Article title: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States

Resident: Cho

Author(s): Adair, et al.

Journal: Morbidity and Mortality Weekly Report (CDC)

Year. Volume (number). Page #’s: 2001. 50. 1-26.

Major topic: Fluoride

Minor topic: Dental Caries

Type of Article: Report

Main Purpose: Provide recommendations for using fluoride to prevent and control dental caries in the United States

Overview of Method of Research: Recommendations were developed by work group of 11 specialists in fluoride research or policy convened by CDC during the late 1990s and reviewed by an additional 23 specialists.

Findings/Key points/Summary:

- Fluoride inhibits demineralization of sound enamel and enhances remineralization.

- As fluoride concentrates in the dental plaque, it inhibits the process by which cariogenic bacteria metabolize carbohydrates to produce acid and affects bacterial production of adhesive polysaccharides.

- Risk for fluorosis for permanent upper incisors: 15-24 months for boys, 21-30 months for girls

- Counsel parents and caregivers regarding use of fluoride toothpaste by young children, especially those aged younger than 2 years old due to risk of fluorosis

- Supervise use of fluoride toothpaste among children aged <6> swallow a mean of 0.3g of toothpaste per brushing -> use pea-sized amount

- Risk of fluorosis limited to children aged 8 years and younger. Enamel is no longer susceptible once preeruptive maturation is complete.

- Judiciously prescribe fluoride supplements

- Dietary fluoride supplements: 1.0, 0.5, 0.25mg fluoride tablets and lozenges

- Continue and extend fluoridation of community drinking water -> in 1989, annual cost 51 cents per person; maximum allowable limit is 4ppm; 0.7-1.2ppm optimal concentration in community drinking water

- Most bottled water contain <0.3ppm style="mso-spacerun:yes">

- Target mouthrinsing and high-concentration fluoride products to persons at high risk -> most common fluoride compound used in mouthrinse is sodium fluoride.

Assessment of Article:

Informative article. It brought up an interesting idea of developing a toothpaste containing around 550ppm fluoride instead of 1000ppm fluoride for children to use. This would possibly minimize the risk of fluorosis for children.

The role of fluoride mouthrinses in the control of dental caries: a brief review

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: The role of fluoride mouthrinses in the control of dental caries: a brief review
Author(s): Adair DDS MS, Steven
Journal: AAPD
Year. Volume (number). Page #’s: 1998. 20-2. 101-104
Major topic: Mouthrinses effectiveness and it’s varied use
Overview of method of research: Review of studies

Findings: Fluoride mouth rinses (FMR) have been found to be efficacious as a means of controlling caries incidence. In 1996, the CDC developed the Fluoride Work Group. The purpose of this group was to review the mechanism of fluoride action, he modes of delivery, and the risks of fluorosis.
Low potency/high frequency regimens assessed the use o .05% NaF(230ppm Fl) or .44% APF, while high potency/low frequency protocols tested weekly or bi weekly use of .2% NaF(900ppm). Early studies in Scandinavia listed reductions in caries as high as 80%.
In the 70’s, 75000 kids in the US and Guam used the weekly regimen was followed and had a 34% reduction in caries incidence. The studies showed that Fl was most effective on smooth surfaces, on newly erupted teeth, and worked better on permanent teeth than primary teeth. In adults, FMR can reduce root caries, help remineralization, and prevent demin.
Unfortunately, aside from school base programs, only 10% of kids use some kind of FMR(remember this study is 12 years old)

Key points/Summary:
1. School based programs should only be used in a community with a population caries rate high enough to warrant a cost effective outcome.
2. Providers should only consider recommending FMR (.05% NaF) for individuals who are at a high risk.
3. Only kids who can spit should be using FMR
4. Alcohol free FMR are best.
5. More research is needed to further investigate FMR and their effectiveness

Assessment of Article: Good info. Good info to give parents.

08/13/2010 The prevalence and risk factors of fluorosis among patients in a pediatric dental practice

Resident: J. Hencler
Date: 08/13/2010

Article title:
The prevalence and risk factors of fluorosis among patients in a pediatric dental practice

Author(s): Lalumandier, DDS, MPH and Rozier, DDS, MPH
Journal: Pediatric Dentistry-17: 1, 1995

Major topic: Fluorosis

Main Purpose:
To determine the prevalence and severity of enamel fluorosis occurring in patients of a pediatric dental practice in a fluoridated community and to identify those factors contributing to the fluorosis.

