Download Oral Health in Pediatric Patients

Definition
B. Etiology of Disease
A.
a) Lesion Initiation & Cavitation
C.
Risk Factors

Caries is a multi-factorial disease resulting
from the interactions between a
susceptible oral cavity, cariogenic
bacteria, and cariogenic diets.
Development of dental disease:
Cariogenic bacteria, colonize a susceptible tooth, in the
presence of carbohydrates
The American Academy of Pediatric Dentistry (AAPD) defines
early childhood caries (ECC) as:
the presence of one or more decayed
(noncavitated or cavitated lesions), missing (due
to caries), or filled tooth surfaces (dmft) in any
primary tooth in a child 71 months of age or
younger.

In children younger than 36 months of age, any sign of
smooth-surface caries is indicative of severe early childhood
caries (S-ECC).
›

Unique pattern of caries development (eruption sequence)
From ages 36 months through 60 months, one or more
cavitated teeth, missing (due to caries), or filled smooth
surfaces in primary maxillary anterior teeth or a decayed,
missing or filled score of ≥4 (36 months), ≥5 (48 months), or ≥6
(60 months) surfaces constitutes S-ECC.
Enamel Pellicle and Biofilm

Immediately after eruption or thorough cleaning,
the tooth surface is covered by an acquired
enamel pellicle

Provides a base for the development of biofilm
and plaque

Promotes enamel maturation
Matrix of multiple colonies of bacteria (300-500
different species)
 Formed in steps:

›Pellicle formation
›Bacterial colonization
›Biofilm maturation
Function #1: Lubricates tooth surface for more efficient mastication
Function #2: Provide protection from demineralization and allow
post-eruption enamel maturation (

Components within biofilm attempt to negate the effects of the
by-products of bacterial metabolism
Acquired
Enamel
Pellicle
Dental
Biofilm
Mature
Plaque

Streptococcus mutans
***The early acquisition of S. mutans is a significant
predictor in the development of ECC
Approximately 90% of children who acquire S. mutans
by the age of 2, develop ECC
Lactobacillus
 Streptococcus sobrinus


Behavioral

Social

Genetic

Access to Care
In 2015 (Massachusetts):
 Approximately 50% of MA Medicaid-enrollees aged 121 (>355,000) did not have any dental care (no
submissions to Mass Health).
 Only 35% of MA dentists billed Medicaid for dental
services.
› Mass Health reimburses MA dentists 57.9% of
commercial dental insurance fees.
• As of January 2016, more than 500,000
Massachusetts residents lived in areas with a
shortage of dentists.
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, Annual EPSDT Participation Report, Form CMS-416,
(State) Fiscal Year: 2014. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-ScreeningDiagnostic-and-Treatment.html.
Participation calculated as a percent of professionally active dentists in Massachusetts. American Dental Association via Redi-Data via Kaiser
Family Foundation, State Health Facts: Professionally Active Dentists (September 2014); Tracy Gilman, executive director, MassHealth, DentaQuest,
via email to The Pew Charitable Trusts (Jan. 22, 2016).

Process begins when sugar (sucrose) is
made available to cariogenic bacteria

pH drops from 7.0 to 5.0 (pH at which
enamel integrity is compromised)
=demineralization begins

After time, pH is restored,
remineralization begins
The effects of demineralization can be
reversed if,
there is adequate time between acid
exposures to allow for remineralization of
the enamel structure.
Preventive Modalities
B. Restorative Materials
A.

Biology and genetics

Individual behavior

Social environment

Physical environment

Health services
(CDC, 2014; US DHHS, 2009; WHO, 2015)
Determinants
Behaviors
Outcomes
Fluoride

Enhances the absorption of calcium and
phosphate present in biofilm into demineralized
enamel

Fluoride absorption in bone and teeth decreases
with age
Silver diamine fluoride (SDF)
 Silver diamine fluoride (SDF), an antimicrobial agent with
remineralizing capabilities, has been utilized in Asia for
decades as a medicament for caries arrestment. SDF (38%
w/v Ag(NH3)2F, 30% w/w) is a topical solution comprised of
24.4-28.8% (w/v) silver and 5.0-5.9% fluoride.
Risk Assessment/ CAMBRA
B. Dental Home
C. Interprofessional Care
D. Education
A.

