Category Page: Oral HP for Children & Youth

Over the past three decades there has been significant decline in the dental decay rates for children and adolescents. Nevertheless, dental decay is still by far the most common chronic childhood disease, and is most severe in children from lower socio-economic backgrounds who also have the least access to preventive and treatment care.

In order to improve health outcomes and to provide access to care for children and adolescents, there is a need for community-based, effective health promotion and disease prevention interventions.
School-based delivery of preventive dental services has been shown to be the most effective way of improving the oral health of children and adolescents on a community basis. Services that can be delivered in school-based programs include:

  • Oral hygiene education
  • Tooth brushing programs utilizing fluoride containing toothpaste
  • Screening, and referral to oral health professionals when indicated
  • Application of topical fluoride
  • Fluoride rinse programs
  • Pit and fissure sealants
  • Surveillance and monitoring the interventions for effectiveness

Topical flouride research evidence suggests that public programs such as school-based brushing and/or fluoride varnishes, gels or rinses can improve oral health outcomes, especially in high-risk children. Systematic reviews endorse the use of dental sealants for preventing dental decay in the permanent teeth of children and adolescents.

Resources

School-Based Delivery…

School-Based Preventive Dental Services

Dental decay is the most prevalent disease affecting children, with rates that are five times higher than asthma and seven times higher than hay fever.

The most effective way of assuring that preventive dental services are available to all children is to provide them within a school setting. Using school-based portable or fixed preventive dental clinics, services can be provided to all children universally or can be targeted to schools with a higher percentage of children who have a greater risk of dental disease.

Although there are no recent statistics on utilization rates for preventive dental services for children, they are quite likely close to the overall utilization rates for dental services, which according to most surveys are approximately 65-70%. The children who are not accessing preventive services are usually from lower income homes and tend to have higher rates of dental disease. School-based preventive services on the other hand can reach over 90% of school-aged children.

There are many advantages of providing preventive dental services within elementary, junior high and senior high schools.

  • Access to care – All children in the target age groups are available at schools, including the children who would be least likely to seek out services elsewhere.
  • Efficiency – School based services provide a steady flow of clients, with fewer slow-downs due to failed appointments, making the services more cost-efficient. Also, the services can be provided by the most effective and efficient dental professionals, working within their scope of practice.
  • Effectiveness – Through providing better access to care, especially for high-risk children, school-based services produce better health outcomes on a community basis.
  • Surveillance – The screening done in schools provides high quality data on the level of oral health, which helps in monitoring the outcomes of the services.
  • Risk assessment – School based services enable preventive services to be provided to children on the basis of individual risk of dental disease.
  • Parental and school support – Health units that provide school-based services report a high degree of support from parents and from school staff.
  • Referral for care – School-based services enable screening of nearly all children for dental disease, and referral to dental professionals for treatment.
  • Integration of health services – Services can be integrated with other health jurisdictions, enabling sharing of physical space and supporting a more holistic approach.
  • Health promotion/education – provision of oral health information and promotion can be facilitated by using which ever format is shown to be the most effective; One-on-one, small groups, or classrooms.
  • Educational advantages through:
    • Reducing disease rates so that children can learn better (through reduction of pain, etc.) and have less time missed from school for dental treatment appointments.
    • Less time missed from school for preventive appointments.

The services that can be included in school-based preventive clinics include risk-assessment screening, referral for treatment of dental disease, application of topical fluoride, pit and fissure sealants, oral health education, scaling and selective polishing.

Basic requirements for provision of school-based preventive services include:

  • Consent protocol – a method of acquiring informed consent for the provision of services.
  • Physical space – a room dedicated for the service, with adequate space, lighting, electrical outlets and sinks.
  • Portable equipment – services such as dental sealants or scaling require a dental chair, suction, light and hand pieces as well as sterilizing equipment.

Other considerations:

  • Functioning referral system – When dental disease is uncovered in a screening, it is important to have an effective referral system.
  • A good working relationship with private dentists within the community helps to facilitate referrals and understanding.

Evidence base

In the United States, the Association of State and Territorial Dental Directors (ASTDD) include “Improving Children’s Oral Health through Coordinated School Health Programs” as a topic area in its Best Practice Approaches for State and Community Oral Health Programs[1]. For the specific services provided in school-based clinics, ASTDD refers to the Guide to Community Preventive Services[2] which recommends school-based services based on results from systematic reviews[3].

An expert panel, established by the American Dental Association Council on Scientific Affairs, provided evidence-based recommendations on the use of professionally applied topical fluoride[4]. The panel recommended that periodic fluoride treatments (fluoride varnish or gel) be considered for children age 6-18 years who are at moderate or high risk of developing tooth decay. School-based services provide the best access to these moderate or high risk children. The recommendations were confirmed in a later report of the U.S. National Institute of Health in 2009[5].