Overview of method of research:
780 patients aged 5-19 y.o. were selected using a random start, systematic sampling procedure, and enrolled in a case control study to determine risks for fluorosis. Examinations for enamel fluorosis were performed using the Tooth Surface Index of Fluorosis (TSIF). Information on fluoride exposure was obtained through parent interviews and mail questionnaires. Fluoride exposure was confirmed by fluoride assay of community drinking water samples. MHX2 statistics and logistic regression was used to analyze the data.

Findings: See tables and results section

Key points in the article discussion:
Understanding of F exposures has increased over the last 5 decades and the ADA has made exposure recommendations. A number of studies have implicated F supplements; other’s have pointed to F varnish, rinses, and swallowing toothpaste. Certain food and drinks are also a major source of F. Soy-based formulas can cause fluorosis b/c of their F binding properties. In this study, F supplementation use was the most consistent risk factor for fluorosis. More frequent use and within the first 2 years of life were most associated with fluorosis. PCPs in NC comprised 65.7% of providers prescribing F supplements. PCPs need to be educated to prevent inappropriate dietary F supplementation prescriptions if needed.

Summary of conclusions:
For children drinking fluoride deficient water, fluorosis was associated with fluoride supplementation frequency and the age of the child when brushing was initiated. For children drinking fluoridated water throughout their lives, fluorosis was associated with the age of the child when toothbrushing was initiated. These findings suggest that supplements and brushing at an early age place children at an increased risk for enamel fluorosis. Dietary fluoride supplements increase the risk of fluorosis for those in nonfluoridated areas by more than 6 fold. Children who begin using toothpaste before age 2, regardless of whether their drinking water is fluoridated, increase their chance of fluorosis by 3 times.

Assessment of article:
Article was okay, lots of statistics. At 15 years old it is a little dated and the conclusion and F recommendations have been established for some time now.

Fluoride varnishes: Should we be using them?

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Fluoride varnishes: Should we be using them?
Author(s): Vaikuntam BDS, Jay
Journal: AAPD
Year. Volume (number). Page #’s: 200. 22-6. 181-186
Major topic: Fluoride varnish’s use and effectiveness
Minor topic(s): Type of FV
Main Purpose: To evaluate the efficacy and use of FV in the US
Overview of method of research: Clinical Review

Findings: Recognition and identification of children at risk of developing caries is paramount. Once a child’s risk has been determined, an appropriate regimen tailored to suit their individual needs must be instituted. With an growing emphasis on prevention based dentistry, new treatments are coming on the market all the time. In 1994, the FDA approved the use of FV for liners and desensitization agents(they’ve been used in Europe for many years).
Topical fluoride can provide effective control and protection against caries. Recently, concerns regarding fluorosis, ingestion, and toxicity have spurred recent research evaluating the clinical efficacy of FV agents. Numerous studies have shown a reduction in caries after having FV applied. When used appropriately, a possible 40-56% reduction is possible.
There are many different types of FV on the market today. Duraphat, Fluor protector, Duraflor, Cavityshield, and Vanish are a few trade names you may see.

How to apply it?
Studies have shown that a prophy is NOT essential prior to FV application, although it is preferred. The most important thing is that the teeth are dried. Not bone dry…. Just dry. Apply the FV to every tooth surface, and instruct the parents not to brush the child’s teeth that night.
There are 3 different recommended treatment applications of FV. Every 6 months, 4x a year, and 3 applications of a 1 week period.
Is ingestion an issue?
Yes and no. While FV have a high amount of Fl in them, and the fact that over application is often a problem, there is concern. However, the toxic dose for a 20kg child is 100mg. If .5ml FV is used, and the child ingests the entire dose, they will ingest 11.2 mf, well below the toxic dose. So be aware, but don’t sweat it.

Key points/Summary:
1. FV are a safe and effective way of delivering and retaining Fl on a tooth.
2. They can help control the caries process.
3. They are most effective when used on early lesions (white spot lesions), and not cavitations.
4. Great for special needs kids.
5. Children in Ortho tending to have poor plaque control can benefit greatly from FV.

