ED5 - Oral Health (Levy 2011-12)

7/29/2019 ED5 - Oral Health (Levy 2011-12)

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Oral Disease Prevention –

Considerations for M3 Students

University of Iowa, November 12, 2012

Steven M. Levy, DDS, MPHDept. of Preventive and Community Dentistry,

College of Dentistry

Dept. of Epidemiology, College of Public Health

Supported by NIH and other grants





Preventive Dentistry

Eliminates disease

Establishes good habits





Background

Despite efforts to develop improved

mechanical, chemical and dietary

methods of plaque control and caries

prevention, fluoride remains the best

defense against dental caries (alongwith sealants).

5



Topical

vs. Systemic Fluorides

6



Topical FluoridesWater fluoridation

Diet

Dietary fluoridesupplements (chew, swish,

swallow)

DentifriceMouthrinse

Office (professional)7



Systemic Fluorides• Water Fluoridation

• Diet

• Dietary FluorideSupplements

• (Dentifrice)

8



Pre-eruptive

vs.

Post-eruptive

9





Esthetic Perceptions of

Dental Fluorosis

11



Difficult to interpret the

significance of the increase

in dental fluorosis because

there is little known about

people’s perceptions of the

esthetics of fluorosis.

(Ripa, 1991)12



13



Relationships Among

Fluoride Ingestion, Dental

Caries, and Dental Fluorosis

14



DMFT and Dental Fluorosis Prevalence Rate by Fluoride

Concentration of Water, Comparison of Dean’s Data from

1930’s-1940’s to More Recent Data (Leverett, et al., 1991)

D en t al F l u

or o s i s P r ev al e

n c eR a t e

D M F T

Fluoride Concentration of Water (x Optimal)

Dean’s Data

Recent Data

(1980’s)

90

80

70

60

50

40

30

20

10

0

100

11

10

8

7

6

5

4

3

2

1

12

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4

0

9

15



Bottled Water

For drinking and reconstitution of

formulas and beverages

Most < 0.3 ppm F

Some > 1.0 ppm F

Tested once per year, fluoride levelsnot listed

16



Home Water

Filtration Systems

Usually carbon or charcoal, do not

remove fluoride

Distillation and reverse osmosis

remove the majority of fluoride

17



Fluoride in Milk

Breast milk: 0.004 to 0.01ppm F

Cow’s milk: 0.01 to 0.05 ppm F

More fluoride if reconstituted with fluoridated water.

18



Infant FormulaConcern about high levels in the

1970s.U.S. manufacturers voluntarily

lowered their F concentrations.

19



Emphasis on Infant Formula, Fluoride

and Fluorosis

20



Infant Formula and Enamel

Fluorosis: A Systematic Review

(Hujoel, et al., J Am Dent Assoc 140:841-853, 2009)

• No controlled (randomized) studies designed to assess

this

• Most studies case-control or retrospective cohort• Infant formula from 0-24 months weakly associated

with dental fluorosis – summary odds ratio = 1.87

• No individual studies analyzed statistically if due to

fluoride in formula• Limited adjustment for other confounders

• Could be due to water added to reconstitute (and/or

other fluoride intake)

21

W Fl id i



Water Fluoridation -

U.S.(2010) 63% adjusted water fluoridation

3% natural fluoridation

66% of total U.S. population withfluoridation - ~204 million people

This is 74% of U.S. population(~277

million) on public water systems. – Varies by state from 10.8%(HI) to

100%(DC)—IA has 92%

– 9 states have <50% 22















www.cdc.gov/fluoridation/ 29



http://apps.nccd.cdc.gov/MWF/Inde

x.asp 30



http://apps.nccd.cdc.gov/MWF/CountyDataV.asp?Stat

e=IA 31



http://apps.nccd.cdc.gov/MWF/PWSDetailV.asp?PWSID=5208071&State=IA&Start

Pg=1&EndPg=20&County=Johnson&PWSName=&Filter=0&PWS_ID=&State_ID=

IA&SortBy=1&StateName=Iowa 32



R d i f U i Fl id



Recommendations for Using Fluoride

to Prevent and Control Dental Caries

in the United States (2001)

• 11 Member Work Group

• Scientific Review of Manuscript by23 Fluoride Experts

• Extensive Outside Review of Report

34



Key Findings

Good evidence for water fluoridation, toothpaste,

mouthrinses, supplements (>6years), and high strength topical products

Seek low concentration, highfrequency presence of fluoride -CWF and TP

35



Key Findings

Target other modalities based oncaries risk

Measured use of toothpaste,dietary supplements, and high

concentration topical productsfor <6 years old

36

N i l R h C il/N i l



Reaffirmed safety (and merit) of

optimally fluoridated water.

