Dentistry Uncensored with Howard Farran
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337 Innovations in Caries Assessment and Management with Margaret Scarlett : Dentistry Uncensored with Howard Farran

337 Innovations in Caries Assessment and Management with Margaret Scarlett : Dentistry Uncensored with Howard Farran

3/19/2016 1:19:27 PM   |   Comments: 0   |   Views: 436

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AUDIO - DUwHF #337 - Margaret Scarlett

This episode’s discussion:

-New approaches to caries assessment and management are available.

-Population studies indicate that old ways to assess caries in populations with DMFT underestimate caries by 45% and above. 

-Early caries can be assessed with new methods of assessment. 

-Early caries can be reversed with a variety of remineralizing agents.

-Patients are not aware of agents that can reverse early caries.

-Diagnostic codes are new for dentistry since this year.  

-Reimbursement for reversal of early caries is rare, except for fluoride varnish for young children.

-Evidenced based approaches to treat and manage caries using ICCMS are available. 

-These can be used to prevent and treat caries in individuals and among populations.


An international lecturer, author, clinician and public health dental leader, Dr. Scarlett is a noted infectious disease and chronic disease expert. As the author of the first infection control guidelines from the Centers for Disease Control and Prevention's (CDC), she now focuses her career on caries assessment and management for populations. Beginning her career providing oral care to the proud Gullah people of the sea islands below Charleston, she has been a professor and director of dental research at one dental school and head of the hygiene program. Her most recent accomplishment was training over 100 health workers for Ebola Treatment Units infection control last year for the CDC.    


www.scarlettconsulting.com 


Dr. Farran:

It is a huge unbelievable honor today to be podcast interviewing an actual dentist who works for the Centers for Disease Control in Atlanta Georgia. How cool is that? You’ve been working with them for 17 years?

 

Dr. Scarlett:

I’ve worked as an employee for 17 years and for the last 15 years I’ve been a contractor or subcontractor for CDC so it’s been kind of fun.

 

Dr. Farran:

Wow! You’re putting my podcast on the map. I’m usually just podcast interviewing all my hilly billy friends and now I’ve got someone from the Centers for Disease Control now that is just truly amazing. How did you end up going from dental school to the Centers for Disease Control? How cool is that?

 

Dr. Scarlett:

Well it was a lot of fun. It was 1 of those things that juts happened. I was in Charleston South Carolina caring for patients, dental patients on the Sea Islands and Charleston. I was on faculty at the dental school and I applied for a job at CDC and it was to do work actually on fluoridation. When I got to CDC there was this new disease it had been called GRID or Gay-related Immune Disorder and shortly after I got there it was renamed AIDS. We all know that there was a lot of interest in AIDS. Because of that there was also interest in what kind of infection control practices to perform to safely treat patients with AIDS and HIV the Human Immunodeficiency Virus. I had a really interesting time learning about the new and emerging science at that time. That was very, very exciting and so it was fun.

 

Dr. Farran:

1 of my top 10 favorite movies of all time was about AIDS. It was called And The Band Played On, did you ever see that movie?

 

Dr. Scarlett:

I did.

 

Dr. Farran:

What did you think of that movie?

 

Dr. Scarlett:

Well it was interesting because I knew some of the folks that were in it and I loved the way that they portrayed Dr. Mary Guinan. She was 1 of the few women who was involved in the early part of the epidemic and Dr. Jim Curran who was actually my boss for about 5 years. Sometimes they were … and Herold Jaffe who was also in that movie I know pretty well. Some of the portrayals were pretty accurate and some of them were a little bit overdone. I think the excitement about the early part of the epidemic and how doctors and patients worked together to transform the approaches to the disease and discover things about the disease. That was new and different.

 

 

Because at the beginning of the epidemic only a bunch of epidemiologists and geeky people like me would read the Morbidity and Mortality Weekly Report. As time went on it became … patients were reading it. People who cared about their family members were reading it. We were all working together and that was kind of fun. That was exciting too.

 

Dr. Farran:

When did that epidemic actually break? Was it ‘79?

 

Dr. Scarlett:

Well it probably existed before ‘79. There was a Hepatitis study but really the first cases were reported at CDC about ‘81. There were actually cases before that time and we’ve got cases now I guess back to the 50s and 60s because they’ve gone back and done some lookback studies. There was a Hepatitis B study in San Francisco that had been ongoing and the really first cases of AIDS came out of that study. As well as some independent doctor case reports when doctors had cases of patients who had this constellation of disorders that they hadn’t seen before in young healthy men. It was very interesting. We were all learning together and working together collaboratively. It was fun.

