Tuesday, August 30, 2016

Title: The association between enamel fluorosis and dental caries in U.S. schoolchildren.

Resident’s Name: Semantha Charles  Date: 08/31/2016 Article  Mentor: Dr. Mindy Sapir
Title: The association between enamel fluorosis and dental caries in U.S. schoolchildren. 
Authors: Lida, H. and Kumar, J. V. 
Journal: J Am Dent Assoc 
Date: 2009 
Topic: Caries, Fluorosis 
Type of Article: Review of surveys 
Main Purpose: Association between enamel fluorosis and dental caries to determine if there is any beneficial effect of enamel fluorosis in U.S. schoolchildren. 

Key Points/Summary: 
Milder forms of enamel fluorosis are usually not noticeable by lay people.  
Analyses of only children 7 to 17 years old who had a history of single residence was used. 
Examiners, examined mouth of children and assigned each tooth very mild, mild, moderate, severe fluorosis index. 
Water sample was obtained. 
Analysis was focused on the permanent maxillary right first molar. 
Permanent first molar is one of the most susceptible teeth to dental caries and fluorosis. There is no preceding primary tooth and therefore no chance that a primary tooth could affect the eruption and formation of the 1st molar. 
Permanent first molars presented similar pattern of caries and enamel fluorosis according to preliminary analysis. 
Mean DMFS of permanent teeth was consistently lower in children with enamel fluorosis when compared with that in children without enamel fluorosis. 
An estimated 35 percent of permanent maxillary right first molars had caries experience, and an average of 0.6 surfaces per tooth were affected by caries. 
Molars without fluorosis had a higher count of DMFS and a higher prevalence of caries than did molars with fluorosis. 
The degree of fluorosis exhibited an inverse dose-response relation to both mean DMFS and the prevalence of caries. 
Fluoride concentration of (<0.7ppm) had decreased odds of having caries as compared with molars without fluorosis, in communities with higher ppms the protective effect of enamel fluorosis was not statistically significant. 
Conclusions: The results of this study suggest that teeth with fluorosis were more resistant to caries in U.S. schoolchildren than were teeth without fluorosis and consideration of these effects in regards to reduction of fluoride exposure. 
Level of Evidence/Comments: Good article that addresses pros and cons of the rationale for fluoride exposure.

My comments on the article are as follows:
Flouride prevents proximal (smooth surface lesions) better than occlusal caries. This study did not take bitewings only clinical assessment , therefore it did not rule out proximal lesions unless they were already filled.
First molars have a higher tendency for developmental defects like MIH and it is not easy to differentiate hyperplasia from fluorosis on a molar, from that aspect incisors are easier to examine. A molar with hypoplasia will be more susceptible to caries, and not taking DDE into account can bias the results.
Enjoy the rest of your weekend,


Impact of pharmacological interventions in expectant mothers resulting in altered mutans streptococci levels in their children

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Nicholas Paquin                                                                           Date: 08/31/2016
Mentor: Dr. S. Sapir

Article Title: Impact of pharmacological interventions in expectant mothers resulting in altered mutans streptococci levels in their children
Author(s): Satta Muthu M. et al
Journal: Pediatric Dentistry
Date: 2015
Major Topic: Does prenatal Pharmacologic intervention to prevent vertical MS transmission
Type of Article: Systematic Review
Main Purpose: to provide a systematic review of the current literature assessing the efficacy of maternal administration of fluoride, chlorhexidine mouthrinses, and xylitol in altering the mutans streptococci levels in children.
Key Points/Summary:
- Phenotypically and genotypically, SM levels in mothers and children have been shown to be similar. MS found in ECC is predominantly acquired from the mother’s saliva; thus, the caries risk of the infant is directly proportional to the bacterial load of the mother
- a knowledge of various methods for the prenatal prevention of MS colonization is mandatory to suppress the maternal MS reservoirs, thus preventing or delaying the infant acquisition of MS
- Pharmacological interventions, such as xylitol gums, fluoride tablets, varnish, rinses, and chlorhexidine mouthrinses/varnish have been used during pregnancy to assess the possible reduction of caries incidence
- Thorild et al. reported that maternal xylitol gum-chewing in six- to eight-month-olds significantly reduced MS transmission compared with the chewing of two control gums by the two control groups containing chlorhexidine/xylitol and sodium fluoride, with respective MS prevalences of 10 percent, 16 percent, and 28 percent
- Xylitol reduces MS levels in plaque and saliva. It acts by decreasing the synthesis of insoluble extracellular polysaccharides, thus reducing the risk of adhesion of MS to the enamel and, consequently, inhibiting MS transmission
- Chlorhexidine has been studied as an antimicrobial agent for the chemical control of plaque and prevention of caries. It is a strong base and has a bacteriostatic effect at low concentrations. At higher concentrations, chlorhexidine acts as a bactericidal agent.
- The caries-preventive effect of topical fluoride is based on three main mechanisms: (1) promotion of remineralization; (2) inhibition of demineralization; and (3) interference with bacterial growth and metabolism
- The use of maternal postpartum chlorhexidine regimen, combined with oral health counseling and preventive child fluoride varnish applications, did not, however, show a significant reduction in ECC
- 1. Statistically significant results were reported in both the included studies. 2. However, systematic analysis revealed a lack of current evidence to support the general recommendation of pharmacological interventions for expectant mothers resulting in altered mutans streptococci levels in their children.
Dr. Nick: This study aimed to focus on pharmacologic intervention only. MS colonization and biofilm development which can lead to caries as we know is dynamic. This article is weak because it tried to make the prevention of transmission very simple, which we know is not. Ultimately, prenatal counseling including eliminating caries and having proper hygiene should still be recommended to mothers to decrease the risk of ECC in their children.
Dr. Sapir: Only 2 studies were the base of this article! Which can be interesting by itself: a third article discussing the findings of to other articles.

