Transcribed by Albert Cheng 9/5/14

[DOD Cariology] [Lecture 27/28 Caries in a Pediatric Population I & II by Dr.

Herman]

Slide 1 Dental Decay and Caries Management in the Pediatric Population
[Dr. Herman] Nice to see you again. Welcome back. Im Neal Herman. I think weve met
a few times. Today, we will be talking about dental caries in children. This is a part of Dr.
Allens course. Let me apologize in advance. I did not post this yet; I just recently got
back from a trip abroad.

Slide 2 Tanzania August 2014
I was with Dr. Fernandez. A group of dentists did a mission in Tanzania. Anyways, I just
got back and Im a little under the weather as well. Ill do my best and cover the material.
I promise you that Dr. Allen will post this. Just sit back and enjoy it. One of the great
things about being in dental academia and public health, we have the opportunity to go to
East Africa to a dental outreach mission. We were there for 2.5 weeks.

Slide 3 Pictures of his outreach
This is some of my photos. Ive been there before 5 years ago. We went to the south of
Tanzania which nobody in their right mind goes. The tourist stuff that you would like to
see in Tanzania is to the North. We were in the deep south (Songea) by the Mozambique
water which not much is there, lots of needy and poor people in the villages. Just some
interesting tidbits of village life. You see the bus terminalObama/Barack
Expresstheyre very enamored with President Obama. Its very interesting if youve
never been to that part of the world before.

Slide 4 Pictures of him and other dentists working on children
The main reason we were there was to provide some oral health care to some children.
Thats me up there with my custom made scrubs ($7). We were in schools to provide
these children their first experience with some of them with toothbrush and how to take
care of themselves. This is a dental clinic here, which is built on 150 acres plot of land
right outside of town by this foundation called Miracle Corners of the World. We worked
with 6 dental therapy students from the village of Mbyea. They came and worked with
us. I had the opportunity to work with them. As you can see, we did a little morning
session and I actually did some treatment myself. Professor Hernandez applying fluoride
varnish to the kids. Same kinds of things we do on the outreaches here to educate not
only the children but also the schoolteacher and try to make this a sustainable project.
Having the dental therapy students there was wonderful because talk about sustainability,
we only come occasionally there, but theyre there all the time. They learn very little
about preventive care and theyre basically extracting teeth and even restorative care is a
new experience for them. So we introduce them to new dental materials.

Slide 5 Slides of elephants/zebra/giraffe etc
We worked 9 days in the clinic. And on the way home, we managed to squeeze in a
Safari and this is a general dentist and he actually went to school herehis name is Clint
Timmerman (not sure)hes practicing out in Colorado Springs in Denver. These were
my photos. We actually saw these animals.

Slide 6 The search for a CURE for, or at least a way to MANAGE, dental caries has
been ongoing for many years
Lets talk about dental caries. Im going to give you the pediatric version. I dont think
its all that different. Although, one of things we do in pediatric dentistry more than on
the clinic floor for adults is that we practice what we preach. We talk about doing
conservative therapy, therapeutic intervention and leaving the decay behind. Those of
you who have the opportunities to come to our clinic see that we actually do it. We dont
expose pulp if the tooth is capable of reversing itself and healing. We manage deep caries
very differently than you would in the adult clinic. Im going to talk to you about that
todaywhy we do thatwhat the benefits are etc. As you can see from the dates here,
this is not something new. I was a pediatric resident over 40 years ago here. We were
leaving decay behind and doing pulp therapy 40 years ago. Its not new. I mentioned this
to you. The literature goes back to the 70s. This is just how long it takes to get this into
practice. Theres many reasons why it takes so long and well get into that later but its
been very frustrating watching this evolutionwhich hasnt really been an evolution but
it should be a part of practice and hopefully you guys will be the ones carrying it
forwardthats why it takes generations. People in my generation, who are out in
practice, many of them are practicing the way they were in dental school and thats
unfortunate with all the wonderful changes weve hadthe material, technology, and
research. Youve all heard the attempt to find a vaccinesome way of curing dental
caries. Something that can be universally applied. The closest thing weve achieved to
that is water fluoridation. Even that to this day is a controversial issue. Some of you may
have just read that a few countries, the last one being Israel, have just banned water
fluoridation. This is how powerful the anti-fluoridation lobby is around the world. People
who are not of the scientific mind, who do not know how to properly read the literature,
feed into the natural human fears about adding things to our environmental water. Its
playing out that countries such as the Czech Republiceven Sweden which is a pretty
sophisticated scientifically oriented country has banned community water fluoridation.
As I said just last week, Israel had pass legislation there too. So this cure for caries has
not happenedwill not happen. So what were looking for is a way to manage as best we
can this disease call dental caries. Youll have these slides available to you. Ill skip over
some stuff but I also include references. I try to give you evidence based stuff. But there
have been many attempts over the yearsback in the 1800syouve all maybe heard of
silver nitrate but you wont learn much about it unless its from me, its having a
resurgence now. It was pretty popular about 50-60 years ago, definitely popular during
the turn of the last century. Its a proven therapeutic agent that arrests decay but has an
unfortunate side effect of turning the decay black. And in this days and age of cosmetics,
thats a no-no. But it does has its place maybe not in your average Manhattan practice but
certainly in places like Tanzania in the middle nowherein certain communities its very
appropriate as a caries control measure. Some dentists have come up with a sort of
scheme to reduce caries. I dont know if you know about 100 years ago here in NYC and
the US, dental caries was a huge problem. The numbers now of caries-free children are
enormous. If you look at the national statistics, Ill show you in a few minutes. Virtually
every child (~98-99%) at the turn of the 1900s had cavities. Anybody know how many
children are caries-free today in this country? Its 65% and its pretty impressive. Most of
that has been attributed to water fluoridation because 75% of the population does get
fluoridated water. But there are still problems because 80% of the dental caries we do
find are found in only 25% of the population. Thats the population were involved with
here at the school and out on your outreach locations in under-served areas where you do
the find the population with high caries rate. So while caries is being reduced nationally,
were not really doing a good job in certain populations. And again, well talk about that
in a few minutes

