“Opening the Mouth”
Continuing MCH Education in Oral Health
Columbia University
School of Dental and Oral Surgery
Division of Community Health
Learning Objectives
 Understand the connection between oral health and overall health
 Understand that dental caries is an infectious, transmissible,
communicable disease
 Understand the prevalence, acuity and consequence of dental disease
 Understand dental care finance, delivery and workforce
 Identify Title V opportunities for intervention
Oral Health and Health Care
Introduction:
 Despite great strides in improving oral health, disparities still exist across
population groups of all ages.
 The Surgeon General reports:
“those who suffer the worst oral health are found among the poor of all ages,
with poor children and poor older Americans particularly vulnerable. Members
of racial and ethnic groups also experience a disproportionate level of oral health
problems. Individuals that are medically compromised or who have disabilities
are at a greater risk for oral diseases, and, in turn, oral diseases further jeopardize
their health”(1).
Oral Health and Health Care
 Tooth decay remains the single most common, chronic disease of childhood; 5x
more prevalent than asthma (1)
 Children suffering the highest rates and most severe dental disease tend to be
preschool-aged and disadvantaged by poverty, minority status or social
conditions.
 Approximately 25% of children under age 19, account for 80% of the dental
disease.
 Dental disease, untreated, results in pain, infection, and may inhibit general
growth and development (2)
 Periodontal disease and chronic oral infections are considered a risk factor for
heart disease, inadequate glycemic control in diabetics and more recently, poor
pregnancy and birth outcomes.
Oral Health and Health Care
Healthy People 2010
 “Oral diseases and conditions may have a significant impact
on general health…..Oral health care is an important, but
often neglected, component of total health care. Regular
dental visits provide an opportunity for the early diagnosis,
prevention, and treatment of oral and craniofacial diseases
and conditions for persons of all ages, as well as for the
assessment of self-care practices”. (3)
Part I: Conception to Birth
 Meet Mrs. Perez. She is a 32-year-old, Hispanic mother of 2 children, under the
age of 6 years, and pregnant for her third.
 She presents to the dental clinic at her local community health care center,
complaining of “bleeding gums and loose teeth”.
 Her dental pain has progressed to the point that eating has become difficult.
 Mrs. Perez was unable to attend the clinic prior to today, as she could not afford
to pay for the dental treatment, not to mention child-care for her 2 children and
the cost for public transportation.
 The private dentist located “relatively” close to her inner-city home, informed
her that he “does not accept Medicaid”.
 After her examination, the dentist informs Mrs. Perez that she has periodontal or
“gum” disease.
Periodontal Disease
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The case of Mrs. Perez is unfortunate, but commonplace in community health center
dental clinics.
The reality of this case?
Hispanic and African American populations have higher rates of oral disease and
tooth loss than the white, non-Hispanic majority population
Approximately 26% of adults aged 18-34 years, do not have health insurance (1)
72% of adults not obtaining dental care state that the major reason is financial (4)
Few dentists participate in the Medicaid program (approx 1/3 of dentists provide at
least one dental appt under medicaid, & only 14% are active medicaid providers, i.e..
billing > $10,000 as a percentage of total active patients) (5)
There is a decline in the number of dentists per 100,000 people and it is anticipated
this shortage will increase over time. As of June 2003, 2112 dental health professional
shortage areas have been identified. It would take 8481 additional dentists to achieve
a target dentist-to-population ratio of 1:3,000. (6)
Periodontal Disease
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The number of underrepresented minorities in the dental profession is significantly
low compared to their proportion in the overall population (5.7% of graduate dentists
are African American and 5.3% are Hispanic; These percentages are far below the
percentage of African American (12%) and Hispanics (11%) in the general
population) (7). Thus, patients may be faced with language barriers and/or cultural
incompetence.
Safety net facilities (e.g. dental schools, community health centers, hospital clinics
and mobile vans) are few in number compared to the medical safety net (primarily
because community hospital emergency rooms comprise a major component of the
medical safety net, whereas emergency rooms typically only offer palliation with
medication for dental complaints. In addition, there are 4x as many medical schools
than dental schools.
Although only 1% of Medicaid expenditures is related to dentistry (0.5% for
children)(8), fiscal demands have led to reductions in, or elimination of dental
benefits for adults and the disabled. In 2003, only 8 States had comprehensive adult
dental coverage under Medicaid, while 43 States had no coverage or limited coverage
(53)
Periodontal Disease:
Poor Birth Outcomes
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Despite pain and discomfort, some
women never present for care (Fact: less
than two thirds of adults reported having
a dental visit in the last year{1}).
What happens if Mrs. Perez does not
receive the necessary dental treatment
for her periodontal disease? The most
obvious consequence will be continued
mouth pain, disease progression and
eventual tooth loss.