 

Dr. Farran:

Did you know Don Francis in the movie?

 

Dr. Scarlett:

Sure.

 

Dr. Farran:

Was he portrayed pretty accurate?

 

Dr. Scarlett:

Well we used to call him Saint Don but I think in that movie he was portrayed a little more saintly than he was but he was certainly I think someone who continued to advocate on behalf of patients and the people he cares about.

 

Dr. Farran:

The big question is Alan Alda from MASH played Dr. Robert Gallo and they did not portray that man very nicely in all the movie. Was that accurate?

 

Dr. Scarlett:

I would say that some of the portrayals were accurate and I’m not sure I could argue with that portrayal.

 

Dr. Farran:

Yeah, kind of an arrogant egomaniac?

 

Dr. Scarlett:

Well I would just say that Luc Montangier might agree with that and there’s a lot of mystery behind their rivalry. I think at some point in time there were scientists who decided that Luc Montangier deserved more recognition than he had had. I think there’s another story to be told about that as well.

 

Dr. Farran:

Well I think if there was any takeaway from whatever we talk about that if my hommies never say that movie And The Band Played On you’ve got to go back and watch it. I think it’s just an HBO movie. I don’t think it’s on Netflix or … I never found it on Apple TV. I just had to go set up my computer on the internet and google YouTube And The Band Played On and watched it off HBO I don’t even know if that’s legal. I’m probably give illegal advice and they’re going to come penalize me with that but just a phenomenal movie.

 

Dr. Scarlett:

It is and I think it’s really helpful because I was thinking about doing another lecture called from AIDS to Zika with Ebola in between because it was a very exciting time at the early part of the AIDS epidemic as we were discovering. AIDS is a global pandemic but it also makes us realize not only how vulnerable we are and how we need to work together collaboratively. It also lets us know that we can learn and quickly disseminate information that’s life saving. I think there’s a second story that can be told about not only the AIDS epidemic but some of the newer epidemics that we’re dealing with right now with Zika. That story that has to be told is how working collaboratively we can overcome some of these diseases and particularly what we’ve seen with tamping down on Ebola in West Africa.

 

 

Also I think the story of the 17 new drugs that got approved to treat people with AIDS in the late 1990s there’s a story to be told. I think there’s another movie on that because that's everyone working together to get speedy approval of these life saving drugs. I think it ought to be not And The Band Played On but how we all work together to combat a global pandemic.

 

Dr. Farran:

We are so off topic which what we were going to talk about today. I just want to keep going off topic. What did you think Friday night when Bill Maher gave a television time with Charlie Sheen’s doctor when he went to Mexico, went off his HIV triple cocktail and is trying some unproven method? It almost sounded like the Americans … Well did you see it first of all?

 

Dr. Scarlett:

No, I didn’t see it. Send it to me I’ll take a look at it.

 

Dr. Farran:

It was … I’ll just read you … it was Bill Maher gave airtime on a show Real Rime with Bill Maher to a so called doctor who’s unlicensed in the US and promotes his scientifically unproven cure for HIV. The Australian who claims to be a doctor and practices in Mexico has been receiving scrutiny after HIV positive celebrity Charlie Sheen revealed he went off his antiretroviral drugs to try Chachoua's so called cure. The treatment consists of consuming the milk from arthritic goats which is neither scientifically proven nor approved therapy. I thought that was stunning because Bill Maher's a huge journalist for 20 years, it’s on HBO. You didn’t see that?

 

Dr. Scarlett:

No, I didn’t.

 

Dr. Farran:

Trying to email this to you right now.

 

Dr. Scarlett:

If you go to the internet there’s lots of conversations about unproven methods. In fact there was actually some political leaders in South Africa who thought that HIV was not the virus that caused AIDS and promulgated that in a particular country which will remain nameless for right now. There’s a lot of unproven techniques that are out there to combat not only HIV but all kind of other diseases. I would just say that there’s proven scientific methods, there’s clinical trials to tests that is timeworn and proven to be helpful to individuals.

