sfl_6_fluoridevarnish

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Third Edition June 2010www.smilesforlife2.org

Copyright STFM 2005-2010


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Course Steering Committee Editors

Russell Maier, M.D.

Wanda Gonsalves, M.D.

Hugh Silk, M.D.

James Tysinger, Ph.D.

Dental Consultant

Joanna M. Douglass, B.D.S., D.D.S.

Smiles for Life Editor

Alan B. Douglass, M.D.

Funded By


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Educational Objectives Discuss the etiology of early childhood caries (ECC) Assess a childs risk of developing ECC Perform an appropriate oral examination on small children

Recognize the various stages of ECC Discuss the effects, sources, benefits and safe use offluoride

Describe the benefits and indications for fluoride varnish Demonstrate the application of fluoride varnish Describe strategies for a successful office-based fluoride

varnish program Advise parents on caries prevention and describe when to

arrange dental referral


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Early Childhood Caries:A Brief Review

Chapter Objective Discuss the etiology of early

childhood caries (ECC)


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What is ECC?5

Etiology Infectious, chronic disease that

destroys tooth structure leading toloss of chewing function, pain, andinfection

A variety of feeding habits beyond justnursing or bottle use are implicated

Affects 35% of 3-year-olds from lowincome families

Progression Upper front teeth that are least

protected by saliva are affected first

Disease moves posteriorly as teetherupt. Photos: Joanna Douglass, BDS, DDS


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6ECC Etiology: Triad

What causes dental caries?

Oral bacteria (mutans streptococci)metabolize the sugars from dietarycarbohydrates into acid

The acid demineralizes the toothenamel

If the cycle of acid production anddemineralization continues, theenamel will become weakened andbreak down into a cavity


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Etiology: BacteriaEtiology

Mutans streptococci is vertically transmitted from the primarycaregiver, typically the mother

Transfer is thought to occur via saliva contact

The higher the bacteria level in the caregivers mouth, the more likelythe child will become colonized

Caregivers can decrease the risk of passing bacteria tochildren by

Receiving regular comprehensive dental care

Limiting the frequency of sugar in the diet

Maintaining excellent oral hygiene and using a fluoride containingtoothpaste

Using preventive agents such as topical fluorides, antibacterial mouthrinses, and xylitol containing gums

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Etiology: Sugars

Its not just WHAT, but HOW children eat Oral bacteria produce acids that persist for 2040 minutes aftersugar ingestion

Oral acids lead to enamel demineralization

Remineralization occurs when acid is buffered by saliva

If sugars are consumed frequently, there is insufficient time forremineralization to occur

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Etiology: Teeth

Nature of Enamel Defects

20 to 40% of children have enameldefects

Defects may appear as changes intranslucency, color, or texture

May be difficult to distinguish enameldefects from early clinical signs ofcaries (lower photo)

Diagnosis is immaterial as it does not

affect management Enamel defects are associated with

substantially increased risk of ECC

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Photo: Joanna Douglass, BDS, DDS



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ECC: Risk Assessment

Chapter Objective Assess a childs risk of

developing ECC


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Why Is It Important?11

80% of ECC occurs in 20% of children. Oral healthrisk assessment should begin around 4 to 6months, just before the first tooth erupts.

A childs risk status determines: Age of first dental visit

Use of fluoride

Depth of nutritional and hygiene counseling provided


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Assessing Caries Risk12

ModerateOne of the following risk factors:

Lower SES Poor access to health care Family members have cavities particularly mother

Diet drinks or eats sugarcontaining foods two or moretimes between meals

Diet - sleeping with bottle or atbreast

Special health care needs Developmental defects

HighMultiple moderate riskfactors and one of thefollowing:

Plaque on teeth Presence of white spots

or cavities No systemic fluorideexposure


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ECC Recognition

Chapter Objectives

Perform an appropriateoral examination on smallchildren

Recognize the variousstages of ECC



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Knee-to-Knee Oral Exam14

1. Child is heldfacing thecaregiver in astraddle position

2. Child leans backonto examiner whilecaregiver holdschilds hands

3. Provider performsexam while caregiverholds childs handsand legs

Photos: Mark Deutchman, MD

Look at all the teeth front, back, sides

Note plaque, white spots, cavities, abscesses

Palpate for submucosal clefts


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15Healthy Teeth

Nature of Healthy Teeth

Creamy white with no signs ofdeviation in color, roughness, orother irregularities

