Product Focus
February, 2010 edition

Children’s Products

By Allison Walker

Anne Malkasian, RDH, BS, MEd, is the dental hygiene program director at the Burbank Campus of Mount Wachusett Community College. Her students are involved in providing dental hygiene care in partnership with Community Health Connections in Fitchburg, Mass. “Twenty-eight students provided care for over 1,000 patient visits last year,” Malkasian said. First-year students provide prophylaxes, take X-rays and apply fluoride varnishes and sealants in children and adolescents. “We provided care for 251 children under the age of 21 last year, 55 of them in the sealant program, which takes place in the spring,” Malkasian reported. The second-year students provide dental hygiene care for adults and other patients who have more complicated periodontal needs.

In the spring semester, second-year dental hygiene students also visit local schools, outreach centers and nutrition sites to talk about oral health and nutrition and dispense toothbrushes and toothpaste. During this semester, in partnership with the Massachusetts Department of Public Health, Office of Oral Health, the students implement a sealant program in the Fitchburg middle schools. “Although the Fitchburg water supply is fluoridated, few people drink the water, and the percentage of school children with dental caries is high,” Malkasian continued. She personally requests samples for the program on a rotating system from as many dental manufacturers as possible, including Procter & Gamble (Crest Kid’s Cavity Protection Gel-Sparkle Fun), Oral-B (toothbrushes), Colgate (SpongeBob SquarePants toothpaste), GlaxoSmithKline (Sensodyne, Pro-Enamel and Biotene products), Tom’s of Maine, McNeil (Listerine products), Johnson & Johnson (Reach dental floss) and Chattem (ACT Anticavity nonalcohol rinse), giving everyone who comes to the clinic a handful of appropriate products based on their individual needs.

In the clinic, students routinely apply Durashield 5 percent sodium fluoride varnish (Sultan Healthcare), Nupro Fluoride Foam neutral sodium fluoride, CavityShield 5 percent neutral sodium fluoride varnish (Omni Preventive Care), Embrace WetBond dental sealants (PulpDent) and Clinpro sealant (3M ESPE). “The advantage to using fluoride varnishes is ease of application,” Malkasian explained. “You can have a wet surface, and the tooth doesn’t need to be isolated.” For prophylaxes, Oral-B and Sultan prophy pastes are used, along with Young Prophy angles and Butler paste-free prophy angles. The students have also participated on a mobile van sponsored by the Massachusetts Dental Society to the local YMCA to provide screenings at local schools. “It’s a really remarkable experience for the hygiene students,” Malkasian said.

Joel Berg, DDS, director of the Department of Dentistry at the Seattle Children’s Hospital, as well as chair of the Department of Pediatric Dentistry at the University of Washington School of Dentistry in Seattle, recommended that parents need to determine whether their children, starting at 6 months of age, are getting the right amount of fluoride (as established by the American Dental Association) from their drinking water, whether tap or bottled. If fluoride supplementation is necessary, the dosage is based on the age of the child and the amount of fluoride present in local water. However, Berg noted that there is some new discussion going on about how low compliance is with fluoride supplementation, and therefore, some suggest focusing efforts only on children at the highest risk for caries. This is not an official position at this juncture, however.

“I think fluoride varnishes are the safest and most effective form of delivery of fluoride for children of all ages now,” Berg continued. “The reason is that they typically have twice the concentration, 5 percent sodium fluoride instead of 2.5 percent you get in a gel, but with a much lower volume. The actual volume of the fluoride you paint on the teeth is about one-tenth of what you’d put in gel form in a tray, so the potential for swallowing excessive [amounts of] fluoride is almost nonexistent. Secondly, it’s fast and easy. Also, the tenacity of the sticky varnish is greater, so it stays on the teeth longer. Third, while taste and color used to be an issue, we now have several brands that are white, such as Vanish (3M ESPE), or clear, such as ClearShield (DMG America). These taste good and are compatible esthetically. So to me, there’s really no reason not to use fluoride varnish as the primary method of fluoride application.”

Berg recommended that every child with teeth should use fluoridated toothpaste. “The question is,” he said, “how much should they use? For an adult or full-sized adolescent child, 1 mg, which is about half the toothbrush length, is plenty. For a young child, starting when the first teeth come in, we recommend a lentil-size amount, or the equivalent of one tuft or six tiny bristles on the toothbrush. A lentil is small—about a fifth the size of a pea. We feel when it comes to fluoride toothpaste, frequency of use is more important than quantity. Small amounts used frequently (twice daily) is always the best option. If they brush twice a day, even if they were to swallow all of it, that tiny amount would not contribute to fluorosis. By age 3 to 4, they can gradually transition to about a pea-sized amount until they’re 6, when they can migrate slowly to half of the toothbrush length.”

