Wednesday, August 28, 2013

Evidence-based clinical recommendations for the use of pit and fissure sealants: A report of the American Dental Association Council on Scientific Affairs

Resident: Mackenzie Craik

Author: Beauchamp et al.

Journal: JADA, March 2008, vol. 139.

Goal of Article: To answer the questions:

Key Points: Placement of resin-based sealants on the permanent molars of children and adolescents is effective for caries reduction.
-Reduction of caries incidence in children and adolescents after placement of resin-based sealants ranges from 86% at one year to 78.6% at two years and 58.6% at four years.
-Sealants are effective in reducing occlusal caries incidence in permanent first molars of children, with caries reductions of 76% at four years, when sealants were reapplied as needed.
-Pit and Fissure sealants are retained on primary molars at a rate of 74.0 to 96% at one year.


These evidence-based recommendations are a resource to be considered in the clinical decision-making process, which also includes the practitioner's professional judgment and the patient's needs and preferences.  The recommendations address circumstances in which sealants should be placed to prevent caries, sealant placement over early (noncavitated) lesions, conditions that favor the placement of resin-based versus glass ionomer cement, and techniques to improve sealants' retention and effectiveness in caries prevention.

Assessment:  I thought it was an interesting article.  Pit-and-Fissure sealants can be used effectively as part of a comprehensive approach to caries prevention.  While sealants have been used for primary caries prevention, current evidence indicates that sealants also are an effective secondary preventive approach when placed on early non-cavitated carious lesions.  Caries risk assessment is an important component in the decision-making process, and it is important to re-evaluate a patient's caries risk status periodically.

Policies on Early Childhood Caries

Policy on Early Childhood Caries (ECC): Classifications: Consequences, and Preventive Strategies.
Oral Health Policies, Reference Manual V34 NO6
Authors: American Academy of Pedodontics, American Academy of Pediatrics, and Council on Clinical Affairs.
Adopted 1978. Revised 1993, 1996, 2003, 2007, 2008, 2011
Resident: Margaret Cannon

Policy Statement: The AAPD recognizes caries as a common chronic disease resulting from an imbalance of multiple risk factores and protective foctors over time. To decrease the risk of developing ECC, the AAPD encourages professional and at-home preventive measures that include:
1.     Reducing the parent’s/siblings’ MS levels to decrease tranmission of cariogenic bacteria.
2.     Minimizing saliva-sharing activities to decrease the transmission of cariogenic bacteria.
3.     Implementing OH measures no later than the time of eruption of the first primary tooth. Toothbrushing should be performed for children by a parent twice daily, using a soft toothbrush of age-appropriate size. In children considered at moderate risk under the age of 2, a “smear” of fluoridated toothpaste should be used. In all children ages 2-5 a “pea-size” amoung should be used.
4.     Establishing a dental home withing 6 months of eruption of the first tooth and no later than 12 months of age.
5.     Avoid high frequency consumption of liquids and/solid foods containing sugar.
6.     Working with medical providers to ensure all infants and toddlers have access to dental screening, counseling, and preventive procedures.

Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment Options.
Oral Health Policies, Reference Manual V34 NO6
Authors: Council on Clinical Affairs
Adopted 2000. Revised 2003, 2007, 2008, 2011

Policy Statement: The AAPD recognizes the unique and virulent nature of ECC> Non-Dental heath care providers who indentify ECC should either provide therapy or refer the patient to a licensed dentist for treatment and establishment of a dental home. Immediate intervention is medically mecessary to prevent further destruction, as well as more widespread health problems. Because children who experience ECC are at greater risk for subsequent caries development, preventive and therapeutic measures such as optimizing hone care, ITR, more frequent professional visits with regimented applications of topical fluoride, and full crown coverage often are necessary. The dentist must assess the patient’s development level and comprehension skillsm as well as the extent of the disease process, to determine the need for advanced behavior guidance techniques such as protective stabilization, sedation or general anesthesia.

The role of chlorhexidine in caries prevention

Resident: Derek Nobrega
Title: The role of chlorhexidine in caries prevention.
Authors: Autio-Gold, J.
Journal: Oper Dent (2008) 33(6): 710-716.

Main Purpose: To determine whether chlorhexidine should be prescribed to prevent caries.

Background: The use of chlorhexidine for caries prevention has been controversial. In several reviews it has been concluded that the most persistent reduction of mutans streptococci have been achieved by chlorhexidine varnishes, followed by gels, and lastly mouth rinses. Currently the only chlorhexidine containing products in the US are mouthrinses.

