1. Pediatric Oral Health: Dental Caries, Therapeutic Strategies, and Prevention
Erin A. Kierce, RDH, BA, MS, MPH
2017 Northeast Regional Nurse Practitioner Conference

2. Part I: Dental Caries Definition Etiology of Disease Risk Factors
Lesion Initiation & Cavitation
Risk Factors

3. A. Dental Caries Definition
Caries is a multi-factorial disease resulting from the interactions between a susceptible oral cavity, cariogenic bacteria, and cariogenic diets.
Development of dental disease:
Cariogenic bacteria, colonize a susceptible tooth, in the presence of carbohydrates
When we talk about dental disease, we need to first differentiate between dental caries and cavities. Dental caries is the transmissible, bacterial infection in the oral cavity, while cavities are the end result of that disease. Therefore, to restore a tooth, does not eliminate or “cure” the disease. If the same ingredients are still present and allowed to continue the process, more cavitation will occur over time. This is why we see children come back over and over again with new or recurrent lesions or cavitations, even after they just had work done 6 months before. So it is critical to break the interactions otherwise the cycle just gets repeated.
Caries is the interaction between specific cariogenic bacteria, fermentable carbohydrates, and a susceptible tooth surface. So remember the depiction of the layers of buildup, with the pellicle, then the biofilm, and then finally the plaque. The process of this interaction occurs at the interface between the enamel surface and the biofilm.

4. In order to understand dental caries, the chronic disease, we first need to acknowledge it as a process. Cavities are not the disease, but the outcome/result, of the disease.

6. ECC Definition
The American Academy of Pediatric Dentistry (AAPD) defines early childhood caries (ECC) as:
the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces (dmft) in any primary tooth in a child 71 months of age or younger.

7. Severe ECC (S-ECC) Definition
In children younger than 36 months of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC).
Unique pattern of caries development (eruption sequence)
From ages 36 months through 60 months, one or more cavitated teeth, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing or filled score of ≥4 (36 months), ≥5 (48 months), or ≥6 (60 months) surfaces constitutes S-ECC.

8. Prevalence of dental caries in primary teeth, by age and race and Hispanic origin among children aged 2–8 years: United States, 2011–2012 CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012.
Statistics
Most common chronic disease of childhood.

9. B. Etiology of Dental Disease

10. B. Etiology of Dental Disease
Enamel Pellicle and Biofilm
Immediately after eruption or thorough cleaning, the tooth surface is covered by an acquired enamel pellicle
Provides a base for the development of biofilm and plaque
Promotes enamel maturation
Within minutes after brushing or prophylaxis, the pellicle begins to form. It is primarily made of from glycoproteins from the saliva that are selectively absorbed by the hydroxyapatite of the enamel surface.
This discussion of disease etiology will first begin with the basics of biofilm and plaque formation. When teeth first erupt in the oral cavity, or immediately after a thorough brushing or prophylaxis, a layer forms over the teeth called the enamel pellicle. This protein-rich layer provides a base for bacterial adherence, allowing for the formation of biofilm and ultimately, plaque. The enamel pellicle also plays a significant role in the maturation of enamel. When enamel first erupts, the cellular structure is very porous and highly susceptible to acid dissolution, which we will talk about coming up. The pellicle protects the enamel structure by not only physically covering the pores, giving the hydroxyapatite crystals time to strengthen, but it also allows fluoride in the saliva and biofilm to absorb into the enamel, enhancing the maturation. This is why it is of utmost important to apply professional fluoride to the teeth of young children with newly erupted teeth.

11. Biofilm Formed in steps:
Matrix of multiple colonies of bacteria ( different species)
Formed in steps:
Pellicle formation
Bacterial colonization
Biofilm maturation
Function #1: Lubricates tooth surface for more efficient mastication
Function #2: Provide protection from demineralization and allow post-eruption enamel maturation (
Components within biofilm attempt to negate the effects of the by-products of bacterial metabolism
In contrast with the pellicle, dental biofilm is more dense, it is a matrix of multiple colonies of bacteria, it can be from different species. This biofilm adheres to the pellicle, teeth, calculus, and restorations. The biofilm is formed in a series of steps, pellicle formation, bacterial colonization, biofilm maturation.
During the first two days of the maturation process, S. mutans is already present and the dominate bacterial species. If this biofilm is left untouched for 2-3 weeks, gingivitis will begin to develop. But if the biofilm is removed, the gingiva will return to health within a few days.
When teeth first erupt, they are porous and the structure is susceptible to acid dissolution. Using components within the saliva (calcium, phosphate, fluoride), these substances become incorporated into the enamel structure. Application of topical fluoride to newly erupted teeth can reduce caries susceptibility.
The biofilm consists of multiple types of bacteria, both good and bad. Poor OH or certain feeding practices will favor the deleterious components within the biofilm and over time, is when you see the development of mature plaque.

