Chapters Transcript Video Teeth of a Tender Age: Strategies for Protecting Kids’ Oral Health Ling. So is a professor in the division of pediatric Dentistry Department of Oral Facial Sciences at U CS F. She obtained her D DS and phd degree in West China University of Medical Sciences. She joined U CS F as a Lee Hen scholar in 2000, completed her pediatric dentistry residency training and became a faculty member at U CS F in 2008. As a researcher, an educator and a pediatric dentist. She focuses on translational research on microbiological aspects of tooth decay in Children. Her current research project uses high through poom assays to identify virulent genes and study their function in a major cavity causing bacterium mutant streptococci. She hopes that this work will help to develop tools for more effective and targeted prevention in Children with high carries risk. Her other research projects include evaluating carry management by risk assessment protocols in Children at different age groups and global oral health research with interdisciplinary teams. She is also actively providing routine as well as complex care including care for Children with dental or medical conditions who require treatment under sedation or general anesthesia at both U CS F mission Bay and Parnassus campuses. Her treatment philosophy is very prevention oriented. She works closely with her patients and their families to identify risk factors for common dental diseases such as dental caries and to adopt scientifically based preventative and treatment regimens to avoid future diseases. Thank you doctor. So for joining us, thank you so much um for inviting me um to give this grand run. Um I'm a part of children's hospital and um very honored to give this presentation and hope. Um our medical colleagues um can help us um finding um this really um pandemic disease in Children, especially um in Children with uh low income and high risk families. And you can, I've put my email address here um as a U CS F um faculty. If you have any questions, please um uh feel um uh free to contact me. So today, our topic, it's gonna focus on um infant oral health and carious management by uh guided by risk assessment um for all Children. Um I have disc disclosure saying no one involved in the planning or presentation of this activity has any relevant financial relationships with an uh with a commercial interest to disclose. So there's some key facts about early childhood caries. It's actually the most common chronic childhood disease. Um in the United States, it's five times more common than um asthma, which is the other medical condition that's most common in Children by age. Um five about um uh more than a quarter of the Children already, um, affected by dental caries and, um, the development of dental caries is very disappoint skewed. Um, that means about 15% of the Children actually accounts for 85% of the decay. And that's why prevention identified that group. It's very, very important. And as time goes on, um, the, um, prevalence of, um, dental carers is increasing, actually by age 12, more than half of the Children would have some carers experience already. And um what's unique of dental caries, it's a disease that can develop as soon as the truth, it rots. And you can see, I have a photo of actually one of my patient that we treated in the clinic. Um This is um a child that's um um the 18 months old and you can see a large um um dental abscess has formed. Um and her anti, that's why it's important to identify early. And our pediatric um medical um colleagues are probably sometimes at better position and uh in preventing and voting for um prevention of the disease than pediatric dentist because a lot of times we see them later than you are. Um And also the other facts of that dental period, it's also a transmissible uh multi factual infectious disease. So it's caused by a certain group of the bacteria and the biases of um the microbiota. So, if prevention can happen early and that can benefit Children for the lifetime. Um The last fact about dental caries is also um dental restorations alone to cannot change um the cavity causing bacteria level. The challenge of tooth decay, that's why no matter in Children or adults, if you only address um to fix the cavities that presents in the mouse, about 6 60 to 70% of the Children with previous dental caries will develop new carers in a year or two. That's why we emphasize on prevention and go hand. Um new work, go hand on hand on with our medical colleagues. What does the tooth decay develop? It's very simple. It's basically is the carro bac bacteria that stay inside the mouse. Most of them are on the surface of the tooth and in combination of any ferment carbohydrate. So it's including the sugar or candy, but not only those anything that can be fermented carbohydrate, um can be metabolized by uh carro bacteria produce acid with extensive time that overcomes what can be repaired um inside the mouse, then eventually it's resulting uh irreversible um or aggressive uh demoralization, mineral loss on on the two surface and result in two cavities in the early phase. Um If the demoralization happens daily in our mouths, and the reason you don't get cavities is that balance is where balance, that's why um it's important to discuss the balance in the tri. And this chart summarized um what the car is a tri including and um the two uh factors that in the um red warm shields. Um the pink um red shields, a diet and acid producing bacteria. Those are the factors are risk factors to cause to decay and all the areas that we can contribute the most. And people will say, oh