Substantial concern beyond 2.0 ppm,

especially concerning dental fluorosis.

EPA currently considering possible

changes

National Research Council/National

Academy of Sciences Review of

Fluoride Safety (2006)

37

P d N U S N ti l



Single water fluoride level for whole

U.S.

Lower level (0.7 ppm)

To better balance fluorosis and caries Still not finalized. (Probably will be

late in 2012 or early in 2013.)

Proposed New U.S. National

Community Water

Fluoridation Recommendations



Presents an economic analysis of water fluoridation under modern

conditions of widespread availabilityof fluorides.

The analysis accounts for capital and operating costs for fluoridation,expected effectiveness of

fluoridation, estimates of expected caries in non-fluoridated communities and treatment costs.

39



Under typical conditions, the annualreduction in treatment costs was $19

per person, well above the averagefluoridation cost of 50 cents per

person in large communities

(>20,000).

In communities with fewer than

5,000 residents where per personfluoridation costs are highest,fluoridation saves $16 per person.

40



Fluoride - Evidence-based recommendations (JADA--

December 2010 and January 2011,

respectively)

Evidence

Patientsneeds and

preferences

ClinicalExpertise

41



Supplements

When and to whom should fluoridesupplements be prescribed?

What is the recommended schedule

for dietary fluoride supplements?Infant formula

What is the risk for enamel fluorosis

from consumption of infant formulareconstituted with water containingfluoride?

42



Dietary Fluoride Supplements: Evidence-based Clinical Recommendations

Practitioners are encouraged to evaluate all potential fluo ride sources and conduct a caries risk assessment before prescribing

fluoride supplements.

• For children at low caries risk, dietary fluoride supplements are not recommended and other sources of fluoride should be considered

as a caries preventive intervention. (D)

• For children at high caries risk, dietary fluoride supplements are recommended according to the schedule presented in the following

table. (D)

• When fluoride supplements are prescribed, they should be taken daily to maximize the caries prevention benefit. (D)

* 1.0 ppm = 1 mg/liter

ADA dietary fluoride supplement schedule for children at high car ies r isk

Age (Years) Fluoride Concentration in Drinking Water (ppm)* <0.3 0.3-0.6 >0.6

Birth to 6 months None (D) None (D) None (D) 6 months to 3 years 0.25 mg/day (B) None (D) None (D)

0.50 mg/day (B) 0.25 mg/day (B) None (D) 6 to 16 years 1.0 mg/day (B) 0.50 mg/day(B) None (D)

43



Encourage parents to follow AAP

guidelines on infant nutrition (exclusive

breast-feeding to age 6 months and continued breastfeeding to at least 12

months of age, unless specifically

contraindicated)

Continue to reconstitute formula concentrate with optimally fluoridated

drinking water while being cognizant of the potential risk of enamel fluorosis.

(Strength of recommendation - D)

Use ready-to-feed formula or reconstitute liquid or powder concentrate

formula with fluoride-free water when the potential risk for enamel fluorosis

is a concern. (Strength of Recommendation - C)

44



Overall Recommendations

Dietary Fluoride Supplements

To be used cautiously – only for high

risk

45



Overall Recommendations

Fluoride dentifrice

Parents/guardians should supervise

brushing with fluoride dentifrice for all preschoolers

Small amounts should be used:

–Small smear for infants

–Small pea-sized amount for toddlers46

F ll 2008



Fall 2008Expert panel for the federal Maternal

and Child Health Bureau recentlydrafted more aggressive, routine use of F dentifrice for high-risk of caries

infants and preschoolers (soon to bereleased).

Not wait until age 24 months

Important for Head Start, WIC, healthdepartments, medical and dentaloffices

47

Fl id d B



Many limitations and concerns with measuringfluoride intake and bone health in these studies

Overall, studies have demonstrated conflicting

results, with some reporting increased bonedensity and reduced fractures, while others

decreased bone density and increased fractures

Fluoride may affect cortical and trabecular bone differently, enhancing trabecular bone

density and diminishing cortical bone density

Fluoride and Bone

48

Iowa Bone Development Study



Paper published on age 11 dual-energy x-

ray absorptiometry (DXA) – Levy, et al.(CDOE 37(5):416-26, 2009)

After adjustment, modest correlations

diminished further

Some possible differences by gender

No evidence of clear, consistentrelationships of fluoride intake with bone

outcomes.

Iowa Bone Development Study

49



No significant relationships (all p >0.05) between

lifelong fluoride intake and DXA bone outcomes

at age 15.

– Relationships with calcium and Vitamin D found for boys (p<0.01), but not girls.

