ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦ
Department of Health
Munaqhiliqiyitkut
Ministère de la Santé
Dental Health: Prevention of decay
and fluoridation of water
Vinay Pilly, BDS, MPH, MSc, FRCD(C)
DentalCareinNunavut
Howdentalcareisfunded?
1.
Non-InsuredHealthBenefitsprogram.
2.
HealthCanadaContributionAgreements(NWA,THIF).
**Dentalinsurance,clientfunded,etc.
Howdentalcareisdelivered?
1.
DentalTherapyprogram(ArcticBay,Arviat,Rankin,Iqaluit).
2.
Children’sOralHealthProject.
3.
OralHealthPromotionprogram.
4.
Contractdentists,dentalhygienistsanddenturists.
**PrivatedentalserviceinIqaluit.
OralHealthStatusofChildrenandYouth
inNunavut
Indicator
First NationsOralHealth Inuit OralHealthSurvey Canadian Health
Survey(2011)
(2008)
MeasuresSurvey(2009)
Children(3-5years)
Decayprevalence
85.9%
85%
-
Untreated decay
35.2%
49.0%
-
Children(6-11years)
Decay prevalence
93.9%
93.4%
57.0%
Untreateddecay
16.7%
32.0%
14.5%
Children(12-19years)
Decay prevalence
91.4%
96.7%
59.0%
Untreated decay
22.9%
38.1%
13.6%
WhyPrevention?
•
Oralhealthimpactsallaspectsofdailylivingandgeneralhealth.
•
Decayispreventable.
•
Preventivedentalprogramscandrasticallylowerdecayinchildren.
•
Lessmissedschooldays.
•
Instilsgoodoralhygienepracticesatayoungage.
•
Highlevelsofdecayinchildrenarecostlyandtraumatictotreat.
Whychildren(schoolbased)?
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Notanindividualresponsibility.
1/3 ofNunavutspends1/3 ofdayintheschool.
Catchthemearly.
Safeandwellaccepted.
Mitigatebehaviourandagoodstartingpoint.
Futureworkforce.
InuitOralHealthSurvey- Recommendation
“Oralhealthconditionscannotbetreatedaway,evenif
moreresourcescouldbeapplied.Moreemphasis
(shouldbeplaced)oncommunitybasedprimary
preventivemeasuresbackedupbyearlydetection
andpromptbasictreatment”.
NunavutChildren’sOralHealthProject
• 2013– Pilotprojectin3communities.
• 25communities.
• BasedontheChildren’sOralHealthInitiative(COHI)program.
• CommunityOralHealthCoordinators(COHCs)– Inuitoral
healthserviceproviders(75%).
OralHealthEducationandPromotion
“Teeth for Life”
DentalScreening
DentalSealants
•
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Protectivecoatingonnewlyeruptedadultteeth.
Pitsandfissures– Mostvulnerable.
Grades2– 7.
Containfluoride– actasreservoir.
Evaluation– 6months.
HighlyEfficacious.
Provider.
Greatpatientacceptance.
http://wakedentalwellness.com/dental-sealants/
FluorideVarnish
• Safe,effectiveandhighlyefficacious.
• Appliedonanyonewithteeth.
• Bi-annualapplication.
• Adhesive.
• Highfluoride(22000ppm)concentrationusingsmallamounts.
• Provider.
• Easeofapplication,fastsettingandgreaterpatientacceptance.
FluorideMouthRinseProgram
•
•
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Rinseliquidcontainingfluorideatschool(onceaweek).
Supervisionofatrainedstaffmember.
Beginingradeone(childrenolderthan6years).
Provider.
Cons.
http://www.register-herald.com/news/new-river-health-is-putting-the-rinse-on-tooth-decay/article_8299f440-a2b3-558d-8c5d-032dcca5ccda.html
SchoolToothBrushingProgram
• Mosttoothpastescontain1000ppmoffluoride.
• Supervisionofatrainedstaffmember.
• Amountoftoothpaste.
<3years:Adultshouldbrush;Ricegrain
3- 6years:Adultshouldassist;Peasize
• Provider.
• Benefits.
http://www.esperanca.org/what-we-do/u-s-program/
InterimStabilizationTherapy
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Simplewayofstabilizingthedecayprocess.
Handinstruments.
Specialfillingmaterial,whichcontainsfluoride.
Highclientacceptability- Nofreezing.
Benefits.
Provider.
http://www.dentalcompare.com/Featured-Articles/2008-Small-Cavities-Big-Problems-Diagnosis-and-Treatment-of-Non-Cavitated-Carious-Lesions/
http://www.mistrymedical.com/item/8657/instramed-sterile-spoon-excavator-d-ended--s42-9403-
FluorideinCommunityWaterFluoridation
The“F”word
Community Water Fluoridation
• Waterisnaturallyfluoridated– high/low.
• Adjustingtheamountoffluorideindrinkingwatertooptimallevel
thatpreventstoothdecayandreducesthechancesofdental
fluorosis.
• In2007,HealthCanada’sFluorideExpertPanelrecommended
waterfluoridationlevelsbereducedto0.7ppm(Maximum
AcceptableConcentrationis1.5ppm).
Howmuchisppm?
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1 pennyin$10,000.
1minutein2years.
1dropin50litresofwater.
2.5cmin25Kms.
1inchin16miles.
Fluoride: How does it work?
• Constantlowleveloffluorideismaintainedintheoralcavity.
Post-eruptive(major)
• Remineralizationofearlycariouslesions.
• Inhibitionofglycolysis.
Pre-eruptive(minor)
• Preventsenamelsolubility.
