early childhood caries (ecc) prevention and oral health promotion
DESCRIPTION
EARLY CHILDHOOD CARIES (ECC) PREVENTION AND ORAL HEALTH PROMOTION. Pacific Islands Continuing Clinical Education Program (PICCEP) The following presentation was adopted by me to use in American Samoa and Palu in the Pacific Islands. - PowerPoint PPT PresentationTRANSCRIPT
EARLY CHILDHOOD CARIES (ECC) PREVENTION AND
ORAL HEALTH PROMOTION
Pacific Islands Continuing Clinical Education Program (PICCEP)
The following presentation was adopted by me to use in American Samoa and Palu in the Pacific Islands.
The program was designed and implemented by Dr. Peter Milgrom a professor at the University of
Washington and has been used in much of Micronesia with great success
EARLY CHILDHOOD CARIES (ECC) PREVENTION AND
ORAL HEALTH PROMOTION
EARLY CHILDHOOD CARIES (ECC) PREVENTION AND
ORAL HEALTH PROMOTION
Pacific Islands Continuing Clinical Education Program (PICCEP)
Fred Quarnstrom, DDSFICD, FASDA, FAGD
Department of Dental Public Health SciencesUniversity of Washington, Private Practice, Seattle WA
Palau
2003
We have a problemWe have a problem
ECC in American Samoa
James B. Quartey, DDS, MPH, Dental Department, LBJ Tropical Medical Center, Pago Pago, AS. Lepetia Aga-Letuli, BS, Department of Health,
American Samoa Government, Pago Pago, AS
208 children
3 y. o. 37%
4 y. o. 58%
5 y. o. 75%
had 5 or more decayed, missing or filled dmf teeth
1% had 20 or more dmf teeth
Average 6.4 dmf teeth
13% were caries free
ECC on OfuECC on Ofu
Fred Quarnstrom, DDS, University of Washington, Dept. Public Health Sciences
5/8/02
1 was caries free 93% had caries
Study was visual exam with no x-rays
38 children
4 y. o. 100% had decay av. 6.7 decayed
n=12
5 y. o. 93% had decay av 5.4 decayed n=
14
6 y. o 100% had decay av. 5.4.decayed n=6
Dentistry on Ofu and OlosegaDentistry on Ofu and Olosega40 children had 250 teeth that needed treatment.
Fluoride varnish took less than 3 minutes per child.
Projection (realizing that projections can be inaccurate)
A population of 400 has 2,500 teeth needing treatmentIf 7 patients had 3 teeth treated per day - a very optimistic schedule.
It would take 125 dentist days to take care of basic needs. 200
days if you include cleanings and exams. A full time dentist with
an assistant is needed at the Ofu clinic..
Another dentist and assistant is needed at the clinic on Ta’u.
Multiply this need by 100 to 150 for all of American Samoa.
You can not possibly provide this much service.
Prevention is the only solution
We have a problemWe have a problem
It is an epidemic.
We have a problemWe have a problem
It is an epidemic.
It is bacterial.
We have a problemWe have a problem
It is an epidemic.
90% of 6 year olds are infected.
We have a problemWe have a problem
It is an epidemic.
It causes many children to have severe pain on
a regular basis.
It is an epidemic.
If they were adults, they would not put up with
the pain.
We have a problem
We have a problemWe have a problem
It is passed to the children by
their mothers.
We have a problemWe have a problem
If it were an STD like Clamydia, mothers would be treated prior to giving
birth.
We have a problemWe have a problem
We treat it by amputating tissue and providing
prosthesis.
We have a problemWe have a problem
If we treated diabetes this way, rather then
controlling blood sugar, we would amputate feet.
We have a problemWe have a problem
It costs 10 times as much to treat as it does
to prevent.
We have a problemWe have a problem
It is much easier and less costly to prevent than it is
to treat.
NORMAL PRIMARY DENTITIONNORMAL PRIMARY DENTITION
We have a problemWe have a problem
It is early childhood caries (decay),
ECC.
Who are “WE”Who are “WE”
We are American migrant workers.We are American Indians.
We are recent American immigrants.We are from Siapan, Northern Marshal Islands, Guam, Pohnhpei, Yap, Palau,
Chuuk and American Samoa.
We are Children.
