Download Early Childhood Caries Redux, Part II

Early Childhood Caries
Redux, Part II
Burton L. Edelstein DDS MPH
Chair, Social & Behavioral Sciences
Columbia University School of Dental and Oral Surgery
Founding Director, Children’s Dental Health Project
When dentists see these…
And find this…..
They often think this….
And plan this…..
…and call this a success
And it would be a success….
If it worked
to stop disease progression
(But it generally doesn’t)
Alternative Dental Office
Management of ECC
Alternative Dental Office
Management of ECC
•
New Techniques
1.
2.
3.
4.
Changed Terminology with Parents & Staff
Caries Risk Assessment
Primary Prevention & Anticipatory Guidance
Caries Arrest/ART
1. Changed Terminology and
Resultant Opportunities
New Terminology
• Premise: Can’t treat what you can’t name
• Terminology:
–
–
–
–
Caries: The pathologic decay process
White Spots: An initial-stage sign of caries damage
Cavities: A late-stage sign of caries damage*
Tooth Decay: A global term for caries and cavities
• Conclusion: Terminology allows caries treatment
at various levels
*GV Black 110 years ago, “Cavities of decay”
Cavities are the result of
failed
caries management
Current care for young children
Presentation
Diagnosis
Cavities Yes
Surgical
Treatment
Cavities No
No Treatment
Health
Maintenance (Recall)
Proposed care for young children
Presentation
Diagnosis
Caries Active
Caries Inactive
Treat Caries (“medically”)
Cavities No
Cavities Yes
“Surgical Tx”
Health
Maintenanc
e (recall)
Patient Classification
CAVITY
Present
Active
Absent
ACTIVE
AT RISK
(in trouble)
(prodromal)
ARRESTED
INACTIVE
(out of trouble)
(safe for now)
CARIES
Inactive
New opportunities emanating from
new terminology
• Opportunities
– to assess
• caries activity as well as cavity status
• level of individual risk for future disease
– to engage in
• true primary prevention
• anticipatory guidance
• disease suppression
– To treat active, at risk, arrested, and inactive
patients through four different approaches
Differential Treatment Approaches
• Active
– Suppress caries activity before repairing any teeth
– If necessary, treat sufficiently to stop pain/infection
• Arrested
– Minimal repair: Restore only those teeth essential to
esthetics and function
– Maintain arrest
• At Risk
– Aggressively treat caries process to prevent cavitation
– Watch for “white spot lesions” & manage aggressively
• Inactive
– Initiate “anticipatory guidance” and monitor
2. Caries Risk Assessment
Caries Risk Assessment
“NIH Consensus Development Conference on
Diagnosis and Management of Dental Caries
Throughout Life” March 2001
1.
2.
3.
4.
5.
6.
Part III: Indicators of Risk
Socioeconomic and Behavioral
Sugar Consumption
Low Birth Weight
Microbiologic Factors
Inheritance
Metal Ion Exposure
Caries Risk Assessment
1.
2.
3.
American Academy of Pediatric Dentistry
Caries-Risk Assessment Tool (CAT)
Risk Factors
Clinical Conditions
Caries evidence, Hygiene/gingivitis, Appliances,
Hypoplasia, Mutans levels
Environmental Characteristics
Fluoride exposure, Sugar exposure/frequency,
Socioeconomic status, Use of dental care
General Health Conditions
Saliva impairment, Special needs children
Caries Risk Assessment
The Most Useful Tautology
“Past Caries Experience is the Best Predictor of
Future Caries Experience”
CAT includes:
–
–
–
White spots
Radiographic evidence of early decay
Past caries experience in last 12-24 months
These are not risk factors for caries
but are evidence of existing caries activity
Caries Risk Assessment
Mutans Streptococci
•
•
•
•
•
•
Necessary but not sufficient for caries initiation
Acquired by children, typically from mothers
Transferred by salivary contact
First evident in youngest children as
voluminous plaque on anterior teeth
Associated with inception, prevalence, and
incidence of caries (also extent and severity)
Readily cultured at chairside
Caries Risk Assessment
Mutans Streptococci
•
•
•
Useful measure of current caries activity
Maternal suppression delays transmission and
subsequent caries in children
High specificity but low sensitivity
(Kids who lack cavities have little mutans but kids with
cavities may or may not have high mutans)
•
Highly responsive to diet control and fluoride
exposure
Caries Risk Assessment
1.
2.
3.
4.
5.
