Julie Maniate BSc, DMD, FRCD(C) Children’s Dental World “A dietary CHO-modified infectious disease in which saliva is a regulating factor”    Most common chronic infectious disease in childhood 5x as common as asthma Is a disease process The presence of 1 or more decayed, missing or filled tooth surfaces in any primary tooth in a child under the age of 6. 1. Microbiology ◦ ◦ ◦ ◦ 1683 van Leeuwenhoek observes microorganisms 1890 W.D. Miller, “non-specific plaque theory” 1924 Clarke, isolates streptococcus mutans 1960 Keyes, specific microorganisms cause caries and are transmissible  MS (mutans streptococcus) ◦ Ecological niche in human oral cavity  Acidogenicity, aciduricity and adherence to teeth  Metabolizes variety of sugars  Responsible for initiation of caries, not sole factor  MS acquisition by infants ◦ Oral cavity colonized after eruption of teeth ◦ Window of infectivity ◦ Mostly acquired between 19-33 mths of age  Those who acquire early may be at ↑ caries risk  Transmission ◦ direct or indirect ◦ Vertical, usually from mother  Colonization ◦ +: sweet fluids, sugar exposure, snacking, food sharing ◦ -: toothbrushing, multiple courses of abx 2. Dietary Factors ◦ Food factors that are protective  Milk: calcium, phosphate, casein, protease peptones  Cheese: similar to milk, ↑ saliva  Apples, cranberries: flavonoids, inhibit bact adherence, antibact action  High fiber foods: mechanical stimulation of salivary flow Healthiest alternative: whole foods, non-processed foods 3. Host Factors: ◦ Tooth Factors  Enamel quality, pits & fissures, hypoplasia, Fl exposure ◦ Saliva  mineral content, pH, flowrate, buffering capacity, antimicrobial components, Fl, supersaturated with Ca and P, proteins, immunologic components  Flow rate  ↓ by meds, disease, dehydration, radiation, age  ↑ by gustatory and masticatory stimulants 4. Modifying Factors ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Race/ethnicity Healthcare delivery system Socioeconomic status Behaviour/education General health Culture Stress Genetic factors Other  Shifts in Presentation ◦ 19th vs 20th/21st centuries  19th century: disease of affluence  20th/21st centuries: disease of poverty ◦ 1900-1950: pandemic ◦ 1950-1970s: era of fluoridation ◦ 1970s-present: decline in caries prevalence  shifts in ethnic/SES distribution  80% caries in 20-25% population  Primary Teeth: dx and tx considerations ◦ ◦ ◦ ◦ More rapid progression of caries Enamel and dentin thinner Pulp relatively larger Flat contacts ◦ Caries sequence  Mand molars → Max molars → Max anteriors  Principles: ◦ Reorient: tx of cavities (disease) → mgmt of caries (process) ◦ Surgical approach problematic ◦ Treat cause than manifestation of disease  Strategy: ◦ Determine child’s current caries experience ◦ Estimate risk for future caries ◦ Develop plan to address current problem and prevent future disease  Why: health supervision, not disease tx  Old Model: ◦ Caries inevitable treat effects → preventive care → start age 3  New Model: examine early → risk assessment → anticipatory guidance → true prevention  AAP, ADA, AAPHD: ◦ support initial evaluation by age 1  AAP Policy Statement: ◦ Identify high-risk children at an early age ◦ Identify high-risk mothers during pregnancy ◦ Use anticipatory guidance, behaviour modification (OH, feeding practices) ◦ Establish dental home by age 1 year  AAP recommends referral to dentist by age 1 ◦ ◦ ◦ ◦  Child has special health care needs Mother has high caries rate Child has caries, plaque, demin and/or staining Family is low SES Anticipatory Guidance ◦ Practical, dvlpt-appropriate health info ◦ Alert impending change, teach role in maximizing child’s dvlpt potential, identify child’s special needs  Concept of Dental Home ◦ Modeled after AAP medical home ◦ Philosophy embraced by dental practice ◦ Characteristics:  Accessible, family-centered  Comprehensive, coordinated, continuous  Compassionate, culturally competent  Embraces prevention  Coordinates specialized care  Provides personalized recall program and emerg care Risk Assessment 1. Tx disease process than outcome of disease 2. Understanding of disease factors & aids in individualizing preventive discussions 3. Individualizes, selects & determines frequency of preventive and restorative tx 4. Anticipates caries progression/stabilization Social factors Diet Cultural factors Host Behavioural factors Fl exposure Microflora CRA is the determination of: the likelihood of the incidence of caries during a certain time period or the likelihood that there will be a change in the size or activity of lesions already present.  Caries risk indicators are variables ◦ thought to cause disease directly ◦ shown useful in predicting disease ◦ considered protective factors Best tool to predict future caries is past caries experience    Children with white spot lesions should be considered at high risk for caries Plaque accumulation is strongly associated with caries development MS levels and age at which child becomes colonized with cariogenic flora Factors High Risk Mother/primary caregiver has active cavities Yes Parent/ caregiver has low socioeconomic status Yes Child has >3 between meal sugar-containing snacks/beverages per day Yes Child is put to bed with a bottle containing natural or added sugar Yes Moderate Risk Child has special healthcare needs Yes Child is a recent immigrant Yes Protective Factors High Risk Moderate Risk Protective Child receives optimallyfluoridated drinking water or fluoride supplement Yes Child has teeth brushed daily with fluoridated toothpaste Yes Child receives topical fluoride from health professional Yes Child has dental home/regular dental care Yes Factors High Risk Child has >1 DMF surfaces Yes Child has active white spot lesions or enamel defects Yes Child has elevated mutans streptococci levels Yes Child has plaque on teeth Moderate Risk Yes Protective  CRA Tool can: ◦ Aid in identification of reliable predictors to identify and refer high-risk children ◦ Assist in providing evidence for and justifying:  periodicity of service  modification of third-party involvement in the delivery of dental services  quality of care with outcomes assessment to address limited resources and workforce issues  Designed to assist in clinical decision-making Provide criteria regarding dx and tx Lead to recommended courses of action  Result:   ◦ aids in developing an individualized treatment plan ◦ based on specific patient’s risk levels, age and compliance ◦ incorporates preventive strategies  Caries management: ◦ Past: caries a progressive disease that eventually destroyed tooth unless surgical/restorative intervention ◦ Now: known surgical intervention alone does not stop disease  modern management more conservative and individualized 1. Determine risk category a. b. c. d. e. Low risk Moderate risk – parent engaged Moderate risk – parent not engaged High risk – parent engaged High risk – parent not engaged 2. Diagnostics: recall schedule, rads, MS levels 3. Interventions: Fl, diet, sealants 4. Restorative: surveillance incipient, restore cavitated lesions 1. 2. 3. Dental CRA, based on child’s age, biological factors, protective factors and clinical findings should be part of new & periodic examinations Estimating caries risk will help establish periodicity and intensity of diagnostic, preventive and restorative services Clinical management protocols will enable individualized patient management of dental caries