there's some Children and a lot of parents may ask that I have two kids and they, I treat them the same way and one got a lot of decay and the other one never. But most of the case, um they do get and um all the cavities if you practice high risk procedure, just like any other medical disease, um the differences can happen because of the host factor. Uh study have been shown genetic factors like some of the protein encoding or tooth development or tooth structure, salivate component that mediating the bacteria, adhesion to the tooth surface can play a role. And that's why some people can get cavities where the others cannot. But the risk factor is what we're discussing trying to prevent that to happen. The other thing is the prevention protocols that include fluoride and other prevention that can change um the bacteria composition in the tooth. So I'm gonna discuss a little bit mostly uh in the later of the slides focused on, on the three factors including acid bacteria diet and other prevention protocols that we can insulate to prevent cavity formation. Um Because those are the modified uh factors that we can do. And um the ca carry balance. Philosophy is trying to combing and mediating the pathological factor um by uh protective factors was actually proposed do by Dr John Featherstone, our um a previous dean of the dental school. And that lead a paradigm shift actually of how we treat dental decay and how our teaching curriculum changed uh since 2003 in the United States. And it does um gave us a better tool to prevent the care instead of just chasing after the cavities. And I'm going to discuss um the pathological factors first, then at the last two slides and discuss about protective factors that we can work with the parents to change um the patient's behavior and outcome. So, uh the pathological factors that can be modified um is the carro bacteria and the frequency of injection, uh ingestion of ferment carbohydrates and also um reduce salary function that could be present in a lot of Children with medical complication. And because saliva uh holds on calcium and phosphate and to help us to repair what's been dissolved in our mouth. So that's actually dictates a lot, especially on Children with medical complications. Um why they develop cavities after they have those medical um condition and um abnormal abnormal too structure is um something that propose a risk factor that we may not be able to change, but that can happen in a lot of Children, especially when they get sick at early age. Um between um between actually the second to third two master until they're about six year old. If they got sickness, then their two structure can be affected. And we can propose in the future monitoring that two structure and maybe needs to add more prevention because if they have a weakened two structure or morphology. So the first risk factor we're gonna discuss is about um the carro bacteria, allogenic bacteria actually are a part of endogenous um bacteria in the healthy plaque. So they usually were present in adult dental plaque and usually um um composite that's than 1%. But if the environmental changes or the Children happen to acquire uh bacteria that have high higher violence, then they can all overpopulate and resulting um that more than 30% of the microbiome comp um population are carro bacteria in that way, dental care is can happen. So, um the nature of tooth decay, it's actually a result of microbiome dys biosis. And we know microbiome is a part of um could be a part of the protective um mechanism of a mouse. And in that. So um this comsal bacteria are critical for oral health and defense for the rest of the body problem um um systems and most of the conven comsal bacteria, if you see on the right hands are actually built naturally to have um much faster reproduction rate. Uh In a natural um tooth environment usually is 6.5 to 7. And in those environments, they grow much faster than cara bacteria because naturally they reproduce much slower, will never be able to compete with comsal bacteria. However, if you create an environment, that's very acidic, that means that acidic environment is less than 5.5 majority of the comsal bacteria will not be able to survive where the carro bacteria are very acid tolerate. And a lot of them uh prefer acidic condition and they were also populate and also create antibiotics. Those are the bacterias to suppress um the conso bacteria. That's when the para di and dime of microbiome were shifted and resulting. Um the continues um progressing of two decades. So I'm just gonna discuss two of the major car cavity causing bacteria. Um Since now, currently, um microbiome dysfunction is one of the key um um theory of how tooth decay happens. But there's two key bacteria still play a significant role in Children, especially early childhood. Carries a Mutant Strapped Coca on the left. Here is one of the most steady bacteria and convinced um to be associated with initiation of dental caries. And you can see um the photo here is actually a picture of the colonies of Mutant Strapped Coca and those bacteria prefers to grow in high sucrose um content and the mediums locked up for um Mutant Strapped Coca grows it has content, 10% of sucrose. It could be bacteria cy to a lot of common bacteria. But Mutant Strap Coca love them. What's unique about this bacteria is it can use sucrose to produce uh extracellular poly. That's why you can see the colony look very gummy. And what this means, it can produce a substrate of plaque that can attach to the two surface. It's really hard to remove and it becomes very non permeable. In that way, all the