But what about the systemic effects of
her periodontal disease? How will her
oral disease affect her pregnancy or her
unborn child?
Learning Objectives:
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What is the association
between periodontal disease
and poor birth outcomes
Putative Biologic Pathway
Putative effectiveness of
intervention & evidence for
intervention
Periodontal Disease:
Poor Birth Outcomes
Periodontal Disease:
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Periodontal disease (periodontitis or
“gum disease”) is a chronic infection
caused by bacteria existing at the gum
line in the form of plaque and calculus
(“tarter”). (Picture of periodontitis –
Papos Papapanou- waiting for picture)
Periodontal disease causes inflammation
and bleeding gums and, if not treated,
leads to tissue destruction, tooth mobility
and eventually tooth loss.
Growing body of research supports an
association between periodontal disease
and Pre-term low birth-weight (PLBW)
(link to studies further on in module)
Periodontal Disease:
Poor Birth Outcomes
Preterm Low Birth-weight:
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PLBW pregnancy outcomes in the U.S. remain a concern because of the significant
consequences to maternal and child health, high costs, long-term disease burden, and
individual suffering.
Economic consequences exceed $5 billion annually
Accounts for 6-9 percent of all births (9)
Centers for Disease Control maintains that the second leading cause of infant
mortality is premature/low birth-weight (10)
Accounts for 70% of all perinatal deaths and 50% of long-term neurologic morbidity
(9)
NIH reports that “as many as 18% of the 250,000 premature low-weight infants
born in the United States each year may be attributed to infectious oral disease”
(call out box?)(11)
Periodontal Disease:
Poor Birth Outcomes
State of the Science:
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Known causes of PLBW, that may be medically managed, include asthma,
cigarette smoking, bacterial vaginosis and diabetes
However, much of its incidence remains unexplained
Classic measures for association between periodontal disease and poor birth
outcomes, are being explored and show likely causality
Based on this emerging science, there is hope that the severe developmental,
behavioural, health and economic consequences of PLBW may be
minimized by improving oral health during pregnancy
Periodontal Disease:
Poor Birth Outcomes
State of the Science:
 Animal Studies
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Inducing experimental periodontitis in animals, leads to significantly smaller litter
weights (12).
These animals show higher levels of blood-borne chemical mediators that are
responsible for causing uterine contraction, cervical dilation, labour and abortion
(13).
Periodontal Disease:
Poor Birth Outcomes
State of the Science:
 Humans studies:
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The association was first identified by secondary analysis of
NHANES III (13)
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One case-controlled study, after adjusting for all other risk factors (e.g.
tobacco use and maternal age) found that women with periodontal disease
had 7 times the risk of delivering a PLBW baby (13).
More recent human studies following women through pregnancy, compares
favourable and unfavourable birth outcomes. Preliminary results indicate
that mothers with advanced periodontitis have a higher risk of delivering a
PLBW infant. (14,15)
NIH supported, multicenter, RCT studies are currently underway
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Periodontal Disease:
Poor Birth Outcomes
Effectiveness and Evidence for Intervention:
 Can treating periodontal disease in pregnancy
reduce poor birth outcomes?
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Two studies have shown an association between treating periodontal disease during
pregnancy and improved birth outcomes (16, 17)
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For the mother, there are no known negative consequences associated with
improving the oral health of pregnant women. The positive is that it may
reduce poor birth outcomes, which is a considerable benefit for the child.
Thus, there is great enthusiasm in promoting optimal oral health during
pregnancy.
Dental Care for
Pregnant Women
The National Healthy Mothers, Healthy Babies Coalition (HMHB):
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Issued a statement of position that “oral health care during pregnancy is crucial and should be
available to all women, regardless of income level”. They are committed to “working with dental
and other health care providers to increase awareness of, and support research on, the possible link
between periodontal disease and pre-term, low birth-weight babies” (18)
See The National Healthy Mothers, Healthy Babies Coalition Position Statement on Oral Health
and Pregnancy at www.Hmbh.org/ps_oral health.html
American Academy of Periodontology:
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Has recently developed a draft policy statement that recommends pregnant women have a
periodontal examination performed and appropriate preventive and/or therapeutic services
provided, as there is immerging evidence that women with periodontal disease may be more at
risk to deliver a preterm low birth weight baby (August 2003)
See the AAP website @ www.perio.org
Dental Care for
Pregnant Women
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Clinical guidelines suggest that routine plaque and calculus removal via polishing, scaling
and curettage, can be performed safely during pregnancy, regardless of trimester (19)
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Dentists and obstetricians agree that routine dental care should be maintained throughout
pregnancy. (20,21)
Despite the growing evidence and literature to support the association between periodontal
disease and PLBW, it has not been widely translated into clinical or public policies.
