EARLY CHILDHOOD CARIES (ECC) PREVENTION AND ORAL HEALTH PROMOTION

1. EARLY CHILDHOOD CARIES (ECC) PREVENTION AND ORAL HEALTH PROMOTION Pacific Islands Continuing Clinical Education Program (PICCEP) The following presentation was adopted by me to use in American Samoa and Palu in the Pacific Islands. The program was designed and implemented by Dr. Peter Milgrom a professor at the University of Washington and has been used in much of Micronesia with great success

2. EARLY CHILDHOOD CARIES (ECC) PREVENTION AND ORAL HEALTH PROMOTION Pacific Islands Continuing Clinical Education Program (PICCEP) Fred Quarnstrom, DDS FICD, FASDA, FAGD Department of Dental Public Health Sciences University of Washington, Private Practice, Seattle WA Palau 2003

3. We have a problem

4. ECC in American Samoa 208 children 3 y. o. 37% 4 y. o. 58% 5 y. o. 75% had 5 or more decayed, missing or filled dmf teeth 13% were caries free 1% had 20 or more dmf teeth Average 6.4 dmf teeth James B. Quartey, DDS, MPH, Dental Department, LBJ Tropical Medical Center, Pago Pago, AS. Lepetia Aga-Letuli, BS, Department of Health, American Samoa Government, Pago Pago, AS

5. ECC on Ofu 38 children 4 y. o. 100% had decay av. 6.7 decayed n=12 5 y. o. 93% had decay av 5.4 decayed n= 14 6 y. o 100% had decay av. 5.4.decayed n=6 1 was caries free 93% had caries Study was visual exam with no x-rays Fred Quarnstrom, DDS, University of Washington, Dept. Public Health Sciences 5/8/02

6. Dentistry on Ofu and Olosega 40 children had 250 teeth that needed treatment. Fluoride varnish took less than 3 minutes per child. Projection (realizing that projections can be inaccurate) A population of 400 has 2,500 teeth needing treatment If 7 patients had 3 teeth treated per day - a very optimistic schedule. It would take 125 dentist days to take care of basic needs. 200 days if you include cleanings and exams. A full time dentist with an assistant is needed at the Ofu clinic.. Another dentist and assistant is needed at the clinic on Ta’u. Multiply this need by 100 to 150 for all of American Samoa. You can not possibly provide this much service. Prevention is the only solution

7. We have a problem It is anepidemic.

8. We have a problem It is anepidemic. It is bacterial.

9. We have a problem It is anepidemic. 90% of 6 year olds are infected.

10. We have a problem It is anepidemic. It causes many children to have severe pain on a regular basis.

11. We have a problem It is anepidemic. If they were adults, they would not put up with the pain.

12. We have a problem It is passed to the children by their mothers.

13. We have a problem If it were an STD like Clamydia, mothers would be treated prior to giving birth.

14. We have a problem We treat it by amputating tissue and providing prosthesis.

15. We have a problem If we treated diabetes this way, rather then controlling blood sugar, we would amputate feet.

16. We have a problem It costs 10 times as much to treat as it does to prevent.

17. We have a problem It is much easier and less costly to prevent than it is to treat.

18. NORMAL PRIMARY DENTITION

19. We have a problem It is early childhood caries (decay), ECC.

20. Who are “WE” We are American migrant workers. We are American Indians. We are recent American immigrants. We are from Siapan, Northern Marshal Islands, Guam, Pohnhpei, Yap, Palau, Chuuk and American Samoa. We are Children.

21. What we know about dental disease: • Dental caries is an infectious disease. • The mother is usually the primary source of the infection. • The infectious bacteria is easily transmitted from mother-to-child prior to tooth eruption.

22. ECC in Saipan 13.8% had hypoplasia

23. Strep. Mutans vs Decay

24. 66.7% of 6-12 mo olds were colonized on teeth or tongue. Concepts of a later “window of infectivity” do not appear to apply to this population. S. mutans was found in 25% (4/16) children who had no erupted teeth raising questions about the validity of previous arguments.

