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Pediatric Oral Health - A Medical Solution

Physicians and Dentists must talk

It has been 10 years since the US surgeon’ General called for interdisciplinary training between healthcare providers, and this was reiterated in a recent IOM report saying it is time for dentists and physicians to work together (1)

A study was presented to IADR in 2011 linking dental disease to increased body weight in a study of 4,537 patients at the University of Pittsburg. Many other studies have shown the associations between poor oral health and general health, increasing risk for heart attack (2), stroke, arthritis, diabetes (3), and inflammatory conditions.

We know periodontal disease increases the risk of pre-term birth for a pregnant mother, so it seems obvious that OB-GYN physicians should talk with patients about oral health (5). For a child to enjoy a lifetime of wellness, this conversation must begin early – even before birth and before teeth erupt (6).

Transmission of Dental Disease:

Dental caries is a bacterial infection that is shared as bacteria spread from a parent’s mouth to children. Newly erupting teeth are easily infected, although preventing this infection will offer profound and long-term health benefits for a family. Children born by cesarean section are at greater risk for this infection, a finding most likely explained by the fact that bacteria from the birth canal provide protection against strep.mutans infection.

Dental disease will be controlled most easily if protocols are explained to parents before the disease has transmitted to the baby. This means the message must be delivered during pregnancy or at early “well child” pediatric visits. Parents most often seek advice from a dentist too late - after cavity-producing bacteria have caused damage.

Preventing Transmission:

Ultimate oral health is a mouth without infection, without inflammation, and without any loss of tooth structure or strength. Teeth are comfortable, do not become weak, damaged or painful. In a healthy mouth a thin layer of proteins, called a pellicle or biofilm, covers the surface of teeth to protect them from chemical, thermal and biological assault. Healthy biofilm is the powerful protector that prevents teeth being damaged by decay-producing bacteria (7).

Plaque and Caries:

Extreme mouth dryness or acidity, certain abrasives, and even ingredients in toothpaste and medications, have the potential to disrupt this protective layer. Without healthy biofilm, teeth are vulnerable to infection and damage. When this protective layer is damaged, cariogenic bacteria have the capacity to grow and multiply on teeth, sticking to their surface with glycoprotein strands, to form a visible known as dental plaque (8). Acidogenic bacteria in plaque derive energy from carbohydrates in the diet, and the acids they produce diffuse into teeth to weaken the underlying enamel.

Tooth Eruption:

Oral bacteria quickly colonize erupting teeth and studies show that the first bacteria to colonize grooved and fissured teeth become the dominant strain of strep. mutans in the mouth (9). Ensuring a healthy oral flora prior to the eruption of molar teeth (primary and adult) is vital for oral health as it has been shown to reduce a child’s chance of tooth decay by up to 80%. This method of caries control is less costly than sealant placement and may be more appropriate for communities with limited access to care (10).

A Healthy Flora as Teeth Erupt:

Pediatric studies show that children with decay in primary molars at age 4 are 85% more likely to have a lifetime of damage in their permanent dentition. Knowing the importance of infection during eruption explains why this is so. Permanent molars erupt during the fifth year of life and if grooves of these teeth become infected, damaging bacteria will colonize the grooves and dominate the oral flora. The concept of cultivating a healthy oral flora before adult molar eruption (1-6 years of age) is of extreme importance and can reduce the chance of caries by 80% (11).

Developing a Healthy Oral Flora:

Evidence-Based studies show that 5-10 grams of xylitol daily will eliminate 98% of disease-causing bacteria from the mouth and promote a healthy, non-infected biofilm on teeth within 6 months (12)(13). Xylitol is available in grocery stores, on the Internet and in health and nutrition stores. Xylitol can be offered to children in many forms such as chewing gum, mints, candies, sprays, lollypops, gels etc. The most cost-effective method is using granular xylitol eaten off a spoon or dissolved in water as a drink. This drink can be sipped by a child -in a baby bottle or Sippy cup to provide small, frequent applications of xylitol to teeth.

The application of xylitol should begin as early as possible, preparing the mouth before teeth erupt. This regimen should continue until all permanent teeth have erupted. Xylitol is anti-fungal and can prevent thrush and other mouth infections. Studies show that this amount of xylitol can also lower a young child’s risk of Otitis Media by 42%. (14)

Oral Health Education:

OB-GYN, Primary Care Physicians and Pediatricians have access to parents and children at the critical stage before oral disease is established in the mouth. Education about how to develop a healthy mouth should be delivered before or during pregnancy and repeated during the early years of life. This health education has the potential to impact and improve the oral health of the mother (reducing the risk for pre-term birth) and also to reduce the risk of cavities in the child’s teeth (15).

Application of xylitol to a baby’s gums or incorporated into the diet can ensure development of a healthy biofilm as teeth erupt to prevent Early Childhood Caries (ECC). This offers a solution to the problem of poor oral health that has plagued some families for generations.

References:

  1. The Surgeon General’s Report: http://www.surgeongeneral.gov/library/oralhealth
  2. The American Academy of Periodontology Report on the connection between periodontal disease and heart health www.perio.org/consumer/mbc.heart.htm
  3. The American Academy of Periodontology Report on the connection between periodontal disease and diabetes www.perio.org/consumer/type2-diabetes.htm
  4. M.K. Jeffcoat J.C. Hauth and N.C. Geurs. Periodontal Disease and Pre-term Birth: results of a Pilot Intervention Study.” Journal of Periodontology 74 (2003): 1214-18
  5. The American Academy of Periodontology Report on the connection between periodontal disease and pregnancy www.perio.org/consumer/pregancy.htm#2
  6. Michalowicz BS et al. “Treatment of Periodontal Disease and the Risk of Preterm Birth.” New England Journal of Medicine 355 (2006): 1885-94.
  7. Anderson MH, Shi W. “A Probiotic Approach to Caries Management”. Pediatric Dentistry 28 (2006): 151- 53
  8. Keene HJ, Shklair IL. “Relationship of Streptococcus Mutans Carrier Status to the Development of Carious Lesions in Initially Caries-Free Recruits.” Journal of Dental Research 53 (1974):1295
  9.  “Symposium of the Prevention of Oral Disease in Children and Adolescents.” Conference Papers. Pediatric Dentistry 28 (2006):95-191
  10. Hildebrandt GH, Sparks BS. “Maintaining Mutans Streptococci Suppression with Xylitol Chewing Gum.” Journal of the American Dental Association 131 (2000): 909-16
  11. Marsh PD, Bradshaw DJ. “Microbial Community Aspects of Dental Placque.” In H.N. Newman and M. Wilson eds. Dental Plaque Revisited: Oral Biofilms in Health and Disease ( Cardiff: BioLine, 1999), 237-53
  12. Milgrom P. et al. “Mutans Streptococci Dose Response to Xylitol Chewing Gum.”Journal of Dental Research 85 (2006):177-81
  13. Hayes C. “The Effect of Non-Cariogenic Sweetners on the Prevetion of Dental Caries: A Review of the Evidence.” Journal of Dental Education 65 (2001): 1106-09
  14. http://www.med.umich.edu/pediatrics/ebm/cats/xylitol.htm
  15. Marsh PD. “Microbial Ecology of Dental Plaque and Its Significance in Health and Disease.” Advances in Dental Research 8 (1944): 263-71