protective factors in the saliva cannot penetrate and buffer out all the acid. The other bacteria that plays a significant role in the progress as well is Lacto Baila. Um Previously, a lot of study think it's a follower of the mutant strep coca um uh colonized. But some study in Children also show it can be an initiator, especially bef microbiome can start um um maturing so they can and also lactobacilli is present in a lot of um the probiotic products. Um study, I mean, show once in adults, if your microbiome is solidified, it's hard for them to invade and become uh overpopulate um bacteria in the plaque. But at young age, if they consistently take it, it could be a threat. And one of the key factor of lactobacillus is it's preferable um growing ph is actually for its very acidic and that's why the environment plays a major role for them um to um colonize, determine whether they will colonize on the mouse or not like the zilla. It's definitely a great but probiotic for G I or um vagina system. But inside oral cavity, it's actually a paic bacteria. So we want to keep it low, not on the mouse. And one of the key modifying factor is trying to keep the mouse in the neutral Ph, in that way, it would not be able to grow. The, this recent study have showing a lot of uh other bacteria might be related to um Kerry's progress and a more confirmed one of um Canada AINS where the other ones um is uh still under more uh steady and see whether they play uh um more like uh a company role for the progression of the decay because the acidic environment. So uh in short summary, all the ca carries associate bacterias are usually acidogenic and a very acid Duric because they love low ph to grow. Where does those bacteria come from? Um the study in this area um More is more mature for mutant strep coca because it's the one of the most commonly studied and believed to want to be one of the key initiators um for a majority of the tooth decay. Um And a study had been showing the early um seeing or transmission of the bacteria. It's coming mostly from family members. And that's because um the Children at that time are more likely to have close contact with parents. And in dental study, they emphasized on whether it's vertical transmission or horizontal transmission, it's based basically if it's coming from the parents or the caregivers or more horizontally from the society, playmates and si siblings. And at early childhood, if the child's life, it's um mostly closely involves within home. Then those are mostly coming from the family members. Once their um lifespan expanded out um to outside, then the chance for getting those bacteria from um even the pre uh playmates in preschool or nursery schools or even in elementary schools um or other people is possible and study have also shown that horizontal transmission can um be happening between spouses and partners. Um Basically transmission medium for um mutant strap Coca through saliva. So any saliva sharing um habits can result in transmission of mutant strapped Coca. Some of the key factors that has been showing related transmission um of mutant strap coca is that from birth to three years old. It's one of the key critical time for the transmission of mutant strap coca and and result in a significant risk difference between children's future to get cavities or not. Study have been showing Children get mutant strep Coca before four years old compared to those who don't get it until four later imposes 4 to 5 times higher risk to get early childhood care is compares those who don't until four. And um so Children who got them early, if they don't get rid of them, they would be high risk for carers for the rest of their lives. And also um Children can acquire bacteria from anybody who has close contact with them. And also have sharing um salary. Um ha so saliva with others and is by a nature, we know all little kids um use that mouse stick spear um to explore the world and not create a high chance for transmission. But the risk factors associated with the, whether they get the transmission of the bacteria to be permanently inoculated or colonized on the children's mouths. It's also can be besides the salary uh saliva sharing habits. It's also uh depends on their oral cavity environment. That's small divide, whether they actually frequently take sugary intake or not or um whether they have their early commensurate or not. Um And those um we can work on to prevent transmission. And one of the most successful um transmission prevention protocol um has been developed for tens of years and have been steadied but many groups internationally in the world is showing um solito, it's one of the sugar free. Um um and sugar alcohol have been showing be able to prevent transmission of the bacteria. And most of the study has been done on maternal transmission because um um study had been showing especially um when mom is breastfeeding and has closed contact with Children. If they have cavities, those um to they have a higher chance to transmit the bacteria into the um child. And study have been showing if the parents are using Xle products back then. In Europe, the um common protocol is true little gums at 3 to 4 times a day and 6 to 10 g. Um during pregnancy, uh during the infancy when the child is from birth to three years old, show the most um active preventions transmission of the bacteria. And in the um one study that's got in Finland show about 70% of prevention compares other regimen such like uh fluid or mass and that conducted by mom. Um that show the Children um from 70% of the Children compared to control groups to get um mutant strap coca