1. Caries Risk Assessment and Disease Prevention
Thuan Le, DDS, PhD
Associate Professor of Clinical Pediatric Dentistry
University of California, San Francisco
4/1/2019
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2. Objectives
Inspire medical and dental personnel to evaluate oral health status in infants and young children.
Be able to assess caries risk and to individualize interventions and recall.
Demonstrate key elements addressed in the knee-to-knee encounter.
Promote the use of fluorides and dental sealants.
Understand and promote the use of early intervention techniques.
Understand motivational interviewing and goal setting.
Promote healthy daily family behaviors for optimal oral health.
Our goal today, in addition to meeting the specific learning objectives for the course, is to spark a commitment from each and every one of you to work towards improving the health of California children.
The purpose of this course is to encourage dental teams to provide oral health assessments, and simple interventions to prevent Early Childhood Caries or tooth decay among children ages birth to 5.

3. You too can see young children and learn to do a Caries Risk Assessment!

4. Early Childhood Caries (ECC)
Any tooth decay, including extractions and fillings from previous decay, in the primary dentition.
Let’s take a look at what ECC is, how it affects children and their families, and the magnitude of the problem here in California.
What is Early Childhood Caries, or ECC? The American Academy of Pediatric Dentistry defines ECC as one or more decayed, missing, or filled tooth surface in any primary tooth in a child 71 months or younger. In this definition, “decayed” includes incipient or cavitated lesions and “missing” refers to teeth lost due to caries.

5. Severe Early Childhood Caries (S-ECC)
Distinctive pattern of tooth decay that begins on upper primary teeth.
Rapidly progressing to other teeth as they erupt.
Severe ECC is characterized by a distinctive pattern of tooth decay in infants and young children, often beginning on the maxillary anterior teeth and rapidly progressing to the other primary teeth as they erupt. ECC can begin to develop as soon as teeth erupt into the mouth at 6-10 months of age, which is why an early oral health assessment is so important.

6. Early Childhood Caries (ECC) in California
California’s children fall well below the nation in oral health.
About 1/3 of preschoolers and almost 70% of children in grades K-3 have experienced tooth decay.
Data from the 2006 California Smile Survey showed that California’s children have poorer oral health than children living in most other states. Over 70% of school children by grade three have experienced tooth decay. While ECC is more prevalent in low-income families and certain cultures, it can happen in any family!
Data from the 2006 California Smile Survey

7. We must treat the infection!
Treatment of ECC
40-50% of children treated with severe ECC have new decay within months.
Restorations alone do not solve the problem.
We must treat the infection!
Is traditional treatment effective?
Once the disease is established and caries penetrate to dentin and beyond, restorative care is essential. Close monitoring for follow-up care is needed. Unless there is follow through using contemporary preventive education and other strategies, various studies have shown that 40-50% of children treated for ECC have recurrent decay within 4-12 months. With only traditional treatment and no preventive follow-up, the disease rages on.

8. Primary teeth are important!
Eating and Nutrition
Holding Space
Talking
Smiling!
We want to dispel the myth among families that baby teeth are not important. The primary teeth are important for several reasons:
Eating
Talking
Holding space for the permanent teeth
And smiling, which contributes to increased self-esteem.

9. White Spot Lesions
The first visible sign of tooth decay is decalcification.
Reversible!
The first visible sign of tooth decay or demineralization is a chalky “white spot” lesion that is reversible. The reversal of the process is remineralization, which happens when the tooth heals from the calcium and phosphate provided by saliva. This natural tooth repair is enhanced by fluoride if it is present in the mouth, and the renewed fluoride enhanced mineral is more resistant than before to acid from the bacteria. The process of demineralization and remineralization is going on in most of our mouths as part of our daily eating, snacking and oral hygiene activities.
It is important to rethink the way we “treat” dental caries. Most lesions do not need to be restored until they have penetrated through the enamel into the dentin. Lesions contained in the enamel can be reversed with a combination of fluoride and home care

10. ECC can be prevented.
Interventions with pregnant women and mothers of infants.
Interventions with babies and young children.
Through interventions with pregnant women and young children, we can both prevent ECC and provide early intervention for those children who already have the disease. This course will focus on what can be done with young children and their families.