 

Dr. Farran:

I just want to read you a bio Dr. Scarlett. Dr. Margaret Scarlett, an international lecturer, author and clinician and public health dental leader Dr. Scarlett is a noted infectious disease and chronic disease expert. As the author of the first infection control guidelines from the Centers for Disease Control and Prevention, CDC, she now focuses her career on caries assessment and management for populations. Beginning her career providing oral care to the proud Gullah people of the Sea Island below Charleston. She has been a professor and director of dental research at 1 dental school and head of the hygiene program.

 

 

Her most recent accomplishment was training over 100 healthcare workers for Ebola Treatment Unit infections control last year for the CDC. Wow! You want to talk today about new approaches to caries assessment and management? Or what did you want to talk about?

 

Dr. Scarlett:

Yes, I wanted to talk about caries. Caries and periodontal disease are the 2 man diseases that we deal with in oral health and dentistry. I think what’s so exciting about it is that we’re finding out so much about the biology of it right now. I think that we have some real ways to prevent it. If I could say what the formulas is and you know I don't know ... I guess ...

 

Dr. Farran:

Don’t tell me what it is, I bet I can guess. It’s swishing with coconut oil for 20 minutes every day.

 

Dr. Scarlett:

No, no. This oil pulling is all over the internet oh my gosh.

 

Dr. Farran:

Hey I read it on the internet so it has to be true.

 

Dr. Scarlett:

No, no, no, please. That’s …

 

Dr. Farran:

I think that’s so funny that they can’t brush for 2 minutes but now they’re going to swish with coconut oil for 20 minutes to pull the toxins out.

 

Dr. Scarlett:

No, no, no. It’s  not been proven. We need to use the scientific method like clinical trials they're proven methods. Most people don’t know what clinical trials are but they are a fairly lengthy multiyear process to test different items that can either prevent or treat different disease or are used for not only drug testing but for vaccine testing. There’s a phase 1 test where you test for safety and healthy volunteers with a small number of people. There’s a phase 2 testing which is testing for safety in the individuals impacted but the disease. Then there’s the phase 3 which is a much larger study, usually thousands that test the efficacy or the effectiveness of the vaccine or drug. That’s the proven scientific method.

 

 

You want to look for clinical trials data. There’s not any clinical trials data that I’ve seen on oil pulling or coconut oil or anything else. I think it points to something too. Caries impacts about nearly every person on the planet. WHO says that caries impacts nearly 100% of the population. We think about infectious diseases in this way, anything that had over 50 cases per 100,000 is an epidemic. That’s the way CDC thinks about it. We’re talking about something … caries is a disease that impacts 90,000 out of 100,000 or maybe as WHO says maybe 100,000 out of 100,000. That tells you the scale of the disease is pretty great among human populations. I got pretty excited when I started looking at the new science on caries. That’s why I wanted to talk to you about today.

 

Dr. Farran:

Well let’s talk about it.

 

Dr. Scarlett:

Yeah. The message that I’d like for people to take home is detection plus remineralization is actually real prevention. CDC is the prevention agency. I think it’s 1 of the things that excites me about this new biology is that we have an opportunity as oral health providers to prevent disease, how about that? That’s fun. I’m going to review a couple of things that might be useful and might be helpful to people. Let me see if I can get this out.

 

Dr. Farran:

Did the CDC change its name to CDCP Centers for Disease Control and Prevention or did that not stick?

 

Dr. Scarlett:

Yeah.

 

Dr. Farran:

Because I remember them adding a P for prevention but I never really see people refer to the CDCP, they still only refer to the CDC.

 

Dr. Scarlett:

Yeah, that’s true?

 

Dr. Farran:

What’s the real name?

 

Dr. Scarlett:

The real name is the Centers for Disease Control and Prevention.

 

Dr. Farran:

It’s CDCP?

 

Dr. Scarlett:

Yeah, well but we don’t use that.

 

Dr. Farran:

You still call it the CDC.

 

Dr. Scarlett:

Yeah, and when I was at CDC in the very early years it was the Center for Disease Control and that was it. Then it became the Centers for Disease Control and then it became the Centers for Disease Control and they added and Prevention because it was the prevention agency. CDC’s mission is to prevent and detect diseases. There’s a group of individuals who are called epidemiologists who are the lieutenants of CDC. If you’ve seen Outbreak you’ve seen this training that people go through at CDC to detect and understand disease in population.

 

Dr. Farran:

That movie is called Outbreak?

 

Dr. Scarlett:

Yeah, go check it out, yeah. They film some of the zombie movies too at CDC so of you get some views of some of the labs, yeah.

 

Dr. Farran:

Right on.