If the clinician cannotdetermine whether anabnormality in the tooth surfaceis a defect versus an early cavity,it does not matter

Any child with enamel

abnormalities is at high risk forcaries and should be referred toa dentist for further evaluation

Photos: Joanna Douglass, BDS, DDS


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White Spots16

Appearance & Symptoms White spots and lines are the first

clinical signs of demineralized enamel

Typically begins at the gingival margin

If the disease process is not

managed, lesions will progress tocavities that are initially yellow

Treatment Immediate dental referral

Dietary and oral hygiene counseling

Topical fluoride to reverse or arrestlesions



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Brown Cavitations

Appearance & Symptoms

Brown cavitations represent areaswhere loss of enamel has exposedunderlying dentin

Lesions darken as they becomestained with pigments from food

Treatment Immediate dental referral

Lesions are small enough thatsimplified restorative techniques thatdo not use high speed drills and local

anesthesia can be used

Dietary and oral hygiene counseling

Topical fluoride to arrest lesions notrequiring restorations

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19Advanced ECC

Appearance & Symptoms

Multiple dark cavities appear inanterior and posterior teeth

Possible for abscesses and drainingfistulae to be present

Patients may experience pain


Treatment Urgent dental referral for

comprehensive treatment including

extractions and/or silver crowns Dietary and oral hygiene counseling

Use of fluoride to prevent developmentof new lesions


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20Caries Progression


Order of Progression

Upper incisors (maxillary anterior teeth)

First molars (mandibular primary molars)

Second molars (maxillary primarymolars)

ECC affects the teeth that erupt early

and are least protected by saliva.


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Ongoing Balance

Preventing or reversing the caries process is possible

by enhancing protective factors and reducingpathologic factors.

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Fluoride

Chapter Objective

Discuss the effects,sources, benefits, andsafe use of fluoride


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Effects and Sources ofFluorideTopical Mechanisms (main effect)

Inhibiting tooth demineralization Enhancing remineralization

Inhibiting bacterial metabolism

Systemic Mechanisms

Reducing enamel solubility throughincorporation into its structure during toothdevelopment

Fluoride Sources

Topical: Fluoride toothpastesGels, foams, mouthwashesFluoride varnish

Dietary: Water fluoridationDietary fluoride supplements

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l id


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Fluoride UseRecommendations

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All children should receive fluoride through water

fluoridation or fluoride supplements.

id f fi


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Evidence of Benefit

General Population (USPSTF 1989, 1996)

Fluoridated toothpaste (I, A)

High Risk Populations (MMWR 2001)

Topical fluoride gels (I, A)

Fluoride varnishes on permanent teeth (I, A)

Fluoride varnish on high risk infants (I, A)

Fluoride supplements if water


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Fluorosis26

Appearance and Significance

White mottling of teeth due to chronicexcessive exposure to fluoride duringtooth development

Cosmetic issue that does not affectsystemic health

Risk Reduction Determine fluoride content of drinking

water before prescribing currentdosage schedules

Avoid duplicating fluoride prescriptions Use only a smear (< 2 yrs) or pea-sized dab (>2 yrs) of toothpaste

Fluoride varnish is not a risk factor forfluorosis


Photo: John O'Donnell, DDS

Moderate Fluorosis

Severe Fluorosis


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Fluoride Varnish

Chapter Objective Describe the benefits and

indications for fluoride varnish

Fl id V i h B fit


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Fluoride Varnish Benefits28

Safe and effective

Inexpensive Quickly and easily applied

Children can eat and drink immediatelyafter application

Strengthens enamel and prevents

initiation of disease Studies demonstrate 38% reduction in

caries with use

Can reverse early decay (white spots)and slows enamel destruction in active

ECC Medicaid reimburses application by

nondental clinicians in majority of states

I di ti d F f


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Indications and Frequency ofUseCurrent Standard of Care Moderate risk children should receive a professional fluoride

treatment at least every 6 months

Higher risk children should receive fluoride treatment every 3 to 6months

Ideally, occurs as part of comprehensive care in a dental home If a dental home cannot be established, periodic applications of

fluoride varnish by trained non-dental healthcare professionals maybe effective in reducing the incidence of early childhood caries

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V i h S l ti


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30Varnish Selection

Examples of Various Varnish Products

Guidelines

Unidose preparation recommended for safety Preschool children: 0.25 ml 5% Na F (2.26% F)