Monday, August 29, 2016

Evidence-based clinical recommendations on the prescription of Dietary fluoride supplements for caries prevention: A report of the American Dental Association Council on Scientific Affairs.

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Amir Yavari, DDS (Mentor: Dr. Kane)                                      Date: 08/31/2016
Article Title:
Evidence-based clinical recommendations on the prescription of Dietary fluoride supplements for caries prevention: A report of the American Dental Association Council on Scientific Affairs.
Author(s): Rozier, R. G., et al
Journal: Journal of American Dental Association
Date: 2010
Major Topic: Recommendations on prescribing dietary fluoride supplements
Type of Article: Systematic review 
Main Purpose:
Evidence-based clinical recommendations for the prescription of dietary fluoride supplements. 
The prevalence of fluorosis apparently has increased in US. This is because of an increase in the number of sources of exposure to fluoride, including ingestion of water, toothpastes, dietary fluoride supplements, beverages, foods and professional dental products. The ADA and CSA (council of scientific affairs) addressed when and for whom should fluoride supplements be prescribed, and what should the recommended dosage be.

A MEDLINE search was conducted to identify publications that addressed the research questions: Systematic reviews as well as clinical studies published since the systematic reviews were conducted (June 1, 2006). Total of 23 full text articles were reviewed

v For children at low risk of developing caries, dietary fluoride supplements are not recommended and other sources of fluoride should be considered as a caries-preventive intervention
v For children at high risk of developing caries, dietary fluoride supplements are recommended according to the schedule presented in the table below
v When fluoride supplements are prescribed, they should be taken daily to maximize the caries-preventive benefit
v Systemic fluoride has an indirect topical effect when redistributed in the oral environment by means of saliva.  Supplements that are chewed or lozenges are the best and supplementation can be beneficial after the completion of amelogenesis.
v Recommendation emphasizes the need for caries risk assessment and judicious prescription of dietary fluoride supplements with consideration of total fluoride intake.

1. Very evidence-based article with a very good description of their methods for doing a MEDLINE literature review search and how they distill down and identify the best articles and publications to include and address the question they are asking.
2. This article is a good review and resource for clinical decision making process although I think the “practitioner’s professional judgment” in prescribing can be a bit squishy or open to too much interpretation.
3. It is still a challenge to understand all the other sources of fluoride that our patients may be getting
4. I like the recommendation to consult the local, county or state health department or water board for information. You never know where you all will be setting up practices or working so you should be very familiar with the area and what is and is not fluoridated. For example, Greater Providence is fluoridated, but many communities (rural) here are on well water. Some of that well water has a high FL content and it should not be assumed that a child needs FL supplement because they are on a well. Test the well water for FL content before prescribing supplements.
Assessment of Article:  Level of Evidence: I

Diet and Caries-associated Bacteria in Severe Early Childhood Caries

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: John Diune              Mentor’s Name: Dr. Shabtai Sapir                  Date: 8/31/2016