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Oral Health Programs for
Pregnant Women
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Medicaid programs, administered by the
states within federal guidelines, are
required to provide certain populations
with specified (“mandatory”) benefits.
Dental is only mandated under Early and
Periodic, Screening, Diagnostic, and
Treatment Services Program ( EPSDT).
Dental coverage for pregnant women (+
21 years) currently is not a “mandatory”
benefit (see note)
Pregnant young women (< 21 years) that
are covered by Medicaid, must be
enrolled under the EPSDT to receive
comprehensive dental benefits (22)
Centers for Medicare and Medicaid Services (HCFA)
Medicaid Services State by State, October 1, 1996.
HCFA Publication 02155-97.
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California: first in the nation to extend
dental benefits to pregnant women
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Adult women and minors who are
pregnant become eligible for either
adult dental coverage (if over the
age of 21) which includes
periodontal treatment or the full
range of EPSDT dental services,
which also include periodontal
treatment (23)
Note: Louisiana and Utah have recently
added benefits – Waiting for info
from Ann DeBiasi at CDHP
(Insert this in a “popup” box ?)
 In California, with the addition of preventive periodontal to the scope of MediCal benefits for women in the pregnancy services only and pregnancy and
emergency services only aid categories, the estimated savings for fiscal year
2004-2005 is $24,427,000 (23).
 (Based on the estimate that in FY 2003-2004, the number of Medi-Cal low
birth-weight babies attributable to periodontal disease is estimated at 2,655. The
average neonatal savings per child is $22,000. Approx. 50% of women will
complete sufficient preventive periodontal care to bear a normal birth-weight
infant
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Mrs. Perez was unable to undergo periodontal treatment as she could not afford to pay for
the service. Six months after her visit to the health center dental clinic, she delivers a
preterm low birth-weight baby girl.
Fortunately, with advances in neonatal care, survival rates of pre-term, low-birth-weight
babies have dramatically improved.
Unfortunately, studies indicate that pre-term children suffer from a multitude of acute and
long-term problems, including significant delays in physical and psychological growth and
development of all structures, including the craniofacial complex and teeth
Oral structures, like other tissues, are affected by prematurity and low birth- weight
(24)
Part II: Early Childhood
Tooth Decay
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Meet 12 month-old Maria Perez.
During Maria’s well-baby exam at her
primary care physician’s office, Mrs.
Perez states that Maria’s front teeth
“didn’t look right” when they erupted.
The health history indicates that Maria
was a pre-term infant (i.e.. < 37 weeks
gestation) with a low birth weight (i.e.. <
2500gm).
Her physician takes a brief look,
reassures Mrs. Perez that it is a
“developmental problem” and suggests if
she has further dental concerns, that she
should see a dentist. He does not write a
referral letter.
Early Childhood
Tooth Decay
 Learning Objectives:
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What is early childhood tooth decay
Prevalence, acuity and consequence of early childhood tooth decay
Infection and transmission
Current treatment (Restorative dentistry)
Emerging treatment (Prevention and disease management)
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The goal of an early dental assessment is primary prevention (see slide 36). This may be
accomplished with the timely delivery of oral health information, including the conditions
that create caries & cavities; its natural progression; and its prevention (Anticipatory
Guidance – see slide 37), and the identification of populations at high risk for tooth decay,
The traditional approach of treating the effects of dental decay (i.e.. “drilling and filling”)
is being replaced by disease prevention and disease management.
Prevention focuses on the establishment and maintenance of good oral hygiene, optimizing
systemic and topical fluoride exposure, and eliminating prolonged exposure to simple
sugars in the diet. Prevention is the foundation for the establishment of a “dental home” by
1 year of age.
The concept of the "dental home" is derived from the American Academy of Pediatrics
concept of the "medical home." This concept states that “the primary health care of infants,
children, and adolescents should be accessible, continuous, comprehensive, family
centered, coordinated, compassionate, and culturally effective. It should be delivered or
directed by well-trained child health specialists who provide primary care and help to
manage and facilitate essentially all aspects of pediatric care” (25).
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As young as this child is, both
developmental and acquired disease are
already evident on examination.
Active Disease:
 Maria was noted to have thick plaque
and decalcification (mineral loss) on her
primary teeth (red arrow). The gingival
tissue appeared shiny and full (blue
arrow), indicating inflammation.