Mutans Culture
Collect saliva on sterile
tongue blade from
dorsum of tongue
Impress onto selective
medium
Provide low Oxygen
environment
Incubate 2 days
Read using chart as
zero, low, mod, high, or
very high
Low
Moderate
Photo credit: Ivoclar vivadent
High
Very High
Caries Risk Assessment
Mutans Conference Report
•
•
•
•
•
•
•
Colonize only after first teeth appear
Highest concentration over lesions
Increased in volume with sugar ingestion
Synthesize macromolecules to attach to teeth
Rapidly produce acid and are acid tolerant
Always recovered on initial & advanced lesions
Virulence associated with sugar consumption
3. Primary Prevention and
Anticipatory Guidance
Prevention/Guidance
1.
2.
3.
4.
True “primary prevention”
“Anticipatory guidance”
“Dental Home”
“Age one dental visit”
Prevention/Guidance
True Primary Prevention
•
•
By definition, prevents disease occurrence by
avoiding disease determinants
For caries, must target mutans implantation by
–
–
–
•
Reducing source availability
Reducing transfer opportunities
Increasing receptor resistance
Intervention in saliva transfer only appropriate
for “high-risk” mothers – those who have had
high caries experience
Prevention/Guidance
True Primary Prevention
•
Reduce source:
–
•
Xylitol chewing gum,
Stannous Fluoride,
Chlorhexidine (dental
repair)
Reduce transmission
–
–
•
Spoon sharing, Pacifier
cleaning, Hand-in-mouth
Frequency, timing, amount
Reduce implantation
–
Fluoride varnish
Prevention/Guidance
Anticipatory Guidance
•
Pediatricians’ Concept:
–
•
Classic Example:
–
•
Providing information and guiding health behaviors
in anticipation of normal development or onset of
risk
Informing parents of child’s impending ability to roll
over and instructing on fall prevention
Application to dentistry:
–
Informing parents of the conditions that create
caries & cavities; its natural progression; and its
prevention
Prevention/Guidance
Dental Home (AAPD Policy2001)
•
•
Built on concept of “Medical Home” – AAP
“Child’s first visit establishes dental home”
–
–
–
Opportunity for prevention
Goal is to reduce risk of preventable disease
Provides risk assessment; tailored counseling;
anticipatory guidance; emergency plan; access to
comprehensive dental care, including any
necessary referrals
Prevention/Guidance
Age One Dental Visit
•
•
•
Accepted policy by ADA, Pediatric Dentists,
Pediatricians, and Public Health Association
Intended to allow for true primary prevention,
establishment of dental home, and ongoing
anticipatory guidance
Consists of history, risk assessment,
examination, tailored anticipatory guidance,
and counselling
4. Caries Arrest and ART
Caries Arrest/ART
Precavitated Lesions
Clinical signs
1. Hazy, acid-bleached
appearance
2. Gingival inflammation
3. Initial proximal lesions
with intact enamel
4. Normal band of
exposed enamel
Caries Arrest/ART
Precavitated Lesions
Clinical signs
1. Hazy, acid-bleached
appearance
2. Gingival inflammation
3. Initial proximal lesions
with intact enamel
4. Normal band of
exposed enamel
Caries Arrest/ART
Early Cavitated
Lesions
Clinical signs
1.
Hazy, acidbleached
appearance
2.
Initial cavitations –
dark
in color
3.
Modestly inflamed
gingiva
4.
Normal band of
exposed enamel
Caries Arrest/ART
Arrested Cavitated
Lesions
Clinical signs
1. Dark color to lesions or
glassy surface to fully
excavated lesions
2. Sharp margins to
lesions
3. Clear band of normal
enamel between lesion
and gingiva
4. Gingival health
Caries Arrest/ART
Partially Arrested
Cavitated Lesions
Clinical signs
1. Note that inaccessible
lesions are lighter in
color and softer (more
active)
2. Need to gain access for
fluoride therapy and
possible ART
restoration
Caries Arrest/ART
• Attaining Caries Arrest
– Intensive diet control to reduce frequency of
attack
– Intensive fluoride control to increase
resistance and remineralize
– Sequential excavation to prevent pain and
build trust
– Intensive follow-up visits with sequential
cultures to monitor compliance
Caries Arrest/ART
Atraumatic
Restorative
Technique
•
•
No anesthetic
Hand excavation
–
–
•
Remove overhangs
Debreid softened
tooth structure
Place fluoride
leaching material
Warning about change & its uncertainty:
“Yesterday, we stood at the brink
of the future.
Today, we take a giant step
forward.”
President of the Ukraine
on declaring independence