth receive maternal levels of fluoride. However, prenatal supplementation of fluoride for expectant mothers cannot be recommended at this time because conclusive clinical evidence of its efficacy is lacking. Fluoride acquired in utero has little effect on caries in primary teeth since the major part of enamel is formed postnatally. Safety and Toxicity of Fluoride When used appropriately, the various forms of fluoride are safe and effective. However, as with any other therapeutic agent fluoride has a potential to produce undesirable side effects if used improperly. The dental professional must be knowledgeable and vigilant in order to ensure safe and effective utilization of fluoride by children and their families. Acute toxicity can occur from ingestion of excessive amounts of fluoride. Nausea and vomiting are the usual result of acute toxicity, however more serious problems are possible and on at least one occasion toxic levels of fluoride ingestion have resulted in the death of a child. The greatest risk to the child occurs when she/he is left unattended and has access to excessive amounts of fluoride. Therefore, care should be taken to limit the amount of fluoride stored in the home to a safe level for a toddler. In prescribing fluoride supplements the provider must limit the total amount to that amount which would be within safe limits for an infant or toddler. Thus, there is a limit of 120 tablets of 2.2 mg NaF that can be prescribed to a family at any given time. A 2.2 mg tablet yields one (1) mg of fluoride ion therefore ingestion of the entire prescription would result in the intake of 120 mg of fluoride. In the dental office great care should be exercised to prevent children from having access to excessive amounts of fluoride. Never allow children access to large containers of APF and use no more than half a teaspoon (2.5 ml) of topical fluoride per tray. Note that "Duraflor" is packaged in 10 ml tubes which, in the unlikely event that the contents of the tube were swallowed, would result in a maximum ingestion of 226 mg of fluoride. The lethal dosages for a three year old, a 6 year old, and a 9 year old are about 500 mg, 750 mg, and 1000 mg respectively. Fluoride products in homes, schools, institutions, and dental facilities must be secure and carefully monitored. The "worst case scenario" would invariably involve a young child who had access to massive amounts of fluoride. The tendency to use products that are pleasantly scented and flavored to enhance acceptance by children can be dangerous. Children who like the flavor of a product may swallow excessive amounts of the agent or, worse yet, may seek out the product to ingest it simply because it "tastes good". Should excessive amounts of fluoride be swallowed vomiting should be induced immediately. This can be accomplished by administering Syrup of Ipecac (Eli Lilly and

52

Co.) with a few ounces of water. A tablespoon of syrup is suitable for children over the age of one and 2 teaspoons are indicated for babies less than one year of age. FIRST AID FOR INGESTION OF FLUORIDE •Induce vomiting •Give milk or milk of magnesia (will bind fluoride temporarily) •If possible, calculate dosage and call the Poison Control Center FIRST AID FOR INGESTION OF FLUORIDE 1-800-572-0638 Emergent Information To be used by Health Care Professionals 1-800-732-6985 Parent Access Line Enamel fluorosis is a result of ingesting excessive amounts of fluoride during tooth development. Fluorosis is a hypomineralization of tooth enamel and dentin. The degree of fluorosis can range from barely noticeable whitish opacities to confluent pitting of the enamel surface and unsightly brown staining, depending on the amount of fluoride and duration of exposure during tooth development. In a recent survey of 3rd grade children in Washington State 7.6% of the children surveyed had fluorosis affecting their maxillary permanent incisors. Fluorosis can only be produced during the relatively short period of pre eruptive enamel development. Since the degree of fluorosis that is seen on US children is primarily of the "very mild" to "mild" category this problem is primarily one of esthetics. The maxillary permanent incisors are the teeth that are most important in protecting from fluorosis. The critical "window of vulnerability" for fluorosis in these teeth is 18 to 24 months of age. Enamel development is usually completed in the maxillary incisors by age four. The concentration of fluoride in the water being ingested by a given child must be known. Seattle water supplies have been adjusted to deliver the optimum concentration of 1 part fluoride per million (ppm) parts of water. One ppm is equal to 1 mg of fluoride ion to a quart of Seattle water. When the level of fluoride is unknown in a particular water supply steps must be taken to determine the concentration of fluoride that children and others are ingesting. Local water districts and the county and state Departments of Health may be able to provide that data from existing records. If it is not possible to obtain the fluoride levels in this manner one must have the water tested for fluoride. Well water has been the most common source requiring testing. However, with the increase in the use of bottled water and water filters of various types it is essential for testing of water to occur at the point where the child would be ingesting the water. Fluoride analysis can be obtained from the Washington State Public Health Laboratory (see the box on the following page for the address and phone number). Information and a container for a water sample can be obtained by contacting the laboratory below. The cost of the analysis is $22.

53

Washington State Public Health Laboratory Environmental Chemistry 1610 N.E. 150th St. Seattle, WA 98155-9701 Telephone: (206) 361-2898 In order to prevent mild to moderate fluorosis in the maxillary incisor teeth it is also necessary to carefully supervise the tooth brushing of the infant and the toddler. Fluoride dentifrices have been implicated in increasing the risk for fluorosis when their use is started before age three. Children swallow a large percentage of any dentifrice that may be used. The use of fluoridated toothpaste is recommended when primary teeth have erupted, but only a small amount - just a thin smear. ONLY A “SMEAR” OF DENTRIFICE IS NECESSARY! Also encourage the parents to teach the child to spit in order to prevent swallowing of the dentifrice. Fluoride Supplements: When fluoride concentrations in the water supply fall below 0.6 ppm dietary fluoride supplementation is necessary for children, 6 months to 16 years of age. The following table delineates the dosage schedule that was approved by the Council on Dental Therapeutics of the American Dental Association and the American Academy of Pediatric Dentistry in 1994. Continuous compliance with fluoride supplementation has been shown to produce caries reductions of around 30-50%. *Council on Dental Therapeutics, 1994 C.D.T. *Dosage Schedule (mg/day) for fluoride supplements Concentration of Home Water Supply** or Primary Source of Drinking Water Age (yrs) <0.3 ppm 0.3 - 0.6 >0.6 ppm Birth to 6 mos. 0 0 0 6 mos. to 3 0.25 mg 0 0 3 to 6 0.5 mg 0.5 mg 0.25 mg 0 6 to at least 16 1 mg 0.5 mg 0 **The fluoride content of the home water supply should be known to be fluoride deficient before a daily fluoride supplement is prescribed. Dietary fluoride supplements are available in liquid, lozenges, tablets, chewable tablets and preparations combined with vitamins. When the appropriate dosage for an infant is determined a liquid fluoride supplement with a calibrated dropper should be used. A calibrated dropper as opposed to a dropper which delivers, for example, 0.125 mg of fluoride per drop is preferred since measuring the proper amount on a calibrated delivery system is more reliable than a "drop". Ross Laboratories provides 50 mL bottles of 0.5 mg F/mL with a calibrated dropper. Half a dropper delivers 0.25 mg of fluoride ion. Infants and toddlers will receive liquid fluoride supplements when it is indicated based on fluoride testing. As soon as the child is able to chew and swallow a

54

tablet she/he should be switched to a chewable tablet. This chewable form of fluoride is most advantageously given at bedtime after brushing. The tablet should be chewed or sucked and "swished" around the mouth prior to swallowing. "Chew, swish, and swallow" will produce both systemic and topical benefits of fluoride. Both the form and dosage of the fluoride must be tailored to the needs of the individual children in the family. Note the dosage of fluoride on a body weight is 0.05 mg F/kg body weight. The 1994 dosage schedule does not recommend initiation of supplementation until, at the earliest, 6 months of age. The following are sample prescriptions for a fluoride deficient water supply. Rx for 7-month-old Arthur receiving water that has less than 0.3 ppm F. NaF drops 1.1 mg/dropper Sig: One half dropper once per day, directly in mouth or in water, juice or milk. Dispense 50 ml Refill as needed Rx for 26-month-old Beth receiving water that has less than 0.3 ppm F NaF1.1 mg/dropper Sig: One half a dropper once per day, directly in mouth or in water, juice or milk. Dispense 50 mL Refill as needed Rx for 3-year 8-month-old Charlie receiving water that has less than 0.3 ppm F. NaF1 mg chewable Sig: Chew, swish, and swallow one tab per day before bed. Dispense 120 Refill as needed Rx for 3-year 8-month-old Darlene receiving water that has 0.5 ppm F. NaF0.55 mg chewable Sig: Chew, swish, and swallow one tab per day before bed. Dispense 120 Refill as needed Rx for 8-year-old Eddie receiving well water with no fluoride present. NaF2.2 mg chewable Sig: Chew, swish, and swallow one tab per day before bed. Dispense 120 Refill as needed NOTE: No more than 120 tablets of NaF, 2.2 mg, should be dispensed at a time.

55

COMMON QUESTIONS ASKED ABOUT FLUORIDE Q. Should pregnant women take fluoride supplements to benefit the

developing teeth of their babies? A. Prenatal administration of dietary fluoride supplements cannot be recommended

at this time. Conclusive evidence is lacking to support the benefit to the fetus. Q. Should breast fed infants receive fluoride supplementation? A. The fluoride concentration in breast milk is low. Since the earliest age that an

infant might receive supplementation is 6 months, there is initially no need for supplementation whether the baby is exclusively breast fed or not. If the infant is exclusively breast fed after 6 months of age supplementation of 0.25 mg of fluoride should be prescribed even in a fluoridated community. When the baby begins to ingest fluoridated water, whether it is in foods or beverages, the supplementation should be discontinued.

Q. Should I prescribe vitamin-fluoride combinations for children? A. Since vitamins do not enhance or potentate the effect of fluoride, the Council on

Dental Therapeutics of the ADA does not endorse any vitamin -fluoride preparation. However, if vitamins were needed, a vitamin-fluoride combination would be more convenient and less expensive than two separate preparations. A combination prescription should be coordinated with the child's health care provider when vitamins are being taken. As with any prescription, the content and dosage should be reviewed periodically for efficacy and appropriateness.

