In two months, paediatric dentistry specialist will gather in Pasay City, the Phillipines, for the 7th biennial congress of the Pediatric Dentistry Association of Asia. Dental Tribune Online spoke with the presenters Prof Jill Fernandez, Dr Neal Herman and Lily Kim from the University of New York, about their participation and recent developments in the field.

Dental Tribune Online: The US congress has recently approved a new proposal for health care reform. In your opinion, what impact will this policy change have on children’s dental care?
Prof Jill Fernandez: It is still too early to know what exactly will be in the final health reform bill, but as of now it does include mandatory paediatric dental care which requires dental coverage be offered as part of any essential benefits package for children under the age of 21. The new law will enable stand-alone dental plans to offer dental benefits as part of any health insurance exchange and/or subcontract with medical plans. The impact of this on the public and the profession could be monumental – the message is to begin oral health preventive interventions early in the lives of children, and that oral health is an integral part of overall health.

The oral health of children in the US is lacking and caries figures are at an all time high. What are the reasons for this development?
Prof Jill Fernandez: Actually, the oral health of children in the US has improved significantly over the past few decades, when you look at a national sample across all age groups. Today most American children enjoy excellent oral health, but a significant subset suffers a high level of oral disease. The most advanced disease is found primarily among children living in poverty, some racial/ethnic minority populations, children with special needs, and children with HIV infection.

You might be referring to the National Health and Nutrition Examination Survey study that showed an increase in dental caries in the 2 – 5 year old group, from 24 per cent to 28 per cent. It is presently unclear as to why this has occurred, but has reignited efforts in the US to try to improve access to care for this age group and motivate more dentists to treat the very young in our population.

Unfortunately, Early Childhood Caries (ECC) has not only increased in the US but also worldwide. Should this field be considered a new priority in paediatric dentistry?
Prof Jill Fernandez: ECC, and the effort to intervene and treat early dental decay, has always been a major priority. To effectively combat the current national epidemic of ECC in young children, a more comprehensive, collaborative approach to the education of parents by all newborn and paediatric health care providers, such as nurses, paediatric and general dentists, dental hygienists, paediatricians, paediatric nurse practitioners and OB-GYN physicians is essential.

The American Academy of Pediatrics (AAP) began a collaborative effort with paediatric dentists to address the issue of early childhood caries. The AAP has made strides in developing educational programmes for paediatricians and family physicians to identify at risk children and refer them for dental treatment.

However, for many children, access to dental care remains a problem and the number with dental caries seems to be growing. A large number of parents lack dental insurance, thus they postpone dental treatments until the problem is so advanced that it can no longer be ignored. It is unfortunate that even parents who have third-party coverage for dental care (Medicaid, Child Health Plus) and are from lower socioeconomic backgrounds often fail to seek dental care as part of general health care services. As a result, pre-school children with Medicaid may still have multiple untreated decayed teeth.

Frequent bottle feeding at night has been identified as a driving factor for ECC. Other studies have found a microbiological connection between mother and child, labelling it as a transmissible disease. What is your opinion on the latest research and how will it impact the way children should be treated?
Dr Neal Herman: The nursing bottle is only one of many confounding factors in ECC. What we conclude from the latest research is that the disease called dental caries is highly complex and perplexing, not easily prevented or treated in the most susceptible children. It is believed these days that there are nutritional, behavioural, immunological and bacterial factors that must be contended with and overcome in order to understand and successfully prevent dental caries.

The surgical approach to ECC, that is, the “drill and fill” solution of placing restorations in teeth as they become cavitated, has long been proven to be futile and often counter-productive. Therapeutic interventions, particularly utilizing fluoride varnish, have shown promise in preventing, arresting and reversing carious lesions. Much more work must be done to document its success, but at least this “medical model” has begun to address the fact that ECC is a bacterial disease requiring more than just filling up the holes that are merely its symptoms.