Developmental Findings:
 Notching of incisors (yellow arrows),
eruption hematoma (purple arrow),
atypical eruption sequence (pink arrow),
and an anatomical variant of the labial
frenum (green arrow)
Caries Risk Assessment
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Advances in the understanding of dietary influences and fluoride on dental disease become
instrumental in supporting early intervention
Every child should have an examination and oral health risk assessment by 12 months of
age by a dentist or qualified pediatric health care professional. (26)
The Caries Risk Assessment Tool (CAT), provided by the American Academy of Pediatric
Dentistry (27), was designed to assist both dental and nondental health professionals in
assessing the risk of tooth decay in infants, children and adolescents.
The CAT can be used to determine the relative risk of caries of the patient
Questions directed at dietary practices, fluoride exposure, oral hygiene, utilization of dental
services, socioeconomic status and general level of health can help determine if a child is
at low, moderate or high risk for dental disease.
Using the CAT ( http://www.aapd.org/members/referencemanual/pdfs/0203/Caries%20Risk%20Assess.pdf ), and Maria’s history (low socioeconomic status and no
usual source of dental care) and exam findings (thick plaque, areas of demineralization and
gingivitis), Maria would be considered at high risk for dental disease.
 Maria’s main problem is the abundant plaque on her front teeth.
 Visible plaque on the front teeth, is positively correlated with caries
development by age 3 (28) (Call out box?)
 The primary components of dental plaque are bacteria. Acid, produced by these
bacterial species (mainly Streptococcus mutans) is considered the most
important activity in the production of tooth decay.
 Maria,being a low birth-weight infant, is at risk for enamel hypoplasia, as 20 %
of low birth-weight children are affected.
 Enamel hypoplasia is defined as a deficiency in enamel formation, that manifests
clinically as grooves or pits, or a lack of surface enamel (29). These surface
irregularities act as “plaque traps” allow for an increased colonization of harmful
bacteria and increase Maria’s risk for developing cavities.
 It is too late for Maria to gain the advantage of primary prevention and some
aspects of anticipatory guidance, as she already exhibits signs of dental disease.
 Maria is not too late for disease suppression (see slide 39). With proper diet
control and the application of topical fluoride, Maria may have avoided surgical
intervention. Unfortunately, without a timely referral, disease progression is
inevitable.
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Maria is now 33 months old.
She has presented with her mother to the local
health center dental clinic, because, according
to Mrs. Perez, Maria has “been up all night,
crying about her teeth”.
Dental History- in the last 2 months, Maria
has become increasingly irritable at mealtimes.
It began as whining with cold or sweet foods,
and has progressed to crying when biting with
the front teeth. For the last 3 nights Maria has
awoken from sleep and Mrs. Perez was able to
console her with her usual bottle of apple juice.
Last night, she was inconsolable and required
pain medicine (“oral numbing gel”) to help her
sleep.
Mrs. Perez did not take Maria to the dentist
before, as her local dentist doesn’t except
medicaid and she is aware of the unpredictable
wait and long hours for walk-in “emergencies”
at the health center. Additionally, Mrs. Perez
stated that since these are Maria’s “baby
teeth”, that they will “just fall out anyway, so
why bother fixing them”.
Maria’s upper (maxillary) teeth, with
severe early childhood tooth decay
Failure of Early Intervention
Failure of Early Intervention?
Tooth decay in the primary teeth, has significant functional and disease
progression consequences:
Disease
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Since the mouth is the locus of disease, and not all the primary teeth are replaced
simultaneously, disease in the primary teeth will spread to the incoming permanent teeth. Dental
disease impacts all the new teeth as they become available, and because the exchange takes so
long (12-13 years), children that have untreated, active oral disease are at an increased risk for
more generalized, severe tooth decay.
Child
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As can be seen in Maria’s case, early childhood tooth decay in the primary teeth, if not cared
for, results in chronic pain, infection and sleepless nights. It may also lead to poor weight gain,
the inability to eat (2) and affects overall quality of life. (30)
Dentition
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Loss of primary teeth impairs mastication, affects the development of the craniofacial system,
and results in loss of arch space for the succeeding permanent teeth to “grow in” (erupt) into the
proper position.
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Maria is diagnosed with severe early
childhood caries or “tooth decay”.
Maria’s upper (maxillary) teeth, with
severe early childhood tooth decay
Early Childhood Tooth Decay
What is dental caries?
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Dental caries, better known as “tooth decay”, is the disease process that leads to the loss of tooth
mineral and eventually, cavitation of the tooth surface (“cavity”). It is a dieto-bacterial, infectious,
transmissible, oral disease.
Three things are required for dental caries activity to become established: one or more susceptible tooth
surfaces, "cariogenic“ (decay causing) bacteria and fermentable carbohydrates (particularly sucrose).
What is early childhood caries?
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Early childhood caries (ECC) or early childhood tooth decay, previously termed “nursing caries” or
“baby-bottle tooth decay”, is a particularly virulent form of tooth decay, that affects the teeth of infants
and preschool children.
