How Fluoride Varnish Combats Early Childhood Caries Daniel Ravel, DDS Fayetteville, NC

1. How Fluoride Varnish Combats Early Childhood CariesDaniel Ravel, DDSFayetteville, NC

2. Early Childhood Caries (ECC) Caries in primary dentition under age 5 Affects 35% of 3 year olds Bacteria are the causative agent Destroys tooth structure, often rapidly Usually affects maxillary incisors first Potentially severe consequences could include pain, tooth loss, pulpitis, pulp necrosis and dental abscess 8

3. ECC Etiology Triad Teeth Bacteria Caries Sugars Oral bacteria (mutans strep) break down dietary sugars into acids which break down the tooth 9

4. ECC Risk Assessment 10

5. Why is Risk Assessment Important? • 80% of ECC occurs in 20% of children • Risk status determines: • Age of first dental visit • Use of fluoride • Depth of nutritional and hygiene counseling • Begin before or with first tooth (4-6 months) 11

6. Assessing Caries Risk • High: • Multiple risk factors and: • Plaque on teeth • Presence of white spots or cavities • No systemic fluoride exposure • Moderate: • One of following risk factors: • Lower SES • Poor access to health care • Family members have cavities – particularly mother • Diet – drinks or eats sugar containing foods two or more times between meals • Diet - sleeping with bottle or at breast • Special health care needs • Developmental defects (often in premature babies) Low 12

7. ECC Recognition Photo: Joanna Douglass BDS DDS

8. Knee to Knee Oral Exam 1. Child is held facing care giver in a straddle position 2. Child leans back onto examiner while caregiver holds child’s hands 3. Provider performs exam while caregiver holds child’s hands and legs Photos: Mark Deutchman MD 14

9. Healthy Teeth Photos: Joanna Douglass BDS DDS 15

10. Early Stage of ECC: White to Brown Spots Photos: Joanna Douglass BDS DDS 16

11. Early Aggressive ECC Photos: Joanna Douglass BDS DDS 18

12. Fluoride 20

13. Ongoing Balance Protective Factors Salivary flow Fluoride Pathologic Factors mutans strep Carbohydrates Reduced salivary flow Caries No caries 21

14. Topical (greater effect) Inhibits demineralization Promotes remineralization Produces anti-bacterial activity Systemic (lesser effect) Reduces enamel solubility by incorporation into its structure Mechanism of Action 23

15. Sources of Fluoride Systemic • Water fluoridation • Fluoride supplements Topical • Fluoride toothpastes • Gels, foams, mouthwashes • Fluoride varnish 24

16. Fluoride Use Recommendations Low Risk Mod Risk High Risk Fluoridated water Yes Yes Yes Systemic Fluoride Fluoride tablets/drops Yes Yes ? * Yes Yes Toothpaste Topical Fluoride Fluoride Varnish No Yes Yes * After age 2 all children should use fluoridated toothpaste 25

17. General Population (USPSTF 1989, 1996) Fluoridated toothpaste (I, A) High Risk Populations (MMWR 2001) Water supplementation reduces caries by 30% Fluoride supplement if water <.3ppm (6-12 yr-olds)(I,A) Topical fluoride gels (I, A) Fluoride varnishes on permanent teeth (I, A) Fluoride varnish on high risk infants (I, A) Evidence of Benefit for Fluoride 26

18. Fluoride Varnish 27

19. Benefits Can be quickly and easily applied Application does not have to be done by a physician Dry tooth surface facilitates fluoride uptake Sets on contact with moisture Taste is tolerable Can reverse early decay (“white spots”) and slow enamel destruction in active ECC 28

20. Indications Moderate and high risk children without caries Children with “white spots” Children with caries Generally applied twice per year beginning when teeth erupt Varnish is not a replacement for appropriate diet, regular brushing, indicated systemic fluoride supplements, or routine dental care! 30

21. Available Preparations0.25ml unidose 5% NaF (2.26% F) CavityShield OMNII $1.00 per dose Enamel Pro Varnish Primier $1.60 per dose Duraflor Medicom $1.00 per dose All Solutions Dentsply $1.60 per dose Flor-Opal Ultradent $2.00 per dose 31

22. Follow-up • After application of topical fluoride: • Offer caries preventive advice • Assess need for fluoride supplements • Plan next visit to the medical home • Refer to dental home (if needed) • If a child has active caries • Intensive counseling and preventive measures • Urgent definitive dental referral 33