References

  1. Association of State and Territorial Dental Directors Best Practices Committee. Best practice approach: improving children’s oral health through coordinated school health programs [monograph on the Internet]. Sparks, NV: Association of State and Territorial Dental Directors; 2010 Mar 5 [cited 2011 Jan 31].
  2. The Guide to Community Preventive Services. Oral Health [Internet]. Atlanta: Centers for Disease Control and Prevention; c2001-2011 [updated 2010 Feb 10; cited 2011 Feb 1].
  3. The Guide to Community Preventive Services. Preventing Dental Caries: School-Based or –Linked Sealant Delivery Programs [Internet]. Atlanta: Centers for Disease Control and Prevention; c2001-2011 [updated 2010 Sept 28; cited 2011 Feb 1].
  4. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. J Am Dent Assoc. 2006 Aug [cited 2011 Feb 2]; 137(8): 1151-9.
  5. Gooch BF, Griffin SO, Gray SK, Kohn WG, Rozier RG, Siegal M, et al. Preventing dental caries through school-based sealant programs: updated recommendations and reviews of evidence. J Am Dent Assoc. 2009;140(11):1356-65.
Topical Fluoride…

Topical Fluorides for the Prevention of Dental Decay

The topical application of fluoride, in the form of gel, foam, varnish, or fluoride rinses has been a standard preventive procedure for several decades. It has been shown to reduce dental decay by 20-40% in children at moderate to high risk (NNT= 2)[6] of decay. Although there is also a demonstrated benefit for low risk children as well, the cost-effectiveness of its application for low-risk children (NNT=24)[6] is questionable.

In the past, application of fluoride was associated with a dental prophylaxis, however there is good evidence that shows that a prophylaxis prior to fluoride application is not necessary and does not add to the effectiveness of the fluoride[7-9].

While dental sealants are most effective on occlusal surfaces of molar teeth, the main benefit of topical fluoride is on the smooth surfaces of all teeth.

Public programs, especially those that are school-based, can target topical fluoride applications to children from low-income families, Aboriginals and recent immigrants, who tend to have higher rates of dental decay and reduced access to these services. Targeting can be done for individuals through screenings within schools, or for entire schools according to the risk levels of the majority of students who attend them.

The various modes of application have different costs associated with them. Fluoride foams and gels are applied in a disposable tray, thus adding to material costs and greater environmental waste. Also, depending on how they are applied, they may require a suction unit. To achieve the maximum benefit, foams and/or gels are applied for four minutes.

Fluoride varnishes are becoming more widely used in public programs, because there is less need for equipment, materials and time for their application. Fluoride varnishes are equally as effective as foams and gels, and are well accepted by children of all ages.

Fluoride rinse programs are less costly than the other modes of application, as school-based weekly rinses can be conducted by school staff and they require minimal supplies. There is a difficulty, however, in maintaining an on-going commitment to carry them out. While two systematic reviews show that fluoride rinse programs have a pooled preventive fraction of 26% and 29% respectively, one of them emphasises the preventive benefit for high risk children[10] and the other suggests a lack of evidence for children otherwise exposed to fluoride in other forms, such as fluoride tooth paste[11].

Evidence for topical fluoride use for the prevention of dental decay

The application of topical fluoride has a good base of evidence of benefit for high risk children, though weak evidence for low-risk children. In a Cochrane systematic review, Marinho et al put the Number Needed to Treat (NNT) at 2 and 24 respectively and the pooled preventive fraction at 21-28%[6]. The same authors in another review[12], on the topical application of fluoride varnish found a DMFS (Decayed, Missing, Filled Surfaces – Permanent Teeth) pooled preventive fraction of 46% and defs (Decayed, Extracted, Filled Surfaces – Primary Teeth) pooled preventive fraction estimate of 33%.

When looking at topical fluoride in general, including tooth paste, topical gels or varnishes, or mouthrinse programs, Marinho et al[13] determined a pooled prevented fraction estimate of 26%, regardless of exposure to water fluoridation. The prevented fraction was higher for fluoride varnish, and lower for unsupervised home use compared with supervised community applications. At the same time, however, they found that a combination of fluoride regimens[14] compared to a single regimen such as tooth brushing with fluoride toothpaste produced a modest (pooled prevented fraction of 10%) over the tooth brushing alone.

Evidence for the application of topical fluoride through public programs

The U.S. Association of State and Territorial Dental Directors include “Improving Children’s Oral Health through Coordinated School Health Programs” [15] as a Best Practice Approach. In their evidence-based report, the use of fluoride varnish is one of the recommended strategies. Fluoride mouthrinse programs are also recommended as a Best Practice Approach by the ASTDD[16].

The systematic review by Marinho et al[14] comparing combinations of fluoride types with a single application stated that outcome results are better using supervised community applications as opposed to unsupervised home use. This would suggest that public programs such as school-based brushing and/or fluoride varnishes or gels would improve oral health outcomes.

Fluoride mouth rinse programs (mentioned above) have shown to be an effective method of reducing the decay incidence, however in order to be effective, they have to be done regularly and they need to be supervised. This is best done as a school-based procedure. The trials reported in the systematic review are from school-based settings.