Methods: A search of literature was carried out using PubMed and Evidence-Based Medicine Reviews. The search included systematic reviews and randomized clinical controls that were done on humans, in English, and reviews. 55 articles were found with the keywords “chlorhexidine” and “carie”, and 3 focused specifically on chlorhexidine and caries prevention. A second search using the additional keyword “rinse” revealed 7 articles, with 3 papers focusing on chlorhexidine.

Key Points:
- Earlier studies of chlorhexidine rinses show low-to-moderate reduction of S mutans in plaque and saliva, but none-to-moderate caries-inhibiting effects when compared to placebo treatment.
- A second article concluded that daily rinse with 0.25% NaF solution reduced caries more than 0.12% chlorhexidine rinse.
- 1 article focusing on gels showed significant reduction in dental decay in high caries risk children. However, a recent study concludes that there is limited evidence on the effectiveness of chlorhexidine gels and rinses in preventing caries.
- Chlorhexidine varnish has been shown to reduce the number of S mutans in several studies, although there has been no statistically significant reduction in caries with chlorhexidine varnish.
- Based on the available reviews, chlorhexidine rinses are not highly effective in preventing caries. Due to the current lack of long-term clinical evidence for caries prevention and reported side effects, chlorhexidine rinses should not be recommended for caries prevention.

The number of papers that had studied the link of chlorhexidine and caries limited this review article. More work needs to be done to definitively determine whether chlorhexidine is effective in preventing caries. Currently, there is not enough information to warrant the use of chlorhexidine to prevent caries.  

Evidence-based clinical recommendations regarding fluoride intake from reconstituted infant formula and enamel fluorosis

Resident: Jeff Higbee
Article: Evidence-based clinical recommendations regarding fluoride intake from reconstituted infant formula and enamel fluorosis
Journal: JADA 2011;142;79-87
Authors: Berg, J.; et al

To present evidence based clinical recommendations regarding the intake of fluoride from reconstituted infant formula and its potential association with enamel fluorosis. The recommendations were developed by an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs (CSA). The panel addressed the following question, is consumption of infant formula reconstituted with water that contains various concentrations of fluoride by infants from birth to age 12 months associated with an increased risk of developing enamel fluorosis in the permanent dentition?

The panel of experts convened by the ADA CSA, in collaboration with staff of the ADA Center for Evidence-based Dentistry (CEBD), conducted a MEDLINE search to identify systematic reviews and clinical studies published since the systematic reviews were conducted that addressed the review question.

Key Points/Results:
The authors of the systematic review concluded that in infants from birth to age 24 months, formula consumption can be associated with an increased risk of developing at least some detectable level of enamel fluorosis.  Most of the articles included in the review provided minimal information about the extent of the participant’s exposure to infant formula, the type of infant formula the participant consumed (powdered or liquid concentrate or ready to feed), the fluoride concentration of the formula and, if the formula was reconstituted, the fluoride content of the water.

Practitioners should be aware that children are exposed to multiple sources of fluoride during the tooth development period. Reducing fluoride intake from reconstituted infant formula alone will not eliminate the risk of fluorosis development.  It also is important that clinicians provide advice to parents regarding the proper use of fluoridated toothpastes along with the informed prescription of fluoride supplements.  The panel of experts encourages clinicians to follow the American Academy of Pediatrics’ guidelines for infant nutrition, which advocate exclusive breastfeeding to age 6 months and continued through at least age 12 months unless specifically contraindicated. Human breast milk has been shown to have consistently low levels (0.005-0.01 ppm) of fluoride.

This was a good article with a lot of information.  This may be a topic that new or expectant mothers could ask us so it is important to be able to have some information to provide proper guidance on fluoride intake for infants.

AAPD Handbook Chapter 1: “Infant Oral Health”

AAPD Handbook Chapter 1: “Infant Oral Health”
Resident:  Avani Khera

Definition: Professional strategies within six months after eruption of first primary tooth or not later than 12 months of age directed at factors affecting the oral cavity, counseling on oral disease risks, and delivery of anticipatory guidance.
à Early identification and management provide primary prevention and cost effective outcomes.

1.     Timely delivery of family education on caries etiology/process, OHI, and nutritional counseling.
2.     Fluoride management.
3.     Anticipatory guidance (identify high risk mothers during pregnancy)
4.     Establish a dental home by 12 months of age.