Berg noted that there are several new brands of children’s power toothbrushes, such as those offered by Sonicare and Oral-B, but that his philosophy is “the best toothbrush is the one that you use, and that is used effectively. If a power toothbrush enables you to do a better job, and you stick with it because it’s got the timer and it makes your compliance better, it’s a good choice. It’s the cycle of compliance. If you know how to brush, you can brush really well with a manual brush. The power brush is a tool to make your life easier. But the bottom line is, the best brush is the one that you’ll use.”

When asked about the effectiveness of xylitol, Berg said, “Xylitol definitely has been shown to be anticaries. It has an antibacterial effect itself, but it’s also a sugar substitute. So if you’re eating food with xylitol instead of sugar, you’re eliminating sugar from the diet.” Berg referred to Milgrom’s studies on the application of xylitol in public health settings related to caries.1 “There have been several studies by Milgrom showing that you have to have enough xylitol to have the desired effect. The threshold amount is 4-6 g/day. You’d have to eat six to eight xylitol mints a day, determined by age and caries risk.”

David Bresler, DDS, is a pediatric dentist who manages six practices in the Philadelphia area with his two sons, Josh and Jason, also pediatric dentists. Bresler is a proponent of pit-and-fissure sealants because topical fluoride is not as effective on occlusal surfaces as it is on smooth surfaces. “If you place sealants starting at 6 or 7 years of age, it’s a terrific way to prevent children from getting decay on their permanent molars,” Bresler said. “Our policy is to apply sealants two times—at 6 or 7 and again at 12 or 13. At that point, we’ve put 16 sealants on. We use Ultraseal XT (Ultradent Products Inc.), and we rarely have to reapply sealants. We make sure that the parent is aware that they can still get cavities in between the teeth, and we recheck them every six months.”

Bresler frequently speaks to prenatal and parenting groups. “Bottled water is a huge issue that parents don’t seem to have a good grasp on. I don’t think people should be drinking fluoridated water in a bottle or giving it to their children because when I’ve called the manufacturing companies, they cannot tell me the parts per million of fluoride in their bottled water. It depends on where they get their water, which is different every day. That’s not a good answer! The optimum dose is 1 ppm. If kids live in an area with fluoridated water, you don’t want to give them any supplements at all. I will put kids who live outside the city, or in a nonfluoridated area, on a fluoride supplement. It’s always best to err on the side of less [systemic] fluoride than more fluoride.” Bresler recommended that as soon as they have teeth, kids should have an in-office topical fluoride treatment every six months.

Bresler is as concerned with the amount of toothpaste children tend to use as he is with their brushing habits. “The most important thing we try to get parents to understand is not to leave a tube of toothpaste out on the counter and let the child squeeze out what I call a ‘Madison Ave’ big thick snake of toothpaste. You just want a film of toothpaste on the bristles. We encourage the parents to supervise brushing until the kids learn to spit out the contents, which may not be until they’re 5 or 6 years old.”

Regarding children’s toothpaste brands, Bresler recommended that parents buy toothpastes that first have fluoride, and second have the ADA Seal of Approval, which guarantees it has a long shelf life. “We tell parents to stay away from the no-frills, generic, and some of the brands in health food stores because we don’t know if they’ve ever been tested for shelf life.”

Bresler is also a big believer in power toothbrushes, especially if it’s difficult to get the child to brush more than 20 seconds. “If it makes the child brush longer or better, it’s a good thing,” he said. In regards to when parents should stop brushing their kids’ teeth, he recommends they use pink disclosing tablets to determine how well they’re brushing. “We use them every day. They don’t lie!” Bresler continued. “That will show whether they’re doing a good job brushing or not. If you’ve got a kid who’s getting his teeth pretty clean, you can be pretty confident, but I always tell parents to reserve the right to give pop quizzes. You can say to them, ‘Did you do a good job? Here—chew this up.’ You’ve got to keep them on their toes. Some of the worst mouths I see are in 11- and 12-year-olds.”

What about flossing? “Kids really can’t do it until they’re 6 to 8 years old,” he said. “The little handles with the floss between them certainly make it easier for them. We also try to help parents and kids know what order to do these things in. We call it the ‘FBI,’ which everyone can remember—first floss, then brush, and then irrigate or rinse afterwards.”

