Francisco Ramos-Gomez

Fluoride Varnish Efficacy in Preventing Early Childhood Caries

To determine the efficacy of fluoride varnish (5% NaF, Duraphat®, Colgate) added to caregiver counseling to prevent early childhood caries, we conducted a two-year randomized, dental-examiner-masked clinical trial. Initially, 376 caries-free children, from low-income Chinese or Hispanic San Francisco families, were enrolled (mean age ± standard deviation, 1.8 ± 0.6 yrs). All families received counseling, and children were randomized to the following groups: no fluoride varnish, fluoride varnish once/year, or fluoride varnish twice/year. An unexpected protocol deviation resulted in some children receiving less active fluoride varnish than assigned. Intent-to-treat analyses showed a fluoride varnish protective effect in caries incidence, p < 0.01. Analyzing the number of actual, active fluoride varnish applications received resulted in a dose-response effect, p < 0.01. Caries incidence was higher for ‘counseling only’ vs. ‘counseling + fluoride varnish assigned once/year’ (OR = 2.20, 95% CI 1.19–4.08) and ‘twice/year’ (OR = 3.77, 95% CI 1.88–7.58). No related adverse events were reported. Fluoride varnish added to caregiver counseling is efficacious in reducing early childhood caries incidence.

Recruitment for Health Disparities Preventive Intervention Trials: The Early Childhood Caries Collaborating Centers

Background Four trials of interventions designed to prevent early childhood caries are using community-engagement strategies to improve recruitment of low-income, racial/ethnic minority participants. The trials are being implemented by 3 centers funded by the National Institute of Dental and Craniofacial Research and known as the Early Childhood Caries Collaborating Centers (EC4): the Center for Native Oral Health Research at the University of Colorado, the Center to Address Disparities in Children’s Oral Health at the University of California San Francisco, and the Center for Research to Evaluate and Eliminate Dental Disparities at Boston University. Community Context The community contexts for the EC4 trials include urban public housing developments, Hispanic communities near the US–Mexican border, and rural American Indian reservations. These communities have a high prevalence of early childhood caries, suggesting the need for effective, culturally acceptable interventions. Methods Each center’s intervention(s) used community-based participatory research approaches, identified community partners, engaged the community through various means, and developed communication strategies to enhance recruitment. Outcome All 3 centers have completed recruitment. Each center implemented several new strategies and approaches to enhance recruitment efforts, such as introducing new communication techniques, using media such as radio and newspapers to spread awareness about the studies, and hosting community gatherings. Interpretation Using multiple strategies that build trust in the community, are sensitive to cultural norms, and are adaptable to the community environment can enhance recruitment in underserved communities.

Maintaining and Improving the Oral Health of Young Children

Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

Mother and youth access (MAYA) maternal chlorhexidine, counselling and paediatric fluoride varnish randomized clinical trial to prevent early childhood caries

BACKGROUND Mexican-American children have a higher caries prevalence than the U.S. average. The Mothers and Youth Access (MAYA) study was a randomized clinical trial initiated to address this problem. AIM Comparison of the efficacy of two prevention interventions in reducing early childhood caries (ECC). DESIGN All 361 randomized mother-child dyads received oral health counselling. Beginning at 4 months postpartum, intervention mothers received chlorhexidine (CHX) mouthrinse for 3 months beginning 4 months postpartum and children received fluoride varnish (FV) every 6 months from age 12-36 months. Control group children received FV if precavitated lesions developed. Salivary mutans streptococci (MS) and lactobacilli were assessed. RESULTS No significant difference in childrens 36-month caries incidence between groups; 34% in each group developed caries [(d(2+) fs) > 0]. About half of control group developed precavitated lesions and received therapeutic FV. Maternal MS levels declined during CHX use, but increased when discontinued. CONCLUSIONS Maternal postpartum CHX regimen, oral health counselling and preventive child FV applications were not more efficacious than maternal counselling with child therapeutic FV for precavitated lesions for ECC prevention. FV for young children with brief maternal CHX use and oral health counselling may need to be combined with additional or longer-term therapies to significantly reduce ECC in high-risk populations.

(A1) Identification of Oral Health Care Needs in Children and Adults, Management of Oral Diseases:

The workshop considered five questions reviewing the identification of international oral health care needs of children and adults, and the management of oral diseases in resource-poor countries: (1) What is the role of the dental profession in the management of the HIV-infected individual? (2) Identifying health care needs-What are the epidemiology and disparities of HIV-associated oral lesions in children from different continents? (3) How effective is HIV treatment in controlling oral diseases? (4) Could we develop basic inexpensive oral and dental care protocols for economically deprived HIV-infected patients? and (5) What is the best method of arranging resources to meet the oral health care needs of people with HIV disease? The consensus of the workshop participants was that there is a need to re-target research efforts to non-established market economy countries and prioritize research in these regions to children with HIV disease. It will be important to assess commonalities and variations in oral health needs across geographical and cultural boundaries, and research efforts should be centralized in resource-poor countries to support multi-center longitudinal standardized studies. It is essential that oral health research be integrated into other health care research programs, to make these research priorities and public health initiatives feasible.

