ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ ... · Department of Health Munaqhiliqiyitkut Ministère de la Sant ... water fluoridation levels be reduced to 0.7 ppm ... • Forum

Dental Health: Prevention of decay and fluoridation of water

Vinay Pilly, BDS, MPH, MSc, FRCD(C)

ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦDepartment of Health

Munaqhiliqiyitkut Ministère de la Santé

DentalCareinNunavutHowdentalcareisfunded?1. Non-InsuredHealthBenefitsprogram.2. HealthCanadaContributionAgreements(NWA,THIF).

**Dentalinsurance,clientfunded,etc.

Howdentalcareisdelivered?1. DentalTherapyprogram(ArcticBay,Arviat,Rankin,Iqaluit).2. Children’sOralHealthProject.3. OralHealthPromotionprogram.4. Contractdentists,dentalhygienistsanddenturists.

**PrivatedentalserviceinIqaluit.

OralHealthStatusofChildrenandYouthinNunavut

Indicator First NationsOralHealthSurvey(2011)

Inuit OralHealthSurvey(2008)

Canadian HealthMeasuresSurvey(2009)

Children(3-5years)Decayprevalence 85.9% 85% -Untreated decay 35.2% 49.0% -

Children(6-11years)Decay prevalence 93.9% 93.4% 57.0%Untreateddecay 16.7% 32.0% 14.5%

Children(12-19years)Decay prevalence 91.4% 96.7% 59.0%Untreated decay 22.9% 38.1% 13.6%

WhyPrevention?• Oralhealthimpactsallaspectsofdailylivingandgeneralhealth.

• Decayispreventable.

• Preventivedentalprogramscandrasticallylowerdecayinchildren.

• Lessmissedschooldays.

• Instilsgoodoralhygienepracticesatayoungage.

• Highlevelsofdecayinchildrenarecostlyandtraumatictotreat.

Whychildren(schoolbased)?

• Notanindividualresponsibility.• 1/3 ofNunavutspends1/3 ofdayintheschool.• Catchthemearly.• Safeandwellaccepted.• Mitigatebehaviourandagoodstartingpoint.• Futureworkforce.

InuitOralHealthSurvey- Recommendation

“Oralhealthconditionscannotbetreatedaway,evenifmoreresourcescouldbeapplied.Moreemphasis(shouldbeplaced)oncommunitybasedprimarypreventivemeasuresbackedupbyearlydetectionandpromptbasictreatment”.

NunavutChildren’sOralHealthProject• 2013– Pilotprojectin3communities.

• 25communities.

• BasedontheChildren’sOralHealthInitiative(COHI)program.

• CommunityOralHealthCoordinators(COHCs)– Inuitoralhealthserviceproviders(75%).

OralHealthEducationandPromotion“Teeth for Life”

DentalScreening

DentalSealants

• Protectivecoatingonnewlyeruptedadultteeth.• Pitsandfissures– Mostvulnerable.• Grades2– 7.• Containfluoride– actasreservoir.• Evaluation– 6months.• HighlyEfficacious.• Provider.• Greatpatientacceptance.

http://wakedentalwellness.com/dental-sealants/

FluorideVarnish

• Safe,effectiveandhighlyefficacious.• Appliedonanyonewithteeth.• Bi-annualapplication.• Adhesive.• Highfluoride(22000ppm)concentrationusingsmallamounts.• Provider.• Easeofapplication,fastsettingandgreaterpatientacceptance.

FluorideMouthRinseProgram

• Rinseliquidcontainingfluorideatschool(onceaweek).• Supervisionofatrainedstaffmember.• Beginingradeone(childrenolderthan6years).• Provider.• Cons.

http://www.register-herald.com/news/new-river-health-is-putting-the-rinse-on-tooth-decay/article_8299f440-a2b3-558d-8c5d-032dcca5ccda.html

SchoolToothBrushingProgram• Mosttoothpastescontain1000ppmoffluoride.• Supervisionofatrainedstaffmember.• Amountoftoothpaste.

<3years:Adultshouldbrush;Ricegrain3- 6years:Adultshouldassist;Peasize

• Provider.• Benefits.

http://www.esperanca.org/what-we-do/u-s-program/

InterimStabilizationTherapy• Simplewayofstabilizingthedecayprocess.• Handinstruments.• Specialfillingmaterial,whichcontainsfluoride.• Highclientacceptability- Nofreezing.• Benefits.• Provider.

http://www.dentalcompare.com/Featured-Articles/2008-Small-Cavities-Big-Problems-Diagnosis-and-Treatment-of-Non-Cavitated-Carious-Lesions/http://www.mistrymedical.com/item/8657/instramed-sterile-spoon-excavator-d-ended--s42-9403-

FluorideinCommunityWaterFluoridation

The“F”word

Community Water Fluoridation• Waterisnaturallyfluoridated– high/low.

• Adjustingtheamountoffluorideindrinkingwatertooptimallevelthatpreventstoothdecayandreducesthechancesofdentalfluorosis.

• In2007,HealthCanada’sFluorideExpertPanelrecommendedwaterfluoridationlevelsbereducedto0.7ppm(MaximumAcceptableConcentrationis1.5ppm).

Howmuchisppm?

• 1 pennyin$10,000.• 1minutein2years.• 1dropin50litresofwater.• 2.5cmin25Kms.• 1inchin16miles.

Fluoride: How does it work?• Constantlowleveloffluorideismaintainedintheoralcavity.

Post-eruptive(major)• Remineralizationofearlycariouslesions.• Inhibitionofglycolysis.