11. Ways to Prevent ECC Water Fluoridation Application of Fluoride Varnish
Sealants on primary teeth
Daily brushing with fluoride toothpaste
Dietary changes
Ways to prevent ECC include the promotion of water fluoridation, application of fluoride varnish, sealing the primary teeth, daily brushing with fluoride toothpaste, and dietary interventions.
While fluoride hasn’t wiped out tooth decay, it is a key factor in the prevention and reduction of tooth decay. Fluoride works by inhibiting demineralization, enhancing remineralization, and inhibiting plaque bacteria.
Fluoride toothpaste is effective at preventing dental caries and daily use should be encouraged for all babies and young children, beginning soon after the first tooth erupts. A small smear is the recommended amount, administered by wiping it around the teeth with a soft toothbrush, finger tender or soft cloth

12. Fluoride Varnish Easily applied topical fluoride treatment
Safe for babies and young children
Fluoride varnish is a highly-concentrated fluoride product that is both safe and beneficial for use with high-risk babies and young children.
Fluoride varnish can be used 3 times in a two-week period for remineralization of white spot lesions. For more general prevention purposes, it can be applied 3-4 times a year.

13. Dental Sealants
Dental sealants have proven to be one of the most effective ways to prevent caries in the permanent teeth of children. Because of its additional protective qualities, using a glass ionomer product is optimal.
Note: Some sources suggest considering placing sealants to prevent tooth decay on the primary molars of high-risk children. The California Denti-Cal program does not include this as a covered benefit.

14. Dietary Counseling Limit sugary foods and drinks.
Limit simple carbohydrates like white crackers.
Need to limit both frequency and total sugar intake.
Encourage drinking water and fresh fruit and vegetable snacks.
What about diet? It is important that medical and dental teams talk with families about limiting the frequency of ingestion of simple carbohydrates, including sugary foods and drinks, and foods like white crackers and potato chips. As you already know, it is the frequency of fermentable carbohydrate intake that contributes to dental caries. It is also important is encourage health promoting alternatives, such as drinking water and eating fresh fruit and vegetable snacks

15. Limit Total Sugar Intake
Dentistry does not practice in a vacuum.
Increased obesity and diabetes type II among children requires limiting both frequency and total sugar intake.
With increased obesity and diabetes among California children, we have a responsibility to counsel families to limit both total sugar intake and the frequency of exposures per day to enhance both general overall health as well as oral health.

16. Weaning Recommend using a cup at 6 months of age.
Consider weaning at months of age.
Don’t let baby sleep with the bottle or walk around with a bottle or sippy cup all day.
Furthermore, children should begin using a cup at 6 months of age and parents should consider weaning from the bottle at months of age, transitioning to an open cup that isn’t easily carried around all day. It is important to counsel families not to let their babies sleep with a bottle or Sippy cup because this greatly increases the exposure to carbohydrates, thus upsetting the caries balance. Prolonged exposure to the bottle effectively produces an acid bath around the teeth.

17. Oral Health Assessment and Caries Risk Assessment (CRA) for Babies and Young Children
There are 6 steps to complete an Oral Health Assessment on a young child. Handout: "Oral Health Assessment: 6 Steps (link that be clicked to access it? Or?)

18. Supply List 2X2 gauze Direct light source Baby/child toothbrush
Fluoride Varnish
Vinyl/latex gloves
Plastic mirror/tongue blades
Floss
Here is the list of supplies needed for the oral health assessment and fluoride varnish application. You will want to have needed supplies ready for both procedures because once the child is positioned, you will accomplish the oral health assessment and fluoride varnish application all in a matter of minutes.
2 x 2 gauze squares to clean and dry the teeth
Direct light source such as a flashlight/penlight or head lamp
Toothbrush
Plastic mirror or tongue blades (optional)
Fluoride varnish (individual dose with applicator)
Vinyl/latex gloves

