Early Childhood and the Crisis in Oral Health. Dr. Stephen Abrams Dr. Ian McConnachie

Transcription

1 Early Childhood and the Crisis in Oral Health Dr. Stephen Abrams Dr. Ian McConnachie

2 Today as Part of a Continuum Current state of government action and ODA lobbying IADR 2008 ODA Special Report on Tooth Decay in Ontario`s Children Radio ads ODA web site Reprinted articles in Ontario Dentist from the California Dental Association ASM presentation: continue education of the oral health team Campaign on water fluoridation

3 Overview of Today s Presentation The Problem Current Concepts on Early Childhood Caries Assessment and Diagnostic Tools Dental Public Health

4 Overview of Today (cont d) Risk Management Strategies Community Mothers Infants Recommendations Provincial Public Health Local Public Health

5 The Problem

6 Dental Caries is one of the most common diseases among 5 17 year olds Percentage of children & adolescents ages 5 to 17 Caries Asthma Hay Fever Chronic Bronchitis Note: Data included decayed or filled primary and or decayed filled or missing permanent teeth. Asthma, chronic bronchitis and hay fever based upon household respondent about the sampled 5 17 year old Source NCHS 1996 Oral Health in America: A Report of the Surgeon General DHHS 2000

7 Public perception In other words no big deal

8 Our reality A very big deal

9 Early Childhood Caries - Prevalence < 4 yrs Data Collected using DMFT not ICDAS 4% Quebec convenience sample of month infants Veronneau et al 1% USA representative sample of mo infants Kasteet etal % USA sample of yr old children Kaste et al % Whole Cree population age months Quebec Veronneau et al % Whole Inuit population age months in NWT Albert et al % representative sample of mo old Ojibway Lawrence 2008 (N Ontario) infants 53% representative sample 408 children First Nations DEFT of % of caries in 31% of population in Manitoba Schroth et al 2005

10 Early Childhood Caries prevalence 0-5 years United States Decay rates dropped until 90 s Rates now documented as increasing 2-5 year olds 24% in % in Wide variability with population groups Dye et al, National Center for Health Statistics NHANES III 2007

11 Lida et al 2007

12 Ontario Prevalence 0-5 years 87% of First Nations sample Lawrence % in Health Units Survey* OAPHD % of Toronto 5-year olds * 25.1% in daycare community Leake 2001 Ottawa Public Health * * Survey under reports children sampled due to methods * Children sampled not representative of population in general

13 Defining the Problem - Prevalence Local Screening Program - London Ontario 46 % of children of entire elementary school district surveyed % (1 in 8) of all JK and K had untreated visible decay 4.5% required urgent care Of JK children who had experienced decay 49% did not have needs met Untreated or children needing treatment located in specific school districts Families least likely to afford treatment have highest levels of decay Current Data 5 yr olds from % needed dental work 67% observed decay free courtesy Dr. C. Friedman

14 Early Childhood Caries - risk factor for future caries - good indicator of future caries experience *Al Shalan TA, et al. Primary incisor decay before age 4 as a risk factor for future dental caries. Pediatr Dent. 19(1):37 41, 1997 *O'Sullivan DM, Tinanoff, N, The association of early dental caries patterns with caries incidence in preschool children., J Public Health Dent 56(2):81 3, 1996 *Kaste, LM, et al. The assessment of nursing caries and its relationship to high caries in the permanent dentition. J Public Health Dent. 52(2):64 8, 1992 *Almeida, Al et al. Future caries susceptibility in children with Early Childhood Caries following treatment under General Anesthesia. Pediatr Dent 22 (4) , 2000 BY THIS TIME IT IS TOO LATE

15 Terminology Early Childhood Caries Severe Early Childhood Caries Early Childhood Tooth Decay Baby Bottle Syndrome Nursing Bottle Syndrome Nursing Caries

16 Early Childhood Caries (ECC) The presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. AAPD Definition from National Institute for Dental and Craniofacial research (NIDCR) workshop 1999

17 Severe Early Childhood Caries (S-ECC) Any sign of smooth-surface caries in a child younger than 3 years of age AAPD 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth, or decayed, missing or filled score of at least 4 (Age 3), 5 (age 4), or 6 (age 5) surfaces Drury et al 1999

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19 Clinical presentation: early lesions Begins soon after dental eruption Typically develops on smooth surfaces Appear as chalky white decalcification Most often starts on lingual surfaces of maxillary incisors