• Incorporationoffluorideintohydroxyapatitecrystals.
StatusofCommunityWaterFluoridationin
CanadaandNunavut
• IqaluitandArviat(28.9%).
• RankinInlet- July2016.
• Canada- <35%.
CommunityWaterFluoridationin Nunavut
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MunicipaldecisioninCanada.
Logistics- Robustcapitalinvestments.
Feasibility.
Notclearthatpeopledrinktapwaterregularly.
Misconceptionsandfear.
Othersourcesoffluoride.
SystematicReview
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SystematicReviewofWaterFluoridation.UK/Internationalstudy,2000.
http://www.bmj.com/content/321/7265/855.full
RecommendationsforUsingFluoridetoPreventandControlDentalCariesintheUnitedStates.US
DepartmentofHealthandHumanServicesCentersforDiseaseControlandPrevention,2001.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm
ASystematicReviewoftheEfficacyandSafetyofFluoridation.NationalHealthandMedicalResearch
Council,AustralianGovernment,2007.
http://www.nhmrc.gov.au/publications/synopses/eh41syn.htm
FindingsandRecommendationsoftheFluorideExpertPanel,healthCanada,January2007.
http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-fluorure/index-eng.php
RecommendationsforUsingFluoridetoPreventandControlDentalCariesintheUnitedStates ,USCDC,
2001.
ForumonFluoridation,Ireland,2001.
ASystematicReviewoftheEfficacyandSafetyofFluoridation
NationalHealthandMedicalResearchCouncil,AustralianGovernment,2007.
InstitutNationaldeSantePubliqueDuQuebec,2007.
SafetyofFluoride
•
Safetyaspectshavebeenextensivelystudied.
•
Toxicityofanysubstanceisrelatedtothelevelofexposureordose(theamount
ingestedoveraperiodoftime).
•
Substancesessentialforlifelikewater,oxygen,andsaltcanbetoxicinexcess
amounts.
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Inconcentrationsused,fluorideisnottoxicorharmful.
•
Theoptimalrangeoffluoridealreadyhasabuilt-inmarginofsafetythattakesinto
considerationthevarioussources.
HealthEffects
• Dentalfluorosis- mostwidelystudiedadverseeffect.
• Mildandverymild- Notanadverseeffect.
• Moderate- isapotentialaestheticconcern.
• Severefluorosisisaconcern.
• The2007-2009CommunityHealthMeasuresSurveyrevealedthat
moderatetoseveredentalfluorosisissolowthatitisunreportable.
HealthEffects
• Skeletalfluorosisisthemostseriouseffectwithprolonged
exposuretohighlevelsoffluoride(8-10ppmdailyformany
years).NotseeninCanada.
• Overall,theweightofevidencedoesnotsupportalink
betweenexposuretofluorideindrinkingwaterandbone
fracture,intelligencequotient,skeletalfluorosis,
immunotoxicity,reproductivetoxicity,genotoxicity,cancer
orneurotoxicitybasedonaMaximumAllowable
Concentration(MAC)of1.5ppm.
Do we still need water fluoridation?
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Safe.
Cost-effective.
Equitable.
Lackofcompliance.
Valid.
Noevidenceofnegativeenvironmentalimpacts.
Silver Diamine Fluoride: New (old) way to
treat tooth decay
What is Silver Diamine Fluoride (38%)?
• Colorlessliquid
• pHaround8.0
• 25%silver:antimicrobial
0.1ml- unitdoseampule
• 8%ammonia:solvent
• 5%fluoride:remineralization
http://www.oralscience.ca/en/products/advantage_arrest/
8mlbottle
Silver Diamine Fluoride has been around…..
2014
2017
SilverDiamineFluoride
•
Arreststoothdecayby80%;90%when2X/year.
•
Preventsdecay– directlyandindirectly.
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$220/bottle=~250drops.
•
~88¢/drop;1droptreats~5teeth.
•
18¢/tooth.
•
Disadvantage:Staining(permanentandtemporary)
Programcosts/person
•
CommunityWaterFluoridation:
0.77¢- $4.00a
•
DentalSealants:
$20.00- $36.00b
•
ToothBrushingProgram:
$6.74c
•
FluorideVarnish:
$2.5
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FluorideRinsingProgram:
$2.24- $6.10
•
InterimStabilizationTherapy:
$16.20- $24.80
•
SilverDiamineFluoride:<$1
Note:Costprovideddoesnotincludeanyestimatesforthecostsofshipmentandstorageofsupplies,trainingandstaff
remuneration(includingtravel).
aCurrentcostanalysesdatathattheannualcosttofluoridateaCanadiancommunity
bCostsreflectNIHBfeesforinitialsealantperquadrant
cost assumesan8monthschoolyearinwhicheachparticipantreceives3toothbrushesand2tubesoftoothpaste
DaySurgeryforToothDecayinNunavut
www.cihi.ca
DentalTreatmentunderGeneralAnesthetic–
Estimation
• AsofMarch62017,thewaitlistwas588.
• Seriousmorbidityandpotentialmortality.
• $3,000- $5,000totreat*.
• Avoidablehealthcarecosts.
• Detrimentallongtermcognitiveeffects.
*Costprovideddoesnotincludeanyestimatesforthecostsoftravel,accommodation,food,
facilityfee,escortcharges,etc.
MovingForward
• Approachesarenotexclusiveofeachother.
• Multi-facetedapproach.
• Common-riskfactorapproach.
Questions?
Contact:VinayPilly
Email:[email protected]
Phone:(867)975-5778/
222-0318