Slide 7 The Global Perspective
Lets take a quick look at the global perspective

Slide 8 The burden of oral diseases and conditions
The global perspective is pretty much like this. This is WHO stuff. They have a
wonderful website by the way which you might want to look at on your own time. So
they talk about these oral conditions of which dental caries lead the list. Again, Im not
going to go through everything but some things you dont know a lot about like
thiswhich in certain parts of the worldNoma is a degenerative diseasea skin-eating
disease similar to some of the pictures youve seen like Ebola. A big problemnot in the
USbut certain part of the world. If youre interested in public health or global
perspective, hopefully youll learn more about that but you wont learn any more about it
in dental school. I dont even think they mention it in Oral Pathology or even general
pathology

Slide 9 Global trends in oral health Developed countries
So the trendsin public healthwe talk about the developed countries which are
westernized countries including North America, Europe mostly, parts of Asia (not that
many parts). And then we talk about developing countries. These are the global trends
in developed countries and youll see a decline in dental caries in the western world.
Adults are keeping their teeth longer. As the economic conditions get better and the
quality of life gets better, people start becoming more interested and involved with their
oral health. The use of tobacco and alcohol is down compared to the developing world.
And most of the burden falls in the under-served and disadvantaged populations

Slide 10 Global trends in oral health Developing countries
In the developing countries, often the dental caries is low. Why? Because their diet is
generally more an endemic diet. Its not westernizedall the sugar and processed food.
Problems that we experience here, as a major part of dental caries, is not present in that
part of the world. But whats happening with globalization is that more and more of these
developing countries are being exposed to western products. Even in Tanzania, people
are living on small amounts of money, high unemployment, and living a very basic life-
style. But if you go to any of the shops there, youll see candy bars and soda. Theyre
being inundated with these Western products. While dental caries is initially low, the
more civilize they become, dental caries becomes more and more of a problem because in
addition to all that, the dental infrastructure is non-existent. There are either no dentists or
the people cant afford to go to the dentists. And theres very little dental awareness in
these countries. If you put the two together, you find an increasing trend towards dental
decay.

Slide 11 World map on dental caries (DMFT), 35-44 years
So this is looking at DMFT indices to show you, which countries are very low and which
countries are very high. The US is considered moderate. Many parts of Africa are
considered quite low. This is changing over the year. Again this is ADULTS not children.

Slide 12- World map on dental caries (DMFT), 12 years
Children are hereat least the 12 year olds. This is consistent. The US does pretty well
in the pediatric population. But again, dental caries isnt a disease of childhood; it affects
adults as well especially after adolescence.

Slide 13 Graph
Here it is in a graph form. Youll see the developed countries; theres been a decrease in
DMF scores. Here youll see the total around the world is relatively stable. Its been on
the increase in developing countries.

Slide 14 Epidemiology of Dental Caries in the United States
So what about the U.S

Slide 15 Some Data to Consider
Heres some data on the US. The NHANES study is done every 10 years. Here is some of
the last statistics we saw. And you can see as the children get olderat age 5, almost
the children have dental diseaseat least 1 cavitated lesions. Heres that statistic I threw
at you earlier. 65% of the population as a whole seems to be caries free up to the age of
12. How do you make sense of all that?

Slide 16 Increased Access to Care?
Here are some of the reasons why. Issues such as dental insurance. People with dental
insurance access dental care more frequently than people without dental coverage. Here
are some things about public dental coverage versus private dental coverage. Dental
utilization, which means you can have dental insurance but if you dont go to the dentist,
youre not using it. So utilization is how often people go the dentist and seek care even if
its preventative care. So look this over and you can see here some interesting numbers
about the public sector. The children havethis is Medicaid mostlythe different forms
of public assistance has actually increase the access to dental care for the under-served.
Privateits a different story

Slide 17 1999-2004 NNHANES findings
So heres the interesting thing we found in that last NNHANES study that while for all
age groups the dental caries has continued to decline, the younger age group (2-5 year
olds)theres actually an increase4% increase from 24%-28%. This really threw the
pediatric and public health community for a loop because nobody really understood what
was going on. Why in this particular age group was this happening?

Slide 18 Supposed increase in incidence of dental caries in 2-5 year olds
So theres been a lot of debate and analysis of this phenomenon. And again without going
a lot into details, as you know its not easy reconciling datadifferent people can take
the same data and analyze it differently and come to different conclusions about why.
And thats sort of whats happened here. I still havent heard of any good explanation as
to why this is happening. Some people believe that it was a statistical glitch. In fact, its
possible that the caries has continued to decline but what this basically says here is that
the number of filled teeththe F part of the DMFT has actually skewed the data in a way
that makes it seem like caries has risen. In fact, what it means is that more and more
children are actually getting to a dentist to get treatment. Im not sure if thats clear. It is
kind of complicated. They think it has to do with the fact that access to care has increased
and that more teeth are being treated and filled. Its not that cariesthe untreated part of
the diseasethe decay part may have decreased. [student question inaudible] No they
use DMFTits just notated differently. Children under 5 do get teeth extracted so
missing is an appropriate usage. Ill look into that for you but Im not quite sure

Slide 19 caries increase between NHANES III and 99-04 reported by
So again, these explanations may help a little about how its analyzed. Im not a
statistician so I dont really understand a whole lot of this stuff but they talk about
aggregated versus disaggregated data. As I said, its complicated. Most of us meaning
pediatric dentist and public health people do believe that its still open to debate whether
this has actually increase. We will be getting a new NHANES shortly. I guess well see if
it works itself out in the next one.

