Prevention-board review.pptx.pdf

Prevention Raffi Miller, DMD  First Dental Visit American Dental Association (ADA), American Academy of Pediatric Dentistry (AAPD) and American Academy of Pediatrics (AAP) all endorse the first dental visit within 6 months of eruption of the first tooth but no later than t...

Prevention Raffi Miller, DMD  First Dental Visit American Dental Association (ADA), American Academy of Pediatric Dentistry (AAPD) and American Academy of Pediatrics (AAP) all endorse the first dental visit within 6 months of eruption of the first tooth but no later than the child’s first birthday  First Dental Visit Why so young? – 40% of children have caries before kindergarten – Caries rates are increasing in children under the age of 5, especially in underserved communities – Caries progression occurs rapidly in children – Establish a dental home for continuing care  Dental Home Established no later than 12 months of age Ongoing relationship between dentist, patient, and parent Place to provide continuing care, education, and referrals as needed  Dental Home Important to connect with medical home – Medical home can promote oral health and prevention – Dental home can recognize abuse, prevent trauma, prevent obesity and monitor weight, check immunizations, monitor developmental milestones, refer for neurodevelopmental and therapeutic services – Children ages 6-12 see the dentist 4 time more often than their pediatrician Immunization Schedule Growth Charts Speech and Language Development  Components of a Comprehensive Clinical Examination General health and growth assessment Pain assessment Extraoral soft tissue examination TMJ assessment Intraoral soft tissue examination Oral hygiene and periodontal risk assessment Intraoral hard tissue examination Assessment of developing occlusion Radiographic assessment, as indicated Caries risk assessment Assessment of cooperative potential/behavior of child  Infant Dental Visit Review medical history, social history and dental history Perform clinical exam, prophylaxis, fluoride application, and radiographs (as needed) Review oral home care regiment Parental counseling Anticipatory guidance  Clinical Exam Soft tissue exam – Lips – Cheeks – Tongue – Gingiva – Palate  Clinical Exam Common soft tissue pathology in infants – Eruption cyst Associated with erupting tooth Smooth, translucent, painless swelling If filled with blood, will be bluish in color No treatment indicated  Clinical Exam Common soft tissue pathology in infants – Bohn nodule Developmental anomaly from remnants of mucous gland tissue Found on buccal and lingual aspects of maxillary and mandibular ridges and on the hard palate No treatment needed  Clinical Exam Common soft tissue pathology in infants – Dental lamina cyst Lesions from epithelial remnants of the dental lamina Found on crest of maxillary and mandibular ridges in infants No treatment needed  Clinical Exam Common soft tissue pathology in infants – Epstein pearls Keratin filled cysts Found on mid-palatal raphe at junction of hard and soft palate  Clinical Exam Common soft tissue pathology in infants – Congenital epulis of the newborn Usually on anterior alveolar ridge – Maxilla>mandible Presents at birth Pink, smooth or lobulated, pedunculated mass Benign Treatment is excision, usually no recurrence  Clinical Exam Common soft tissue pathology in infants – Fordyce granules Yellow-white sebaceous glands Found on buccal mucosa or lips No treatment needed  Clinical Exam Common soft tissue pathology in infants – High frenum Maxillary or mandibular (buccal or lingual) No treatment needed in young children unless frenum attachment interferes with speech or feeding  Clinical Exam Common soft tissue pathology in infants – Oropharyngeal candidiasis White plaques on mucosa that leave red inflamed area when removing May be self limiting May need to apply topical nystatin to affected areas and to nipples of breastfeeding mother  Clinical Exam Natal and neonatal teeth – Natal teeth are present at birth – Neonatal teeth erupt within first month of life – Can be normal primary teeth or supernumerary – Usually little to no root formation – Can cause trauma and issues with feeding – Consider extraction if they are an aspiration risk – Consider smoothing incisal edge if tooth is stable and causing issues feeding or trauma  Clinical Exam Common soft tissue pathology in infants – Riga-Fede disease Ulceration, bleeding and discomfort of tongue due to rubbing on natal or neonatal teeth Treatment includes smoothing incisal edge or extracting teeth  Clinical Exam Dental exam – Eruption – Caries – Development – Occlusion – Hygiene  Prophylaxis Toothbrush or rubber cup prophy Scaling (as needed) Flossing (if contacts closed) Fluoride application  Radiographs Indicated if caries or pathology noted Indicated if proximal contacts cannot be visualized Usually not taken prior to 3 years old Will likely need patient to sit on parent’s lap while taking radiograph Most common radiograph is occlusal  Radiographs Occlusal film How do you do this in an infant? Lap to