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22 Clinical Presentation (Early) Initial cavitation can appear on the lingual surface of the maxillary incisors

23 Later Tooth Decay

24 Baby Bottle Tooth Decay (Severe)

25 Facial cellulitis Infection spreading into surrounding tissues

26 Systemic Effects from Severe ECC Malnourishment in a population with severe early childhood caries, Clarke et al 2006 Among the findings: 66% have normal weight, 18 % underweight 28% have haemoglobin levels below acceptable and 46% in the low range of acceptable 51% have low albumin levels 77% have low ferritin Conclusion: children with severe tooth decay have borderline or low nourishment

27 Detrimental health effects of ECC pain, infection, loss of function affects learning, communication, nutrition, sleep lower body weight chronic inflammation psychological impact lasting detrimental impact on the dentition

28 Cariology What is Tooth Decay?

29 What do you need to create tooth decay? Teeth Food particularly carbohydrates Bacteria in Plaque or Biofilm

30 Elements involve in the Caries Process Plaque containing bacteria Caries Sugars & Carbohydrate Exposure Tooth When all three are present, and enough time passes, large carious lesions will occur

31 NIH Consensus Conference on Caries 2001 Dental caries is an infectious, communicable disease resulting in destruction of tooth structure by acidforming bacteria found in dental plaque, an intraoral biofilm, in the presence of sugar."

32 NIH Consensus Conference March 2001 Caries is a bacterial infection caused by specific bacteria. Caries is a reversible multi factorial process. In other words, caries is an infectious disease with cavitation being the last step of the process

33 The Paradigm Shift One can place a number of restorations in a mouth and yet not treat the underlying disease. The bacteria remain in the plaque biofilm on the remainder of the teeth capable of creating new areas of decalcification and cavitation. We need to shift from a surgical approach to a disease management & preventive approach.

34 The Shifting Focus of Dentistry Treatment of Prevention of Reduced Results of Dental Disease Risk Dental Disease Factors This should be particularly true in ECC

35 Caries Progression

36 Early Carious Lesion in Enamel

37 Pathogenesis of Dental Caries (biological balances) SALIVA PLAQUE PLAQUE Polysaccharides ENAMEL mouth Calcium Salts Plaque buffers SUGARS ACID inside of tooth Calcium Salts Salivary buffers Bacterial Enzymes Demineralization Re-mineralization

38 The Caries Balance Pathological Factors Acidogenic Bacteria (S. Mutans, S. Sobrinus & Lactobacilli) Reduced Salivary Flow Frequency of fermentable carbohydrate ingestion Protective Factors Saliva flow & components Proteins, calcium, phosphate, fluoride, immungloulins Antibacterials In saliva and extrinsic Fluoride, Chlorhexidine, iodine Caries No Caries Adapted from Featherstone, J. D. B., JADA 2000

39 Demineralization Dental Mineral Acid soluble Calcium phosphate + Organic Acids Demineralization Calcium & Phosphate into solution If fluoride is present in the water between the crystals it inhibits mineral loss

40 Remineralization Calcium in tooth Water (from saliva) + Phosphate In tooth Water (from Saliva) Remineralization Builds on existing crystal remnants New mineral less soluble Fluoride helps Fluoride speeds up remineralization creating a less soluble mineral

41 demineralization ph Critical ph FAP HAP deposit caries erosion ph remineralization Carious lesion forms at ph Erosion lesion forms when ph < 4.5

42 Healing a Small Cavity Initial Treatment (3 months) Lesion size is 2 mm x 4 mm along the gum line with difficult visual access Do not want to probe the lesion to check on integrity

43 What contributes to the extent of ph drop after glucose challenge? Type and amount of carbohydrate available Bacteria present Salivary composition and flow Other food ingested Thickness and age of dental plaque

44 Caries is a Bacterial Infection!

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46 Mode of Transmission Both this spoon and pacifier have been in the mouth and then cultured in a selective broth. They show S. Mutans growing on them. Courtesy of Ivoclar Vivadent.

47 Caries Is An Infectious Disease: 1. Demonstration of Mother to Child Transmission of Streptococcus mutans using Multilocus Sequence Typing Lapirattanakul et al. Caries Research Genotypic Diversity of Mutans Streptococci in Brazilian Nursery Children Suggests Horizontal Transmission Mattos Graner et al. J Clin. Microbiology 2001

48 Bacteria Involved in Caries Streptococcus Mutans, Streptococcus Sobrinus Lactobaccillus

49 Plaque & Biofilms Some New Thoughts on Plaque

50 What is a Biofilm? A biofilm is a well organized, cooperating community of microorganisms. The slime layer that forms on rocks in streams is a classic example of a biofilm. Biofilms are everywhere in nature. It is estimated over 95% of bacteria existing in nature are in biofilms.

