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Perio Reports

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Perio Reports  Vol. 25, No. 12
Departing from our usual research summaries, this month we present summaries of key presentations at the IADR World Oral Health Congress in Budapest, October 9-12, 2013.
Pacifier Cleaning by Parents has Benefit for the Child

More children today have allergies than ever before. The "Hygiene Hypothesis" suggests that children living in crowded housing, being part of large families, having early contact with pets or farm animals and early exposure to microbes in food have a reduced risk of developing allergies. In the Western world today, parents are more concerned than parents in the past with protecting their children from germs. This overprotection and fear of microbes may be responsible for allergy levels increasing to one in three children in affluent countries.

Infants are exposed to the oral microflora of their parents through kissing, sharing the feeding spoon and by the parent putting the pacifier in his or her mouth after it falls on the floor before giving it back to the infant. This sharing of oral flora may be helpful in protecting the child from allergies, asthma and eczema. Researchers in Sweden took saliva samples from nearly 200 four-month-old infants to determine the microbiota. The children were evaluated for allergies at 18 and 36 months of age. Medical histories were taken from the parents as well.

Babies born vaginally and whose parents cleaned the pacifier in their mouths before giving it the child were less likely to have allergies, asthma and eczema. The microbial flora found in the saliva of babies whose parents cleaned the pacifier in their own mouths differed from children whose parents rinsed the pacifier off with tap water or cleaned it in boiling water. Transfer of microbes from the parent to the child may trigger a protective immune response in the child.

Hesselmar, B., Sjöberg, F., Saalman, R., Åberg, N., Adlerberth, I., Wold, A.: Pacifier Cleaning Practices and Risk of Allergy Development. Pediatrics originally published online May 6, 2013.

Early Childhood Caries May Actually be Triggered by Enamel Hypoplasia

The first 1,000 days in the life of a child, from conception to two years of age are critical in determining health prospects for life. Events happening to the mother during pregnancy will have an impact on developing cells of the fetus. Ameloblasts lay down enamel in eight day cycles, laying down cells for seven days and resting on the eighth day. This pattern can be seen within the enamel layers when analyzed microscopically. Also visible is the date of birth in neonatal lines in both dentin and enamel. Changes within the various layers of enamel tell the story of the child, much like rings in a tree trunk provide evidence of various stressors encountered during a lifecycle. In this case, it’s the life cycle of the deciduous tooth.

Stressors on the mother that can inhibit ameloblastic function include malnutrition, smoking, celiac disease, infection, fever or other systemic conditions. Early childhood caries occurs around two years of age in normally calcified enamel and earlier in children with hypoplastic enamel. These children show earlier and greater Strep mutan colonization, probably due to the defects in the enamel providing an ideal place for bacterial colonization. Add to this a high carbohydrate, cariogenic diet and you have hypoplasia-assisted severe early childhood caries (HASECC).

The "frown" line of enamel hypoplasia reflects the exact time teeth were developing when the mother experienced a significant stress. This would be considered a birth defect in the enamel by the March of Dimes.

Cauflield, P., Li, Y., Bromage, T.: Hypoplasia-associated Severe Early Childhood Caries - A Proposed Definition. J Dent Res 91:(16)544-550, 2012.
Targeting Populations or Individuals at Risk

Fluoride can be compared to a seat belt - easy to use, required by everyone even though only a small percentage of those using one will actually be involved in an accident where the seat belt is needed. Fluoride is easy to use and often provided community-wide in water, salt or milk. When evaluating prevention programs, all successful programs include fluoride in some form.

The toothbrush is a delivery system for fluoride toothpaste, more than for plaque removal. The highest level of scientific evidence is with fluoride toothpaste of at least 1,000ppm used twice daily. When asked why not focus on diet and sugar consumption, it was said that a single diet intervention doesn’t actually result in reduced sugar intake.

Researchers in Sweden realized that one specific area within the suburbs of Malmo was inhabited by a wide variety of immigrants with as many as 50 different languages. Perhaps because of lack of education or bad dental experiences in their home countries, these families did not take advantage of the free dental care available. In this area, 85 percent of three year olds had dental caries, compared to 30 percent in surrounding areas. Researchers took the clinic to the neighborhood and created a nonthreatening center called Toothbrush where dental assistants saw each child four times per year for toothbrushing instructions and discussions about diet and dental disease. The children brushed with fluoride toothpaste or took fluoride tablets. Three years later the caries rate was significantly reduced.

