Canada Fluoride Handout2 2016 - CAPD/ACDP

CAPD / ACDP 2016SATURDAY MORNING1. Caries Risk Assessment2. Fluoride Issues3. Managing EruptionFluoride 2016 --A Decade of Changesv Review of how FLUORIDE worksv What is FLUOROSISv 2001 CDC Fluoride Guidelinesv 2006 ADA Topical Fluoride Recommendationv 2007 ADA Infant Formula & Non-fluoridated H2Ov 2008 JADA Systematic review of Fluoride SupplementsFluoride 2016 Over a Decade of Changesv 2010 JADA Causes of Fluorosis in Permanent Incisors –v Iowa Study – Steve Levyv 2011 ADA Evidence-Based Clinical Recommendationsregarding Fluoride Intake from Reconstituted InfantFormula and Enamel Fluorosisv 2011 Dept of Human and Health Services and EPArecommendation for fluoride level in public water systemsFluoride 2016 Over a Decade of Changesv 2012 AAPD Revised Guideline on Fluoride Therapyv 2013 ADA Fluoride Toothpaste Efficacyv 2014 AAP Fluoride Policyv 2015 ABIM Choosing Wisely Statementsv 2015 “The Harvard Study” Fluoride and IQv 2015 Silver Diamine FluorideMechanism  of  Action  of  FluorideKEY CONCEPT --- primarily a TOPICAL ACTION(even when given systemically):Ü Reduces enamel solubilityFluoride mechanismLow pHfavorsDemineralizationCa PO4-Ü Ü Ü Promotes remineralization of enamel, and mayarrest or reverse early cariesInhibits the growth of cariogenic organisms thusdecreasing acid productionIncreased pHfavorsRemineralizationH H H F- H H Ca PO4-Protein?FFFFFF-Concentrated in saliva1

Sources  of  FluorideSystemic fluoride – worksÜ Ü Ü Ü Community water fluoridationBottled water with fluoride addedFluoride supplementsSwallowed toothpasteTopical fluoride – worksÜ Ü The Fluoride Zonetopically like sodiumtopically too little topical fluoride - caries risk too much ingested fluoride - fluorosis riskFluoride toothpastesProfessionally-applied: gels,foams, rinses, and varnishes** if too much fluoride is ingested before age 5 – risk FLUOROSISAmount of FLUOROSIS depends onRisk Period for fluorosis while Perm Teeth are developing1) Amount of exposure2) Duration of exposure3) Timing within Enamel Maturation4) Individual susceptibility genetic predisposition ?Anteriors - 3months – 5 years of ageEnamel Maturation for all Permanent Teeth – complete by age 8Critical Risk Period for Fluorosis3 mos – 5 years of ageToothHard TissueFormationBeginsEnamelCompleteEruptionIssue of FluorosisPermanent DentitionMaxillaryCentral incisor3-4 mo4-5 yr7-8 yrLateral incisor10-12 mo4-5 yr8-9 yrEsthetic and Trauma ConcernsMandibularCentral incisor3-4 mo4-5 yr6-7 yrLateral incisor3-4 mo4-5 yr7-8 yr2

Fluorosis – is treatableFluorotic Incisors& MolarsSYSTEMIC EFFECT1) Cool Dam2) 18% HCL and pumiceLD’s Generalized Fluorosis and Enamel PittingLD’s Generalized FluorosisCJ’s Fluorotic Incisors & 6 yr MolarsCJ’s Fluorotic Incisors & 6 yr Molars3

CJ’s Fluorotic MolarsFluorosis of Primary and Permanent DentitionEureka MomentFLUOROSIS SYSTEMIC CONDITIONFluorosis of Primary and Permanent DentitionFluorosis of Primary and Permanent DentitionFluoride When and Where 2016v Review of how FLUORIDE worksv What is FLUOROSISFLUOROSIS age limiting conditionv 2001 CDC Fluoride Guidelinesv 2006 ADA Topical Fluoride Recommendationv 2007 ADA Infant Formula & Non-fluoridated H2Ov 2008 JADA Systematic review of Fluoride Supplements4

