Early Childhood Dental Caries

Grant Christensen, DDS – State Dental Officer

A presentation to Wyoming health care providers

January 25, 2007

11:30 am – 1:00 pm

Prevention Goals

Goals
ƒ Reduce incidence and impact of
tooth decay in pre-school population
ƒ Reduce costs associated with
treatment Severe early
childhood caries
In a 30-month
old child

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 Public Health Points

ƒ Disparities in oral health:

¾ Access to care, SES, ethnicity, CSHCN
ƒ Workforce issues:
¾ Dental workforce
¾ Education gaps in dentistry and medicine
¾ Shared responsibility with PCP
ƒ Evidence-based caries prevention:
¾ Need to reach children early

Disparities and Oral Health

ƒ Oral disease is common and has

consequences for overall health
ƒ Most oral disease is preventable
ƒ Profound disparities* in oral health and
access to care (all ages) by SES, ethnicity,
children with special health care needs
(CSHCN)+
*USDHHS, Oral Health in America: A Report of the Surgeon General, 2000
+Vargas et al, 1998; Newacheck et al, 2000a, 2000b, Mouradian, Wehr and Crall,
2000

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 Disparities and Oral Health

ƒ Ethnically diverse populations have more oral

disease

ƒ Cultural dimensions of eating, sleeping, child-

rearing, health behaviors in relation to oral
health

Disparities and Oral Health

ƒ Dental caries (tooth decay) most common

chronic disease of childhood
ƒ Dental care most common unmet health
need*
ƒ Dental insurance: children 2.5 x more likely to
lack dental coverage than medical coverage*
ƒ Medicaid: only 1/5 children accessed
dental care*
*Vargas et al, 1998; Newacheck et al, 2000a, 2000b,
Mouradian, Wehr and Crall, 2000

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 Oral Disease: Impact on Children

ƒ Disease burden, pain

¾Systemic infections; growth problems
¾ER visits, hospitalizations and surgeries
¾Oral-systemic consequences - especially for CSHCN
ƒ Economic, quality of life, long term impacts
ƒ 52 million school hours lost per year for dental
problems

Dental Workforce Issues

ƒ Number of dentists per capita

declining
ƒ Few pediatric dentists (3,500)
nationwide
ƒ Acute shortages in rural and
underserved areas

4
 Gaps in Dental Training

ƒ General dentists not trained in oral health

care of infants and young children, or those
with special needs

ƒ Ten dental schools have closed

ƒ Dental education isolated from

medical education

Oral Health in Medical Training

ƒ Survey of pediatricians in US*

¾ Lack of knowledge: > 50% of pediatricians - little
oral health training

ƒ Willingness to participate in oral health

promotion
¾90% felt oral health is their job

*Lewis et al, 2000

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 PCP Role in Oral Health

ƒ Anticipatory guidance and counseling

ƒ Risk assessment
ƒ Oral screening exam
ƒ Applying fluoride varnish
ƒ Dental referral and collaboration

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PCP Role in Oral Health

ƒ Management of dental emergencies and

simple trauma
ƒ Oral-systemic health interactions, especially
for CSHCN, and all patients with chronic
illnesses
ƒ Ages and Stages:
¾ Adolescent oral health
¾ Maternal oral health

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6
 Evidence Based Prevention Recommendations

ƒ Personal:
¾ Brush with fluoridated toothpaste
¾ Visit dentist regularly

ƒ Professional (high-risk populations):

¾ Sealants, F supplements, F gels/varnishes (perm),
dietary counseling
ƒ Public Health Advocacy:
¾ Water fluoridation
¾ School based sealant programs

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Public Health Advocacy

ƒ Help monitor children’s health in community

ƒ Mobilize community partnerships
ƒ Help develop policies, actions at community
level
ƒ Link families to needed care
ƒ Problem solving with local
dental society

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 Sources of Fluoride

ƒ Systemic
¾ Water fluoridation
¾ Fluoride supplements

ƒ Topical
¾ Fluoride toothpastes
¾ Gels
¾ Fluoride varnish

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 Early Childhood Dental Caries

Learning Objectives
1. Understand the caries process and early
childhood caries (ECC)
2. Provide anticipatory guidance in oral health,
including appropriate nutrition messages
3. Assess risk of developing caries – “The Oral
Health History”
4. Recognize caries on an oral exam
5. Refer children for dental visits as appropriate
6. Collaborate with dental professionals

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Caries Process

ƒ Biofilm (‘plaque’) is a living community of

bacteria
ƒ Bacteria ferment carbohydrates and produce
acid
ƒ Over time acid demineralizes enamel (white
spot lesion)
ƒ REVERSIBLE stage
ƒ End result is a cavity (caries)
hole in the tooth
non reversible