Maternal Oral Bacterial Levels Predict Early Childhood Caries Development

Objective: To calculate the association of maternal salivary bacterial challenge (mutans streptococci [MS] and lactobacilli [LB]) from pregnancy through 24 months’ postpartum with child caries incidence (≥1 cavitated or restored teeth) at 36 months. Materials & Methods: Dental, salivary bacterial, sociodemographic, and behavioral measures were collected at three- to six-month intervals from a birth cohort of low-income Hispanic mother-child dyads (N = 243). We calculated the relative child caries incidence, adjusted for confounding, following higher maternal challenge of MS (>4500 colony-forming units per milliliter of saliva [CFU/mL]) and LB (>50 CFU/mL) based on multivariable models. Results: Salivary MS and LB levels were greater among mothers of caries-affected children versus caries-free children. Mothers with higher salivary MS challenge were more likely to have MS-positive children (>0 CFU/mL), but maternal LB challenge was not a statistically significant predictor of child LB-positive status. Adjusting for sociodemographics, feeding and care practices, and maternal dental status, higher maternal salivary challenge of both MS and LB over the study period predicted nearly double the child caries incidence versus lower MS and LB (cumulative incidence ratio: 1.9; 95% confidence interval: 1.1, 3.8). Conclusion: Maternal salivary bacterial challenge not only is associated with oral infection among children but also predicts increased early childhood caries occurrence.

Disease Management of Early Childhood Caries: ECC Collaborative Project

Until recently, the standard of care for early childhood caries (ECC) has been primarily surgical and restorative treatment with little emphasis on preventing and managing the disease itself. It is now recognized that surgical treatment alone does not address the underlying etiology of the disease. Despite costly surgeries and reparative treatment, the onset and progression of caries are likely to continue. A successful rebalance of risk and protective factors may prevent, slow down, or even arrest dental caries and its progression. An 18-month risk-based chronic disease management (DM) approach to address ECC in preschool children was implemented as a quality improvement (QI) collaborative by seven teams of oral health care providers across the United States. In the aggregate, fewer DM children experienced new cavitation, pain, and referrals to the operating room (OR) for restorative treatment compared to baseline historical controls. The teams found that QI methods facilitated adoption of the DM approach and resulted in improved care to patients and better outcomes overall. Despite these successes, the wide scale adoption and spread of the DM approach may be limited unless health policy and payment reforms are enacted to compensate providers for implementing DM protocols in their practice.

Management of Dental Trauma in a Primary Care Setting

The American Academy of Pediatrics and its Section on Oral Health have developed this clinical report for pediatricians and primary care physicians regarding the diagnosis, evaluation, and management of dental trauma in children aged 1 to 21 years. This report was developed through a comprehensive search and analysis of the medical and dental literature and expert consensus. Guidelines published and updated by the International Association of Dental Traumatology (www.dentaltraumaguide.com) are an excellent resource for both dental and nondental health care providers.

Oral Health Considerations in HIV-Infected Children

Children with the human immunodeficiency virus (HIV) have a higher probability of hard and soft oral tissue diseases because of their compromised immune systems and socioeconomic factors such as poor access to medical and dental care and limited availability of fluoridated water or toothpaste. To improve health outcomes and help monitor the progression of HIV, a preventive, child-specific oral health protocol for children with HIV that is easy to use and appropriate for all different resource settings should be established. Further, both medical and dental health practitioners should incorporate such a protocol into their care routine for HIV-infected children. Using proactive oral health risk assessments complemented by scheduled follow-up visits based on individual risk determination can prevent opportunistic infection, track the HIV disease trajectory, and monitor the effectiveness of highly active antiretroviral therapy (HAART) while improving the quality of life and longevity of children living with HIV.

A model for community-based pediatric oral heath: implementation of an infant oral care program.

The Affordable Care Act (ACA) mandates risk assessments, preventive care, and evaluations based on outcomes. ACA compliance will require easily accessible, cost-effective care models that are flexible and simple to establish. UCLA has developed an Infant Oral Care Program (IOCP) in partnership with community-based organizations that is an intervention model providing culturally competent perinatal and infant oral care for underserved, low-income, and/or minority children aged 0–5 and their caregivers. In collaboration with the Venice Family Clinics Simms/Mann Health and Wellness Center, UCLA Pediatrics, Women, Infants, and Children (WIC), and Early Head Start and Head Start programs, the IOCP increases family-centered care access and promotes early utilization of dental services in nontraditional, primary care settings. Emphasizing disease prevention, management, and care that is sensitive to cultural, language, and oral health literacy challenges, IOCP patients achieve better oral health maintenance “in health” not in “disease modality”. IOCP uses interprofessional education to promote pediatric oral health across multiple disciplines and highlights the necessity for the “age-one visit”. This innovative clinical model facilitates early intervention and disease management. It sets a new standard of minimally invasive dental care that is widely available and prevention focused, with high retention rates due to strong collaborations with the community-based organizations serving these vulnerable, high-risk children.