Slide 20 I ask everyone to consider that this may reflect the possibility of
These are some quotes from a dental public list serv, which I subscribe to which if any of
you are interested in public health pediatric, I highly recommend you look at it. A lot of
the real experts in the field chime in on certain issues that I think are pretty important.
This is something thats important to me. Theyre talking about the increased access to
care for children and the whole issue of drilling and filling teeth. The concept basically
youve all heard is that you cannot drill away dental caries. You will not solve the dental
caries problem by just increasing people going to the dentist. You have to manage and
have people understand, this is a disease and you have to treat the disease not the
symptoms of the disease. Every time youre filling the tooth, youre treating a symptom
of dental caries. Youre not treating dental caries, youre filling a tooth which is a
symptom of dental caries. So this is the essence of conservative and preventive dentistry.
This talk about the monetization of our professionthat we earn our living by filling the
teeththe more fillings you do the more money you make. Unfortunately, thats one of
the reality of not just dentistry but health care in general. Many well intention people as
you can see from reading this dont always make the right decisions for the right reasons.
And what were trying to do is to focus on the evidence and best practices to figure out a
way to make this thing work. In the 20
th
century, there was no solution. We had dental
amalgam. We had no understanding about the role of fluoride. We had no materials that
we have now like glass ionomers and bonding material that could offer us any alternative
to drilling and filling. We do have them now. We also have the knowledge and research
to show us now. When I was in dental school, we were taught that hard tissue cannot
remineralize. We know now that thats absolutely not true. Not only can bone regenerate
but you can remineralize early lesionslesions that have not cavitated. We have tools
and materials available to us that allow us to overcome our history and practice more like
we ought to be practicing now.

Slide 21 The National Survey of Childrens Health 2003
Again, Im not going to go over these. Just some more statistics about the under-served,
the young children

Slide 22 The National Survey of Childrens Health 2003
This is the federal poverty level showing that the poorer children are less likely to receive
preventive care. It gets higher as the family earns more money. Not a surprise, the more
educatedthe more money you make.

Slide 24 This is consistent with the statement
This is the number I threw at you earlier. Statisticsstatistics[starts skipping through
slides] about the different ethnic groupsutilization dataIll let you look at this
yourself.

Slide 29 Summary of Issues
Im not gonna spend a lot of time because Ive mentioned most of these. But these are the
kind of issues that as pediatric and public health people, we are concerned with. That gap
between access to care for the underservedthats a big onehow do people get the care
that they needthat theres this clash of social, monetary and professional values. There
are too few providers for the safety net. Very few people open practices in the
underserved areas. Try to find a pediatric dentist in the community health center in this
country. Its a rarity because pediatric practice is lucrative and thats where everyone
goes. Our own residents do the same thing. We try to encourage them to come back,
teach and do something. This whole issue of a safety net is a big problem in a country
such as ours, which focuses on the private practices system.

Slide 30 Summary of Issues cont
These are issues that you probably wont hear much of because its not really technical
based in doing the dentistry. But as people who are entering the profession, I think you
ought to be aware of. You know what Head Start isthe only program in the country that
has oral health standards. Thats another problem. Most public schools and children who
go to school do not have oral health requirements. They all have medical requirement but
oral health is not considered in them. If they are, its often voluntary not mandatory. So
we have a long way to go. There are other parts of the world that do have these
requirements.

Slide 31 Suggested Short-Term Strategies
Much of Europe and Scandinaviayes they have socialized systems that are in
placethey have better safety nets than we have, but their awareness is greater. They
understand the concept that you have to get to children early and you have to educate
their parent to understand how do you prevent these problems before they began. We
dont do such a good job with that. We spend a lot of effort trying to educate the people
to do it but the economic system we operate in doesnt reward that. It rewards
actions/treatment. It doesnt reward prevention unfortunately. That is gradually changing
I believe but not fast enough. Heres some strategies you can look at. Some of the things
that we public health people talk about to try to get some of this stuff into law.

Slide 32 Suggested Long Term Challenge Winds of Change for the profession
Just as an example. The latest Affordable Care Act (Obamacare)the intentions were
goodthe Children Dental Project out in D.C. was lobbying strongly to get pediatric
dentistry included in that and it was initially successful and as the politics worked out and
as it was implemented gradually nowas some of you may knowit is not a mandated
service anymore, it was included as an optional add-on which again most people who
arethe 40 million people who are going to benefit from the ACA, many of them have
benefitted but not the kind of people who are going to opt to pay for additional oral
healthcare. Thats a big disappointment. So I mentioned this paradigm changeback to
dental caries. Were looking at the medical versus the surgical model. I am going to be
talking to you starting in November for the D2 pediatric series but Im going to give you
a little insight as to what that means. Its the concept of treating dental caries as an
infectious disease and focusing on diagnosis rather than drill and fit and treating those
symptoms. Treating caries as a transmissible infectious disease. Promoting a therapeutic
approach and conservative therapies, not drill and fill.

Slide 33 What is the latest thinking regarding caries management, dental education and
licensure?
A little bit of editorializing about some of the ways this kind of infiltrates into our
practices. Heres a little bit about dental licensure and how some of this affectsyou will
know when you take your boards. This is again the last holdout in this country about
conservative therapy. Theyre still requiring complete caries removal or else you dont
pass your boards. This is insulting in a way. Heres a statement I think you should all
read and think about carefully. In the latest Cochrane study, the highest-level meta-
analysis of critical analysis of research, leaving decay at the base actually gives better
outcomes than caries removal. So what does that mean? It means when you look at the
longevity of the tooth thats been treated in that manner, and when you at the fact that
when you remove all the decayhow many pulps you expose which then require further
RCT or possible extraction. When you measure the outcomes from a patients POV, you
keep more teeth in the mouth and you keep them healthier by actually being conservative
and letting the tooth heal from within, getting a good seal on the tooth and moving on
from there. Theres extensive literature on that. This is not new. This has been around a
long time. Theyre not integrated into our education enough certainly not integrated into
board exams so this is just something thats an issue for the future. Hopefully, it may
change when you take the NERBs in 3 years. The dental board examiners in this country
are the last holdout and so far theyre doing a good job.

