Prevention/Anticipatory Guidance Flashcards
Definition of anticipatory guidance
To provide developmentally relevant information about a child’s health to help prepare parents for milestones in the future
Definition of dental caries
Chemical dissolution of tooth surface caused by metabolic events in the biofilm covering the affected area
Contributing factors to caries
Oral hygiene Diet Microbiology Fluoride Genetics (immune, enamel, saliva) Environmental factors
Keyes Triad
Host and teeth
Microflora
Substrate (diet)
Very simplistic approach
Koch’s Postulates
Describes requirements for a microorganisms to be considered in an etiologic agent for disease
Found in all cases of disease
Organism should be grown on artificial media for several subcultures
Pure subculture should produce disease in susceptible animal
Not able to be done in caries
-many confounders (behavior, education, SES, genetics, etc.)
Specific Plaque Hypothesis
Only certain species of bacteria are involved in caries process
Nonspecific Plaque Hypothesis
All plaque/bacteria are pathogenic
Ecological Plaque Hypothesis
Shifts in pH of biofilm cause a shift toward cariogenic bacteria (S mutans) in the balance of resident oral flora, resulting in dsease
Extended Caries Ecological Hypothesis
Dental plaque as a dynamic microbial ecosystem in which non-mutans bacteria are key players for maintaining dynamic stability
Low pH environments can stimulate non-mutans bacteria to be more acidogenic
Variety of bacteria that are acid-producing, not just S mutans
Given the right environment, even the good bacteria can cause demineralization and destruction of tooth surface
Composition of enamel
95% hydroxyapatite
- 5% water
- 5% organic matrix
Calcium phosphate crystals make up 99% of dry weight
Active vs inactive carious lesion
Active lesions: white, opaque, rough
Inactive lesions: smooth, hard
White Spot Lesion
Intact surface zone: 20-50um
Body of lesion - pore volume > 5%
Dark zone - pore volume 2-5%
Translucent zone - advancing front of lesion
Dentin reaction to caries
Vital tissue that reacts to external insults
Most common reaction to caries progression is tubular sclerosis and occlusion of dentin
Pulp-dentin reactions
Histologically early signs of tubular sclerosis can be seen before the enamel lesion reaches the DEJ
Dentin demineralization does not extend laterally beyond contact area with enamel lesion
Reactionary dentin may form before dentin is invaded by bacteria
Biofilm
Necessary but not sufficient to cause disease
Microbial biofilm on teeth is prerequisite of caries lesions
Primary route of transmission of caries
Saliva
Vertical transmission from mother
Early colonizers of bacteria
S. Mitis
S. Salivarius
S. Oralis
Prior to tooth eruption, these bacteria are transient, usually on gingival tissues
Acquired pellicle formation
Acellular, proteinaceous film that forms on teeth within minutes after cleaning
Composed of salivary glycoproteins, phosphoproteins, lipids and components from gingival crevicular fluid
1 micron thick
Critical role in bacterial colonization
Facilitates remineralization by maintaining calcium and phosphate
Microbial succession
Early bacteria create environment either favorable to others or unfavorable to themselves
Gradual replacement with other species who are better suited to modified environment
Microbial hemostasis is a state of equilibrium between microflora and local environment
Disruption can result in disease
Characteristics of cariogenic bacteria
Rapid transport and conversion of sugars to acid
Ability to maintain metabolism under extreme conditions like low pH
Production of extracellular polysaccharides such as glucans that shift to acidic
Acid producing cocci and rods
SECC bacteria
More anaerobic cultures found
S sanguinis generates alkali from arginine and decreases cariogenicity of acidogenic bacteria
Window of Infectivity
Between 19-31 months of age
Window appears to close after all primary teeth erupt
Once stable plaque or biofilm covers tooth surface, MS is less likely to be established
2nd window of infectivity at 6 years when 1st molars erupt
Transmission of caries
Vertical: parent to child (most often from mother)
Horizontal: spouses
Factors affecting acquisition of MS
Erupted teeth
Presence of hypoplasia
Diet high in fermentable carbohydrates
Antibiotic intake (?) - conflicting results
Stephan Curve
Curve that shows the pH drop after sucrose intake
Shows time below 5.5 pH where demin is occurring
Takes up to 30 minutes to buffer back to neutral
Why frequency is important
Critical pH
Varies depending on total calcium and phosphate concentration in saliva
Average 5.5 for hydroxyapatite
Average 4.5 for fluorapatite
Low concentrations of calcium and phosphate can increase the critical pH as high as 7 in some people
Remineralization
Saliva acts as source for calcium and phosphate that helps in maintaining supersaturation with respect to tooth minerals
When saliva is stimulated, rapid rise in pH occurs, calcium phosphate and glycoprotein called salivary precipitin is formed - complex readily incorporated into dental plaque
Fluorapatite
Fluorapatite has higher pH for dissolution
Displacement of hydroxide with fluoride removes a weakness of hydroxyapatite to lactic acid
Overview of Fluoride
Fluorine = most electronegative element
Fluoride is widespread in nature (water, milk, vegetables)
NaF= sodium fluoride SnF2 = stannous fluodie Na2PFO3 = sodium monofluorophosphate (MFP)
Does fluoride cross the placenta?