51 Plaque as a Biofilm Within the microcolonies are differing environments Microorganisms have primitive communication system Microorganisms in biofilm behave differently than bacteria in a culture medium Microorganisms in biofilm are resistant to antibiotics, antimicrobials, and host response

52 Plaque Biofilm Artist Depiction of Plaque Bioflim

53 CAMBRA Caries Management by Risk Assessment

54 A Caries Risk Assessment (CRA) is just weighing the factors of each patient.

55 And CAMBRA is just removing weight from one side and adding weight to the other.

56 The Shifting Focus of Dentistry Treatment of Prevention of Reduced Results of Dental Disease Risk Dental Disease Factors This should be particularly true in ECC

57 Risk Factors BioMedical Social Determinants

58 Risk Factors: History Child has special needs Socio economic status of the family Parents & siblings have decay

59 Risk Factors: Dental History Child has decay Time lapse since last cavity Child wears braces or oral appliance Reduced saliva flow

60 Risk Factors: Dental History Frequency of brushing Daily between meal exposure to sugars & carbohydrates On demand bottle Sippy cup Sports drinks & carbonated beverages

61 Risk Factors: Reduced Fluoride Exposure Fluoridated water Fluoride supplements Fluoridated toothpastes

62 Risk Factors: Clinical Evaluation Visible plaque Gingivitis Areas of enamel demineralization ICDAS 1 3 Enamel defects / deep fissures

63 Risk Factors: Clinical Evaluation Part 2 Radiographic evidence of caries Levels of Strep Mutans in saliva Use commercial tests Not critical for establishing risk

64 Caries Risk Indicators Clinical Conditions Environmental Characteristics General Health Conditions AAPD Caries Risk Assessment Tool (CAT) Low Risk Moderate Risk High Risk No carious teeth in past 24 months No enamel demineralization (enamel caries white spot lesions ) No visible plaque; no gingivitis Optimal systemic and topical fluoride exposure Consumption of simple sugar or foods strongly associated with caries initiation primarily at mealtimes Regular use of dental care in the established dental home Carious teeth in the past 24 months 1 area of enamel demineralization (enamel caries white spot lesions ) Gingivitis Suboptimal systemic fluoride exposure with optimal topical exposure Occasional between meal exposures to simple sugar or foods strongly associated with caries Mid level caregiver socioeconomic status Irregular use of dental services Carious teeth in the past 12 months More than 1 area of enamel demineralization (enamel caries whitespot lesions ) Visible plaque on anterior teeth Radiographic enamel caries High titers of mutans streptococci Wearing dental or orthodontic appliances Enamel hypoplasia Suboptimal topical fluoride exposure Frequent (ie, 3 or more) between meal exposures to simple sugars or foods associated strongly with caries Low level caregiver socioeconomic status (ie, eligible for Medicaid) No usual source of dental care Active caries present in the mother Children with special health care needs Conditions impairing saliva composition/flow Chart based on the AAPD Caries-Risk Assessment Tool. For more information on using the tool, refer to

65 Copyright 2007 American Academy of Pediatrics FIGURE 1 Child, family, and community influences on oral health outcomes of children Fisher-Owens, S. A. et al. Pediatrics 2007;120:e510-e520

66 Oral Health Individual Sex, Age, Genes, Biology Oral Health & Related Behaviours Diet, Hygiene, Smoking Alcohol, Injury Social & Community Context Social Norms, Peer Groups, Social Capital Cultural Identity, Social Network Economic, Political & Environmental Conditions Poverty, Housing, Sanitation, Leisure Facilities, Shopping Facilities Employment, Work / Educational Environment, Commercial Advertising, Social Policy)

67 Overview of the Morning The Problem ECC Current Concepts Assessment and Diagnostic Tools Dental Public Health

68 Dental Public Health Big picture reality getting to the populations Making connections Motivational interviewing Ottawa pilot project Role of medical community?