Anticipatory Guidance: At 6-12 mo, 12-24 mo, and 24-36 mo
1.     Dental and oral development (patterns of eruption, teething, exfoliation)
2.     Fluoride Supplementation (sources, formula and Fl, daily access)
3.     Non-nutritive habits (pacifier, digit habit issues)
4.     Injury prevention (car seats, replantation of permanent teeth, signs of trauma)
5.     Diet (bottle use/weaning, sippy cup content, frequency of snacks)
6.     Oral hygiene (smear amount of TP, floss, how to position baby for OH)

Oral Health Risk Assessment: systemic evaluation of presence and intensity of etiologic and contributory caries risk factors designed to provide anticipatory guidance.
What to Assess:
1.     Medical Hx
2.     Oral hygiene
3.     Infant feeding
4.     Dietary habits
5.     Fluoride adequacy
6.     Bacteria transmission
7.     Demographic data
8.     Teeth characteristics
9.     Iatrogenic factors
1. Salivary assays for MS
*perceived risk (gut feeling) by dental professional is reliable.

Caries Risk Assessment Form: 0-5 years (how to determine if child is low, moderate, or high risk)
High Risk Factors:
1.     Mother/primary caregiver has caries     
2.     Low socioeconomic status
3.     More than 3 between meal sugar containing snacks or beverages/day
4.     Bed with bottle containing sugary drink
5.     More than 1 dmfs
6.     Child has active white spot lesions/enamel defects
7.     Child has elevated strep mutans levels
Moderate risk factors:
1.     Child has special health care needs
2.     Child is a recent immigrant
3.     Child has visible plaque on teeth
Protective factors (low risk):
1.     Child receives fluoridated drinking water or supplements
2.     Child has teeth brushed daily with fluoridated TP
3.     Child receives topical fluoride from health professional
4.     Child has a dental home/regular dental care

Tuesday, August 27, 2013

AAPD Oral Health Policy on the Role of Dental Prophylaxis in Pediatric Dentistry

American Academy of Pediatric Dentistry
Adopted: 1986
Last Revision: 2012
Reaffirmed: 1996

Resident: Anna Abrahamian

Several approaches to professionally remove plaque, stain, calculus:
-       “toothbrush prophylaxis,” “rubber cup prophylaxis,” dental scaling (ultrasonic or hand instruments), full mouth debridement (may be necessary as a preliminary treatment for those who are not able to perform daily tooth brushing)
Cleaning the tooth surfaces facilitates examination, introduces dental procedures to the child, and demonstrates proper OH methods to the patient/caregiver.
Numerous reports show that plaque and pellicle are NOT a barrier to fluoride uptake in enamel and there is no evidence of a difference in caries rate or fluoride uptake in subjects who receive rubber cup prophylaxis or a toothbrush prophylaxis before fluoride treatment.
“Selective polishing” of only specific teeth that have indications (eg, stain) receive a rubber cup pumice prophylaxis to prevent wear and loss of the fluoride-rich zone of enamel.
A patient’s risk for caries/periodontal disease should determine interval for prophylaxis

Policy Statement:
Professional prophylaxis is indicated to:
-       instruct caregiver and child or adolescent in proper OH techniques
-       remove plaque, stain, and calculus
-       facilitate examination of hard and soft tissues
-       introduce dental procedures to the young child and apprehensive patient
-       assess cooperation
Patient’s risk for caries/periodontal disease determines frequency of recall. Higher risks should have recall more frequently than every 6 months 