Most does not cross
No evidence that prenatal fluoride supplements taken by women during pregnancy are effective in preventing dental caries in offspring
Fluorosis and infant formula
Clinicians should consider potential fluoride exposure to infants when fluoridated water is used to reconstitute infant formula
1ppm = 1mg/L
Ex: if baby drinks 2.5oz/lb/day, 10lb baby drinks 25oz or 3 cups per day
-if powdered reconstituted with fluoridated water, 0.64-1.07ppm = 0.72mg F
Mechanism of Fluoride
Frequent exposure to topical fluoride is more effective in caries prevention than fluoride that is incorporated into enamel through systemic exposure during tooth development
Main mechanism = enhance remineralization and inhibit demineralization (topical)
Systemic effect (increase crystallinity of enamel) is minor
Antimicrobial effect is minor
Fluoride in toothpaste
Sodium fluoride dentifrice offers greater cariostatic activity than MFP
Increased fluoride concentration leads to increased cariostatic activity
Fluorosis
Permanent, intrinsic stain caused by excessive fluoride during tooth development
Usually white, but can be brown/orange
Severe cases damage tooth enamel
Directly related to total fluoride ingested during tooth development
Permanent maxillary molars most susceptible during first 3 years of life
Can affect both dentitions
Community water fluoridation
0.7ppm
Used to be 0.7-1.2ppm but changed in 2015
Goal is to maintain anti-caries effect but minimize risk of fluorosis
Amount of fluoride in regular toothpaste
1000ppm
Fluoride mouthrinse
Provides moderate dose (226mg/L) fluoride topically on daily basis for those using it
Effective and available OTC
Not for young children
Professionally applied fluoride gels
High dose (12,400pmp) of fluoride 1-2 times per year
Contraindicated in younger children due to ingestion control concerns
Frequent use is impractical and expensive
Professionally applied fluoride varnish
High dose (22,500ppm) of fluoride several times per year
Effective under providers’ control and locally retained for several hours
Small amount used, less ingestion
Dietary fluoride supplements
Provides moderate dose (0.25-1mg per tab) on daily basis
Designed to take place of fluoridated water
Indicated if child not living in fluoridated community
Halo effect
People in non-fluoridated areas receive fluoride from foods and beverages processed in fluoridated areas
Very difficult to perform research comparing effects of water fluoridation and non-fluoridation
Fluoride toxicity
Toxic effects at 5mg/kg body weight
Lethal dose: 15mg/kg
Fluoride in toothpaste (g)
1gm: full brush size amount of toothpaste
0. 25mg: pea size
0. 125mg: smear (less than 3 years)
Fluoride supplements for 0-6 month old
None
Fluoride supplements for 6months - 3 year old
If water fluoride is <0.3ppm, 0.25mg
If water fluoride is >0.3ppm, none
Fluoride supplements for 3-6 year olds
If water fluoride is <0.3ppm, 0.5mg
If water fluoride is 0.3-0.6ppm, 0.25mg
If water fluoride is >0.6ppm, none
Fluoride supplements for 6+ year old
If water fluoride is <0.3ppm, 1mg
If water fluoride is 0.3-0.6ppm, give 0.5mg
If water fluoride is >0.6ppm, none
Indications for fluoride supplements
Only for those at very high risk for dental caries with deficient water fluoridation
Must determine all sources of fluoride
Sodium fluoride calculations
Fluoride toothpaste at 0.243% fluoride = 0.1215% fluoride ion
0.1215% fluoride ion = 1215ppm
?