57

GLASS IONOMERS AS SEALANTS Purpose We have rather limited experience in the United States with the use of glass ionomer sealants as a preventive approach. And, obviously, conventional resin sealants are a superior strategy when satisfactory isolation can be achieved. Nevertheless, experience in other countries and research data demonstrate that ionomer sealants do confer some protection against carious activity, especially when periodic reapplication can be obtained. The general findings have been that some degree of prevention has been achieved even when the glass ionomer sealants fracture off, either in part or totally. Rationale Of course, glass ionomers as sealants need to be used where there is some reasonable expectation of adhesion, even if the procedure were still viewed as a “temporary” or “interim” sealant. The most common example of the justifiable use of glass ionomer sealants occurs where conventional sealants cannot be used successfully on first permanent molars due to behavior and/or lack of sufficient eruption preventing acceptable isolation. In such cases, glass ionomer sealants can be used to seal erupting first permanent molars very early in their stages of eruption (e.g., glass ionomer can be used for any exposed occlusal surface of these molars). When glass ionomer sealants are used, partial or total loss of coverage can be expected at subsequent recall examinations. One major goal of ionomer sealant therapy needs to be periodic reassessment and possible reapplication. Another important objective is to obtain conventional sealant coverage as soon as behavior and development make that possible. Procedure

1. Mix the ionomer material before isolating the tooth, so the material is ready for application when the tooth is isolated. The material can be mixed to a “conventional sealant consistency.” This usually will mean an approximately two drop to one scoop mix. Vitrebond is a good choice for an ionomer sealant since no priming step is necessary with that material.

2. Isolate the tooth as much as possible with cotton rolls or gauze and apply air to

dry the tooth.

3. Apply the ionomer as you would any other sealant (i.e., with a burnisher-type instrument, a brush, or an excavator).

4. Complete the operation by light activating the material.

58

5. Checking occlusion usually is impractical (and of course unnecessary in the case of partially erupted first permanent molars). Also it will aggravate any behavior problems that might be occurring. However, placement of the ionomer so that it is out-of-occlusion will increase its longevity significantly.

RESOURCES/REFERENCES OF POTENTIAL INTEREST

1. Berg, JH. The continuum of restorative materials in pediatric dentistry-a review for the clinician. Ped Dent. 20: 93-100, 1998.

2. Christensen, GJ. Restoration of pediatric posterior teeth. JADA. 127: 106-108,

1996.

3. Christensen, GJ. Compomers vs. resin-reinforced glass ionomers. JADA. 128: 479-480, 1997.

4. Damen, JJ, et al. Uptake and release of fluoride by saliva-coated glass ionomer

cement. Caries Research. 30: 454-457, 1996.

5. Dogon IL, et al. Biological investigation of a new light cured glass ionomer restorative material. IADR abstract #68, 1992. Harvard School of Dental Medicine/Forsyth Dental Center.

6. Hse, K. Clinical evaluation of compomer in primary teeth: 1-year results. JADA.

128: 1088-1096, 1997.

7. Kanellis, MJ. Atraumatic restorative treatment (A.R.T). JSSPD. 4:22-23, 1998.

8. Komatsu H, et al. Caries-preventive effect of glass ionomer sealant reapplication: study presents three-year results. JADA. 1994; 125:543-549.

9. Kupietzky A, et al. Fluoride exchange from glass ionomer preventive

restorations. Ped Dent. 1994; 16:340-345.

10. Lacy, AM, Young, DA. Modern concepts and materials for the pediatric dentist. 18: 469-475, 1996.

11. Leinfelder KF. Glass ionomers: current developments. JADA 1993; 124:62-64.

12. Papathanasiou AG, et al. The influence of restorative material on the survival

rate of restorations in primary molars. Ped Dent. 1994;16:282-288.

13. Peterson, DS and Davis, JM. Atlas of pediatric dentistry pulp therapy chapter. CD-ROM. University of Washington HSCER, 1998. Also released as Atlas of pediatric dentistry pulp therapy chapter. Online. University of Washington HSCER. Available with password: http://eduserv.hscer.washington.edu/pulp/index.htm, 1998.

59

14. Peterson, DS and Davis, JM. Pediatric restorative dentistry. Microdiscs.

University of Washington School of Dentistry, 1995.

15. Wandera, A, et al. In vitro comparative fluoride release, and weight and volume change in light-curing and self-curing glass ionomer materials. Pediatric Dentistry. 18: 210-214, 1996.

16. Winkler, MM, et al. Using a resin-modified glass ionomer as an occlusal sealant:

a one-year clinical study. 127: 1508-1514, 1996.

61

Glass Ionomer Restorations

62

GLASS IONOMER RESTORATIONS TO CONTROL CARIOUS LESIONS IN PRECOOPERATIVE CHILDREN Devereaux Peterson DMD, MSD, PhD, MBA, Associate Professor, Department of Pediatric Dentistry Purpose The purpose of this section is to present a method of controlling caries in precooperative children using glass ionomer restorative material with Atraumatic Restorative Therapy. The term Atraumatic Restorative Therapy, as we will use it in this section, refers to providing restorative therapy to children in a way that no pain is involved. Atraumatic Restorative Therapy usually is known by its acronym ART at the University of Washington. Treatment using ART encompasses a range of restorative therapies where no pain is caused. In particular, as it is used here, this means that local anesthetic is not used and the specific restorative therapy provided is still accomplished without eliciting pain. These are important distinctions since clinicians in different institutions and from various parts of the United States may use the term ART somewhat differently. For example, some clinicians may administer local anesthetic and still call it ART. For our purposes, we are going to limit our discussion to the use of ART and glass ionomer restorative material to restoring carious lesions in precooperative children. We are referring to treatment of carious lesions, usually in infants and toddlers, in a way that is painless, requires no local anesthesia, and the lesions are restored using a resin-modified glass ionomer (henceforth referred to as RMGI). The caries excavation is accomplished very carefully and painlessly, using hand instruments or a slow speed handpiece. The excavated lesions are restored with RMGI and light-cured, which is also done without causing pain. Because of the clinical approach, the restorations often are referred to as scoop-and-fill restorations or band-aid restorations. We will use the term band-aid restorations since it is consistent with terminology used in our department’s Electronic Atlas Of Pediatric Dentistry (please see the resource/reference segment at the end of this article). For wider coverage of the range of restorative care for children using glass ionomer-type materials or related materials, such as compomers, we refer you to our chapter on restorative dentistry for children in the Electronic Atlas of Pediatric Dentistry. Our purpose in using Resin-Modified Glass Ionomers (RMGI’s) with ART is to stabilize the child and the lesion(s). Indeed, sometimes the lesions can be quite large, but they still can usually be stabilized. The RMGI restorations often may be interim in nature, lasting until more durable restorations can be placed at a time when the child’s behavior can be better managed. In fact, the basic idea is to provide a therapy that may last only several months, but still last long enough so that the child gains the maturity to be

63

treated conventionally at a later time. In fact, sometimes retreatment is needed. On the other hand, some of the RMGI restorations last for the life of the primary teeth involved. Rationale RMGI materials are excellent choices for controlling carious lesions in infants and toddlers by using them in band-aid restorations. They have the following advantages: 1. Good handling characteristics for the practitioner 2. Good adhesion and clinical retention 3. Fluoride release 4. Biocompatibility The resin-modified glass ionomer systems are relatively easy to handle for the dentist. They are easily mixed and can be placed in cavity preparations with minimal excavation if necessary, or in very difficult cases with no excavation at all. Placement can be accomplished using a very limited number of steps, with minimal conditioning of the tooth. Once again, in extreme cases, ionomers can be placed with no conditioning of the tooth at all. Of course, better conditions during placement will result in improved adhesion and durability of the restorations. We generally use Vitrebond (3M Dental Products) as the RMGI band-aid restorative material in our clinic. Other materials can be used also according to the preferences of the clinician. The RMGI systems can be light cured, which of course expedites the speed of placement and helps with managing infants and toddlers. Most RMGI systems, including Vitrebond, also have the benefit of being self-cure systems, so layering the material during placement is not necessary. However, the light cure reaction results in improved physical properties in the case of Vitrebond. The RMGI systems also adhere well clinically to dentin and enamel, giving them advantages over many other materials that also might be used for interim band-aid restorations. The RMGI’s also provide fluoride release. Studies also show that ionomers result in no adverse pulpal reactions. There is even some evidence that pulpal reactions are favorable with glass ionomer in deep preparations (i.e., less that 1.0 mm). Nevertheless, the general advice remains to place a calcium hydroxide base in areas of preparations which are in very close proximity to the pulp (less than 1.0 mm). RESIN-MODIFIED GLASS IONOMER APPLICATION Armamentarium Resin-modified glass ionomer restorative material (in this case, Vitrebond Liner/Base is used as the example) Air/water syringe, evacuation, or alternatively 2x2 gauze sponges Slow speed handpiece with a #330, #6, or #8 bur (or another bur of your choice) Brush applicator Beaver tail, excavator, composite syringe, plastic instruments as preferred Light cure unit Mouth props/other restraints as necessary

64

Procedure

1. Stabilize the child and restrain as necessary. Isolate the tooth or teeth to be restored. 2 x 2 gauze can be helpful here to “grip” the mucosa.

2. Remove “soft” or superficial decay with the low speed handpiece using a #330,

#6, or #8 bur or an excavator.

3. In cases where the behavior is very difficult and the decay not too deep, ionomer application can be attempted without excavation. Obviously this approach involves some compromises; but sometimes it is the most practical alternative.

4. Isolate the area and dry the tooth with air or gauze until it is moist (i.e., not really

wet; do not desiccate the tooth). The RMGI actually should be mixed immediately prior to isolating and drying the tooth so that the material is ready for placement. In this way, the amount of time “managing” or “restraining” the child is kept to a minimum.

5. Vitrebond Light Cure Glass Ionomer Liner/Base is mixed just prior to drying the

tooth. One level scoop of powder is used for each drop of liquid. The powder to liquid ratio may be altered to change the viscosity of the mix. Ratios ranging from 1 scoop powder/2 drops liquid to 2 scoops powder/1 drop liquid are acceptable. Mix rations beyond this range are not recommended. Using a cement spatula, mix for 10 to 15 seconds until the Vitrebond is a smooth and glossy consistency. Apply a thin layer to the tooth with a Dycal applicator, excavator, beaver tail, or a plastic instrument and light cure for at least 30 seconds. Repeat this process as needed. The delayed auto-setting mechanism of the Vitrebond liner/base will ensure the eventual cure of the material.