AAPD Clinical Guidelines on Adolescent Oral Health Care

American Academy of Pediatric Dentistry
Adopted: 1986
Last Revision: 2010

Resident: Anna Abrahamian

- Adolescents are defined very broadly as youths between 10 and 18.
- Adolescent patient has distinctive needs: potentially high caries rate, increased risk for traumatic injury and periodontal disease, tendency towards poor nutritional habits, an increased esthetic desire and awareness, complexity of combined orthodontic and restorative care, dental phobia, potential use of alcohol/drugs/tobacco, pregnancy, eating disorders, and unique social and psychological needs
- Recommendations
-       Caries: Caries rate is highest during adolescence; immature permanent tooth enamel, environmental factors such as diet, independence to seek care or avoid it, low priority for hygiene all may contribute to this; importance to emphasize routine care, fluoridation, personal hygiene
-       Management of Caries (Recommendations):
§  Primary prevention:
§  Fluoride: Adolescent should receive maximum fluoride benefit dependent on risk assessment.  Systemic fluoride incorporation into developing enamel up until the age of 16, supplements should only be given after all other sources of fluoride have been evaluated; topical fluoride from fluoridated water, fluoridated toothpaste 2x per day, professionally applied and prescribed compounds
§  Oral Hygiene: Adolescents should be educated/motivated to brush and floss in a frequency and pattern based on disease process and OH needs
§  Diet management: Adolescents consume high quantities of refined carbohydrates and acid-containing beverages; diet analysis should be completed for all patients
§  Sealants: for any tooth, primary or permanent, at risk for pit and fissure caries; an individual’s caries risk may change over time, so continually re-assess for sealant need
§  Secondary prevention:
§  Professional preventive care: Initial and periodic radiograph evaluation (type, number, frequency) should be determined only after examination and history taking; timing periodic oral exams to take into account individual needs and risk indicators
§  Restorative dentistry: Refer when treatment needs are beyond your scope of practice
-       Periodontal Disease (Recommendations):
o   For acute conditions, immediate treatment based on currently accepted techniques should be performed; otherwise, referral should be made if necessary treatment is outside the scope of the treating dentist
o   For chronic conditions, educate patients regarding cause and prevention; provide a personal, age-appropriate hygiene program, emphasize importance of regular professional intervention, develop a periodontal evaluation (probing, charting, radiographic periodontal diagnosis) on an individual basis, and appropriately evaluate for procedures to facilitate orthodontic treatment
-       Occlusal considerations (Recommendations):
o   Malocclusion: Treatment of malocclusion by a dentist should be based on professional diagnosis, available treatment options, and patient motivation; problems include malposed teeth, tooth/jaw size discrepancy, craniofacial disfigurements
o   Third molars: Role of third molars as functional teeth should be established; prophylactic removal of all impacted or unerupted disease-free third molars is not indicated; see AAPD’s Guideline on Pediatric Oral Surgery for diagnostic and extraction criteria
o   TMJ problems: Evaluation of this structure should be part of the adolescent exam; refer when necessary
o   Congentially missing teeth: Need to plan for immediate and long-term management and refer when necessary
o   Ectopic eruption: Early diagnosis is key; the dentists should carefully evaluate radiogarphs for abnormal eruption patterns
-       Traumatic injuries: Most common injuries to permanent teeth occur secondary to (in this order): falls, traffic accidents, violence, and sports; dentists should introduce a comprehensive trauma program to help reduce incidence of traumatic injury then fabricate an age-appropriate, sport-specific, and properly fitted mouthguard/faceguard; players and parents must be informed that injury may occur even with properly-fitted protective equipment
-       Additional considerations in oral/dental management of the adolescent:
o   Discolored or stained teeth: Judicious use of bleaching can be considered part of a comprehensive, sequenced treatment plan; dentist should monitor the bleaching process so that it is the least invasive but also most effective; always consider side effects of bleaching
o   Tobacco use: Educate all patients regarding oral and systemic consequences; for those who use tobacco products, refer patient to the appropriate educational and counseling services
o   Positive youth development: PYD is a framework to take into account the psychological and social needs of the adolescent patient whereby the dentist has a strong interpersonal relationship with the adolescent patient to be influential in improving oral health and transitioning patients to adult care.
o   Psychosocial and other considerations: Behavioral considerations when treating an adolescent may include anxiety, phobia, or intellectual dysfunction; oral problems associated with adolescent behaviors include: oral manifestations of venereal disease, perimyolysis (severe enamel erosion) in bulimia, intraoral piercing with possible local and systemic effects; an oral health care program that addresses these particular concerns, assigns shared responsibility for care between the patient and provider, and focuses on consequences of adolescent behavior on oral health
o   Transitioning to adult care: At a time agreed upon by the patient, parent, and pediatric dentist, the patient should be transitioned to a dentist knowledgeable and comfortable with managing that patient’s specific oral health needs; for the special health care needs (SHCN) patient, the dental home can remain with the pediatric dentist and appropriate referrals for specialized dental care should be recommended when needed.

Guideline on Caries risk Assessment and Management for Infants, Children, and Adolescents

Resident: Todd Bushman

Article: Guideline on Caries risk Assessment and Management for Infants, Children, and Adolescents and

Guideline on Periodicity of Examination, Preventative Dental Services, Anticipatory Guidance/Counseling, and Oral Tx for Children, and Adolescents

Journal: Oral Health Policies



The AAPD recognizes and uses the Caries-risk Assessment Tool (CAT) for diagnosis and management of caries in Infants, children and adolescents. The purpose of this paper was intended to educate the clinician in decision making regarding diagnostic, fluoride, dietary and restorative protocols using the most updated and approved material by the AAPD.