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9
 Food Lesson - Eating Frequency

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Ongoing Balance

Protective Factors Pathologic Factors

Salivary flow Strep Mutans
Peptides (defensins) Carbohydrates
Fluoride Reduced salivary flow

No caries Caries

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10
 Fluoride Can Prevent and/or Reverse White Spot Lesions

Mechanisms of action:
ƒ Reduces enamel solubility
ƒ Promotes remineralization of
enamel
ƒ Anti-bacterial activity in
higher concentrations
ƒ Action is topical, in saliva

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Sources of Fluoride

ƒ Systemic
¾water fluoridation
¾fluoride supplements
ƒ Topical
¾fluoride toothpastes
¾gels
¾fluoride varnish

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 Recommended Fluoride Supplement

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Early Childhood Caries

Decay in primary teeth

Formerly known as:

ƒ “Baby bottle” tooth decay
ƒ Nursing bottle caries

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 Early Childhood Caries

ƒ A transmissible infection caused by

Streptococcus Mutans
ƒ Diet dependent – fermentable
carbohydrates with frequent exposure
ƒ Occurs on erupted susceptible teeth
ƒ Causes cavities to develop over time
ƒ ECC affected children are at higher risk
for decay as adolescents and adults

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Cariogenicity of Foods

Non- Low High

Cariogenic Cariogenicity Cariogenicity
DON’Ts
Tuna, chicken, Milk, fresh fruits, Cookies, cake,
eggs, cottage whole grain candy, raisins,
cheese, vegetables, products dried fruit, fruit
seltzer water, diet rolls, breakfast
soft drinks, diet bars, doughnuts,
yogurt, cheese crackers, pretzels,
[nuts, sunflower, sugared cereals,
pumpkin seeds, granola bars,
popcorn] juice, Koolade,
Tang
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 Early Childhood Caries

Characteristics:
ƒ Usually affects maxillary
incisors first
ƒ Lesions can progress
rapidly
ƒ Enamel on primary teeth
thinner than enamel on
permanent teeth

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Early Childhood Caries - Maternal Transmission

ƒ Window of infectivity:
before age 2
ƒ Transmission is a natural
process
ƒ Don’t suggest mother
decrease contact with infant
ƒ Help mother meet her oral
health care needs
ƒ Provide and suggest other
preventive measures

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14
 Messages for Parents

General:
ƒ Oral health - important to overall health
ƒ Primary teeth matter
ƒ Caries can start when teeth erupt
ƒ Strep Mutans is transmissible
¾Stress importance of caretaker’s oral health
¾Advise pregnant mothers to get dental care
ƒ Diet/feeding
¾Avoid frequent intake of
carbohydrates

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Messages for Parents

Specific:
ƒ “Lift the Lip” and check for decay

ƒ Use Fluorides
¾Brush teeth, use fluoridated toothpaste
¾Use fluoride supplements if water
not fluoridated
ƒ Dental exam
¾By age 1 (high risk
¾By age 2-3 (lower risk)

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15
 Tooth Brushing

< 1 year
¾ clean teeth with cloth or soft
toothbrush
¾ no toothpaste

1-2 years
¾ pea-sized amount of fluoridated toothpaste 2x/day
¾ parent performs

age 2 - 6 years
¾ pea-sized fluoridated toothpaste 2x/ day
¾ parent performs or supervises

> age 6 years

¾ brush with fluoridated toothpaste 2x/day

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Diet And Feeding: 0-12 months

ƒ Hold infant for bottle and breast feedings

ƒ No bottles at bedtime or nap (water only)
ƒ No pacifiers dipped in honey
ƒ Introduce cup at 6 mos, wean
bottle at 12-18 mos
ƒ Avoid constant use of sippy cup
ƒ Avoid cariogenic snacks between meals
ƒ Introduce appropriate snacks

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 Diet And Feeding: 1-2 yr.

ƒ Discontinue bottle feeding 12-18 mos

ƒ Avoid constant use of sippy cup unless it
contains water
ƒ Avoid excessive intake of juice (> 4oz/day)
ƒ Limit cariogenic snacks between meals
ƒ Reserve soda, candy and sweets for
“special occasion” treats

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Diet And Feeding : 2-5 yr.

ƒ Limit cariogenic snacks between meals

ƒ Reserve soda, candy and sweets for
‘special occasion’ treats
ƒ Avoid excessive intake of juice (> 4oz/day)
ƒ Choose fresh fruits, lightly
cooked vegetables, or
whole grain foods for snacks
ƒ Good preventive medicine
for obesity too!