Wennhall I, Mårtensson E-M, Sjunnesson I, Matsson L, Schröder U, Twetman S. Caries-preventive Effect of an Oral Health Program for Preschool Children in a Low Socioeconomic, Multicultural Area in Sweden: Results after One Year. Acta Odontol Scand. Jun;63(3):163-167, 2005.

Mother’s Beliefs Impact Children’s Oral Health

Researchers from the University of Otago, in Dunedin, New Zealand, visited Ajman in the United Arab Emirates to evaluate the caries levels in five- to sixyear- old children. Boys had more caries than girls and the children of well-educated mothers had lower caries rates than children of mothers with less education.

In a group of more than a thousand children, 76 percent had at least one decayed, missing or filled tooth and the boys had more caries than the girls. In this case, cultural differences impacted the caries rates of the children. To the mothers, the boys are treated like princes and overindulged with sweets. Mothers believe the sweet treats are good for their children and it shows their love for their children. The same is not true for daughters.

In another study conducted in Dunedin, New Zealand, children born in 1972 and 1973 have been followed since birth with many medical and dental evaluations. At the start of the study, mothers rated their own oral health on a five-point scale from excellent to very poor. When evaluated at age five, the mothers’ self-evaluations of oral health predicted their children’s oral health.

Recently, 95 percent of those still alive were evaluated and the mother’s oral health predictions were even better predictors of their child’s oral health at age 32 and 38. Many things impact oral health. In many cases the focus is on plaque, oral hygiene and sugar consumption. This study shows the significant impact personal beliefs held by the mother can have on the oral health of children.

Hashim, R., Williams, Sl, Thomson, W.: Oral Hygiene and Dental Caries in 5- to 6-year-Old Children in Ajman, United Arab Emirates. Int J Dent Hyg 11(3):208-215, 2013.

Prevention Beyond Fluoride

Following children from five years of age to 40 years of age, the caries experience is always on the upswing. The increase is low for about 40 percent of the people while the middle of the upswing affects about 45 percent and the last 15 percent is on the highest trajectory.

Despite a variety of fluoride sources, dental caries is still a serious problem impacting a significant portion of the population. There is a small segment of the population for whom traditional prevention is effective and they have no dental disease. For some, it might possibly be effective and for the rest, traditional prevention is not effective in preventing dental disease.

Researchers in Denmark wanted to see what the effect of simply toothbrushing would be. Children were seen frequently in the dental office for professional toothbrushing. Nothing else was used, just toothbrushing: no fluoride toothpaste, no pit and fissure sealants, nothing but toothbrushing. This group was compared over a several-year period to a control group receiving traditional prevention and dental care. The toothbrushing group experienced fewer surfaces of decay compared to the control group. Comparing time spent in the dental office, it was almost the same for both groups, one receiving toothbrushing and the other more restorative care. The biggest difference between the groups was the amount of money earned by the dentist. Significantly more money was earned by repairing decayed services than by preventing the carious lesions with professional toothbrushing. It is an effective preventive model, but not one that is likely to be adopted by dentists anytime soon.

Ekstrand, K., Christiansen, M.: Outcomes of a Non-operative Caries Treatment Programme for Children and Adolescents. Caries Res 39: 455-467, 2005.

Oral Cancer - Still a Serious Problem

Oral cancer is on the rise and remains a deadly disease with a five-year survival rate at approximately 50 percent. The major risk factors are tobacco, alcohol, betel quid and HPV virus. Awareness of oral cancer is particularly low in many third-world countries and also in Europe where the highest rate is found in Hungary and northern France. These figures are due to the high incidence of tobacco use in these countries. Those living at a low socio-economic level are also at higher risk for oral cancer.

Public awareness of oral cancer is very low, with 50 percent of people in areas of risk not knowing about oral cancer. In Hungary, 48 percent are not aware of oral cancer. In the past 10 years in the UK, oral cancer incidence increased 35 percent. This is due in part to changing demographics as many more young people are affected in particular by oral pharyngeal cancer.

Early screening is considered the answer to cutting the time between detection and treatment, this despite the lack of research showing that screening in high risk populations results in fewer deaths. Cuba has a screening system implemented at the primary health-care level with physicians, which has led to a high cure rate. However, primary care physicians are not trained to recognize oral cancer, so additional training is needed to teach the steps in a visual exam and palpation of the head and neck.

Similar to the Great American Smoke Out, held each year on the third Thursday of November, colleagues in the UK have adopted a blue ribbon Mouth Cancer Action Month for a full month of activities focused on tobacco cessation. Ireland, Spain and Portugal also adopted this program.

Warnakulasuriya, S. Kings College, London. Resources: http://www.oralcancerldv.org/en/
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