Caries risk assessment - risk indicators
Factors that have been associated with risk of caries - modifiable
Poor oral hygiene Inadequate fluoride exposure Frequency of between meal carbohydrate snacks Inadequate saliva (drug use) Recreational drug use Radiation therapy
Caries risk assessment - risk factors
Part of causal chain or expose host to causal chain
Genetic component to caries, susceptibility and resistance
Demographic factors
Factors that predict future caries
Demineralized or cavitated lesions
Stained occlusal pits or fissures
Indicies for caries
DMFS index does not establish if lesion is active or not
Development of technology to detect and quantify early caries lesions and directly assess caries lesion status may prove to be best way to identify patients that require intensive prevention intervention
Caries Management
Relies on assessment of risk Classification of lesions Intervention Documentation of intervention provided Measurement of outcomes of care
Caries risk assessment tools
AAPD
ADA
CAMBRA
Disease indicators
WSL
Cavities
Restorations
Protective factors for caries
Exposure to topical fluorides
Xylitol
MI paste
Antimicrobial rinse
Fluoride varnish
Concentrated topical fluoride (NaF 5%)
Sets in contact with saliva
Well-tolerated by infants and children
Minimal risk for ingestion
Should be high priority for children with developmental disabilities
Apply 2-3 times per year depending on caries risk
MI paste
No significant difference between enamel lesions in subjects versus controls after 12 months with using fluoride toothpaste, MIP paste and MI varnish quarterly
Better than no fluoride, but not better than fluoride (could be alternative for fluoride resistant parents)
Xylitol
Requires frequent high doses to be effective
May reduce mother-child transmission of MS
Silver Diamine Fluoride
24.4-28.8% w/v silver + 5-5.9% fluoride (44,800ppm)
Ammonia and silver fluoride combine to form a diamine silver ion complex
pH of 10
Silver = antimicrobial and inhibits enzymes that break down dentin organic matrix
Fluoride = remineralization of lesion
FDA and SDF
FDA approval for SDF for dentin sensitivity
Used off label for caries arrest
SDF side effects
Metallic taste
Black staining
Transient gingival irritation
Stains clothes, skin, floor, etc.
No major adverse effects or systemic illness
Indications for SDF
High caries risk Behavioral/medical management issues Dentin hypersensitivity Caries stabilization Xerostomia from cancer/medications Difficult to treat caries lesions Patients with dental phobia Patients with limited access to restorative services Physical or cognitive disability Very young/very old
Contraindications for SDF
Silver allergy
Ulcerative gingivitis/stomatitis
Abscessed tooth needing extraction
Irreversible pulpitis
Advantages of silver solutions
Controls pain by arresting caries Affordable Procedure is fast Minimal support in staff or equipment required Non-invasive and safe
Maternal Nutrition
Linear enamel hypoplasia in primary incisors is more common in malnourished children
Caused by disruption during appositional stage of enamel formation in neonatal period
Most common in middle third of maxillary central incisor and incisal third of lateral incisor
Enamel Hypoplasia
Quantitative defect of enamel formation
Caused by variety of stresses during tooth development
Neonatal line is present in almost all children either clinically or subclinically
Enamel hypoplasia in primary incisors
Correlated with poor prenatal care in first trimester Premature labor or birth Greater pre-pregnancy weight of mother Postnatal measles infection Maternal smoking
Enamel hypoplasia in permanent teeth
Localized (trauma, intubation, irradiation)
Postnatal (otitis media, other conditions)
Vitamin D
Essential for proper bone and tooth formation
Regulates serotonin synthesis in brain
400 IU/day recommended in all infants from birth to 12 months
Beyond 12 months, 600 IU/day recommended
Calcium
Works with Vitamin D for mineralization of bones and teeth
Needed for nerve and muscle activity
Intake of 500mg/day during childhood and adolescence
Deficiency: most common in children with restricted diets
Food security
Access by all people at all times to enough food for an active and healthy life
Food insecurity is limited or uncertain access to adequate food for a healthy life
Undernutrition
Insufficient ingestion of essential nutrients
Failure to thrive in infants
Marasmus: severe wasting
Kwashiorkor: adequate calories but inadequate protein
Zinc
Important for immune function
Severe deficiency in US is uncommon but can lead to stunted growth, altered immune response, xerostomia, poor appetite
Zinc and iron supplementation should be staggered - interfere with each other’s absorption
Overnutrition
Result = obesity and/or diabetes type II
BMI: overweight is 85-95%, obese > 95%
Sugar consumption
WHO recommendation that no more than 10% of adult’s calories (ideally less than 5%) come from added or natural sugars
Children and adolescents in US obtain 16% of total caloric intake from added sugars alone
Vipeholm Study
Institutionalized adults
Compared types of sugar consumption - sucrose, bread, chocolate, caramel, sticky toffee
Stickiness, clearance time, and frequency increase caries risk
Turku Sugar Study
Compared fructose, sucrose, xylitol
Xylitol was acceptable for human consumption and showed dramatic reduction in caries incidence after 2 years
Feeding Infants
No bottles in bed No sweetener on pacifier Introduce cup by 6 months Avoid cariogenic foods/beverages between meals No sweetened beverages Avoid introducing juice
Feeding Toddlers
Avoid excessive juice Discontinue bottle by 12 months Avoid unrestricted use of sippy cup Avoid cariogenic snacks between meals Avoid candy, soda, etc.