This paper is an update to the guideline approved by the AAPD “ policy on Use of a Caries-risk Assessment Tool for Infants, children, and Adolescents, revised in 2006.   A search within the last ten years was performed using criteria, “caries risk assessment”, “caries clinical protocols” which yielded 1909 articles of which 75 were used in formulation of the article.

Caries risk assessment models currently involve a combination of factors including diet, fluoride exposure, a susceptible host and microflora that interplay with a variety of social cultural and behavioral factors. Caries risk assessment is the determination of of the likelihood of caries or the likelihood of change in caries status within a host. Although all factors can play a part in the likelihood of a patient to be susceptible to caries the patients past caries experience is the best predictor of future development of the disease.

Factors to identify High/moderate risk patients include:

High risk category

  • Primary caregiver has active cavities
  • Primary caregiver has low SES
  • Child has more than 3 sugar containing snacks or beverages between meals a day
  • Child is put to bed with a bottle containing natural or added sugar
  • Child has white spot lesions
  • Child has visible cavities or fillings
  • Child has elevated mutans streptocoocci levels
  • Patient has more than one interproximal lesion
  • Patient has low salivary flow
  • Does not use fluoridated water or toothpaste

Moderate risk
  • Child has one white spot lesion
  • Child has 1 or 2 sugary snacks or beverages between meals
  • Child has special health care needs
  • Child is a recent immigrant
  • Child has visible plaque on teeth
  • Patient is wearing an intraoral appliance
  • Patient has defective restorations
  • Uses fluoridated toothpaste but not water

Patients with moderate/high risk status should have xrays more frequently than low risk, their oral hygiene regime may include a high dose fluoride toothpaste, a professional topical application of fluoride on a more frequent basis(3 months) and will need counseling to instruct the parents on matters of concern such as diet( sugar substitutes such as xylitol, sugary snacks and beverages), fluoride exposure (via water, toothpaste, and in office tx), regular dental visits, and preventive measures such as sealants.


Guideline on Periodicity of Examination, Preventative Dental Services, Anticipatory Guidance/Counseling, and Oral Tx for Children, and Adolescents
Key points in the article discussion:
I. General:
A. The AAPD recommends initiating professional oral health intervention in infancy and continuing through adolescence and beyond.
II. Clinical Oral Examination:
A. Components of a comprehensive oral examination include assessment of:
1. General health, pain, extraoral soft tissue, TMJ, intraoral soft tissue, OH, perio health, intraoral hard tissue, occlusion, caries risk, behavior.
2. 6mo interval is typical however frequency may be increased based on clinical need.
III. Caries Risk Assessment:
A. KEY element of preventative care.
B. Prevention by identifying causative factors and optimizing protective factors.
C. Risk Assessment must be repeated regularly due to changes in habits and development of the child.
IV. Prophylaxis and Topical Fluoride Treatment.
A. Many patients lack the skill and will to become and remain plaque-free for a significant time.
B. Hormonal changes can affect oral microflora.
C. Caries risk changes with age and eruption pattern.
D. Prophylaxis and fluoride treatment is typically 6mo but should be individual

1. Moderate risk: every 6mo
2. High risk: more frequent
V. Fluoride Supplementation:
VI. Anticipatory Guidance:
A. Thorough discussion should occur at every appointment.

B. High risk dietary habits begin by 1yo.
C. Include injury-prevention counseling.
D. Non-nutritive sucking habits encouraged to stop by 3yo
E. Speech referrals if needed.
F. Smoking and smokeless tobacco use becomes an issue later in child’s life.
VII. Radiographic Assessment:
A. Timing should not be based on age. but of dental history and full exam.
VIII. Tx of Disease:
A. Immediate and timely intervention
IX. Tx of Malocclusion:
A. Early Tx of malocclusion.
1. Reversing adverse growth
2. Preventing dental and skeletal problems
3. improving aesthetics of the smile
4. improving self image
5. improving occlusion
X. Sealants:
A. Reduce the risk of pit and fissure caries

XI. Third Molars:
A. Pan or PA assessment is indicated during late adolescent life. Decision to remove should be made before mid-twenties.
XII. Referral for Regular and Periodic Dental Care:
A. Proper education and transition to an adult dentist.
B. Until the Pt has found appropriate adult dental care, he/she should maintain relationship with pedo for emergency services.