and result in much less um carries in those Children that, that effect um lasted until those Children were 10 years old. Although the prevention and education happened only in the first two years of those children's life. And um so. Right. Yeah. Um and establishment of the oral microbiota. Um and current study, there's several um funded study to look at um uh the uh establishment and the maturation of oral Biota showed um that early infancy is in the um seating community. Um that good comsal bacteria and um um mutant strap Coca can happen that can be seated in the little child and present a lung factor um for um lifetime and some of the modifier including um the ban internal gu vaginal um microbiome de delivery mood, whether they catch those early comsal bacteria or not, whether they're breastfeed or not in the diet and the um maternal um oral um bacterial level. But um it maternal is important the environmental, it's as important as well. We have conducted the study uh when we included in the family's grandparents are the key caregiver. Then the transmission rate shift from how, how, how often the Children get the bacteria from mom to the grandparents. So it's really um follows all the infectious disease transmission guideline is the close contact that's majorly influence what's happening. And once they get older, um go out to the um to the wider environment and their diet modifies, then the oral microbiome also changes differently. And for the carro bacteria, um the sugar uh really change uh um huge of decision whether the bacteria frequency and a month and especially whether Children experience tours or not um determine that my microbiome. And if they are actually getting more, less um frequency um carbohydrate, then their microbiome, it's gonna change dramatically. And we know the microbiome, it's like the development of the Children. Uh usually not until six or older, the child's microbiome is not um come close to the adult yet. And during that period of time, they're very, very vulnerable to all those carro bacteria um attack. And that's why we see uh also a study have been showed that prenatal um um health or health care prevention programs or early childhood actually plays a very, very important role uh in prevent caries and its most effective um in those parents. So, parent education um and uh it's very, very important and why this is um relevant um to clinic um co outcomes and I'm just gonna present, present what changed the dental um practice differently. It's an adult study that conducted by Doctor John Fell um regarding care risk management by risk assessment that um adults that who had at least one cavity are randomized to two groups with conventional treatment and, or health education and restoration compared to those who also treat with antimicrobial for adults. Uh At that time was the of uh the antimicrobial and fluor rents. And the study actually, um we uh followed up Children, uh the adults for three years. And you can see at the baseline what the orogenic bacterial level is related to how many decays they were held. Um which is the z um um access of the study and you can see the higher the mutant strap co la level, the more decay it would be, it's like a apes and that shows how the bacterial level is closely related. Um was um was um the car level what is unique? And this is one of the steady showed um uh traditional um dental care restoration doesn't change the carriers. Uh cavity um um carries genetic bacteria challenge level and this is mutant strep to level. And the blue is the uh conventional group. So by the second uh point, the third visit, one year post their enrollment, all their baseline, uh all their cavities has been fixed, but the bacterial level did not change over the time. And you can see where the intervention group because they got antimicrobial and treatment. Then the bacteria level dropped during um where the cavities are fixed and stayed low over the study. And those also result in a reduction of number of decays they develop in the future. And that's why we said modifying the diet, modifying the bacteria is very, very important. I love the slides that I borrowed from Doctor Featherstone a lot is you should, you should never put a new roof on the house that's burning because if you don't change the bacteria level, whatever the filling we put on that tooth, it's going to be ruined later. And that's why uh about 60% to um 70% of Children who had cavity. If we don't treat it properly, they will get new cavity again. And basically that says patient with decay indicates um their high risk for future cavity levels. They have high bacterial levels. If we just treat them with fluoride or um restorations, that doesn't change their bacterial level, they will still want to get new cavities in the future. We need to do more. And dental care is, is probably one of the most preventable disease um that we can do uh if we can change the challenge. And one of the key factor um to regain um this microbiome despised biosis is to modify our oral environment. Um neutralize the acid environment, reduce sugary and carbohydrate frequency at a month and they use antibiotic treatment for Children. It's really, really hard um uh to um find a good mouth reds in Children cannot be. So I'm going to talk about, we're gonna focus on how we can create a neutralizing um um um environment to encourage the comsal bacteria to come back and find disease in a more um non hazardous way. And we talked earlier already cavity causing bacteria. It's not only juice, not only candies, it's any food contains f ferment, carbohydrate. And one of the key is the contact