It results from an overgrowth of specific organisms that are a part of dental plaque (sticky white or
yellow film found on the tooth surface) . Although numerous types of bacteria live in the mouth, tooth
decay results from the overgrowth of specific cariogenic (decay causing) organisms. Studies
demonstrate that children with early childhood tooth decay, have Streptococcus mutans (S. mutans),
counts that exceed 30% of the cultivable plaque flora (31-33). Conversly, in children with negligible to
no caries activity, S. mutans comprises less than 1% of total cultivable flora (34). Thus, S. mutans have
been implicated as the most likely infectious etiologic agents of tooth decay (35).
Transmission:
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Infants are colonized with the eruption of the
primary dentition at approximately 6 to 30
months of age. The primary caregiver of the
infant, frequently the mother, has been shown
to be the most likely source of inoculation of
an infant’s dental flora. There are no studies
that explain absolutely how transmission
occurs, however, examples include cleaning
the baby's pacifier in the mother's mouth
before giving it to the baby, sharing utensils or
pre-chewing the baby's food.
Transmission and colonization of S mutans
depends on the magnitude of the innoculum.
Higher levels of S mutans are associated with
untreated tooth decay, thus, infants of mothers
with untreated tooth decay are at higher risk of
acquiring the bacteria (36)
Acid Production and Demineralization:
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Decay causing bacteria ingest sugar and other fermentable carbohydrates and produce acid
as a by-product, causing a drop in the plaque pH. The acid attacks the outer surface of the
tooth (enamel) for approximately 20 minutes, resulting in mineral loss (demineralization).
Perhaps the single strongest predictor of disease acquisition and progression, is
frequency (rather that quantity or source) of fermentable carbohydrates (e.g.
sweetened milk, juice, soda). (CALL OUT BOX?)
“White Spot lesions” - Clinically, this is the first detectable stage of tooth decay. It is an
area of demineralization, characterized by a chalky, white appearance. Although white spot
lesions represent loss of mineral from the tooth, the loss is localized mainly in the
subsurface of the enamel. The enamel surface in the incipient lesion is essentially intact
and amenable to remineralization. THIS STAGE IS REVERSIBLE.
“Cavities” - When demineralization exceeds remineralization as a result of frequent or
prolonged acid attacks, the result is a breakdown of the enamel, and the formation of a
hole or “cavity” in the tooth surface. This is a late-stage sign of tooth decay. Cavities are
not reversible, but can be arrested with intense diet control and oral hygiene and topical
application of fluoride.
Early Childhood Caries
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Despite it being easily preventable, ECC continues to be a public health issue.
Dental caries affects approximately 1/5th of preschoolers, ½ of second
graders (3, 36)
80% of tooth decay is concentrated in 25% of children (37)
Low income children, who suffer the most from dental disease, have the least
access to care
Call-out box: Low income pre-schoolers are twice as likely to experience
caries, twice as likely to experience dental pain, have more than twice the
extent of dental disease, and are twice as likely to have insurance coverage
because of medicaid, but are only ½ as likely to have a dental visit because of
lack of access (CDHP 38)
Dental disease, untreated, results in pain, infection, and may inhibit general
growth and development (2)
Early Childhood Tooth Decay:
Classical Treatment
 Classical treatment typically
involves surgical removal and/or
restoration of carious teeth. Due to
age appropriate inability to tolerate
outpatient surgical treatment,
coupled with the extent of
restorative needs, Maria will be
treated under general anesthesia.
 In the U.S., the initial cost of
treating a child in the operating
room for severe caries, exceeds 5
million dollars annually. (39)
Early Childhood Tooth Decay:
Classical Treatment
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Unfortunately, restorative dentistry alone, has had minimal impact on outcomes of
children with early childhood tooth decay because it is non-therapeutic in that it doesn’t
impact the underlying disease process. Relapse remains high and children frequently
require a second general anesthetic. (40-43)
Dental restorations are “prosthetic”, rather than therapeutic, in that they function to replace
missing tooth structure, but the majority of restorations are not bioactive (the exception are
glass-ionomer cement restorations that release fluoride).
Early childhood tooth decay is a risk factor for future caries and is a good indicator of
future caries experience (42, 44-46). Thus, the initial cost of treatment grossly
underestimates the long term cost.
With the knowledge that tooth decay is an infectious and transmissible disease, that it is
diet dependent and fluoride mediated, and that restorative dentistry has minimal impact on
outcomes, the emerging trend in dentistry focuses on Disease Prevention and Disease
Management.
