Oral Disease Prevention – Considerations for M3 Students

University of Iowa, November 12, 2012 Steven M. Levy, DDS, MPH Dept. 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


5 .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 (along with sealants).

Systemic Fluorides 6 .Topical vs.

swish.Topical Fluorides  Water  Diet fluoridation Dietary fluoride supplements (chew. swallow)  Dentifrice  Mouthrinse  Office (professional)  7 .

Systemic Fluorides • Water Fluoridation • Diet • Dietary Fluoride Supplements • (Dentifrice) 8 .

Pre-eruptive vs. Post-eruptive 9 .

10 .

Esthetic Perceptions of Dental Fluorosis 11 .

1991) 12 .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.

13 .

and Dental Fluorosis 14 .Relationships Among Fluoride Ingestion. Dental Caries.

DMFT and Dental Fluorosis Prevalence Rate by Fluoride Concentration of Water. 1991) 12 11 10 9 8 7 60 50 40 30 20 2 1 0 0.0 1.8 1. et al.0 0. Comparison of Dean’s Data from 1930’s-1940’s to More Recent Data (Leverett.2 0.2 1.4 0..4 10 0 100 90 Dental Fluorosis Prevalence Rate Dean’s Data Recent Data (1980’s) 80 70 DMFT 6 5 4 3 Fluoride Concentration of Water (x Optimal) 15 .6 0.

Bottled Water  For drinking and reconstitution of formulas and beverages  Most < 0.0 ppm F  Tested once per year.3 ppm F  Some > 1. fluoride levels not listed 16 .

do not remove fluoride  Distillation and reverse osmosis remove the majority of fluoride 17 .Home Water Filtration Systems  Usually carbon or charcoal.

05 ppm F  More fluoride if reconstituted with fluoridated water.004 to 0.01ppm F  Cow’s milk: 0. 18 .01 to 0.Fluoride in Milk  Breast milk: 0.

S. 19 .  U.Infant Formula  Concern about high levels in the 1970s. manufacturers voluntarily lowered their F concentrations.

Fluoride and Fluorosis 20 .Emphasis on Infant Formula.

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 .. 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.Infant Formula and Enamel Fluorosis: A Systematic Review (Hujoel. J Am Dent Assoc 140:841-853. et al.

population(~277 million) on public water systems.Water Fluoridation U.S. population with fluoridation .~204 million people  This is 74% of U.S. – Varies by state from 10.8%(HI) to 100%(DC)—IA has 92% – 9 states have <50% 22 .S.(2010)  63% adjusted water fluoridation  3% natural fluoridation  66% of total U.




cdc.gov/fluoridation/ 29 .www.

gov/MWF/Inde x.nccd.cdc.asp 30 .http://apps.

asp?Stat e=IA 31 .http://apps.nccd.cdc.gov/MWF/CountyDataV.

gov/MWF/PWSDetailV.http://apps.cdc.nccd.asp?PWSID=5208071&State=IA&Start Pg=1&EndPg=20&County=Johnson&PWSName=&Filter=0&PWS_ID=&State_ID= 32 IA&SortBy=1&StateName=Iowa .


Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States (2001) • 11 Member Work Group • Scientific Review of Manuscript by 23 Fluoride Experts • Extensive Outside Review of Report 34 .

supplements (>6 years). toothpaste. mouthrinses. and high strength topical products low concentration. high frequency presence of fluoride CWF and TP 35  Seek .Key Findings  Good evidence for water fluoridation.

dietary supplements. and high concentration topical products for <6 years old 36  Measured .Key Findings  Target other modalities based on caries risk use of toothpaste.

National Research Council/National Academy of Sciences Review of Fluoride Safety (2006)  Reaffirmed safety (and merit) of optimally fluoridated water. especially concerning dental fluorosis.  EPA currently considering possible changes 37 .0 ppm.  Substantial concern beyond 2.

(Probably will be late in 2012 or early in 2013.S. National Community Water Fluoridation Recommendations  Single water fluoride level for whole U.7 ppm)  To better balance fluorosis and caries  Still not finalized.) .  Lower level (0.Proposed New U.S.

analysis accounts for capital and operating costs for fluoridation. estimates of expected caries in non-fluoridated communities and treatment costs. Presents an economic analysis of water fluoridation under modern conditions of widespread availability of fluorides. expected effectiveness of fluoridation. 39  The .

40  In . Under typical conditions.000). the annual reduction in treatment costs was $19 per person. communities with fewer than 5. well above the average fluoridation cost of 50 cents per person in large communities (>20.000 residents where per person fluoridation costs are highest. fluoridation saves $16 per person.

Evidence-based recommendations (JADA-December 2010 and January 2011. respectively) Evidence Clinical Expertise Patients needs and preferences 41 .Fluoride .

Supplements  When and to whom should fluoride supplements be prescribed?  What is the recommended schedule for dietary fluoride supplements? Infant formula  What is the risk for enamel fluorosis from consumption of infant formula reconstituted with water containing fluoride? 42 .