Lap Exam  Lap to Lap Exam Let parents know that the infant will cry and it is expected for the infant to be uncooperative Instruct parent to hold child like they are hugging child Lay child back in your lap You secure child’s head Parent secures child’s arms and legs  Lap to Lap Exam Perform exam, prophylaxis, and fluoride application within a short time span – Usually under 5 minutes – Use toothbrush to help open mouth and as bite block – Educate parent on proper brushing and flossing technique for child as you are brushing and flossing child’s teeth The most important part of infant dental visits is parent counseling and anticipatory guidance  Parental Counseling Topics Oral hygiene Diet Habits Mutans streptococci (MS) transmission Fluoride  Anticipatory Guidance Topics Eruption sequence Trauma prevention Future dental visits Changes in – Oral hygiene – Diet – Habits  Oral Hygiene Counseling Parent should be brushing for child as soon as first tooth erupts Use a soft toothbrush Brush twice daily with appropriate size toothbrush Floss when contacts are closed  Oral Hygiene Counseling Patient positioning when parent brushes – Parent should brush from behind Provides stability of the patient’s head Lay child on bed or couch and brush Brush using lap to lap technique Cradle in arms as other adult brushes When older, have child stand in front of parent or sit in chair with parent behind child Oral Hygiene Counseling  Diet Counseling Breast milk is better than cow’s milk – Breast milk has not been shown to cause caries Breastfeeding more than 7 times/day after 12 months of age is associated with ECC – Nighttime feeding with cow’s milk is associated with caries Frequent drinking of milk, juice, and formula in a bottle or sippy cup associated with increased caries risk – Especially if in between meals  Diet Counseling Limit sugar intake – Juice and milk only at meal times No more than 4oz of juice a day – No soda – Limit candy, cookie, and other sweet consumption – AHA recommends not to introduce sugar in diets of children under age 2 Water in between meals and before bed Diet Counseling Diet Counseling  Oral Habit Counseling Bottle/sippy cup – Should be stopped as soon as possible – Associated with higher caries risk Digit and pacifier – Normal in infants – Discuss stopping habit by age 3 to prevent any skeletal changes from occurring – Prolonged habits can cause flaring of maxillary incisors, anterior open bite and posterior crossbite  MS Transmission Counseling Inform parent of vertical transmission – Do not lick pacifier clean – Do not test food with same spoon used to feed child  Fluoride Counseling Ask if patient is taking a fluoride supplement – Often prescribed by pediatrician Assess fluoride intake from different sources – Tap water – Formula – Juice – Prepared foods – Toothpaste  Fluoride Counseling Community water fluoridation – Most equitable and cost-effective method of delivering fluoride to all members of most communities – As of 2018, 73% of US population on community water systems had fluoridated water – As of 2015, HHS revised recommendation to 0.7ppm fluoride in drinking water – Estimated reduction in caries is 35% in primary teeth and 26% in permanent teeth of children – Controversy regarding lower IQ in children; majority of studies do not support this  Fluoride Counseling If needed, prescribe fluoride supplementation Age 0.6ppm F 0-6 months 0 0 0 6 months-3 0.25mg 0 0 years 3-6 years 0.50mg 0.25mg 0 6-16 years 1.00mg 0.50mg 0 Prescribe with caution for children under 6 – Prescribing recommendations not updated since lower optimal levels set by HHS and recommendation made to use fluoride toothpaste at younger age – Continued dental development and mineralization at a young age  Fluoride Counseling Different types of fluoride supplements – Drops – Chewable tablets – Lozenges  Fluoride Counseling Recommend fluoride toothpaste at any age – “smear” for children under 2 years (0.1mg F) – “pea size” for children 2-5 years (0.25mg F)  Eruption Sequence Review which teeth will be erupting by next dental appointment to anticipate teething activities  Eruption Can cause discomfort, low-grade fever, irritability, excessive salivation Recommend systemic pain relief or teething rings as supportive measures Warn against use of topical anesthetics or homeopathic remedies – Benzocaine use under 2 years of age can lead to methemoglobinemia  Trauma Prevention Topics to discuss – Falls when children become mobile – Play objects – Electric cords – Car seats  Future Dental Visits Patient should be seen every 6 months to evaluate oral health and become familiar with dental treatment Anticipate behavior at future visits – Children generally do not cooperate until 3-4 years old  Caries Risk Assessment Should be performed on every patient Helps to create individualized preventive and restorative plans Start CRA’s when first tooth erupts Trends – Early school age: unsupervised brushing and increased consumption of cariogenic foods and beverages at school – Adolescents: increased number of tooth surfaces, increased