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An Examination of the Advances in Science and Technology of Prevention of Tooth Decay in Young Children Since the Surgeon General's Report on Oral Health
Address correspondence to Peter Milgrom, DDS, Department of Dental Public Health Sciences, Box 357475, University of Washington, Seattle, Washington 98195-7475.
Northwest Center to Reduce Oral Health Disparities, University of Washington, Seattle, Wash (Dr Milgrom); Preventive and Community Dentistry, Oral Health Research Institute, Indiana University School of Dentistry, Indianapolis, Ind (Dr Zero); and Departments of Oral Health and Diagnostic Sciences and Pathology and Laboratory Medicine, University of Connecticut Health Center, Farmington, Conn (Dr Tanzer)
Northwest Center to Reduce Oral Health Disparities, University of Washington, Seattle, Wash (Dr Milgrom); Preventive and Community Dentistry, Oral Health Research Institute, Indiana University School of Dentistry, Indianapolis, Ind (Dr Zero); and Departments of Oral Health and Diagnostic Sciences and Pathology and Laboratory Medicine, University of Connecticut Health Center, Farmington, Conn (Dr Tanzer)
Northwest Center to Reduce Oral Health Disparities, University of Washington, Seattle, Wash (Dr Milgrom); Preventive and Community Dentistry, Oral Health Research Institute, Indiana University School of Dentistry, Indianapolis, Ind (Dr Zero); and Departments of Oral Health and Diagnostic Sciences and Pathology and Laboratory Medicine, University of Connecticut Health Center, Farmington, Conn (Dr Tanzer)
This paper addresses a number of areas related to how effectively science and technology have met Healthy People 2010 goals for tooth decay prevention. In every area mentioned, it appears that science and technology are falling short of these goals. Earlier assessments identified water fluoridation as one of the greatest public health accomplishments of the last century. Yet, failure to complete needed clinical and translational research has shortchanged the caries prevention agenda at a critical juncture.
Science has firmly established the transmissible nature of tooth decay. However, there is evidence that tooth decay in young children is increasing, although progress has been made in other age groups. Studies of risk assessment have not been translated into improved practice. Antiseptics, chlorhexidine varnish, and polyvinylpyrrolidone iodine (PVI-I) may have value, but definitive trials are needed. Fluorides remain the most effective agents, but are not widely disseminated to the most needy. Fluoride varnish provides a relatively effective topical preventive for very young children, yet definitive trials have not been conducted. Silver diamine fluoride also has potential but requires study in the United States. Data support effectiveness and safety of xylitol, but adoption is not widespread. Dental sealants remain a mainstay of public policy, yet after decades of research, widespread use has not occurred.
We conclude that research has established the public health burden of tooth decay, but insufficient research addresses the problems identified in the report Oral Health in America: A Report of the Surgeon General. Transfer of technology from studies to implementation is needed to prevent tooth decay among children. This should involve translational research and implementation of scientific and technological advances into practice.
Ample evidence demonstrates that the country is failing to move toward meeting Healthy People 2010 goals to improve the oral health of preschoolers with respect to tooth decay,
The Midcourse Review for Healthy People 2010 suggested that tooth decay (caries) rates for children aged 2 to 5 years were increasing, primarily among the poor and minorities, and most lesions are untreated, to say nothing of prevented.
Figure 1 is excerpted from this report. The problem likely extends to older poor and minority children, as dental caries lesions are cumulative, and untreated decay of primary teeth strongly predicts the same condition of secondary (permanent) teeth.
This paper examines advances in science and technology associated with prevention of tooth decay in young children since the report Oral Health in America: A Report of the Surgeon General of 2000.
US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
Strategies for dental caries prevention and management can take advantage of the infectious nature of the disease, or it can be viewed as independent of its infectious nature. The evidence of transmission, initially from mother to child, is demonstrated not only by the correlation of maternal salivary titers of mutans streptococci (MS) (a collective term used to embrace S. mutans, S. sobrinus, and other species less frequently found in humans) with the early colonization of her child and the early inception of caries lesions in the child, but also by the identity of MS colonizing mother and her child, based on bacteriocin typing, endonuclease, and ribotyping.
A strong scientific basis supports evaluation of the microbial status of young mothers as predictors of the colonization of their young childrens' teeth.
Interventions in the mother to suppress her MS prolong the time to colonization of her children and prolong the time and reduce the severity of carious lesion inception.
has been expanded following studies that showed colonization at younger ages and prior to tooth eruption. It is estimated in one study that MS is harbored by at least 20% of children under 14 months of age
The source of the MS after 5 years of age is not known but is likely to include siblings and caretakers, at least.
