Prevention of Dental Disease
The patient between 6 and 12 years of age presents an interesting professional challenge for the dentist. At the beginning of this period, the dentist is dealing with a patient who continues to depend on the parents but is now thrust into a new environment—school—for approximately 8 hours a day. By the end of this period, the dentist is dealing with a patient who has gained partial independence from his or her parents and is nearly ready for junior high school and, in the case of the female patient, approaching womanhood.
In addition, all through this period a number of oral-facial changes are taking place. Most of the primary teeth will be replaced with permanent teeth during this period. The alignment and occlusion of the teeth are developing, and the “adult face” is emerging. What “I” look like becomes important, as does the opinions of others, especially peers.
Diet and dietary practices are severely challenged by the educational environment and social pressures both during the day and after school hours. Requirements vary from year to year in this period. Prevalence of obesity increases greatly as opportunities to purchase high calorie foods in schools, vending machines, and convenience stores may be combined with reduced physical activity. As the growth pattern of the patient changes from slow progressive physical growth early in the period to substantial physical growth at the end of the period, the requirements of the child must stay in tune. These dietary requirements depend not only on growth and development but also on the level of physical and mental activity engaged in by the child. Snacking becomes a common practice during this period and children are constantly prompted to think about food and eating.
Many changes in manual dexterity take place during this period. Although continuing gross motor development prevails, this is the period when fine motor skill begins to mature. Luckily so, because during this period the child is challenging the parents for independence, especially in areas of personal hygiene, clothes selection, and dietary choices. Conflicts emerge between the parents’ desires and the child’s wishes. It is a time when parents must have a strong daily influence on all types of activity, including oral care. With eruption of the permanent teeth, topical fluoride needs take on added importance. Periodic assessments and input by the dentist is important so that the child receives the optimal protection available.
The period from 6 to 12 years is extremely important with regard to fluoride administration for three major reasons: (1) the crowns of many permanent teeth continue to form during this period, (2) the posterior permanent teeth erupt and are at greater risk for developing caries until the process of “posteruptive maturation” has occurred, and (3) the child becomes increasingly responsible for the maintenance of his or her oral health. For the child at highest risk for caries the optimal use of selected fluoride therapy should be employed to provide protection during this first phase of carious attack on those teeth that will constitute the permanent dentition.
Studies suggest that a substantial portion of the anticaries protection provided by water fluoridation in humans occurs during the preeruptive period.1,2 Additional studies in laboratory animals have reported that daily doses of fluoride administered via gastric intubation during the period of tooth formation reduced the incidence of caries in these teeth after eruption.3 Because systemically acquired fluoride may be deposited and redistributed in developing teeth during the mineralization phase as well as during the subsequent period before eruption, current recommendations call for systemic fluoride supplements for children at high risk of developing caries and residing in areas where the water is fluoride deficient until they reach the age of 16 years.4 This protocol should help to ensure maximum protection for the posterior teeth, which are more vulnerable to carious attack. Supplemental fluoride dosages remain constant for children between the ages of 6 and 16 years.
During the period from 6 to 12 years of age, the child should become increasingly responsible for the maintenance of his or her oral health. Many forms of topical fluoride are appropriate for children in this age group, including fluoride toothpastes, fluoride mouth rinses, and concentrated fluoride preparations for professional and home application.
Accumulating evidence continues to support the effectiveness and importance of frequent application of agents that contain relatively low concentrations of fluoride. The two principal forms of these agents in the United States are fluoride toothpastes and fluoride mouth rinses (Figure 31-1).
The twice daily use of a fluoride-containing dentifrice should form the foundation of the child’s preventive dental activities. To maximize the effect of fluoridated toothpaste, rinsing after brushing should be kept to a minimum or eliminated altogether.5 Although many toothpastes include fluoride in their formulations, products that have obtained approval by the Council on Dental Therapeutics of the American Dental Association (ADA) should be recommended. Formulations of toothpastes that have not obtained ADA approval may impede the release of fluoride from these products, thereby compromising their effectiveness.5 Currently, approved fluoride toothpastes contain sodium fluoride (NaF) or sodium monofluorophosphate (MFP) as active ingredients. In the United States, the maximal allowable concentration of fluoride in toothpastes that have not received New Drug Approval from the Food and Drug Administration is 1100 parts per million (ppm).6 Parents should be advised that some over-the-counter products contain higher fluoride concentrations (e.g., 1500 ppm).
The use of fluoride mouth rinses increased considerably during the 1980s as a result of school-based mouth rinsing programs. The most popular preparations contain neutral NaF, although stannous fluoride and acidulated phosphate fluoride rinses also are available. Several fluoride mouth rinses, including many 0.05% NaF products, are available on an over-the-counter (nonprescription) basis.
Numerous clinical trials conducted in the 1960s and 1970s reported caries reductions in the 20% and 40% range among children in nonfluoridated areas who rinsed either weekly with a 0.2% NaF rinse or daily with a 0.05% NaF product.5 More recent studies, conducted since the overall decline in dental caries in children became evident, have reported that (1) the expected benefits from fluoride rinsing in terms of the actual number of tooth surfaces saved from becoming carious are generally less than previously reported, and (2) rinsing appears to have a greater effect in older children (10 years of age).5 Nevertheless, the observation that fluoride rinsing provides greater protection to erupting teeth during the time when rinses are being applied provides a rationale for their use in some 6- to 12-year-old age groups.
Rinses are particularly indicated for persons deemed to be at high risk for caries. Included in this category are those who lack the motivation or manual dexterity necessary to carry out effective oral hygiene procedures, patients who wear orthodontic appliances or prostheses that may complicate the process of plaque removal, and patients who have medical conditions that place them at increased risk. Examples of persons in the last group are patients undergoing head and neck radiation therapy, which may compromise their salivary flow, and patients who are required to take frequent doses of liquid or chewable medications that have high sugar content.
Applications of more concentrated forms of fluoride should be considered for persons who are at elevated risk for dental caries, including those who cannot or do not make optimal use of the high-frequency, low-concentration forms of fluoride therapy. Generally, this implies semiannual applications of concentrated fluoride gels or forms in the dental office. Fluoride varnish applications have also been suggested for Acidulated phosphate fluoride [high-risk patients (see Chapter 14).
Several fluoride gels and solutions, including combinations of acidulated phosphate fluoride (APF) and stannous fluoride, are available for home use. Practitioners should be aware that some of these products contain concentrations of fluoride that are similar to those found in fluoride toothpastes or over-the-counter rinses, and in most cases they have not undergone clinical testing. Some of these low-concentration products have also been advocated for professional application, but they are unlikely to be effective when used infrequently.7 Therefore the advantage of these less concentrated products over commercially available fluoride toothpastes and mouth rinses is questionable. More concentrated fluoride gels (0.5% acidulated phosphate fluoride [APF]) have been shown to be effective in reducing the incidence of caries and may be useful in high-risk patients with rampant caries.