69 Big picture reality THE RESPONSIBILITY STARTS WITH GOVERNMENT

70 Ontario Statistics 55% with employer sponsored plans 4% with private dental plans 5% on government plans Balance self-paying 14.4% defined as low income (Statistics Canada) 70% of Ontarians visit a dentist annually Highest percentage in Canada

71 Ontario government perspective on government plan coverage Gap coverage High needs, not high risk Low socioeconomic levels Disabled and their families Emphasis on basic or urgent treatment with minimal emphasis on prevention or education Possible shift with new Phase II programme Other provincial governments have quite different strategies

72 36 Public Health Departments in the province All provide dental services required by mandatory provincial programs Some have dental clinics Services vary with local mandates and funding New proposals to Ministry January 2010 Over 4000 private dental practices

73 Mandatory government dental programs for public health Dental Indices Survey (DIS) Oral health screening Monitor fluoridation of water supply Provide Children In Need of Treatment Program (CINOT) Provide dental education to high risk schools,

74 Ontario Public Health Programs for At-Risk Children Healthy Babies, Healthy Children Best Starts Early Years Centers 18-month Well Baby Visit Nipissing District Developmental Screen Healthy Schools Initiative Oral Health involvement is not currently required as a part of these programs but may be done as local initiative

75 Dental Indices Survey (DIS) Value in giving very general overview of problem Non-calibrated Less than ideal examination No radiographs Inconsistent data collection methods Beynon et al 2004

76 Provincial government children s dental plans Children in Need of Treatment (CINOT) Ontario Works (OW) Ontario Disability Support Program (ODSP) Assistance for Children with Severe Disabilities (ACSD)

77 Number of Procedures CINOT Procendure Code Profile Restorative vs Preventive by Number of Procedures Paid for Preventive Restorative * Year

78 Prevention Strategies Communities Mothers Infants

79 Dental Public Health Big picture reality getting to the populations Making connections Individual oral health promotion Role of medical community

80 Dental Public Health Making connections Understanding the at-risk populations Variable with each health unit Mostly socio-economic criteria Sub-populations and understanding their needs is critical to success e.g. cultural, language

81 Dental Public Health Big picture reality getting to the populations Making connections Individual oral health promotion Role of medical community

82 Strategies for Primary Prevention of ECC

83 Motivational Interviewing Success in dentistry Early childhood caries Harrison RL, Wong T. An oral health promotion program for an urban minority population of preschool children. Community Dent Oral Epidemiol, 2003 Oct;31(5):393 9

84 Dental Public Health Big picture reality getting to the populations Making connections Motivational interviewing Ottawa pilot project Role of medical community?

85 Ottawa Pilot Project Predates current new funding envelope Recognition of need to work outside of the box Funding by local budget with politician buy-in OPINION The current dental public health gold standard within the Ontario government constraints

86 Ottawa Pilot Project Selected Analysis of Statistics city-wide 11.3% need Group 1 city-wide in two groups 9.7% need Group 2 community age % need Group 3 sub-group across city age % need Group 4 daycare centers within group 2 community age % need

87 Dental Public Health Big picture reality getting to the populations Making connections Motivational interviewing Ottawa pilot project Role of medical community? Families First

88 Families First Model Youth at Risk Public Health Unit Dental Public Health Literacy CHC Dental Team Community Social Services Agencies Family Faculties of Dentistry Employment School Primary Health Team

89 Prevention Strategies Communities Mothers Infants

90 Evidence-based Dentistry Integration into clinical decision making Evolution of patient-centered care More rapid adjustment of clinical practice

91 The Infant Oral Health Exam Why The new standard of care Slight variations in recommendations Canadian Dental Association Ontario Dental Association Canadian Academy of Paediatric Dentistry American Academy of Pediatric Dentistry

92 The Infant Oral Health Exam How Dental Public Health Identify the populations Prioritize the education/prevention Unique skill sets Motivational interviewing Preventive therapies

93 The Infant Oral Health Exam How Private Dental Practice Optimal evidence-based preventive strategies Internal marketing and practice building

94 The 12 Month Oral Health Exam Objectives Recording medical history and dental history Complete oral exam Assess infant risk and determine prevention plan Provide anticipatory guidance Plan for comprehensive care Refer where appropriate if necessary

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108 Are Parents Interested? 1. How can my infant get cavities by 1 year? 2. I brush and floss. Isn t that enough? 3. I brush my child s teeth before bed like you showed us and in the morning now look at what happened? 4. My child eats no sweets yet we still have cavities? 5. What can I do as a parent to prevent cavities?

