Preventing early childhood caries through medical and dental provider education and collaboration

“First Tooth” for Head Start/Child care providers Project goals:

• Educate Head Start staff and child care providers on prevention of early childhood caries.

• Train local oral health educators to provide education for non-dental/non-medical child care providers.

• Facilitate collaborative referral relationships between WIC/HS staff /child care providers, dental providers and primary medical care providers so that all Oregon children have a dental home.

The prevalence and impact of Early Childhood Caries

Defining early childhood caries

• Process of demineralization to cavities in primary dentition • Lesions can progress rapidly • Affects teeth least protected by saliva • Often associated with bottle or sippy cup use throughout the day or at night

Early childhood caries can lead to…

• • • • Extreme pain/no pain Spread of infection and cellulitis Psychological/Developmental Impairment: – Inability to concentrate – Malaise, low grade fever – Impaired language development – Low self-esteem Long term affects: – Malocclusion – Extensive dental treatment – High risk of developing tooth decay in permanent teeth

Current status of children’s oral health

https://apps.state.or.us/Forms/Served/le8667.pdf

Disparities in Oregon children’s oral health

Hispanic/Latino children have higher Rates of decay, untreated decay and Rampant decay.

Black/African American children have Higher rates of untreated decay.

Children from lower income homes have nearly twice the decay rates, untreated decay and rampant decay than children from higher income homes.

https://apps.state.or.us/Forms/Served/le8667.pdf

Why Head Start staff/child care providers?

• They have frequent contact with pregnant moms, infants and children.

• They teach children how to brush to prevent or reduce the risk of tooth decay.

• They provide nutritional information that can reduce tooth decay.

• Children in low socio-economic homes have higher rates of decay.

Early childhood caries and risk assessment

First clinical signs of caries

• • • • First clinical signs of caries White spots Acids have demineralized enamel First appear at gumline of upper front teeth High risk for developing cavities White spots can be remineralized • • • with early intervention Fluoride Behavior modification: improved brushing & dietary habits Indication for dental referral

Used with permission by the Washington Dental Service Foundation

Photo: Crest Slide Set and ICOHP

2 Example of fluorosis

Mild Fluorosis Severe Fluorosis

ECC disease progression See Head Start pocket guide

Photo: Crest Slide Set and ICOHP

Severe caries Abscess See Head Start Pocket Guide

Caries process Tooth Requires 4 factors Bacteria Food source Time

Used with permission by the Washington Dental Service Foundation

Caries process: ongoing balance

• • •

Protective Factors

Strength of the enamel Fluoride Adequate salivary flow

No caries

• • •

Pathologic Factors

Strep mutans Carbohydrates Reduced salivary flow

Caries

Used with permission by the Washington Dental Service Foundation

Caries process and diet ← Plaque level acids → Regular meals Regular meals plus frequent snacks

Used with permission by the Washington Dental Service Foundation

2 Caries process and transmission

• Bacteria established by age 2 • Natural process occurs through normal activities • Encourage regular dental care for pregnant women and mothers of infants • Xylitol can decrease caries risk

See Handout and www.orohc.org

: Guidelines for Oral Health In Pregnancy

2 Why do pregnant women need a healthy mouth?

• Reduces bacteria in mouth that can cause caries and gingivitis • Less bacteria passed to baby in the first two years of baby’s life • Research has shown that having gum disease while pregnant may cause pre-term births or low birth weight • Mother learns importance of early dental intervention for her baby

2 Is dental treatment safe during pregnancy?

• • • All dental treatment safe during pregnancy, including xrays, cleanings, fillings and extractions Getting regular dental care during pregnancy can prevent gingivitis and improve the health of the gums, which often get red and puffy during pregnancy Getting a dental infection during pregnancy can be dangerous to the mother and baby

See www.orohc.org

: Oral Health During Pregnancy Consensus Statement

2 Giving your baby a head start on a healthy mouth

• Mother is often the family member who establishes good eating and brushing habits for entire family • Mothers should model good brushing and eating habits • Start brushing baby’s teeth as soon as the first tooth erupts • Only put breast milk, formula or plain water in bottles and sippy cups

Be conscientious of cultural diversity

• Increased rate of dental caries in certain ethnic groups.

• Beliefs about health, disease, diet and hygiene in different cultures may impact practices and child rearing habits.

2 Who is most at risk? See handout and www.orohc.org

: OrOHC Caries Risk Assessment <6

Oral health education and anticipatory guidance for parents/caregivers

3 Healthy primary teeth are important!

• • • • For normal development For space maintainers For cavity-free permanent teeth For keeping treatment costs low

First Dental Visit

Before age 1 After age 1

Ave. 5 Year Cost

$263 $447

Motivational interviewing (MI)

• • • • MI techniques can help teach good oral health habits- for the child and for the parent Since a child does not have the dexterity to do adequate brushing without assistance, MI techniques such as modeling techniques can help teach parents how to brush their child’s teeth at home.

Many parents have fears about getting dental treatment for their children, so using MI techniques such as summarization can help understand these fears so they can be addressed directly MI techniques, such as encouraging incremental changes in behavior, are helpful when improving oral health habits at home.