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 Caries Risk Assessment

HIGH RISK if by history:

¾ Previous or current caries

¾ Siblings or mom with caries
¾ No fluoride in water
¾ Chronic health condition and/or
medication use
¾ Inadequate fluoride
¾ SES, cultural factors
¾ CSHCN
Adapted, Bright Futures in Practice, Oral Health, 1996

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Children with Special Health Care Needs

ƒ Frequent feedings may be necessary

ƒ Oral -motor skills often delayed, longer use
of bottles
ƒ Oral aversion may impede home care
ƒ Medications (decrease saliva, contain sugar,
cause gingival hypertrophy)
ƒ Other oral/craniofacial problems
ƒ Monitor closely
ƒ Refer for dental care early!

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18
 Oral Screening Exam

ƒ All children: oral/dental evaluation - age 1

ƒ Anticipatory guidance earlier
ƒ Trained PCP can do first oral exam at 6 -12 mo.
ƒ Prioritize dental referral: visible disease or high
risk for disease
ƒ Pregnant women, mothers with
disease need referral
ƒ All children need a regular source
of dental care (“dental home”)

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Oral Screening Exam

ƒ Facial Structure
ƒ Teeth
ƒ Soft Tissues – Lips,
gingiva, buccal mucosa,
palate
ƒ Pharynx
ƒ Salivary glands
ƒ Tongue, floor of mouth

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 Recognizing Early Decay

White Spot Lesions

=
Subsurface
demineralization

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White spot lesion

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 “Lift the Lip” Exam

ƒ Knee-to-Knee position
ƒ Use toothbrush
ƒ Place mirror in baby’s cheek
ƒ Examine the front surfaces of the 4 upper front
teeth
ƒ Using the mirror, examine the back surfaces of
the 4 upper front teeth

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Oral Exam - Teeth

ƒ Look at each tooth for plaque, looseness,

decay
ƒ Check occlusion (bite)
ƒ Examine gums – firm and pink, not soft,
swollen or inflamed

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 Oral Screening Exam

High Risk
ƒ Visible plaque on the teeth
White spot
ƒ Enamel defects
ƒ White spots or cavities
ƒ Inflamed gums

Fistula
(abscess)
cavity
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Routine Dental Visits and Preventive Care

ƒ Frequency of visits based on individual need

ƒ Evaluate
¾ Personal hygiene success
¾ Periodontal status – probing,
radiographs
¾ Complicating factors – malocclusion,
medical disorders, handicapping
conditions

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 Routine Dental Visits and Preventive Care II

ƒ Plaque removal on a regular basis

ƒ Sealants
¾ Important preventive measure, esp. for
teeth with deep fissures and pits
¾ A resin material which is bonded to the
biting and chewing surfaces of the teeth
¾ One treatment may protect for a lifetime,
but may need replacement at the bond
breaks down over time

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Pocket Guide

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Risk Assessment

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Risk Assessment

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 Risk Assessment

If you see this: White Spot Lesions

Do this:
1. Apply fluoride varnish.
2. Make referral to dentist.
3. Explain the importance of regular tooth brushing with fluoride
toothpaste.
4. Emphasize early decay can be reversed.

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Risk Assessment

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Risk Assessment

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Risk Assessment

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 Risk Assessment

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Medical Office Billing Information

ƒ EqualityCare will reimburse PCP for Early

Childhood Caries Risk Assessment and
Prevention Procedures, namely fluoride
varnish application.
ƒ Children up to three years of age
ƒ Three applications per year
ƒ Use CPT code 99429 which pays $35.00 per
application

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 Summary

ƒ Dental decay is a significant health problem

for children
ƒ Primary care providers have a key role
ƒ Anticipatory guidance during WCC
ƒ Oral exam by age 1
ƒ Fluoride – safe and effective
ƒ Collaborate with dentists to
improve oral health and
access to care

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Additional Resources

ƒAmerican Academy of Pediatrics:

http://www.aap.org/

ƒAmerican Dental Association:

http://www.ada.org/

ƒWyoming Department of Health Dental Program:

http://wdh.state.wy.us/dental/index.asp

ƒUniversity of Washington College of Dentistry:

http://www.dental.washington.edu/

ƒNational Maternal Child Oral Health Resource Center

(Web-Based Oral Health Curricula for Professionals) :
http://mchoralhealth.org /SpecialCare

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 Resources

ƒ If you are treating EqualityCare clients, they are

eligible for health and case management services
through the Wyoming Department of Health’s
Healthy Together! program.
ƒ The program is provided at no cost to EqualityCare
clients and family.
ƒ Refer EqualityCare (Medicaid) clients to the
Healthy Together! Health Management program

¾ 1-888-545-1710
¾ www.wyoming.apshealthcare.com

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