109 Copyright 2007 American Academy of Pediatrics FIGURE 1 Child, family, and community influences on oral health outcomes of children Fisher-Owens, S. A. et al. Pediatrics 2007;120:e510-e520

110 Elements: 1. Visual exam to assess risk 2. Parent / Guardian interview 3. Oral Hygiene Instruction 4. Set up frequency of visits 5. Develop a preventive protocol 6. Apply or dispense preventive therapies The key is to assess risk and have parent / caregiver provide proper care.

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114 Risk Intervention Implementation into office Office prevention programme Patient tools Decision tree

115 Therapeutic and Preventive Interventions Parents and Caregivers Patients

116 Parents and Caregivers Knowledge transfer In-office education Individual oral health promotion models

117 Anticipatory Guidance for Mother Goal: anticipatory guidance for the mother both before the baby is born and following the infant s birth on several information items for her health and that of baby

118 Water Good for mom s health Does it have fluoride If bottled water, does it contain fluoride Benefit is to mothernot fetus

119 Oral Hygiene Care For mom s health as well as control of bacterial transfer Brush and floss daily to disturb cariogenic bacteria and reduce bacterial plaque levels Use toothpaste with fluoride

120 Diet Chose foods low in sugar. Eat healthy snacks like fruit, cheese and vegetables. Get enough calcium for mom and baby s healthy teeth and bones. Calcium is in milk, cheese, dried beans and leafy green vegetables. Avoid carbonated drinks

121 Canada s Food Guide Interactive guide for all family members sc.gc.ca/fn an/foodguide aliment/tour/indexing.php

122 Now is the time for mom to learn Get her mouth healthy Do a Smile Check on a baby How to clean a baby s teeth How to prevent early childhood caries Ask her doctor or dentist to check the baby s teeth by age one. Talk with her doctor or dentist about fluoride.

123 ODA s Ten Tips For Parents Downloadable from the website

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127 Motivational Interviewing Success in dentistry Early childhood caries Harrison RL, Wong T. An oral health promotion program for an urban minority population of preschool children. Community Dent Oral Epidemiol, 2003 Oct;31(5):393 9

128 Parents and Caregivers Caries infection transfer prevention Caries treatment Fluoride Xylitol Chlorhexidine other

129 Dental care for mother To maintain or to restore to health the oral tissues If dental caries are present, removal of decay and restoration of teeth

130 Dental Care for Mothers Univ of Wash Study 2009 Safe at any time during pregnancy (ACOG) High utilization if offered Significant increased utilization by children Mothers rated children s oral health higher Also Michigan PRAMS data

131 Mother chewing xylitol gum Recent evidence suggests that chewing xylitol gum kills cariogenic bacteria Chew 1 piece of gum for 5 minutes 3 5 times a day decreases the child s caries rate.

132 The Xylitol Story in Brief Natural long chain sugar Non-cariogenic Can reduce mutans strep in plaque and saliva Can reduce caries in young children, mothers and in children via their mothers

133 Key Xylitol Studies Soderling et al 2001 Maternal transmission of MS Xylitol gum Starts 3 months after delivery and for 21 months Fluoride varnish Applied at 6, 12, 18 months CHX varnish Applied at 6, 12, 18 months Measured MS levels in children at age 3 and 6

134 Key Xylitol Studies Soderling et al 2001 Children age 3 MS levels 2.3x higher with Fl Var and CHX Var in mother Children age 6 Protection maintained with same higher benefit of xylitol in mother Isokangas et al 2000 At 5 years, need for treatment 71-75% lower in Xylitol group

135 Why Xylitol and When Maternal 3 months post partum (Soderling 2001) Characteristic of infection at eruption determines life-long (Loesche 1985) Once colonized with benign, ms will not displace (Svanberg and Loesche 1977) May be due to less cariogenic xylitol-metabolizing ms strain (Trahan et al 1996)

136 Risk Intervention Implementation into office Office prevention programme Patient tools Decision tree

137 Apply or Dispense Therapies Xylitol Povidone Iodine Remineralization Agents Fluoride Other

138 Additional In-Office Strategies Knowledge transfer Pit and Fissure sealants A.R.T.

139 Knowledge transfer Awareness of the problem Diet Oral hygiene

140 Sugar + Acid = Double Trouble (a partial list) Acid (ph) Sugar (12 oz) Water tsp Propel fitness water tsp Minute Maid OJ tsp Red Bull tsp Sprite tsp Diet Coke tsp Gatorade tsp Coke Classic tsp Battery Acid tsp Lab tests: Dr. J Ruby, Univ. of Alabama Birmingham School of Dentistry Minnesota Dental Association, Sip All Day, Get Decay c2002