time. And the reason for that um this is the graph um about with what we call a step curve. It's actually using a Michael um ph meter inserted in between the two where the dental plaque is and you measure the plaque ph over time after the person runs with 10% sucrose. And then after that, uh normal intake and saliva is gonna wash out that sucrose actually quite quickly. And you can see in the normal people after one minute runs of 10% um sucrose. Um the the low the ph going below um six period of time, it's about 30 minutes. And actually, if for a high car um risks with the uh carro plaque because of the extracellular poly, that period is gonna go extend to 45 minutes to an hour means that period of time, the tooth continue to dissolve, resulting mineral loss. What's different. Um It's very important is for um for people that has dry mouth, their stomach, that low ph period can last 3 to 4 hours long, depends on how their stomach it is. Children is really rare if you see a normal pediatric um group to see they're um actually um experiencing biological dry mouse. But Children using multiple medication, asthmatic Children, those can cause dry mouth and can result in a risk factor as well, especially for our um cancer patient BMT patient. The um Children can result in dry mouth and those cavities can develop. Um That's what we say, people with their stom can develop rapid decay within um a number of months and that's prevention and re uh raise the ph and modify that um habits in the mouse is very, very important and naturally. Um inside mouse, you can see this is a study that we're measuring p um people's um P um on the plaque over the time, depends on they have multiple snacks or not. And you can see um the ph that um with, for people who has frequent snack, they're gonna have multiple attack and very simple. Um way I talk to my patient is if you know, you have one minute to eat uh drink of any juice, um that means resulting about 30 to 45 minutes could up to one hour dissolving up to two and you need at least equal amount of time for the saliva to repair it if the plaque is removed, um um frequently. And that means between each snacks, you need about two hours with starchy food. If they stayed, it's one hour, 45 minutes to an hour after those food has been removed. That's why it's not only the frequency of the carbohydrate diet, it's also whether you clean your tooth good or not because dental plaque is a mixture of food and the bacteria. And if they don't, if you don't clean them up, it's continuously dissolve your tooth and create that environment to make the bacteria stronger and stronger. And I love this study a lot. This is one of the study that um um conducted by um they did a survey and also um isolated bacteria level in 72 carries active Children and 38 carries three Children and they looked at their um food and s um intake. Um and um throughout the day and what's I marked in a green bottle, are they drink milk um between meals or drink water with or with that meal? It's all associated with um Children that are more likely to be cars free. And um Children who are within severe uh ecc means they have more than um five of the decay twos in that day are more likely to take meal milk with meal. So if you mixed milk with um carbohydrate, it can become a carro food as well and that answers a lot of the question. We're talking about nursing bottle decay or breastfeeding. Um can relate it to tooth decay, breast milk or milk itself actually does not cause cavity. It's actually have protective factors against tooth decay if it stands all along. But if you mix them with uh carbohydrate or sugar, it's actually more carro because it produce better nutrients to those bacteria. And you can also see the frequency of diet. It's closely related with whether you are more likely to get cavities or not and carries free. Children are more likely to have less than five times total intake of snacks and diet meals per day where um Children with ECC are usually have more frequent diet throughout the day. And how could we use um to neutralize ph one of the protocol that we have been recommended for adults, cancer patient is baking soda, rinse and for Children, they may not be able to rinse and wiping it. Actually a great tool you can do and what baking soda would do. This is one of the curve that we um um study have been showed. Um for um two for adults who are hyper salivating or have normal uh salivate. You can see after they have the sugar rinse, the PH goes down dramatically and recovers in about uh an hour for normal accelerating patient where for their stomach patient, it lingers over two hours and still go below the ph, that demoralization can happen. But if you rinse with baking soda that after that the PH can um increase dramatically and that allows the mens bacteria to recover and stop um the um m demoralization process and even you rinse again with um the sucrose. Yes, the ph will go down dramatically again. And that's why see it can be baking soda, wiping on rents, especially for those patients. That's a medically compromised, that frequent intake of food is needed. Um then or Children who have cavities and they already have controlled their diet in a way. It's gonna be helpful to keep the oro vitamin neutral and beneficial um for the comsal bacteria and prevent um carro bacteria, overpopulating early prevention. Um dental visit, it's very, very critical. It's really sad to see a lot of Children that we meet them even they come at 12 months. Um they already have decay. So current A P and A APD recommendation of dental uh first dental examination is the eruption