Caries Risk Assessment, Fluoride Varnish, and Counseling

Question 1

ECC Overview

Answer 1

Early Childhood Caries (ECC) is a chronic disease that destroys tooth structure leading to loss of chewing function, pain, and infection in children through five years of age. Defined as > 1 decayed, missing, or filled primary tooth surface in children less than 6 years of age.

Progression
* Upper front teeth that are least protected by saliva are affected first.
* Disease moves posteriorly as teeth emerge.

Question 2

ECC Triad

Answer 2

Multifactorial process affected by environmental, behavioral and host risk factors

Oral bacteria (Polymicrobial including Mutans Streptococci and Lactobacilli) metabolize dietary sugars into acids

Acids demineralize the tooth enamel

If the cycle of acid production and demineralization continues, the enamel weakens and breaks down into a cavity

Question 3

Eating Patterns & ECC

Answer 3

• Oral bacteria produce acids that persist for 20-40 minutes after sugar ingestion.
• Oral acids lead to enamel demineralization.
• Remineralization occurs when acid is buffered by saliva.
• If sugars are consumed frequently, there is insufficient time for the remineralization process to occur. The tooth is then subjected to continued demineralization and the caries process progresses.
• If sugars are consumed infrequently, teeth are able to fully remineralize and the caries process halts.

Question 4

Knee to Knee Oral Exams

Answer 4

Small children are best examined while lying down. For infants and toddlers, the knee-to-knee oral examination allows you to carefully examine the child’s teeth with assistance from a caregiver.

If the child’s legs don’t fit around the caregiver’s body, the child may lie sideways or diagonally on the caregiver’s lap.

Procedure
* Lift the lip
* Examine the soft tissues - tongue, lips, gums
* Examine the hard tissues - front, back, sides of all teeth for plaque, white spots, cavities, abscesses, and damaged teeth
* Palpate for submucosal clefts.

Question 5

Healthy Pediatric Teeth

Answer 5

Healthy teeth should be a creamy white with no signs of deviation in color, roughness, or other irregularities.

If the clinician cannot determine whether an abnormality in the tooth surface is a defect versus an early cavity, this will not alter management.

Any child with enamel abnormalities is at high risk for caries and should be referred to a dentist for further evaluation.

Application of topical fluoride varnish may prevent decay.

Question 6

Progression of Caries

Answer 6

ECC affects the teeth that emerge early and are least protected by saliva. Visualize a child sucking a bottle. With the child’s tongue thrust forward, the maxillary incisors get maximal sugar exposure.

Typically ECC progresses in the following order:
* Upper incisors (maxillary anterior teeth)
* First molars
* Second molars

Mandibular incisors, although they emerge first, are generally not affected because they are protected by the tongue and pooling of saliva in that area.

Question 7

Early ECC: White Spots

Answer 7

White spots and lines are demineralized areas of enamel that represent the first clinical signs of caries.

Appearance & Symptoms
* Caries typically affects the teeth that emerge first and are least protected by saliva (e.g., the upper incisors).
* White spots or white lines typically begin at the gingival margin.
* If the disease process is not managed, the lesions will progress and the demineralized enamel will break down to frank cavities that initially appear pale yellow.
* In time, these lesions will progress to larger brown cavities.

Treatment & Referral
* Immediate dental referral should be arranged.
* If the clinician cannot determine whether an enamel lesion represents enamel hypoplasia or early caries, refer to establish a dental home, as the child is at high risk for ECC in both scenarios.Use topical fluoride to reverse or arrest lesions.
* Dietary and oral hygiene counseling should be given

Question 8

Severe ECC: Cavitations

Answer 8

Cavitations represent areas where loss of enamel has exposed underlying dentin.

Appearance & Symptoms
* Anterior upper incisors are typically affected first.
* Lesions are initially pale yellow and become progressively darker as they become stained with pigments from food.
* Teeth may be sensitive to thermal changes and sweet or sour foods or drinks.
* Children may be too young to articulate symptoms.

Treatment & Referral
* Immediate dental referral should be arranged
* Some cavities may be restored using fluoride releasing restorative materials.
* Provide dietary and oral hygiene counseling.
* Use of topical fluoride to prevent development of new lesions.