Assessment, identification, and
acknowledgement of each patient’s
individual disease indicators, risk
factors/behaviors, and protective factors
to:
› determine their risk of dental disease.
› create a patient-specific approach to
managing their disease.
“ongoing relationship between the dentist
and the patient, inclusive of all aspects of
oral health care, delivered in a
comprehensive, continuously accessible,
coordinated, and family-centered way.”
(AAPD, 2010)
AAPD, ADA, CDC, WHO recommend a
dental home is established by one year of
age

Comprehensive oral health care- acute
care, preventive services

Individualized preventive dental health
program based upon a caries risk
assessment

Dietary counseling

Anticipatory guidance about growth and
development
Kierce EA, Boyd LD, Rainchuso L, Palmer, CA, Rothman, A. Association between early
childhood caries, feeding practices and an established dental home. J Dent Hyg.
2016;90(1):18-27.
Abstract
PURPOSE:
Early Childhood Caries (ECC) is a significant public health concern disproportionately affecting lowincome children. The purpose of this study was to assess the association between the establishment of a
dental home and ECC prevalence in a group of Medicaid-enrolled preschool children, and to explore
feeding practices associated with an increased prevalence of ECC in Medicaid-enrolled preschool children
with an established dental home was evaluated.
METHODS:
A cross-sectional survey was conducted among Medicaid-enrolled children (n=132) between 2 and 5
years of age with an established dental home and no dental home to compare feeding practices, parental
knowledge of caries risk factors and oral health status.
RESULTS:
Children with an established dental home had lower rates of biofilm (p<0.05), gingivitis (p<0.05) and
mean decayed, missing and filled teeth (DMFT) scores (p<0.05). Children with no dental home consumed
more soda and juice (p<0.05) daily, and ate more sticky fruit snacks (p<0.05) than children with an
established dental home. Establishment of a dental home had a strong protective effect on caries and
DMFT index (odds ratio=0.22) in both univariate and confounding adjusted analyses.
CONCLUSION:
The results suggest establishment of a dental home, especially among high-risk, low-income populations,
decreases the prevalence of ECC and reduces the practice of cariogenic feeding behaviors.

Data:
99% of Medicaid-enrolled children had well-baby visits before age 1, compared
to 2% who had a dental visit
89% of a group of children under age 1 had routine medical examinations, but of
them only 1.5% had dental exam
Medical home/personnel play a substantial role in referring
patients in a timely manner as well as the early identification of
high-risk behaviors and communication of oral hygiene
education and instruction and nutritional counseling
Hale KJ. American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental
home. Pediatrics. 2003;111 (5 pt1):1113-1116.
Vargas CM, Ronzio CR. Disparities in early childhood caries. BMC Oral Health. 2006;6 Suppl 1:S3.
AAP recommended interval of oral health
risk assessments performed by medical
providers:
6 months
 9 months
 18 months
 24 months
 30 months
 3 years
 6 years

Smiles for Life
http://www.smilesforlifeoralhealth.org/

ECC Resource Center
http://earlychildhoodcariesresourcecenter
.elsevier.com/

Oral hygiene instructions (OHI)

Thoroughly brush 2x/day to remove plaque/dental biofilm

Flossing nightly to adequately remove interproximal
plaque/dental biofilm
› Recommend for parents to help with brushing and flossing
until at least age 10
› Allow older children to brush on their own in morningpromote autonomy
Fluoride

Using fluoridated mouthwashes and dentifrices to incorporate
fluoride into the saliva

Xylitol
› Reduce amount of dental plaque
› Reduce S. mutans levels in plaque and saliva
› Reduce acid production in plaque
› Prevent vertical transmission of S. mutans
from mothers to children
Nutritional Counseling
Limit sugar exposure
1. Consume milk/juice/etc. at meals only
2. Discontinue bottle feeding by age 1
› Discuss prolonged/on-demand nursing (recommend
wiping child’s teeth with wet cloth after nursing)
3. Avoid putting a child to bed with milk/juice/etc. in either
bottle or sippy cup
4. Avoid snacking throughout the day
It is not the
quantity or the quality of the
exposure but the frequency that
matters in increasing the risk of
developing ECC.

Replace milk/juice with water in the bottle at night

When recommending discontinuation of bottle and pacifier,
have caregiver focus on one first (bottle), pacifier after

If nighttime help with brushing and flossing is not ideal,
encourage caregiver to ensure there is help 1x/day

For patients on nutritional supplements per the pediatrician,
encourage water use immediately after consuming
 Engage
 Encourage
 Empower
 Educate

Paige is a 3-year-old girl, brought to her
pediatrician’s office by her mother for her
yearly physical and immunizations.

Her mother has no concerns, but mentions that
her sister (Paige’s aunt) is concerned about her
teeth, saying that she (Paige)has cavities and
should be seen by a dentist.

She also states that Paige’s grandmother
informed her that “cavities are normal at this
age and those teeth will just fall out anyway.”

Social and Family History: Lives with mother and 5year-old sister. Paige is a picky eater and drinks juice,
water, or whole milk from a bottle.

She eats several snacks, such as gummies and raisins,
between meals each day.