Root canal treatments in primary teeth are also becoming more common. Does the treatment differ in any way from that of permanent teeth?
Dr Lily Lim: We’re not sure that pulp therapy is on the increase, but if it is, it’s probably because more parents (and dentists) realize it’s best to try to preserve a primary tooth rather than extract it (whenever possible!). The goals of treatment for primary teeth are not much different than for permanent teeth; in both cases, diseased portions of the dental pulp are removed in an effort to preserve the hard structure of the tooth for functional or cosmetic purposes.

Anatomical and physiological differences between primary and permanent teeth make a difference in the principle of root canal treatment. A permanent tooth requires an inert, solid, non-resorbable material that can last a lifetime, and gutta-percha fills that bill. The ideal root canal filling material for primary teeth should resorb at a similar rate to the primary root to permit normal eruption of the successor tooth; not be harmful to the underlying tissues or to the permanent tooth germ; fill the root canals easily; adhere to the walls and not shrink; be easily removed if necessary; be radio-opaque; be antiseptic and not cause discoloration of the tooth. There is currently no material that meets all these criteria, but the filling materials most commonly used for primary pulp canals are non-reinforced zinc-oxide-eugenol (ZOE) paste, iodoform-based paste (KRI), and iodoform and calcium hydroxide (Vitapex).

What other challenges do paediatric dentists currently have to deal with?
Dr Neal Herman: Children most in need of the services of paediatric dentists are least likely to have access to them. Success to most paediatric dentists means a thriving, middle-class urban or suburban practice that pays big bucks and treats mostly low risk children of the privileged classes. This means children who need paediatric dentists most have little or no access to them.
Distribution of practitioners is highly concentrated around cities and metro areas – rural populations have little or no access to paediatric dentists. Again, a large, needy portion of the population is without oral health services.

A study from the Netherlands has found that prevention involving the counseling of parents about caries-promoting feeding behaviour is often ineffective in the long-term. Is there a lack of quality intervention strategies?
Dr Neal Herman: If we (or the WHO) could answer this question, we’d have found the key to unlocking the mystery of improving or enhancing human motivation. It is probably true that without continual and periodic follow-up, counselling will “wear off” even among highly motivated individuals. We think the key lies with education that begins early and promotes a sound nutritional and sustainable oral hygiene model for parent and child alike. As you might imagine, this is a task not well suited to the traditional dental care delivery model, and will require some serious paradigm changes to permit effective implementation.

What preventative measures do you recommend from your clinical experience in New York?
Dr Neal Herman: Preventive measures and conservative therapies that confront the cause of the disease, rather than treat the symptoms, are the most effective and work the best. Fluoride varnish has proven to be a godsend, although most of the evidence to date is empirical and anecdotal. Good long-term longitudinal studies are needed to prove conclusively what we already know as clinicians – an intensive regimen of fluoride varnish, along with adjunctive measures, can control and often reverse dental decay, as well as prevent it.

Dr Lily Lim: Starting in infancy, children at-risk for dental decay should be receiving twice yearly applications of fluoride varnish, whether by a dentist or dental professional, or as part of their well-baby care from their pediatricians. More than 40 states in the US now have such programmes up and running, and the outcomes are impressive – as much as 40 per cent fewer children with early signs of ECC.

Prof Jill Fernandez: Collaboration between other health providers and the dental professions is key to combat the incidence of ECC.

You will be presenting at this year’s PDAA congress in Pasay City, the Philippines. What will the participant be able to take home from your presentation?
Dr Lily Lim: At New York University (NYU) through education, outreach, training and collaboration with other health professionals we have developed a multi-faceted approach to deal with the many aspects of oral health problems. This presentation will describe the coordination of the strategies and programs that NYU employs, particularly to combat ECC.

Dr Neal Herman: These presentations will examine and offer solutions to the management of ECC. We will offer up a clinical therapeutic protocol that effectively stabilizes and/or arrests active caries, and which suggests a disease-intervention model of care replacing restoration of teeth as the primary approach to the treatment of ECC in infants, toddlers and pre-school children.

Prof Jill Fernandez: Setting up an Infant Oral Health Programme in your office using auxiliary persona. The auxiliary should be able to conduct a risk assessment, provide anticipatory guidance and prescribe an individualized preventive program. This presentation will outline the steps in creating an infant oral health programme in the office.

Thank you very much for this interview.