Question 9

Severe ECC w/ Soft Tissue Involvement

Answer 9

Cavitations represent areas where loss of enamel has exposed underlying dentin.

Appearance & Symptoms
* Anterior upper incisors are typically affected first.
* Lesions are initially pale yellow and become progressively darker as they become stained with pigments from food.
* Teeth may be sensitive to thermal changes and sweet or sour foods or drinks.
* Children may be too young to articulate symptoms.

Treatment & Referral
* Immediate dental referral should be arranged
* Some cavities may be restored using fluoride releasing restorative materials.
* Provide dietary and oral hygiene counseling.
* Use of topical fluoride to prevent development of new lesions.

Question 11

Early Childhood Caries Management

Answer 11

All stages of Early Childhood Caries require treatment, including:

• Comprehensive dietary and oral hygiene counseling.
• Fluoride Varnish to arrest cavitated lesions and prevent development of new lesions.
• Urgent Dental Referral for Comprehensive Treatment.

Misc Info
* Some cavities can be restored using fluoride releasing restorative materials.
* Small lesions that do not require local anesthesia or high speed drills, can be stabilized using simplified restorative techniques.
* Severe disease may require extractions, fillings or root canals.

Question 12

ECC Risk Assessment

Answer 12

Oral Health Risk Assessment Tool
* Oral Health Risk Assessments start at 6 months of age
* Should be completed at each well child visit or dental visit
* Several risk assessment tools are available, including from the ADA, AAPD, and the AAP.
* The AAP Risk Assessment Tool is the most commonly used tool in primary care in the United States. This tool has been endorsed by the NIIOH.
* Reviews to date suggest there is no validated risk assessment tool available to primary care practitioners.

Why Perform Risk Assessment?
* The tool will help you to better understand dental caries risk and protective factors in young children.
* Aids in documenting clinical findings and guides counseling.
* Fluoride varnish is recommended for all children ages 5 and under, independent of caries risk. A risk assessment tool may help you decide which children would benefit from more frequent varnish application, as the American Academy of Pediatrics 2014 guidelines recommend fluoride varnish twice annually for all children and 4 times annually (quarterly) for children at high-risk for caries.

Question 13

AAP Risk Asseessment Tool

Answer 13

The AAP and National Interprofessional Initiative on Oral Health (NIIOH) have collaborated to create a formal Oral Health Risk Assessment Tool piloted through the Quality Improvement Innovation Network (QuINN)

An Oral Health Risk Assessment tool should document the following components:
* Risk Factors
* Protective Factors
* Clinical Findings
* Level of Caries Risk
* Urgency of Dental Visit
* Depth of nutritional and hygiene counseling

Over 80% of practices found the AAP Risk Assessment tool easy to implement. Clinicians did not need to significantly alter current practice to incorporate risk assessment.

Oral health recommendations can be implemented in just 2 minutes and identification of high-risk patients for oral health referral increased from 11% to over 87% with use of the tool.

Question 14

Protective Factors

Answer 14

Protective factors decrease overall caries risk and include:
* Having a dental home
* Tooth brushing
* Fluoride use: Toothpaste, Varnish, Supplements

Question 15

Clinical Findings which Increase Risk

Answer 15

Yes answers to the following clinical findings places a child at increase caries risk
* Plaque
* Gingivitis
* Brown or white spot lesions
* Evidence of treated decay

Question 16

Interpreting Risk

Answer 16

Interpretation of caries risk is based on the balance of Risk Factors, Clinical Findings, and Protective Factors.
* The caries risk assessment tool helps to:
* Stratify children as low or high risk children for caries to inform clinical decision making.
* Determine need for routine vs. urgent referral
* Create self management goals with the families of young children.

Question 17

Balancing Risk & Prevention

Answer 17

Preventive strategies enhance protective factors and reduce pathologic factors. Disease can be halted and early lesions remineralized.