Slide 34 Controversies that proved to be true
I just have this slide on to make a point and that is a lot of the stuff youre hearing from
people who advocate newer or innovative type of thinking/therapy. Here are some
examples of some things that were considered controversial in my lifetime. But we know
now that indirect pulp caps not only work but are superior to removing decay. Dental
sealants were once considered controversial and in fact are still by some dentists who do
not believe that sealing over decay will arrest the lesion. Again, its an effective
conservative therapeutic approach that works. People are still fighting this concept that
you cannot reverse or arrest caries. Fluoride is superior to CaOH as a pulp liner. I do
believe there are still parts in the dental school that use CaOH under restorations. Big
problem with that in my book. Extensive literatures showing CaOH while equally
effective as fluoride in promoting pulp healing, CaOH has other major side effects that
fluoride does not have such as internal resorption and pulp remineralization. Think twice
before you put a liner in with CaOH because it MAY have not always some detrimental
reactions by the pulp while fluoride has neither of those reactions. That a tooth that is
traumatized or avulsed that has a pulpotomy in it after trauma that you absolutely must do
RCT after thatjust not true. There are number of studies and I have some personal
experience with this, where often the tooth heals by itself. So a lot of the traditional
values that have been promoted for decades or longer in the dental profession have been
gradually proven to not hold up to scrutiny as far as statistically. Another example that I
just thought ofprophylactic 3
rd
molar extractionoral surgeon earn half of their
income on thatremoving 3
rd
molar in teenagers because orthodontists are afraid its
going to crowd up their anterior teeth after they do their orthodontics. No evidence for
that, never been shown to be true. We do stainless steel crowns in pediatric dentistry all
the time. We dont get a good seal on them right. We think thered be secondary decay
under them sometimes right. Never happenswere not sure whywe think it has to do
with the chemistry in the crevice and gingival sulcuswere not really sure but no one
has ever seen secondary decay under stainless steel crowns, which means that were
getting some sort of a seal in there. So even on a badly decayed primary tooth that you
need a crown on, you can still do indirect pulp therapy even though one of the critical
components to being successful is getting a good sealit works with stainless steel
crown. And of course the whole issue of how does fluoride work? When I was a dental
student, we were all learning it works by ingesting it and coming back and incorporating
itself into the tooth structure and we now know pretty clearly at least the present thinking
right nowwhich may change again as more research is donebut its the topical nature
of fluoride that prevents decay not systemically.

Slide 35 Disease Management (Therapeutic vs. Surgical)
So this whole thing about leaving decay and doing conservative therapynot drilling and
fillingwell its controversial nowI think as you guys mature and progress in your
career, its going to become more and more the standard of care. Thats going to involve
major changes in the way we get reimbursed, the way insurance companies deal with
payments etc.

Slide 36 Another promising therapy we will NOT discuss
There are many agents we use, the major one being fluoride. I mentioned already fluoride
varnish. You will be applying fluoride varnish when you head out to outreaches. That is
still the major agent we use nowadays for prevention and other interventions such as
remineralization and arresting decay. Any of you heard of silver diamine fluoride. This is
a product that is a version of varnish but its got that silver ion that I mentioned to you
earlier in silver nitrate. This has just been approved by the FDA about 3 weeks ago. It has
never been available in the US. Its been used worldwide for decades as was fluoride
varnish by the waywell its never been approved here. It was approved here as a
sensitivity agent not as an anti-caries agent. We use it off label. Interesting right, thats
never been approved as an effective anti-caries agent yet its the standard of care for
prevention. Silver Diamine fluoride is used similarly to fluoride varnish but its been
actually shown to be a little more effective. Again, we have this issue again as we do with
silver nitrate. Its the silver ion that becomes a compound that turns the decayed dentin
black. Theres actually research going on right now to counteract that by potassium
iodide being applied on top of that to remove that. Once that happens, I think you will
find that this is going to be the new agent that everyone going to be talking about. So
even better, maybe theyll find a way to combine the two into one agent. The big
objection is not the effectiveness. We all know its extremely effective. Its that
darkening/black color that stains the dentin, thats the objection to using it

Slide 37 Two teeth treated with silver diamine fluoride
Heres what it looks like. Here are two teeth that were treated with silver diamine
fluoride. Here we see a cavitated lesion where you can see by the color and its
hardthis is what arrested decay looks like. And this one was never cavitated. This is not
just staining. This was actually what applying a silver compound to a non-cavitated
fissure or pit would look like. Not particularly objectionable. Many people have natural
staining like that thats hard to remove anyway. This makes these fissures less permeable
and less incline to become carious and a lot easier to do than a sealantand you dont
have retention issues. Something to think about and something I think youll be seeing a
lot more of in the future

Slide 38 Another Therapy We Will NOT Discuss
Again, stuff were not going to spend a lot of time on because as this emerges into a
product, you will hear more details. Heres some preliminary readings about how its
used and applied

Slide 39 Fluoride Varnish and Application
Here are some of the traditional therapeutic agents we use now. All of these are
varnishes. Heres how theyre applied. Usually we use the brush but sometime you can
use a cotton applicator or even the tip of an explorer if you really want to get into grooves
and fissures.