Assessment of Article: Good stuff. Good info to give worried parents.

Dental Visits and Professional Fluoride Applications for Children 72-108 Months Old

Meghan Sullivan Walsh August 9, 2010

Literature Review - St. Joseph/LMC Pediatric Dentistry

Dental Visits and Professional Fluoride Applications for Children 72 to 108 Months Old

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Dental Visits and Professional Fluoride Applications for Children 72 to 108 Months Old

Authors: Abed A. Hamasha, DDS, MS; Steven M. Levy, DDS, MPH; John J. Warren, DDS, MS

Journal: Journal of Dentistry for Children

Volume (number), Year, Page #’s; 73:1, 2006, pages 20-24

Major Topic: Study to report patterns of dental visits and fluoride application for children during ages 7 to 9.

Overview of Method of Research: Longitudinal study as part of Iowa’s Fluoride Study which collected data from children in Iowa ages 0-9 years.

Findings: The following authors used data collected from Iowa’s Fluoride Study to focus on fluoride application and dental visits for patients ages 6- 9 years old. Survey’s from the Fluoride study were sent to participants questioning their child’s frequency of dental visits and professional fluoride application from ages 0-9 years old. Using these results, the authors pulled data from ages 6-9 to discuss any patterns associated with this age bracket. The results showed that the percentage of children visiting a dentist ages 72-78 months to 102-108 months increased slightly from 76% to 83%. In addition, there was also an increase in professional fluoride application for 72-78 months, 53%, to 62% for ages 102-108 months. Dental visits involving professional fluoride application increased from 71% ages 72-78 months to 76% for 96-102 months and then declined to age 108 months, 74%. The authors did not find any connection with dental visits and fluoride application with regards to gender, whether the child visited the dentist before age 3, presence of primary teeth with caries, presence of caries in permanent teeth or mother’s education. There was, however, a connection with increased dental visits in a family with higher SES and higher family income. Fluoride applications were higher in children who had primary caries. The children who showed a consistent pattern of dental visits from age 7-9 received professional fluoride application 68-74% of the time. Finally, the percentages of children with dental visits and fluoride applications annually were more consistent after the age of 6.

Key Points: Summary: Children past age 6 are more likely to have a dental visit and receive professional fluoride applications. Higher SES and presence of primary caries is associated with a greater percentage of dental visits and fluoride application respectively.

Assessment of the Article: The data collected for this article was part of another study and should be noted when assessing these numbers. The results were fairly predictable.

The Impact of Research and Development on the Prevention of Oral Diseases in Children and Adolescents: An Industry Perspective

Resident: Swan

Article Title: The Impact of Research and Development on the Prevention or Oral Diseases in Children and Adolescents: An Industry Perspective

Author: Diane Cummins, PhD

Journal: Pediatric Dentistry 28(2) 2006. Pgs 118-123

Major Topic: A Review of the Existing and Prospective means available for preventing oral diseases

Main Purpose: This article provides a perspective of the impact of research and development on the prevention of oral diseases in children and adolescents. It reviews significant advances in oral health and new scientific approaches to prevention, and reviews the biggest challenges and opportunities in putting these measures into practice.

Method of Research: This article is a Conference Paper

Findings/Key Points: The author first (and at great length) highlights the importance of translational research in developing new methods to lessen oral disease. The "major breakthroughs" of the past 50 years were reviewed, including the development of topical fluoride-, calculus removing-, and hypersentivity relieving- products. The author points out that in each case, getting these products from the lab to the clinic took more than 20 years, and we can expect the same timing with products that are in development.

The next area of discussion was the contribution of consumer products and the oral care industry to the prevention of caries and periodontal disease in children. Specifically, toothbrushes designed for children, topical fluoride treatments (toothpastes and mouthrinses), and topical antimicrobial treatments were highlighted. The author points out that daily use of fluoride toothpaste still seems to be the most effective and efficient means of preventing decay in this age group, and that the various formulations of fluoride in different toothpastes are equally effective.