65

Treatment of Pregnant Women

66

Managing the Pregnant Dental Patient

Susan D. Reed, MD Assistant Professor

Department of Obstetrics and Gynecology University of Washington

Box 359865 Telephone (206) 731-4292

Fax (206) 731-5249 Email: [email protected]

67

I. Introduction When treating a pregnant dental patient, a practitioner must always take in to consideration the developing fetus. The gestational age of the fetus and the health of the mother are very important in deciding the safety of dental care and procedures in a pregnant woman. Each trimester should be considered separately, as the risks may vary depending on the physiology at various times in pregnancy. It is important to be familiar with conditions in pregnancy and their possible associated risks: including syncope, hypoglycemia, aspiration, and seizures. Table I outlines general standards of care in treating the pregnant dental patient.

Table I. Standards of Care 1. Follow OSHA, WISHA guidelines 2. Wear gloves, mask and eyewear. 3. Consider conditions specific to the trimester. 4. Take x-rays when necessary using proper precautions and shielding. 5. Property position your patient (See section 11). 6. Follow medication guidelines (See section 111). 7. Know how to treat potential complications with pregnant patients (See section VI).

II. Physiology of Pregnancy The physiologic changes that occur with pregnancy determine the special considerations in caring for the pregnant dental patients. Some general changes that occur are applicable for all trimesters. Vital signs differ from the non-pregnant patient in that the heart rate usually increases 10 to 15 beats per minute, the diastolic and systolic blood pressure falls by 5-15 mm Hg. Respiratory rate may increase slightly with a 30-40% increase in tidal volume (or the amount of air inspired and expired with each breath). Average weight gain in pregnancy is 25 to 35 pounds. Because of increased metabolic rate, pregnant women are prone to hypoglycemia and should eat small amounts frequently. Caloric intake increases by 200-300 kcal/d (Catalano, 1992). Mechanical changes and progestin hormone result in bladder pressure and the urge to empty the bladder frequently. Because of urinary frequency and possible discomfort in the dental chair for prolonged procedures, consideration to breaking up procedures into several appointments should, be given. Cardiac output and blood volume increases by approximately 50% in pregnancy. Peripheral vascular resistance falls. In addition the reinioangoiension system recalibrates, such that moving from a lying to a standing position, vasoconstricion is somewhat retarded and patients should move slowly to alleviate risk of syncope. Warm environments can put a patient at risk for a syncopal episode. Physiologic changes relevant to the different trimesters are outlined below. The first trimester is associated with nausea and vomiting, and a hypersensitive gag reflex. Typical onset of nausea in pregnancy is 4-8 weeks with resolution by 14-16 weeks; and is probably related to increased progesterone resulting in smooth muscle relaxation and relaxation of the gastric sphincter. This could potentially put a patient at

68

risk for aspiration. Careful history of pregnancy symptoms prior to a procedure is important. Discussion with the patient prior to positioning that would allow her to signal the care provider if she were to feel nauseated is of importance. If the patient is at risk for emesis, proper suctioning device should be available and proper positioning of the patient in a lateral and upright position so that she might protect her airway is imperative. Because of decreased gastrointestinal motility the patient is more apt to have a full stomach for extended periods of time. "Blow by" oxygen can sometimes alleviate symptoms of nausea. The late second trimester and third trimester require care in positioning the pregnant patient. Because of the weight of the gravid uterus on the vena cava, blood return to the heart is diminished in a supine position. There is probable complete occlusion of the inferior vena cava in the supine position in late pregnancy (Ueland, 1969). Therefore, the pregnant patient in the late second and throughout the third trimester should always be positioned with a pillow under the left or right hip to displace the gravid uterus off of the vena cava. The shoulders can be square on the dental chair, but the hips should be laterally rotated. Total lung volume decreases by 5% and 60-70% of pregnant women experience a sense of dyspnea. Increased progesterone levels may act as a direct respiratory center stimulant (Skatrud, 1978). Therefore, the dental patient may require more frequent breaks because of this increased sense of "air hunger" or shortness of breath, Gingival hypertrophy and epulis gravidarum (pedunculated lesions at the gum line) is most commonly seen in the third trimester and will disappear postpartum. This can result in increased bleeding when brushing and if excessive, the epulis gravidarum should be removed. In addition, tooth mobility increases in pregnancy quite possibly secondary to increasing levels of the hormone, inhibin, and resolves postpartum.

III. Special Preventative Dental Care in the Pregnant Patient Special recommendations for the patient with frequent emesis would include careful rinsing and application of fluoride gels or baking soda rinse following each emesis; thereby reducing the risk for enamel demineralization. Increased risk for caries and bacterial overgrowth in pregnancy, due to immunosuppression and an estrogen rich environment, require increased preventive care and daily oral care maintenance. Increased tooth mobility and gingival hypertrophy can be anticipated to cease postpartum. Careful brushing with a soft bristle and flossing will diminish risk of excessive bleeding. The incidence and magnitude of bacteremias of oral origin are directly proportional to the degree of oral inflammation and infection (Pallasch, 1996). Any systemic infection resulting in bacteremias can be associated with chorioamnionitis which can lead to low birth weight and premature deliveries. A single study suggests untreated periodontal disease is a risk factor for preterm low birth weight (Offenbacher, 1996). It follows that conscientious preventative care is very important in the pregnant patient.

69

Vitamin and mineral supplementation can be reinforced by the dental practitioner. Fluoride supplementation is not currently recommended. All pregnant women should be taking a prenatal vitamin with 0.4 milligrams of folic acid and dietary or vitamin supplementation of calcium for a total intake of 1500 milligrams per day. The dental practitioner can encourage the need for proper nutrition in pregnancy.

IV. Medications All medications have been classified by the Federal Drug Administration (FDA) for teratogenic risk in pregnancy. This ABCD and X classification system has historically been cumbersome and too often misinterpreted. It is being reevaluated by the FDA and a new system should be in place within the next two years. Precautions when administering local anesthesia, analgesia, sedation and antibiotics are outlined here with designation of risk under the existing FDA guidelines. Lidocaine is safely used throughout pregnancy as a local anesthetic quite commonly given with a vasoconstrictor, epinephrine, for dental procedures. Significant intravascular infiltration results in syncope, seizure and cardiac arrest. The hypervascularity of the pregnant state might slightly increase this risk, but doses of less than 3cc make this ram complication exceedingly uncommon. The precautions as with a non-pregnant patient should be taken. Other "caine" anesthetics should be avoided as experience in dental procedures in pregnancy is limited. Intravenous or mask sedation should be avoided in the absence of a controlled operative setting. Controversy as to the possible teratogenic effects of nitrous oxide in the first trimester continues (Aldridge, 1986). Data to date suggests that these risks are exceedingly low if not negligible. However, the greater risk of oversedation, and subsequent untoward consequences to both the mother and the fetus should be taken into consideration. The mainstay of analgesia in the pregnant patient is acetaminophen. Aspirin is avoided because of its prolonged action as a cyclooxygenase inhibitor, which can result in decreased platelet aggregation and prolonged bleeding times. This has been associated with risk for placental abruption. Non-steroidal anti-inflammatory agents such as ibuprofen and indocin are used by obstetricians to inhibit pre-term labor. These agents are used safely at gestations less than 32 weeks with normal amniotic fluid volumes for brief periods of time, less than 48 hours. They can result in decreased amniotic fluid volumes and reversible closure of the fetal ductus arteriosus when used for periods of greater than 48 hours (lams, 1996). Lastly, narcotics are used safely in every trimester and are not associated with any teratogenic effects. Just as with a non-pregnant patient, consideration for promotion of addictive behaviors should be considered. Use of antibiotics in the dental patient are important to decrease the risk of bacteremia, in the treatment of tooth abscess, and in prophylaxis against bacterial endocarditis in

70

the at risk patient. The American Heart Association published guidelines in 1997 which are included in Table 2A and 2B (Dajani, 1997). Antibiotics of choice for prophylaxis in the pregnant dental patient include amoxicillin, ampicillin, clindamycin, azithromycin and cephalosporins (See Table 3). A cephalosporin is the broad-spectrum coverage of choice for the patient with an oral infection. Table 4 summarizes FDA classification of antibiotics for pregnancy and lactation. Table II A. Cardiac Conditions Associated with Endocarditis

Endocarditis Prophylaxis Recommended High-risk category Prosthetic cardiac valves, including bioprosthetic and homograft valves Previous bacterial endocarditis Complex cyanotic congenital heart disease (e.g. single ventricle states, transposititian of the great arteries tetralogy of Fallot) Surgical constructed systemic pulmonary shunts or conduits Moderate-risk category Most other congenital cardiac malformation (other than above and below) Acquired valvar dysfunction (e.g. rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvar regurgitation and/or thickened leaflets*

Endocarditis Prophylaxis Not Recommended Negligible-risk category (no greater risk than the general population) Isolated secundum atrial septal defect Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 mo) Previous coronary artery bypass graft surgery Mitral valve prolapse without valvar regurgitation Physiologic functional, or innocent heart murmurs Previous Kawasaki disease without valvar dysfunction Previous rheumatic fever without valvar dysfunction Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators * Prophylaxis is recommended for patients with high- and moderate-risk cardiac conditions.

