ed5 - oral health (levy 2011-12)
TRANSCRIPT
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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
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Preventive Dentistry
Eliminates disease
Establishes good habits
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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).
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Topical
vs. Systemic Fluorides
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Topical FluoridesWater fluoridation
Diet
Dietary fluoridesupplements (chew, swish,
swallow)
DentifriceMouthrinse
Office (professional)7
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Systemic Fluorides• Water Fluoridation
• Diet
• Dietary FluorideSupplements
• (Dentifrice)
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Pre-eruptive
vs.
Post-eruptive
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Esthetic Perceptions of
Dental Fluorosis
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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
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Relationships Among
Fluoride Ingestion, Dental
Caries, and Dental Fluorosis
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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
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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
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Home Water
Filtration Systems
Usually carbon or charcoal, do not
remove fluoride
Distillation and reverse osmosis
remove the majority of fluoride
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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.
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Infant FormulaConcern about high levels in the
1970s.U.S. manufacturers voluntarily
lowered their F concentrations.
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Emphasis on Infant Formula, Fluoride
and Fluorosis
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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)
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W Fl id i
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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
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www.cdc.gov/fluoridation/ 29
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http://apps.nccd.cdc.gov/MWF/Inde
x.asp 30
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http://apps.nccd.cdc.gov/MWF/CountyDataV.asp?Stat
e=IA 31
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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
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R d i f U i Fl id
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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
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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
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Key Findings
Target other modalities based oncaries risk
Measured use of toothpaste,dietary supplements, and high
concentration topical productsfor <6 years old
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N i l R h C il/N i l
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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)
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P d N U S N ti l
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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
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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.
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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.
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Fluoride - Evidence-based recommendations (JADA--
December 2010 and January 2011,
respectively)
Evidence
Patientsneeds and
preferences
ClinicalExpertise
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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?
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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)
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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)
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Overall Recommendations
Dietary Fluoride Supplements
To be used cautiously – only for high
risk
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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
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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
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Fl id d B
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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
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Iowa Bone Development Study
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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
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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
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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
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The bottom line is that at low dosages
(such as in fluoridated water),
fluoride appears to have little effecton bone health.
Fluoride and Bone
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IDPH School based Screening
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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
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I-Smile
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Up to about 88% of dental caries
occurred on pit-and-fissure surfacesamong U.S. school children in 1988-
91.
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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.
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Sound vs Carious or Restored Surfaces on
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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
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The Effectiveness of Sealants in
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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
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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).
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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
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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.
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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.
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Thank You
Questions?