This review focuses on the preventive strategies and technologies that address goals of Healthy People 2010 applicable to individual children, which, if applied, might mitigate the inequities identified by the Surgeon General's Report on Oral Health (SGROH).
US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
The science and technologies to be reviewed are 1) detection and risk assessment and 2) interventions to improve prevention of tooth decay.
Detection and Risk Assessment
Early Tooth Decay Lesion Detection
Industry has developed high-technology devices that allow detection of early signs of decay lesions. Early detection could increase opportunity to arrest and reverse tooth damage by using a “medical” approach”
and prevent the need for traditional “surgical” interventions that partially remove and reconstruct (fill) the teeth, or extract them. The devices generally have high sensitivity but inadequate specificity. Their clinical application is further limited because one method cannot be used for all tooth surfaces and under all circumstances.
Moreover, these devices may be misused to justify surgical interventions and fabrication of fillings, sometimes mislabeled “minimally invasive,” instead of intensifying efforts to arrest early lesions. Devices with the best performance are expensive and cumbersome, and their use is time consuming, with little application in typical dental practice, community practice, or community health centers. Simpler approaches, such as fiber-optic transillumination, may be more readily adopted.
A multinational academic group has begun testing a totally visual caries lesion assessment scheme (International Caries Detection and Assessment System) that focuses on early lesion detection before cavitation has begun.
As with the technology-based systems, the rationale is that earlier detection will increase opportunity to arrest and reverse lesions and prevent need for surgical interventions. The International Caries Detection and Assessment System has acceptable reliability and validity but requires rigorous training and remains in development.
To date, there has been limited impact on training of dental students or adoption by community or health center practices, although this situation could rapidly change if research demonstrated how best to achieve this aim. These methods, whether high tech or visual, rely on detection of lesions after they have occurred.
Timely Risk Assessment
As cited above, detection of carious lesions of young children is a strong risk predictor of carious lesions of older children. Also, early carious lesions (“white spots”) are strong predictors of frank cavitation of the teeth.
These strategies may be helpful to primary care providers who see infants and toddlers on a regular basis. One example is the CAMBRA Caries Risk Assessment Form for Age 0 to 5 Years.
American Academy of Pediatric Dentistry. Policy on use of a Caries-risk Assessment Tool (CAT) for infants, children, and adolescents. 2006. Available at: http://www.aapd.org/media/policies.asp. Accessed September 21, 2009.
However, assessments of the childrens' mothers or caretakers in terms of microbiology or caries experience, or on their infection status, may be appropriate as well.
At lower levels of colonization, the relationship is poorer, no doubt due—at least in part—to the confounding effect of fluoride exposure and the diverse testing methods used. Testing is relatively simple and cost effective if it leads to sound anticipatory guidance and prevention of disease in children. Nevertheless, bacterial testing in US dental practices does not appear widespread. Research on the adoption of these technologies in both primary medicine and dentistry practice is needed.
Interventions to Improve Prevention of Tooth Decay
Vaccines, Bacterial Replacement, and Targeted Antimicrobial Peptides
Efforts to develop vaccines against dental caries based on both active and passive immunization continue. Secretory immune response to antigens of MS can influence caries pathogenesis.
Immunogenic and protective potential of mutans streptococcal glucosyltransferase peptide constructs selected by major histocompatibility complex Class II allele binding.
With some exceptions, most work has been done in animal models. Protection is attributable to salivary sIgA antibodies (active). Antibodies made in another host and delivered to humans (passive immunity) are also of interest. By selection of different antigens as the target for immunization, both active and passive strategies seek to inhibit a variety of functions critical to MS in the biofilm on teeth (dental plaque). Replacement of virulent (cariogenic) MS with nonvirulent streptococci is also being investigated in experimental animals and humans.
continues but no in vivo validation has been reported. Approval by the US Food and Drug Administration (FDA) of specific immunization and clinical applications is still problematic because of unresolved risk-benefit questions and commercial investment required to fund extensive trials to meet regulatory requirements.
Antiseptics
There are several studies of the utility of antiseptic agents to inhibit caries in older, self-compliant individuals.
With regard to preschoolers, some practitioners are strong advocates for combining fluorides with various antimicrobials, especially for those with disparities and whose families are mobile, because topical fluorides do not provide complete protection against tooth decay.
Two topical antimicrobials have been investigated to some extent: chlorhexidine digluconate (CH) and polyvinylpyrrolidone iodine (PVP-I).
