1. Smiles for Life Smiles for Life A National Oral Health Curriculum Second Edition Module 6(b) Fluoride Varnish: State Training Copyright STFM 2005-2008 December 2008

2. Smiles for Life Steering Committee Alan B. Douglass, M.D. (Editor and Group Co-Chair) Middlesex Hospital, University of Connecticut Mark E. Deutchman, M.D. University of Colorado Wanda C. Gonsalves, M.D. Medical University of South Carolina Russell Maier, M.D. (Group Co-Chair) University of Washington Hugh Silk, M.D. University of Massachusetts James Tysinger, Ph.D. University of Texas Medical Branch, San Antonio A. Stevens Wrightson, M.D. University of Kentucky 2

3. Smiles for Life Funders Delta Dental of Kentucky DELTA DENTAL OF COLORADO FOUNDATION T HE H EALTH F OUNDATION OF CENTRAL MASSACHUSETTS, INC. Connecticut Health Foundation Oral Health Foundation A DSM INITIATIVE Washington Dental Service Foundation Community Advocates for Oral Health 3

4. Smiles for Life Curriculum Overview ACGME formatted educational objectives 7 annotated 50 minute PowerPoint modules 1.The relationship of oral to systemic health 2.Child oral health 3.Adult oral health 4.Acute dental problems 5.Oral health in pregnancy 6.Fluoride varnish 6(b) Fluoride varnish: State Training 7.The oral examination Test questions Resources for further learning 4

5. Smiles for Life The materials in this module were originally developed in part by: Washington Interdisciplinary Oral Health Project (ICOHP) Univ. Texas Health Science Center San Antonio Project Smile Washington Dental Services Foundation University of Connecticut Schools of Medicine and Dental Medicine Steering group editors for Module 8 Hugh Silk, M.D. Russell Maier, M.D. Wanda C. Gonsalves, 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. Acknowledgements 5

6. Smiles for Life Educational Objectives 1. Discuss the etiology of early childhood caries (ECC) 2. Assess a child’s risk of developing ECC 3. Recognize the various stages of ECC on oral exam 4. Discuss the mechanism of action of topical fluoride 5. Describe the benefits and indications for fluoride varnish 6. Demonstrate the application of fluoride varnish 7. Offer parents advice for caries prevention, referral 8.Describe strategies for a successful office-based fluoride varnish program 6

7. Smiles for Life Early Childhood Caries A Brief Review 7

8. Smiles for Life 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

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

10. Smiles for Life ECC Risk Assessment 10

11. Smiles for Life 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

12. Smiles for Life 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

13. Smiles for Life ECC Recognition Photo: Joanna Douglass BDS DDS

14. Smiles for Life 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

15. Smiles for Life Healthy Teeth Photos: Joanna Douglass BDS DDS 15

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

17. Smiles for Life Early Aggressive ECC Photos: Joanna Douglass BDS DDS 18

18. Smiles for Life Fluoride 20

19. Smiles for Life Ongoing Balance No caries Caries Protective Factors Salivary flow Fluoride Pathologic Factors mutans strep Carbohydrates Reduced salivary flow 21

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

21. Smiles for Life Sources of Fluoride Systemic  Water fluoridation  Fluoride supplements Topical  Fluoride toothpastes  Gels, foams, mouthwashes  Fluoride varnish 24

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

23. Smiles for Life Evidence of Benefit for Fluoride 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) 26

24. Smiles for Life Fluoride Varnish 27

25. Smiles for Life 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

26. Efficacy in Preschool Children StudyCountry% Caries Decrease Holm 1979Sweden44 Grodzka et al. 1982Poland10 Clark et al. 1985Canada9 Petersson et al. 1998Sweden7 Frostell et al. 1991Sweden37 Twetman et al. 1996Sweden30 Weintraub et al 2006US50 29

27. Smiles for Life 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

28. Available Preparations 0.25ml unidose 5% NaF (2.26% F) CavityShield OMNII $1.00 per dose Duraflor Medicom $1.00 per dose Enamel Pro Varnish Primier $1.60 per dose 31 Flor-Opal Ultradent $2.00 per dose All Solutions Dentsply $1.60 per dose

29. Smiles for Life 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

30. Smiles for Life 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 30

31. Smiles for Life 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 31

32. Smiles for Life 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 32

33. Smiles for Life Fluoride Supplementation Advice 33 Dosages are in milligrams F/day 6 mos – 3 yrs0.25 mgNoneNone 3 yrs – 6 yrs0.50 mg0.25 mgNone > 6 years1.00 mg0.50 mgNone 0.6 ppm ppm Water Fluoride Concentration Child’s Age

34. Smiles for Life Age 1 Dental Visit Referral The American Academy of Pediatric Dentistry recommends a dental evaluation by the 1 st birthday The American Academy of Pediatrics recommends establishment of a dental home by the 1 st birthday for children at high risk If limited dental access, clinician assumes responsibility for screening and guidance 34

35. Smiles for Life Applying Fluoride Varnish 34

36. Smiles for Life Clinical Case Melissa is 3 years old and new to your un- fluoridated community. At a well child visit Mom tells you that a dentist has never examined Melissa’s teeth and her daughter does not take fluoride supplements. On exam you note 2 small “white spots.” You decide to apply fluoride varnish. What steps would you take next? 35

37. Smiles for Life Applying Fluoride Varnish: Step 1 Assemble the required supplies: – Varnish – Toothbrush – Gauze 36

38. Smiles for Life Applying Fluoride Varnish: Step 2 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 Photos: ICOHP 37

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

40. Smiles for Life Applying Fluoride Varnish: Step 4 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 Photos: ICOHP 39

41. Smiles for Life Applying Fluoride Varnish: Step 5 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 40 Photo: ICOHP

42. Smiles for Life Fluoride Varnish Application Video Play Video Now (separate application)

43. Smiles for Life Fluorosis and the Safety of Fluoride Varnish 41

44. Smiles for Life Fluorosis 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% Photos: John McDowell DDS, Joanna M. Douglass BDS DDS 42

45. Smiles for Life Reducing the Risk of Fluorosis 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 43

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

47. Smiles for Life In certain circumstances States with Medicaid Funding for Physician Oral Health Screening and Fluoride Varnish Medicaid coverage approved Considering Source AAP 45

48. Smiles for Life Office-based Fluoride Varnish Tips Establish buy-in from ALL staff Train all providers – MD/DOs, NPs, RNs, (MAs) Assign 1 person to be varnish champion Use a one page/screen document form Divide tasks – RN do screen; MD apply varnish; front staff set up dental referral Keep supplies in exam rooms or in a portable kit Update billing forms with varnish code(s) Have copies of patient handouts pre-printed

49. Smiles for Life 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 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 46

50. Smiles for Life Questions? Complete post-test now and submit by email through website to receive proof of training 47

51. Smiles for Life Post-Module Assessment 1.What is the etiology of ECC? 2.What factors impact a child’s risk of developing ECC? 3.What does ECC look like? 4.How would you assess a child’s ability to benefit from fluoride varnish? 5.What is topical fluoride’s mechanism of action? 6.What steps are used to apply varnish? 7.What is fluorosis, and how can you prevent it? 8.What topics should be covered at a fluoride varnish visit to promote prevention? 9.Who should be referred to a dentist? 10.What steps should be taken to ensure success of a fluoride varnish program in your office? 48