71

Table II B. Dental Procedures and Endocarditis Prophylaxis Endocarditis Prophylaxis Recommended*

Dental extractions Periodontal procedures including surgery, scaling and root planing, probing, and recall maintenance Dental implant placement and reimplantation of avulsed teeth Endodontic (root canal) instrumentation or surgery only beyond the apex Subgingival placement of antibiotic fibers or strips Initial placement of orthodontic bands but not brackets Intraligamentary local anesthetic injections Prophylactic cleaning of teeth or implants where bleeding is anticipated

Endocarditls Prophylaxis Not Recommended Restorative dentistry† (operative and prosthodontic) with or without retraction cord‡ Local anesthetic injections (nonintraligamentary) Intracanal endodontic treatment; post placement and buildup Placement of rubber dams Postoperative suture removal Placement of removable prosthodonlic or orthodontic appliances Taking of oral impressions Fluoride treatments Taking of oral radiographs Orthodontic appliance adjustment Shedding of primary teeth * Prophylaxis is recommended for patients with high- and moderate-risk cardiac conditions. † This includes restoration of decoyed teeth (filling cavities) and replacement of missing teeth: ‡ Clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding. Source: Dajani, 1997

72

Table III. Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures

Situation Agent Regimen Standard general prophylaxis

Amoxicillin 2.0 g po 1 h before procedure

Unable to take oral medications

Ampicillin 2.0 g intramuscularly (IM) or intravenously (IV) within 30 min before procedure

Allergic to penicillin Clindamycin 60D mg po 1 h before procedure Or Cephalexin or 2.0 g po 1 h before procedure Cefedroxil* Azithromycin or 50 mg po 1h before procedure Clarithromycin Allergic to penicillin and unable to

Clindamycin 600 mg within 30 min before procedure

take oral medications or Cefazolin* 1.0 g within 30 min before

procedure

* Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillin. Source: Dajani, 1997

73

Table IV. Medications Commonly Used in Dentistry Type of medication FDA pregnancy risk factor Analgesics:

Acetaminophen (Tylenol) B Aspirin C3 Codeine C* Dihydrocodeine (Synalogos-DC) B* Ibuprofen (Motrin) B3 Meperidine (Demerol) B* Morphine B* Oxycodone (Tylox, Percocet) C* Pentazocine (Talwin) B* Phenacetin B Phenylbutazone (Azolid, Butazolidin) D Propoxyphene (Darvon) C*

Antibiotic Amikacin C Amoxicillin B Amphotericin B B Ampicillin B Caphalosporins B Chloramphericol C Clindamycin B Clotrimazole B Dicloxacillin B Erythromycin B Gentamicin C Kanamycin D Methicillin B Metronidazole (Flagyl) B Miconazole B Nafcillin B Nitrofurantoin B Oxacillin B Penicillin G B Penicillin G procaine B Penicillin G benzathine B Penicillin V B Streptomycin D Sulfonamides B2 Tetracycline D Vancomycin C

Antiemetics Hydroxyzine (Atarax Vistaril) C Prochlorperazine (Compazine) C Promethazine (Phenergan) C Trimethobenzamide (Tigan) C

Bronchodilators Aminophylline C Terbutaline B

Local anesthetics Etidocaine B Lidocaine B Marcaine C Mepivacaine C Miscellaneous Atropine C Cyclamate (sweetener) C Dexamethasone C Diphenhydramine (Benadryl) C Epinephrine C Prednisolone B Prednisone B

Sedatives Diazepam Valium D Chlordiazepoxide (Librium) D Phenobarbital D

* Risk factor changes to Category D it used for prolonged periods or in high doses at the end of the term 2 Risk factor changes to Category D if administered near the end of the term 3 Risk factor changes to Category D if used in the third trimester Source: Briggs, 19%

74

V. Documented Human Teratogens The list of documented human teratogens is actually quite limited. Teratogenic agents listed that could potentially be associated with dental procedures include: kanamycin, lead, mercury, streptomycin, tetracycline, doxycycline, and radiation exposure. Of note is doxycycline which is a tetracycline derivative. The amount of mercury used in amalgams is minimal. Teratogenic effects at the amounts used for routine amalgams have never been demonstrated. Radiation exposure significant enough to result in teratogenic effect has never been seen at less than 10 rads (Briggs, 1983). In contrast to these large doses, the amount of exposure to the fetus from a full mouth dental series (18 intraoral, D film, with a lead apron) is 0.00001 rads. A panoramic series results in 0.00015 rads (Manson-Hing, 1976). In contrast, a daily dose from the background radiation is considered to be 0.004 rads and the radiation dosage to the fetus from a shielded chest x- is 0.008 rads. Therefore, the risk of radiation exposure from dental films is minute. Use of dental x-rays should not be withheld in the pregnant patient

Table V. Documented Teratogenic Agents Alcohol Mercury Androgens Methotrexate ACE inhibitors Paramethadione Carbamazepine Phenytoin Cocaine Radiation

exposure Diethylslilbestrol (DES)

Streptomycin

Doxycycline Tetracycline Etretinate Thalidomide lsotretinoin Trimethadione Kanamiycin Valproate Lead Vitamin A Lithium Warfarin

Source: Ronald J. Ruggiero Pharm. P. in M. Gyn News 8/15/98

VI. Handling Emergencies in the Pregnant Dental Patient Prior to caring for any pregnant patient, the practitioner should assess his/her dental suite for basic emergency equipment. The ability to assess vital signs in a timely fashion with blood pressure cuff and stethoscope in the room are essential. In addition, equipment for delivery of oxygen by mask, up to 10 liters per minute should be accessible. Treatment of anaphylaxis with diphenhydramine (Benadryl®) at dosages of 25 milligrams IV or 50 milligrams IM should be readily available. Awareness of potentially emergency situations and treatment are outlined below. Syncope can result from dehydration, hypoglycemia, supine hypotension or pulmonary embolus. The patient should be positioned in Trendelenburg position with hips displaced to either the left or right side. Suction should be administered because of

75

aspiration risk in this position. Oxygen should be administered and immediate vital signs obtained. If the patient isn't immediately arousable, call 911. Aspiration can occur when a patient is poorly positioned, i.e. tilted with her bead below her stomach. In this position, she is unable to clear her mouth of secretions in the event of massive emesis. In the absence of a syncopal episode, the pregnant patient should never be positioned with the stomach higher than the mouth. With loss of consciousness, a suction device should always be available in order to help suction and clew secretions in the patient with an unprotected airway. The Heimlich maneuver should not be administered in the pregnant patient during the second or third trimester, because of possible fetal injury. Seizures can occur in the event of an intravascular injection of lidocaine, a significant bypotensive episode, or in the event of a seizure associated with preeclampsia. Dental procedures should be avoided on all patients with a diagnosis of preeclampsia. Preeclampsia is diagnosed by the obstetrician in the patient with elevated blood pressure, edema and proteinuria. Preeclampsia is most commonly seen in the last month of pregnancy, however in high-risk individuals it can be seen as early as twenty weeks gestation. Careful triage of these patients with an office questionnaire prevents untoward complications in your office. Vaginal bleeding would not be expected to be associated with any dental procedures. However, vaginal bleeding could coincidentally occur in the dentist's office. Careful screening for risk of bleeding with dental history prior to procedure will assist the dentist in triaging this problem. Uterine contractions occur in association with severe pain or high stress levels. Contractions association with pain and emotional stress would rarely result in a pre-term birth. However, these are disconcerting for the patient and the care provider and if significant contractions occur in the dental office, the procedure should be curtailed and the patient rescheduled after consultation with the obstetrician_ Cardiopulmonary arrest in the pregnant patient most commonly occurs in association with pulmonary embolus or amniotic fluid embolus. Other etiology of cardiopulmonary arrest in the pregnant patient would include a severe hypotensive episode or an intravascular injection of lidocaine. This medical emergency in the pregnant patient is handled in identical fashion to a non-pregnant patient with the exception that the uterus should be displaced to the left or right lateral position by wedge or pillow under the hip of the patient- The thorax should be positioned on a flat surface such that proper cardiac and respiratory resuscitation can be administered. Office staff should all be trained in Basic Cardiac Life Support (BCLS).

VII. Care of the Lactating Patient Care for the post partum lactating patient is quite similar to the non-pregnant patient. The dental practitioner should be aware that all narcotics are secreted into the breast

76

milk and will result in some mild sedation of the infant. In addition, antibiotics are also secreted in the breast milk and can result in diarrhea for the newborn infant. After discussion with the patient, if these medications are indicated for the dental procedure, they are usually prescribed. These essential medications are not withheld for any necessary surgical procedures.

VIII. Summary/Goals in Managing the Pregnant Dental Patient Apprehension of providing dental care for the pregnant patient can be alleviated by careful screening for at risk situations through the use of the dental history questionnaire and by taking proper precautions appropriate to the gestation of the patient. Careful maintenance and provision of emergency equipment in the dental suite is imperative for all dental procedures in pregnant and non-pregnant patients. Dental care in the gravid patient should emphasize maintenance of hygiene, provision of all required procedures, and common sense in the provision of routine care. Preventive care, emergency care, orthodontics, scaling and curettage can be provided in all trimesters. Consultation with the obstetrician is encouraged if uncertainty regarding medications or procedures arise; however, adherence to the guidelines outlined in this review article will make consultation with the obstetrician a rare event Certainly for any procedure requiring a general anesthetic, obstetrical consultation should be obtained.

IX. Health History and Dental Interview Dental Interview How many weeks are you? Rationale - This will help you know what trimester the patient is in. Second trimester is the best time to treat. Do you have children? Rationale - If a patient has had children, she will know more about conditions associated with pregnancy. Have you bad any complications with this pregnancy? Rationale - This will alert you to changes in procedure or a consult with the doctor. Has your blood pressure been normal? Rationale - If the blood pressure is high, you may not want to treat this patient today. If the blood pressure id borderline high, you may want to use an anesthetic without Epinephrine. Have you had morning sickness or nausea? If so, how recent? Rationale - If the patient is not felling well, you may elect to do a shorter procedure or reappoint

77

Are you using any drugs, alcohol or are you smoking? Rationale - Many pregnant teens do not know the risks of drugs, alcohol, or smoking during pregnancy Do you have a safe place to live? Rationale - Many pregnant teens may be living with friends, on the street, or with a boyfriend. There is the possibility of domestic violence. Do you have transportation? Rationale - If the patient has difficulty coming to the appointment, it is likely she will miss other appointments. Are you eating or sleeping well? Rationale - It is a good way to assess the overall health and attitude of self. When was your last dental visit? Rationale - This a way to assess if the patient has had access to dental care. Was it a routine visit? Rationale - This is a way to see if the patient has had a lot of emergencies or just had routine care. Do you feel your teeth and mouth are healthy? Rationale - This will assess their own feeling about their teeth and their attitudes about Dentistry What are your expectations for your baby's teeth? Rationale - This will assess if the patient feels she can stop dental caries through early intervention and education about dentistry. It is also recommended to do an updated health history at each visit in a modified form. This can alert you to any changes in health and help you to decide if you need to modify the treatment plan. Updated Health History at each visit: How are you feeling today? Have you had morning sickness in the past 24 hours? Was your blood pressure normal at your last OB visit? Have you been sleeping/eating well? Did you have difficulty coming to this appointment? Any changes in your health? Do you have any pain in your mouth or teeth? What can I do to make your visit easier?

