Tooth Decay in Ontario s Children: An Ounce of Prevention A Pound of Cure

ONTARIO DENTAL ASSOCIATION SPECIAL REPORT O r a l H e a l t h I s s u e s f o r O n t a r i a n s Tooth Decay in Ontario s Children: An Ounce of Prevention A Pound of Cure 2008

Introduction The following Special Report is a direct result of the International Association of Dental Research (IADR) conference that was held in Toronto earlier this year, and which featured international experts and high-profile oral health-care stakeholders focusing on best practices aimed at the prevention of tooth decay, especially in the children s high-risk category. Tooth decay can be transmitted by licking a pacifier, kissing or sharing a spoon. This report was written for a public audience and is meant to serve as a springboard for actions needed to make a difference. Tooth decay is an infectious disease and it is a reality. All children are at risk. This report is a call to action for parents, government and the community we all need to work together on prevention. The time to act is now. We owe it to all of our children. The ODA really does believe that an ounce of prevention is a pound of cure. SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 3

Childhood Caries Dental caries is a transmissible, infectious disease that damages tooth structures, resulting in cavities, which are holes in the teeth. It is more commonly known simply as tooth decay. If left untreated, the disease can lead to pain, tooth loss, infection, and, in particularly severe rare cases, death. It is a disease to which people of all ages are vulnerable, but as a problem it is most severe in children. In 2000, the US Centers for Control reported that dental caries is the Disease most common chronic childhood disease, five times more common than asthma in children aged five through 17. The Ontario Dental Association (ODA) is a voluntary association that represents this province s 7,000 practising dentists. The ODA is dedicated to the provision of exemplary oral health care and promotes the attainment of optimal health for the people of Ontario. This report reflects the ODA s concern about a serious childhood disease that receives neither the public attention it merits, nor the government commitment and investment that is required to bring it under control. Look Ma, No Cavities It has been more than 40 years since the famous ad campaign that featured happy children rushing into the house, brandishing notes from their dentists, crying out, Look Ma, no cavities. The grim irony facing the dental profession today is that if asked, most people would probably say that tooth decay is less of a problem than it has ever been. And the simple fact is that we are raising a generation of children who are terrifyingly vulnerable to that particular problem, and the often damaging side effects that accompany it. In 2000, the US Centers for Disease Control (CDC) reported that dental caries is the most common chronic childhood disease, five times more common than asthma in children aged five through 17, and significantly more prevalent than chronic bronchitis. Research in Canada and Ontario bears out this finding. A year after the CDC report, Toronto Public Health painted this grim picture of the tooth decay situation facing Ontario children, in a report titled Toronto s Health Status: A Profile of Public Health in 2001: Early childhood tooth decay affects 6 to 10% of all preschoolers. It is a rapidly progressing disease, often rotting front teeth completely 4 ONTARIO DENTAL ASSOCIATION SPECIAL REPORT SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 5

Look Ma, No Cavities to the gum line within a year. In 1994 and 1999, 30% of 5 year old children in Toronto had caries (dental decay), similar to Ontario. At age 5, nearly 11% of children have two or more teeth with open, untreated cavities and almost 7% have need for urgent care. In 2000, 9.6% of 5 year-olds had one or more front baby teeth affected by decay. All children are at risk but children living in poverty are particularly susceptible to tooth decay. In 1999, 40% of 13 year old children in Toronto had caries; 12% of all children suffer dental neglect and require immediate care. Dental decay is the most frequent condition suffered by children other than the common cold and is one of the leading causes of absences from school. It isn t hard to guess why children are particularly vulnerable to tooth decay. They have less awareness of the dangers, less understanding of hygiene, and they are growing up in a world where sweets and junk food are the norm as never before. Ultimately, the reasons seem rather less important than the reality, which is that children today suffer from tooth decay at an alarming rate. Research into which populations are particularly at risk for dental caries always includes children. Sadly, the more in depth the research, the more vulnerable the children turn out to be in more ways than one. All children are at risk but children living in poverty are particularly susceptible to tooth decay, as are children with asthma because of the oral side-effects of their medications. Children with colic are at increased risk of erosion. Children with cerebral palsy are at increased risk for reflux, which has implications for dental health. Children who take multiple doses of antibiotics are also at a greater risk, and the list goes on. 6 ONTARIO DENTAL ASSOCIATION SPECIAL REPORT SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 7