19. Step 1: Begin assessing risk factors and protective factors
Family history of caries
Bottle use and other dietary habits
Developmental disabilities or special needs
Assess water fluoridation/systemic fluoride supplements
Home care and use of fluoride toothpaste
Dental Home
The first step of a caries risk assessment is to interview the caregiver, building trust with both the caregiver and the child, and asking questions to learn more about the family’s situation and habits .Prior to beginning the question portion of the interview, you may want to comment on how important the caregiver’s role is at home for preventing disease.
Questions for the interview portion should be closed and open-ended and cover the following topics:
Have the primary caregivers or any of the child’s siblings experienced lots of cavities? Note if mother or primary caregiver has had decay in the past 12 months.
Is the child weaned from the bottle yet? Does the child sleep with the bottle all night or walk around with a bottle or Sippy cup throughout the day? How often does he/she snack, and is milk offered at each meal instead of sweetened beverages? OR ask the caregiver to describe a typical day’s diet.
Is the family’s home served by fluoridated water or do the children take fluoride supplements? You will probably want to keep a chart handy that lists the fluoride content of local water sources because families don’t usually know if their water is fluoridated.
Have you started cleaning your child’s teeth yet with a fluoride toothpaste? If so, tell me how you clean them.
Does the child/family have a regular source of dental care – a dental home?
 Anticipatory guidance begins during the interview and continues throughout the 6 Steps

20. Building Rapport Play and talk with child
Use toys or a baby toothbrush for distraction
Use staff to occupy child during the interview
During the interview with the caregiver, you'll want to build rapport with the child by playing with the child and talking with the child. A soft toy can be helpful to play with as you talk with the parent and then describe what you plan to do. An assistant can come in handy here, distracting the child while you talk with the caregiver.
The 6 steps.
Child-friendly atmosphere.
The way rapport is established with the child and caregiver.
What happens when the child begins to cry?
Finally, the oral health assessment is completed quickly, and the baby is calmed when raised back up to their caretaker’s arms.

21. Step 2: Knee-to-Knee Position
The second step is to position the child. Note again the knee-to-knee position preferred by most dental health professionals. The child is initially held in the mother’s arms and slowly lowered to the health professional’s lap. Ask the mother to hold the child’s hands and help keep the child from wiggling.
on video

22. Bad News: Child is crying. Good News: You can see the teeth clearly.
Expect Crying
Bad News: Child is crying.
Good News: You can see the teeth clearly.
Most young children will cry when lowered back into the health provider’s lap. This is normal behavior for a young child and gives you a wonderful opportunity to see the child’s teeth. The key is to do the screening quickly and to keep your cool!

23. Tips for Behavior Management
Focus on the nature of the cry
Use distraction techniques
Tell, show, do
Above all, stay calm!
If the child cries, there are a few things to consider
Focus on the nature of the cry (pain, fear, or just annoyed?)
Use distraction techniques like toys, a plastic mouth mirror that the child can hold, stories, and humor
If the child is older, involve the child in holding the toothbrush or helping you count the teeth.
"Tell, show, do" works nicely with older children but might not be very helpful with 1-2 year olds.
Use self-talk…this is to help YOU cope. Tell yourself that the child is fine and you will be done in a couple of minutes. Over time, you will become less sensitive to the crying.
Above all, stay calm. If you are calm, it will help both the child and the caregiver to remain calm.
You can download "Tips for Managing Child behavior" as a reminder and to share with your dental staff

24. Step 3: Toothbrush Prophy
Remove plaque so you can see teeth clearly
Discuss home care
Reinforce the use of a small smear of fluoride toothpaste
Step #3 is the toothbrush prophylaxis. By introducing the toothbrush first, and providing a toothbrush prophylaxis, or cleaning, you are using something the child is familiar with, and you can let a toddler “help” with the cleaning of the teeth, while showing the mother proper oral hygiene and positioning techniques. This is a good time to reinforce the importance of cleaning the teeth daily using a small smear of fluoride toothpaste and a child-size toothbrush.