3-0.50 mg/day (B) 6 to 16 years * 1. dietary fluoride supplements are not recommended and other sources of fluoride should be considered as a caries preventive intervention.0 mg/day (B) 43 .6 None (D) None (D) None (D) None (D) 1. • For children at low caries risk.25 mg/day (B) 0.Dietary Fluoride Supplements: Evidence-based Clinical Recommendations Practitioners are encouraged to evaluate all potential fluoride sources and conduct a caries risk assessment before prescribing fluoride supplements.25 mg/day (B) 0.6 None (D) None (D) 0.3 Birth to 6 months 6 months to 3 years None (D) 0.50 mg/day(B) >0. they should be taken daily to maximize the caries prevention benefit. (D) • For children at high caries risk.0 ppm = 1 mg/liter 0. dietary fluoride supplements are recommended according to the schedule presented in the following table. (D) • When fluoride supplements are prescribed. (D) ADA dietary fluoride supplement schedule for children at high caries risk Age (Years) Fluoride Concentration in Drinking Water (ppm)* <0.

(Strength of recommendation . unless specifically contraindicated) Continue to reconstitute formula concentrate with optimally fluoridated drinking water while being cognizant of the potential risk of enamel fluorosis.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.C) 44 .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 .

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 amounts should be used: – Small smear for infants – Small pea-sized amount for toddlers 46  Small .

Fall 2008  Expert panel for the federal Maternal and Child Health Bureau recently drafted more aggressive. medical and dental offices 47  Not  Important . routine use of F dentifrice for high-risk of caries infants and preschoolers (soon to be released). health departments. wait until age 24 months for Head Start. WIC.

while others decreased bone density and increased fractures  Fluoride may affect cortical and trabecular bone differently. studies have demonstrated conflicting results. enhancing trabecular bone density and diminishing cortical bone density  48 . with some reporting increased bone density and reduced fractures.Fluoride and Bone Many limitations and concerns with measuring fluoride intake and bone health in these studies  Overall.

49 .Iowa Bone Development Study  Paper published on age 11 dual-energy xray absorptiometry (DXA) – Levy. (CDOE 37(5):416-26. 2009)  After adjustment. consistent relationships of fluoride intake with bone outcomes. modest correlations diminished further  Some possible differences by gender  No evidence of clear. et al.

Results  No significant relationships (all p >0.05) between lifelong fluoride intake and DXA bone outcomes at age 15. .01).Fluoride Intake and Age 15 DXA . but not girls. – Relationships with moderate PA found for boys. – Relationships with calcium and Vitamin D found for boys (p<0. but not girls.

3 yrs before scan) for boys or girls – The few fluoride associations with p<0.Longitudinal Analyses for Bone at Ages 8. but not girls. 0-scan.11.13 & 15 . .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.Results  No significant relationships of DXA outcomes with AUC F intake (0-5 yrs.001).

54 . fluoride appears to have little effect on bone health.Fluoride and Bone  The bottom line is that at low dosages (such as in fluoridated water).

2% .13% » Requires urgent dental cares.IDPH School-based Screening Program  2010-2011 – Required for kindergarten and 9th grade – 55.85% » Requires non-urgent dental cares.000 screened (~73%) » No obvious problems.

I-SmileTM .









school children in 198891.Up to about 88% of dental caries occurred on pit-and-fissure surfaces among U. .S.

 As long as the sealant stays on the tooth. and after five years. Caries protection is 100% in pits and fissures that remain completely sealed. the pit or fissure will not decay. at least 50%. . complete retention rates after one year are 85%.



8% (106) 100% (128) 100% (128) .3% (88) (40) Group without Sealant 17.Sound vs.2% (22) 82. Carious or Restored Surfaces on Permanent First Molars at 15 Years (Matched pair analysis. 16 subject pairs) Group with Sealant Sound surfaces Carious or restored surfaces Total surfaces 68. n = 128 surfaces.8% 31.


et al.The Effectiveness of Sealants in Managing Caries Lesions (Griffin. 2008)    Focus on effectiveness in preventing caries progression 6 major studies included in review Reduced annual rate of progression of carious lesions 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 . – J Dent Res 87(2):169-174.

. 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).Preventing Dental Caries Through School-based Sealant Programs: Updated Recommendations and Reviews of Evidence (J Am Dent Assoc 140:1356-65.

us/hpcdp/oral_heal th_school_sealant.IDPH Dental Sealant Program  2009 – 2010 – – – – 79 elementary schools 21 Junior high schools 9.381 sealants placed on 2nd molars  http://www.idph.asp .941 sealants placed on 1st molars 2.state.ia.

126:760-768)   Systematically compiled and critically evaluated literature on BPA BPA is detectable in saliva up to 3 hours after resin placement. . al. along with care in application. Use minimized during pregnancy. Authors recommend: 1. 3. Continued use of resin-based materials. 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. 2. Pediatrics 2010. whenever possible.“Bisphenol A and Related Compounds in Dental Materials” (Fleisch et. Manufacturers report chemical composition and develop materials with less estrogenicity.

75 . Aggressive use of fluoride dentifrice for high-risk individuals. including infants and young children is warranted. Fluoride should continue to be the cornerstone of caries prevention.Conclusions     Caries prevention will be maximized by working with public and private practice colleagues in both dentistry and medicine. Fluorosis concerns should be considered less important since mostly mild.

 Work with all dental and health professionals. Education and counseling about dietary risk factors for caries (and general health) also warranted. Continue and expand use of fluoride dentifrice and varnish.Conclusions     Water fluoridation should continue. Continue to maintain and expand sealant use. political/government leaders. 76 . and lay groups.

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