Dental Caries More Serious Than You Might Believe Dental disease, particularly in serious cases, affects school performance, a child s ability to thrive and his or her sense of self-worth. The problem with dental caries goes much further than the actual decay of the tooth. In and of themselves, when caught early, cavities can almost always be treated. It is the symptoms and conditions that too often accompany the disease, particularly in children, that are of particular concern. Evidence shows that untreated caries may affect the growth of adult teeth, with poor dental health and disease persisting into adulthood. Caries can lead to infection, pain, abscesses, chewing problems, malnutrition and gastrointestinal disorders. It can affect speech and articulation, and like many chronic diseases, the risk factors of early childhood caries also contribute to childhood obesity and malnutrition. Of specific concern to families and dentists is the increased risk for treatment under general anesthesia, often in hospital, for children with extensive dental caries. Wait times for hospital operating rooms and general anesthesia mean more delays in access to dental treatment for children in urgent need of care. Perhaps most alarming is a common manifestation with childhood caries that is seldom measured, though it is widely accepted to exist. Dental disease, particularly in serious cases, affects school performance, a child s ability to thrive and his or her sense of self-worth. 8 ONTARIO DENTAL ASSOCIATION SPECIAL REPORT SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 9

Treating the Problem Dollars and Sense The American Dental Education Association (ADEA) estimates that more than 51 million school hours and 164 million hours of work are lost in the United States each year due to dental related absences. The ODA believes that there is a clear and obvious moral imperative at work when it comes to dental caries. It is a disease, and in a civil society like Ontario one which prides itself on the quality of its health-care system we have an obligation not only to treat that disease, but to help people avoid getting it in the first place. Early intervention can make all of the difference. As this report will detail further down, in the particular case of tooth decay, prevention and reversing the disease is entirely possible. There is another argument in favour of prevention, however, and it is one that cost-conscious governments everywhere should both understand and respect. The cost of waiting until dental caries has manifested itself is significantly higher than the cost of preventing it in the first place. The American Dental Education Association (ADEA) estimates that more than 51 million school hours and 164 million hours of work are lost in the United States each year due to dental related absences. Similar research for Ontario is not available, but there is no good reason to believe it would yield different results. The ADEA also claims that the prevention of dental diseases ranks above HIV screening and influenza immunization in terms of cost savings. It is estimated that for every dollar spent on prevention in oral health care, as much as $50 is saved on restorative and emergency dental procedures. Dental costs for children who receive preventive dental care early in life are 40 percent lower than costs for children whose oral health is neglected. Finally, the cost of providing preventive dental treatment is estimated to be 10 times less costly than managing symptoms of dental disease in a hospital emergency room. The combination of a moral imperative and persuasive economic argument is something the ODA feels cannot be overlooked. Because of all the things that we know about dental caries, the most important single fact is that it can be prevented. And in cases where prevention fails, early detection means that the disease can easily be reversed. In other words, early intervention by dentists is the single most effective, humane and cost-efficient way to deal with childhood tooth decay. 10 ONTARIO DENTAL ASSOCIATION SPECIAL REPORT SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 11