25. Cleaning the Teeth at Home
Begins when first tooth erupts
Let older children and caregivers practice while you watch
Inform caregivers that the earlier they start cleaning the baby’s teeth, the easier it will be as the child grows older. At home, parents can use the knee-to-knee position or the caregiver can hold the baby on her lap, facing outwards, and clean the teeth from behind. Some caregivers clean the teeth during bath time or while the child is on the changing table, approaching the baby from the front. Encourage families to find a method that works for them, and to be sure to include fluoride toothpaste as part of this daily routine.

26. Step 4: Clinical aspects of CRA
Presence of thick plaque
Chalky white spots, brown spots, or obvious dental caries
Tooth defects
Visually inadequate saliva flow
Step #4 is the clinical portion of the caries risk assessment. Use the toothbrush to “count” the child’s teeth, while looking for the following things:
Obvious plaque and/or gums bleed easily (oral hygiene status)
Chalky white spots or obvious dental caries
Recent restorations (within previous 12 months indicates high risk)
Tooth defects
Abscesses
Other clinical signs of disease
The toothbrush can also serve as a mouth prop, preventing the child from biting down on your fingers…ouch!

27. White Spots or Gingival Inflammation
These are what the chalky white spots look like. Remember, the chalky white spots can actually be remineralized with the use of fluoride varnish and daily brushing with fluoride toothpaste at home.

28. Mild, Moderate and Severe Early Childhood Caries
As the decay progresses, it looks like this.

29. Lift the Lip Show caregivers any signs of tooth decay
Teach them to “lift the lip” monthly to check for chalky white spots or brown spots
If you see any signs of tooth decay, you can point these out to the parent. Encourage the caregiver to lift baby’s lip while cleaning at home and keep an eye out for chalky white or brown spots, being sure to look at both the front and back of teeth, and near the gum line.

30. Caries Risk Assessment
High risk = Active disease or recent disease activity
White spot lesions
Carious lesions in previous 12 months
Active caries in caregiver
Moderate risk = Presence of risk indicator but no active disease
Visible plaque
Frequent carbohydrate exposure
No carious lesions in previous 12 months
Low risk = Absence of factors in either category
At this point, you have gathered the data you need to provide a caries risk assessment. Using the information you gathered from the interview and your observations from the oral assessment, you can determine if the child is at low, moderate, or high risk for dental caries. 
Many caries risk assessment forms are available and can be downloaded from professional websites. The CAMBRA - caries management by risk assessment - form can be located in the October 2011 issue of the California Dental Association Journal, along with detailed support for its use. The American Dental Association, the American Academy of Pediatric Dentistry, and other professional organizations have developed forms as well. Though each form will have its own specific measures and own methodology for determining risk. the principles for assessing risk are applicable to all risk assessment processes.
In California, beginning January 1, 2017, Denti-Cal dentists in identified counties will be eligible for a pilot program to test caries risk assessment and early prevention. The factors to assess high, moderate and low risk listed on this slide are specific to the risk assessment approach for children ages 0-6 that will be used in California’s pilot. If you are taking this course as a prerequisite to participate in this pilot project, you will be directed to additional resources at the end of this presentation to learn more about your participation and the specific caries risk assessment form the California Department of Health Care Services will accept for pilot participation.

31. Step 5: Apply Fluoride Varnish
Step #5 is the application of fluoride varnish, especially for moderate and high-risk children. Fluoride varnish is a highly-concentrated fluoride treatment that is safe and effective for use with babies and young children.

32. Fluoride Varnish Procedure
Dry teeth lightly with a gauze square
Open the packet of varnish
Stir with applicator
“Paint” the varnish on the child’s teeth
“Less is More”
To apply fluoride varnish, you will first dry the child’s teeth lightly with a gauze square. The teeth don’t need to be super dry, in fact fluoride varnish requires a certain amount of saliva to set up. Open the packet of varnish by tearing away the paper cover, dip the applicator in the well of fluoride varnish, mix the varnish up a bit, and “paint” the varnish on the child’s teeth. This is a product where “less is more” and you want to apply a thin layer for optimum benefit

33. Fluoride Varnish Procedure
Begin with lower teeth. Do the outsides of all teeth and then the insides.
Repeat with upper arch.
Develop a pattern that works for you.
It is usually good to begin on one side of the mouth and “paint” the varnish on all of the outsides of the teeth and then return and do all of the insides, or tongue-sides of the teeth. Do one arch at a time, beginning with the lower teeth because this is where the saliva will pool. The total procedure shouldn’t take more than a couple of minutes and even less time for babies with only a few erupted primary teeth. If saliva flow is heavy, you may need to dry a few teeth at a time and paint the varnish on, using a “wipe and paint” technique.