The most interesting section of the article was the author's discussion of potential new therapeutic approaches. In addition to briefly discussing potential new methods of early caries detection (including digital fiberoptic transillumination and light-induced fluorescence) the author identifies two key areas of research that are on-going:

1) limiting caries by strengthening the enamel

a) tiny intra-oral device attached to tooth surface that can constantly and slowly release fluoride

b) microcapsules of fluoride and/or calcium that adhere to the mucosa.

c) dual component toothpaste containing dical and 1000 ppm fluoride (two long-term studies have shown this to be effective)

2) targeting bacteria to inhibit plaque formation

a) topical antimicrobials (Chlorhexidine varnish, triclosan toothpase)

b) S mutans vaccine

c) replacement therapy (replace S. mutans with genetically altered benign strain--clinical trials in progress)

Assessment: The last 1/4 of this article was pretty interesting, and brought up some potential new therapies that I hadn't heard of. Overall, what I took from it is the importance of solid laboratory and clinical research that will then translate in improved care for patients. The new therapies discussed sound pretty cool, but it will be a long time before we use them in the clinic.

Policy on Use of a Caries-risk Assessment Tool (CAT) for Infants, Children, and Adolescents

Department of Pediatric Dentistry

Resident's Name: Jessica Wilson Lutheran Medical Center - Providence

Article title: Policy on Use of a Caries-risk Assessment Tool (CAT) for Infants, Children, and Adolescents

Author(s): AAPD

Journal: Reference Manual

Year. Volume (number). Page #’s: 2007-2008. 29(7). 29-33.

Major topic: Caries-risk Assessment

Overview of method of research: A systematic literature review as well as expert opinions and best current practices were used to establish this policy.

Findings: Through interview with parent/caregiver and clinical examination the CAT helps healthcare providers determine the likelihood of the incidence of caries in a child as well as the likelihood of an increase in size or activity of existing carious lesions (see TABLE on pg 30).

Key points/Summary: A child’s risk classification is determined by the highest risk category present.
While previous caries experience may be the best indicator for caries susceptibility, it does not allow for prevention of caries.
The CAT is an adjunctive tool assessing risk at a single point in time and needs to be updated periodically.
The CAT does not deliver a diagnosis and can be used by non-dental personnel.
Although not included in the CAT, radiographic assessment and microbial testing are encouraged.

Assessment of Article: This article encourages practitioners to become more involved in the recognition of children at risk and the delivery of preventative treatment, especially in those categorized as “high-risk”. In corollary, this study guides the dentist in identifying exactly which risk factors are important in determining the proper treatment for a child or whether caries control measures are needed and if they are working properly.

Association of Mutans Streptococci Between Caregivers and Their Children 8/6/10

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Association of Mutans Streptococci Between Caregivers and Their Children
Author(s): Douglass MS DDS, Joanna. Yihong Li, DDS, MPH. Tinanoff, DDS
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2008. v30 #5. 375-387
Major topic: Early colonization of SM in children and how what causes it
Minor topic(s): How we can stop the colonization
Main Purpose: Determine how SM colonize early, and how to stop it
Overview of method of research: Systematic review of numerous literature

Findings: The incidence of dental caries has been steadily declining over the past 30 years. However recently, this decline has slowed down considerably. In order to get a cavity, three things are needed. A surface(a tooth), a substrate(carbs/sugar), and some type of antagonist(bacteria). A particular group of bacteria has been isolated, and shown to be the major cause of dental caries, Strep Mutans and Strep Sorbinus. This group of bacteria has the ability to adhere to enamel, produce acid for dietary carbs, and survive at a very low pH.
In children, SM colonization is believed to be caused from the child’s primary caregiver. The transmission has been associated with high SM levels, open lesions, poor oral hygiene in caretakers, LSES, and frequent snacking by the child.
The authors searched PubMed for strep mutans, mother, father, infant, child, transmission, and colonization. 46 studies published from 1975-2006 came up, and they were reviewed by the authors. In 1975, Berkowitz and Jordan were the first to demonstrate the vertical transmission of SM from mother to child.
One question that was raised by the authors was, is the father(or other caretakers) an SM source as well. Various studies said different things. There was basically a 50/50 split on yes or no.
How can we stop the invasion?
Four separate studies reported that a mom using a chlorhexidine rinse or gel combined with fluoride rinses or varnishes had decreased SM levels, and thus, the children had a reduction of SM colonization. Another study discussed having the mom chew xylitol gum to help control SM levels, leading to decreased SM levels in mom.