Prevention Versus Treatment Why Are We Waiting? These programs only attempt to address catastrophic dental needs, with no attention on preventive options that could save children the agonies and embarrassment of recurring dental disease, and save the government and in some cases their parents the cost of treating them. In Ontario today, however, the wait and see approach is very much in evidence. For more than a decade the ODA has been expressing concerns about the limitations of publicly funded dental programs, in particular the Children in Need of Treatment (CINOT) program. This program only attempts to address catastrophic dental needs, with no attention on preventive options that could save children the agonies and embarrassment of recurring dental disease, and save the government and in some cases their parents the cost of treating them. Under the CINOT program, only children who have identified dental conditions requiring urgent care, children who have no access to dental insurance or any other government program, and children whose parents have signed a written declaration that the cost of the necessary dental treatment would result in financial hardship are eligible for dental care. It is the strongly held view of the ODA that this policy is counter-productive and unfair to the children of this province particularly the low-income children. Our children are vulnerable to tooth decay. Prevention is the best option and first requires a commitment from government. The ODA calls on the government of Ontario to examine the extensive body of evidence regarding the benefits of preventive oral health measures and bring in programs designed to enact these measures. 12 ONTARIO DENTAL ASSOCIATION SPECIAL REPORT SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 13

Talking to the Experts They reflect the views of the foremost experts in the field, and they address a problem childhood tooth decay that is more serious than is widely known, and too preventable to be as serious as it is. In July, 2008, the International Association for Dental Research (IADR) held its annual meeting in Toronto. The ODA forwarded a proposal to the IADR to sponsor a symposium on Designing Dental Programs for High-Risk Children, to be held during the Toronto meetings. The intention was to provide a forum in which local and international experts could discuss the best programs, and the best ways to design those programs, in order to improve the oral health status of children at risk of dental caries. The proposal was accepted and a panel presentation that included Dr. Clive Friedman, University of Western Ontario, Canada; Dr. Nigel Pitts, University of Dundee, Scotland, UK; Dr. John Featherstone, University of California, USA; and, Dr. Ian McConnachie, a pediatric dentist with Children s Hospital of Eastern Ontario, Ottawa, Ont., and Past-President of the ODA, was held on the morning of Friday, July 4, 2008. The ODA extended an invitation to a wide range of interested stakeholders, including government, dental hygiene, dental assistants, public health, Ontario s dental regulator (the Royal College of Dental Surgeons of Ontario), universities and organized dentistry to attend the symposium and to participate in a follow-up stakeholder session that would explore designing dental programs for children at high risk for dental disease. The proposals that follow are informed in large measure by what was discussed during that symposium. It is the hope of the ODA that the Ontario government will give them due consideration. They reflect the views of the foremost experts in the field, and they address a problem childhood tooth decay that is more serious than is widely known, and too preventable to be as serious as it is. 14 ONTARIO DENTAL ASSOCIATION SPECIAL REPORT SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 15

Childhood Caries What We Should Be Doing We have an obligation not only to treat that disease, but to help people avoid getting it in the first place. Early intervention can make all of the difference. The essence of the argument being advanced by the Ontario Dental Association, as articulated in this report, is that children should not have to wait to have dental surgery in a hospital under general anesthesia to access dental care. This should be simple common sense, and it is certainly the view of Ontario s dentists. The ODA is calling on the Ontario government to shift the focus of publicly funded dental programs away from catastrophic treatments that focus primarily on alleviating pain and trauma to programs that enable early identification of dental disease and early interventions. The ODA is making five basic recommendations to government. They are as follows: Improve Access to Publicly Funded Programs and Services Application of Fluoride Varnish Community Water Fluoridation Adopt a Sensitive, Reliable Screening Tool The Ministry of Health Promotion Should Promote Oral Health Awareness Improve Access to Publicly Funded Programs and Services It is the view of the ODA that Ontario programs are too restrictive and too focused on treatment at the expense of prevention. The best example is the program designed to help Ontario children combat dental disease is the Children in Need of Treatment Program (CINOT). It provides restorative dental treatment for children in kindergarten to Grade 8 identified as having large open carious lesions, dental pain and/or oral infection. The problem is, however, that the CINOT program is available only to children whose parents declare that it would be a hardship to pay for urgent dental treatment. Those who do take advantage of CINOT are forced to rely on a program that promotes episodic invasive treatment options rather than preventive opportunities, and consequently these children and their families remain trapped in the chronic cycle of dental disease. 16 ONTARIO DENTAL ASSOCIATION SPECIAL REPORT SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 17