34. Fluoride Varnish Procedure
When in doubt, follow the manufacturer’s instructions
Whenever you are in doubt about the specific product you are using, follow the manufacturer’s instructions.

35. Parent Instructions
Mild yellow or brownish tint that will disappear when the teeth are brushed.
Don’t brush until the next day for optimal benefit.
Inform the parent that the varnish may leave a mild yellow or brownish tint on the teeth. The tint will disappear when the teeth are brushed, but we don’t want the parents to clean the child’s teeth until the next day. The fluoride treatment works best if it is left on the teeth overnight.

36. All done!
Raise the child back into their caregiver’s arms for comforting.
Most children stop crying at this point.
Give them a toothbrush or toy to play with while you talk with the caregiver.
Now it is time to raise the child back up into the mother’s lap. Most young children will stop crying at this point. This is a good time to give the child the toothbrush or a soft toy to play with while you talk with the caregiver.

37. Motivational Interviewing
What is Motivational Interviewing? While there are entire courses on motivational interview, and we highly recommend them, motivational interviewing involves listening to your patients and letting them set their own goals. The conversation that you have will help you understand why they do/do not want to change certain behaviors. By setting their own goals, research shows us that they are much more likely to follow through. You can use the Caries Risk Assessment/Goal Setting Handout and have the caregiver circle the goal(s) upon which they want to focus. (Click on video link)

38. Step 6: Summary and Goal-Setting
Summarize findings, follow- up, and home care.
Discuss risk.
Set goals.
Step #6 is a summary and goal setting. Summarize your findings and recommendations for follow-up, anticipatory guidance and home care. Talk with the caregiver about whether the child has any signs of tooth decay and whether the child is at low, medium, or high risk for future tooth decay. Using motivational interviewing, work with the caregiver to set 1-2 short-term goals to work on before you see them again.

39. Non-judgmental and friendly Culturally sensitive Remain positive!
Small Steps
Choose 1-2 key messages
Non-judgmental and friendly
Culturally sensitive
Remain positive!
Most health education is overwhelming. As eager as we are to give families a multitude of good advice, keep in mind that health education research and learning theory support providing 1-2 key messages at each visit. Think “baby steps.” Ask yourself, “If this family only made one or two changes to improve their child’s oral health, what would I want them to be?” This will guide you to your choices of what to focus on at any given visit. Then, you can make notes about what to cover at the next appointment.

40. Multiple Triggers Over Time
Changes in health behavior do not happen overnight.
It often takes many triggers, delivered over a period of time, in combination with a person’s own experiences and values to change health behavior.
Research in tobacco cessation has taught us that it usually takes many triggers, over time, to change health behavior. Try not to get discouraged, but consider each dental visit as getting one-step closer to change.
It is also very important to remain positive. People learn most effectively when they are in a positive environment. A positive environment is built when you treat your patients with respect and kindness.

41. Documentation
After providing the summary and goal-setting with the family, you will want to record any signs of tooth decay, document if the child is at low, moderate, or high risk for future dental caries, and whether a referral to a pediatric dentist is needed. You will want to refer children to a pediatric dentist at the point when you feel you are unable to provide needed treatment .

42. Silver Diamine Fluoride
Disease Management
Interim Therapeutic Restorations (ITRs) using fluoride-releasing glass ionomer
Silver Diamine Fluoride
As the dental team becomes more comfortable working with infants and young children, you will encounter some young children who need simple restorative treatment. You can use "minimally invasive dentistry" techniques that include Interim Therapeutic Restorations and the use of silver diamine fluoride. Research is building that the outcomes for minimally invasive dentistry are good and should not be overlooked when treating young children.