Key points/Summary:
1. SM can be transmitted from mother to child, especially when mom has high SM levels. Other ways transmission occurs is through diet, SES, behavioral factors, and other factors not yet known.
2. Fathers, grandparents, and other caregivers may play a role in the early colonization of SM in children
3. Studies showing strategies that lower mom’s SM levels are too small and need to be broadened.
4. More clinical trials are needed

Assessment of Article: Long winded article, definitely important info. Take away the basics.

A longitudinal controlled study of factors associated with mutans streptococci infection and caries lesion initiation in children 21 to 72 months old.

Resident: Adam J. Bottrill
Date: 06AUG10
Region: Providence
Article title: A longitudinal controlled study of factors associated with mutans streptococci infection and caries lesion initiation in children 21 to 72 months old.
Author(s): Law V.
Journal: Pediatric Dentistry
Page #s: Jan-Feb; 28(1): 58-65
Year: 2006
Major topic: Strep mutans infections and carious lesions
Minor topic(s): NA
Type of Article: Longitudinal, controlled study
Main Purpose: To determine factors associated with mutans streptococci (MS) infection and development of carious lesions in a group of children 21-72 months old.

Key points in the article discussion:

I. Methods:

A. 63 caries-free children divided into:
1. 24 children colonized with MS.
2. control group of 39 children without MS.
B. Recalled every 3mo for approx 24mo.
C. Each visit, data recorded
1. Plaque, enamel hypoplasia, carious lesions, MS status

II. Results:

A. MS associated with...
1. visible plaque, enamel hypoplasia
2. begining "tooth-brushing" AFTER 12mo.
3. lack of parental assistance
4. increase hours of non-parental "child care."

B. Those who developed carious lesions during study did/presented with the following MORE than those children who remained caries-free.
1. had more hypoplastic teeth
2. ate more sugar
3. did not brush regularly

III. Conclusions!

A. You might want to sit down for this one!!! .... Lack of oral hygiene, consumption of sugary snacks and enamel hypoplasia are significant factors for both MS infection AND carious lesion initiation.

Assessment of article:

This is EITHER:
1. The article to end all articles...
OR
2. An irrefutable breakthrough that will shock the world...
OR
3. An article describing stuff we sort of already knew...

....YOU DECIDE

Article title: Future caries susceptibility in children with Early Childhood Caries following treatment under general anesthesia

Resident: Ara Cho

Date: 8/6/2010

Author(s): Almeida, G. et al.

Journal: American Academy of Pediatric Dentistry

Year. Volume (number). Page #’s: 2000. 22. 302-305.

Major topic: Early Childhood Caries

Minor topic: Mutans Streptococci

Type of Article: Scientific Article

Main Purpose: Assess the susceptibility of children to future development of caries following comprehensive treatment for ECC

Overview of method of research: A retrospective study was conducted at Franciscan Children’s Hospital & Rehabilitation in Boston, MA. 42 patients who were diagnosed with ECC and treated under general anesthesia were seen at recall visits at six to nine months over a two year period. ECC was defined as the occurrence of one or more carious lesions involving maxillary anterior teeth of toddlers (1-2 years) and preschool children (2-5 years). Bitewing radiographs were taken at recall appointments. New smooth surface caries (NSSC) and new pit and fissure caries (NPFC) were recorded. The number of NSSC and NPFC were also recorded in a control group of 31 children who were of similar age to the ECC subjects. All children diagnosed with ECC were given a more intensive preventive regimen than the control group.

Findings: 79% of ECC children had detectable carious lesions at subsequent recall visits, compared to 29% in the control group. Of the 42 patients treated for ECC under general anesthesia, 7 patient required retreatment under general anesthesia. No relationship was found between subjects who required retreatment under anesthesia and frequency of recall visits. Those initially diagnosed with ECC were more likely to develop NSSC lesions than NPFC lesions. In contrast, children who were initially caries-free were more likely to develop NPFC lesions rather than NSSC at subsequent visits.

Key points/Summary: This study suggests that ECC can predict the risk of future caries development. Dental caries can develop in high caries risk children even after intensive preventive oral hygiene counseling. Perhaps more aggressive antimicrobial therapies may be required to prevent risk of development of caries in ECC children.

Assessment of Article: Good article. Gives scientific support for taking an aggressive approach to OR cases.