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)

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





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


It is an epidemic.


It is an epidemic.

It is bacterial.


It is an epidemic.

90% of 6 year olds are infected.


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


It is passed to the children by

their mothers.


If it were an STD like Clamydia, mothers would be treated prior to giving

birth.


We treat it by amputating tissue and providing

prosthesis.


If we treated diabetes this way, rather then

controlling blood sugar, we would amputate feet.


It costs 10 times as much to treat as it does

to prevent.


It is much easier and less costly to prevent than it is

to treat.

NORMAL PRIMARY DENTITIONNORMAL PRIMARY DENTITION


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


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


technique

Excavate decay

New decay

Arrested surfaces

Ag Fl yes 0.44 2.84

Ag Fl

Na Fl V

Na Fl V

Control


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


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


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


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



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



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.

EARLY CHILDHOOD CARIES (ECC) PREVENTION AND ORAL HEALTH PROMOTION

Documents

problemit costs

american indians

american samoajames

american samoa government

pago pago

early childhood caries

dental caries i

department of health