3 Anticipatory guidance Early childhood caries is: TRANSMISSIBLE PREVENTABLE TREATABLE

MI menu of options See Motivational Interviewing Tool

3 Anticipatory guidance/education See www.orohc.org

: Posters

Use diverse formats for delivering oral health education

• DVDs • AAP flip chart • Pocket guide • Posters • Handouts • Puppets or plastic models

Diet and feeding: 0-12 months

• • • • • • • Breastfeeding does not increase the risk for caries, but limit to meals Hold infant for bottle and breastfeeding, minimizing pooling of milk on teeth No bottles at bedtime/naptime (or use plain water only) Introduce cup at 6 months, wean bottle at 12-18 months Avoid constant use of sippy cup, pacifier Introduce appropriate snacks Encourage rinsing the mouth out with water

Diet and feeding: toddlers

• •

1 – 2 years

• • • Discontinue bottle feeding at 12-18 months Limit juice to 6 oz once daily at mealtimes, or eliminate altogether Avoid sweet, sticky snacks – dried fruit, crackers, candy • Reserve soda, candy and sweets for “special occasion” treats

2 and older

Choose fresh fruits, vegetables, or whole grain snacks Good preventive medicine for obesity too!

Wean from pacifier and thumb-sucking

Used with permission by the Washington Dental Service Foundation

Oral hygiene < 1 year

– Clean gums with cloth or soft toothbrush – As teeth erupt, use smear of toothpaste 2x/day*

1-6 years

– Brush 2X/day using half-pea sized amount of fluoridated toothpaste – Parent/caregiver performs and supervises – Spit and don’t rinse *It is recommended by ASTDD, AAPD and AAP that children at high risk for caries use fluoridated toothpaste when the first tooth erupts.

Oral hygiene Age 6 years through adults

– Brush 2X/day with pea-sized amount of fluoridated toothpaste – Brush for 2 minutes at least once daily use a timer if needed – – Spit and don’t rinse Use fluoridated mouthwash in addition to brushing, preferably mid-day – Clean between teeth daily with floss or toothpicks to keep plaque levels low, particularly adults.

Pregnant women can become nauseous while brushing

– Avoid pushing toothbrush against tongue – Use fluoridated mouth rinse more frequently – Rinse with fluoridated mouth rinse after vomiting

Sources of fluoride Systemic

– – Water fluoridation Fluoride supplements – Fluoridated bottled water

Topical

– – – – Fluoride toothpastes Fluoride varnish Water fluoridation Fluoridated bottled water – – – Fluoride supplements Fluoride rinses Gels, foams

Adapted from the Washington Dental Service Foundation

Fluoride varnish Effective

• 30% - 69% decrease in caries

Safe

• • No preservatives, BPA, dyes No evidence-based contraindications

Easy

• Takes 30 seconds to apply Photo: ICOHP, WDSF

Use of fluoride varnish for caries prevention has been endorsed by the ADA, but remains an “off label” use of the product, because it is not cleared for marketing by FDA for this purpose.

Fluoride varnish at WIC or Head Start

Post varnish instructions

• • • • • • • Child may take a drink of water immediately No brushing until the next day Can skip fluoride supplement for the day Ok to drink as usual Avoid hard, crunchy and sticky foods the rest of the day Advise caregiver teeth may be yellow for a day (based on varnish) Repeat every 3 months for children at high risk for caries

Used with permission by the Washington Dental Service Foundation

Tips for educating children and families

Treatable

• Parents/caregivers must take an active role in their child’s oral health. Cleaning the teeth and providing healthy food is the parent’s job in helping the child have a healthy mouth • Intervention with fluoride varnish can reverse early stages of caries.

• Early access to a dental home is important, including a regular maintenance schedule.

Show the parent how to brush

• Utilize overhead lighting in bathroom • Lift the lip to brush at gumline and look for white spot lesions • Use short strokes to slowly scrub the teeth • Use a sequence to make sure no areas are missed • Brush tongue to remove germs on tongue

Tricks if the child refuses

• Use toothpaste that the child likes (bubble gum or berry flavored) • Use silly songs to engage the child • Have child brush parent’s teeth first • Establish patterns which cannot be changed, like washing hands before dinner • Engage older children to model good brushing behavior for younger children

Other interventions for ECC Interim Therapeutic Restorations- ITR

• • • Stabilizes and treats some caries Minimizes fear for child and parent No anesthetic is needed, quick procedure

Silver Nitrate/Silver Diamide Fluoride

• • • Used by some dentists to treat infection Initially turns infection black, but follow up care includes tooth colored filling No anesthetic is needed, quick procedure

Referrals And Resources

Local resources and collaboration

• As advocates for your clients, you probably already know how to access dental and medical providers, and encourage utilization of those providers.

• Keep in contact with referral sources to establish good working relationships and to maintain an accurate referral list.

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Take home messages You play a huge role in preventing dental disease!!

• Primary/baby teeth are important for the development of the child • Understanding the disease helps you advocate for the health of your families • Early childhood caries can be prevented and treated • Pregnant women need access to dental services • Support efforts to provide preventive services to the children you serve

“First Tooth” training and technical assistance contacts Karen Hall, RDH EPDH

First Tooth trainer/technical assistance [email protected]

or

[email protected]

971-224-3018 You can also access our website for materials

First Tooth Website http://www.orohc.org/

Questions?

Please fill out the training feedback form

Thank you!

• • • • Oregon Oral Health Coalition’s Early Childhood Caries Prevention Committee “First Tooth” Advisory Group Washington Dental Service Foundation American Academy of Pediatrics www.kidsoralhealth.org