Transcribed by Amit Amin August 07

th
, 2014

1
[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]
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[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
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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 17
th
. 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 18
th
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
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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?]
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[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
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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]
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[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]
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[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 1/4
th
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 1/3
rd
has early
childhood caries and we want to bring it down to 30%. Its not a huge decrease but
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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]
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10
[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]
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[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 2
nd
,
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
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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.
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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
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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) 1/3
rd
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
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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
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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
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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
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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
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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.
Transcribed by Amit Amin August 07
th
, 2014

20
[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.