23. Hygiene Advice: Tooth Brushing Start when teeth erupt Brush twice daily Bedtime most critical Caregiver brushes until age 6 Child can stand in front of caregiver or lie face up in lap Spit after brushing, not rinse Use rice size or smear of fluoridated toothpaste Lift lip; brush behind teeth Photos: Joanna Douglass BDS DDS 23

24. High Risk Eating Pattern Advice Eating Pattern Frequent snacking – 2 +times between meals Sticky, retentive snacks, slow dissolving carbohydrates Sequence of eating & time Examples Candy, sippy cup of juice or soft drink, graham crackers, cookies Raisins, dried fruit, fruit rolls, bananas, caramels, jelly beans, peanut butter/jelly sandwich Chewable vitamins at end of meal, food or drink after brushing and before bed 24

25. Healthy Snacks Advice Happy Foods Fruit Veggies Cheese Crackers Pretzels Popcorn Nuts Peanut Butter Cheese Crackers Sugar Free Gum Milk Water 100% pure fruit juice (only 4 oz per day) Sad Foods Fruit Roll-ups Fruit by the Foot Fruit Wrinkles Gummy Bears Cookies Cupcakes Sugared Cereals Granola Bars Pop Tarts Soda, Gatorade, Ice Tea Donuts Sugar drinks 25

26. Fluoride Supplementation Advice Water Fluoride Concentration Child’s Age < 0.3 ppm 0.3 – 0.6 > 0.6 ppm ppm 6 mos – 3 yrs 0.25 mg None None 3 yrs – 6 yrs 0.50 mg 0.25 mg None > 6 years 1.00 mg 0.50 mg None Dosages are in milligrams F/day 26

27. Age 1 Dental Visit Referral The American Academy of Pediatric Dentistry recommends a dental evaluation by the 1st birthday The American Academy of Pediatrics recommends establishment of a dental home by the 1st birthday for children at high risk If limited dental access, clinician assumes responsibility for screening and guidance 27

28. Applying Fluoride Varnish 34

29. Assemble the required supplies: Varnish Toothbrush Gauze Applying Fluoride Varnish: Step 1 36

30. Visually inspect all the child’s teeth and document any white spots and/or cavities for future follow-up Hints Use the knee-to-knee exam Show the toothbrush to prompt opening of the mouth Applying Fluoride Varnish: Step 2 Photos: ICOHP 37

31. Use a 4x4 gauze pad to dry the child’s teeth and remove gross plaque Applying Fluoride Varnish: Step 3 Photo: ICOHP 38

32. Apply varnish to all the surfaces of the dry teeth Note: The varnish will not adhere if it is applied to wet teeth, but saliva contamination after the application is fine Applying Fluoride Varnish: Step 4 Photos: ICOHP 39

33. Tell the caregiver: The child’s teeth will be discolored for 24-48 hours Do not brush the child’s teeth for 12-24 hours Avoid giving the child hot, sticky or hard foods for 24 hours Applying Fluoride Varnish: Step 5 Photo: ICOHP 40

34. Fluorosis and the Safety of Fluoride Varnish 41

35. Discoloration of teeth due to chronic excessive exposure to Fluoride while teeth are developing Risk greatest at intake of greater than 0.06 mg/kg/day Prevalence of Fluorosis: 0.2% - 27% Fluorosis Photos: John McDowell DDS, Joanna M. Douglass BDS DDS 42

36. Determine the fluoride content of the child’s drinking water Consult with the child’s dentist to avoid duplicating fluoride prescriptions Follow current dosage schedules for systemic fluoride supplementation Tell the child’s caregiver to place only a rice-grain size dab of fluoridated toothpaste on the child’s toothbrush Keep fluoride containing products out of the reach of small children Reducing the Risk of Fluorosis 43

37. 5% NaF varnish = 26,000 ppm fluoride A 0.5 milliliter application of fluoride varnish contains < 6 milligrams of fluoride Negligible fluoridelevels are detected in blood and urine Fluoride varnish is as safe as other topical fluoride applications via toothpastes, rinses, and gels Safety of Fluoride Varnish 44

38. 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 comprehensive approach to a child’s oral health Fluoride varnish is safe and effective You can apply fluoride varnish to a child’s teeth as a part of a routine visit You can minimize the risk of fluorosis by educating the child’s caregivers Take Home Messages 46