of the first tooth and no later than 12 months, we do want to see them earlier. So you can provide the information to the parents um and they can do prevention for the Children. And as we see the slides earlier, if those information uh can be provided even in the prenatal air time um from um the, the physicians PC PS that would be even better and we want them to be um seen routinely for every six months. If they're high risk, we might schedule them to come in um earlier um in their lives. Um So I'm, I don't want to emphasize this again. We said why early um prevention assessment? It's important. It's because the same way it goes with um uh other general health. Um because at first, the first three years and first five years that microbiome grows, it's so um maturation is so important to determining the future feat for those um those Children. And this time prevention provides the maximum protection for that group of Children. And also it's definitely good diet and uh oral hygiene habits. Last a long, long time. Um seen so many decay in young Children. I was going extreme when my daughter just explains that. Um So she was not actually um exposed to any true sugar um sucrose products until she was three, she was led all up until she was three in the first time when she was given a cotton candy. Um That's this uh just a case study. Um by one of my friends, she had one leak and give it back to me. She didn't like the taste. Um So it's possible if you don't view that tolerance at early childhood can change their experience in taste buds and that could be long lasting as well. So, um the curious risk assessment tool is available that's summarized by Doctor Feathers jog. Um and um the frontal oral health in 2021. And we also want to make it really easy for um for um um for all the medical colleagues. Um The goal for the um car risk management by um risk assessment tool, the camera tool is trying to identify what's the causal factors and balancing. Um It was a protective factor and trying to tell their um prevented care to each Children to work as needs. And um we usually repeat it uh at each visit. Um So, from your perspective, what we want to when you do, if it's possible adding um one examination, look inside the mouse, the children's mouse and ask a couple questions, then you can know whether that child is at high risk or not. Um First look inside their mouth, this is we disclosed the plant, but you can see a lot of food Debra uh stuck in the surface of the tooth. And if you brush it off and that you can see chalky white there, those are early decay that can be reversed. And that process actually is happening when we're eating every day. The reason we got decay is we give enough time for it to repair. But if you don't clean it off and let it go, that's when it it cavitation. Uh when the the structure of the tooth um surface broke and especially advanced in the in the layer of the tooth structure, that's non reverse reversible and that's going to progress. And the other thing you can look is I mean, a lot of the um pediatrician is shocked when the decay is black, actually back decay, especially. Currently, we're using some medication called silver dami fluoride um can cause the darkening of the cavities. The white light color tooth decay usually indicates early fast progressing active decay. And mean even the pigmentation in the fruit cannot stay natural decay. If the parents change their behavior naturally, they will turn darker or even black when it's arrested. So we want to ideally don't want to see calories and clean teeth, but important um to see it's not like color decay that way. And one of the question for young Children, um if you're doing an interview is ask their family members if they have cavities or not and make sure they don't put any drinks in the bottle that contains a sugar sweetened bottle because that's ex increase um the contact time and avoid especially drinking from a bottle, your tongue separates your teeth um from saliva. So basically the tooth abin in all the sugar and that's why tooth decay happens. And um if that's the case, those Children are at high risk and please refer it to a dentist. We can identify and work them, work with them to prevent to decay. And I think go hand in hand because we'll all worry about sugar with the new guidelines showing Children under um the five year olds should not have more than 15 g of total sugar per day per day. But for dentistry contact time is really, really important. One of the myths we usually encountered by the parents is like, yeah, we have diluted the juice and put it in the bottle. That's actually more damaging. Yeah, it's probably better with less sugar content for them to intake, but it's actually more dam damaging because if you dilute the juice and drink it throughout the day, you increase the exposure time for two K development, exposure time is very, very important. So that's some of the studies that we have done. Uh looking at what the baseline carries risk factor are linked to the future decay of the Children. 