Transcribed by Amit AminAugust 07th, 2014

[Diagnosis of Oral Diseases] [21&22] [Cariology I & II] by [Dr. Dasanayake]

[1] [Title][Dr. Dasanayake] So tell me when you guys want me to start. Ill be happy to talk to 10 people. No problem. Do you have an exam today? What? Tomorrow? Do you know where the rest of the class is? This is it? Ok. Fantastic. You want to go home? No. Ok. Alright. So attendance is not mandatory for this one ok. Fantastic. Ill give you the choice. I have 2 hours to talk to you guys. Let me go ahead and get started. So is the lighting ok? Can you see the slides on the screen? You can. Thank you. Is it? It is. To me, its not you. Alright. Somebody. Can somebody tell me what you see on this particular slide and what is the relevance of that? Caries. Arising from? There are two potential sources right? Lateral incisor and the caninal premolar in the primary dentition. The lesion is on the palate so what is your diagnosis here? Other than caries? Do you see this lump on the roof of the mouth? What do you call that? Its a classical dentinal alveolar abscess. In the mid 70s this is what I dealt with on a daily basis. This is imagine, pre-facemask, surgical glove era. The moment I open this up, I collect about a gallon of pus coming out of that full of various organisms so next day sore throat. You guys are lucky that you dont have to deal w/ that. This is what we will talk about today, dental caries, not the dentinal alveolar abscess. [2] [No title][Dr. Dasanayake] I want to talk about that within this context. What is the distribution of caries in your population and what are their determinants of dental caries. We probably have a vague understanding of what some of these are. [3] [Topics of Discussion][Dr. Dasanayake] But this is where Im going to frame my discussion. Why do we care? You are here right? You want to learn about this. Youre in the dental school. Youre spending thousands of dollars to become dentist so lets look at it from different angles. How many people are affected in your own communities where you end up as a practitioner? If there is 0 prevalence youre not going to have a good practice. Maybe you can do other things but not treating tooth decay and to what magnitude? When I say what magnitude for a given mouth, how many teeth/ how many surfaces are effected by tooth decay and you can multiply that by what you need to do to rest or form and function in those oral cavities. Any trends in this patterns? This is getting very interesting to first/ second year dental students. If I tell you by the time you finish there wont be any tooth decay, its a good thing in a sense but at the same time you may want to think about other options. What is causing caries? Where is the evidence? Cause you know sugar in your drink youre drinking right now may contribute to a certain extent to tooth decay. Where is the evidence? My intention is to show you the highest level of evidence or factors that are implicated in the etiology of tooth decay. Why do we do all of these things? Because you have a better sense of how you can prevent and treat caries when you get out of school. This is my framework for the discussion. Its Thursday at 3 oclock, I dont want you to fall asleep so Im going to keep it a two-way interaction. Please participate ok. [4] [Question 1][Dr. Dasanayake] Why is oral health important? If a mother of a little child comes to you in your clinic and asks you doctor these are baby teeth. Why is it important why do we care? Yes sir. Fantastic, very good answer. Anybody else? I would like everybody to participate then you will stay awake. Anything else? Fantastic. Primary dentition probably has a direct correlation that happens w/ permanent teeth. Youre answering a different question. Im asking what its important to have good proper oral health. Youre saving if youre not going to chew, fantastic. Anything else. Yes sir? Systemic health. Of course. There are a number of studies that shows what is going on here, the inflammation can travel to other parts of the body and cause havoc in various systems including the heart and pancreases and other places in the body and pre-termed deliveries expel. This is how I see this one. Number one. This is highly prevalent. If I ask you in your particular age group what is the prevalence of tooth decay in the United States. Prevalence is a proportion right? It can range from 0 to 100 percent. Your age group, young adults, what is the prevalence of tooth decay in this country? Take a guest. 80%? 50%? Im talking about the permanent teeth. Let me clarify further. This is highly prevalent. Youre going to see the numbers in a moment. A little bit higher than what you thought. Oral diseases and access to dental care show great racial, ethnic, and economic disparities. Midtown Manhattan is a totally different story from Queens. From Birmingham, Alabama. If you look at the Mexican Americans and this country and the poor Mexican Americans, thats a double whammy right there right? This is another reason why you need to care. Dental care is very costly. Ill ask you later how much money you think we spend in this country to take care of peoples teeth? So think of that so when I come to that question you have the answer. Oral diseases might be linked to overall health and even death. There are cases in the literature where children and young adults have died due to neglected untreated tooth decay. [5] [Common Childhood Diseases][Dr. Dasanayake] This is the famous report of the surgeon general in 2000. Thats the only report that talks about oral health specifically in this country. What are they saying here? This is the commonest ailment in children, asthma. Prevalence, 10%. The second, hay fever is 7%. Look at what youre dealing w/. 50% prevalence. What is this telling you, 5x more prevalent than the commonest children disease (#1). #2. If you remember, your primary school days, idk if you had any tooth decay when you were a primary school child. 51 million school hours are lost each year as a result of this condition ok? Among poor children, what you called the restricted activity days, youre sitting in a corner b/c of the pain and swelling due to caries are 12x higher if you are one of these poor/ minority kids. These are greater social issues as well as public health issues. [6] [Figure 1-C][Dr. Dasanayake] So this is that access to care when I was in Alabama. I look at the data from 1990-1997 looking at access to care, about 1.5 millions records that I was looking at (Medicaid data). This is no surprise to you right? There is a great racial disparity in terms of utilizing oral health services. Even though you have Medicaid, you dont necessarily go unless you have an emergency right? This limited access to care and not using the care would compound this particular problem. So now Im going back to that slide again. Burden of this inadequate access to care. Can this be fatal? You already know this answer since I told you. So here is a Washington post article from March 2007. About a week ago or just before that a 12-year-old boy died as a result of complications from a tooth abscess. Kind of infection, but common among people that dont have access to care. If you go back and think of your oral pathology, dental anatomy, and everything else, this infection can spread from here to the intracranial structures such as? Whats the commonest place? Cavernous sinus remember? This can spread if it is unchecked. As in this particular case, this child had2 operations, spent 6 weeks in the hospital, yet the end result was fatal. [7] [Deamontes Law] [Dr. Dasanayake] So this actually led to some silver lining in this dark cloud. U.S. Congress immediately acted upon that. That was May 17th. The child died in March. By May Congress had passed this particular law, HR 2371, and in that particular law they said there was a 15%in early childhood caries b/w 1988 & 1994 and 1994& 2004 (data from the Center for Disease Control). You should be thinking why is there an increase? We are in one of the richest countries in the world. 