 

Dr. Scarlett:

Caries I think 1 of the things like I said that it strikes me about caries is that I can take what I learned about AIDS and even working in chronic disease and nutrition issues and breastfeeding issues among women. Not that those were diseases but there’s assessment systems for those. We haven’t had a really good assessment system for caries even though it infects nearly everyone. That’s what I wanted to talk about today. We use crude methods that are pretty old and not really designed for today’s ways of thinking about disease. What I’m excited about is the opportunity to share with you what scientists around the world, dental scientist, oral health scientists, biologists and others have come together to really think about caries in a different way.

 

 

I’m going to see if I can share some of the slides that I created. I just want to say that I’ll be talking about assessing and managing caries with biology and evidence. That’s the thing with what I’m talking about today. I was a contributor to the certain journal’s report on oral health 2000 and the certain journal’s report on oral health stressed the importance of good oral health. I also talked about the fact that caries is pretty much a universal condition but well we've got 50 or 60% of individuals who go to the dentist in a year so we’re missing 40 or 50% of the individuals who don’t go to dentists. What do we we need to think about? We need to be thinking about understanding the biology and change our thinking to managing caries in a new way.

 

 

Helping patients to understand how we can manage caries in a new way and using evidence to manage carie. There’s something called the Triple Aim that’s being utilized across health which is … just a concept it’s pretty alarming in 1 way but it’s also very practical in another way. Which is to think about that health should be what is going to work for a large group of people which is what you have, a large group of people impacted by caries. Think about their experience of care as well as the evidence and the cost of it. There are some costing measures which makes reversing oral caries pretty reasonable. You can be sure that the insurance companies are looking at this. If they’re looking at it this is just some data I can't see this very well.

 

 

It shows the cost savings when sealants are used when a person gets sealants at age 12 or 13 and the cost savings by the time they’re 19 and so the insurance companies are definitely looking at this Triple Aim. Not only cost savings but really preserving tooth structure. That’s the new way to think about things too. When I was in dental school I can’t tell you every lecture on caries was referring to G.V. Black and boy in his day he was terrific. I think we’ve got to move beyond that extension for prevention. That’s an old concept and think about the whole idea of detection and remineralization is prevention. That’s the new word for today. When I go back to what I like to do which is to look at population-based health we have to think about a population-based approach to oral health kind of a dashboard view.

 

 

Really think about it with a sense of urgency. If nearly everyone is impacted by caries and we’re going to have 4 million more children covered under the Affordable Care Act for pediatric dental benefits by 2018 we don’t have systems in place to take care of all these folks. There’s really been no problem and more people visiting the dentist in the last 10 years from 1999 to 2009 according to the National Center for Health Statistics at CDC. Then there is really persistent disparities in terms of access to care if you’re well to do and you have dental insurance you’re much more likely to go to visit a dentist in a year than someone who doesn’t. There are also disparities in terms of race, ethnicity and culture.

 

 

I don’t want to get into the issue of workforce issues and models but we know that there’s a lot of diverse opinions about that and what their role should be. I’ll talk a little bit later about the fact that you’ve got a lot of medical professionals who are now being reimbursed. Pediatricians and most practitioners and physicians assistants in many states are being reimbursed for basic diagnosis and early intervention [inaudible 00:20:20] among children in many states for public programs. I think the other sense of urgency that I have is the use of evidence–based practice is underwhelming, we know a lot. There’s individuals like John Featherstone at the University of California San Francisco that’s been a champion for talking about caries risk assessment for many years.

 

 

The balance between various factors like diet and saliva and oral care at home and also at the dentist office and fluorides. He’s talked about these balancing factor but we haven’t really utilized that in many places, sometimes in dental schools and sometimes in practice. If you also look at the pay rates yes we’ve gotten better in the last 50 or 60 years than we have been but there are some many countries in the world that have much lower decay rights than we do in the United States. A last thing is is that measuring caries and talking about it among different professionals is very difficult because of the measures that we’re using which was something called DMFT which I’m not a fan of, decay-missing-filled teeth.

 

 

It’s something I want to tackle today and I want to say that in terms of detection in the past our visual detection and radiology and instruments were used to detect caries. Well today we want to use evidence. This is an evidence-based world that we live in and there was a lot of consternation back in the early 90s I remember when I was at CDC and on a daily basis. That was pretty funny because a lot of physicians were calling up CDC and saying, “Oh my gosh these scientists are trying to tell us what to do and how to practice.” There were articles in the New England Journal of Medicine and other places that talked about this issue. I think that people have begun to calm down in the medical world about the use of evidence and are seeing it's a tool that … I’ve seen doctors scouring out of a patient room.

