Coordinated by: Bonnie Bruerd, Drph and Kathy Phipps, Drph april 2007

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Stop the Pop

There has been increasing concern about soda pop as it relates to dental caries and overall health. Health concerns include obesity, diabetes, weakened bones, and tooth decay. A 12 ounce can of pop has 9-12 teaspoons of sugar. As soda pop use increases, milk intake decreases. Milk is an important source of calcium for children and teenagers. In coordination with the Toddlers, Obesity, and Tooth Decay Project (TOTS), we encourage you to provide the following recommendations for the families you work with:

  • Soda pop has no place in a toddler’s diet.

  • Don’t keep pop in your home.

  • Encourage milk at every meal.

  • Offer water as an alternative to sweetened drinks.

Discourage These Snacks

Pop or soda Candy Cookies

Kool Aid/Tang Cakes Chips

Any sweetened drinks Donuts/sweet rolls White crackers

Gum containing sugar Pop Tarts Jellies/jams

Encourage These Snacks

Milk Yogurt Fruits

Vegetables Vegetable dips Cheese

Sugar-free drinks Unsweetened juices Eggs

Meat cubes Nuts/seeds Popcorn

Dried fish Pizza pieces Sandwiches

Pretzels Tacos Sugar-free gum

NOTE: All foods must be chosen as appropriate for age, especially for babies and toddlers who can easily choke.

Tell Your Patients:
Drink pop and eat sweets less often.
When you drink or eat cavity-causing foods, have them at mealtime.

That's because you get an acid attack at each meal anyway.

Eat snacks all at once. For example, cereal in a bowl with milk is an OK snack. A baggy full of dry cereal that is carried around and eaten at

different times during the day will cause cavities. That's because you'll

have more acid attacks.


Oral hygiene instruction (OHI) for all patients should include disclosing the plaque, having the patient remove the plaque, and then having the dental professional provide helpful suggestions for plaque removal specific to the patient's particular problems. The parent should be involved in the OHI for children until the child is eight years old. Flossing instructions should begin between the ages of eight and ten depending on the child's manual dexterity and interest. OHI may also include the use of videotapes,

pamphlets, and other educational materials. Remember: Education is most effective when it provides a consistent message that is individualized for each patient depending on his/her level of skill and motivation.


We all know that the bacterial agents causing dental caries are harbored in plaque, yet OHI in itself has not been proven to be an effective method of caries control. The major reasons for these findings are poor patient motivation and a lack of technical skill. Regardless, OHI is our best tool in the primary prevention of periodontal disease. Furthermore, a toothbrush is the vehicle for delivering fluoride toothpaste on a daily basis. Effective OHI requires both skill-building and patient motivation, with patient motivation presenting us with our greatest challenge.


  • Evaluate patient brushing technique.

  • Use a disclosing solution or tablet to show any areas of remaining plaque.

  • Have patient remove the plaque with the dental professional providing helpful suggestions.

  • Demonstrate floss or other interproximal cleaning devices.

  • Provide instructions dependent on the patient's dexterity, oral health, and interest.

  • Stress ongoing self-assessment of oral health.

The more you involve the patient, the more successful you will be!

It is recommended that all children under the age of 18 be given a toothbrush

prophylaxis with a fluoride toothpaste unless there is extrinsic stain that could most efficiently be removed by a rubber cup. Mechanical plaque removal by dental

professionals does not produce beneficial reductions in gingivitis nor improvements in oral hygiene levels. (24-28)


A rubber cup prophylaxis unnecessarily removes a significant amount of the outer layer of fluoride-rich enamel. One study demonstrated that children who

administered a self-prophylaxis with a toothbrush had lower plaque scores and greater dental knowledge than children who either had no prophy or only had a rubber cup polishing from a dental professional. The only indication for doing a rubber cup prophylaxis is extrinsic stain.
It is not necessary to use a rubber cup prior to topical fluoride application. The toothbrush prophy will provide a better educational experience for your patients as they learn that plaque can be adequately removed with a toothbrush.


During disclosing and completion of oral hygiene instruction, most of the plaque is removed by the patient. The dental professional should then perform the toothbrush prophylaxis. The following is a recommended procedure. The sequence listed is not crucial.

