Walking into dental school, I dreamed of changing the world. Walking out, I had been trained to repair teeth and make a great smile. Where was the disconnect?! My dental training was excellent and my Class II box was a work of art. Looking back over the better of two decades, there was no discussion that the entire body is connected to and influenced by the mouth and vice-versa. After fifteen years of repairing teeth and paying lip service to prevention, I was not able to stomach the thought of another restoration without addressing the complete health of the child sitting in my chair.
What could I do to take this child that was suffering from oral disease and change their life, without picking up a handpiece? I knew that if we wanted to truly become preventive that we needed a better system. Parents are frustrated and tired of repairing cavities in their children’s mouths. According to the CDC, more than half of children six to eight years old have had at least one cavity in their primary teeth and more than half of children from 12 to 19 years old have a cavity in their permanent teeth. This accounts for 34 million hours of school missed and an estimated 45 billion dollars in lost productivity in the workforce. Children are unable to concentrate in school, sleep at night, etc., all of which lead to unhealthy children that turn into unhealthy adults. From the AAPD, “the consequences of Early Childhood Caries often include a higher risk of new caries lesions in both the primary and permanent dentitions, hospitalizations and emergency room visits, high treatment costs, loss of school days, diminished ability to learn, and diminished oral health-related quality of life.”
I love the phrase “the absence of disease is not health.” So, how do we move from a society that waits for disease to manifest to a society that prefers to manage things before they create a problem?
The ADA has recognized that caries is a complex multifactorial disease where “drill and fill” is not adequate control. To address this, the advent of Caries Risk Assessments (CRA) has taken shape over the years. On quick examination, I found eighteen different CRA options all with varying ideas. Featherstone’s research says that no one knows which is best, and predictably, the provider will have to be the one that decides what to use and how.
As a dental professional we were all taught the caries balance between protective and pathological factors. Everything from buffer capacity and adequate saliva flow on one end to cariogenic bacteria and frequent carbohydrates on the other.
In my practice, in an effort to assess risk and prevent disease, we incorporated the assessment we felt best fit our situation with an interesting modification (which incidentally Featherstone alluded to).
Objective and subjective risk assessment items were the hurdle we needed to cross. The subjective information would be everything the parent tells us, accurate or not! The objective items were always the usual: recent restorations, white spots, etc. How do we impart this information that shows risk for disease to a person that is not familiar with oral disease or is not interested? That is where saliva testing in our facility came into play. By showing data with actual measurements, or criteria, we have been able to engage more parents and caregivers in a way that captured their attention. The two methods we use involve either a swab of the lingual surface of the mandibular anteriors (for our non-cooperative patients) or collecting a small volume of expectorated water. The swab gives us a relative acid content of the plaque in that area, and the expectorated water shows relative levels of cariogenic bacteria, acidity, buffer capacity, protein, blood, leukocytes, and ammonia. This shows caregivers a number that takes a vague, nonspecific discussion into a more concrete discussion that opens doors that we previously were not aware existed.
We now have the option, especially with the expectorant test, to discuss caries risk, inflammation, and relative biome content of the oral cavity and how that can affect the rest of the body.
As a pediatric dentist I deal with children for the most part, but unfortunately children come with baggage. They are called parents. Fortunately, most parents truly do want the best for their children, but dentally, they generally do not know what that is.
The microbiome of a child, depending on C-section or vaginal birth, will be similar to the parents during the first year of life. Beyond the first year we start to see deviation as more foods are introduced. Why are we waiting until the parent, especially if they have an unhealthy oral microbiome, transfers that microbiome to the child? The AAPD recommends we see every child six months after the eruption of the first tooth or by age one. That works great if we have parents that are healthy with a healthy microbiome feeding their child the proper foods, etc. That also works if we have all the medical/dental providers providing the necessary information to the parents at the appropriate times. We as dental professionals need to step up and demand this to truly prevent future health issues plaguing both children and adults from day one.
Why are we not screening parents prenatally to try and alter what bacteria they are going to transfer to the next generation? As I do not have a large number of women who are pregnant coming to my office, this screening will require a collaboration between pediatric and general dentists along with pediatricians, obstetricians, and any other medical or dental providers they see.
In addition, we will be able to screen for oral inflammation which has been linked to low birth weight, premature labor, and other pregnancy issues. While the initial screening gives relative information on caries risk and inflammation, it is low cost and gives results in less than five minutes. This info can catapult at-risk individuals into more definitive testing for specific results.
With the subjective and objective clinical data, along with salivary information, we have been able to discuss risk, behavior, and track the progress of the interventions we are using. Each child we see is unique, and in a unique situation, so placing a blanket prevention program does not work.
With the conversation open and the discussion with parents taking more of a concrete approach, now we are able to discuss the root issues that are causing the decay, inflammation, etc. Counseling on diet, issues with salivary flow due to medications, nasal versus mouth breathing, inflammatory status and sleep disordered breathing are just the start of where the conversations have now moved. Early referral to pediatricians for children that are showing high inflammation in the salivary screening can now be evaluated for obesity, prediabetes, SDB, UARS, and the list goes on.
We now see traction with involving whole family discussions on diet modification to improve health for the family unit versus focusing on single children. No longer does the phrase, “grandma/grandpa/random person at the store gives them candy all the time” work.
To wrap this all up…I have heard the question, “Are you “preventing” yourself out of a job”? If only this were a real possibility!
Let’s assume that we can completely eradicate decay. What would people do with that estimated forty-five billion dollars in lost productivity? Realistically, we are setting ourselves up to be the “go to” place for oral health!
Just imagine this: Healthy patients, Healthy practice, Healthy baseline.