Early Childhood Tooth Decay:
Disease Prevention
 True Primary Prevention – prevents disease occurrence by avoiding disease
determinants. In tooth decay, this relates to reducing the reservoir of bacteria,
reducing transmission and reducing colonization of cariogenic bacteria.
(Reservoir  vector  receptor).
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Reducing the reservoir: xylitol chewing gum (use of xylitol containing chewing gum
has been shown to inhibit mutans streptococci colonization and reduce the caries
experience in children (47, 48)stannous fluoride and chlorhexidine (with dental
repair)
Reducing transmission: avoid sharing utensils, cleaning pacifier in mouth etc.
Reducing colonization: oral hygiene (brushing with fluoridated toothpaste), diet
control (reduce frequency of carbohydrates) and topical fluoride application (e.g.
fluoride varnish)*
Role of Fluoride:
1.
Antibacterial action on plaque bacteria
2.
Inhibits demineralization
3.
Enhances remineralization
Early Childhood Tooth Decay:
Disease Prevention
PATHOGENIC FACTORS
Cariogenic Bacteria
Frequent Carbohydrate Ingestion
Reduced Salivary Function
TOOTH DECAY
PROTECTIVE FACTORS
Reduce the Reservoir
Dietary Control
Fluoride
Optimal Oral Hygiene
Saliva (Flow/Components)
HEALTHY TOOTH
Early Childhood Tooth Decay:
Disease Prevention
Primary disease prevention may be achieved with early intervention and anticipatory guidance:
 Anticipatory guidance
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In dentistry, this involves informing parents of the conditions that create caries & cavities; its
natural progression; and its prevention.
Dental Home
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The concept of the “dental home” is derived from the American Academy of
Pediatrics concept of the “medical home” (49). It affords the opportunity for
prevention.
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Goal is to reduce risk of preventable disease
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Provides risk assessment; tailored counseling; anticipatory guidance; emergency plan;
access to comprehensive dental care, including any necessary referrals
Age One Dental Visit
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Accepted policy by ADA, Pediatric Dentists, Pediatricians, and Public Health Association
Intended to allow for true primary prevention, establishment of dental home, and ongoing
anticipatory guidance (50)
Consists of history, risk assessment, examination, tailored anticipatory guidance, and counseling
Early Childhood Tooth Decay:
Disease Prevention
 Secondary Prevention – prevents disease by maintaining a state of balance
between disease and health. A state of oral health is not absence of activity, but
rather a balance of activity. The teeth are in a constant state of demineralization
(loss of mineral) and remineralization. When demineralization exceeds
remineralization, the earliest signs of tooth decay (“white spot”) begin, however,
at this point it is reversible. Remineralization can occur when there is a balance
between diet, oral hygiene and fluoride exposure.
Early Childhood Tooth Decay:
Disease Management
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Disease Management – when children have not
had the benefit of primary prevention and
anticipatory guidance, and caries activity has
progressed to the point that there is tooth
destruction, the following concepts are
employed:

Disease Suppression: this is suppression
of the disease (caries activity) before
repairing the teeth. It involves intensive
diet control to reduce frequency of acid
attack on teeth, fluoride applications to
increase remineralization and resistance
to attack and gross caries excavation to
decrease bacterial load.

Disease Arrest: once caries activity has
been suppressed, affected teeth will have
lost tooth structure (“cavity”) but will be
dark or glassy in appearance and will not
need to be restored unless it is an issue of
function or esthetics.
Dark brown/black discoloration:
Arrested Disease
TOOTH DECAY
Decay Causing Bacteria
Carbohydrates
Acid
Acid
Acid
Acid
Acid
Mineral Loss
Acid
Acid
Acid
Acid
Acid
DEMINERALIZATION
TOOTH DECAY
TOOTH DECAY
Saliva
(Minerals)
Fluoride
Acid
Acid
Acid
Acid
Acid
Acid
Acid
Acid
Decreased Carbohydrate
Frequency
Acid
Acid
REMINERALIZATION
Acid
TOOTH REPAIR
Delaying and Reducing Transmission, Delays and Reduces Tooth Decay:

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Studies on controlling infection and colonization of the oral cavity with the primary
etiologic agent for early childhood tooth decay (mutans streptococci) have shown
promise.
Mother-child couples receiving prenatal counseling on oral health and preventive care
(dental cleanings and fluoride applications) every 6 months, had a significant
improvement in oral health and a reduction of mutans streptococci in the 4 year study
period.
Children enrolled in the study from before birth to 4 years of age, that received
preventive treatment had a reduced caries incidence and delayed S. Mutans
colonization (51)
 Prevention of oral disease, whether it is periodontal disease
or tooth decay, will not work if the populations at risk can
not access care.
 By identifying the barriers to care, specific action steps can
be taken to increase oral health awareness and access for
high risk populations.