0 to 325. Um, and we can see existing decay. It's um, most, um, confounding factor followed by frequent snacking reset, restorations, heavy, um, plaques and bottle use for no water or milk. I mean, any sweetened beverage and low socioeconomic status. So, if you see any of those, that means the child is at high risk and um, this is just skims if they're low risk, um, only 20% of them develop calories in the next two years where, um, if they're high risk, it's over 70% of them is gonna develop new cavities. And this is the traction, how much decay they can get if they're high risk, um, um, to get cavities. And you can see, uh, within, um, two years, they can get as high as five decay um, compared to those who are stayed low risk or medium risk, um, that's why we said home instruction um, for Children is important. Um, first checking their family members have cavities or not, whether they take um frequent um, um carbohydrate snack, whether they drink sweet and beverages or they breastfeed a lot of it on time. Those are very, very important for our special Children with medical specialties. We need to um, concern about their salivary function into the play as well because those Children would be actually at extreme risk to get tooth decay and poor oral hygiene is a combination of the bacteria plus food in their mouth as well. So we talked about the prevention already um especially for 0 to 5 years old. If they don't have decay yet, then prevention of the transmission of mutant strep COCA is important. If they already have tooth decay, then that means they already got the bacteria. Then we need to focus on how to change the diet. Use um uh protocols to raise the ph inside the mouse. Um So if you look, this is one of my last slides is um um actually a scheme by um um in Doctor Feathers Stone's um 2021 paper um that you can use for your education. What parents can do is drink water as possible using baking soda. It has the formulation here as well that you can. It's basically uh two teaspoons of baking soda in eight ounces of water. They can raise all the parents can wipe, using Q tips or a gas or any um paper towel, dip it and wipe the teeth after we, after they eating any um and uh carbohydrate containing food as well and brush twice daily. Um I'm just emphasizing for Children under three years old. Um because the risk of the ingesting toothpaste, we recommend rice size toothpaste or a smeal layer of toothpaste to brush instead of a pea size. And also Children, it's better, not under five year olds cannot spit proficiently. They always swap some off the water and all the toothpaste steady done for prevention is recommending no rinsing afterwards because we want that topical effect of light last for a long time. So we recommend parents to um brush as much as possible and wipe out everything. Um after they're brushing, they, they can have the Children rinse them out with water before brushing uh um to get rid of all the food debris. And also we also emphasize on the parents should help Children to brush until they're eight years old can tie their shoelaces. But uh and write prof um neatly, that's the time they might have their uh fine modal skills to brush but still need training. Just brushing is actually a really hard task. And for Children older, they can use disclosing tablets, then they can see it and practice it. Um and take takes about for my daughter three months when she was um eight to train her uh how to brush profoundly uh with disclosing tablets every day. So she can see where she needs to brush and develop that muscular memory, muscle memory so she can brush well. But we actually, that practice lasted for three years. I mean, not every day but later on um um once to twice a week to keep that oral hygiene going on. The sec second item is really how to change um their carbohydrate intake daily. Um One of the tip worked well and I share with my parents all the time is you cannot pride all sweet beverages or food from Children because they want it. And um so since my daughter was, uh this is adopted from us European custom, since my daughter was young, we have that a happy hour concept every um week to my daughter that we don't eat junk food. We know they're no good, but we, they are nice treats. So every week she has one hour to choose as her happy hour and the whole family go out to whatever food she wants. Um, we eat it um and she can finish it what, as many as it, we don't bring home. And that gave her a sense of healthy styles. But if she eats any of the other junk sweets on the day, we lose that privilege. And that helped her to develop a habit to stay away. Frequent, uh, junk food and I share with the parents whatever it works for them. Um, um, or they can try to use um, cheese or proteins or, um, veggies snacks to break out, especially when we see signs of tooth decay and juice is one of the major reason of tooth de develop um decay development in Children. And I think it's relevant to both medical health and um, child health and, um, uh, we need to ask the parents to read labels and reduce that. Mhm And um yeah, he is modifying um habits, um dietary habits that way. So I'm going back to my uh last slides. Um It's the key factor to prevent tooth decay. It's regain that um microbiome dys biosis to symbiosis. So we want to create basically a neutral environment to promote comsal bacteria growth and uh of course, and treat all the in that way they can stay healthy that way. Thank you so much for listening and I put my email um here if you have any questions, we can uh always feel free to contact me. Thank you so much, Doctor Sun Super Informative and very helpful. Um We do have a few questions from the audience. Um So the first one is um you do mention the need of fluoride and using fluoride and toothpaste. Um However, a lot of the kids' toothpaste are marketed as fluoride free. Um Can you comment on that? And um should parents just be recommended on getting any fluoride containing toothpaste. Yeah. Um Thank you. That's a great question, especially um in the Bay Area. Um that um we have a great population is actually, most of them are highly educated parents are anti fluoride. Um And that concern coming from uh and it's