28% young children had experienced cavities b/w 1999&2004 and 80% of dental decay occurs in just 25% of children. Tooth decay is the single most common childhood chronic disease and disproportionally affects poor and minority children. [8] [Deamontes Law Part II][Dr. Dasanayake] Just to give you some interesting facts so you can talk about these things at cocktail parties in the summer. 9 million children as of 2007 dont have medical insurance. More than 2x (20 mil) dont have dental insurance. Does that surprise you? 20 mil in our country dont have dental insurance. If youre a parent, youre 3x more likely to report that your childrens dental needs are unmet when compared w/ general medical care. Child has fever, stomachache, youll take the child to the doctor. The dentistry will come later when you have enough money saved and you can take time off work. Its not necessarily preventive care, its usually emergency care. These are the realities that you will face w/ your patients when you graduate. More than 31 million people in this country live in what we call dental health, provider shortage areas. Go to upstate NY just below Canadian border you have dental provider shortage areas. People have to travel hundreds of miles to see a dentist. This report says we needed about 5,000 additional dentist to serve in these particular areas. [9] [Melissa Rogers][Dr. Dasanayake] So this is the press report in May 18th saying that this is again, I cant remember what, Washington post. They passed this law by Representative Cummings and it is interesting for you to see and whether something came out of this congressional action. What they were proposing here, 2 steps. #1 Establish 2 5 year 5 million pilot programs. First provide money to staff and equip community clinics. The second was to help recruit and train pediatric dentist. I was looking to see if there was a follow up to this one. Maybe you will be able to find something along these lines. [10] [Breaking News][Dr. Dasanayake] This is the other sign of the coin. Tell me what you think of this right. Real stories. This is Philadelphia 2007. Mother was sentenced to time behind bars for failing to treat 5-year-old sons dental problems. There is a solution to this problem. Put the mother, father, or grandmother in jail b/c they have untreated tooth decay, no access to care, and no insurance. Thats the other side of the coin. You can have an entire session debating on that. [11] [24 year old dad][Dr. Dasanayake] This is an adult. Those were children I was talking about. This man from Cincinnati, Ohio went to the emergency room, infection, inflammation, and acute pain. Emergency room, giving two prescriptions. One for pain, one for infection. Guess which one he purchased. He could only afford one. He went and bought the pain medication. End result? Death. This is happening in your communities. This is why youre sitting here and youre trying to take a closer look at this particular problem b/c of tooth decay. [12] [Emergency Room Visits for Dental Conditions][Dr. Dasanayake] So these people that have no access to care. No insurance. What do they do? The go to the emergency room for dental care. This is 2009 data. About a million visits to the emergency room related to dental visits. Thats not where you should go right? It should be preventive care by dental hygienist or local dentist. These people end up in the emergency room. Look at the hospitalizations, about 13,923 treated and released just like the Cincinnati gentleman. Fill a prescription, no follow up, go home, and anything can happen to them. [13] [Measuring Ways of Impact of Oral Diseases][Dr. Dasanayake] Any other ways of measuring impact of oral disease? Yes. I think that is emergency room protocol. They give the prescription, take care of the acute problem, and tell them to go see a dentist. Sometimes there are dentist affiliated w/ the hospital in the emergency rooms. Im sure there are protocols related to that. Any other ways of measuring this true impact? These are talking points for you to convince the parents who come to your practice or the adults about oral health. Anybody? Any other ways of addressing the impact of oral diseases. Why is it critically important to have good oral health. Im just trying to stimulate your thinking. Participate in the discussion please.[14] [Picture of $50 bill][Dr. Dasanayake] How about this? Lets put some numbers. [15] [How much money do we spend?][Dr. Dasanayake] I told you Im going to ask you how many dollars we spend in this country to keep the Americans healthy? Not orally, healthy. Somebody give me a guess. $4 billion. Any other guesses? These are interesting numbers to remember as healthcare professionals. $200 billion. What proportion of that expenditure do you think we spend to take care of oral health? What percent? 10%. 2%[16] [Percentage Distribution of Health Care spending][Dr. Dasanayake] Alright. Here are the real numbers. Ok. $1.3 trillion. This is 2011. I cant find anything after that. Theres a lag. These are government numbers. Where do we spend all this money? Hospital inpatient, these are the office based visit, prescribed medications, hospital outpatient. Here is you. 6.4%, which is greater than what we spend in emergency rooms. Thats mind-boggling. Oral health or dental services expenditure is about 6.5% of the total expenditure on overall health, $1.3 trillion dollars. After Obamacare I dont know what these numbers are. [17] [How many are affected by caries?][Dr. Dasanayake] Ok, so now the question is why do we spend so much money to take care of teeth b/c we have a problem right? So lets ask how many people are affected by tooth decay and how many teeth or surfaces are affected by tooth decay. That is why we are spending so much money right? [18] [Trends in caries][Dr. Dasanayake] So as I told you if you look at the prehistoric man just out of caves, do you think they had cavities? Why not. Refined carbs were not a part of their diet. What else? Usually grind the corn using stones there are course particles incorporated into your diet, you get occlusial surfaces a bit smoother, pits and fissures are taken care of. Throughout the history, we started to become more prone to caries. If you look at the major wars in any part of the world. One of the criteria to join the military was to have good teeth. Why? Youre fighting your enemy, youre hiding in a trench and your buddy next to you is groaning and moaning w/ pain giving away your hiding place to your enemies. The warriors made sure people have good teeth before they join the military services. If you looked at the American Civil War, one of the requirements was to have at least 6 anterior maxillary and mandibular teeth to join the army. Why is that? Pull the pin of the grenade. If you dont have anterior teeth youll have a hard time since your other hand may be occupied. Its interesting to hear the history of these things. We have gone from here to here. This is what you call childhood caries. Why, how, how can we reverse that. This is what well talk about. [19] [Trends in Oral Health Status][Dr. Dasanayake] Ok, Ill give you a wonderful reference right. This is govt data. Are you familiar w/ this NHANES. National Health and Nutritional Education Survey. Every few years govt put a lot of money together and do a representative sample from different age groups and look at various aspects of health. This is Bruce Dye and a few other people from the National Center for Health Statistics. They summarized the data, look at 88-90 post survey, 99-00 for the most recent survey even though its 10 years old. Itll give you some idea where we are in regards to this particular problem. So just type this into your Google and youll get the whole publication and download it as a pdf and keep it as a files. [20] [Table 5][Dr. Dasanayake] Its a bit small to read but Im going to read this w/ you/ for you. Here Im looking at the primary teeth, decayed and filled primary teeth. Children 2-11 years of age. Here Im looking at prevalence per survey. 88-94. This is the percentage, this is the standard error. This is the 99-04 survey. This is the difference. This little symbol that its statistically significant increase or decrease. Lets look at the 2-5 year old babies. No permanent first molar erupted yet most of the time. 20 baby teeth, milk teeth. 88-94 about 24% now we are dealing w/ about 28%. 