Oklahoma State Department of Health 01-2018 Revised

DENTAL CARIES (TOPICAL VARNISH)

I. DEFINITION: Dental caries is the decay of structure due to bacterial activity. Early childhood caries (ECC) is a chronic, infectious disease affecting children under the age of 6 years. The upper incisors (front teeth) and primary molars are the most susceptible to ECC. Dental caries in children may interfere with eating, talking, and learning. Left unchecked, dental caries can destroy teeth and lead to pain and infection.

II. ETIOLOGY:

Dental caries have a complex etiology involving many factors, such as high bacterial load in the mouth, high consumption of carbohydrates, frequent feedings of long duration, poor oral hygiene, decreased saliva, and a susceptible tooth. Progression is variable; however primary teeth may decay at a rapid rate in comparison to permanent teeth.

III. CLINICAL FEATURES:

A. Normal dentition: White teeth properly spaced with no signs of decay.

B. Early caries: Chalky white lesions or spots often along gingival margin, incipient lesions and pre-cavitated lesions. May be reversible.

C. Dental caries: Can range from minimal yellow/brown lesions to multiple brown lesions, rampant , and abscesses.

IV. NURSING ASSESSMENT:

Conduct an oral health risk assessment. Use ODH 1274, Oral Health Assessment Tool to document the oral health findings and application of topical fluoride varnish. The children who benefit most from fluoride varnish (FV) are those with the highest risk for dental caries. A child is at risk for caries if one or more risk factor is met:

A. Mother/primary caregiver or siblings with dental disease

B. Mother/primary caregiver has no dental home

C. Mother/primary caregiver neglects to care for child’s teeth

D. Lower socio-economic status

E. Sleeps with a bottle containing liquids other than water

F. Continual use of bottle or sippy cup after age 1 year with liquids other than water

G. Frequent snacking or drinking of high cariogenic substances (carbohydrates/sugar)

H. Frequent use of high sugar oral medications

I. Child with special health care needs or premature child

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J. No dental home or limited access to dental care

K. Non-fluoridated drinking water

L. Defective teeth observed

M. Plaque on teeth observed (poor oral hygiene)

N. White chalky areas or decalcification of teeth observed

O. Dental decay observed or dental restorations observed

V. MANAGEMENT PLAN:

A. Anticipatory Guidance

Provide counseling to mother/primary caregiver on proper diet, proper feeding techniques and oral hygiene practices to prevent dental caries. Advise clean/brush teeth twice daily (tiny rice-sized fluoride toothpaste for children under age 2 years; small pea-sized fluoride toothpaste for children over age 2 years who can spit; toothpaste is not meant to be swallowed by children), wean off bottle by age 1 year, limit juice, only water in sippy cup, drink from tap, no soda or sport drinks for young children, healthy snacks, and find dental home. Relate that FV is used to prevent, reverse and arrest tooth decay.

B. Treatment

The optimal frequency of FV applications has not been firmly established and depends on the professional’s determination of risk for dental caries. It is recommended that children between the ages of 6 months and 18 years, with at least one risk factor, receive FV minimally two times per year. For children determined to be at high risk, the applications may be given every 3 months. To prevent ECC, the primary focus group is children under the age of 6 years.

1. Fluoride Varnish

a. FV single unit dosage packets. b. 5% (2.26% fluoride ion). c. Choose appropriate dosage (generally, 0.25 ml for children under age 6 and 0.5 ml for older children).

2. Contraindications

Contraindicated when ulcerative gingivitis/ is present or with known sensitivity to product ingredients. There are no confirmed allergic reactions to fluoride. FV should not be applied to large open lesions.

3. Adverse Reactions

Teeth may appear golden/yellow due to coloration of some varnishes. Adverse events are very rare. Edematous swelling, dyspnea and nausea have occurred. FV can be removed by brushing the child’s teeth.

C. Application Procedure:

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1. Pre-application a. Position the child (consider knee-knee for babies/toddlers). b. Lift the lip and assess the child’s dentition and oral mucosa. c. Consult eruption chart tables for guidance, if needed. (Tables 1 and 2) d. Open FV packet and mix varnish with applicator e. Wipe the teeth with gauze, in areas, prior to application.

2. Application a. Follow manufacturer’s instructions. b. Apply FV by painting a thin layer to all surfaces of dried erupted teeth. c. Be aware of most susceptible teeth: For ECC, upper anterior teeth and primary molars. For older children, permanent molars and gingival margins. d. FV will adhere to teeth and harden when comes in contact with saliva.

D. Post-application Instructions

1. May resume eating and drinking immediately, however – eat a soft diet, avoid hard or sticky foods, and avoid hot liquids for remainder of day. 2. Do not brush teeth for 4-6 hours. If possible, leave varnish on teeth until brush off the next morning.

E. Follow-up

1. Apply FV minimally two times per year. 2. Applications may be given during well child check-ups.

F. Referral

1. Encourage parents to seek a dental home for their child. 2. If carious lesions are observed, refer to a for treatment.

REFERENCES:

American Academy of Pediatrics, Oral Health Risk Assessment Tool (2011). Retrieved from https://www2.aap.org/oralhealth/docs/RiskAssessmentTool.pdf American Association of State and Territorial Dental Directors, Fluoride Varnish: an Evidence-Based Approach Research Brief (2014). Retrieved from http://www.astdd.org/docs/fl-varnish-issue-brief-9- 10-14.pdf American Dental Association Center for Evidence-Based Dentistry (2013). Topical fluoride for caries prevention full report of the updated clinical recommendations and supporting systemic review. Retrieved from http://ebd.ada.org/~/media/EBD/Files/Topical_fluoride_for_caries_prevention_2013_update.ashx Chou, R., Cantor, A., Zakher, B., Mitchell, J. P., & Pappas, M. (2014). Prevention of Dental Caries in Children Younger Than 5 Years Old. Clark, M. B., Slayton, R. L., Segura, A., Boulter, S., Gereige, R., Krol, D., ... & Keels, M. A. (2014). Fluoride use in caries prevention in the primary care setting. Pediatrics, 134(3), 626-633. Douglass, A. B., Clark, M. B., & Maier, R. (2010, modified 2015). Smiles for Life: A National Oral Health Curriculum. Retrieved from http://www.smilesforlifeoralhealth.org/buildcontent.aspx?tut=584&pagekey=64563&cbreceipt=0 Final Recommendation Statement: Dental Caries in Children from Birth Through Age 5 Years: Screening. U.S. Preventive Services Task Force (2014). Retrieved from http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/dent al-caries-in-children-from-birth-through-age-5-years-screening

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Fluoride Varnish: An Effective Tool for Preventing Dental Caries (2010). National Maternal and Child Oral Health Resource Center, Georgetown University. Retrieved from http://mchoralhealth.org/PDFs/ResGuideFlVarnish.pdf Tucker J, Barzel R, Holt K, Siegal M. (2009). Caries Prevention, Risk Assessment, Diagnosis, and Treatment. Washington, DC: National Maternal and Child Oral Health Resource Center. Weyant, R. J., Tracy, S. L., Anselmo, T. T., Beltrán-Aguilar, E. D., Donly, K. J., Frese, W. A., ... & on Scientific, A. D. A. C. (2013). Topical fluoride for caries prevention. The Journal of the American Dental Association, 144(11), 1279-1291.

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TABLE 1

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TABLE 2

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