CDC Fluoride RecommendationsSelect a fluoride modality according to: a caries risk assessment ( high or low ) recognize that an individual’s risk canchange over time change from low tohigh be familiar with the quality of the evidenceof each fluoride modalityWeigh the Risks before Rx FluorideProtective FactorsNo CariesPathologic FactorsCariesCDC Fluoride RecommendationsPublic Health and Clinical Practice promote community water fluoridation counsel parents regarding the risk ofswallowing toothpaste, especially 2yo target mouthrinsing to high risk judiciously Rx fluoride supplements apply high-concentration Fl- products tohigh risk Ref – JDB Featherstone. J Dent Res 83 (Spec Iss C): C39-C42, 2004.Community water fluoridationÜ 61.5% of US population receiving fluoridatedwater (2006, CDC Statistics)Ü 69.2% of US population on public water systemreceiving fluoridated water.""#1 Kentucky 99.8%# 49 New Jersey 22.6%Ü Difficult to determine how much F in water inmany communities.5

2001  CDC    Tooth  BrushingRecommendationsAge 1yearTooth BrushingRecommendations (CDC, 2001) clean teeth with soft toothbrush1-2 parent performs brushingyears2 - 6 pea-sized amount of fluorideyearscontaining toothpaste 2x/day parent performs or supervises 6 brush with fluoridatedyearstoothpaste 2x/dayToothpasteFluoride FREEContain 0.15% fluoride ionToothpaste and ChildrenÜ Children ingest substantial amounts of toothpaste because ofimmature swallowing reflex Children 2 yrs swallow about 60% of toothpaste onbrushÜ Early use of fluoride toothpaste may be associated withincreased risk of fluorosisÜ Once permanent teeth have mineralized, dental fluorosis is nolonger a concern (after age 6 yrs, only molars are stillforming)Ü PRIOR TO AGE 2 – DDS can prescribe use of fluoridetoothpaste for high caries risk children – use SMEARSAME AS ADULT TOOTHPASTEFluoride rinses Recommended tobegin after age 6years.CDC Fluoride Recommendations-Self Care know the fluoride content of your drinkingwater frequently use small amounts of fluoride– drink Fl- water and brush BID supervise children 6yo use of toothpaste consider additional fluoride modalities if youare at high risk for caries use alternative water if 2ppm & child 8yo6

CDC Fluoride RecommendationsConsumer Product Industry & Health AgenciesFluoridated bottles water . Alternative to supplement label bottled water promote use of small amounts of toothpastewith children develop a low-fluoride toothpaste forchildren 500 ppm collaborate to educate public and healthcare professionalsFluoride When and Where 2016v Review of how FLUORIDE worksv What is FLUOROSISv 2001 CDC Fluoride Guidelinesv 2006 ADA Topical Fluoride Recommendationv 2007 ADA Infant Formula & Non-fluoridated H2Ov 2008 JADA Systematic review of Fluoride SupplementsFluoride 2016 A Decade of Changesv 2006 ADA Topical Fluoride Recommendationv Fluoride Gelsv Fluoride Foamsv Fluoride VarnishWhat should we use in our offices ?What is the best topical fluoridetreatment for our patients ?VARNISH 4 minute GEL 4 minute FOAMUse of any topical fluoride tx should be based ona caries risk assessmentADA 2006 Topical Fluoride RecommendationsJADA 137:1151-1159, 2006.7

Role of MDs in Oral Health22,600 ppmShown to be 30-63%effective inpreventing ECCs**Bader JD, Rozier RG, Lohr KN, Frame PS. Physicians’ roles in preventingdental caries in preschool children. Am J Prev Med. 2004;26:315-325.White Fluoride VarnishPreventive Role of Fluoride VarnishImproved taste for children!Cherry or MelonJane Weintraub et alFluoride Varnish Efficacy in Preventing Early ChildhoodCariesJ Dent Res 85(2): 172-176, 2005.Available in singledose disposablepackets1,2,3 and 4 applications of fluoride varnish & parentalcounseling were efficacious in preventing ECCNote – similar findings in NC Gary Rozier study39% reduction in anterior caries 20073 Treatment Scenarios1. White spots – treat chemically2. Beyond white spotsBeginning breakdown –ART plus Fluoride VarnishorART w/ Glass Ionomer(Fuji IX or Ketac Nano)3. Frank caries – mechanical tx8