3% increase is statistically significant. Not due to chance. We train 360 dentist every year in this school and all the other schools and there is something not right in our population right. What is happening there. Look at the 6-11 year olds. About 50% here. 51%. Not a significant difference. Why is early childhood caries going up? We can think about/ discuss that. Lets break it down by gender, male/ female, and race/ ethnicity. If you look at this way, these are whites 35%, Im going to ignore this survey, and Im going to look at the most recent survey. 38%, 43%, 55%. These differences come in this way, statistically significant. If youre a Mexican American you have the highest rates no matter what survey youre looking at. If youre a black, non-Hispanic you have higher rates than the whites. Not surprising to you right? Thats not something you have to write home about. Lets look at the poverty. Less that 100% federal poverty level means the very poor people. Look at them. 54%, next group 48%, the people who are a little bit more affluent they are 32%. If you put Mexican-Americans in this particular category, youre going to see huge proportion affected by caries right? Be mindful when you go to your communities, look at the distribution of the population, and you can get a good understanding of what kind of issues youre going to deal w/ in as a dentist in that community. This is baby teeth. [21] [Table 40][Dr. Dasanayake] Lets go to the DMFT. This is the, permanent teeth. You know the notation right? DMFT- means permanent teeth. D- Decay, M- Missing, F- Filled, T- Teeth not surfaces. So, again, the same format right? Looking at the prevalence here. Early you said 80% prevalence in your age group. The answer is 90% right? 94% 88-94. I ask you prevalence of caries in your particular group. Much higher. When you come to 1999-2004 still 9 out of 10 adults are affected by tooth decay. If you want to see all of these differences except here 50-64 year old there is a decrease here. Everything is decrease compared to the previous survey except in that very little children. Theres something happening. Something not right. [22] [Chart but no title][Dr. Dasanayake] This is just to give you an idea about the mean number of surfaces in babies mouth. Thats the second part. Magnitude. First I said the prevalence or what proportion affected. This is the magnitude. The number of surfaces that you as a dentist need to treat. So again, two surveys 88-94, 99-04. Two age groups. This is the poorest people right? Its somewhere around 6 here in the most recent survey. 6-11 year old. 6-surfaces/ mouth affected by tooth decay. You can look at the data across different poverty group. These are more affluent people. Less of a problem. Prevalence is lower, number of surfaces are much lower. Makes a lot of sense to you. [23] [Chart but no title][Dr. Dasanayake] And here is the mean DMFT. I know I have to give a couple of questions for your final exam so I may ask you something like what is the prevalence of dental caries of adults in the U.S. I may ask you the magnitude or mean number of teeth affected by caries. Here you are looking at the mean number of teeth across various age groups, the darker bar is the earlier survey and the lighter is the most recent. Lets look at this particular age group. Maybe 35-49. Its about close to 15. It has come down a bit over time. When you get older, close to 15-20 teeth are affected by tooth decay b/c this is age related. The longer you live, the more likely youre going to get cavities. Xerostema, polypharmacy. When you get older you take cholesterol medications, hypertension medications, whatever will make your mouth dry. Then youre going to have another set/ episode of tooth decay in life. [24] [Picture of tooth][Dr. Dasanayake] One of the things I want you to remember when you see data from national surveys is to ask yourself how did they measure tooth decay. Did the take X-rays? Do you think they took X-rays when they did this national survey? No, this is fieldwork right? Trained, calibrated people go and lift the lip and look at the mouth w/ air or w/o it. Go and look at your dental anatomy lectures. This is a cross-section of a molar and of course youre going to see this fissure right? Youre probably going to be taught to be used an explorer or not. When I was a dental student the first thing you do is grab a sharp explorer to see if its a cavity. So just think of that. These people, the survey I showed you used explorers. If you look at the diameter of the tip of the explorer and the diameter of this one it wont go more than .4mm into the fissure. If you remember your dental pathology days, the initial lesion is at the bottom of the fissure along the sidewalls of the fissure. There is no way you can put this all the way into the tooth and see if there is any demineralization. European dentist, epidemiologist would say dont use the explorers. There are sharp eyes, no explorers or blind explorers. 3 reasons. #1 you wont see what is really happening using that. #2. This is actually something you can reverse. There is something called remineralization. Very early lesion you can take up fluoride and other things and you can go back to the original status. If youre going to probe around w/ a very sharp instrument youre going to disturb that. There is some evidence that you can examine a carious tooth, take a good dose of Strep M. and other bacteria, go to the sound tooth right next to it and implant a nice colony or multiple colonies of that organism and you ask that patient to come back 6 months later. Youll see a cavity in the tooth that was sound last time you were looking at it. You dont realize you may have contributed to its transmission. I dont know what they teach you in the clinics. Ask the person who is giving the lecture if we are supposed to used explorers or not. The point Im trying to make, all these figures Ive showed you 90% and 20 surfaces are based on limited methodology. [25] [Occlusial caries into dentin?][Dr. Dasanayake] To prove that point, Im going to give you a little quiz. This is to wake you up if youre sleeping right. How many of you think that this little thing right here is all the way in dentin? Raise your hand. This is what youll do in clinic/ field. Youre going to dry it, no probe/ explorer and then make a determination of whether its in dentin or enamel. People who said dentin keep your hand up. Im going to take a section. This is the same tooth. You can see cement-enamel junction. So thats the challenge youre facing. Ive done thousands of dental examinations under field conditions and its no easy. In the clinic its much easier, you have everything you need and you take an x-ray. Just to make it interesting, how about this guy? How many do you think its in the dentin? Ok. Remember what I was telling you earlier? Its going to spread sideways along the CEJ. So whats the treatment for this as opposed to what you saw earlier. Whats the most likely thing you want to do to this one? Fill? Seal it. Ok. She wants to seal that. Anybody is inclined to take the largest round burr you can find, cut it up and fill it? No. How about dabbing a little fluoride and see if you can reverse that. When it comes to this one, youre options are more limited. This is why it is critical that initial diagnosis is accurate. [26] [Diagnosis of dental caries][Dr. Dasanayake] This is some data, which shows you various techniques. This is what we call visual tactile w/ a little probe/ explorer. This is the visual only. These are the university guys like me. Other people who are seeing 100s of patients on a daily basis. These are the real private practices. You know what sensitivity is right? Sensitivity is, taking 100 truly carious teeth, what proportion that you would diagnose as carious. Confirmation comes later right. Theoretically 100% caries, you only pick up 65% using these techniques. That means 35% of the time you let them go even though they have carious lesions. Not an ideal way right? If it is breast cancer, would you go to a practitioner that as 60% sensitivity to detect your cancer? You want better odds than that. This is other. This is radiographic. Do you think that will improve it hugely? This based on some real data. Not much. This is the