Pre-eruptive(minor)• Preventsenamelsolubility.• Incorporationoffluorideintohydroxyapatitecrystals.

StatusofCommunityWaterFluoridationinCanadaandNunavut

• IqaluitandArviat(28.9%).

• RankinInlet- July2016.

• Canada- <35%.

CommunityWaterFluoridationin Nunavut

• MunicipaldecisioninCanada.• Logistics- Robustcapitalinvestments.• Feasibility.• Notclearthatpeopledrinktapwaterregularly.• Misconceptionsandfear.• Othersourcesoffluoride.

SystematicReview• SystematicReviewofWaterFluoridation.UK/Internationalstudy,2000.

http://www.bmj.com/content/321/7265/855.full• RecommendationsforUsingFluoridetoPreventandControlDentalCariesintheUnitedStates.US

DepartmentofHealthandHumanServicesCentersforDiseaseControlandPrevention,2001.http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm

• ASystematicReviewoftheEfficacyandSafetyofFluoridation.NationalHealthandMedicalResearchCouncil,AustralianGovernment,2007.http://www.nhmrc.gov.au/publications/synopses/eh41syn.htm

• FindingsandRecommendationsoftheFluorideExpertPanel,healthCanada,January2007.http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-fluorure/index-eng.php

• RecommendationsforUsingFluoridetoPreventandControlDentalCariesintheUnitedStates ,USCDC,2001.

• ForumonFluoridation,Ireland,2001.• ASystematicReviewoftheEfficacyandSafetyofFluoridation

NationalHealthandMedicalResearchCouncil,AustralianGovernment,2007.• InstitutNationaldeSantePubliqueDuQuebec,2007.

SafetyofFluoride• Safetyaspectshavebeenextensivelystudied.

• Toxicityofanysubstanceisrelatedtothelevelofexposureordose(theamountingestedoveraperiodoftime).

• Substancesessentialforlifelikewater,oxygen,andsaltcanbetoxicinexcessamounts.

• Inconcentrationsused,fluorideisnottoxicorharmful.

• Theoptimalrangeoffluoridealreadyhasabuilt-inmarginofsafetythattakesintoconsiderationthevarioussources.

HealthEffects• Dentalfluorosis- mostwidelystudiedadverseeffect.

• Mildandverymild- Notanadverseeffect.

• Moderate- isapotentialaestheticconcern.

• Severefluorosisisaconcern.

• The2007-2009CommunityHealthMeasuresSurveyrevealedthatmoderatetoseveredentalfluorosisissolowthatitisunreportable.

HealthEffects• Skeletalfluorosisisthemostseriouseffectwithprolonged

exposuretohighlevelsoffluoride(8-10ppmdailyformanyyears).NotseeninCanada.

• Overall,theweightofevidencedoesnotsupportalinkbetweenexposuretofluorideindrinkingwaterandbonefracture,intelligencequotient,skeletalfluorosis,immunotoxicity,reproductivetoxicity,genotoxicity,cancerorneurotoxicitybasedonaMaximumAllowableConcentration(MAC)of1.5ppm.

Do we still need water fluoridation?• Safe.• Cost-effective.• Equitable.• Lackofcompliance.• Valid.• Noevidenceofnegativeenvironmentalimpacts.

Silver Diamine Fluoride: New (old) way to treat tooth decay

What is Silver Diamine Fluoride (38%)?• Colorlessliquid

• pHaround8.0

• 25%silver:antimicrobial

• 8%ammonia:solvent

• 5%fluoride:remineralization

0.1ml- unitdoseampule

8mlbottlehttp://www.oralscience.ca/en/products/advantage_arrest/

Silver Diamine Fluoride has been around…..

2014

2017

SilverDiamineFluoride• Arreststoothdecayby80%;90%when2X/year.

• Preventsdecay– directlyandindirectly.

• $220/bottle=~250drops.

• ~88¢/drop;1droptreats~5teeth.

• 18¢/tooth.

• Disadvantage:Staining(permanentandtemporary)

Programcosts/person• CommunityWaterFluoridation: 0.77¢- $4.00a

• DentalSealants: $20.00- $36.00b

• ToothBrushingProgram: $6.74c

• FluorideVarnish: $2.5

• FluorideRinsingProgram: $2.24- $6.10

• InterimStabilizationTherapy: $16.20- $24.80

• SilverDiamineFluoride:<$1Note:Costprovideddoesnotincludeanyestimatesforthecostsofshipmentandstorageofsupplies,trainingandstaff

remuneration(includingtravel).aCurrentcostanalysesdatathattheannualcosttofluoridateaCanadiancommunitybCostsreflectNIHBfeesforinitialsealantperquadrantcost assumesan8monthschoolyearinwhicheachparticipantreceives3toothbrushesand2tubesoftoothpaste

DaySurgeryforToothDecayinNunavut

www.cihi.ca

DentalTreatmentunderGeneralAnesthetic–Estimation

• AsofMarch62017,thewaitlistwas588.

• Seriousmorbidityandpotentialmortality.

• $3,000- $5,000totreat*.

• Avoidablehealthcarecosts.

• Detrimentallongtermcognitiveeffects.

*Costprovideddoesnotincludeanyestimatesforthecostsoftravel,accommodation,food,facilityfee,escortcharges,etc.

MovingForward• Approachesarenotexclusiveofeachother.

• Multi-facetedapproach.

• Common-riskfactorapproach.

Questions?Contact:VinayPilly

Email:[email protected]

Phone:(867)975-5778/222-0318