78

X. References

Aldridge LM, Tunstall ME. Nitrous oxide and the fetus: A review and the results of a retrospective study of 175 cases of anaesthesia for insertion of shirodkar suture. Br J Anaesth 1986;58:1348-1356. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation: A reference guide to fetal and neonatal risk. 5th ed. Baltimore, Maryland: Williams & Wilkins,1998. Catalono, PM, Hollenbeck C. Energy requirements in pregnancy: A review. Obstet Gynecol Surv 47:368, 1992. Dajani, AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, et al. Prevention of bacterial endocarditis: Recommendations by the american heart association 1997;277(22):1794-1801. lams JD. Preterm birth. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics: Normal and Problem Pregnancies. New York- Churchill Livingstone, 1996. Manson-Hing L.R. Panoramic dental radiography. Springfield, Illinois: Charles C. Thomas Publishers, 1976. Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight J Periodontol 1996;67:1103-1113. Pallasch TJ, Slots I Antibiotic prophylaxis and the medically compromised patient Peridonlo12000. 1996; 10:107-138 Ruggerio RJ. Pharm D. Ob Gyn News, 1999. Skatrud JB, Dempsey JA, Kaiser DG. Ventilatory response to medioxyprogesterone acetate in normal subjects: Time course and mechanisms. J Appl Physiol 1978;44:939. Ueland K, Novy MJ, Peterson EN, et al. Maternal cardiovascular dynamics, IV: The influence of gestational age on thematernal cardiovascular response to posture and exercise. Am J Obstet Gynecol 1969;104:856.

79

Restorative Dentistry

80

CURRENT METHODS OF PULPAL THERAPY IN THE PRIMARY DENTITION A. Direct Pulp Therapy -- A pulp dressing is placed in contact with a pulp exposure over which a temporary or permanent restoration is inserted. Calcium hydroxide is currently the drug of choice. The objective of this therapy is the creation of new dentin in the area of exposure and subsequent healing of the pulp tissue. Direct pulp capping is ordinarily contraindicated in the primary dentition because internal resorption is frequent sequelae. B. Indirect Pulp Therapy -- All of the superficial carious dentin is excavated, the caries that is estimated to be approximating a potential pulp exposure is left in the tooth if it is still sufficiently healthy (i.e., affected - not infected dentin), and a pulp dressing is placed in the tooth for a determined period of time (1-6 months). At the second appointment, all of the carious material is excavated, and the floor of the cavity is examined for pulp exposures. If no exposures are seen and the tooth has been asymptomatic, the treatment is considered successful, and a permanent restoration is place. The single appointment procedure is also gaining popularity, where a permanent restoration is placed at the first appointment, with periodic monitoring of the tooth. The preoperative x-ray of the tooth to be treated by indirect pulp therapy must not indicate a carious exposure of the pulp, the tooth should be asymptomatic, and no periapical change is observable on the x-ray. C. Pulpotomy -- That procedure in which the coronal pulp tissues are completely extirpated while the radicular pulp tissues are left intact. A zinc oxide eugenol base is placed over the amputation sites and a permanent restoration is completed. The objective is to maintain the restored tooth so it may function as a healthy biological unit. Because of systemic distribution and potential mutagenic and carcinogenic effects from full strength formocresol alternative pulpotomy procedures are suggested:

1. One-fifth dilution of formocresol - acceptable procedure 1. (Note: cotton pellets are not sealed ion the tooth) 2. Glutaraldehyde - acceptable procedure 3. Electrosurgery - acceptable procedure 4. Laser - acceptable procedure 5. Ferric Sulfate - acceptable procedure 6. Ca(OH)2 - usually not acceptable 7. Zinc oxide eugenol - usually not acceptable 8. BMP (bone morphogenic protein) - futuristic procedure

81

Pulpotomy Indications 1. Radiographic P.D.M. - normal Lamina dura - normal P.A. bone - normal Bifurcation - normal Lack of internal resorption 2. Subjective Symptoms Lack of spontaneous pain 3. Miscellaneous Lack of tenderness to percussion Lack of mobility Lack of fistulae Lack of gingival inflammation D. Pulpectomy -- That procedure in which the entire pulpal contents are removed from the crown root portions of the tooth. Children seen in your clinic will vary in age, but many dental problems fall in the 4 to 7 year age group. The primary molars have been present from 2 to 5 years and it is possible to observe any condition from a clean caries-free mouth to infected and necrotic teeth. Once the pulp has become infected, you are faced with the decision to treat or remove the tooth. There are many advantages to retaining the pulpally involved molar, but of most importance is preserving space for erupting permanent teeth. Endodontics for the primary dentition is a relatively quick and easy procedure for treating teeth with necrotic tissue which cannot be treated with the pulpotomy procedure. A high-speed bur is used to gain access into the pulp chamber and Hedstrom files are then used for filing the canals. The canals are irrigated to wash any remaining tissue and loose dentin. The canals and chamber are then filled, a post-operative x-ray is taken to evaluate the condensation procedure, and the tooth is then usually restored using a stainless steel crown. Indications: A tooth that is restorable with stainless steel crown. No pathological root resorption. Layer of overlying bone between permanent tooth bud and area of pathological bone resorption. (On the x-ray, a layer of healthy bone should exist between the lesion and the permanent tooth bud. This allows the lesion to fill in with normal bone once the endodontic therapy is completed.) Contra-Indications:

82

Pulpal floor opening into the bifurcation. Radiographic indication of extensive internal resorption (tooth has been weakened to the extent that it cannot support a stainless steel crown). More than 2/3 of the roots have been resorbed. No bone between the permanent tooth bud and the lesion.

83

SPACE MAINTAINERS The premature loss of a primary molar may have a deleterious effect on the development of a normal occlusion for the child. Careful considerations are necessary to determine the need to maintain this space. The most common types of appliances to maintain space are: A. Fixed 1. Crown - loop space maintainer 2. Band - loop space maintainer 3. Distal shoe 4. Mandibular lingual arch 5. Maxillary lingual arch B. Removable

1. Bilateral acrylic spacers occasionally indicated provided there is patient compliance.

2. Unilateral acrylic spacers contraindicated.

84

Initial Assessment and Management of Infection

and Trauma

85

INITIAL ASSESSMENT AND MANAGEMENT OF INFECTION AND TRAUMA Injuries and Trauma Prevention: Suggest that infants and toddlers always use safety seats in autos to avoid injury. No running with dangerous objects; no standing while swinging. Any injury to primary teeth can damage developing permanent teeth, especially before age 3. Report all such injuries to dentist. Child Toothaches—What to do at first: See a dentist as soon as possible. Don’t wait, the pain may go away, but will surely return and be more difficult to eliminate. If all else fails, over-the-counter-preparations that numb baby’s gums are available. It is our belief that teething time is especially important for babies—as erupting teeth are especially vulnerable to decay (Teeth erupt at night when saliva flow is shut off.). Suggest increased attention to protecting them by home care activities (cleaning), and professional application of fluorides (and in the future, the use of antimicrobials—a research topic right now). A note about drooling: it is not unusual for healthy children. Many things stimulate drooling—including food, smells, tastes, or irritation around an erupting tooth that has not been cleaned. Initial Patient Contact Telephone checklist for reception staff Advantages - Determine if true emergency - Determine responsibility of parent - Clinician can narrow diagnosis Only Two Real Emergencies - Trauma - Infection with pain Trauma Primary Incisor Injuries Coronal Fractures- Enamel only- Smooth as necessary- Enamel/Dentin- Vitrebond bandage- Pulpal Exposure- Pulpotomy/Pulpectomy - Extract Root Fractures - Coronal, Middle 1/3- Extract - Apical 1/3- Leave if Firm Luxation - Mild with little mobility- Leave - Major +/- mobility- Extract - Do not splint except to hold alveolus

86

Intrusion -Up to 2-3mm leave if tooth firm - >3mm or if mobile- Extract ODONTOGENIC INFECTIONS Unprovoked Pain Primary Incisor- Extract- Pulpect Primary Molar-Pulpectomy-Extract Pulpotomy? Not reliable if infection extended beyond pulp chamber Therefore pulpotomy unreliable in situations with unprovoked pain Odontogenic Infection Antibiotic Therapy is not a substitute for correcting the problem but an adjunct to dental treatment to treat the problem. The best antibiotics are those that are active against staphylococcus aureus and streptococcus viridans. The usual antibiotics recommended for cardiac prophylaxis are excellent choices.

87

RECOMMENDED TREATMENT FOR COMMON ORAL LESIONS Angular Cheilitis: Rx: Triamcinolone and nystatin ointment (Mycolog II Disp: 15 g tube Sig: Apply to affected area after each meal and at bedtime Category: Topical corticosteroid. Antifungal Mechanism: Nystatin alters fungal cell membrane. Triamcinolone decreases inflammation. Side effects: Dryness, itching, burning Aphthous Ulcer: Rx: Triamcinolone acetonide (Kenalog in Orabase) Disp: 5 g tube Sig: Dry lesion. Coat lesion with a thin film after each meal and at bedtime Category: Topical corticosteroid Mechanism: Decreases inflammation. Warning: Do not use on fungal ulcerations. Do not use for diabetics *If significant improvement has not occurred in 7 days, discontinue treatment and reassess the diagnosis. Candidiasis: Rx: Nystatin suspension 100,000 units/ml Disp: Infants :125 ml (Infant dose:200,000 units qid) Child/adult:300 ml (Child/adult dose:500,000 units qid) Sig:Infants: 2 ml qid. Swab oral tissues and encourage swallowing. Child/adult:5 ml qid. Swish for two minutes and swallow. Category: Antifungal Mechanism: Alters fungal cell membrane Side effects: Nausea, vomiting, diarrhea, contact dermatitis Rx: Fluconazole suspension 40 mg/ml or Fluconazole tablets 100 mg (Diflucan) Dose:6 mg/kg loading dose, then 3 mg/kg qd x 13 days Sig: 1 dose qd x 14 days Category: Antifungal