clinical examination. This is what 38% according to this particular report. [27] [Decisions about Occlusial Caries][Dr. Dasanayake] What Im trying to tell you is that if it is a sound tooth, no harm done. Ok, you send them, give them advice, dab a little fluoride. If it is in this spectrum w/ a real cavity, get your drill cut it and fill it. This is where you have the problems. Early occlusal enamel lesions or suspicious dentinal caries. The evidence will tell you the sensitivity in detecting these is not very good. This is something for you researchers in the audience to think about and those w/ engineering backgrounds there is stillroom for you to come up w/ a better diagnostic technique. [28] [title of slide][Dr. Dasanayake] So the bottom line is, in all of those figures I gave you, 90%, 15 surfaces and all that youre describing the tip of the iceberg since the detection techniques are limited. So if I want to put some numbers, we tend to miss 35-40% of lesions using the current diagnostic techniques that we have. We tend to cut sound teeth over 20% of the time since we have problem in our diagnosis. We use inappropriate treatment decisions maybe 1/4th of the time. This is something for you to think about. Before you grab that drill, think about the diagnostic criteria. Think about the reality and ask yourself. [29] [Where do you want to go?][Dr. Dasanayake] Alright. So where do you want to go from here? Whatever the numbers that I gave you, 90%, 15 teeth. Where do we want to go from where we are today? The U.S. government do something called the healthy people objectives. The last set was 2010. This is 2020 objectives. We are 6 years away from meeting those objectives. It is good for you to know what these objectives are in relation to tooth decay. [30] [Webpage][Dr. Dasanayake] If you go to healthypeople.gov/2020 you can see the entire spectrum of oral health related objectives. Ill give you one example. Reduce the proportion children and adolescence of dental caries experience in their primary or permanent teeth right? They further break it down 1.1 3-5 year old children. Remember we saw an increase b/w the two surveys. Their objective, currently 33% of children had dental caries and you want to bring it down to 30%. Thats the 2020 objective. Ask yourselves how we will do that as a nation. Right now 1/3rd has early childhood caries and we want to bring it down to 30%. Its not a huge decrease but they are being practical and it has to be feasible. If you say 5% you know they are not going to reach that objective. [31] [Prevention of Oral Disease][Dr. Dasanayake] Ok so. I want to sort of take a step back and look at it from the theoretical point of view of you understand. Prevention of any disease, oral or any other disease. Lets look at the conceptual framework for that. It is so easy right [32] [No title][Dr. Dasanayake] ?#1. Lets identify the determinants of health. We talk about minorities, we talk about poverty. I didnt talk about education but it plays a role. All of these things that determine what happens down stream. These are the upstream events. Then when it comes to tooth decay of course you have to expose yourself to pathogens. We know there is a microbial component to tooth decay. There is fluoride and sugar and all these other things. Then in a biological time frame, the biological onset of diseases, there is that early enamel lesions, disturbance to the mineral structure of the hard tissues right? Were not capable of detecting that. If it is a cancer maybe we can. Tooth decay, we are not capable of predicting the biological onset. We have this preclinical phases where the kids are walking around. Then the symptoms appear. Pain, swelling, whatever it is. Parents will notice and they will bring the child to. Then this is the clinical phase. At some point they come to you. You give the therapy whatever it is, and the outcome is that you cure that w/ sealants like you said earlier or fluoride application or filling or the child can die as in the case of the (says some word I cant understand) or living w/ the disease that gets worse and then death. This is a vicious cycle that goes on and on. I [33] [Stages of Prevention][Dr. Dasanayake] f you look at that framework. The primordial prevention that is the actions to minimize future hazards to health and to inhibit known environment, economic, social, behavioral, and cultural factors to increase disease risk. Thats a very broad determinants. I talk about all the other things. This is where the education and access to care and all the other things come into play. As a single clinician you have a very little role in this primordial prevention. This is where the policy makers will come into the picture and work w/ dental organizations and professional groups put pressure on the congress and various other parties to make some changes in the broader determinants or upstream events related to tooth decay. This is a perfect example, the sugary drink ban. You remember that? Where you remember when it happened in NYC? The former mayor wanted to ban 16oz or larger sugary drinks in restaurants in NYC. [34] [Sucrose for comfort][Dr. Dasanayake] Do you know what happened to that? This is to just give you an idea of how much sugar we eat. 1980- 120lbs/ captia. 2010-132lbs/ captia. That is probably the same weight that I have right now. This is the diabetes going from 2.5 to 6.8. The children who are obese 5.5-16.9. Not only the tooth decay, but also the sugar is the new tobacco. Idk if you have read the books on that. If you have any interest go and type sugar is the new tobacco. Just to tell you the 16oz story. What happened to the former mayor. [35] [Picture of Mayor][Dr. Dasanayake] This is a govt coercing lifestyle decisions. That is the American Beverages Association taking them to court. I think it is still in court. [36] [Stages of Prevention][Dr. Dasanayake] So the second stages of primary prevention. That is a reduction of personal exposure to risk factors or enhancing the resistance to the risk of exposure. Can you think of an example in relation to caries? Put a little fluoride in your drinking water. Now you increased the resistance of the tooth and mineral tissues to the acid attack. Secondary prevention is the detection and treatment of preclinical pathological changes. This is where you come in. Varnish application on early enamel lesions or putting sealants since youre dealing w/ these preclinical pathological changes. And most of the time, they dont come to us during the preclinical stages, they come to us at the completely advanced stages of the disease and now you take attempts to soften the impact caused by the disease on function, longevity, and quality of life. This is where famous drill, fill, and bill come into the picture. This is what we do most of the time. 90% of my practice when I was a practicing as a dentist this is what I was doing. Its not effective as a clinician. Its not effective at the community level. [37] [Yet the prevalence of these diseases are still very high][Dr. Dasanayake] Yet the prevalence of these diseases are still very high. I told you. [38] [Web Page][Dr. Dasanayake] This is an interesting article. This is NY Times Business section Oct 2007. When it ends up here people pay attention to it. Previously unreleased figures by the CDC show that 03-04 27% (1/4) children and 3/10 adults had cavities untreated. They are walking around w/ untreated tooth decay. [39] [HP 2020][Dr. Dasanayake] This is the same things that I told you about. HP 2020 objectives early childhood caries. This is where we are 33.3% and we want to come down to 30%. This is the untreated tooth decay. Right now we are at 23.8% and 2020 objective is to bring that down to 21.4%. If youre in charge for this for NY State how are you going to do that? What are you going to do? Reduce the prevalence of ECC and now reduce the untreated childhood caries. Ok. Anything else? I like you to participate as well. You might have brilliant ideas that may solve these problems. NYC 25,000 children to do sealants and varnish application. There are a number of different ways of doing that. [40] [Need to identify][Dr. Dasanayake] So how are we going to do that? You already gave me some answers. Need