Barriers to Care
 Reasons are complex
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Low socioeconomic status
Lack of community programs (e.g Fluoridated water supplies)
Barriers to access (lack of transportation, inability to get time off work, physical
disability
Lack of resources to pay for care
Lack of dental insurance
Inadequate public dental insurance programs
Lack of public awareness and understanding of the importance of oral health
Few dentists accept patients on Medicaid due to low re-imbursement rates, abundance
of paperwork, and broken appointments
Action Steps



In March 2000, a forum of experts from a variety of disciplines, convened for the Surgeon
General’s Workshop on Children and Oral Health to discuss how to address the disparities
in oral health and dental care for America’s children.
Eight major recommendations arose from the deliberations, and were presented at the June
2000 Surgeon Generals’ Conference entitled The Face of a Child (52)
The following recommendations can be used as initial action steps to help not only our
nation’s children, but other vulnerable populations, to enjoy comprehensive oral health
care, so they may enjoy sound, sustainable health:
Action Steps
Start early and involve all:
1.

Includes establishing a child’s dental home at age one, identifying high-risk
children and promoting individualized preventive regimens in both medical
and dental practice, developing community-based health coordinators to
promote ongoing integration of oral health with general health care,
developing day-care accreditation standards on oral health, and addressing the
oral health needs of caregivers to promote more widespread attention to oral
health
Assure competencies:
2.
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Includes developing common core curricula on oral health for all health
professionals and developing accreditation standards, guidelines, and
performance measures that assure the inclusion of oral health promotion and,
where appropriate, treatment unprofessional training and practice.
Action Steps
Be accountable:
3.

Includes promoting school-based prevention, education, screening , and
referral programs on oral health and developing performance measures and
tracking systems to ensure that these programs are effectively implemented.
Take public action:
4.

Includes developing activist coalitions that ensure stable-funded, communitybased comprehensive health promotion and disease prevention and crafting
messages that specifically target providers,policy makers, and the public
Maximize the utility of science:
5.

Includes expanding the range and utility of science-based interventions;
developing an evidence base on the effectiveness of oral disease management
techniques; and developing a coordinated agenda across basic, applied , and
health services research to promote oral health and effective dental care.
Action Steps
Fix public programs:
6.

Includes demonstrating cost benefits of prevention and disease management,
overhauling Medicaid Early and Periodic Screening Diagnostic and Treatment
Program (EPSDT) dental programs, encouraging provider participation in
Medicaid through various incentives, and enhancing the strength and viability
of the dental safety net.
Grow and adequate workforce:
7.

Includes prioritizing community-based educational experiences for dentists
and hygienists in training; expanding the number of pediatric and public health
dentists; engaging allied personnel more effectively, especially in health
promotion and disease prevention, and encouraging an expanded number of
minority providers in the dental professions.
Action Steps
Empower families and enhance their capacities:
8.

Includes developing media and key-contact campaigns to translate oral health
needs into demands for dental educational and treatment services; and using
risk-based methods to tailor care to the individual needs of children and their
families while respecting family and cultural determinants of health and health
behaviors.
Title V Opportunities
The following seven recommendations regarding Title V opportunities for expanding
and improving oral health, were published by the Association of Maternal and Child
Health Programs issue brief, Putting Teeth in Children’s Oral Health Policy and
Programs: The State of Children’s Oral Health and the Role of State Title V Programs:
1.
2.
Integrate the provision and promotion of dental health services into all aspects of
maternal and child health program implementation, needs assessment, policies, and
planning, including all programs and policies affecting children with special health care
needs (CSHCN).
Help train private and public health care practitioners about the oral health needs of
children, including those of CSHCN, to ensure that these needs are covered in a
comprehensive exam.
Title V Opportunities
3.
4.
5.
Through training and capacity building, help increase the number and quality of dental
health auxiliaries to alleviate the provider shortage in underserved areas.
Apply expertise in providing outreach and other enabling services to ensure that every
pregnant women, child and adolescent has access to full comprehensive, oral health
services.
Become involved in the development and/or acceptance of appropriate standards of
care as well as more extensive performance measures to monitor what level of dental
care children get (e.g. what percentage of children enrolled in Medicaid and CHIP
actually get dental services, reparative services, or complete care).
Title V Opportunities
6.
7.
Collaborate with oral public health programs and the private dental delivery system and
others, to raise awareness of oral health needs of children and youth, especially those
CSHCN, ensure access to care, and evaluate existing and novel program approaches.
Allocate appropriate staff, time, training and funds to identify, target, and help treat
high risk children, including CSHCN. Title V should meet the unmet need that remains
during and after CHIP implementation.