  • Remove all calculus.

  • Put a pea-sized dab of fluoride toothpaste on the brush and explain that this is the correct amount of toothpaste to use on a daily basis. Brush all surfaces of the teeth. It is helpful if you have a sequence. Use a small circular motion being sure to get the brush into the gingival sulcus. Substitute a rubber cup prophy when stain is present that a toothbrush won't remove.

  • Floss between all of the teeth.

Periodontal Disease Protocol

Northwest Tribal Dental Support Center

Healthy People 2010 U.S. National Objective

Objective 21.5: Reduce destructive periodontal disease in adults aged 35-44 years.

U.S. general population baseline data (1999-2000): 20%

Target: 14%

IHS 1999 Oral Health Survey: Adults 35-44 Years

Total IHS 36% 23%

Portland Area 27% 7%
Have Diabetes Use Tobacco

Total IHS 10.8% 37.8%

Portland Area 8.5% 47.5%
Note: Periodontal disease status remained unchanged between the

1991 and 1999 Oral Health Surveys

Fact: Native American diabetics between 35-44 years are 38 percent more likely to have advanced periodontal disease compared to those without diabetes. Further, a higher proportion of diabetic patients with poor blood sugar control had advanced periodontal disease (31%) compared to those with controlled blood sugar (18%).

Fact: Native American tobacco users between 35-44 years are 46 percent more likely to have advanced periodontal disease compared to those that do not use tobacco on a regular basis. Furthermore, periodontal disease increased with the length of time and the amount an individual has smoked or used smokeless tobacco.

Community Periodontal Index: CPI

The Community Periodontal Index (CPI) is a quick, easy method for assessing and describing the overall periodontal status of a community.  The CPI, which is promoted by the World Health Organization and used throughout the world, evaluates three indicators of periodontal status – gingival bleeding, calculus, and periodontal pockets. It does not evaluate clinical loss of attachment.  Until recently, the CPI was known as the Community Periodontal Index of Treatment Needs (CPITN).Changing patterns of periodontal treatment, however, have invalidated the treatment needs portion of the original index. For this reason, the index is now used to evaluate periodontal status rather than periodontal treatment needs.

All patients 18 years and older should be routinely screened for periodontal disease during the exam appointment. The Indian Health Service Dental Program recommends the use of the CPI. This screening does not replace thorough periodontal charting when complex periodontal treatment is being considered.
A specially designed periodontal probe is used for screening. The probe features a 0.5mm balled end and a colored band extending 3.5 to 5.5mm from the tip. The balled tip enhances patient comfort and aids in the detection of overhanging margins and subgingival calculus. Gentle pressure should be used to avoid pain and discomfort. This gentle movement will also detect subgingival calculus on the root surface.
Simplicity is the core element of the CPI. The mouth is divided into sextants and only the deepest probing depth of each sextant is recorded in the patient’s record using the unique CPI code.

Score Indicators

0 no disease

1 bleeding

2 calculus

3 4-5 mm pockets

4 6 mm or deeper pocket


Given a shortage of resources, our goal is to seek methods to attain maximal health improvement with available resources.

Clinical services should be targeted to those at highest risk who have the highest potential for success.

Periodontal Protocol

For children ages 12-17 Probe index teeth and assess future risk. Pseudo pockets due to eruption or orthodontics are not a risk factor. You are looking for calculus, early onset bone loss, and any unexplained bleeding. By identifying children at high risk for future periodontal disease, we can intervene early to prevent future disease.

orthwest Tribal Dental Support Center
Patients > 18 Years

Dental Exam Must Include CPI

CPI = 0

No Treatment

Recall 1-2 Years

Annual Recall

Unless assessed at high

risk for future perio disease

CPI = 1

OHI Tobacco Cessation

Annual Recall

Unless assessed at high

risk for future perio disease

Scaling, OHI

Tobacco Cessation

CPI = 2

CPI = 3

CPI = 4

Scaling, OHI

Tobacco Cessation

Scaling, OHI

Tobacco Cessation

Complete Perio Charting if multiple

sextants of CPI 3

Treatment Plan

Debridement/Root Planing (as needed)

Discuss Treatment & Recall Intervals with Patient

Complete Perio Charting

Treatment Plan

Debridement/Root Planing

More Complex Treatment or Referral

Discuss Treatment & Recall Intervals with Patient

For CPI 3 and 4, initially set a 3 month recall, assess response to treatment,

reassess the treatment plan, and then reassess the recall interval.