to identify the factors implicated in the etiology of dental caries. I havent done that formally. I just gave you some examples. Lets look at it formally. [41] [Etiology and Preventive Factors in Caries][Dr. Dasanayake] This is how I see the oral cavity. Its a jungle. You have your teeth, then you have your sugar, you have your bacteria. If youre on a fluoridated water supply/ toothpaste you have fluoride in the equation and then you have saliva or you dont have saliva. When I talk for 2 hours I can see my mouth is drying b/c I am on medications for various things. This complex ecological system in your mouth is what is going to dictate what is going to happen to your teeth. [42] [Casual Model][Dr. Dasanayake] This is my simplified way of looking at this. I see that as a balance b/w preventive factors (the good factors in the factors in the model earlier such as saliva full of antibodies and pH neutralizing effects, fluoride which is known to reduce caries through antibacterial action and remineralization), and heres some of the etiological factors such as sugar and bacteria. If you can tilt this to the preventive elements than maybe youll get a better outcome, like the school health program that youre talking about. Lets take one element from that complex etiology. [43] [Fluorine, Stains,][Dr. Dasanayake] Lets take fluoride. This is a story, fluorine, stains, and tooth decay. Fascinating story if youre interested in history. Someone like you graduated from a NE dental school went west to Colorado. Frederick McKay in 1901. He was looking around and sees these children in Colorado Springs area w/ brown stains on their teeth. There is nothing in the literature during that time. Being a curious person he started to work w/ famous G.V. Black. Did some studies to look at what is happening to these children 1909-1915. The theories at that time was b/c of some inferior pork/ milk, or calcium in the water. This is how you do investigation. There are theories. Around the same time, the American aluminum corporation were making pots and pans, the director of that corporation thought I dont want this to come back to my cooking pots and pans so he put someone in charge a biochemist to take the water samples from these areas and test it and see whether you can see an exposure to aluminum and these stains. During this investigation they found out these children were drinking water w/ vary high levels of fluoride. Thats the fluorosis connection that was first reported in 1931. As a result of that, the state that youre living in right now (NY)1944 started what we called the community innervation trial. Have you been to Newburg. Newburg-Kingston studies. Its right here. If you take the Metro North, you go up a 100 miles or so north of here on the beautiful Hudson valley, that is where the experimental community where they put fluorine in the drinking water. They wanted a comparison group and they went further up into Kingston and no fluoride in the drinking water. Heres the fascinating story. 1944 June, did the baseline examination in both communities. 10-12 year old children and they were going to follow them up w/ oral examinations w/ plans to do 10-12 year follow ups to see if addition of fluoride would make a difference. May 2nd, 1945 NaF was added to Newberg 1-1.2ppm. Within 3 years in Newberg there was a 18% reduction in the first permanent molar caries in that time period. This actually allowed a lot of credibility. This is one of my buddies from dental school who is practicing in Newberg. Notice we are testing the local water supplies for fluoride. The first community in the world that put fluoride in their water was Grand Rapids, Michigan in 1945 as a result of these studies. The fascinating stories is that things have changed since then. [44] [Percentage map][Dr. Dasanayake] This is a little old map to tell you in which states we have a lot of fluoride. You know how to read this one. These areas, Oregon, Montana, Utah, less than 25% want fluoride. Our neighbors in NJ, not a lot of fluoride in the water. [45] [Web Page][Dr. Dasanayake] If look at more recent data. 2010 just to give you an idea we have 308 million people in the country and only about 66% are living in fluoridated communities. Youre shaking your head right. Youll see the other side of the coin in a moment. If youre interested in NY state 74% of the people. You go to NJ or some of those states w/ little fluoride its very small numbers. [46] [Systemic Review..][Dr. Dasanayake] Now here, lets take the scientific approach. Lets do a systematic search and see whether we can gather enough evidence to show and convince people that putting fluoride in your drinking water really is going to reduce caries. This is called a York study published in 2000. Little old. Now if you came to my SAPL 1 seminar you already know how to read this. This is a forest plot. Let me orient you. All these are the studies going across, individual studies they looked at. Here they are looking at the percentage change in children w/o caries in fluoridated compared w/ nonfluroidated communities. They are looking at the mean difference and 95% CI. If there is no effect you would be w/ the line w/ 0 no difference. Mean value in community minus the mean value in another would be 0 if they are the same. Most of these studies if they are right of this vertical line 1, that is favoring fluoridated water. As a mean difference. All of these studies, if they are crossing the line that goes through 0, its not a statistically significant study. When you pool all of these things, you can see clearly 5,8,12,15 year olds on average adding fluoride makes a difference in terms of prevalence. This is the proportion of children w/o caries. Caries free children. They are actually doing something good. If you take a look at a mean number of decayed, missing, and filled teeth, either permanent or primary, you can see clearly significant difference. Everything favoring adding fluoride in the drinking water except this little study that is crossing the null value of 1. Its a good thing to add fluoride to your community water. This is a systematic review, large review, peer reviewed journal. [47] [Webpage][Dr. Dasanayake] W/ that in the background lets see what is happening in our communities. This is March 2007. Mount Desert residence (Maine) wanted to remove fluoride from drinking water, 229-42 margin. Why are people doing that? Have you anti-fluoridationist. There is a group that is against that. Mass medication, govt has no right how to tell me how to live my life. Dont put fluoride in my drinking water event though you have scientific evidence that it reduces the prevalence and it reduces the number of teeth that are affected by caries. Thats the problem. It doesnt only happen in this country [48] [title of slide][Dr. Dasanayake] This is one of my favorite slides. This is Florida. That was Maine. Now go from one end to the other. Pinellas County will stop adding fluoride to its drinking water ending a cavity fighting effort that riled critics of big brother govt despite decades of advocacy by dental and medical experts. This is the funniest part. Fluoride is a toxic substance said tea party activist. This is all part of an agenda that has been pushed forth by the so-called globalist in our and world govt to keep the people stupid and they dont realize whats going on. So you will see the arguments on both sides of the equation. I was in Newberg visiting my friend. I went to a gift shop to buy something. The cashier had a laptop on the counter and it was covered w/ anti-flurodiationist propaganda. We had a fantastic 2-hour conversation, her father is against fluoride. He got divorced b/c of that. His mother was fighting him. He built a system in his house to remove fluoride in his drinking water. Youre going to work w/ people like that in your communities. When you have a little of free time, read these arguments on both sides and there were some concerns in relation to fluorosis. [49] [EPA and HHS][Dr. Dasanayake] Thats a genuine concern. So as a result, 2011 this is the EPA in the U.S. They proposed the recommendation of .7mg of fluoride/ liter going from 1.0-1.2. Now its .7 if you put fluoride in drinking water. Water