cariogenic food and beverage consumption, decreased priority on oral health Caries Risk Assessment Caries Management Pathway  In addition to oral health, dentists play an important role in: A. Dietary counseling to help prevent or treat obesity B. Ensuring immunizations are up to date C. Checking developmental milestones for potential delays D. Recognizing signs of child abuse E. All of the above  In addition to oral health, dentists play an important role in: A. Dietary counseling to help prevent or treat obesity B. Ensuring immunizations are up to date C. Checking developmental milestones for potential delays D. Recognizing signs of child abuse E. All of the above  The first dental exam for children is recommended at A. The time of eruption of the first tooth B. No later than 12 months old C. No later than 3 years old D. A or B E. A or C  The first dental exam for children is recommended at A. The time of eruption of the first tooth B. No later than 12 months old C. No later than 3 years old D. A or B E. A or C  Carious lesions are cumulative and progressive. Caries in primary teeth is not a predictor of caries in permanent teeth. A. The first statement is true; the second statement is false B. The first statement is false; the second statement is true C. Both statements are true D. Both statements are false  Carious lesions are cumulative and progressive. Caries in primary teeth is not a predictor of caries in permanent teeth. A. The first statement is true; the second statement is false B. The first statement is false; the second statement is true C. Both statements are true D. Both statements are false  Caries risk assessment models take into account all the following factors except A. Diet B. Geographic location C. Fluoride intake D. Microflora analysis E. Psychological determinants of health  Caries risk assessment models take into account all the following factors except A. Diet B. Geographic location C. Fluoride intake D. Microflora analysis E. Psychological determinants of health  A smear or rice-sized amount of toothpaste should be used until what age? A. 2 B. 3 C. 6 D. 10  A smear or rice-sized amount of toothpaste should be used until what age? A. 2 B. 3 C. 6 D. 10  What is the maximum recommended amount of fruit juice for children up to age 6 to consume? A. 2-4 oz B. 4-6 oz C. 6-8 oz D. Children up to age 6 should not drink any fruit juice  What is the maximum recommended amount of fruit juice for children up to age 6 to consume? A. 2-4 oz B. 4-6 oz C. 6-8 oz D. Children up to age 6 should not drink any fruit juice Our goal is to prevent caries through education… …but that doesn’t always happen  Early Childhood Caries The presence of 1 or more decayed, missing (due to caries) or filled tooth surfaces in any primary tooth in a child under the age of 6 years  Early Childhood Caries Severe ECC (S-ECC) – any smooth surface caries in a child younger than 3 years – 1 or more cavitated, missing (due to caries) or filled smooth surfaces in primary maxillary anterior teeth in children ages 3-5 – Decayed, missing, or filled surface score greater than or equal to 4 (age 3), 5 (age 4), or 6 (age 5)  Early Childhood Caries Statistics – High rates in poor and near poor US preschool children – Largely untreated in children under 3 years old – Often multiple teeth are affected by the time it is diagnosed  Early Childhood Caries Etiology – “bacterial-mediated, sugar-driven, multifactorial, dynamic disease that results in the phasic demineralization and remineralization of dental hard tissues” Previously called “nursing bottle caries” and “baby bottle tooth decay,” indicating some of the factors that cause ECC Dietary factors increase risk for caries, but are not the direct cause of caries  Early Childhood Caries MS transmission – Dental caries is a transmissible disease, often caused by MS – In infants, transmission of MS is often vertical From mother/caregiver to child Lowering MS levels in caregivers delays transmission to infants – Transmission can also be horizontal Between family members or other children (daycare) – Eliminate saliva sharing activities  Early Childhood Caries MS transmission – Caregiver factors associated with vertical transmission MS salivary levels Oral hygiene Periodontal disease Snack frequency Socioeconomic status  Early Childhood Caries MS colonization – Can start from birth – Originally thought to only occur when teeth are present Now known that MS can colonize soft tissue, including the tongue, in infants before tooth eruption – Colonization increases once teeth erupt  Early Childhood Caries Dietary influence – Frequent nighttime bottle feeding with milk and nighttime breast-feeding associated with ECC – Other dietary practices that increase ECC risk: Nighttime bottle feeding with juice Use of sippy cup Frequent in between meal consumption of sugary snacks and drinks  Early Childhood Caries Consequences – Higher risk of carious lesions in primary and permanent teeth – Increased hospital and ER visits – Increased treatment costs – Risk for delayed physical growth and