Slide 40 Adjunctive products to assist in remineralizing or arresting carious lesions
Here are some of the other products. OTC fluoride rinses. Any child with any caries risk
should be on this in my opinion. Its cheap, no prescription required, a daily rinse in
addition to twice a day brushing will increase the likelihood that any incipient lesions
developing in the child will either stabilize or remineralize rather than progress. Heres a
form of ReCaldent, calcium and phosphate ions that are delivered right to the teeth by
wiping on the teeth. This is MI paste. We use this in our clinic as well. This is a
prescription toothpaste with 5x the fluoride of normal toothpaste. Instead of a 1000ppm,
we have 5000ppm. This again we prescribe to high-risk children. Children who are likely
to get decay or already have had dental caries.

Slide 41 The Medical Model of Care
Thats our repertoire of agents that we use when were trying to use this medical model
care. Again, I will talk to you more extensively about this in November. This is the
paperModern Management of Dental Cariesas you can see its already 20 years
oldMax Anderson was the authorwonderful thing about this paper, it did not appear
in the pediatric journal, it appeared in the Journal of the American Dental Association as
you can see which meant everybody was reading it. You dont have to read it but you
benefit by reading it. He gives you what all of us love to have. A cookbook approach to
how do you do this. Whats the regimen, how do you do it, when do you do it, why do
you do it. Why does this work better than traditional drill and fill dentistry. So again well
talk more about the details of it but this is what he talks aboutthat were being pretty
ineffective with our present surgical model and that while open lesionsand these are
terms he usessequestering of the infection are vital to success, the therapeutic
intervention mostly fluoride really ensures us that this is going to work. The trick is
getting patient to comply with that. And therefore not only do we have to buy into it; the
patients have to buy into it. We dont do such a good job with that as dentists

Slide 42 The Key is Diagnosisand Risk Assessment
Were spending more time worrying about billing those Class II and crowns than we are
spending time working on the patients for prevention. So the key is diagnosis not how
many fillings they need and its a disease intervention model focused on diagnosing and
treating the bacterial infectionnot the lesionsthe lesions are not the disease. Its very
interesting. You go to professional meetings and many of your lecturers are going to
stand up here and talk to you about caries on the tooth. Its not correct. Dental caries is
not something you can see. Its the disease. You can see the cavity and cavitation. You
can see the result of dental caries. If you have diabetes, you cannot see a diabete. You
have a disease called diabetes, there is no lesions right. Even in the profession among
very educated people, its misunderstood and not used properly. So Im a stickler for
terminology but I think as professionals, its a little embarrassing when it happens.

Slide 43 Effectiveness of Fluoride Varnish
So a little bit about fluoride varnish. Again, we talk about this in D1. I know I gave you a
very early lecture on the different types of fluoride we use. Very successful in reducing
caries in permanent teeth

Slide 44 Fluoride Varnish: Therapy of choice for preventing, controlling or reducing
Its the therapy of choice right now because of all these great advantages. Its safe for
childrenno ingestion. Thats always a problem that the anti-fluoridation is concerned
aboutswallowing too much fluoride. It has extended contact with enamel. These are all
the nice things. It dries under moisture; you dont have to keep it totally dry. All the
benefits, why we use it universally pretty much these days.

Slide 45 Hypothesis: Intensive fluoride regimens can arrest decay in cavitated lesions
Gels are gone. All the other modalities of delivering it are gone. Its pretty much varnish
varnish varnish. Heres our hypothesis based on this conservative approachthat
intensive fluoride can arrest decay in cavitated lesions and remineralize teeth with non-
cavitated, incipient carious lesions. Heres some study that talk about that

Slide 46 Therapeutic Remineralization (14 year old)
Heres some proof. I have other radiographs to show you. Here are some examples from
my own patients where we actually documented some of these things. Heres a 14 year
old over a period of a year which showed on the initial radiograph a E2 lesion and here it
is a year laterIm not sure which regimen this child was on but my guess is we added
the OTC rinse in addition to the 2x a day brushing right before bedtime, rinse with one
minute the OTC (0.5%) rinse and after 1 yearpretty impressivenot only have they
not progressed, they look a little more mineralize to me. Normally I can assure you when
I was in dental school, this was a MO/DO here. This is evidence of a few things. One,
that weve come a long way. Two, now we have products that can remineralize. And yes
hard tissue can definitely be remineralized.

Slide 47 Arrested Caries
So as far as arresting caries, this is what arrested caries look like. Here it is in primary
molars. There is arrested decay here. Even teeth like this, probably not going to cause any
problems. As dentists, were just dying to pick up that hand piece and put stainless steel
crowns on those teeth. I can tell you honestly from my experience if you just left these
teeth alone and did nothing, the decay cannot progressed because this decay has arrested.
Once decay arrests, it does not un-arrest and it does not continue to progress. These are
arrested and theyll stay like this for the life of the child. They have a characteristic
appearance.

Slide 48 So, what is this process weve come to know as ARRESTED DECAY
If you look at a radiograph, it has a horizontal nature rather than a vertical nature. It
doesnt barrel its way towards the pulp. It just flattens out and the pulp gradually recedes
from it. Youll never get a clinical exposure. Theyre darker in color, harder in texture,
and slow in progression. Sometime, they dont progress at all depending whether theyre
fully arrested or on their way. Heres some pretty crummy mouth. But again, a child like
thismy guess is this child treated with intensive fluoride which Im going to talk about
in a minutethe teeth were not restoredand these teeth would normally exfoliate
around 6.5 to 7.5 years of ageif this child was 4 nowcould go all that time without
worrying about it. The only reason for restoring this is for cosmetics. As far as disease
progression or treatment of disease, theres really no reason to be doing that anymore

Slide 49 Histological Differences
This is a big change because of not covering decay still irritates most dentists including
many of my colleagues in pediatric dentistry. This is a little piece I picked out. I was
trying to read up a little bit about what is arrested decay. I dont really have a good
definition for you. This talks a little bit about some of the zones that you find. So Ill let
you look it over. I couldnt really find a good definition of what arrested decay was. I
would love to see any references about what exactly is arrested decay and the nature of it

Slide 50 Risk Factors (Individual)
You all know about risk factors. Im not going to spend a lot of time on that. We talk
about in public healthindividual risk factors and we talk about community risk
factors...theyre very differentjust like epidemiologic research versus individual
research.