Chlorhexidine
Chlorhexidine rinses, available in the United States, are sold by prescription but are lower in concentration (to reduce staining of teeth) than products sold in other countries. Approved by the FDA for gingivitis control, no formulation has FDA approval for caries control in children. Research, particularly in Europe and China, has examined the effectiveness of a CH varnish coating for the teeth, with mixed results. A recent systematic review of 14 publications of controlled clinical trials concluded there was a moderate caries-reducing effect when the varnish was applied every 3 to 4 months.
The variability in CH varnish formulations may have strongly influenced bioavailability and thus effect of CH. Although CH varnish and other CH-containing vehicles may have value in caries prevention for very young children, the evidence is inconclusive; no child products are available in the United States, and none can be recommended.
PVP-I
The in vitro and in vivo iodine antiseptic literature of 3 decades ago on dental caries was promising, but most human studies were very small.
Amin MS, Harrison RL, Benton TS, et al. Effect of povidone-iodine on Streptococcus mutans in children with extensive dental caries. Pediatr Dent. 26:5–10.
Larger scale evaluations are warranted and timely.
Topical Fluorides
The benefits of fluoride delivery via professional in-office applications, and home-use mouthrinses, gels, and toothpastes, are well established. These strategies have had limited impact on populations with little access to the dentist. Community water fluoridation is highly effective but depends upon public water supplies and political approval of their fluoridation. Mouthrinses, gels, and toothpastes are individual compliance–dependent, and dependent on economic and access feasibility. In the late 1990s, manufacturers gained approval from the FDA to market topical sodium fluoride varnishes, first available in Europe in the 1960s. Although indicated formally for tooth sensitivity reduction primarily in adults, they are being used for decay prevention and arrest in children, and good data suggest that they are more effective than the older technologies.
Manufacturers have not sought, however, an indication for prevention of decay, perhaps because they see the market as small and return on investment not large. The formulation of the varnishes is largely unregulated, and manufacturers have produced various forms of varnish that alter the properties of the varnish. No data show that these competing products are equivalent.
The varnishes are important because they provide an easy-to-use, safe, and cheap fluoride vehicle for preschoolers, our most vulnerable population. Although the varnishes are being adopted in public health practice, use in private dental practice lags. There has been movement for physicians and nurses to apply varnish, and in some states Medicaid reimburses these primary care practitioners, in addition to dentists and dental hygienists, for this service.
The Preventive Services Task Force, Centers for Disease Control and Prevention, American Dental Association, and American Academy of Pediatrics have not endorsed topical fluoride treatment for primary prevention in children aged before 24 months, and American Academy of Pediatrics guidelines specifically note the lack of a definitive trial.
Thus, a multicenter clinical trial is needed to demonstrate the effectiveness of fluoride varnish delivered by primary care physicians and nurses during well-baby visits.
New studies on the adoption of this technology in practice are needed. There have been almost no attempts to study ways to spread adoption.
Research outside the United States has highlighted the value of diamine silver fluoride to both arrest and prevent recurrences of ECC. This product has been available in Japan and several other countries for years but was never brought to the United States. Evidence suggests that it is at least twice as effective as sodium fluoride varnish.
Differences between normal and remineralized dentine pretreated with silver fluoride and potassium iodide after an in vitro challenge by Streptococcus mutans.
Research is needed to learn how this compound works. The National Institutes of Health is just beginning to sponsor research regarding this potentially helpful approach, but lack of FDA approval is a barrier.
Xylitol
Xylitol is a sugar substitute that is “generally regarded as safe” (GRAS) by FDA.
In teens and young adults, it is not only noncariogenic but also anticariogenic. Its use is limited, like that of other sugar alcohols, by its limited absorbability from the gut. Its benefit cannot be attributed merely to a salivation stimulatory effect of chewing gum use.
Its use, like that of fluoride, is associated with promotion of remineralization of white spots and established lesions. Considerable evidence indicates that it inhibits the metabolism of MS.
The American Academy of Pediatric Dentistry supports use of xylitol chewing gum as a caries inhibitor but recommends further research. It emphasizes the need for proper labeling of xylitol products so that parents and professionals can make appropriate choices.
Nevertheless, application has been limited by absence of formulations that demand minimal adherence and are acceptable in a greater variety of settings, such as in preschools/schools. A minimum of 5 to 6 g and 3 exposures per day from chewing gum or candies are needed for clinical effect in adults.
A landmark study showed that when mothers of preschoolers chewed high-content xylitol chewing gum habitually, their preschoolers had delayed colonization and lower levels of MS and similarly delayed and much reduced caries experience.