13. Acquired Enamel Pellicle
Dental Biofilm
Mature Plaque
Within biofilm are cariogenic bacteria that ferment carbohydrates into acid
Here is a depiction of this process as it occurs over time. With certain patients, you can see the layers upon layers of mature plaque and how they build upon each other. The formation of mature plaque is complete in about a week.
This mature plaque is where the problem lies both with inducing gingivitis, aggressive periodontitis, and initializing dental caries. Within mature plaque, there are more than 800 species of bacteria, some beneficial, some deleterious. The good bacteria can actually inhibit the bad bacteria from proliferating, whether it be impacting their ability to replicate or attacking their cell walls. However, whether or no these bacteria are favored, is directly dependent upon the environment within he oral cavity. For example, a more acidic oral environment will favor the cariogenic bacteria and promote their growth. So now let’s focus on the specifics of disease etiology.
While more than 800 species of bacteria have been found in dental plaque, the four primary oral bacteria associated with the development and progression of caries is S. mutans, Lactobacilli, Streptococcus sobrinus, and Bifidobacteria.

14. Plaque on floss

15. Plaque on toothbrush bristle

19. Cariogenic Bacteria Streptococcus mutans Lactobacillus
***The early acquisition of S. mutans is a significant predictor in the development of ECC
Approximately 90% of children who acquire S. mutans by the age of 2, develop ECC
Lactobacillus
Streptococcus sobrinus

20. C. Risk Factors Behavioral Social Genetic Access to Care
Acquisition of S. mutans

21. Access to Care In 2015 (Massachusetts):
Approximately 50% of MA Medicaid-enrollees aged 1-21 (>355,000) did not have any dental care (no submissions to Mass Health).
Only 35% of MA dentists billed Medicaid for dental services.
Mass Health reimburses MA dentists 57.9% of commercial dental insurance fees.
As of January 2016, more than 500,000 Massachusetts residents lived in areas with a shortage of dentists.
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, Annual EPSDT Participation Report, Form CMS-416, (State) Fiscal Year:  
Participation calculated as a percent of professionally active dentists in Massachusetts. American Dental Association via Redi-Data via Kaiser Family Foundation, State Health Facts: Professionally Active Dentists (September 2014); Tracy Gilman, executive director, MassHealth, DentaQuest, via to The Pew Charitable Trusts (Jan. 22, 2016).

22. Tooth Susceptibility

25. Lesion Initiation and Cavitation
Process begins when sugar (sucrose) is made available to cariogenic bacteria
pH drops from 7.0 to 5.0 (pH at which enamel integrity is compromised) =demineralization begins
After time, pH is restored, remineralization begins
The integrity of the enamel is disrupted secondary to the formation of biofilm
The caries process occurs at the interface between the biofilm and enamel

26. The effects of demineralization can be reversed if,
there is adequate time between acid exposures to allow for remineralization of the enamel structure.

34. Part II: I. Therapeutic Strategies and Restorative Approaches
Preventive Modalities
Restorative Materials

35. Health determinants and a model of health
Biology and genetics
Individual behavior
Social environment
Physical environment
Health services
(CDC, 2014; US DHHS, 2009; WHO, 2015)
Determinants
Behaviors
Outcomes
Biology and genetics: sex and age
Social environment: discrimination, income, and gender;
Income and social status - higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.
Education – low education levels are linked with poor health, more stress and lower self-confidence.
Social support networks – greater support from families, friends and communities is linked to better health. Culture - customs and traditions, and the beliefs of the family and community all affect health.
Physical environment: where a person lives and crowding conditions; safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. Employment and working conditions – people in employment are healthier, particularly those who have more control over their working conditions
Health services: Access to quality health care and having or not having health insurance; access and use of services that prevent and treat disease influences health

36. A. Preventive Modalities for Initial Lesions
Fluoride
Enhances the absorption of calcium and phosphate present in biofilm into demineralized enamel
Fluoride absorption in bone and teeth decreases with age

37. Fluoride Varnish (5% NaF)

38. B. Restorative Therapy

39. Alternative Restorative Therapy
Silver diamine fluoride (SDF)
Silver diamine fluoride (SDF), an antimicrobial agent with remineralizing capabilities, has been utilized in Asia for decades as a medicament for caries arrestment. SDF (38% w/v Ag(NH3)2F, 30% w/w) is a topical solution comprised of % (w/v) silver and % fluoride. 