Slide 51 Risk Factors (Community)
These are certain risk factors when we look at a community.

Slide 52 Application Frequency
So one of the important parts, if youre going to talk about therapeutic, one of the very
important things is to know what youre doing and why youre doing it. Unfortunately,
theres very little data on this. But the application frequency is what really makes this
work. One fluoride varnish application is not going to suddenly arrest dental caries or the
results of dental caries. Its not going to result in a cavitated lesion arresting. But multiple
might. Also agents like silver nitrateone or two applicationsthe literature is not
always clear on thatIve seen some literature where it says only one applicationsome
of it Ill show you it at the end, they recommend a pretty intensive regiment. So a lot of
this stuff is just emerging as far as the disease management approach but to be effective
with non-cavitated lesions, you must have multiple applications. Thats why the
rinseits the beauty of the rinse. The child is getting it every night over and over again.
Youve all heard of constant low-dose fluoride is the way to go in terms as far as
prevention and remineralization. So here you see some data about how it works and that
you get significant caries reduction in these studies.

Slide 53 Application Frequency (There is no single protocol)
No single protocol seems to be the standard. Different people seem to do different things.
The ADA recommends one thing. The US Navy recommends another. So different
practitioners have different versions of this. What we do have in common is were all
wiling to try it and were all pretty successful at it. So one of these days when we get
some good data, we will have an actual standardized regimen for doing this

Slide 54 Onset of ECC Early Demineralization
Lets look at some examples. So heres a 10-month-old babywalks into your office and
this is whats in their mouth? Whats going on here? We have the early signs of
demineralization. You may be beginning to see the edges start chipping. Soon you may
start seeing some cavitation either on the facial or possibly interproximally. You just
dont know how this is going to progress. But already at 10 months, were a little late.
Wouldnt it have been nice to educate the parents and have them avoid this? When we
talk about early intervention, we mean really early intervention. Sometimes pre-natal is
the best time. This is why the Academy of Pediatric Dentistry recommends a dental visit
by the first year but often even that can be a little late. First year or the eruption of the
first tooth. I recommend as soon as the baby is born, the parent should be in the mouth
with a piece of gauze wiping the gums. Why? To get them use to itlet the kid know.
You see these parents come into our clinic with their 3 year old and look like theyve
never had a toothbrush on their teeth. You have to get in early. The children when youre
in their mouth early, it becomes a routine.

Slide 55 - How about this case?
Heres a 1 year old. Hes got his 4 upper and lower anteriors and yet you already got
some problems here. No this is not tetracycline staining/hypoplasia. This is
demineralization. You can see it by the texture and quality of the gingival tissue. This is a
child probably sucking on a bottle at nightbeing stuff with sorts of snack food/chip
whatever. No semblance of oral health careno tooth brushingno wiping with
gauzeprobably no supplemental fluoride being given either

Slide 57 An older child
So heres an example of wherewhat do you do when you see thatthe first thing a
dentist does is put a composite in therethats not solving the problem. You want to
teach the parent about why this happens so it doesnt continue happening. You know you
do get a 2
nd
chance in life at least with your teeth. The earlier you start the better. They
should know what this is caused bywhat they can do to avoid it and then put them on a
therapeutic program. First, see if they can follow some directions and arrest the decay
somehow and then worry about the cosmetic part of it. So heres an example where after
a few months, theyve gone from here to here [left to right]. But this is definitely a little
darker and harder in texture.

Slide 58 How would you handle this? What are your priorities?
Same thing here. We didnt do anything here as far as restorationsthat will come later
if they want it. This is on the lingual of the upper incisorsno one can see them
anyways. Were more concern about controlling the disease and keeping it under control.
Kid is not even 2 yet. What are you gonna do? You think theyll sit in the dental chair
and let you treat them. Again these are all done lap-to-lap, knee-to-knee. You need
something you can do quickly yet effective and thats where the fluoride varnish comes
in

Slide 59 3 months of intensive Fl- varnish and Prevident 5000%...
Heres a little more dramatic. Same case. You can seenot even a year old11 months
old and in a few months, weve gotten this. We used 3 months of intensive varnish and
Prevident 5000 for the second brushing. One brushing with regular toothpaste and
nighttime brushing with Prevident.

Slide 60 So, what are the protocols for therapeutic intervention to combat dental caries?
So what are the protocols? What do we recommend to you if youre going to practice this
way?

Slide 61 The following regimens are:
First, my disclaimer. Again, I try to only give you evidence based stuff. Unfortunately,
for some of this, there is no evidence. These regimens are not only based on my personal
experience but also the experience of many of our faculties and many pediatric dentists
around the world. A lot of it is anecdotal and empirical except for the preventive
regimensthat we do have as youll see.