Childhood Caries What We Should Be Doing The ODA recommends an immediate review of the CINOT program to ensure that it provides not only treatment but prevention options and that it is more easily accessible by the children and families that need it. In addition, the government should review other public health children s programs like Healthy Babies, Healthy Children; Best Start, Early Years Centers; 18-month Well Baby Visit and the Healthy Schools Initiative. Currently, these programs do not include initiatives aimed at reducing dental disease and improving the oral health of children at risk for dental caries, and the ODA feels that the children of the province will not be well-served until that changes. The ODA understands dental disease and the barriers to access embedded in the existing programs, and it is therefore essential that the ODA be a key party to this program review. Finally, the government should continue to look at other jurisdictions nationally and abroad to see what other preventative measures or tools can be used to treat and monitor dental disease within the population. Application of Fluoride Varnish There is no question that it is essential to treat cavities through restoration (filling) to reduce existing decay and pain. However, a philosophy of dental care that begins and ends with an invasive treatment is completely insufficient to meet the needs of Ontario children. Restoration does not reduce bacteria that can lead to future decay, and it does not halt the progression or transmission of dental disease. Children at high risk of dental caries should have fluoride varnish applied every six months. This has the real potential of preventing the problem before it occurs, or solving it before it gets serious. White spot lesions, which are the earliest stage of clinically visible tooth decay, have been shown to respond to the application of fluoride varnishes. These quite literally remineralize the enamel. This reduces or eliminates the need for invasive restorative treatment and, importantly, reduces the need to put children through the added risk of general anesthesia and treatment in the hospital operating room. 18 ONTARIO DENTAL ASSOCIATION SPECIAL REPORT SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 19

Childhood Caries What We Should Be Doing The ODA also recommends that children visit the dentist before the age of one, so that an early intervention can occur. Clearly, when it comes to problem prevention, sooner is always better. In addition, when one child in the family has dental caries his or her other siblings are placed at risk for dental caries, owing to the infectious nature of the disease. Community Water Fluoridation The connection between fluoride and dental health began to be seriously explored in the early 20th century. By the 1950s, communities across North America had begun fluoridating their water supplies. Community water fluoridation is an important public health policy that should be adopted in municipalities throughout the province. It is a cost-effective preventive strategy that will provide protective measures to Ontarians, regardless of their economic position. Adopt a Sensitive, Reliable Screening Tool Children at high risk for dental caries need access to protective and preventive therapies to reduce this infectious disease. The current screening mechanism used in Ontario only identifies cavities, fillings and missing teeth. It does not identify teeth that could benefit from remineralization and other preventative therapies, rather than waiting until the lesion progresses to a point of requiring extensive restoration. Clearly, if the goal is to prevent caries and reduce the burden of dental disease in Ontario children, more sensitive screening tools must be used. The ODA supports the introduction of the International Caries Detection and Assessment System (ICDAS). The ICDAS has been used successfully in several jurisdictions worldwide and has been peer-reviewed. Instead of just ranking cavities and missing teeth, the system allows dentists to identify the severity of decay by measuring changes in the lesion. This system would improve upon the current visual screening that captures only decayed, missing and filled teeth, leaving children to be identified as needing care only where there is a hole in the tooth. 20 ONTARIO DENTAL ASSOCIATION SPECIAL REPORT SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 21