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143 Remineralization Fluoride Effect on teeth more topical Other remineralization agents Effects topical and subsurface

144 Remineralization Topical Fluoride Toothpaste Fluoride Rinse Fluoride Varnish Bottled Water Water Fluoridation

145 A brief review Fluoride action Effect largely topical At low levels Inhibits demineralization at crystal surfaces Enhances remineralization at crystal surfaces At high levels Inhibits bacterial enzymes

146 Fluoride-Some Interesting Pieces Low levels after several hours in plaque and saliva can have a profound effect on demin/remin i.e. TOOTHPASTE MOUTHRINSE? Lynch RJ, Navada R, Walia R, Low levels of fluoride in plaque and saliva and their effects on the demineralization and remineralization of enamel: role of fluoride toothpastes. Int Dent J 2004:54(5 Suppl 1):304-9

147 TOPICAL FLUORIDE Toothpaste Position Statements Canadian Dental Association American Academy of Pediatric Dentistry

148 CDA Position on Use of Fluorides in Caries Prevention Fluoride toothpaste twice daily Parents brush under 3 years and assist 3 6 years Smear of toothpaste All children supervised or assisted til appropriate dexterity

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150 Topical Fluoride-The Gold Standard J Dent Educ. 71(3): American Dental Education Association Professionally Applied Topical Fluoride: Evidence- Based Clinical Recommendations American Dental Association Council on Scientific Affairs Key words: fluoride, caries, caries prevention, evidencebased dentistry, clinical recommendations

151 ADA Evidence-Based Recommendations Assess Decide Caries Risk Low Medium High Whether to apply fluoride Type of fluoride Frequency of application How often to re-evaluate

152 Advice ADA Evidence-based Recommendations Professionally Applied Topical Fluoride Risk group /Age Low Medium Less than 6 years Patient may not receive any additional benefit Varnish every 6 months High Varnish every 6 months (or 3 months)

153 ADA Evidence-based recommendations Professionally Applied Topical Fluoride Low risk under 6 years -fluoridated water and toothpaste may provide adequate caries prevention in low risk category -fluoride foam and gel not recommended in this age group

154 5% NaF = approx 22,500 ppm Fluoride Varnish No special equipment No prophylaxis prior to application Easy to apply Dries on contact with saliva Safe and well tolerated Inexpensive Less fluoride than with gel or foam

155 Fluoride and Safety Concerns Two real issues Fluoride toxicity Fluorosis Age of greatest risk for fluorosis 0 3 years Especially months Findings and recommendations of the Fluoride Expert Panel Health Canada Jan 2007

156 Fluorosis Total daily fluoride intake from all sources should not exceed mg F/kg of body weight in order to minimize the risk of dental fluorosis Canadian Dental Association Nov. 2008

157 0.243% NaF 5.0% NaF Current Toothpastes NOTE: Federal advisory panel recommends low-dose fluoride toothpaste be available for children in Canada

158 Other Remineralization Agents A rapidly changing environment Role in dental public health likely limited Role in private practice promising

159 Recommendations Provincial Public Health Local Public Health

160 If I Had 45 Million Dollars Provincial Public Health -province-wide survey of ECC status using CHMS protocol mandatory dental programmes changes collaboration with organized dentistry expert panel composition oral health rep on provincial programs for at risk infants

161 If I Had 45 Million Dollars Local Public Health identify high risk populations for ECC develop local consultative panel with patient groups and local dental society establish valid baseline data collaborative evidence-based oral health literacy strategy collaborative preventive interventions

162 o f Healthy Early enamel decay Advanced enamel decay T Demineralization Remineralization Remineralization therapies Detection Systems X-Ray Drill, Bill, and Fill

163 Some worthwhile web sites to investigate Dental (ODA) Can download this presentation, background papers and charting tools (Minnesota Dental Assoc.) (California Dental Association Foundation)

164 Some worthwhile web sites to investigate: Canada Food Guide (interactive) sc.gc.ca/fn an/food guide aliment/tour/indexing.php Private practice implementation (Dr. R. Ehrlich) Patient info brochure

165 Tooth Decay Infectious Disease Controlling Risk Factors helps in prevention Early Detection = Minimal Intervention First Teeth First Visit

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