Article Title: Diet and Caries-associated Bacteria in Severe Early Childhood Caries
Author(s): C.A. Palmer, R. Kent, Jr., C.Y. Loo, C.V. Hughes, E. Stutius, N. Pradhan, M. Dahlan, E. Kanasi, S.S. Arevalo Vasquez, A.C.R. Tanner
Journal: Journal of Dental Research
Date: Sept 2010
Major Topic: Dental Caries, ECC, Prevention
Type of Article: Case controlled
Main Purpose: examine associations between diet and bacterial colonization in children with S-ECC, including children with and without new caries lesions post-treatment.
Key Points: (2 lines Max): Treatment for and prevention of S-ECC should include attention to putative food frequency, putative cariogenicity, and suppression of cariogenic bacteria
Hypothesis that data from a short diet survey would differentiate S-ECC from caries-free children based on frequency of foods, characterized by putative cariogenicity, and these dietary habits would be associated with detection of caries-associated bacteria.
1)      Dietary survey completed by parents or caregivers at baseline measurement visit – included demographics, beverage consumption, and 24-hour diet recall of previous day or typical day marked in hours
-          Diet information was obtained by clinicians trained to elicit information using non-directive interviewing approaches to obtain accurate reporting
2)      Microbial analysis performed using sterile toothpicks to collect plaque samples.
3)      S-ECC children scheduled for monitoring at 3 to 6 month intervals for 12 months.
1)      Beverage survey
a.       S-ECC drank juice particularly btwn meals and drank milk at mealtimes vs caries-free children
b.      after tx – more children without new lesions drank milk btwn meals at baseline than did children with new lesions
2)      Food frequencies
a.       S-ECC consumed more food and beverage items a day and more frequently than did caries-free children
b.      no difference in baseline food frequencies btwn children w/ different post-op outcomes
c.       More S-ECC than caries-free reported bedtime snacks
d.      Vice-versa – more caries-free children reported no snacks or beverages during the night than S-ECC
3)      Putative Food Cariogenicity
a.       No difference for consumption of foods categorized as caries protective, non-cariogenic, or low in cariogenic potential
b.      S-ECC higher than caries-free for food or beverage cariogenicity
c.       Children without new lesions ate more putative caries-protective foods at baseline than children with new lesions

4)      Microbiology
a.       S. mutans, S. sobrinus, and Bifidobacteria detected more frequently in S-ECC than caries-free children
b.      Mean putative food cariogenicity elevated in children with S. mutans (but no other species)
1)      Findings of stronger association of between-meal juice and S-ECC compared with mealtimes juice and other beverages consistent with research indicating beverage intake during meals not a major risk factor
2)      S-ECC children without new lesions drank more milk between meals than those with new lesions consistent with suggested caries-protective properties of milk
3)      Food or beverage frequencies were independently associated with S-ECC
4)      Eating at bedtime and snacks during the night showed strong association with S-ECC (most caries-free children reported no nighttime snacks or beverages)
5)      Liquid and solid retentive sugars and starch/sugar combinations each significantly associated with S-ECC
6)      Children with new lesions reported lower intake of putative caries-protective foods at baseline consistent with controlled animal studies showing cariostatic effect of certain foods
7)      S. mutans and S. sobrinus significantly associated with S-ECC and with development of new lesions, particularly when detected together
1)      Obtaining accurate diet history is difficult – survey and analysis in this study not tested for reliability and validity
2)      Loss of follow-up of S-ECC children
Treatment for and prevention of S-ECC should include attention to putative food frequency, putative cariogenicity, and suppression of cariogenic bacteria
1.     Results seem to corroborate findings from previous studies, however confounding factors such as Fluoride exposure of the different group and compliance with preventive measures were not accounted for. For argument sake is it possible that the same patients that did not change their diet, not complied with preventive fluoride regimens were the ones that had more caries in the post op recalls (very likely!)..
2.     The diet data was based on one day only. No weekend! Many people change their diet over the weekend...
3.     The remarkable finding in this research is not in their findings per-se (no news), it's in the fact that one the diet diary was sufficient to differentiate between the groups. This results should be repeated in different practise and population/ cultures to verify their validity.
Assessment of Article:  Level of Evidence/Comments:  II-3


Wednesday, August 24, 2016

The role of chlorhexidine in caries prevention

The role of chlorhexidine in caries prevention

Resident: Semantha Charles 
Title: The role of chlorhexidine in caries prevention.
Authors: Autio-Gold, J.
Journal: Oper Dent (2008) 33(6): 710-716.

Main Purpose: To determine whether chlorhexidine should be prescribed to prevent caries.

Background: The use of chlorhexidine for caries prevention has been controversial. In several reviews it has been concluded that the most persistent reduction of mutans streptococci have been achieved by chlorhexidine varnishes, followed by gels, and lastly mouth rinses. Currently the only chlorhexidine containing products in the US are mouthrinses.