Caries & Demineralization
* Caries is a dynamic process involving many protective factors and pathologic factors.
* Teeth undergo cycles of demineralization and remineralization.
* To help prevent or reverse the caries process and tip the balance towards “no caries,” we can:
1. Delay the colonization of pathogenic bacteria by providing preventive care and treatment for mothers.
2. Limit demineralization by decreasing the frequency of dietary carbohydrate consumption.
3. Make teeth more resistant to acid through the use of fluoride.
4. Enhance remineralization through the use of fluoride systemically (water and oral supplements) or topically (toothpaste and varnish).

Question 18

Effects & Sources of Flouride

Answer 18

The use of fluoride, both through dietary and topical applications, has led to dramatic drops in caries rates.

How Does Fluoride Help Prevent Dental Caries?
Through topical mechanisms, the main effect, fluoride works by:
* Inhibiting tooth demineralization
* Enhancing remineralization
* Inhibiting bacterial metabolism

Through systemic mechanisms, the lesser effect, fluoride works by:
* Reducing enamel solubility through incorporation into its structure during tooth development

What Are the Primary Sources of Fluoride?
Topical Fluoride is the most beneficial and is obtained through:
* Fluoride toothpastes
* Gels, foams, mouthwashes
* Fluoride varnish

Systemic Fluoride is obtained through:
* Water fluoridation
* Dietary fluoride supplements

Question 19

Evidence of Flouride Benefit

Answer 19

There is strong evidence supporting many preventive interventions that can be implemented as part of primary medical care.

Question 20

Fluoride Recommendations

Answer 20

In May, 2014, the United States Preventive Services Task Force (USPSTF) issued new recommendations on fluoride use among primary care clinicians for children from birth through age 5 years. The Task Force found that the moderate potential benefits of fluoride varnish and fluoride supplementation outweigh the potential harm of fluorosis in children from birth through age 5 years. The American Academy of Pediatrics endorsed these recommendations.

Question 21

Fluorosis

Answer 21

Fluoride is a very safe and effective agent. However, care needs to be taken to minimize the risk of fluorosis. Chronic excessive fluoride exposure to developing teeth can cause white mottling of the tooth surfaces.
* Mainly a cosmetic effect

Prevalence & Risk Factors
* Prevalence of fluorosis (mostly mild or very mild) in the United States is 23% and rising.
* The risk of developing fluorosis is greatest at an intake of more than 0.06 milligram per kilogram of body weight per day.
* Varnish is not a major risk factor for fluorosis as it is an irregular source of fluoride when applied appropriately and as recommended two to four times per year.

Risk Reduction
* Determine the fluoride content of the child’s drinking water before prescribing supplements.
* Avoid duplicating fluoride prescriptions.
* Follow current dosage schedules for systemic fluoride supplementation.
* Advise appropriate amount of fluoride toothpaste use by age.
* Keep fluoride-containing products out of the reach of small children.

Question 22

Fluoride Varnish Benefits

Answer 22

• Safe, inexpensive, and effective
• Studies demonstrate 30-35% caries reduction
• Quickly and easily applied
• Children can eat and drink shortly after application
• Strengthens enamel and can stabilize and prevent progression of early caries (white spots) and slow enamel destruction in active ECC
• Not associated with treatment-related adverse events in young children
• Medicaid and many private insurers reimburse application by primary care clinicians in all states
• Varnish application can be easily integrated into medical practice

Question 23

Standard of Care

Answer 23

The United States Preventive Services Task Force (USPSTF) in 2014 recommended that primary care clinicians apply fluoride varnish to the teeth of all infants and children, starting with the appearance of the first primary tooth through age 5, at least every 6 months. USPSTF recommendations were reaffirmed in 2021
* Recommendation applies to ALL children; no longer a risk-based recommendation
* Assigned a “B” grade recommendation

• All children should receive a professional fluoride treatment at least every 6 months in the primary care medical home
• Higher risk children should receive fluoride varnish application every 3 months.
• Though helpful for reducing caries, varnish is not a replacement for appropriate diet, regular brushing, indicated systemic fluoride supplements, or routine dental care.