Slide 62 Preventive Regimen
The 2006 Weintraub study, a definitive study that validated fluoride varnish as the most
effective way to prevent dental caries. A terrific study done by very top-notch people.
This has become the standardthe reference that everybody says now we have the
literature for it. They got pretty impressive results. Reductions ranging from 53-93%.
What they did was follow groups up to 3 year. They started applying twice a year varnish
on 1 year old and of course had a control group. The difference on the control group was
up to almost twice fewer caries than the control group

Slide 63 Preventive Regimen (cont)
So the preventive regimen recommended is pretty surprising. It brings up another point
about overtreatment. Even in our own pediatric clinic, when you bring in a patient for
recall, pretty much whether theyre decay free or have extensive decay, they get a
fluoride treatment. Notice that the recommended regimen for a child who is caries free or
really low risk really does not need fluoride. What its telling you is that theyre getting
enough fluoride and theyre probably going to stay that way. Does it hurt to do the
varnish? Probably not, its extremely safe, its low-cost. If it were my child, Id do it
anyways, similarly with sealant but theres not a lot of evidence showing that youre
getting better outcomes on those children. Frankly, dealing with the underserved
population, I think its proven to actually do it even though the recommendation is that
these kids dont need it. Some of these pediatric practices from Long Island to
Manhattanits like the day the child comes in at 1 or 2 up to until theyre teenagers,
they never had a cavity in their mouth yet every 4-6 months, theyre getting fluoride
varnish during their checkup. I think thats a little over treating. Its benefitting the dentist
more than the child. This is in the area of controversypractice patternseffectiveness
of the agents. We could talk for weeks about that but this is the recommendation from
that study. Moderate or high risk patients 2 4 a year. Two for the moderate reallythe
child shows some risk factors but up to 4 times a year. Even Medicaid pays for 4 times a
year in New York. For high-risk caries, you should be getting them every few months but
of course the key is what they do at home. Without a doubt, the one evidence based
strategy about avoiding and preventing caries is that twice a day brushing with the
fluoride toothpaste, not just the brushing. We learn that as a dental student, you break up
the plaque and it forms every 24 hoursno plaque no decay. The evidence says only
with the fluoride toothpaste are you reducing decay. These are the references for the
recommendation

Slide 64 Regimen for Remineralization
So heres the new stuff. Heres the regimen for remineralizing. If you want to
remineralize a tooth even if it has a lesion, instead of worrying about filling it, you want
to get the disease under control first. Heres what you do. You apply FV intensively (3
applications in 3 weeks). Now you cant send fluoride varnish home with the parents. Its
too concentrated and not considered acceptable. Frankly, I dont see the big harm in
doing that but its just not done. We let parents do other things at home just not varnish.
What this means is that theyve got to come back to the office every week for 3 weeks.
Usually, you can frighten the parent when they walk in with a child like that and hold up
an advanced ECCheres whats gonna happen. Its all true. Its not like youre telling
them a lie or anything but they need to get right on top of this thing. They do seem to
come back. Whats critical is reinforcing and accelerating that strategy at homekeeping
those teeth brushed with fluoride toothpaste and thennow you cant give a 1 or 2 year
old OTC fluoride rinse because theyre gonna swallow it so we use other modalities such
as Prevident as the toothpaste for the 2
nd
brushing or we use MI paste ReCaldent which is
something you can just rub on with your fingers 2x a day. That works very well too.
What we started doing lately is you have them buy the OTC rinse and we have them
apply it with a cotton tip applicator and just swab it around the mouth. No evidence that
that really works but how can it hurt. So frequent application of low dosage fluoride.
Thats the regimen for remineralization

Slide 65 Therapeutic Remineralization (6 year old)
Here are a couple more examples of where you have clear incipient lesions that have
been since remineralized over a period of 6 months from July to Jan.

Slide 66 Remineralization using Prevident 5000+ (4-5 year old)
Heres another one over a little longer period (1.5 years). Of course, its nice looking at
the longer ones because you might ask yourself does it really last? And they do last.
Whats different about remineralization and arrestingI mentioned once you arrest they
stay arrestedthats not necessarily true for remineralization. Remineralization needs an
ongoing therapy that youre doing. So a sudden stop may cause reoccurrence because the
bacteria is going to come back

Slide 67 Regimens to Arrest Caries
One of the other thing fluoride does besides strengthen the tooth crystal itself, it keeps the
bacterial count down. When I was a dental student, we didnt know that. It was not
known that fluoride suppress the microbes. Its only since the 80s that we know that. So
in addition to acting on the hard structurehelping with that remineralizationit also
keeps the bacterial count low. The regimen to arrest caries is a little more intensive than
the remineralization. It starts out the same with the 3 initial applications but the we need
the patient to re present themselves to the office for the next 4 monthsonce a month for
4 months. Thats where we run into problems with compliance and we lose people along
the way. Thats something thats gotta be worked on but unfortunately, it takes a
whileremember the remineralization while youre giving those 3 intensive applications
in the officewhat youre really counting on is the extra compliance at home, but it
seems to be critical for the remineralization. In the arresting part, you should see at the
end of the 5 months, you should actually see clinical arresting of decay physically. While
all this is important, that they maintain this, its mostly for prevention of future lesions.
Again youre not going to unarrest what youve already arrested.

Slide 68 Arresting caries with intensive Fl- varnish (4 months)
Heres just some examples of lesionagain I showed you earlier onesthese are a
littleI mean look at whats on the teethits still on the teethit gets darker and
harder. This is a 2-year-old child

Slide 69 In progress, treatment w/ intensive Fl- varnish (2.5 months)
Here are some examples of arresting decay. Heres what the radiographs look like. You
can see these large radiolucency here. No infection which makes it amenable to this. If
they were infected, you would probably want to extract them or doing some RCT therapy

Slide 70 Silver Nitrate
Thats pretty much it. Just a final word about silver nitrate. Silver nitrate is sort of in a
comeback phase particularly for certain applications such as remote locations and
underserved populationsvery effective as I mentioned beforejust like the silver
diamine fluoride, this is something youre going to be reading about in the next couple of
years.