What we know about dental What we know about dental disease:disease:
What we know about dental What we know about dental disease:disease:
• Dental caries is an infectious disease.
• The mother is usually the primary source of
the infection.
• The infectious bacteria is easily transmitted
from mother-to-child prior to tooth eruption.
Table 1. White spot lesions and enamel cavitation in Saipan children 6 to 36 months.
Cohort N’s % any whitespot lesions
Mean (SD)surfaces whitespot lesions
% any enamelcavitation
Mean (SD)cavitatedsurfaces
6 - 12 mos 47 20.0 (6/30) 0.8 (1.9) 6.5 (2/31) 0.1 (0.4)13-24 mos 81 37.5 (30/80) 1.3 (2.4) 31.3 (25/80) 2.0 (4.3)25-36 mos 47 73.9 (34/36) 4.1 (7.9) 63.0 (29/46) 6.7 (8.7)
13.8% had hypoplasia
ECC in Saipan
Strep. Mutans vs Decay
66.7% of 6-12 mo olds were colonized on teeth or tongue. Concepts of a later “window of infectivity” do not appear to apply to this population.
S. mutans was found in 25% (4/16) children who had no erupted teeth raising questions about the validity of previous arguments.
ECC prevalence in other areas?ECC prevalence in other areas?
• RMI (Majuro) 50% in 2-3 y.o.; nearly 100% by age 5
• Yap 93% by age 3-4
• Other places??
Virtually all the disease goes untreated.
ECC Risk ECC Risk Increases . . .Increases . . .ECC Risk ECC Risk Increases . . .Increases . . .
7x from 12 -24 mo7x from 12 -24 mo
18x from 12-36 mo18x from 12-36 mo
5x from high 5x from high
S. mutansS. mutans
10x from hypoplasia10x from hypoplasia
8x from frequent 8x from frequent high sugar snacks high sugar snacks
How can How can transmission be transmission be
prevented?prevented?
How can How can transmission be transmission be
prevented?prevented?
PRIMARY SOLUTION
Define oral health for mothers as part of
peri-natal care.Moms must get
priority for treatment.
PRIMARY SOLUTION
Define oral health for mothers as part of
peri-natal care.Moms must get
priority for treatment.
How can transmission be How can transmission be prevented?prevented?
Antimicrobial applications to reduce cavity-Antimicrobial applications to reduce cavity- causing bacteria in mothers:causing bacteria in mothers:
Peri-natal: Chlorhexidine gluconate (0.12%) rinses twice daily
Peri-natal: Xylitol chewing gum 4-5 times daily
Dental care for the expectant mother
Kohler program for mothers with infants until age 3
Kohler program for mothers with infants until age 3
• Dietary counseling
• Professional tooth cleaning & oral hygiene instruction
• Topical fluoride treatment
• Treatment of dental caries
• 1% chlorhexidine gel, 1x day, 2 wks; repeated after 2-3 mo.
Chlorhexidine gluconate 0.12% Chlorhexidine gluconate 0.12% rinserinse
Chlorhexidine gluconate 0.12% Chlorhexidine gluconate 0.12% rinserinse
• Many dental professionals are not aware of the use of chlorhexidine for caries
• Safe in pregnancy
• Safe for nursing mothers
Chlorhexidine gluconate 0.12% rinse for Chlorhexidine gluconate 0.12% rinse for pregnant women and mothers with pregnant women and mothers with
infantsinfants
Chlorhexidine gluconate 0.12% rinse for Chlorhexidine gluconate 0.12% rinse for pregnant women and mothers with pregnant women and mothers with
infantsinfants
Rinse twice daily with 1/2 capful for 30 sec and expectorate. Do not rinse with water or eat or
drink afterwards for 30 min
Xylitol Gum and MintsXylitol Gum and MintsXylitol Gum and MintsXylitol Gum and Mints
• Each stick/pellet is 1 gram
• Use 4 or more grams/day
• Up to 10-12 grams
• Chew for 5 minutes
•Safe for pregnant or nursing moms
Maternal consumption of xylitol gum
2 or 3 times a day beginning at 3
months after childbirth was
associated with reduced mother-
child transmissions of MS.
Solderling,Isokangas, Pienihakkien &tenovuo, 2000
PRIMARY CARE SOLUTION
Define oral health as part of well baby care
If we stop decay in thesekids, we do not have
to treat decay later.