replaces the current recommended range .7 to 1.2mg just to prevent fluorosis (mild) in childrens teeth. [50] [Web Page][Dr. Dasanayake] Its not only happening in this country mind you. This is from New Zealand. The bombshell decision to end fluoridation in New Plymouth is the beginning of the end for the practice in New Zealand after 40 years of adding fluoride to their drinking water. B/c this is an expensive proposition. Someone has to monitor that. You cant just put fluoride and just walk away. You have to monitor it. You have to have the resources, the engineering to make sure its not poisonous. All of these things come together and we are taking a great public health measure away from our populations while caries rates are increasing in our children. You do the math. [51] [The fluoride deception][Dr. Dasanayake] This is an interesting investigative reporting. Christopher Bryson use to work for BBC. He wrote a book called the Fluoride Deception. I recommend finding a copy and reading it to look at the other side of the arguments. [52] [On 7/24/2014][Dr. Dasanayake] So one last thing I want to say on fluoride. This is as of two weeks ago. 7/24. Ill give you the latest information. Current information. Senate LHHS released a report accompanying their 2015 budget, their senate bill. Good news the subcommittee proposes funding up to $30.5 billion for NIH. That is for oral health right. $402 million for us NIDCR, dental and craniofacial branch institute of the NIH. Thats good news. They put some language in their report on dental caries. What did they say. Two weeks ago. This committee recognizes that dental caries remain the most prevalent chronic disease in both children and adults resulting in a significant economic and health burden sometimes fatal although caries are significantly decreased for most Americans. Remember the slide I showed you for adults, everything decreased b/w the two surveys. This trend has recently reversed for young children. I already showed you data for 3-5 year olds an increase trend. The committee is concerned about conflicting information in the media regarding the benefits of community fluoridation and urges the NIDCR to enhance efforts to communicate sound science related to dental caries and their prevention. So when you go to your practice either here in the clinics or your own practices, you have to arm yourselves w/ the correct information since there will be people that will come in and tell you that I dont believe in this. This is a national govt effort. [53] [Etiological and Preventive][Dr. Dasanayake] So I talked about fluoride. Lets just briefly talk about sugar. Im going to take a break and Ill finish 10 minutes before 5. Is that ok w/ you. I can finish now and you can go home. Let me get a few more critical points across and Ill let you know. Lets look at this sugar. Theres some things I want to drill into your heads. [54] [Effect of Dietary Sugar][Dr. Dasanayake] How many of you have hard of this Vipeholm study? Have you ever heard of that? No? Its a human trial. These are institution less people in Sweden. 46-51. They were given large amounts of refined carbohydrates. These are sticky balls of sugar the size of a golf ball. Some people got about 8 some people got 24. These are the males and females. Look at the baseline caries DMFT. Look at what happens. As a control group there is a slight increase. All the other groups there is huge increase b/w 46-51. This is the first time we saw that refined carbs are the culprit of this one. Can you imagine doing something like that today? Its highly unethical right? These poor people w/ no power to make decisions. They were in elderly homes. They were guinea pigs in these trials. Go and read these original articles. Its fascinating. [55] [The Vipholm study..][Dr. Dasanayake] This is one of the (Bo Krasse) in this particular study who wrote an article 50 years later in JDR in 2001 50 years later, recollections and reflections. Couple of things the original report didnt point out. #1. 20-30% did not develop caries despite high sugar intake (8 toffees or 24 candies) 1/3rd of them didnt develop caries. #2. Those who avoided refined sugars developed caries in that trial. That makes you think about the role of sugar. [56] [The Michigan Study][Dr. Dasanayake] Here, various famous epidemiologist he was looking at the DMFS increment b/w 82-85 and plugged that against how much sugar you take. These are grams of sugar/ day. Youre gut inclination right now is more sugar = more cavities. You expect a line going like that. He didnt see that in his study. Its all of the place. I can draw a horizontal line here and say there is no correlation in the amount of sugar and the decayed and missing surfaces. These are some of the things that you have to think about. When I was practicing, my major health education messaged: brush your teeth after ever meal and restrict your sugar consumption b/w main meals. Thats it. Maybe thats not enough. There are some other things. [57] [Per capita sugar consumption][Dr. Dasanayake] Just for your information. How much do you think you guys eat/year? Here are some of the countries. Rwanda 1.5kg, U.S. and if I plot the caries experience in these things youll see the same pattern right? Swiss chocolate. Go to Switzerland. 70kg. some background information. [58] [Picture][Dr. Dasanayake] This is something that I actually observed in Grenada. We use to do some fieldwork in Grenada. This was 2011 September. This is what I see when I go to a classroom. 20,000 children in the island of Grenada. [59] [Caries Free][Dr. Dasanayake] Just to give you an idea, these are caries free children. About 80% of them were like that. Right? I saw these two kids outside the classroom during recess. One eating an apple and most everyone else was doing that. When you go to any school you see a little area where mostly a parent is selling sugar to their own children. Just think about that right. Its like selling cigarettes, alcohols and drugs to their children. B/c they dont know. You talk about education. This is why Im sharing this information w/ you. Beautifully dressed children. You know what is this? A plastic bag full of ice and cane sugar. Its a very hot place. They keep themselves cool and they have a lot of cane so they are sucking on that for 7-8 hours a day. No wonder I saw the clinical pictures that I shared w/ you. [60] [Etiological and Preventive Factors in Caries][Dr. Dasanayake] So that is just a little bit on fluoride and sugar. Im not going to talk a lot about bacteria b/c Dr. Caufield will come in and lecture you on microbiology of caries but Ill hit on a couple things to make the story complete. [61] [W.D.Miller][Dr. Dasanayake] Do you know who this guy is? W.D. Miller. Never heard of him. He wrote the first book on oral microbiology. American dentist. He was in Germany working w/ the dentist there. Married the dentists daughter came back and became the dean of Michigan. He wrote the first book. He was asking in his book if there is any one bacterium, which may always found in decayed dentition, which may therefor be called the bacterium of tooth decay. Fascinating. Read the book if you have a chance. How many assignments I have given you know (lists all the books). This is what I wanted to share w/ you. [62] [Evidence in bacterial origin of tooth decay][Dr. Dasanayake] So this is that same picture that I showed you. Think of that child from Grenada. If you take a sample from their biofilm and put it under a microscope you will see organisms like this. Can anybody identify this colony? Have you done oral microbiology? Have you worked saliva samples? Have you grown samples? It use to be fun as students. Wed take samples of each other and grow them and see who is a millionaire. Millionaire is the millionth colony forming units/ mL of saliva. That means youd had very high risks. Its sad we have taken those fun elements of the curriculums. This is S. Mutans. A key etiological factor. What is this? Have you ever taken a sample and grow it on medium and see that it is L. Bacilli. This guy is all over the place. There are over 600 different species of bacteria in your oral cavity. Some are actually harmful to you since they take the sugar in your drink