References

  1. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride gels for preventing dental caries in children and adolescents. Cochrane Database of Syst Rev 2002, Issue 1. Art. No.: CD002280. DOI: 10.1002/14651858.CD002280.
  2. Brothwell DJ, Jutai DK, Hawkins RJ. An update of mechanical oral hygiene practices: evidence-based recommendations for disease prevention. J Can Dent Assoc. 1998;64(4):295-306.
  3. American Academy of Pediatric Dentistry. Guideline on the Role of Dental Prophylaxis in Pediatric Dentistry.
  4. Azarpazhooh A, Main PA. Efficacy of dental prophylaxis (rubber cup) for the prevention of caries and gingivitis: A systematic review of literature. Br Dent J. 2009 Oct 10; 207; (7).
  5. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database of Syst Rev 2003, Issue 3. Art. No.: CD002284. DOI: 10.1002/14651858.CD002284.
  6. Twetman S, Petersson L, Axelsson S, Dahlgren H, Holm AK, Källestål C, et al. Caries-preventive effect of sodium fluoride mouthrinses: a systematic review of controlled clinical trials. Acta Odontol Scand. 2004;62(4):223-30.
  7. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Syst Rev 2002, Issue 1. Art. No.: CD002279. DOI: 10.1002/14651858.CD002279.
  8. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database of Syst Rev 2003, Issue 4. Art. No.: CD002782. DOI: 10.1002/14651858.CD002782.
  9. Marinho VCC, Higgins JPT, Sheiham A, Logan S. Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical fluoride for preventing dental caries in children and adolescents. Cochrane Database of Syst Rev 2004, Issue 1. Art. No.: CD002781. DOI: 10.1002/14651858.CD002781.pub2.
  10. Association of State and Territorial Dental Directors Best Practices Committee. Best practice approach: improving children’s oral health through coordinated school health programs [monograph on the Internet]. Sparks, NV: Association of State and Territorial Dental Directors; 2010 Mar 5 [cited 2011 Jan 31].
  11. Association of State and Territorial Dental Directors Best Practices Committee. Best Practice Approach: Use of Fluoride: School-based Fluoride Mouthrinse and Supplement Programs [Monograph on the Internet]. Sparks, NV: Association of State and Territorial Dental Directors; 2003 Jun 16 [cited 2011 Feb 1].
Sealants…

Delivery of Pit and Fissure Sealants Programs

Pit and fissure sealants are a resin-based material used to seal off the deep pits and fissures on the occlusal (biting) surface of molars, and to a lesser extent on pre-molars and the lingual surface of incisors, from decay producing oral bacteria and sugars. They have been in use for three decades and have been well studied for their efficacy and effectiveness. Dental sealants are most effective when placed on the permanent molar teeth that are at a moderate or high risk of developing dental decay.

Although they are efficacious for use in private dental offices, pit and fissure sealants often are not available to the ¼ or 1/3 of the population that would benefit from them the most – children from lower income families who are not regular attendees for dental services (and tend to be more at risk of dental disease). Because of this, public delivery of dental sealants through schools or community health centres is advocated in order to reach those children who otherwise would not have access to them.

Features of a good sealant program

  • Maximizes effectiveness by providing sealants in locations of a population that is at a higher risk of developing dental decay – targeted to schools with a higher percentage of low-income, immigrant or Aboriginal students.
  • A recall system to monitor the status of the sealants and provide maintenance on them where necessary.
  • A referral protocol so that other treatment needs are attended to.
  • Sustainability – a track record of providing the services on an ongoing basis.
  • Maximizes efficiency by utilizing the best team make-up of oral health professionals, working within their scope of practice.

Evidence for dental sealants

There are systematic reviews that endorse the use of dental sealants as a preventive measure. A Cochrane review[17] on “Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents” stated that “Sealing is a recommended procedure to prevent caries of the occlusal surfaces of permanent molars.” School-based Dental Sealant Programs are also listed as a Best Practice of the U.S. Association of State and Territorial Dental Directors[18]. In designating it as a best program a thorough review of the literature was conducted and the recommendations coming from the review were a strong endorsement of providing resin sealants in school-based clinics.

In a review published in the Journal of the American Dental Association[19], all aspects of school-based dental sealant programs are covered.

References

  1. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Mäkelä M, Worthington HV. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database of Syst Rev 2008, Issue 4. Art. No.: CD001830. DOI: 10.1002/14651858.CD001830.pub3
  2. Association of State and Territorial Dental Directors Best Practices Committee. Best Practice Approach: School-based Dental Sealant Programs [Monograph on the Internet]. Sparks, NV: Association of State and Territorial Dental Directors; 2003 Jun 16 [cited 2011 Feb 1].
  3. Gooch BF, Griffin SO, Gray SK, Kohn WG, Rozier RG, Siegal M, et al. Preventing dental caries through school-based sealant programs: updated recommendations and reviews of evidence. J Am Dent Assoc. 2009;140(11):1356-65.

Subtopics

  1. Strategic Planning for Oral Health
  2. Dental Surveillance, Monitoring and Screening
  3. Oral Health Promotion and Integration of Services
  4. Oral Health Promotion for Vulnerable Populations
  5. Oral Health Promotion for Infants & Preschool Children
  6. Oral Health Promotion for Children and Youth

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