development – Loss of school days – Diminished ability to learn – Diminished oral health-related quality of life  Early Childhood Caries Diagnosis – Visual exam – Radiographs usually not needed to make diagnosis Radiographs help to determine extent of caries and presence of periapical pathology  Early Childhood Caries Treatment options – In dental chair Depends on child’s age May not be definitive treatment – Interim therapeutic restorations (ITR) May require protective stabilization – Papoose – Parental/assistant restraint – Lap to lap treatment  Early Childhood Caries Treatment options – Silver diamine fluoride (SDF) 38% SDF approved for use as a desensitizing agent – Caries arrest is off label use Contains 24-28% (weight/volume) silver and 5-6% fluoride – Always obtain consent with color photo demonstrating color change before applying SDF  SDF 38% concentration available in USA – Approved as dentin desensitizer in adults – Caries arrest is off label use 5% F; 44,800ppm fluoride in colorless liquid pH of 10 Mechanism of action is not known – Silver is antimicrobial – Remineralization from fluoride – Synergy of silver and fluoride to reduce dentin degradation – Inhibits biofilm formation?  SDF Indications for use High caries risk patient with active cavitated lesions Cavitated lesions on patients with behavioral or medical management challenges Patients with multiple cavitated lesions that may not be treated in one visit Difficult to treat cavitated lesions Patients without access or difficult access to dental care Active cavitated lesions wit no clinical signs of pulp involvement Contraindications Allergy to silver Carious lesion with pulp exposure  SDF Preparation of patient and practitioner – Informed consent highlighting expected staining of treated lesions, potential staining of skin and clothing and need for reapplication is recommended – Utilize universal precautions – Protect patient with plastic lined bib and safety glasses – Carefully dispose gloves, cotton rolls and micro brush in waste bag  SDF Application steps Carious dentin removal is not necessary prior to application Remove gross debris from cavitation Minimize contact with gingiva and mucosa to avoid pigmentation or irritation – Consider using cocoa butter Use cotton roll isolation to avoid contact with gingiva Put 1 drop of SDF in plastic dappen dish Dry affected surfaces with gentle flow of air Dip micro brush in SDF and dab on side of dish to remove excess Dry with gentle flow of air for 1 minute; isolate for up to 3 minutes if possible to minimize systemic absorption  SDF Post op instructions No limitations listed by manufacturer Inform parents that tooth will turn darker over a few days and area of decay will be black within 1 week Patient can eat and drink right away – Many trials recommend not eating or drinking for 30 minutes Patient can brush normally 2nd application should be done in 2-4 weeks If any SDF gets on soft tissue, staining will disappear in about 2 weeks  SDF Possible adverse events – Metallic/bitter taste – Temporary staining to skin Resolves in 2-14 days – Mucosal irritation/lesions from inadvertent contact Resolves within 48 hours SDF does not adversely affect bond strength of resin composite to dentin Caries arrest is most likely on the maxillary anterior teeth and buccal/lingual smooth surfaces  Early Childhood Caries Treatment options – Sedation or general anesthesia Depends on amount of treatment needed Full mouth rehabilitation in young children often necessitates treatment in the operating room under general anesthesia Need to weigh risks vs. benefits  Early Childhood Caries Treatment options – If patient is undergoing sedation or general anesthesia, perform definitive treatment Composite or crowns on anterior teeth Stainless steel crowns (SSC) on posterior teeth Need to keep in mind patient compliance, oral hygiene, and longevity of restorations when deciding which restoration is best for children – Also caries risk!  Early Childhood Caries Treatment goals – Stabilize dental disease – Return oral cavity to health – Educate parents and patients on maintaining good oral health Diet Oral hygiene Goal is to prevent all dental caries through early visits and parental education  According to the Clinical Practice Guidelines in the AAPD Reference Manual, what percent of cavitated lesions demonstrated arrested caries lesions 2 years after SDF application? A. 32% B. 56% C. 68% D. 81%  According to the Clinical Practice Guidelines in the AAPD Reference Manual, what percent of cavitated lesions demonstrated arrested caries lesions 2 years after SDF application? A. 32% B. 56% C. 68% D. 81%  What type of recommendation is given for the use of SDF in arresting cavitated lesions in primary teeth? A. Conditional recommendation, low quality evidence B. Conditional recommendation, moderate quality evidence C. Strong recommendation, low quality evidence D. Strong recommendation, moderate quality evidence  What type of recommendation is given for the use of SDF in arresting cavitated lesions in primary teeth? A. Conditional