Risk Factors for Future Periodontal Disease: Age, Diabetes, Tobacco Use, Stress, Medications such as dilantin and cyclosporine. A patient with CPI scores of “1” may be considered high risk because of uncontrolled diabetes and therefore require a 3-6 month recall.

Prevention of Oral and Pharyngeal Cancers

The majority of tumors affecting the oral cavity and pharynx are squamous cell

carcinomas. This includes cancers of the lips, tongue, pharynx, and oral cavity. These cancers are among the most debilitating and disfiguring of all cancers. Primary risk factors for oral cancers in the United States are the use of tobacco and alcohol products and, for lip cancer, exposure to sun.

You can take an active role to prevent tobacco use among children by getting involved with the Tribe and schools to enforce a school policy on tobacco use, strictly enforce no sales to minors in your community, and educate teachers, children, and parents about the short- and long-term negative physiologic and social consequences of tobacco use.
Secondary prevention includes oral cancer screening. This should include a

comprehensive clinical examination of the mouth, full protrusion of the tongue with the aid of a gauze wipe, and palpation of the tongue, floor of the mouth, and lymph nodes in the neck.

We recommend the use of the National Cancer Institute's tobacco counseling model using the "4 As."
ASK all teens and adults if they use spit tobacco or smoke.
ADVISE them to quit or not to start if they don't use tobacco.
ASSIST those interested in quitting by prescribing the use of nicotine replacement and give tips for successful quitting.
ARRANGE for follow-up. Set another appointment to reinforce the decision to quit using tobacco. If the patient is not interested in quitting, make a note in the chart and be sure to ask again at the next appointment.

The number of Native American children and teenagers who use spit

tobacco is much higher than the U.S. general population. Be sure to ask

children if they use spit tobacco. Some of these children sleep with a

wad of tobacco in their cheeks, an indication of the extent of their

addiction. The key to this problem is primary prevention: influencing

children never to start!

Community-Based Prevention

Medical and Community Health Staff Training

Water Fluoridation

School-based Sealant and Fluoride Programs

Early Childhood Cavities Prevention Programs
Community-Based Program Planning

Medical and Community Health Staff Training

For those dental clinics that have a medical clinic in their facility, it is recommended that the dental staff meet with the medical and community health staff yearly to provide information on the prevention of dental diseases. There are numerous ways that these health professionals can assist your efforts towards meeting your prevention objectives.

  • Prescription of systemic fluorides to infants and young children.

Many infants and children under the age of five are not routinely seen in the dental clinic and we must rely on the efforts of the medical staff to provide systemic fluoride prescriptions for these children. You can encourage this intervention by discussing the importance of systemic supplementation and providing the medical staff with updated schedules for prescribing fluoride.

  • Primary prevention of Early Childhood Caries.

Again, since we do not routinely see parents of infants, the medical and Women, Infant, and Children (WIC) program staff are critical to a comprehensive program for primary prevention. Work with community health nurses, immunization clinics, physicians, and WIC so that they have the appropriate information to provide counseling to caregivers of children under one year of age. Medical and community health staff can also be trained to provide infant oral health assessments and apply fluoride varnish.

  • Referral of newly-diagnosed diabetics.

The dental clinic often does not see the diabetic patient until it is time to extract teeth. The referral of newly-diagnosed diabetics to the dental clinic can provide the dental staff with an opportunity to provide a periodontal assessment and OHI.

It is also important that you keep the medical staff informed about your efforts in all areas of prevention so that the medical staff can support the prevention messages when interacting with patients.