88

Mechanism: Inhibits fungal cell membrane formation. Indications: Immunocompromised patients. Patients unable to comply with qid schedule for Nystatin Warning: Not for patients with renal or hepatic dysfunction Recurrent herpes labialis: Rx: Penciclovir cream (Denavir) Disp: 5 g tube Sig: Apply to affected area at first sign, then q 2 h until lesion is gone Category: Antiviral Mechanism: Inhibits viral DNA multiplication Side effects: Mild skin irritation Multiple oral ulcerations: Home remedy coating agent: Diphenhydramine (Benadryl) elixir 12.5 mg/5 ml and Kaopectate Mix equal parts by volume Rinse with 5 ml q 2 h and spit out Maalox can be used in place of Kaopectat By prescription: Rx: Sore-away mouth rinse (equal parts Nystatin oral suspension 100,000 u/cc, diphenhydramine elixir 12.5 mg/5 ml, and Maalox (OTC)) Disp: 12 oz Sig: < 3 years :Swab around entire mouth qid 3-5 years :Swish and swallow 2-3 ml qid > 5 years:Swish and swallow 5 ml qid Halitosis: Rx: Chlorhexidine gluconate mouthwash 0.12% (Peridex) Disp: 16 oz Sig: Brush on posterior part of tongue or gargle with 5 ml for 1 minute at bedtime Category: Topical antibacterial Mechanism: Alters bacterial cell wall. Bacteriocidal or bacteriostatic Side effects: Increases calculus on teeth, altered taste sensation, tooth staining

89

RUG GUIDELINES FOR COMMON PEDIATRIC ORAL CONDITIONS ANTIBIOTICS: Penicillin VK Children’s dose:25-50 mg/kg/day divided q 6 h x 7 days Adult dose:250-500 mg q 6 h x 7 days Maximum dose:3 g/day Forms Suspension: 125 mg/5 ml and 250 mg/5 ml Tablets: 250 mg and 500 mg Category: Bacteriocidal antibiotic Indications: First choice for orofacial infections: cellulitis, periapical abscess, periodontal abscess, acute suppurative pulpitis, pericoronitis, osteitis,osteomyelitis, post-surgical infection, post-traumatic infection Mechanism: Inhibits cell wall synthesis Side effects: Nausea, vomiting, rash, hypersensitivity Warnings: Patients with hypersensitivity to cephalosporins Amoxicillin Trihydrate Children’s dose: 30-50 mg/kg/day divided q 8 h Adult dose: 250-500 mg q 8 h Maximum dose: 1.5 g/day Forms: Suspension: 125 mg/5 ml and 250 mg/5 ml Chewable tablet: 125 mg and 250 mg Capsule: 250 mg and 500 mg Category: Broad spectrum, bacteriocidal antibiotic Indications: First choice for SBE regimen Mechanism: Interferes with bacterial cell wall synthesis Side effects: Diarrhea, rash, superinfection Warnings: Reduces efficacy of oral contraceptives. Efficacy is reduced by tetracyclines

90

Erythromycin Children’s dose: As ethylsuccinate - 50-80 mg/kg/day divided q 8 h Adult dose: As base - 250 mg q 6 h Maximum dose:2 g/day Forms: Ethylsuccinate suspension: 200 mg/5 ml and 400 mg/5 ml As base (enteric coated tablet): 250 mg Category: Narrow spectrum, bacteriostatic antibiotic Indications: Alternative to Pen VK for infections. Alternative to amoxicillin for SBE prophylaxis Mechanism: Inhibition of RNA-dependent protein synthesis Side effects: GI pain, cramping, nausea, vomiting Warnings: Increases blood levels of Tegretol and theophylline Augmentin (Amoxicillin and Clavulanic Acid) Children’s dose:25-45 mg amoxicillin/kg/day divided q 12 h Adult (>40 kg) dose: 400 mg bid (875 mg bid for severe infections) Maximum dose:2 g/day Forms: Suspension: 200 mg/5 ml and 400 mg/5 ml Chewable tablet: 200 mg and 400 mg Tablet: 875 mg Category: Broad spectrum, bacteriocidal antibiotic Indications: Treatment of orofacial infections when beta-lactamase producing staphylococci and bacteroides are present Mechanism: Interferes with bacterial cell wall synthesis Side effects: Diarrhea, rash, superinfection Warnings: Increases efficacy of anticoagulants. Decreases efficacy of oral contraceptives. Clindamycin Children’s dose:8-25 mg/kg/day divided q 6-8 h Adult dose:150-450 mg q 6-8 h Maximum dose:4.8 g/day Forms: Suspension: 75 mg/5 ml Capsule: 150 mg Category: Broad spectrum, bacteriocidal or bacteriostatic depending on dose Indications: Second choice (to Pen VK) for orofacial infections, third choice (to amoxicillin and erythromycin) for SBE prophylaxis Mechanism: Inhibits bacterial protein synthesis Side effects: Diarrhea and rash Warning: Can cause severe colitis. Discontinue if significant diarrhea occurs.

91

Cefpodoxime Proxetil (Vantin) Children’s dose: 10 mg/kg/day divided q 12 h maximum 400 mg /day Adult dose: 400 mg q 12 h Forms: Suspension: 50 mg/5 ml and 100 mg/5 ml Tablets: 100 mg and 200 mg Category: Broad spectrum, bacteriocidal, second generation cephalosporin Indications: Dirty skin wounds Side effects: Dizziness, rash, diarrhea, nausea, vomiting, abdominal pain Warning: Do not take with antacids (decrease absorption) Use with caution in penicillin-allergic patients Analgesics Acetaminophen Children’s dose: 15 mg/kg/dose or 80 mg/year of age/dose qid Adult dose: 325 - 650 mg q 4 -6 h Maximum dose: 4 g/day Forms:Drops: 100 mg/ml Suspension: 160 mg/5 ml Suppository 120 mg, 325 mg, and 650 mg Chewable tablet: 80 mg Tablet: 325 mg and 500 mg Category: Analgesic, Non-narcotic, Antipyretic Indications: Mild to moderate pain Mechanism: Inhibits prostaglandin synthesis in the CNS, peripherally blocks pain impulse generation Side effects: Rash, blood dyscrasias, hepatic necrosis with overdose, renal injury with chronic use Interactions: Barbiturates, carbamazepine, hydantoins increase hepatotoxic potential of acetaminophen

92

Acetaminophen and Codeine Phosphate Children’s dose: Codeine 3 mg/kg/24 h divided qid . Maximum 60 mg codeine/dose Adult dose: 1 - 2 tablets q 4 h Maximum: 12 tablets / 24 h Forms: Elixir: acetaminophen 120 mg and codeine 12 mg/5 ml (with alcohol 7%) Tablets: # 2 - acetaminophen 300 mg and codeine 15 mg # 3 - acetaminophen 300 mg and codeine 30 mg Category: Analgesic, Narcotic Indications: Moderate pain Mechanism: Acetaminophen (as above). Codeine binds to opiate receptors in the CNS, inhibiting ascending pain pathways and altering perception of pain Side effects: Lightheadedness, dizziness, sedation, nausea, vomiting, constipation Interactions: Acetaminophen (as above). Codeine increases toxicity of CNS depressants, tricyclic antidepressants, MAO inhibitors Ibuprofen Children’s dose: 10 mg/kg/dose q 6 – 8 h . Maximum dose 40 mg/kg/24 h Adult dose: 400 - 600 mg/dose q 4 - 6 h Maximum dose: 2.4 g/day Forms: Suspension: 100 mg/5 ml Tablets: 200 mg, 300 mg, 400 mg Category: Analgesic, Non-Narcotic, Non-steroidal Anti-inflammatory (NSAID) Indications: Mild to moderate pain and inflammation Mechanism: Inhibits prostaglandin synthesis Side effects: Indigestion, nauseaInteractions: Increases levels of digoxin

93

Topical Anesthetics and Coating Agents for Primary Herpes Gingivostomatitis Catherine Flaitz, DDS, MS, The University of Texas-Houston Alcohol-free Benadryl elixir (diphenylhydramine HCl) and Maalox. Mix in a 1:1 ratio (OTC). Dispense 200 ml Sig: Rinse with one teaspoonful every 2 hours and expectorate. NB: Kaopectate or other magnesium aluminum hydroxide solution can be used in place of Maalox. Peridex or PerioGard may be beneficial for managing gingivitis once oral ulcerations have resolved. Rx: Benadryl/Lidocaine/Maalox mouthrinse Instruct: Mix 1.5 ml dephenhydramine injectable (50 mg/ml), 45 ml xylocaine viscous 2%, 45 ml magnesium aluminum hydroxide solution. Sig: Rinse with 1 teaspoonful every 3 hours. Spit out excess. Not more than 8 doses should be given in a 24 hour period. NB: Do not use 2% xylocaine HCl viscous in children who cannot expectorate because of potential for aspiration. Overuse of viscous Lidocaine will result in delayed healing of oral ulcerations. Dyclone 0.5% or 1% (Dyclone HCl( may be substituted for viscous Lidocaine for greater anesthetic efficacy. Safety and efficacy under the age of 12 years have not been established. Good substitute for patients allergic to ester or amide compounds. Rx Carafate (sucralfate) suspension 1 gm/10 ml Dispense: 200 ml Sig: Rinse with 1-2 teaspoonfuls 4 times a day. Spit out excess. NB: Should not be used in children who cannot expectorate because its safety has not been established for pediatric use.

94

How to Make a Referral

95

How to Make a Referral Adapted from Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Morris Green, MD, Editor Successful interventions often require efforts that extend beyond what can be provided in any one setting or through any one discipline. Health supervision can be provided in many settings, often with collaboration between a variety of organizations and disciplines. To insure our goal to provide integrated preventive and health-promoting services we need to form a health care team. This may require specific outreach to dental and medical providers in your community. Finding the right provider is important, and should take some time. People who are selected hastily or because of their visibility and accessibility are not necessarily the best contacts for your health promotion efforts. Telephone or Personal Contact Communicate to the health care profession as you would another dental colleague. Introduce your patients to the health care provider either by phone consultation or with a written response. Provide information about the family dynamics and perceived needs. Written Request You will want to develop a collaborative referral form that will provide the information needed to help involve the family in oral health supervision. Factors to Teach the Caregiver 1. Review with the caregiver the importance of making an appointment they can keep.