In spite of the large body of data supporting the effectiveness and safety of xylitol and a growing number of products, its adoption—particularly in the period immediately postpartum, is not widespread. The cost of xylitol sugar-free products for daily use is relatively high by comparison with other sugar-free products, but modest by comparison with the cost of the filling of carious lesions.
Occlusal Sealants
Although there were convincing data at the time of the SGROH for the application of sealants as a key objective of Healthy People 2010, the actual adoption of sealants by dentists has not been achieved.
Sealants are designed to be placed when the permanent molars erupt (around ages 7–8 years and 13–14 years). Data up to 2004 suggest no more than 32% of children receive this service, up from 23% during 1988–1994. The equivalent rate for age 14 is 21%.
CDC Wonder. Data 2010… the Healthy People 2010 Database. 2009 Edition-Objective 21–8a and 21–8b. Available at: http://wonder.cdc.gov/data2010/. Accessed September 21, 2009.
In part, this is because up to one third of permanent molars are cavitated by the time the teeth erupt enough to be sealed, depending on the risk group, and most dentists will not seal caries lesions in spite of evidence that this strategy can be effective in arresting them.
Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific Affairs.
The only innovation since the SGROH has been the development and marketing of glass ionomer sealants. The argument for this strategy is that glass ionomer can be placed on partially erupted permanent teeth, where they release small amounts of fluoride, putatively inhibiting local lesion development. However, only limited pilot studies of these materials exist, and their potential remains unexplored. Retention rates of the glass ionomer cement sealants are lower than current generation of conventional resin-based sealants. The limited literature on sealing primary molars is not encouraging.
There has been considerable interest in developing novel remineralizing agents that complement or substitute for the clinical effectiveness of fluoride. Studies largely sponsored by industry have been conducted to promote products claiming to remineralize early caries lesions.
These products are formulated as professionally applied pastes, toothpastes, and gums. Conceptually, the work is interesting. Nevertheless, the work is not focused on control of early lesions of ECC and claims of effectiveness are not well substantiated. Little has been done to establish how such products would be used to benefit children.
Conclusions
This review has focused on the role of science and technology in achieving the goals of Healthy People 2010. Tooth decay is a serious and growing problem for very young children. It impacts quality of life. It especially affects the poor, ethnic minorities, Native Americans, and Alaska Native populations.
Dental caries is an infectious disease, yet the application of this concept in practice is limited. Accordingly, antimicrobial approaches, directed at both mothers and at young children, have an important place in tooth decay prevention and control. Antiseptics, CH varnish, and PVP-I, as well as xylitol chewing gum used by mothers, have been shown to be effective in inhibiting carious lesion incidence, but definitive trials are needed.
Fluorides remain the most effective agents but are not widely disseminated to the neediest. Fluoride varnish provides a relatively effective topical preventive for very young children, yet definitive trials of its application in primary care practice have not been conducted. Scientific advances outside the United States have suggested the potential of silver diamine fluoride, but it is not FDA approved and no research has been carried out in the US. Data support effectiveness and safety of xylitol, but adoption is not widespread and additional research is needed on formulations and vehicles to increase access. Dental sealants are of unquestioned benefit and remain a mainstay of public policy, yet after decades of research, widespread use has not occurred. Definitive trials of new materials that can be used on erupting teeth are needed.
The research in the United States to address the growing level of tooth decay in our youngest children is too limited. Research and adoption have not kept pace with the problems identified in the SGROH. Transfer of technology from studies to implementation lags.
Acknowledgment
This review was supported, in part, by grants U54DE14254 and U54DE019346 from the National Institute of Dental and Craniofacial Research, National Institutes of Health to Peter Milgrom.
US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
American Academy of Pediatric Dentistry. Policy on use of a Caries-risk Assessment Tool (CAT) for infants, children, and adolescents. 2006. Available at: http://www.aapd.org/media/policies.asp. Accessed September 21, 2009.
Immunogenic and protective potential of mutans streptococcal glucosyltransferase peptide constructs selected by major histocompatibility complex Class II allele binding.
Amin MS, Harrison RL, Benton TS, et al. Effect of povidone-iodine on Streptococcus mutans in children with extensive dental caries. Pediatr Dent. 26:5–10.
Differences between normal and remineralized dentine pretreated with silver fluoride and potassium iodide after an in vitro challenge by Streptococcus mutans.
CDC Wonder. Data 2010… the Healthy People 2010 Database. 2009 Edition-Objective 21–8a and 21–8b. Available at: http://wonder.cdc.gov/data2010/. Accessed September 21, 2009.
Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific Affairs.
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