Paige’s sister has fillings in her teeth but Paige has not
yet seen a dentist. Paige’s mother brushes Paige’s
teeth sporadically and she is not sure if the
toothpaste contains fluoride or not.

The family has Medicaid insurance.
Risk Factors
 Frequent bottle use
 Frequent juice
consumption,
frequent snacking
 Inconsistent oral
hygiene, possibly
lack of fluoride
 No history of dental
care
 Medicaid-eligible
Clinical Findings
 Marginal plaque

Facial gingiva slightly
inflamed

Brown cavitations of
tooth structure visible

Dental referral; promote establishment of
a dental home and communicate
importance of maintaining regular care

Apply topical fluoride varnish

Education of mom on proper oral
hygiene practices (including using
fluoride toothpaste) and dietary habits
following risk assessment
[email protected]
Kierce EA, Rainchuso L. A Comprehensive Approach
to Dental Caries Management. Dimensions of Dental
Hygiene. April 2017;15(4):48-51.
Aas JA, Paster BJ, Stokes LN, et al. Defining the normal bacterial flora of the oral cavity. J Clin Microbiol. 2005;43(11):5721-5732.
American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents.
www.aapd.org Web site. http://www.aapd.org/media/policies_guidelines/g_cariesriskassessment.pdf. Updated 2014. Accessed September,
2016.
American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Unique challenges and management options. www.aapd.org
Web site. http://www.aapd.org/media/policies_guidelines/p_eccuniquechallenges.pdf. Updated 2016. Accessed November 17, 2016.
Arora A, Scott JA, Bhole S, et al. Early childhood feeding practices and dental caries in preschool children: A multi-centre birth cohort study.
BMC Public Health. 2011;11:28.
Arrow P KE. Minimum intervention dentistry approach to managing early childhood caries: A randomized control trial. Community Dent Oral
Epidemiol. 2015;43:511-520.
Caufield PW, Li Y, Dasanayake A. Dental caries: An infectious and transmissible disease. Compend Contin Educ Dent. 2005;26(5 Suppl 1):10-16.
Edelstein BL NM. Chronic disease management strategies of early childhood caries: Support from the medical and dental literature. Pediatr
Dent. 2015;37:281-287.
Featherstone JD, Domejean-Orliaguet S, Jenson L, et al. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc.
2007;35(10):703-713.
Foster T, Perinpanayagam H, Pfaffenbach A, et al. Recurrence of early childhood caries after comprehensive treatment with general
anesthesia and follow-up. J Dent Child (Chic). 2006;73(1):25-30.
Hale KJ. American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental
home. Pediatrics. 2003;111 (5 pt1):1113-1116.
Kagihara LE, Niederhauser VP, Stark M. Assessment, management, and prevention of early childhood caries. J Am Acad Nurse Pract.
2009;21(1):1-10.
Kawashita Y, Kitamura M, Saito T. Early childhood caries. Int J Dent. 2011;2011:725320.
Kierce EA, Boyd LD, Rainchuso L, et al. Association between early childhood caries, feeding practices and an established
dental home. J Dent Hyg. 2016;90(1):18-27.
Mobley C, Marshall TA, Milgrom P, et al. The contribution of dietary factors to dental caries and disparities in caries.
Acad Pediatr. 2009;9(6):410-414.
Nunn ME, Braunstein NS, Krall Kaye EA, et al. Healthy eating index is a predictor of early childhood caries. J Dent Res.
2009;88(4):361-366.
Nunn ME, Dietrich T, Singh HK, et al. Prevalence of early childhood caries among very young urban boston children
compared with US children. J Public Health Dent. 2009;69(3):156-162.
Oliveira AF, Chaves AM, Rosenblatt A. The influence of enamel defects on the development of early childhood caries in
a population with low socioeconomic status: A longitudinal study. Caries Res. 2006;40(4):296-302.
Palmer CA, Kent R,Jr, Loo CY, et al. Diet and caries-associated bacteria in severe early childhood caries. J Dent Res.
2010;89(11):1224-1229.
Paster BJ, Boches SK, Galvin JL, et al. Bacterial diversity in human subgingival plaque. J Bacteriol. 2001;183(12):37703783.
Prakash P, Subramaniam P, Durgesh BH, et al. Prevalence of early childhood caries and associated risk factors in
preschool children of urban bangalore, india: A cross-sectional study. Eur J Dent. 2012;6(2):141-152.
Vargas CM, Ronzio CR. Disparities in early childhood caries. BMC Oral Health. 2006;6 Suppl 1:S3.
Warren JJ, Weber-Gasparoni K, Marshall TA, et al. A longitudinal study of dental caries risk among very young low SES
children. Community Dent Oral Epidemiol. 2009;37(2):116-122.