recommendation, low quality evidence B. Conditional recommendation, moderate quality evidence C. Strong recommendation, low quality evidence D. Strong recommendation, moderate quality evidence  What percent (weight/volume) of silver and fluoride is in SDF? A. 5-6; 24-28 B. 5-6; 33-36 C. 24-28; 5-6 D. 33-36; 5-6  What percent (weight/volume) of silver and fluoride is in SDF? A. 5-6; 24-28 B. 5-6; 33-36 C. 24-28; 5-6 D. 33-36; 5-6  Skin pigmentation is temporary since SDF does not penetrate the ________. Pigmentation will disappear after about _____ days with the desquamation of keratinocytes. A. Epidermis; 7 B. Dermis; 7 C. Epidermis; 14 D. Dermis; 14  Skin pigmentation is temporary since SDF does not penetrate the ________. Pigmentation will disappear after about _____ days with the desquamation of keratinocytes. A. Epidermis; 7 B. Dermis; 7 C. Epidermis; 14 D. Dermis; 14  All of the following are indications for use of SDF except: A. Patients with cavitated lesions that present with behavioral challenges B. High risk patients to prevent the formation of cavitated lesions C. Difficult to treat cavitated carious lesions D. Patients without access to or difficulty accessing dental care  All of the following are indications for use of SDF except: A. Patients with cavitated lesions that present with behavioral challenges B. High risk patients to prevent the formation of cavitated lesions C. Difficult to treat cavitated carious lesions D. Patients without access to or difficulty accessing dental care  Which of the following steps does not need to be taken when applying SDF? A. Remove gross debris from cavitation B. Remove soft carious dentin from cavitation C. Dry area where SDF will be applied D. Dry applied SDF with gentle flow of air for at least 1 minute  Which of the following steps does not need to be taken when applying SDF? A. Remove gross debris from cavitation B. Remove soft carious dentin from cavitation C. Dry area where SDF will be applied D. Dry applied SDF with gentle flow of air for at least 1 minute  What is the recommended application time for SDF? A. 15 seconds B. 30 seconds C. 1 minute D. 3 minutes  What is the recommended application time for SDF? A. 15 seconds B. 30 seconds C. 1 minute D. 3 minutes  What are the post op limitations after SDF application? A. Do not eat or drink for 30-60 minutes B. Do not brush with fluoridated toothpaste for the remainder of the day C. Do not eat or drink warm or crunchy foods for 4-6 hours D. There are no post op limitations  What are the post op limitations after SDF application? A. Do not eat or drink for 30-60 minutes B. Do not brush with fluoridated toothpaste for the remainder of the day C. Do not eat or drink warm or crunchy foods for 4-6 hours D. There are no post op limitations  All of the following are contraindications to SDF application except: A. Tooth near exfoliation B. Silver allergy C. Parent objection to dark staining D. Carious lesions with exposed pulp  All of the following are contraindications to SDF application except: A. Tooth near exfoliation B. Silver allergy C. Parent objection to dark staining D. Carious lesions with exposed pulp  Which teeth and surface show the greatest success of caries arrest with SDF? A. Posterior interproximal B. Posterior occlusal C. Anterior interproximal D. Anterior buccal/lingual  Which teeth and surface show the greatest success of caries arrest with SDF? A. Posterior interproximal B. Posterior occlusal C. Anterior interproximal D. Anterior buccal/lingual  More than ____ of children have caries by the time they reach kindergarten. A. 15% B. 28% C. 36% D. 54%  More than ____ of children have caries by the time they reach kindergarten. A. 15% B. 28% C. 36% D. 54%  Which of the following are consequences of ECC? A. Higher risk of caries in the permanent dentition B. Increased hospital and emergency room visits C. Diminished ability to learn D. Reduced oral health related quality of life E. All of the above  Which of the following are consequences of ECC? A. Higher risk of caries in the permanent dentition B. Increased hospital and emergency room visits C. Diminished ability to learn D. Reduced oral health related quality of life E. All of the above  Modern approaches to ECC include which of the following? A. Chronic disease management B. Active surveillance C. Interim therapeutic restorations (ITR) D. A and C E. All of the above  Modern approaches to ECC include which of the following? A. Chronic disease management B. Active surveillance C. Interim therapeutic restorations (ITR) D. A and C E. All of the above Prevention in School Age Children and Adolescents Caries Risk Assessment Caries Management Pathway  Periodontal Risk Assessment Identifies factors that place individuals at an increased risk of gingival and periodontal disease and pathology Recommended to start probing after eruption of 1st permanent molars and incisors Probe primary teeth only if pathology is noted Bleeding on probing (BOP) in primary teeth is indicative of high susceptibility to periodontal disease Periodontal Risk Assessment