Childhood Caries What We Should Be Doing The Ministry of Health Promotion Should Promote Oral Health Awareness If dental program design and philosophy do not recognize the fundamental fact that dental decay is preventable, the burden of dental disease will not be reduced for Ontario children. It is not enough that dentists understand that dental caries is preventable; their patients must recognize this as well. The ODA is recommending a province-wide public health awareness campaign focusing on the transmission and prevention of dental caries, and is suggesting that the Ministry of Health Promotion (MHP) is perfectly placed to spearhead that campaign. Working collaboratively with the ODA, the MHP should launch a campaign spreading the word about how to reduce the rate of dental caries in children, and specifically targeting those people in the best position to affect change. Pregnant women, parents, caregivers, teachers and health-care professionals should understand that dental caries is a transmissible infectious disease that is almost entirely preventable. Only when the public understands basic prevention options in the transmission of caries can we expect to make a difference in the rates of childhood caries. Children cannot protect themselves. However, they are quite easily protected. They need only informed caregivers and people close to them who can assist in the fight against childhood caries. Everyone who cares about improving the oral health of children in Ontario is encouraged to share facts about: the benefits of visiting the dentist by the first birthday; the relationship of diet to dental disease; the effect of certain medications on oral health; the effect of sleeping with bottle or breast milk in the mouth on caries development; the benefits of regular oral hygiene care, even for babies; the benefits of water fluoridation; the benefit of fluoride varnishes, fluoride toothpaste and Xylitol gum 22 ONTARIO DENTAL ASSOCIATION SPECIAL REPORT SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 23

Ten tips for parents to help build healthy oral habits for their children. 1. Before your baby has teeth, wipe the gums gently with a clean wet cloth after each feeding. 2. If your baby sleeps with a bottle or sippy cup at naptime or bedtime, fill it with water only. 3. If your baby normally falls asleep while feeding, brush his or her teeth before feeding. 4. Lift your baby s lip and watch for changes in colour, lines or spots on your child s teeth as these may be signs of potential problems. 5. As soon as the first tooth appears, start brushing your baby s teeth with fluoride toothpaste in the morning and before bedtime. Fluoride is a mineral that protects teeth. 6. Put a small dab of toothpaste across a small soft brush. Wipe off excess toothpaste until the child can spit it out. Begin flossing at least once a day when your child s teeth are touching. 7. Change your child s toothbrush every one to three months or immediately after an illness. 8. Let your child watch you brushing your teeth and assist your child s tooth brushing. 9. To prevent spreading germs that cause tooth decay, do not put anything in your child s mouth if it has been in your mouth. Don t share spoons, cups, food, toothbrushes, etc. 10. Visit your dentist by the age of one year, or when the first teeth appear. Take your child to the dentist for regular checkups to make sure there are no problems. A Parental Responsibility The ODA is also calling on all parents, grandparents and families to take on the responsibility of preventing tooth decay starting today. We owe it to all our children to give them the very best start in life. Tooth decay needs to be treated as the infectious disease that it is. The ODA is saying there are many things parents can do to build habits that will protect the teeth and lay the foundation for future health. Some of the tips are listed below. Conclusion The ODA really believes that an ounce of prevention is a pound of cure. We are urging parents to act immediately while simultaneously placing the onus on the Ontario government to act on the recommendations in this report. At present, we are failing these children by waiting until they are suffering from serious tooth decay before treating them, instead of preventing the decay in the first place. Dental caries is a serious disease from which our children need not suffer. It is preventable, in almost all cases. We owe it to all our children, and to their families, to do the right thing and prevent it. 24 ONTARIO DENTAL ASSOCIATION SPECIAL REPORT SPECIAL REPORT ONTARIO DENTAL ASSOCIATION 25

ONTARIO DENTAL ASSOCIATION SPECIAL REPORT O r a l H e a l t h I s s u e s f o r O n t a r i a n s Tooth Decay in Ontario s Children: An Ounce of Prevention A Pound of Cure 4 New Street, Toronto, ON M5R 1P6 416-922-3900 info@oda.ca www.youroralhealth.ca 2008