PRIMARY CARE SOLUTION
Define oral health as part of well baby care
If we stop decay in thesekids, we do not have
to treat decay later.
THE PRIMARY CARE PROVIDER
THE PRIMARY CARE PROVIDER
MCH workers have regular and consistent contact with young children at well-child care/immunization visits
Control of ECC cannot be confined to the dental clinic
PRIMARY CARE PROVIDER IN ORAL HEALTH
PRIMARY CARE PROVIDER IN ORAL HEALTH
Role could include:provision of dietary & oral hygiene
guidancedispensing of fluoridated toothpaste application of a caries control
therapy such as fluoride varnish assessment, prompt referral of
children at high risk
ANTICIPATORY GUIDANCEANTICIPATORY GUIDANCE
• Oral health important to overall health• Importance of care provider’s oral
health• Dental Care for Pregnant Mothers• Transmissability of Strep mutans
• Tooth eruption• Lift the Lip/looking for decay
RECOGNIZING EARLY DECAY
RECOGNIZING EARLY DECAY
WHITE SPOT LESIONS=
Subsurfacedemineralization
Decay
Dietary Guidance:Dietary Guidance:Dietary Guidance:Dietary Guidance:
- Dental disease is exacerbated by diet. - Dental disease is exacerbated by diet. -- • Avoid prolonged breast- and bottle-feeding,
especially at sleep times.
• Do not fill bottle with a sugar-containing product. Do not add sugar to solid foods.
• Encourage cup use at 6 - 8 months.
• Limit sweet, starchy snack foods.
Oral Hygiene:Oral Hygiene:Oral Hygiene:Oral Hygiene:
•New moms need training in cleaning kids’ teeth•Wipe infant’s gums with a wet cloth or gauze after each
feeding.)•Brush baby teeth as soon as the first tooth erupts. (~ 6 months in age)• Children do not brush their own teeth effectively•Use a small amount of fluoridated toothpaste on
the toothbrush.
If you cannot brush smear some If you cannot brush smear some fluoride toothpaste on their fluoride toothpaste on their
teeth with your fingerteeth with your finger..
FLUORIDEFLUORIDE
• MECHANISMS OF ACTION• Reduces enamel solubility• Promotes remineralization of enamel• Some anti-bacterial activity
CHARACTERISTICSCHARACTERISTICS
• Dry tooth facilitates fluoride uptake• Sets on contact with moisture• No prophy required• Taste is tolerable• Can reverse early decay and can
arrest active lesions
Fluoride VarnishFluoride Varnish
• More than 25 years of use and research in Europe
• Available in Canada for many years
• Currently, more than 90% of all professionally applied topical fluorides in Scandinavia are varnishes
EFFICACYEFFICACY
• Meta-analysis of Duraphat trials reveals 38% caries reduction*
• More frequent application yields better results
• Fluoride varnish and Acidulated Phosphate Fluoride (APF) have comparable efficacy
*Helfenstein and Steiner, Community Dentistry and Oral Epidemiology, 1994
Comparison of FV to OtherComparison of FV to Other Topical Fluorides: Topical Fluorides:
Comparison of FV to OtherComparison of FV to Other Topical Fluorides: Topical Fluorides:
APF Gel -APF Gel -
• similar clinical effect as FV.
• inappropriate for young children - they will swallow.
• lengthy application time• potential for excessive ingestion – •adverse effects.
How does FV work?How does FV work?How does FV work?How does FV work?
The lacquer-based product adheres to the dental enamel forming a deposit from which fluoride is slowly released.
Fluoride Varnish Application Fluoride Varnish Application • Have everything ready• Position the child• Quick visual inspection• Dry teeth with cotton gauze• Apply fluoride varnish with disposable
applicator• Have a drink of water• No brushing until tomorrow
white spots
holes
missing structure
white spots
holes
missing structure
QUICK VISUAL INSPECTION
Fluoride VarnishFluoride Varnish
• 40-80 applications per 10 mL tube
• Use a brush
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
Contraindications and Adverse Contraindications and Adverse Reactions w/ FVReactions w/ FV
Contraindications and Adverse Contraindications and Adverse Reactions w/ FVReactions w/ FV
Contraindications:Contraindications:
• Contact allergy may occur in those hypersensitive to colophony (skin-sensitizing resin).