40. Part III: Prevention Risk Assessment/ CAMBRA Dental Home
Interprofessional Care
Education

42. A. Risk Assessment/ CAMBRA
Assessment, identification, and acknowledgement of each patient’s individual disease indicators, risk factors/behaviors, and protective factors to:
determine their risk of dental disease.
create a patient-specific approach to managing their disease.

43. Gives an understanding of the disease factors for a specific patient and aids in individualizing preventive discussions
Fosters the treatment of the disease process instead of treating the outcome of the disease

44. B. Dental Home Definition
“ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care, delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.” (AAPD, 2010)
AAPD, ADA, CDC, WHO recommend a dental home is established by one year of age

45. Dental Home
Comprehensive oral health care- acute care, preventive services
Individualized preventive dental health program based upon a caries risk assessment
Dietary counseling
Anticipatory guidance about growth and development

46. Dental Home
Kierce EA, Boyd LD, Rainchuso L, Palmer, CA, Rothman, A. Association between early childhood caries, feeding practices and an established dental home. J Dent Hyg. 2016;90(1):18-27.
Abstract
PURPOSE:
Early Childhood Caries (ECC) is a significant public health concern disproportionately affecting low-income children. The purpose of this study was to assess the association between the establishment of a dental home and ECC prevalence in a group of Medicaid-enrolled preschool children, and to explore feeding practices associated with an increased prevalence of ECC in Medicaid-enrolled preschool children with an established dental home was evaluated.
METHODS:
A cross-sectional survey was conducted among Medicaid-enrolled children (n=132) between 2 and 5 years of age with an established dental home and no dental home to compare feeding practices, parental knowledge of caries risk factors and oral health status.
RESULTS:
Children with an established dental home had lower rates of biofilm (p<0.05), gingivitis (p<0.05) and mean decayed, missing and filled teeth (DMFT) scores (p<0.05). Children with no dental home consumed more soda and juice (p<0.05) daily, and ate more sticky fruit snacks (p<0.05) than children with an established dental home. Establishment of a dental home had a strong protective effect on caries and DMFT index (odds ratio=0.22) in both univariate and confounding adjusted analyses.
CONCLUSION:
The results suggest establishment of a dental home, especially among high-risk, low-income populations, decreases the prevalence of ECC and reduces the practice of cariogenic feeding behaviors.

47. C. Interprofessional Care
Data:
99% of Medicaid-enrolled children had well-baby visits before age 1, compared to 2% who had a dental visit
89% of a group of children under age 1 had routine medical examinations, but of them only 1.5% had dental exam
Medical home/personnel play a substantial role in referring patients in a timely manner as well as the early identification of high-risk behaviors and communication of oral hygiene education and instruction and nutritional counseling
Hale KJ. American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003;111 (5 pt1):
Vargas CM, Ronzio CR. Disparities in early childhood caries. BMC Oral Health. 2006;6 Suppl 1:S3.

48. Interprofessional Care
AAP recommended interval of oral health risk assessments performed by medical providers:
6 months
9 months
18 months
24 months
30 months
3 years
6 years

49. Interprofessional Care
Smiles for Life
ECC Resource Center

50. D. Education Oral hygiene instructions (OHI)
Thoroughly brush 2x/day to remove plaque/dental biofilm
Flossing nightly to adequately remove interproximal plaque/dental biofilm
Recommend for parents to help with brushing and flossing until at least age 10
Allow older children to brush on their own in morning- promote autonomy

51. Education
Fluoride
Using fluoridated mouthwashes and dentifrices to incorporate fluoride into the saliva

52. Education Xylitol Reduce amount of dental plaque
Reduce S. mutans levels in plaque and saliva
Reduce acid production in plaque
Prevent vertical transmission of S. mutans from mothers to children

53. Education Nutritional Counseling Limit sugar exposure
1. Consume milk/juice/etc. at meals only
2. Discontinue bottle feeding by age 1
Discuss prolonged/on-demand nursing (recommend wiping child’s teeth with wet cloth after nursing)
3. Avoid putting a child to bed with milk/juice/etc. in either bottle or sippy cup
4. Avoid snacking throughout the day

54. It is not the
quantity or the quality of the exposure but the frequency that matters in increasing the risk of developing ECC.