Jennifer Boyd, RDH, BSDH, EFDA, a practicing dental hygienist and expanded functions dental assistant who manages the clinical staff at Bresler’s six pediatric dentistry offices, prefers to use the traditional fluoride treatments and unfilled resin sealant materials. “I apply sealants to 20 to 25 children a week. I know some people are starting to use the filled flowable composite materials, but I’ve been using the unfilled resins for 16 years as a hygienist, and I’m comfortable with them and have seen good results with them in patients over and over. Right now I’m using Ultraseal XT (Ultradent), but we’ve used several other brands with good results.”

Boyd acknowledged that fluorides need to be selected according to individual patient need. “One of our offices, the Red Lion Surgicenter, is the nation’s only surgicenter dedicated to dentistry. Patients I work with there, like children with early childhood caries, are under general anesthesia during the dentistry. For patients like that, I’m talking to parents about brushing twice daily, [the importance of] an adult brushing a child’s teeth until age 8 and nothing to eat or drink after tooth brushing at night. If the child must have something to drink, only plain water is permissible.

“No amount of fluoridated water is going to help children who go to bed with juice or milk in their bottles,” Boyd continued. “It is imperative that children go to bed with no source of carbohydrates on their teeth. We also need to determine whether they should have systemic fluoride tablets. Both the American Academy of Pediatrics and the American Academy of Pediatric Dentistry agree and recommend systemic fluoride for children who live in areas without community water fluoridation from 6 months through age 16, so we follow their recommendation to the letter for dosing. We typically prescribe Luride (Colgate), but there are several similar products.

“We recommend the fluoride-free toothpaste until the child is able to spit out adequately, usually around age 4 or so. Oral-B makes a line of fluoridated kiddy toothpastes, such as Oral-B Stages Disney Princess, and they seem to like those … I also recommend to patients over the age of 6 daily fluoride rinses like ACT (Chattem) or Fluoroguard (BioRad) if they demonstrate the need—they have decay or decalcification.

“We also recommend that every child receive in-office fluoride treatments, such as acidulated phosphate gel or neutral sodium fluoride gel, depending on what types of restorations the patient has. I use neutral sodium fluoride if the patient has composite restorations because the acidulated phosphate gel can cause some pitting in composites.”

Tammi Byrd, RDH, past ADHA president (2003-2004), is CEO/clinical director of Health Promotion Specialists, a statewide school-based dental hygiene program in South Carolina. With only 18 full-time dental hygienists, the program serves 38 school districts, targeting schools that provide 50 percent or greater free or reduced-cost lunches because these children have very reduced access to care. Her program provides prophylaxes, fluoride varnishes, dental sealants and dental education to 16,000 underserved school children annually.

“We use sealants that have very little filler, because in a school-based program, you don’t want to worry about adjusting the bite. We usually use the composite resins rather than glass ionomers in our program because we find that composite resins work better in this type of setting. We use different brands of dry tips for any child we feel maintaining a dry field will be an increased challenge during sealant placement,” Byrd explained. The products her program uses depend on quality, the best products for individual children’s needs, and, of course, cost. The program’s expenses are reimbursed by Medicaid, private insurance, and less often, private pay. “Only about 10 percent of our children have private insurance,” Byrd said.

“The majority of our state does have fluoridated water,” Byrd continued. “We also have areas where there is too much fluoride in the water, so we have to talk to individuals there about having it checked and using bottled water and fluoride supplements.” They also see children who drink well water and try to get them connected with a dental office where they can get a prescription for supplemental fluoride products.

“At this time, we use Omni fluoride varnish,” Byrd continued. “We hand out Colgate toothbrushes and Colgate Regular toothpaste, as well as brochures that talk about fluoride, why we need to use it and why they need to be aware of it. We also talk about xylitol products. I would say 99 percent of the children we see are high risk, and I hate to say this, but it’s not even just the lower socioeconomic groups anymore. I’m starting to see more decay in the upper-echelon groups, too. Apparently, we aren’t spending as much time talking with more affluent, college-educated parents about the dangers of sugar and  the acidity of soft drinks—we assume they know that. So we try to make education a large part of what we provide to the children because that is what’s going to equip them for a lifetime. Just providing services here and there isn’t going to keep them healthy; it’s what they learn and their knowledge base that’s going to change their lives.”

For more information about the children’s dental products mentioned in this article as well as other products for children, visit the manufacturers’ Web sites. Visit the American Academy of Pediatric Dentistry at www.aapd.org for parent information and guidelines. The American Academy of Pediatrics also offers oral health information at www.aap.org/healthtopics/oralhealth.cfm.

Reference

1. Milgrom P, Ly KA, Tut OK, et al. Xylitol pediatric topical oral syrup to prevent dental caries: a double-blind randomized clinical trial of efficacy. Arch Pediatr Adolesc Med 2009;163(7): 601-7.

Allison Walker is a freelance oral health writer in Newtown, Penn.