Contains 5.6 mg fluoride

Cost: $1.00$2.50 per unidose

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Follow-up

After application of fluoride

varnish Provide preventive advice

Assess need for dietary fluoridesupplements

Schedule next varnish application

Refer to a dental home. If not available,follow-up in medical home

If varnish Is applied for white

spots or decay Provide intensive counseling on oral

health (diet, hygiene, and systemicfluoride supplementation if appropriate)

Arrange urgent dental referral

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Cli i i R i b t


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Clinician Reimbursement32

Clinicians planning to apply fluoride varnish should consult with theirstate health department regarding current coding requirements and

reimbursement rates.


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Applying Fluoride Varnish

Chapter Objectives

Demonstrate the applicationof fluoride varnish

Describe strategies for asuccessful office-basedfluoride varnish program

P ti


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Preparation34

Steps

1. Assemble varnish and gauze2. Place child in knee-to-knee position

3. Check childs mouth for

Developmental defects

White spots or cavities

Oral hygiene status

Soft tissue pathology and submucosalcleft palate

4. Child may cry during examination

5. If child does not open mouth, slide fingerin buccal sulcus and apply gentle openingpressure

6. Record findings

Photo: ICOHP

A li ti


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Application

Steps

1.Use gauze to dry the teeth as much aspossible. Varnish will not adhere if teethare wet

2. Apply varnish to dried teeth, starting in

posterior3. Apply varnish to anterior teeth last

4.Saliva contamination after application isfine as varnish sets in contact with saliva

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Photo: ICOHP


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Follow-up36

Tell the caregiver

The child's teeth will be discolored for2448 hours

Do not brush the child's teeth for 24hours

Avoid giving the child hot or hard foods

for 24 hours

Provide preventive advice Emphasize the importance of regular

tooth brushing

Offer dietary counseling regardingamount and frequency of refinedcarbohydrate intake

Provide systemic fluoride prescriptionand arrange referral to dental home

Photo: ICOHP

Application Video


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Application Video37

Implementation


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Implementation

Tips

Educate all staff, including front desk personnel, on caries riskassessment and the value of fluoride varnish

Train all clinicians on application procedures

Identify a varnish champion who can answer questions, understand

billing issues, assign tasks, order varnish, and maintain supplies Store supplies in exam rooms or a portable kit

Use a one-page/screen documentation form with check boxes forrisk history, consent, varnish documentation, advice, and referral

Update billing forms with varnish code(s)

Stock educational handouts for parents

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Other PreventionStrategies

Chapter Objective Advise parents on caries

prevention and describe whento arrange dental referral

Hygiene: Toothbrushing


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Hygiene: Toothbrushing

Guidelines

Brush twice daily beginning as soon as teetherupt

Bedtime is most critical due to decreasedsalivary flow at night

Caregiver should brush child's teeth until

age six Young children have difficulty brushing all

areas

Caregiver should stand or sit behind child

Lift lip and brush join between gum and teeth

Child should spit out, not rinse, afterbrushing to increase topical fluorideexposure

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Prevention: Diet Counseling


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Prevention: Diet Counseling41

Infants

Infants should be held when feeding Avoid propping the bottle in crib or car seat, etc

Fill bottle with only breast milk or formula

Older Children

Establish regular meal times for breakfast, lunch, and dinner Limit snacks to once in the morning and once in the afternoon

Only give milk or water between meals

Restrict fruit juice to regular meal times

Don't provide snacks that contain added sugar

Prepare healthy snacks such as cheese, fresh fruit, crackers, andvegetables


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Establish a Dental Home


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Establish a Dental Home43

The American Academy of Pediatric Dentistry and the

American Academy of Pediatrics both recommendestablishment of a dental home by the first birthday.

Dentist will provide Enhanced preventative services

Comprehensive evaluation and diagnosis of oral disease Evaluation of growth and development

Counseling on oral habits and interceptive orthodontic treatment asneeded

Fluoride varnish and cleanings

Dental x-rays when indicated Sealants to permanent molars as child grows


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Take Home Messages ECC is a significant health problem for children As a medical clinician, you can play a key role in

preventing ECC Fluoride varnish is one part of a comprehensiveapproach to a child's oral health

Fluoride varnish is safe and effective

You can apply fluoride varnish to a child's teethas a part of a routine visit


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Questions?

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