If an appointment change is needed, please call at least 24 hours in advance. 2. Not to use the health care visit as a threat. Keep the words hurt, pain or brave out of

the vocabulary when talking to the child about the upcoming medical visit. 3. Go to the health care office with clean teeth and a clean body. 4. Carry a means to dispose of dirty diapers. 5. Only take the child who has an appointment (if possible). 6. How to be a good historian providing the health care provider with information about child's needs. 7. How to ask questions of the dentist.

i

Appendix

ii

ABCD DENTAL PROGRAM BENEFITS

FOR THE CHILDREN: ✰ Provided access to a dentist (previously unavailable to children on medical coupons) ✰ Allows multiple applications of topical fluoride varnish yearly ✰ Allows frequent risk assessment ✰ Early parent education - opportunity for better dental habits ✰ Home care instructions teach parents how to recognize/prevent problems ✰ Early dental visits set up a positive experience for future visits FOR THE DENTAL OFFICE: ✰ Community service and goodwill ✰ The more local dentists address the need of dental access for kids, the less likely the legislature will mandate services ✰ The ABCD Dental program is nationally recognized and published in national journals ✰ Enhanced fee structure - better bottom line ✰ Receive training in how to work with young children ✰ Personalized access to DSHS billing help - free, in your office ✰ Program is designed to get kids decay free and keep decay free ✰ Early care lets the child be seen before problems develop, increasing rapport and trust ✰ Parents have received dental education prior to the child's first visit - easier patients ✰ Not all parents are on public assistance - many are paying for Basic Health and will become regular patients ABCD DENTAL STAFF ASSISTS YOU: ✰ Conducts parent education prior to enrollment ✰ Addresses your no-shows with parents ✰ Helps find addresses and phone numbers for patients who have moved ✰ Provides interpreter information ✰ When CPS-DD referrals are appropriate, can act as the referral facilitator ✰ Billing problems? Can put you in touch with the right people in Olympia ✰ Supports offices in every way possible - appreciates your care for our children

iii

ABCD DENTAL PROGRAM TIPS

✰ The ABCD program is designed to begin seeing children as soon as the first teeth emerge. Parents are encouraged to get their children to the dentist by the child's first birthday. Dental offices examine the child, provide fluoride varnish and other services as needed, then remind the parent to continue to bring the child in at appropriate intervals. ********************************************** ✰ Three topical fluoride varnish treatments are allowed yearly. Currently two applications may be billed under 0122D and the third one under 0123D. As of April's new billing instructions, up to three fluoride applications can be applied using the same code. (All children enrolled in the ABCD Dental Program are considered high risk - no further justification is required.) *********************************************** ✰ Using code 4475D, your office may bill $25 for a "family oral health education" component, twice per year per family. This education piece may be conducted by auxiliary staff. For audit purposes, ensure that all component of the family oral health education (as described on p. 8 - 9 in the ABCD Billing Instructions Manual) are given and documented in the patient file. For your ease, ABCD Dental staff has developed a charting tool for documenting family oral health education. ********************************************** ✰ There is no cost assistance available to you in your office for help in solving DSHS billing problems, coding problems, answering questions and proper reimbursement techniques. To sign up for free in-office billing training, contact:

4

Q. When should I start cleaning my baby's teeth?

A. This is a good habit to start early! The teeth must be cleaned as they erupt. Use a damp washcloth or a toothbrush. If your dentist agrees, use a tiny dab of fluoride toothpaste. Tooth brushing is definitely a parent job in the preschool years and beyond. Children are usually able to brush their teeth well when they are 9-11 years old. Be sure to check your child's teeth regularly for any chalky white or brown spots that could be beginning decay.

Q. Any advice on teething? A. Sore gums from teething often occur for a few days at a time between six months to age three. Babies often get relief from a clean teething ring, cool spoon, cold wet washcloth or toothbrush. Chilled teething rings or rubbing a clean finger on the sore gum area often helps too.

YOUR BABY’S TEETH

5

Q. When should my child first see a dentist?

A. "First visit by first birthday" sums it up. Your child should visit a dentist when the first tooth comes in, usually between six and twelve months of age. Early examination and preventive care will protect your child's smile now and in the future. Q. Why so early? What dental problems could a baby have?

A. Dental problems can begin early. A big concern is Baby Bottle Tooth Decay (BBTD) that is preventable. BBTD can result from long periods of exposing baby teeth to liquids that contain sugar including formula and juice. A baby who has a habit of sleeping with a baby bottle filled with any sugary liquid in their mouth is at risk of getting BBTD. Frequent snacking on sweet or sticky foods can also cause decay. The earlier the first dental

visit, the better chance of preventing dental problems. Children with healthy teeth can chew food well, speak clearly and share precious smiles. Start your child on a lifetime of good dental habits now!

Q. When should bottle-feeding be stopped? A. Begin teaching your baby to use a cup by six months. It's a good idea to introduce juice in a cup. Your baby can be off the bottle by 12 months. Q. Should I worry about thumb or finger sucking? A. Thumb sucking is perfectly normal for infants; most stop by age two. Prolonged (beyond age 5 or 6 years) thumb sucking can create crowded crooked teeth or bite problems. Your dentist will be glad to suggest ways to address a prolonged thumb-sucking habit.

Q. When should I start cleaning my baby's teeth?

A. This is a good habit to start early! The teeth must be cleaned as they erupt. Use a damp washcloth or a toothbrush. If your dentist agrees, use a tiny dab of fluoride toothpaste. Tooth brushing is definitely a parent job in the preschool years and beyond. Children are usually able to brush their teeth well when they are 9-11 years old. Be sure to check your child's teeth regularly for any chalky white or brown spots that could be beginning decay.

6

INTRODUCTION Topical fluoride application on a child’s teeth is proven to be one of the most effective ways to retard, arrest, and reverse early cavities. It is also highly effective in preventing initial decay. Once applied, it helps the tooth “remineralize” or restore surface enamel. Fluoride varnishes are applied directly to the tooth surface, providing for both immediate “remineralization” as well as on-going “time-released” fluoride protection.

An Alternative to Traditional Topical Fluoride Therapy

7

ANSWERS TO COMMONLY ASKED QUESTIONS ABOUT FLUORIDE VARNISH

Q. Is this a new method?

A. No. Fluoride varnish was

developed in the early 60’s in Europe.

Q. Is it effective in reducing decay?

A. Yes. Fluoride varnish has been found to reduce decay on tooth surfaces between 50 and 70%.

Q. Is it more costly than conventional topical fluoride?

A. No. Fluoride varnish applications cost the same as those for conventional topical fluoride.

Q. Why would you use fluoride varnish instead of traditional fluoride?

A. Varnishes provide a more

efficient way for the tooth to absorb fluoride; its slow release time further enhances its effectiveness.

Q. How is the varnish applied? A. Application is quick and easy;

small droplets of varnish are applied directly to the tooth surface.

Q. What about application

precautions? A. After application, the teeth will

have a “yellow film” – that is the fluoride varnish. It’s O.K. for your child to drink or eat after the application of fluoride varnish. The child should not brush the evening following the application, but should resume normal hygiene practices the following morning.

Q. Is it safe?

A. Yes. Fluoride varnishes are very safe. They have been used in Scandinavia and Canada for a long time. A toxic dose of fluoride is not reached until ten times the normal dose.

1

DENTIST PARTICIPATION IN A PUBLIC-PRIVATE PARTNERSHIP TO INCREASE MEDICAID PARTICIPATION AND

ACCESS FOR CHILDREN FROM LOW INCOME FAMILIES Ken McNabb, DDS1 Peter Milgrom, DDS1 David Grembowski, PhD1, 2 1 Department of Dental Public Health Sciences, University of Washington 2 Department of Health Services, University of Washington Correspondence to Dr. Peter Milgrom, Professor of Dental Public Health Sciences, Department of Dental Public Health Sciences, Box 357475, University of Washington, Seattle, Washington 98195-7475. Telephone number 206-543-2034; Fax number 206 685-4258; E-mail: [email protected]. Reprint requests should be addressed to Dr. Peter Milgrom, Professor of Dental Public Health Sciences, Department of Dental Public Health Sciences, Box 357475, University of Washington, Seattle, Washington 98195-7475.

2

Abstract The purpose of this research to solicit feedback from dental society members involved

in a program (Access to Baby and Child Dentistry, ABCD) to provide care for children

receiving Medicaid benefits, and to gain an understanding of dentist participation. We

investigated whether general dentists who were participants in ABCD were more fully

integrated into the dental society, profession and community, and whether they

demonstrated greater interest in children. Dentists were stratified regarding ABCD

participation and randomly selected to be interviewed (N=40). The majority thought it

appropriate for general dentists to care for very young children. Participants found fewer

problems in fee levels in Medicaid but there was no difference in an index of fees

between the groups. Participants were no more active in the dental society, and few

differences existed between the groups regarding other aspects of personal or

professional life. Dentists participating in ABCD to improve access had a good

experience and have positive views of the program. This may encourage other non-

specialist colleagues to participate in programs for children.

3

INTRODUCTION

Access to dental cam for children receiving Medicaid benefits is problematic1, 2.

Although this is not a new problem, there is renewed interest in finding solutions3. As a

result, there have been a number of recent state-based surveys of dentists 4-6. These

studies tend to reinforce the impression that the reasons dentists fail to see Medicaid

child clients is primarily because of low allowable fees, poor payment speed and

bureaucracy, lack of specific benefits, and client behavior.

We previously reported on a community partnership -- Access to Baby and Child

Dentistry (ABCD) -- demonstrated to improve access to dental care for Medicaid

recipients from birth to 5 years old7. The high rates of utilization in the program are in

marked contrast to those in other areas. The program has continued for more than 5

years and was awarded the 1999 Maternal and Child Health Award of the National

Association of County and City Health Officers.

Because this program is unique, we solicited feedback from the dental society regarding

the strengths and weaknesses of the program, and a better understanding of

participation by non-specialists. With respect to the latter, we investigated whether

general dentists who were participants in ABCD were more fully integrated into the

dental society, profession and community, and whether they demonstrated a greater

interest in children than non-participants did.

4

METHODS

General dentist participants (P) in the ABCD program were identified from Medicaid

claims. Non-participants (NP) were defined as general dentists who were members of

the local society, but had no paid claims for the program. These lists were sampled

randomly and dentists approached by telephone. The response rate was 76.7 percent

(23/30) for Ps and 60.7 percent (17/28) for NPs. The constraints of a student summer

research project limited the sample size. The informed consent of all participants was

obtained.