Slide 71 Reportedly used as early as the 1840s
A little more about the background. You can read this for yourself. But basically, its
been used as early as the 1840s. It seems to be very effective. We know it works. It fell
into disfavor in the latter half of the century. There were some suspicions that it also had
adverse effects on the pulp. That has not ever been proven to be true. Others have since
concluded that it penetrates the dentin. It has a mild, self-limiting, localized effects on the
pulp. Again I have never heard of anybody de-vitalizing the tooth with silver nitrate. If it
is, it was probably a carious lesion that was probably to progressed to begin with and
already had some impact on the pulp.

Slide 72 A major disadvantage
Heres another example of what it looks like. You dont need even to make a prep or
open the tooth. Many of the remote locations for example where we were in Tanzania,
there were nice dental chairs but they didnt even work so we had to do a lot of
ART/IPC/IPT (indirect pulp caps/therapy, alternative restorative treatment). They all
mean the same thing. You are just basically opening it up, scooping it out along the walls,
and placing some restoration (like glass ionomers) thats going to give you a good seal
and youre going to arrest whats in there and its going to heal from the inside. We did
tons of that and these are the types of teeth youd be doing it on. Once you get something
like this, theres really no crown left. These teeth are arrested. These are teeth I would be
more incline to not do the ART or IPC and worry about putting a restoration in there.
These would be perfect teeth to be treated with silver nitrate where you just paint it on
and if youre not sure that theyre fully arrested, its kind of going to guaranteed that they
are

Slide 73 Recommended Regimen
This is how we use it. I mentioned that if you read the literature, some people advocate
only 1 application is enough which is very heartening if youre in a remote area in the
world, you may not be coming back againyou may actually be benefitting the people
by using it for the 1 application but Steve Duffin whos out in Oregon, hes the major
advocate for silver nitrate here in the US. He has what you called the Duffin regimen. He
does it at 2,4,8 and 12 weeks and he finds 90%+ of the decay arrest following that
protocol. He doesnt talk about what happens if you only do it twice. Ive never seen
numbers from him on that. Theres not a whole lot of good research on that stuff. This is
his quote. Silver nitrate to arrest carieshe adds it to fluoride varnish which is the
interesting thing... is the most cost effective treatment I have ever encountered. One drop
of silver nitrate to fluoride varnish cost only pennies. Arrest of early to moderate lesions
may eliminate the need to restore the tooth or allow for less invasive atraumatic
restorative treatmentthats the old terminologyits now called alternative restorative
treatment. His experience over the last 6 years with this protocoland this is the big
thing in pediatric dentistrykeeping kids out of the hospital for general anesthesia. You
get a 2-3 year old with ECC. Theres not much you can do with them. They require this
10k hospital experience after you pay for the dentistry and the operating room and the
anesthesiologist and the recovery room and most of that is paid by your tax dollars. This
has been a big effort particularly in NYS to reduce the number of children who get
general anesthesia in the hospital. We have almost a 6 months waiting list to Bellevue.
We do 4-5 cases a week. We have a 6 month backup of cases waiting to get into the OR
and there are 15 other pediatric programs in the city and they have similar backups. The
problem is that there are too few of them and its costing everybody lots of money. So
hes interested in reducing the morbidity, the disease prevalence. Hes interested in
controlling it and keeping the kid out of pain whereas the dental profession has always
been more concerned about other things such as whos going to pay for it and whats it
going to look like. When you speak to parents, theyre very interested in a therapy that is
simple, quick, easy and practically free that is going to keep their kid out of pain. There
has been this disconnect between our standards and desires and what the public really
wants. Again, another reason I think youre going to be hearing a lot more about this.

Slide 74 Contact Information
Thats all I have to say. Id be happy to answer any questions? [Student question] Whats
the best way to detect arrested caries? You got to develop an eye for it I think. If you see
it, you know it kind of thing. It takes a little bit of experience. It comes not that hard. I
think our resident having seen a number of patients even by their mid 1
st
year, theyre
pretty good at it. I think the problem in dental school, you dont get to see a lot of this.
For example, if you come to our pediatric clinic as a pre-doc, these kids will all be in
post-doc just because of the magnitude of the case. Its a little overwhelming for you at
this point to treat that. But I certainly welcome you and invite you to come up. Our
residents are wonderful. They will talk to you. They will clue you in. Watch how they
work, theyre fabulousnot only how to manage kids but we really practice what we
preach there. [Student question] Why dont we use fluoride for pulp capping? You mean
right on the pulp? We dont ever do direct pulp capsactually the success rate of that is
fairly low. Generally, when you expose a pulp, particularly in the primary tooth, you do
pulpotomy. [Student question] We do use fluoride, thats the point. Our department does
not have CaOH anymore for many years. The reason is as Ive mentioned, the traditional
approach to a restoration thats more than halfway into dentin is to CaOH. We now know
because of the 2 major side effects, the mineralizing of the pulp and the internal
resorption that may be triggered and premature resorption of the primary tooth, fluoride
does not have either of those 2 yet has the same ability for the odontoblasts to realign,
pull back, and then lay down secondary reparative dentin. So you get the same biological
response without the side effects. Both of them can be put on the pulp directly, but none
of them gives you a long-term result. Usually you get a chronic inflammatory response
that kind of blows up. So in pediatric dentistry what we do is we either do a Cvek
pulpotomypartial pulpotomy where we only remove the area immediate around the
exposure and not the whole chamberor a traditional pulpotomy where you take out all
the pulp in the chamber. Theyre both pretty successful. Pulpotomy are much more
successful than a direct pulp capping. A direct pulp cap is a last ditch effort to avoid
RCT. In all fairness, it does work in 30-35% of the time if you look at the 5-year results
but thats not very high. We like to see more 80 to 95% which pulpotomies are.