Methods: A search of literature was carried out using PubMed and Evidence-Based Medicine Reviews. The search included systematic reviews and randomized clinical controls that were done on humans, in English, and reviews. 55 articles were found with the keywords “chlorhexidine” and “caries”, and 3 focused specifically on chlorhexidine and caries prevention. A second search using the additional keyword “rinse” revealed 7 articles, with 3 papers focusing on chlorhexidine.

Key Points:
- Earlier studies of chlorhexidine rinses show low-to-moderate reduction of S mutans in plaque and saliva, but none-to-moderate caries-inhibiting effects when compared to placebo treatment.
- A second article concluded that daily rinse with 0.25% NaF solution reduced caries more than 0.12% chlorhexidine rinse.
- 1 article focusing on gels showed significant reduction in dental decay in high caries risk children. However, a recent study concludes that there is limited evidence on the effectiveness of chlorhexidine gels and rinses in preventing caries.
- Chlorhexidine varnish has been shown to reduce the number of S mutans in several studies, although there has been no statistically significant reduction in caries with chlorhexidine varnish.
- Based on the available reviews, chlorhexidine rinses are not highly effective in preventing caries. Due to the current lack of long-term clinical evidence for caries prevention and reported side effects, chlorhexidine rinses should not be recommended for caries prevention.

The number of papers that had studied the link of chlorhexidine and caries limited this review article. More work needs to be done to definitively determine whether chlorhexidine is effective in preventing caries. Currently, there is not enough information to warrant the use of chlorhexidine to prevent caries.  

This is the first time that I had heard of using Chlorhexidine rinse as a means to caries prevention.I often prescribe it in the following circumstances.

1.) The patient has severely inflamed gingiva and is willing to improve home care significantly. The CHX helps decrease the swelling of the gingiva thereby killing many of the bacteria as well as making it less painful for the patient to brush and floss as the gums begin to heal.
2.)  The patient has moderate to severely inflamed gingiva and will be having OR tx. The CHX will help decrease the erythema so that composites can be done with a lesser degree of bleeding.
3.) The patient has deep pocketing and or heavy calculus or moderate forms of each but has other chronic disesaes such as heart disease or diabetes. I usually prescribe it for at least 3 months. Hopefully during this time the patient will be able to improve home care as well as receive SRP as needed.
4.) If a patient has underlying chronic diseases such as heart disease or diabetes, I may prescribe CHX if I anticipate several extractions either in office or under GA.

Mutans Streptococci: Acquisition and Transmission

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Nicholas Paquin                                                               Date: 08/17/2016
Attending: Dr. Rodenas

Article Title: Mutans Streptococci: Acquisition and Transmission
Author(s): Roberrt J. Berkowitz, DDS
Journal: Pediatric Dentistry
Date: 28: 2/2006
Major Topic: Strep mutans colonization in predentate infants
Type of Article: Conference Paper
Main Purpose: To show predentate infants can acquire step mutans and new strategies to delay/prevent early colonization will be helpful
Key Points: (2 lines Max): Predentate infants have been shown to harbor MS, prevention of transmission is key to reduce risk of ECC in infants.
-        Dental caries is an infectious and transmissible disease and step mutans (MS) are most strongly associated with dental caries.
-        Early studies indicate that infants acquire MS from their mothers and only after primary teeth are present.
-        Recent studies have shown that MS can colonize predentate infants via horizontal (siblings/classmates) and vertical (caregiver to child) transmission, usually in the furrows of the tongue.
-        Early acquisition of MS is a major risk factor for early childhood caries and future caries experience. Alaluusua and Renken completed a longitudinal study on Children who harbored MS in their plaque at age 2 had the most caries by age 4. The mean decayed, missing, and filled primary tooth surface (dmfs) scores in these children was 10.6, whereas in children in whom colonization occurred later the mean dmfs score was 3.4 at age 4.
-        Knoweledge of increased risk of caries by early colonization of MS combined with the fact that MS can colonize predentate infants requires better prenatal counseling and prevention techniques to limit caries.
Remarks from St. Joe’s Alumna (Dr. Christa): Salutations everybody!!!! Miss you all; wish I had you in my pocket, Dr. Sapir! :0)

This article sheds light on the importance of educating expecting mothers about going to the dentist for preventative visits and restoring any carious teeth before their babies are born. In the state of Rhode Island, the state’s Medical Assistance program will provide low-income mothers with dental insurance during and a few months after the pregnancy. Many mothers may not take advantage of this service, as they may not receive the proper information regarding oral health and caries prevention from their OB/GYN. Thus, it is important that the dental community starts fostering a stronger relationship with obstetricians so as to educate them and in return, they can provide the necessary dental preventative information to their patients.