DTUS1610

DENTAL TRIBUNE | June 2010 Interview 11A United States is poor and caries figures are at an all-time high. What are the reasons for this? Fernandez: Actually, the oral health of children in the U.S. has improved significantly over the past few decades when you look at a national sample across all age groups. Today, most American children have excel- lent oral health, but a significant subset suffers from a high level of oral disease. The most advanced disease is found primarily amongst children living in poverty, some racial/eth- nic minority populations, children with special needs and children with HIV/Aids infection. You might be referring to the National Health and Nutrition Examination Survey that demon- strated an increase in dental caries from 24 percent to 28 percent in the 2- to 5-year-old group. The reasons for this are presently unclear, but this increase has reig- nited efforts in the U.S. to improve access to care for this age group and motivate more dentists to treat very young children in our popula- tion. Early childhood caries [ECC] has increased not only in the U.S., but also worldwide. Should this area be considered a new priority in pediatric dentistry? Fernandez: Early childhood caries, and efforts in the intervention and treatment of early dental decay, has always been a major priority. In order to combat the current national epidemic of ECC in young children effectively, a more com- prehensive, collaborative approach to the education of parents by all newborn and pediatric health-care providers, such as nurses, pedi- atric and general dentists, dental hygienists, pediatricians, pediatric nurse practitioners, obstetricians and gynecologists, is essential. The American Academy of Pedi- atrics [AAP] began a collaborative effort with pediatric dentists to address the issue of ECC. The AAP has made strides in developing edu- cational programs for pediatricians and family physicians to identify at-risk children and refer them for dental treatment. However, for many children, access to dental care remains a problem and the number with den- tal caries seems to be growing. Many parents do not have dental insurance; thus, they postpone den- tal treatments until the problem is so advanced that it can no longer be ignored. It is unfortunate that even par- ents who have third-party coverage for dental care [Medicaid, Child Health Plus] and are from lower conclusively what we already know as clinicians — an intensive regi- men of fluoride varnish, along with adjunctive measures, can control and often reverse dental decay, as well as prevent it. Lim: Starting in infancy, children at-risk for dental decay should be receiving twice yearly applications of fluoride varnish, whether by a dentist or dental professional, or as part of their well-baby care from their pediatricians. More than 40 states in the U.S. have implemented such programs, and the outcomes are impressive — as much as 40 percent fewer children with early signs of ECC. Fernandez: Collaboration be- tween other health providers and the dental professions is key to combating the incidence of ECC. You will be presenting at this year’s PDAA Congress in Pasay City. What will the participant be able to take home from your presentation? Lim: At New York University [NYU] through education, outreach, train- ing and collaboration with other health professionals, we have developed a multi-faceted approach to the many aspects of oral-health problems. Our presentation will describe the coordination of the strategies and programs that NYU employs, particularly in combating ECC. Herman: Our presentation will examine and offer solutions to the management of ECC. We will offer a clinical therapeutic protocol that effectively stabilizes and/or arrests active caries, and that suggests a disease-intervention model of care that replaces restoration of teeth as the primary approach to the treat- ment of ECC in infants, toddlers and pre-school children. Fernandez: Participants will learn about setting up an infant oral-health program in their offices using an auxiliary. The auxiliary should be able to conduct a risk assessment, provide anticipatory guidance and prescribe an individ- ualized preventive program. Our presentation will outline the steps in establishing an infant oral-health program in the dental office. DT socioeconomic backgrounds often fail to seek dental care as part of general health-care services. As a result, pre-school children with Medicaid may still have untreated decayed teeth. Frequent bottle feeding at night has been identified as a driv- ing factor for ECC. Other stud- ies have found a microbiological connection between mother and child, labeling ECC a transmissi- ble disease. What is your opinion on the latest research and how will it affect the way children should be treated? Dr. Neal Herman: The nursing bot- tle is only one of many confounding factors in ECC. What we conclude from the latest research is that den- tal caries is highly complex and perplexing, not easily prevented or treated in the most susceptible chil- dren. It is believed these days that there are nutritional, behavioral, immunological and bacterial fac- tors that must be considered in order to understand and prevent dental caries. The surgical approach to ECC — the “drill and fill” solution of placing restorations in teeth as they become cavitated — has long been proven futile and often counter- productive. Therapeutic interven- tions, particularly utilizing fluoride varnish, have shown promise in preventing, arresting and reversing carious lesions. Much more work must be done to document its success, but at least this “medical model” has begun to address the fact that ECC is a bacte- rial disease that requires more than just filling up the holes that are merely its symptoms. Root-canal treatments in prima- ry teeth are also becoming more common. Does the treatment dif- fer in any way from that of per- manent teeth? Dr. Lily Lim: We’re not sure that pulp therapy is on the increase but if it is, it’s probably because more parents and dentists realize it’s best to try to preserve a primary tooth rather than extract it whenever pos- sible. The goals of treatment for pri- mary teeth are not much differ- ent to that for permanent teeth. In both cases, diseased portions of the dental pulp are removed in an effort to preserve the hard struc- ture of the tooth for functional or cosmetic purposes. Anatomical and physiological differences between primary and permanent teeth make a difference to the principle of root- canal treatment. A permanent tooth requires an inert, solid, nonresorbable material that can last a lifetime, and gutta- percha fits that bill. The ideal root-canal filling mate- rial for primary teeth should resorb at a similar rate to the primary root in order to permit normal erup- tion of the successor tooth; not be harmful to the underlying tissues or to the permanent tooth germ; fill the root canals easily; adhere to the walls and not shrink; be easily removed, if necessary; be radiopaque; be antiseptic; and not cause discoloration of the tooth. There is currently no material that meets all these criteria, but the filling materials most commonly used for primary pulp canals are non-reinforced zinc-oxide-eugenol paste, iodoform-based paste [KRI], and iodoform and calcium hydrox- ide [Vitapex]. A study in the Netherlands has found that prevention involv- ing the counseling of parents on caries-promoting feeding behav- ior is often ineffective in the long term. Is there a lack of quality intervention strategies? Herman: If we, or the World Health Organization, could answer this question, we’d have found the key to unlocking the mystery of improving or enhancing human motivation. It is probably true that without con- tinual and periodic follow-up, coun- seling will wear off even amongst highly motivated individuals. We think the key lies with educa- tion that begins early and promotes a sound nutritional and sustainable oral-hygiene model for parent and child alike. As you might imagine, this is a task not well-suited to the traditional dental care delivery model, and will require some seri- ous paradigm changes to permit effective implementation. What preventative measures do you recommend based on your clinical experience in New York? Herman: Preventive measures and conservative therapies that confront the cause of the disease, rather than treat the symptoms, are the most effective and work the best. Fluoride varnish has proven to be a godsend, although most of the evidence to date is empirical and anecdotal. Good long-term longitu- dinal studies are needed to prove Prof. Jill FernandezDr. Neal Herman ‘ECC is a bacterial disease that requires more than just filling up the holes.’ ~ Dr. Neal Herman f DT page 1A