AAP Juice Recommendations
0-1: no juice
1-3 years: limit to <4oz/day with snack or meal
3-6 years: <6oz/day with snack or meal
7-12 years: limit to 8oz daily
Grapefruit juice
Should be avoided by any child taking medication metabolized by CYP3A4
Decreases P450 enzymes
Leads to increase levels of drugs and side effects
Ex: cyclosporine, tacrolimus, others
Adolescent Oral Health
Unique needs High caries rate Traumatic injury and periodontal disease Poor nutrition Esthetic desire/awareness Complex ortho/restorative needs Dental phobia Risky behaviors Pregnancy Eating disorders Unique social/psychological needs
Oral findings of anemia
Angular cheilitis
Atrophic glossitis
Iron, B12 or folate deficiency can result in anemia
Leukemia oral findings
May present with paleness of oral mucosa, gingival bleeding, oral petechiae, painless gingival hyperplasia
Be concerned about spontaneous gingival bleeding in absence of plaque, caries, calculus or trauma
Oral manifestations can be presenting clinical signs, especially in AML
Langerhan’s Cell Histiocytosis oral findings
Alveolar bone invasion by histiocytes commonly occurs in the mandible
Can result in pain, loose teeth, fractures
X-ray appearance of teeth “floating in space” due to radiolucent areas in bone
Precocious eruption or exfoliation of primary teeth
Can also cause gingivitis and oral ulcers
Inflammatory Bowel Disease oral findings
8-10% of cases of Crohn’s have oral manifestations that may precede GI involvement
Aphthous ulcers and angular cheilitis found in Crohn’s disease and ulcerative colitis (IBD ulcers are painful)
Cobblestoning or mucosal modularity of buccal mucosa and gingiva indicative of Crohn’s
Diabetes oral findings
Poorly controlled diabetes increases periodontal attachment loss
Xerostomia = increased caries risk
Increased risk for candidiasis
Bulimia Oral findings
Enamel erosion, especially lingual surfaces of maxillary incisors
Increased risk for caries and gingivitis
Patients should rinse mouth with water with baking soda or fluoride mouth rinse (don’t brush for 30-60min)
Counsel to avoid acidic drinks
Need to be referred for medical/psychological evaluation
AAPD Policy on Tobacco Use
90% of smokers started by age 18
6.7% of middle school students and 23% of high school students used tobacco products in 2012
Decrease in cigarettes, smokeless tobacco
Increase in cigarillos, E cigarettes
5 As of tobacco cessation
Ask (ask if they are smoking) Advise (tell them to stop) Assess (see if they are ready) Assist (help them) Arrange (follow up)
Pharmacological tobacco cessation strategies
Nicotine replacement therapies - best if used along with behavioral treatment
Bupropion and Varenicline tartrate prescription drugs
E-Cigarettes
5mL vial contains 100mg of nicotine
Lethal dose of nicotine is 10mg for children, 30-60mg for adults
Most e-cigs have a battery, heating element, and a place to hold liquid
Ingredients of E-cigarettes
Nicotine
Ultrafine particles
Formaldehyde
Other carcinogens
Concerns of e-cigs with children?
Gateway drug for cigarettes
Youth use is associated with appealing flavors
Substance Use Disorder
A maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to repeated use of substance
Signs of Substance Use Disorder
Changes in behavior
Emotional or mental changes
Physical changes
Dental findings of substance abuse
Excessive tooth decay Malnourished appearance Unreliability in keeping appointments Excessive tooth wear from grinding/clenching Xerostomia Hypersensitive teeth
Most common drug used by teens
Alcohol
Adolescents and confidentiality
Each state varies to what age an adolescent can make their own decisions and when parents can or should be told
Can call the pediatrician and ask their advice
When to transition care for adult patients
Have a clear policy and give patients information with enough time to find a general dentist for care
Consider a different timeframe for patients with SHCN