• Ulcerative gingivitis and stomatitis.
Adverse Reactions:Adverse Reactions:
• Nausea
Dyspnea (in patients w/ asthma):Dyspnea (in patients w/ asthma):Dyspnea (in patients w/ asthma):Dyspnea (in patients w/ asthma):
Although listed as an adverse reaction on the product insert -
There are no known reports from the literature or the FDA concerning this
reaction.
Fluoride Varnish Application
Fluoride Varnish Application
• Safe
• Effective
• Quickly completed
TOOLS FOR CONTROL OF ECC
TOOLS FOR CONTROL OF ECC
Fluoride varnish
Silver Fluoride Application
Glass ionomer sealants
Scoop and fill - ART
Ag Fl vs. Na Fl VAg Fl vs. Na Fl V
• All preschool children• 375 children for 18 months• Guangzhou in Southern China• Mean base line 4.73 dmf (anteriors)• Brushed with fluoride toothpaste -
73%• 38% once a day• 17% twice a day
• Ag Fl was applied every 12 months• Na Fl was applied every 3 months• Water for the control group
Ag Fl vs. Na Fl VAg Fl vs. Na Fl V
technique
Excavate decay
New decay
Arrested surfaces
Ag Fl yes 0.44 2.84
Ag Fl
Na Fl V
Na Fl V
Control
Ag Fl vs. Na Fl VAg Fl vs. Na Fl V
technique
Excavate decay
New decay
Arrested surfaces
Ag Fl yes 0.44 2.84
Ag Fl no 0.42 2.99
Na Fl V
Na Fl V
Control
Ag Fl vs. Na Fl VAg Fl vs. Na Fl V
technique
Excavate decay
New decay
Arrested surfaces
Ag Fl yes 0.44 2.84
Ag Fl no 0.42 2.99
Na Fl V yes 0.84 1.69
Na Fl V
Control
Ag Fl vs. Na Fl VAg Fl vs. Na Fl V
technique
Excavate decay
New decay
Arrested surfaces
Ag Fl yes 0.44 2.84
Ag Fl no 0.42 2.99
Na Fl V yes 0.84 1.69
Na Fl V no 0.63 1.50
Control
Ag Fl vs. Na Fl VAg Fl vs. Na Fl V
technique
Excavate decay
New decay
Arrested surfaces
Ag Fl yes 0.44 2.84
Ag Fl no 0.42 2.99
Na Fl V yes 0.84 1.69
Na Fl V no 0.63 1.50
Control 1.22 0.99
TOOLS FOR CONTROL OF ECC
TOOLS FOR CONTROL OF ECC
Silver Fluoride Application
Silver fluorideSilver fluoride
• Available as a 3.8% silver diamide fluoride solution from Japan (Safloride)
• 40% aqueous Silver fluoride solution in Australia
Chinese trial of Safloride
Prevents new lesions from developing in other surfaces
Silver fluoride safetySilver fluoride safety
• Application to all the primary teeth, if done carefully, should be equivalent to taking 2 mg F orally.
• Fluoride should be confined to the lesion to avoid over exposure
• Over exposure could result in fluorosis
Silver fluoride applicationSilver fluoride application
• Dry teeth with cotton gauze
• Apply to open lesion with small brush. Keep it off the gingiva
• OK to eat/drink after 1 hour
• Stains clothes, fingers
TOOLS FOR CONTROL OF ECC
TOOLS FOR CONTROL OF ECC
Glass ionomer sealants
ART
Use glass ionomer (Ketac, Fuji 9) as sealants because they tolerate some moisture
during placement.
Use glass ionomer (Ketac, Fuji 9) as sealants because they tolerate some moisture
during placement.
SUMMARYSUMMARY
• Redefine perinatal care to include oral health.• Redefine well baby care to include oral health.• Much of this work must occur outside of the
dental clinic and involve others.• Effective tools are available.
• Fluoride varnish, silver fluoride• Chlorhexidine• Xylitol gum• Dental Care and Oral Hygiene• Glass ionomer sealants and ART
We have an epidemic!
It is for the childrenIt is for the children
The children are the keyThe children are the key
Prevent decay in the children and you will not need the dentist.
Prevent decay in the children and you will not need the dentist.