Caries Prevention 411
Early childhood caries (ECC) is a multifactorial disease with etiological factors being enamel hypoplasia, elevated levels of cariogenic bacteria, and the metabolism of fermentable carbohydrates, which produce acid to demineralize teeth.
Early childhood caries (ECC) is a multifactorial disease with etiological factors being enamel hypoplasia, elevated levels of cariogenic bacteria, and the metabolism of fermentable carbohydrates, which produce acid to demineralize teeth. Furthermore, statistics reveal that socioeconomic status is the prevalent factor regarding ECC. While race, culture, ethnicity, lifestyle, diet, and oral hygiene practices play a significant role, socioeconomic status outweighs all these factors. In developed countries, the ECC rate is 1% to 12%, while in underdeveloped countries, the rate can be as high as 70%. Little knowledge on the use of fluoride, poor dietary habits, and a lack of understanding for preventive care for children by parents are correlated strongly with low socioeconomic status.
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Strategies continue to evolve to combat this invasive disease. Primarily, the dental hygienist is the key player in prevention. Use of motivational interviewing (MI) and collaboration with other health care providers can create a patient-centered approach to treatment. Other strategies, such as fluoride therapy, including silver diamine fluoride; proper self-care; nutritional evaluation; risk assessment; reduction of MS; and restorative interventions, if necessary; are all part of an effective ECC prevention program.
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Role of Dental Hygienists
Dental hygienists are uniquely positioned to reduce the incidence of ECC via prevention. Strategies in education, including behavioral changes and nutritional counseling, position the dental hygienist perfectly in the profession’s prevention role. Furthermore, interventions, including fluoride usage, monitoring, and referral, are well within the dental hygiene scope of practice. Engaging dental hygienists in collaborative care with other health care professionals and utilizing MI while assessing and strategizing a treatment plan are important aspects of dental hygiene practice.
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The principal approaches to prevent or reduce ECC in high-risk children include altering dietary patterns and implementing fluoride protocols. Nutritional counseling aims to help parents change their children’s dietary behaviors to favor low or noncariogenic snacks, increase use of community fluoridated water, and limit sweet foods to mealtimes. Such recommendations must be realistic and based on the dietary behaviors of the family. Evidence shows that nutritional counseling can be effective for families at high caries risk. Two landmark studies show that nutritional counseling and reinforcement resulted in reduced caries incidence. Use of water instead of juices, especially in bottles or sippy cups, and avoiding frequent consumption of fermentable carbohydrates should be encouraged. Limiting on-demand breastfeeding after the eruption of the first tooth and after dietary carbohydrates are introduced, and weaning from bottle use after 12 months are recommended.
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Fluoride is the first line of defense in the prevention of ECC. The US Food and Drug Administration (FDA) recognizes fluoride as the only compound that prevents dental caries. In the US, community fluoridated water, toothpastes, and mouthrinses are the primary sources of fluoride. Other sources include office gels, varnishes, and silver diamine fluoride (SDF).
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Self-Care Is a Must
Twice-a-day toothbrushing is essential in controlling ECC, and guidelines for toothpaste use have been updated. Previously, fluoride toothpaste was not recommended for infants. However, in 2014, the recommendation changed to twice-daily brushing with fluoride toothpaste for all children in optimally-fluoridated and fluoride-deficient communities. Risk vs benefit is the key issue in preventing dental disease over mild fluorosis occurrences. The American Academy of Pediatric Dentistry recommendation is now a smear or rice-sized amount for children younger than age 3 (0.1 mg fluoride) and a pea-sized amount for children ages 3 to 6 (0.25 mg fluoride). For children at high risk of caries, prescription home-fluoride use should be recommended. Fluoride concentrations from 900 ppm to 5,000 ppm are suggested.