and produce acid and youll see the effects that you see here. Im going to skip some of these slides. Its not very interesting to you. [63] [Oral Colonization][Dr. Dasanayake] Heres a concept. A birth how many do you think babies have caries causing bacteria in their oral cavity? You think they do have? In the 1980s when I was doing my graduate studies this is a question we were asking ourselves b/c the little infant has no immunity to fight pathogens. We though the mouth were sterile at birth or they would die. If you have pathogenic organisms that you acquire through the birth canal or through someone who is taking care of you, youre going to die right? We thought maybe the mouth is sterile, maybe there is a period where all these teeth come into the oral cavity, and the baby will get the organisms from the mother. They are the usual suspect. They have constant contact, share the same spoon, take the feeding bottle and put it in your mouth to taste the temperature and put it in the babies mouth to give it a good dose of S. Mutans. If you go back to read the literature, concept called window of infectivity. We thought that around a little window these babies acquire S. Mutans. Go back and look at the literature. Using that we did a randomized control trial and towards the end of it, what is the source of S. Mutans? We thought it was coming from the mother to the baby. The strains in the baby were similar to the strains of the mother (looking at genotypes of the strains). The question that I put to you is if there is a strong bacterial component to tooth decay shouldnt we take that into consideration when you try to treat/ prevent tooth decay?[64] [Conventional Model][Dr. Dasanayake] So this is what we try to normally do. Stay w/ me if youre sleeping wake up. This is important. This is a conventional model, which we call surgical approach. What do we do? We treat clinical signs w/o effectively addressing the bacterial causes .You see a cavity and you put a little fluoride, put sealant, drill it, fill it, bill the patient. Surgically remove the lesion, fill w/ inert material, restore function, encourage patient to brush, floss, and cut down on snacks. If they come back and you see new lesions youre going to be blame them. Thats what I did and thats what some of you might do. [65] [Surgical Model in Bacterial Infection][Dr. Dasanayake] Lets take this one step further. Lets say youre dealing w/ TB. Its a known bacterial infection right? Mycobacterium tuberculosis. Its causes TB right? Lets use the same approach were using in dentistry. You w/ me? Lets do the same thing. Lets diagnose w/ a skin test. Take a culture. Positive diagnosis. Take an x-ray. See the lesion in the lungs. Cut the lungs out. Take the cavities effected by TB and fill w/ inert material to restore w/ form and function and then ask them to come every 6 months. Will that work? How many of you would take this approach when you know the root cause is T.B. b/c this is malpractice. So we need to think through what we do to our patients. Ask ourselves, the surgical model is disappearing and we need a medical model to treat tooth decay. I know youre going to acquire great surgical skills. Cut the exact textbook definitions. Thats important but at the same time, engage in thinking and ask yourself what am I doing here. Im going to summarize some of the antimicrobial approaches that I have seen in the literature for your benefit here. [66] [Caries Prevention][Dr. Dasanayake] Lets focus on the multispecies biofilm. Its not one bug like in TB. Its a colony. Its a community of bacteria in your biofilm. You brush you clean you get a scaling and everything but within seconds the biofilm formation begins. All of these organisms would come and colonize that. How would blocking the plug build up? Remember GTF? One of you come up w/ a genius way of blocking GTF production so there wont be any plaque right? This is theoretically possible b/c people who have deleted GTFB and C genes actually eliminated 90% of caries. How do you do that? They have used various chemicals/ compounds to do that. How about targeting the extracellular polysaccharide formation. Cranberries. They are known to be antimicrobial. If you have UTI you drink that juice. Its been proven. Cranberries flavonoids can influence GTFB and C. There are some trials around the world. How about combating specific bacterial burden. Use chlorohexidine, use iodides, and use fluorides. Breaking the chain of transmission from mother to the baby. How many of you believe there will be a caries vaccine in your lifetime? Make everybody immune to S Mutans or whatever causative agent there is. There are some trials going on. Ill work w/ some immunologist but I dont think thatll happen in your lifetime. How about altering the oral ecology? Replacement therapy. These are ideas that people have tried. Im sharing that w/ you so youll get your own idea. You take S. Mutans w/ the sugar in your drinks to produce lactic acids. What if you genetically engineer S. Mutans to not produce lactic acid but ethyl alcohol? Right? You dont get cavities. Youll be drunk but you wont get cavities. There is a group in Florida that tried that approached. Lactic acid changed to ethyl alcohol. These are the things I want you to think about. Exciting things that may or may not come to your clinic in the near future. Im going to wrap it up as your requested. [67] [What approaches are][Dr. Dasanayake] So what approaches are available to you as a clinician when you are in this fancy clinic? Of course you can talk to them about oral health and the importance of that. Dietary restrictions, varnish, rinses, sealants. If they dont come to you, you have to go to them in those communities. Minorities, low-income communities. What can you do at the community level? Put fluoride in their drinking water, against their wishes at time. Increase their access to care. School dental health programs. Health education and various other things that are available to you. [68] [Tooth brushing and caries][Dr. Dasanayake] Im going to now collectively w/ you look at some evidence for these things. How many of you think that by brushing your teeth w/ fluoridated toothpaste can help prevent caries. [69] [Article][Dr. Dasanayake] There are some caveats that Ill show you here. This is that famous Cochrane database. They take the number of trials and pool them. Lets look at the evidence. They were summarizing 74 trials. They were looking at this preventive fraction. What proportion is prevented by using fluoride toothpaste. First part, if you use 1000/1055/1100/ 1250-ppm concentration theres about 23% reduction of caries in permanent teeth. It has to be in high concentrations #1. If you go to 36% w/ toothpaste concentration of higher than 2400/2500/2800ppm you go from 23% to 36%. Higher concentration the larger the preventive fraction. If you use very low concentration less than 1000ppm below showed no significant effect. What is the take home message here? Read the label of the toothpaste and see what is the concentration of fluoride in that one? High levels may lead to fluorosis in children and can be lethal if swallowed. I think your safe in the 1,000-1,250 region w/ 25% in caries. Thats stories #1. [70] [Funnyinside.com][Dr. Dasanayake] This is something I saw. I think its funny. I feel that I have the worse job in the world. Yea right. [71] [Fluoride Varnish][Dr. Dasanayake] What about fluoride varnish and caries. Im going to use some of these articles in my future SAPL seminars just to show how confusing it is even to you. Different studies showing different things even to you. Different studies showing different things for the same preventive strategy. This is one study out of the U.S. She is the dean of UNC. Varnish efficacy in preventing early childhood caries. One group received fluoride varnish and the other didnt. This is 5% NaF the Colgate product. Added to care giver counseling to prevent early childhood caries. 2 years randomized trial is the follow up period. 360 caries prechildren that are low income Chinese or Hispanic San Francisco families. 