25. ECC prevalence in other areas? • RMI (Majuro) 50% in 2-3 y.o.; nearly 100% by age 5 • Yap 93% by age 3-4 • Other places?? Virtually all the disease goes untreated.

30. 7x from 12 -24 mo 18x from 12-36 mo 5x from high S. mutans 10x from hypoplasia 8x from frequent high sugar snacks ECC Risk Increases . . .

31. How can transmission be prevented?

32. PRIMARY SOLUTIONDefine oral health for mothers as part of peri-natal care.Moms must get priority for treatment.

33. How can transmission be prevented? Antimicrobial applications to reduce cavity- causing bacteria in mothers: Peri-natal: Chlorhexidine gluconate (0.12%) rinses twice daily Peri-natal: Xylitol chewing gum 4-5 times daily Dental care for the expectant mother

34. Kohler program for mothers with infants until age 3 • Dietary counseling • Professional tooth cleaning & oral hygiene instruction • Topical fluoride treatment • Treatment of dental caries • 1% chlorhexidine gel, 1x day, 2 wks; repeated after 2-3 mo.

35. Chlorhexidine gluconate 0.12% rinse • Many dental professionals are not aware of the use of chlorhexidine for caries • Safe in pregnancy • Safe for nursing mothers

36. Chlorhexidine gluconate 0.12% rinse for pregnant women and mothers with infants Rinse twice daily with 1/2 capful for 30 sec and expectorate. Do not rinse with water or eat or drink afterwards for 30 min

37. Xylitol Gum and Mints • Each stick/pellet is 1 gram • Use 4 or more grams/day • Up to 10-12 grams • Chew for 5 minutes • Safe for pregnant or nursing moms

38. Maternal consumption of xylitol gum 2 or 3 times a day beginning at 3 months after childbirth was associated with reduced mother-child transmissions of MS. Solderling,Isokangas, Pienihakkien &tenovuo, 2000

39. PRIMARY CARE SOLUTIONDefine oral health as part of well baby careIf we stop decay in thesekids, we do not haveto treat decay later.

40. THE PRIMARY CARE PROVIDER MCH workers have regular and consistent contact with young children at well-child care/immunization visits Control of ECC cannot be confined to the dental clinic

41. PRIMARY CARE PROVIDER IN ORAL HEALTH Role could include: provision of dietary & oral hygiene guidance dispensing of fluoridated toothpaste application of a caries control therapy such as fluoride varnish assessment, prompt referral of children at high risk

42. ANTICIPATORY GUIDANCE • Oral health important to overall health • Importance of care provider’s oral health • Dental Care for Pregnant Mothers • Transmissability of Strep mutans • Tooth eruption • Lift the Lip/looking for decay

43. RECOGNIZING EARLY DECAY WHITE SPOT LESIONS = Subsurface demineralization

45. Decay

47. Dietary Guidance: - Dental disease is exacerbated by diet. - • Avoid prolonged breast- and bottle-feeding, especially at sleep times. • Do not fill bottle with a sugar-containing product. Do not add sugar to solid foods. • Encourage cup use at 6 - 8 months. • Limit sweet, starchy snack foods.

48. Oral Hygiene: • New moms need training in cleaning kids’ teeth • Wipe infant’s gums with a wet cloth or gauze after each feeding.) • Brush baby teeth as soon as the first tooth erupts. (~ 6 months in age) • Children do not brush their own teeth effectively • Use a small amount of fluoridated toothpaste on • the toothbrush. If you cannot brush smear some fluoride toothpaste on their teeth with your finger.

49. FLUORIDE • MECHANISMS OF ACTION • Reduces enamel solubility • Promotes remineralization of enamel • Some anti-bacterial activity

50. CHARACTERISTICS • Dry tooth facilitates fluoride uptake • Sets on contact with moisture • No prophy required • Taste is tolerable • Can reverse early decay and can arrest active lesions