March 2019 Volume LIV Number 2


Resident's Corner

March 2018 Volume LIII Number 2

Attention on Prevention: Averting the Epidemic of Early Childhood Caries

Tucson, Ariz., lies just over an hour north of the Mexico-United States border, and is home to an astonishingly high rate of dental caries. My fellow residents and I struggle to combat this epidemic of early childhood caries at El Rio Health in Tucson, one of the largest non-profit community health centers in the United States. Accord- ing to the Centers for Disease Control and Prevention, data from the most recent National Health and Nutrition Examination Survey for the years 1999-2004 indicate that approximately 75 percent of third graders in Arizona have experienced dental caries.1 I feel our patient population at El Rio exhibits a much higher rate than Arizona’s aver- age. Unfortunately, a mouth without caries or restorations is something I infrequently see.

Significant barriers in decay prevention contribute to the high caries rate in the Tucson community. Tucson remains one of the six major U.S. cities without optimally fluoridated community water, as there is no added fluoride. Naturally occurring fluoride in the local wa- ter varies, but is approximately 0.4 parts per million. This is well under the recommended 0.7 ppm for prevention of dental caries. Along with suboptimal fluoride, diet plays a significant role in caries rate in the Tucson community. Local favorites like hot Cheetos, Takis (mini rolled tortilla chips), soda, and fry bread contribute to the high prevalence of caries in the area. Many family members also believe that "milk teeth don’t matter", making it difficult for the provider to motivate patients, change habits, and propose multiple time-consuming appointments for comprehensive dental treatment. In the Tucson area, it is also common to see patients raised by a community of extended family, making diet and oral hygiene instruction difficult to relay for compli- ance and consistency. Reliable transportation for families can also be a challenge, reducing show rates for dental appointments. Lastly, from a public health standpoint, there is currently no coverage through Arizona Medicaid for sealants on primary teeth.

Because of these barriers to decay prevention, we have found in-office fluoride varnish application essential in reducing the caries progression in our patients at El Rio. For higher risk patients, we increase the recall frequency to every three months with fluoride ap- plication. This has shown benefits in reducing the progression of and remineralizing incipient lesions. In the last couple years, silver diamine fluoride (SDF) has proven to be a game changer in our clinic to arrest and prevent caries. Along with its initial antimicrobial action, the bacteria killed by silver ions can act as a reservoir to continue fighting off cariogenic bacteria.2 Unlike conventional restorative methods that may develop secondary caries, SDF strengthens the infected dentin, making it more resistant to the biofilm of cariogenic bacteria. In terms of restorative treatment, stainless steel crowns can be looked upon as a preventative measure as well by providing full coverage protection in a high caries risk patient with decay, and is a widely accepted treatment in Tucson’s pediatric population. Finally, and most importantly, estab- lishing a Dental Home and increasing access to care is fundamental in the prevention of dental caries.

Although my experience may be different from other residents, we are all fighting the same uphill battle with caries. It is the most frequent chronic childhood disease—and frustratingly, avoidable! While each community may have its unique challenges, the future of our profession must be centered on prevention of this disease process.

1 Centers for Disease Control and Prevention: National oral surveillance system: oral health indicators (website). nohss.html. Accessed January 3, 2018.
2 Wakshlak RB-K, Pedahzur R, Avnir D. Antibacterial activity of silver-killed bacteria: the "zombies" effect. Sci Rep. 2015;5:9555. doi: 10.1038/srep09555.

Dr. Sofia Kennel is a first-year pediatric dental resident at NYU Langone Hospitals, Pediatric Dentistry Residency-AZ, Tucson site. She was born and raised in Phoenix, Ariz., and completed her undergraduate education at The University of Arizona in Tucson, Ariz., majoring in Physiology and Business Administration. She graduated from The University of Washington School of Dentistry in 2015 and practiced in the Seattle area prior to residency. When she’s not fighting sugar bugs, she enjoys hiking, photography and cheering on her Arizona Wildcats.

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