References
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6.
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Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute
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U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. 2 vols. Washington,
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Warren, Reuban C., DDS, Dr. PH. Oral Health for All:Policy for Available, Accessible, and
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Source: 2000 survey of State SCHIP and Medicaid Departments by The Forum for State Health
Policy Leadership,National Conference of State Legislatures
Data from Shortage Designation Branch National Center for Health Workforce Analysis Bureau of
Health Professions, HRSA – data as of June 2003
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Basis of Eligibility. Accessed on 2/11/04 at http://www.cms.hhs.gov/Medicaid/msis/msis99sr.asp (table 4)
Gibbs RS. The relationship between infections and adverse pregnancy outcomes: an overview. Ann Periodontol.
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Collins JG, Kirtland BC, Arnold RR, Offenbacher S. Experimental periodontitis retards hamster fetal growth.
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Collins JG, Windley HW 3rd, Arnold RR, Offenbacher S. Effects of a porphyromonas gingivalis infection on
inflammatory mediator response and pregnancy outcome in the hamsters, Infect Immun 1994; 62 (10); 4356-61.
Jeffcoat MK, Hauth JC, Geurs NC, Reddy MS, Cliver SP, Hodgkins PM, Goldenberg. Periodontal disease and
preterm birth:results of a pilot intervention study. J Periodontol. 2003; 74(8):1214-18.
Offenbacher S, Lieff S, Boggess KA, et al. Maternal periodontitis and prematurity. Part I:obstetric outcome of
prematurity and growth restriction. Ann Periodonto. 2001;6:164-174.
Mitchell-Lewis D, Engebretson SP, Chen J, Lamster IB, Papapanou PN. Periodontal infections and pre-term birth:
early findings from a cohort of young minority women in New York.
Eur J Oral Sci. 2001 Feb;109(1):34-9.
Lopez NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women
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The National Healthy Mothers, Healthy Babies Coalition Position Statement on Oral Health and Pregnancy.
Accessed Jan 10, 2004 at: www.Hmbh.org/ps_oral health.html
Little JW, Fallace DA et al. Pregnancy and breast feeding. Dental management of the medically comprimised
patient. St. Louis, Mosby.
Shrout MK, Comer RW, Powell BJ, McCoy BP. Treating the pregnant dental patient:four basic rules addressed.
Journal of the American Dental Association 1992; 123(5): 75-80.
Shrout MK, Potter BJ,Comer RW, Powell BJ. Treatment of the pregnant dental patient: a survey of general dental
practitioners. General Dentistry 1194; 42(2): 164-7.
Centers for Medicare and Medicaid Services (HCFA) Medicaid Services State by State, October 1, 1996. HCFA
Publication 02155-97.
Office of MediCal Dental Services, January 14, 2004
Marlow N, Roberts L., Cooke R. Outcome at 8 years for children with birth-weights of 1250 g or less. Arch Dis
Child 1993;68:286-90.
American Academy of Pediatrics, The Medical Home, 2002; 110(1):184-186. Accessed Feb 19, 2003 at:
htttp://pediatrics.aappublications.org/cgi/content/full/110/1/184?ijkey=35c754b2ad778614cf012a081cf6711c61e3c8
b0
American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): classification, consequences, and
preventive strategies. Pediatr Dent. Reference Manual, 2003-2004; 25 (7): 24-25.
American Academy of Pediatric Dentistry. Policy statement on Use of a caries-risk assessment tool (CAT) for
infants, children, and adolescents. Pediatr Dent. Reference Manual, 2003-2004; 25 (7): 18-20. Accessed Feb 19,
2003 at: http://www.aapd.org/members/referencemanual/pdfs/02-03/P_CariesRiskAssess.pdf
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Low W, Tan S & Schwartz S, The effect of severe caries on the quality of life in young children,
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Tanzer JM, Livingston MS, Thompson BS. The micorbiology of primary dental caries. NIH
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NIDCR/CDC Dental, Oral and Craniofacial Data Resource Center (DRC), NHANES III. Accessed
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LINK!)
Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn DM, Brown, LJ. Coronal caries in the
primary and permanent dentition of children and adolescents 1-17 years of age: United States,
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At-a-Glance Pediatric Oral Health & Oral Health Disparities. Children’s Dental Health Project. Can
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room annually for dental care
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Additional Resources
 Children’s Dental Health Project


This non-profit organization promotes public and clinical
policies with the goal of improving health and access to
comprehensive care for children and other vulnerable
populations.
The CHDP website: www.Cdhp.org contains publications
and resources that can be used by policy makers,
healthcare providers and advocates to help benefit all
children and vulnerable populations
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Opening the Mouth” Continuing MCH Education in Oral …