Norman Tinanoff

Update on Early Childhood Caries Since the Surgeon General's Report

The 2000 Surgeon Generals Report on Oral Health included a limited discussion of the condition known as early childhood caries. Because of its high prevalence, its impact on young childrens quality of life and potential for increasing their risk of caries in the permanent dentition, early childhood caries is arguably one of the most serious and costly health conditions among young children. A necessary first step in preventing dental caries in preschool children is understanding and evaluating the childs caries risk factors. Previous caries experience and white spot lesions should automatically classify a preschool child as high risk for caries. Microbial factors, such as presence of visible plaque and tests that identify a child as having high levels of mutans streptococci, also predict caries in young children. Frequency of sugar consumption, enamel developmental defects, social factors such as socioeconomic status, psychosocial factors, and being an ethnic minority also have shown to be relevant in determining caries risk. On the basis of this knowledge of specific risk factors for an individual, different preventive strategies and different intensities of preventive therapies can be implemented. Caries preventive strategies in preschool children include fluoride therapy, such as supervised tooth brushing with a fluoridated dentifrice, systemic fluoride supplement to children who live in a nonfluoridated area and who are at risk for caries, and professional topical fluoride with fluoride varnish. There is emerging evidence that intensive patient counseling or motivational interviews with parents to change specific behaviors may reduce caries prevalence in their children. Findings regarding antimicrobial interventions, efforts to modify diets, and traditional dental health education are less consistent.

Examination criteria and calibration procedures for prevention trials of the Early Childhood Caries Collaborating Centers

OBJECTIVES To summarize diagnostic criteria and examiner training and calibration of the National Institute of Dental and Craniofacial Research-funded Early Childhood Caries Collaborating Centers (EC4) and report examiner calibration results from 2010 to 2014. The EC4 at Boston University, University of Colorado, and University of California San Francisco are performing randomized controlled early childhood caries (ECC) prevention trials with caries as the main outcome measure. METHODS The EC4 with University of Iowa consultants developed standardized tooth and tooth surface status examination criteria for use in field conditions, examiner training materials, and examiner calibration and re-calibration methodologies. Calibration and re-calibration were performed with 1- to 5-year-old children in the San Francisco Mission District in which assessments from each examiner to be calibrated were compared with those from a single gold standard examiner from 2010 to 2014. Cohens kappa statistic was used to determine inter-examiner agreement. RESULTS A total of seven examiners were successfully (re)calibrated during that period, examining a total of 231 children. Overall unweighted Cohens kappas for 10 surface conditions exceeded the criterion of 0.70. However, separate agreement for assessment of noncavitated lesions, as in other studies, was lower. CONCLUSIONS An experienced multidisciplinary and multi-institutional team was able to develop criteria and training materials to anticipate situations and field conditions the main trials would encounter. Examiners were successfully trained and (re)calibrated.

Potential to improve oral health care through evidence, protocols, and payment models.

Evidence-based health care aims to utilize the best available evidence from scientific methods and apply this evidence to clinical and public health practice. Evidence of the benefits and risks of treatment is derived from randomized controlled clinical trials, systematic reviews, and expert panels. Evidence-based clinical parameters and guidelines should foster the best health outcomes for individuals or populations at reduced costs. By incorporating evidence-based guidelines into payment models, the payers - private or public - have the capacity to improve oral health care and ultimately oral health outcomes. This paper uses examples from pediatric dentistry to show how adoption of caries risk factors, clinical management protocols, and a reimbursement system based on evidence-based guidelines may allow for better quality of care to more individuals and at a lower cost.

Early childhood caries and intake of 100 percent fruit juice: Data from NHANES, 1999-2004

BACKGROUND The results of several studies conducted in the United States show no association between intake of 100 percent fruit juice and early childhood caries (ECC). The authors examined this association according to poverty and race/ethnicity among U.S. preschool children. METHODS The authors analyzed data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES) for 2,290 children aged 2 through 5 years. They used logistic models for caries (yes or no) to assess the association between caries and intake of 100 percent fruit juice, defined as consumption (yes or no), ounces (categories) consumed in the previous 24 hours or usual intake (by means of a statistical method from the National Cancer Institute). RESULTS The association between caries and consumption of 100 percent fruit juice (yes or no) was not statistically significant in an unadjusted logistic model (odds ratio [OR], 0.76; 95 percent confidence interval [CI], 0.57-1.01), and it remained nonsignificant after covariate adjustment (OR, 0.89; 95 percent CI, 0.63-1.24). Similarly, models in which we evaluated categorical consumption of 100 percent juice (that is, 0 oz; > 0 and ≤ 6 oz; and > 6 oz), unadjusted and adjusted by covariates, did not indicate an association with ECC. CONCLUSIONS Our study findings are consistent with those of other studies that show consumption of 100 percent fruit juice is not associated with ECC.

Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions

BACKGROUND An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated evidence-based clinical recommendations for the arrest or reversal of noncavitated and cavitated dental caries using nonrestorative treatments in children and adults. TYPES OF STUDIES REVIEWED The authors conducted a systematic search of the literature in MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane database of systematic reviews to identify randomized controlled trials reporting on nonrestorative treatments for noncavitated and cavitated carious lesions. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and move from the evidence to the decisions. RESULTS The expert panel formulated 11 clinical recommendations, each specific to lesion type, tooth surface, and dentition. Of the most effective interventions, the panel provided recommendations for the use of 38% silver diamine fluoride, sealants, 5% sodium fluoride varnish, 1.23% acidulated phosphate fluoride gel, and 5,000 parts per million fluoride (1.1% sodium fluoride) toothpaste or gel, among others. The panel also provided a recommendation against the use of 10% casein phosphopeptide-amorphous calcium phosphate. CONCLUSIONS AND PRACTICAL IMPLICATIONS Although the recommended interventions are often used for caries prevention, or in conjunction with restorative treatment options, these approaches have shown to be effective in arresting or reversing carious lesions. Clinicians are encouraged to prioritize use of these interventions based on effectiveness, safety, and feasibility.

Individuals Who Brush Their Teeth Infrequently May Be at Greater Risk for New Carious Lesions

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Effect of Toothbrushing Frequency on Incidence and Increment of Dental Caries: A Systematic Review and Meta‐Analysis. Kumar S, Tadadamadla J, Johnson NW. J Dent Res 2016;95(11):1230‐6. SOURCE OF FUNDING Information not available TYPE OF STUDY/DESIGN Systematic review with meta‐analysis of data

Fluoride Therapy for the Pediatric Patient

This article reviews current concepts regarding the mode of action of fluoride, describes the metabolism of fluoride in the child, brings attention to recent changes in protocol for prescribing fluoride supplements, and describes intensive fluoride regimens for patients with special problems.

Evidence of Early Emergence of the Primary Dentition in a Northern Plains American Indian Population

The purposes of this study were to describe primary tooth emergence in an American Indian (AI) population during the first 36 mo of life to compare 1) patterns of emergence between male and female children and 2) tooth emergence between these AI children and other U.S. ethnic groups. Data were derived from a birth cohort of 239 AI children from a Northern Plains tribe participating in a longitudinal study of early childhood caries, with examination data at target ages of 8, 12, 16, 22, 28, and 36 mo of age (±1 mo). Patterns of emergence in AI children were characterized and sex comparisons accomplished with interval-censored survival methodology. Numbers of erupted teeth in AI children at each age were compared via Kruskal-Wallis tests against those in children of the same age, as drawn from a cross-sectional study of dental caries patterns in Arizona; these comparisons were based on the dental examinations of 547 White non-Hispanic and 677 Hispanic children. Characterization of time to achievement of various milestones—including emergence of the anterior teeth, the first molars, and the complete primary dentition—provided no evidence of sex differences among AI children. AI children had significantly more teeth present at 8 mo (median, 3) than either White non-Hispanic (P < 0.0063) or Hispanic (P < 0.0001) children (median, 2 each). This was also true at 12 mo (P < 0.001; medians, 8 vs. 6 and 7, respectively) and 16 mo (P < 0.001; medians, 12 vs. 11 each). Less pronounced differences were seen at 22 mo (P < 0.0001). White non-Hispanic and Hispanic children did not differ at any time considered (P > 0.05). These results provide evidence of earlier tooth emergence in AI children than in the other 2 ethnicities. Although the underlying etiology of the severity of early childhood caries in AI children is likely to be multifactorial, earlier tooth emergence may be a contributing factor. Knowledge Transfer Statement: The findings of this study have practical implications for practitioners providing childhood oral health care to ethnic groups with early tooth emergence. It may be important to provide parents with information on toothbrushing, dentist visits, and other practices supportive of good oral health as early as possible to protect their children’s primary dentition.

Healthy Futures: Engaging the oral health community in childhood obesity prevention – Conference summary and recommendations

Childhood obesity is a major public health problem. An association between obesity and dental caries, the most prevalent disease of childhood, has been identified. One explanation for the association is that consumption of sugar-sweetened beverages and frequent snacking on carbohydrate-rich foods are common risk factors for development of both obesity and caries. The Robert Wood Johnson Foundation (RWJF) has been at the forefront of national efforts to promote healthy weight in children. As part of these efforts, RWJF sponsored the Healthy Futures: Engaging the Oral Health Community in Childhood Obesity Prevention National Conference, held on November 3-4, 2016, at Georgetown University in Washington, DC. The aim of the conference was to increase awareness of evidence-based recommendations; identify strategies; and promote collaborative efforts that oral health professionals, oral-health-related organizations, and others can employ to prevent childhood obesity. This report summarizes the findings presented at the conference and discusses their implications. The report also reviews recommendations made in the areas of research, education, and policy that resulted from the conference.

The Maryland oral health summit: pathways to common ground and action

Correspondence Dushanka V. Kleinman, SPHL School of Public Health, University of Maryland, 2242P SPH Building, College Park, MD 20742-2611. Tel.: 301-405-2438; Fax: 301-405-8397; e-mail: dushanka@umd.edu. Joan B. Wilentz is an independent consultant. Dushanka V. Kleinman is with the School of Public Health, University of Maryland. Norman Tinanoff is with the School of Dentistry, University of Maryland. Penny Anderson is with the Maryland Dental Action Coalition. Harry S. Goodman is with the Maryland Department of Health and Mental Hygiene.