1.8 months at the enrollment. All families received counseling. The children were randomized no varnish, once a year, twice a year, and unexpected protocol deviation. Lets forget that part here. Intent to treat analysis showed a fluoride varnish protected effect statistically significant. Ill show you that data here. [72] [Table][Dr. Dasanayake] This is 0 varnish. 1,2,3,4. Heres the number of children. This is the mean. Cavities in dentin, cavities in enamel in here. Going from 1.6-.8 and heres the preventive fraction at the dentin level. 53% reduction, 1 varnish application compared to 0. 58%, 2 varnish application compared to 0. 93% reduction 3-4 time application over 2 years compared to no application. Thats the U.S. story. [73] [UK Fluoride Study][Dr. Dasanayake] Lets go to UK. Slightly different study but still they are looking at the fluoride varnish. School children. A little older now. 36 month follow up as opposed to 2 year. They are looking at higher concentration. 3 applications. 22,000ppm each year. Or no intervention. Lets see what happened here. 95 schools were randomized for the test 95 for the reference. 1500 kids in each group. Intent to treat analysis was carried out. DFS increment was .65 in the test .67 in the reference group. No significant difference in-group. Young children in California 50-90% reduction but older children w/ higher concentration more frequently applied across the pond, no difference. Perhaps we should study these two articles in one of the seminars and see where is the truth and in conclusion we could find no benefits. [74] [South America Fluoride Study][Dr. Dasanayake] Just to confuse you even more lets go to South America. Its a Brazilian study. Varnish application and caries incidence. Its a 24-month follow-up. Its a smaller study, 89 children, and 92 children. Look at the new dentin caries lesions. 35%, 46%. This is the treatment group. This it the control group. None of these things are statistically significant. This could be due to the fact that its a small study. This is what Im trying to do w/ my SAPL courses. Allow you to make the decision by comparing the various studies w/ conflicting evidence given to you. [75] [Cochrane][Dr. Dasanayake] If I summarize the varnish stories using the Cochrane summaries, they had 22 trials published b/w 1975 and 2012 and this is what they are saying. People treated w/ fluoride varnish experienced on average 43% reduction in DMFS. Thats pretty good right? The one who wanted to go to schools and do a school based program, 43% reduction. In the 10 trials looking at the effect of fluoride varnish on baby teeth, the evidence suggests 37% reduction. It works on primary and permanent dentition when you pool all the studies together. [75] [Dental Sealants][Dr. Dasanayake] Finally lets look at the dental sealants. Again Im going to skip the individual studies and Im going to the highest level of evidence systematic reviews metanalysis. This is a little complicated. I dont like that review for that reason. Let me try to take you through that. I dont want to make assumptions, I want to see the real data. We assume that 40% of the controlled tooth surfaces were decayed during 2 years of follow up depending on the baseline caries risk weather there is fluoride in the water or other things. We assume 40% of those surfaces would become caries in 2 years. Then applying a resin-based sealant would reduce the proportion of caries surfaces to 6.3%. Tiny reduction. Similarly, if you assume risk is much higher in the population, 70% of the controlled tooth surfaces would be decayed over 2 years. Then applying resin-based sealants would reduce the proportion of caries to about 19%. So now you have seen varnish 43%, some evidence for toothpaste, some evidence for sealants. When you put all these things together, perhaps its additive. Maybe one will enhance the effects of another. Live in a fluoridated area rather than drinking bottled water. Drink from your tap. Perhaps you can take a good handle on this one. [76] [Breaking the Chain][Dr. Dasanayake] If youre interested in listening to this story, only 2 slides. Remember that I was telling you that we thought it was coming from the mother so lets treat the mothers mouth w/ antimicrobial agents? This is our fail attempt. Millions of dollars. 5 years of my life. What we did was take samples saliva samples from the mother and baby and look at the bacterial levels of the 3 months. After the delivery we took care of the mothers mouth. Healthy mouth right? Randomly put them into two groups. One group received random weekly application of 10% CHX and covered it w/ a varnish so the fluoride would stay under the varnish for a longer period of time. Slowly releasing into the oral environment. We wanted to see whether if we would make a difference #1 in terms of S. Mutans transmission to baby and as a result of that caries in child later. [77] [Figure 1][Dr. Dasanayake] This is mutans levels. Were looking at the mothers mouth right? First we should reduce the levels in the mother or it wont work. We can see yes, this is baseline, this is when we started the treatment we drastically reduced levels in mother and 4 applications within 1 month and every 6 month applications they stayed low for a longer period of time, but when you look at the caries data, 2.5 surfaces in the treatment group compared to 3.8 surfaces in the control group. In the right direction right? [78] [Figure 2][Dr. Dasanayake] I think this is an unfinished story here. We didnt have enough subjects 75 mother child pairs. Its worth redoing the study since I was encouraged by the direction. 3.8 to 2.5. Not significant b/c there are small numbers so this is something that I think we havent really completed that story. Find out who set up this experiment. Half the patients were given a placebo and it seems that other half were given another placebo. That was supposed to make you laugh. That was not the case in the study. [79] [Picture][Dr. Dasanayake] This is my philosophical slide. Looking back from Millers time 1890s you know what we have been doing? Lets say you go to a cocktail party. You come and cant find your car keys. Youre only looking under the lamppost for the keys? Why? Thats the only place w/ lights. We researchers were doing things that were convenient. We were looking under the lamppost. We havent done a good job in completing this story. [80] [Summary][Dr. Dasanayake] If I summarize everything I have been telling you, very simple. This is your take home message. If youre poor, and if youre minority or you have both you have more caries and untreated cavities. Prevalence is much higher and so is untreated tooth decay. Fluoride in water varnish, toothpaste, may work to some extent. We saw a range from 43% to some other percentages. Sealants will also reduce lesions. We have evidence right. At 42% kids and 95% adults still have current or pass tooth decay. 20-25% children and adults still walk around w/ untreated tooth decay in your own communities. We spend more money on dental care than what we spend in emergency rooms. So think about it, figure out a way when you go out to your communities and I hope you will now be thinking like this person I showed you last time I was here. Thats the first lecture on this series and any questions? Yes sir. Prevalence is if you take 100 people how many or what percentage will have at least 1 surface affected by tooth decay. Thats a proportion. Magnitude is on average how many teeth or surfaces are affected by caries. It could be decayed, missing due to caries, or filled. I feel sorry for the people that are not here. I know you can go to the podcast and get the information but I feel like the interaction is critical. Anything that you would like to add? How many of you have children? Maybe this is close to your heart? How old is your child? 5. No cavities? There you go. How can we make every single mother in our community like that? What do you do differently? I will send a copy to Dr. Allen. I know it is on your podcast. Idk how clear the pictures but you can have your pdf of these things. If you have any questions feel free to email or catch me when I come back next time Ill be there. I might use some of the varnish studies w/ conflicting evidence and see whether we can make sense out of those things.

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