Scenario #1 : Suzanne 3yo presents with mild ECC– Minimal Oral HygieneCaries at CEJ of #D,E,F,GTreatment PlanCaries beginning on lingual surfaces – see #ESuzanne- q3 months Fl tx Apply Fluoride varnish Reassess in 6 weeks / 3 months untillesions stabilize or require definitive tx D1206 ADA codeLesions are holding stable2/05 - 6/07Suzanne age 3yo-6yo with MILD ECCAlex ‘s - Enamel DefectsLesions are holding stable2/05 - 8/089

Scenario #2 18 month old presents with mild ECC– Mild ECC white spot lesions– Underlying enamel defects Mother fainted in 3rd trimester– Breastfeeding during the night– Supplementing with baby food– Minimal Oral HygieneTamirEnamel defects#E,#F and #O,#PART Alternative (Atraumatic)RestorativeTechnique-No local anesthesia-Hand Instrument or Slow Speed removalof soft carious process-Apply Glass Ionomer-Fluoride Varnish-Frequent Recall-GOAL- stabilize lesionScenario #3 –Beyond fluoride varnishEnamel defects #E,#F and #O,#PTreat with ART and Fluoride varnishBeyond fluoride varnishRestorations do NOT fix the bacterialinfection in the mouth or the risky behaviorsthat contributed to ECC!10

After the restorations MUST IMPROVE Oral Hygiene Feeding Behaviors Ensure adequatefluorideFluoride When and Where 2016v Review of how FLUORIDE worksv What is FLUOROSISv 2001 CDC Fluoride Guidelinesv 2006 ADA Topical Fluoride Recommendationv 2007 ADA Infant Formula & Non-fluoridated H2Ov 2008 JADA Systematic review of Fluoride Supplements2007  ADA  Interim  StatementInfant  feeding  0- ‐‑12  months 1st choice breastfeeding 2nd choice Ready-to-feed (premixed) 3rd choice Liquid concentrate or powered formula MIX with FLUORIDE FREE WATER2007  ADA  Interim  StatementInfant  feeding  0- ‐‑12  monthsBaby Formula Fluoride Levels ISSUE – volume of liquid being consumed AAP 24-32 ounces per day FORMULA 8 ounces of fluoridated water 0.25mg fluoride EQUALS 0.75mg -1mg of fluoride per dayADA News 200011

Variable F in Drinking WaterFluoride Content AfterWater FiltrationADA News 200012

JB – 8yo*Had infant formula from 6-12 monthsst*1 tooth erupted around 10 months old*Now seeing Fluorosis on #K, #T, #8,#9, #19, and #30JB – 8yo*Had infant formula from 6-12 monthsst*1 tooth erupted around 10 months old*Now seeing Fluorosis on #K, #T, #8,#9, #19, and #30AH HA Momentpotential role of infant fluoride exposureFluoride When and Where 2016v Review of how FLUORIDE worksv What is FLUOROSISv 2001 CDC Fluoride GuidelinesFluoride Supplements ?§ Caries-preventive effect of fluoride is almostexclusively POST-ERUPTIVE§ Mode of action of fluoride is mainly attributed toits influence on de- and remineralization kineticsof enamelv 2006 ADA Topical Fluoride Recommendationv 2007 ADA Infant Formula & Non-fluoridated H2Ov 2008 JADA Systematic review of Fluoride Supplements§ Therefore, the main focus should be onTOPICAL FLUORIDE MODALITIESRef – Hellwig E & Lennon AM: Caries Res 2004; 38:258-262.13

Testing H20 for fluorideOnly Rx Supplements if –1) No Fluoride in WaterAND2) HIGH Caries Risk It is Complicated If content unknown and child is at highrisk for dental caries, test water source.Dietary FluorideSupplementationLimited Supply ?Weigh the risk before Rx fluorideProtective FactorsPathologic FactorsFAVOR REMINERALIZATIONFAVOR DEMINERALIZATIONNo CariesFluoride  Dosing  RecommendationsCaries Ref – JDB Featherstone. J Dent Res 83 (Spec Iss C): C39-C42, 2004.MMWR: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the 14a1.htmFluoride 2016 A Decade of Changesv 2010 JADA Causes of Fluorosis in Permanent Incisors –v Iowa Study – Steve Levyv 2011 ADA Evidence-Based Clinical Recommendationsregarding Fluoride Intake from Reconstituted InfantFormula and Enamel Fluorosisv 2011 Dept of Human and Health Services and EPArecommendation for fluoride level in public water systemsv 2012 AAPD Revised Guideline on Fluoride Therapy14