43. Interim Therapeutic Restorations
Minimal cavity preparation, no injections, no drilling
Fluoride releasing glass ionomer
Be sure to inform the family:
That this stops the disease for the time- being
That these fillings will be recharged with fluoride when the child drinks fluoridated water or brushes with fluoride toothpaste
Continued check-ups are important
Interim Therapeutic Restorations can be used to stabilize defective or carious teeth with minimal cavity preparation and no anesthesia – making the procedure quicker and easier to complete for a young child than a traditional filling. By removing only a portion of the carious tissue, and then sealing off the lesion using a fluoride-releasing material, such as glass ionomer, the tooth is protected from further caries progression and the child has had a better, less stressful, dental experience.
Although considered a temporary restoration, some of these restorations last the life of the primary teeth involved. And when the child drinks fluoridated water or uses fluoride toothpaste, the fluoride “recharges” the glass ionomer, creating a reservoir of fluoride for healing the tooth. It is important to tell the parent what you have provided their child when you place an ITR. Some dentists describe it by saying they have stopped the disease process in this tooth for the time being and that it may or may not require a permanent filling in the future, but they should be sure to bring their child back for check-ups to ensure the tooth’s health.

44. Silver Diamine Fluoride
Silver’s antibacterial properties; fluoride’s remineralization properties.
Interim Caries Arresting Medicament
CDT Code 1354
FDA approved for tooth sensitivity; off label use for caries arrest.
Silver’s antibacterial properties have been known for decades, but the dark stain left behind has been perceived as a barrier to its use. Today, however, research on Silver Diamine Fluoride is showing that families accept – and even appreciate – that the child’s disease can be arrested easily, quickly and without local or general anesthesia. Discussion with parents on the use of silver diamine fluoride should be thorough and include informed consent.
The combination of the silver and fluoride is proving to be an effective medicament to arrest decay in patients who cannot tolerate the process required to place a traditional filling. Carious tissue does not need to be removed but the soft tissues must be protected during application.
In 2015, the FDA approved this silver and fluoride product to treat tooth sensitivity, but it can be used off label to treat caries. Additionally, the ADA code committee approved a CDT code specifically for SDF: D Interim Caries Arresting Medicament Application
If you are taking this course to participate in the California Department of Health Care Services Dental Transformation Initiative Domain 2 pilot program, silver diamine fluoride is an element of that pilot. Information specific to its use is provided in the resource materials provided by the Department at the end of this presentation.

45. Consider: High risk = 4x/year Moderate risk = 3x/year
Risk-Based Recall
Consider:
High risk = 4x/year
Moderate risk = 3x/year
Low risk = 1-2x/year
Finally, you will want to let the caregiver know when you would like to see the child again. If the child is at high risk for ECC, you will want to stress the importance of fluoride varnish applications 3-4 times a year

46. It’s what families do at home that really counts!
Reinforce Home Care
It’s what families do at home that really counts!
This is another opportunity to reinforce with the family that it is what they do at home that will most likely improve their child's oral health.

47. Follow-Up Visits
Children who have received infant caries risk assessments often make excellent future dental patients.
You can repeat the caries risk assessment, using the knee-to-knee technique, until a child is 3 years old, at which time they can probably be seen in the dental chair for a traditional dental exam and x-rays. In fact, children who have received infant oral health assessments often make excellent future dental patients because they are no longer afraid of having someone look in their mouths.

48. 6 Steps Interview Position the child Toothbrush Prophy CRA
Fluoride Varnish Treatment
Summary and Goal Setting
While we have covered many details in this course, let’s reflect back to the videotape we watched at the beginning to remind ourselves that the entire 6-step process takes just minutes to complete. The time it takes to engage in motivational interviewing. And provide anticipatory guidance and goal setting will vary by family need and also by the personal commitment and style of the health care provider.

49. Healthy Smiles for California’s Children
In closing, let’s look again at what’s really important…to promote healthy smiles for California’s children. This will require the commitment, caring, and energy of dental teams throughout the state to make it happen.