55. Take Home Recommendations
Replace milk/juice with water in the bottle at night
When recommending discontinuation of bottle and pacifier, have caregiver focus on one first (bottle), pacifier after
If nighttime help with brushing and flossing is not ideal, encourage caregiver to ensure there is help 1x/day
For patients on nutritional supplements per the pediatrician, encourage water use immediately after consuming

56. The Four Pillars of Patient Care
Engage
Encourage
Empower
Educate

57. Case Study
Paige is a 3-year-old girl, brought to her pediatrician’s office by her mother for her yearly physical and immunizations.
Her mother has no concerns, but mentions that her sister (Paige’s aunt) is concerned about her teeth, saying that she (Paige)has cavities and should be seen by a dentist.
She also states that Paige’s grandmother informed her that “cavities are normal at this age and those teeth will just fall out anyway.”

58. Case Study
Social and Family History: Lives with mother and 5-year-old sister. Paige is a picky eater and drinks juice, water, or whole milk from a bottle.
She eats several snacks, such as gummies and raisins, between meals each day.
Paige’s sister has fillings in her teeth but Paige has not yet seen a dentist. Paige’s mother brushes Paige’s teeth sporadically and she is not sure if the toothpaste contains fluoride or not.
The family has Medicaid insurance.

60. Assessment Risk Factors Frequent bottle use
Frequent juice consumption, frequent snacking
Inconsistent oral hygiene, possibly lack of fluoride
No history of dental care
Medicaid-eligible
Clinical Findings
Marginal plaque
Facial gingiva slightly inflamed
Brown cavitations of tooth structure visible

61. Care Management
Dental referral; promote establishment of a dental home and communicate importance of maintaining regular care
Apply topical fluoride varnish
Education of mom on proper oral hygiene practices (including using fluoride toothpaste) and dietary habits following risk assessment

62. Questions? Thank you!

63. Kierce EA, Rainchuso L. A Comprehensive Approach to Dental Caries Management. Dimensions of Dental Hygiene. April 2017;15(4):48-51. 

64. References
Aas JA, Paster BJ, Stokes LN, et al. Defining the normal bacterial flora of the oral cavity. J Clin Microbiol. 2005;43(11):
American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Web site. Updated Accessed September, 2016.
American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Unique challenges and management options. Web site. Updated Accessed November 17, 2016.
Arora A, Scott JA, Bhole S, et al. Early childhood feeding practices and dental caries in preschool children: A multi-centre birth cohort study. BMC Public Health. 2011;11:28.
Arrow P KE. Minimum intervention dentistry approach to managing early childhood caries: A randomized control trial. Community Dent Oral Epidemiol. 2015;43:
Caufield PW, Li Y, Dasanayake A. Dental caries: An infectious and transmissible disease. Compend Contin Educ Dent. 2005;26(5 Suppl 1):10-16.
Edelstein BL NM. Chronic disease management strategies of early childhood caries: Support from the medical and dental literature. Pediatr Dent. 2015;37:
Featherstone JD, Domejean-Orliaguet S, Jenson L, et al. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10):
Foster T, Perinpanayagam H, Pfaffenbach A, et al. Recurrence of early childhood caries after comprehensive treatment with general anesthesia and follow-up. J Dent Child (Chic). 2006;73(1):25-30.
Hale KJ. American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003;111 (5 pt1):
Kagihara LE, Niederhauser VP, Stark M. Assessment, management, and prevention of early childhood caries. J Am Acad Nurse Pract. 2009;21(1):1-10.

65. References
Kawashita Y, Kitamura M, Saito T. Early childhood caries. Int J Dent. 2011;2011:
Kierce EA, Boyd LD, Rainchuso L, et al. Association between early childhood caries, feeding practices and an established dental home. J Dent Hyg. 2016;90(1):18-27.
Mobley C, Marshall TA, Milgrom P, et al. The contribution of dietary factors to dental caries and disparities in caries. Acad Pediatr. 2009;9(6):
Nunn ME, Braunstein NS, Krall Kaye EA, et al. Healthy eating index is a predictor of early childhood caries. J Dent Res. 2009;88(4):
Nunn ME, Dietrich T, Singh HK, et al. Prevalence of early childhood caries among very young urban boston children compared with US children. J Public Health Dent. 2009;69(3):
Oliveira AF, Chaves AM, Rosenblatt A. The influence of enamel defects on the development of early childhood caries in a population with low socioeconomic status: A longitudinal study. Caries Res. 2006;40(4):
Palmer CA, Kent R,Jr, Loo CY, et al. Diet and caries-associated bacteria in severe early childhood caries. J Dent Res. 2010;89(11):
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Vargas CM, Ronzio CR. Disparities in early childhood caries. BMC Oral Health. 2006;6 Suppl 1:S3.
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