– Relationships with moderate PA found for boys, but not

girls.

Fluoride Intake and Age 15 DXA - Results

L i di l A l f B A



No significant relationships of DXA outcomeswith AUC F intake (0-5 yrs, 0-scan, 3 yrs before

scan) for boys or girls

– The few fluoride associations with p<0.05 were all

positive:

» Boys’ spine BMC with 0-5 F AUC

» Boys’ spine BMD with 0-5 F AUC

» Girls’ spine BMC with last 3 years F AUC

– Calcium and Vitamin D (separately) related to all bone

outcomes in boys (p<0.001), but not girls.

Longitudinal Analyses for Bone at Ages

8,11,13 & 15 - Results



The bottom line is that at low dosages

(such as in fluoridated water),

fluoride appears to have little effecton bone health.

Fluoride and Bone

54

IDPH School based Screening



IDPH School-based Screening

Program

2010-2011

– Required for kindergarten and 9th grade

– 55,000 screened (~73%)

» No obvious problems- 85%

» Requires non-urgent dental cares- 13%

» Requires urgent dental cares- 2%

I SmileTM



I-Smile



















Up to about 88% of dental caries

occurred on pit-and-fissure surfacesamong U.S. school children in 1988-

91.



Caries protection is 100% in pits

and fissures that remain completelysealed; complete retention rates

after one year are 85%, and after

five years, at least 50%.

As long as the sealant stays on the

tooth, the pit or fissure will notdecay.





Sound vs Carious or Restored Surfaces on



Sound vs. Carious or Restored Surfaces on

Permanent First Molars at 15 Years

(Matched pair analysis; n = 128 surfaces, 16 subject pairs)

Sound surfaces 68.8% (88) 17.2% (22)

Carious or restored surfaces 31.3% (40) 82.8% (106)

Total surfaces 100% (128) 100% (128)

Group Group

with Sealant without Sealant



The Effectiveness of Sealants in



Managing Caries Lesions(Griffin, et al. – J Dent Res 87(2):169-174, 2008)

Focus on effectiveness in preventing caries

progression

6 major studies included in review

Reduced annual rate of progression of cariouslesions substantially: – 65% prevention for cavitated initial lesions

– 83% prevention for non-cavitated initially

– 78% prevention overall

Clinical Recommendations – Place on primary and permanent teeth if elevated risk – all ages

– Should place over non-cavitated lesions – all ages

Preventing Dental Caries Through School-based



Preventing Dental Caries Through School-based

Sealant Programs: Updated Recommendations

and Reviews of Evidence (J Am Dent Assoc 140:1356-65, 2009)

Summary of ADA/CDC Taskforce

Updated earlier guidelines

Used systematic reviews when available

Indications for Sealant Placement School-based sealant programs

– Target high-risk communities and individuals (those

least likely to get to the dentist)

Seal sound and non-cavitated pit-and-fissure

surfaces of posterior teeth (permanent molars get

priority).



IDPH Dental Sealant Program

2009 – 2010

– 79 elementary schools

– 21 Junior high schools

– 9,941 sealants placed on 1st molars

– 2,381 sealants placed on 2nd molars

http://www.idph.state.ia.us/hpcdp/oral_heal

th_school_sealant.asp

“Bisphenol A and Related Compounds in



Bisphenol A and Related Compounds in

Dental Materials” (Fleisch et. al, Pediatrics 2010; 126:760-768)

Systematically compiled and critically evaluated literature on

BPA

BPA is detectable in saliva up to 3 hours after resin

placement, but quantity and duration not clear

– Bis-GMA products are less likely to be hyrolyzed to BPA

BPA exposure can be reduced by cleaning and rinsing

surfaces of sealants (and composites) immediately after

placement.

Authors recommend:

1. Continued use of resin-based materials, along with care inapplication.

2. Use minimized during pregnancy, whenever possible.

3. Manufacturers report chemical composition and develop materials

with less estrogenicity.



Conclusions

Caries prevention will be maximized by workingwith public and private practice colleagues in bothdentistry and medicine.

Fluoride should continue to be the cornerstone of caries prevention.

Aggressive use of fluoride dentifrice for high-risk individuals, including infants and young children iswarranted.

Fluorosis concerns should be considered lessimportant since mostly mild.

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Conclusions

Water fluoridation should continue.

Work with all dental and health professionals, political/government leaders, and lay groups.

Continue and expand use of fluoride dentifrice and

varnish. Continue to maintain and expand sealant use.

Education and counseling about dietary risk factorsfor caries (and general health) also warranted.

76



Thank You

Questions?

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ED5 - Oral Health (Levy 2011-12)