Community Water Fluoridation

For more than half a century, community water fluoridation has been the cornerstone of caries prevention in the United States; indeed, the Centers for Disease Control and Prevention (CDC) has recognized water fluoridation as one of the great public health achievements of the twentieth century. All natural water contains at least trace amounts of fluoride. Numerous studies have documented the effectiveness of water fluoridation. In a review of 95 studies, it was reported that caries reduction following water fluoridation was 40-50 percent for primary teeth and 50-60 percent reduction for permanent teeth. The increase in fluoride exposure through toothpaste, mouthrinses, and foods and beverages processed using fluoridated water has led to a decreased benefit from fluoridated water. Because caries has declined in both fluoridated and nonfluoridated areas, a review of only recent studies concluded that caries reductions ranged between 15-40 percent in fluoridated communities. Water fluoridation continues to be a highly cost-effective strategy in the prevention of dental caries.
The real beauty of water fluoridation is that it benefits everyone in the community, regardless of their socioeconomic status or compliance as a dental patient. Optimal fluoridation is 0.7-1.2 ppm, depending on the mean maximum daily air temperature of the area. This adjustment assumes that people in warmer climates drink more tap water.


  • Find out if the local water community water supply is fluoridated.

  • If you are unsure about the status of water fluoridation, take a water sample and send it to a lab for testing. You can also test several sample wells to see if there are any significant amounts of fluoride in well water. The tests should be done with ion analyzer test equipment, rather than colorimetric test equipment. This is to ensure that interfering ions, if present, do not result in false readings.

  • If the community you work in does not have its community water supply fluoridated, you may want to become involved in working with the Tribe, Environmental Health programs, and other local officials to fluoridate the water.

  • Talk to your patients about water fluoridation to educate about the importance of effective water fluoridation. Building community support could be one of the most important steps you take towards community water fluoridation.

School-Based Sealant

and Fluoride Programs

A multitude of research has documented the effectiveness of school-based and other community-centered sealant and fluoride programs. Regardless of whether these programs used fixed or portable dental equipment and regardless of the physical delivery site or personnel, the effectiveness of these programs has been similar to clinical trials.

It is important that the dental staff look beyond the patient population for the application of sealants and fluoride varnish. By implementing school-based sealant and fluoride varnish programs, you can prevent caries in children who might never come to the dental clinic until they have a toothache. It is also more cost-effective to apply sealants in specified blocks of time. This can be accomplished on-site at the school using portable dental units or by bringing schoolchildren to the dental clinic in groups.

Combined Sealant and Fluoride Varnish Programs
There is evidence that combining school-based fluoride and sealant programs can produce dramatic reductions in caries. While sealants prevent caries on the occlusal surfaces, fluoride varnish or mouthrinses prevent caries on the interproximal and other smooth surfaces.

If you are unable to establish school-based sealant and varnish programs, you must explore other ways to increase access to these important prevention services for school-age children.

  • Consider working with after-school programs.

  • Work with any summer programs for school-age children.

  • Recruit children to the dental program offering incentives such as movie tickets when all sealants are completed.

Early Childhood Caries Prevention Programs:

Steps to Getting Started

Establish baseline prevalence of ECC in the community
Baseline data will provide a means to measure effectiveness and help you evaluate your project.  It will also give you local data to generate support for the program.  A community-based sample such as Head Start, WIC or day-care centers is preferable to a clinic-based sample because those who receive clinical services may not be representative of the entire population.  On the other hand, if a large percentage of children receive oral exams in a clinical setting, this sample would suffice. 
A visual examination is all that is required to determine if there are any cavities or fillings on the primary teeth.  To measure disease severity, you should count the total number of teeth that are decayed, filled, or extracted due to decay. A sample survey form is on the next page.  If full dental examinations are provided for all Head Start children in the dental clinic, you can take the completed exam forms and transfer the necessary information to the survey form.
The easiest group for a program to screen is Head Start children who are usually 4-5 years of age.  The definition of ECC, however, is caries in a child 3 years or younger.  If possible, you may want to also consider screening 1-3 year old children in community settings such as Early Head Start, WIC and day-care centers.  

Contact Key People in Your Community
Contact several key people in the community to get their support and cooperation. The best way to do this is to contact them on an individual basis. Key contacts might include the Tribal Health Board, Head Start, WIC programs, and medical personnel.

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