Question 24

Varnish Preparation

Answer 24

1. Assemble varnish, gauze, and good light source.
2. Place child in knee-to-knee position.
3. Check child’s mouth for:Hard tissue (tooth)
   Developmental defects
   White spots or cavities
   Oral hygiene statusSoft tissue pathology and submucosal cleft palate
4. Child may cry during examination.
5. If child does not open mouth, slide finger in buccal sulcus and apply gentle opening pressure.
6. Record findings.

Question 25

Varnish Selection

Answer 25

A variety of 0.25 ml 5% NaF unidose fluoride varnish preparations are commercially available in the United States. Pricing information is based on average costs when purchased through distributors and is subject to variation and may be less when purchased in bulk.

Each product and applicator system has its own unique advantages and disadvantages, and taste may vary. Smiles for Life authors, editor, and the Society of Teachers of Family Medicine do not endorse any particular product.

Note: Unidose fluoride preparations come in 0.25ml, 0.4ml, and 0.5 ml size. Clinicians should use the 0.25ml amount for preschool children.

Guidelines
* Unidose preparation recommended for safety
* Preschool children: 0.25 ml 5% Na F (2.26% F)
* Contains 5.6 mg fluoride
* Cost: $1.50–$3.00 USD per unidose

Question 26

Varnish Follow Up Guidance

Answer 26

Follow-up interval until the next fluoride varnish application should be determined by a child’s caries risk status and whether he or she has been able to establish a dental home. Record of the varnish application must be documented in the medical chart.

Inform the caregiver
* Child’s teeth may be discolored for 24–48 hours (only with yellow products), will be removed by thorough brushing.
* Avoid hot, sticky or hard foods for the rest of the day. Choose soft foods same day.

Provide anticipatory guidance:
* Emphasize the importance of regular oral hygiene practices.
* Offer dietary counseling regarding carbohydrate intake.
* Provide systemic fluoride prescription if appropriate.
* Arrange referral to dental home.

If varnish is applied for white spots or active decay:
* Provide intensive counseling on oral health (diet, hygiene, and systemic fluoride supplementation—if appropriate).
* Arrange urgent dental referral.
* Schedule next varnish application.

Question 27

Varnish Program Impelementation Tips

Answer 27

• Educate all staff, including front desk personnel, on caries risk assessment and the value of fluoride varnish.
• Train all clinicians on application procedures.
• Identify a varnish champion who answers questions, understands billing issues, assigns tasks, orders the varnish, and maintains supplies.
• Divide tasks among staff to avoid time burdens for one person.
• Store supplies in exam rooms or in a portable kit.
• CPT code effective January 2015 for fluoride varnish application is 99188. It is suggested to append a Z modifier for preventive services (e.g. Prophylactic fluoride administration Z29.3).
• Update billing forms with varnish code(s).
• Have copies of educational handouts preprinted to give to parents.

Question 28

Caries Dietary Counseling

Answer 28

For infants and older children, limit the number of eating and drinking occasions that contain sugar and refined carbohydrates.

Infants
* Strongly promote breastfeeding.
* 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 4 ounces per day at regular meal times.
* Avoid snacks that contain added sugar.
* Prepare healthy snacks such as cheese, fresh fruit, and vegetables.

Question 29

Toothbrushing/Toothpastes

Answer 29

Regular tooth brushing is important to remove plaque and food debris, and most importantly for distributing the fluoridated toothpaste.

Brushing Guidelines
* Brush twice daily beginning as soon as teeth emerge.
* Bedtime is most critical due to decreased salivary flow.
* Caregiver should brush child’s teeth until age 8 or 9, at least until they have developed the manual dexterity to write in cursive and tie their own shoes.
* Young children can not reliably spit and will swallow toothpaste. Children learn to expectorate well between age 3 and 5 years.
* Young children have difficulty adequately brushing all areas.
* Parents should continue to intermittently supervise brushing after children assume independence.
* Caregivers should place only a smear (under two years) or pea size dab (children over age 3) of fluoridated toothpaste on the child’s toothbrush.
* Caregiver should stand or sit behind child.
* Lift lip and brush along the gumline.
* Child should spit out, not rinse, after brushing to increase topical fluoride exposure.