A 35-item questionnaire was constructed8 for use by a single interviewer. Some items

were taken from a previous statewide survey of general dentists and specialists6; others

were written for this survey. Items were pretested and revised as necessary. The items

were in four conceptual areas: knowledge and skills in the care of children; participation

in continuing dental education and dental society activities; integration in the

community; and views about ABCD. Summary measures were created for skill in

treating preschool children and for enjoyment of children in general by summing the

items in each scale. Summing the typical fee for intraoral exam, bitewings, 1 surface

amalgam and simple extraction also created a fee index. The interview lasted, on

average, 20 minutes and was conducted in the dentist's office.

The data were entered, verified, and analyzed using SAS version 6.12 for Power

Macintosh. Descriptive statistics are used to characterize the subjects in the study and

to compare the Ps and NPs in the areas of knowledge and skills, participation in

5

continuing education and dental society, integration into the community, and views

about the ABCD program

RESULTS

The typical (median) general dentist respondent graduated from dental school in 1980

(range 1947-1997) and had been in the current practice arrangement 10 years. Twenty-

five of the 40 dentists (62.5%) had no post-DDS training either in a residency or in a

military service. The remaining dentists had one year (8 dentists) or more (7 dentists) of

training. Dentists reported seeing patients an average of 32 hours per week (SD 5

hours) over an average of 47 weeks (SD 3 hours). The typical (mean) practice size was

five fully equipped operatories (SD 2.5 operatories). Sixty percent (24/40) were in solo

practice.

The typical (median) dentist described the practice as providing care to all that

requested appointments and not overworked. Fifteen practices (37.5%) reported being

overworked (9) or too busy to treat all people requesting appointments (6). The typical

patient pool was 60 percent private insurance (range 0-90%), 15 percent public

assistance (range 0- and 20 percent self-pay (range 0-50%). For child patients seen

during the last year, typical practice profile was 15 percent preschoolers (range 0-45),

and 25 percent elementary school children (range 0-75).

6

Questions about the ABCD Program

Both groups felt strongly that it was appropriate to care for infants and toddlers (1=

strongly agree, mean P 1. 1 v. NP 1.4, t= 1.8, p=0.07). Ps were no more likely to

support the use of fluoride varnish to remineralize white spots in primary teeth than NPs

(1= strongly agree, mean P 2.3 v. NP 2.7, t=1,0, p=0.3) and the use of glass ionomer

fillings for young children versus other materials (mean P 3.4 v. NP 2.9, t= 1.2, p=0.2).

Table 1 gives the responses of the dentists to questions about the ABCD program. PS

were more positive than NPs in their assessments of the adequacy of Medicaid benefit

levels in relation to commercial insurance (mean 2.8, v. 3.7, t=2.3. p=0.02), but held

similar views regarding payment speed (mean 2.9 v. 3.6, t-=1.5, p=0.15). Ps were more

positive on compensation for oral hygiene instruction (mean 4.2 v. 28, t=2.7. p=0.01).

The later is a covered benefit under this special program. Otherwise, there were no

significant differences between the groups. Ps rated the demands made by the ABCD

program as less than NPs (mean 1.4 v. 2.4, t=3.0, p=0.008). Ps were also twice as

likely to know that fluoride varnish was a covered benefit under insurance programs

(20/23 v. 10/17, chisquare=6. 1, p=0.05).

7

Differences between ABCD Participants and Nonparticipants

Ps attended about the same number of dental society meetings per year (mean 3.8 v.

2.8 meetings, p=0.3) and were no more likely than NPs to have been an officer or

delegate (59 v. 4 1 %, p=0.26). More Ps were approached by another dentist to

participate in ABCD (57 v. 41 %; chisquare = 0.9, p=0.3) but the differences are only

suggestive.

Ps took about the same number of CDE hours in the past two years (mean 96 v. 80,

t=.9, p=0.3). There were no differences in their participation in a study club (74% of Ps

and 71% participated in at least one study club). Similarly there was no difference

regarding membership in organization s such as the Academy of General Dentistry.

There were also no differences in the number of dentist close friends or the number of

dentists who consult the subject dentist for advice.

A series of four questions asked about the extent of involvement with youth serving

organizations (e.g. Boy Scouts); fraternal service groups (e.g. Rotary); adult volunteer

organizations (e.g. Sierra Club); or religious organization. Levels in all of these areas

were typically low (means 1-2 on a scale where 5 is maximally involved) and there were

no differences between Ps and NPs. Similarly there was no difference in the proportions

that had been leaders in one of these organizations.

The general dentists were asked to rate their skill (1 =inadequate, 10=adequate) in

response to a series of four patient management scenarios involving preschool children.

8

The typical (median) response was about 7; there were no differences between Ps and

NPs. Similarly, the subjects were asked to respond to a series of four scenarios

regarding interaction with preschoolers in general, outside of the dental office (1=no

enjoyment, 10=a lot of enjoyment). As with the patient management skills, the typical

response was about 7. There were no differences between Ps and NPs.

More Ps than NPs to schedule at least 10 minutes for a preschool child exam (87 v.

69%) but the difference was not significant. Neither group selected chairside staff

especially for its skill or interest in treating children. There was no significant difference

in ABCD participation by practice busyness. The proportion of 'less busy" practices was

nearly the same between the ABCD groups. Similarly there was no difference in the

proportion of patients who had commercial insurance or Medicaid between the groups.

Ps were, however, less likely to see patients on a strictly self-pay basis than NPs (15%

of patients v. 24% of patients, t=2.2, p=0.03). On the other hand, there was no

difference in the fee index between participants and non-participants. The overall fee

index mean was $209 (SD $22).

9

DISCUSSION

In contrast with dentists in the state overall6, most general dentists interviewed rated the

care of infants and preschoolers as either "appropriate" or "very appropriate." In the

state as a whole, only about one-half gave this rating. Thus the creation of a dental

society partnership with other community agencies has created greater awareness of

dental access issues among non-specialists.

Participants were less concerned about fee levels than non-participants. This reflects

their experience with the fee enhancements in the program and steps taken to be sure

that the program functions well. Otherwise, there were few differences between the

groups, perhaps reflecting the publicity about the program and discussion within the

dental society. Nevertheless, there were concerns about patient behaviors such as

parental knowledge and appointment keeping.

The notion that there are unique, readily identifiable predictors of dentist participation

was not supported. Participants were not more active in the dental society or in CDE

than non-participants. Similarly, other measures of integration into dentistry as a

profession failed to identify any meaningful differences. Neither group was particularly

active in community organizations.

Similarly there were few differences regarding their interest and skills with children. This

lack of difference may reflect the limited training provided to be certified in the ABCD

program and suggests an area for improvement. There were no differences between

10

the practices in terms of fees or busyness. AD types of practices have participated in

the program.

These data suggest that non-specialist volunteers for this unique program to increase

Medicaid participation and services for children were quite typical of members of this

local dental society and that the positive results of the ABCD program may be

generalizable to other communities. The results suggest that the problem of access for

children from low income families can be solved if non-specialists become more aware

of the problems faced by children and if they are offered opportunities to participate in

solutions to these vexing problems.

11

ACKNOWLEDGMENTS This research was supported, in part, by Grants No. IR01 DE0982 and T35 DE07150 from NICDR/NIH and by the Medical Assistance Administration, DSHS, State of Washington. The authors acknowledge the assistance of Connie Robohn and Robert Shaw of the Spokane District Dental Society and Professor Linda LeResche of the University of Washington. REFERENCES

1. Brown, J.G.: Children's dental services under Medicaid Access and utilization.

Department of Health and Human Services, Office of the Inspector General April 1996;

Report No. OEI-09-93-00240.

2. Brown, J.G.: Performance report on EPSDT Department of Health and Human

Services, Office of the Inspector General April 1996; Report No. HCFA-416.

3. Federal agencies convene conference on Children's Access to Medicaid Oral

Health Services. N. Y., State Dent J, 64(6):56, June-July, 1998.

4. Capilouto, E.: The dentist's role in access to dental cam by Medicaid recipients. J

Dent Educ, 52:647-652, 1988.

5. Damiano, P.C.; Brown, E.R.; Johnson, J.D., et.al.: Factors affecting dentist

participation in a state Medicaid program. J Dent Educ, 54(11):638-43, November,

1990.

6. Milgrom, P.; Riedy, C.: Survey of Medicaid child dental services in Washington

state: preparation for a marketing program. J Am Dent Assoc, 129:753-763, 1998.

7. Milgrom, P.; Hujoel, P.; Grembowski, D.: Making Medicaid child dental services

12

work: A partnership in Washington state. J Am Dent Assoc, 128:1440-1446, 1997.

8. Salant, P.; Dillman, D.: How to conduct your own survey. New York: John Wiley and

Sons, Inc., 1994.

Dr. McNabb completed his Doctor of Dental Studies degree at the University of Washington in 2001. Dr. Milgrom is professor, Department of Dental Public Health Sciences and Director, Dental Fears Research Clinic, University of Washington, Seattle. Dr. Grembowski is professor, Departments of Dental Public Health Sciences and Health Services, University of Washington.

13

Table 1. Questions about the ABCD program (N=40 dentists). ABCD reimburses at a much lower 3.1 5 8 8 7 8 rate than insurance companies, in general. There are often long delays in gaining 3.2 4 7 4 8 6 payment from ABCD ABCD compensates dentists 3.7 5 2 5 9 14 adequately for time spent on oral hygiene instruction ABCD does not compensate for time 3.6 3 2 5 9 7 spent with preschoolers who are behavior management problems. ABCD benefits exclude procedures 2.8 9 10 1 3 9 that I think are important to children’s health. ABCD children are better behaved 2.5 9 7 8 4 3 than most welfare patients. Parents of ABCD children are not 3.3 1 10 8 8 8 well informed about their children's teeth. ABCD families tend to miss 3.1 3 10 7 7 7 appointments or be late. The ABCD program makes too many 1.7 18 7 7 1 0 demands on me. If I took care of ABCD children then 3.3 7 4 7 8 11 I would feel obligated to take care of their brothers and sisters not in the program *Scale ranges from 1 to 5 where 1 =strongly disagree and 5=strongly agree. Number of responses to each item varies.

abcd pedodontia

Documents