actually when I um came from China, that's one of the major issue that um um China cannot do fluor water Fluoridation because people believe fluoride is toxic. It is a toxic. And I tell the parents everything, if you drink too much, even water is toxic, the amount was using in on Children, the fluoride is very minimum. And if the Children, we we're talking about if you use excessive amount, especially they swallow a lot and especially bay area, a lot of the area are water fluoridated. So if you, they ingest excessive amount of fluid that can result side effects like such as um fluorosis, that means their tooth can become a adult tooth become snow capped Andrea. And so it's not as pretty, but if they're high risk, they should use fluoride toothpaste because thinking about the tooth de development, you have to use it. Right. Fluorosis is caused by ingestion of the fluoride systemically. And fluid prevention only works when it's in contact with the tooth. That's why I teach the parents to brush when the child's laying down and wipe out the fluoride toothpaste and don't. So they don't ingest it that way. So we emphasize on that and um we do have a group, a great group of the parents who don't want to use anti fluid as the meringue. The Berkeley parents uh really have concerns if you can't change them. But those group, group of the parents were really adult. Um uh any other regimens that's natural, that can prevent tooth decay. And usually for those parents, if you talk to them about sole use, control the diet to be more healthy and also using baking soda, they're completely. Ok. So you just need to provide alternatives if the parents really truly cannot accept what it is happening and hopefully that will prevent decay and um work with the parents that way. Thank you very much. Um Another question that was sent through the chat. Um So in terms of timing for the first dental visit, um you recommended um a first dental exam by 12 months of age or at the time of first tooth eruption, but it does seem like many pediatric dental clinics tell families that their child should not be seen until they are two years old. Are you seeing this as well? Is there um Can you comment on this difference? Uh recommendation. Yeah, I, I'll comment a PD guideline is uh when the 1st 26 months or first two hasn't and no later than 12 months. Um I, the reason I'm reaching out to everybody and I do a lot of education for a general dentist as well is we do not have enough pediatric dentist to see all the Children and, and the comment when the parents got the answer is that, oh, the child should not see a dentist until they're three or until they're five. Those are most coming from the general dentists who are trained probably, um, um, in the old school way. So they don't feel comfortable to see young Children yet. And we're hosting a lot of education for um for pediatric dentistry to, to, to implicate that. So um more of the um general dentist will feel comfortable seeing uh a young Children because they would cry. You would do a lap to lap exam. A lot of general dentists don't feel comfortable to see Children who are fighting. Um And uh it's also incorporated in our general dentistry on predo student education. Every single one of our um graduates um has been ha has to see a young Children and do a lap the lab so they feel comfortable to see Children under one year old. Great. We have a few questions about fluoride. Um One does tap water that is filtered, still contain fluoride and it seems a lot of homes are starting to filter their tap water. Um And then second, um how frequently do you inquire about well water or drinking bottled water since these patients are likely getting less fluoride? Um The first question, filtered water, I think unless you buy a very, it's actually really hard to filter fluoride out. You have to buy a very, very expensive equipment to get it out. The majority of the regular theater is just f out, um, um, does not get rid of the flu. So it's still in there. And we do get a lot of concerns of the parents about, uh, fluorosis and drinking bottled water versus, um, uh, tap water because concern of the fluoride. And I remember when I came to United States that debates goes on. Why do you do um Fluoridation? It's fluoride, fluoride effect is topical. Um It's because if, if your child use fluoride, toothpaste, the effect of fluoride water is very minimum. Uh I think water Fluoridation is a public health entity to help fluoride, to reach to those population who do not generally brush their teeth. So they still get the fluoride protection effect. But for young Children, um usually the water fluor organization um is adjusted um to all environmental to raise out a the minimum risk for fluorosis. And um um the the maximum effect you can get for tooth prote um um tooth decay prevention. So, um but it's also have individual variety and if you add on tooth brushing and how much you ingest that some of the parents are concerned about. I do get inquiries about that a lot and I said if you concern the most and if you brush your Children with fluoride, toothpaste um, drinking bottled water may not be a bad choice if you're concerned that much. Although, uh, the bottled water may not uh increase your child's risk for flu that much unless, um, there's some medical conditions that your child drinking a lot of water, um, or uh super sensitive to fluoride that way. Thank you very much. Um This was fantastic. Um, we are definitely seeing a lot of cavities in our clinic and, um it is very helpful to help educate our families as well. 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