 

 

Checking out and app with the latest evidence from the Cochrane Collaboration or whatever, PopMed or whatever to look at the latest information and the latest evidence. They’re using that along with their clinical assessments and laboratory assessments to provide the best possible patient care. I think about evidence as a tool. We know that the biology of caries indicates that caries is not a binary process. In other words by binary I mean you either have it or you don’t. It’s rather a progressive disease and we know that from the biology. If you look at reviews of visual caries diagnosis and Jim Bader did this back in 2002 and Ahmed Ismael did this in 2008. The diagnosis has been critical of those methods of visual detection, radiology and instruments to detect caries.

 

 

We pretty much know that. We also know that the use of these traditional methods where detection or decay is cavitation had been found to be either outmoded or insufficient given what we know about caries. We know about caries and I’ll talk about that in a minute. I know that Nigel Fitz in 2004 and August Don has also done some extensive work on looking at these outmoded or insufficient ways of looking at caries with DMFT. If you look at a comparison of the international classifications of these assessment system with the WHO basic methods of assessment on primary teeth. They found out that if you use this new system ICDAS that you could detect a greater number of lesions with these new detection systems or new ways of measuring.

 

 

Let me just say that the best evidence that I have seen was at the European Caries Association meeting which incidentally we don’t have a Caries Association group in the United States which is interesting. The Europeans have been meeting together for quite some time and I found their meetings really fantastic. There was data presented there the national survey Mota and Portugal with Paula Melo from Portugal who is the from the Portuguese Dental Association. They demonstrate that using this old measure DMFT which was done as a screening tool way back when it underestimates caries by as much as 33 to 100% among children and adults. That’s the evidence that I’ve been looking at to think about new kinds of assessments and a new way of thinking about things.

 

 

Why does this really matter? Who cares? I think if we don’t detect the earliest caries and we don’t actually treat all the caries that’s out there … But I think that we’re really not thinking about the cost in a broad based way. There’s been a lot of cost shifting of untreated dental decay [inaudible 00:26:07] the medical system and to society. Now because now we have the Affordable Care Act but because of rising health costs people are starting to look at this cost shifting issue. You can see that in surveys of the emergency room in Oregon and Washington State, in Maryland, in Florida and others and shows that tooth pain, and its code is 521 and 522, are pretty frequent.

 

 

That’s even with under-reporting and missed codes because sometimes codes are put in because they’ll put facial pain because that might be reimbursed by a particular system where dental or tooth pain will not be. Then there’s also the cost shifting to society. There’s this cost of missed school and work from tooth problems, dental decay but also of course periodontal disease and the cost of poor school and work performance. It’s a huge cost to society when mom has to miss work and take her child out of school, this is impacting a lot [inaudible 00:27:16]. Then there is a cost of missed economic or lost job opportunity or [inaudible 00:27:22] hard to measure that but it is a cost that is there. If nearly everyone is being impacted by dental decay that’s a huge issue.

 

 

This is interesting to me too. There are some interesting projects looking at the human bio. We're understanding more about the biology now than we ever have and the characterization of the oral biofilm is so interesting. You get this wonderful graphic I think from … I think this one is from National Geographic where you get the initial attachment. You just have a couple of cells or a few disorganized cells. Then there’s a growth and proliferation and then there’s a detachment of these and they throw out small seedlings which then go to other areas and repopulate in those other areas. I think that this human biome and the biofilm and our understanding of this and its relationship to caries is so interesting. This is a view here.

 

 

If you look at what’s the impact of this biome? Well the biome then has waste products and it produces acids. That actually demineralize the tooth. If you look at this diagram which is just an iceberg it produces these subclinical initial lesions in a dynamic state of both demineralization and remineralization in this gray area that’s on the slide. That’s what you see. The biofilm is actually in a dynamic state. It’s attached to the tooth itself and it’s demineralizing the strongest substance in the body. In horrible plane crashes or in horrible events such as what occurred with the World Trade Towers teeth were often ... and pieces of jaws were used to identify people.

 

 

They’re very, very hard substances but the bi-products from this biofilm is so strong that it actually can demineralize the tooth. Then we move to a clinically detectable enamel lesion. That’s usually what we … when it's limited to the enamel we think about that as very early decay. Then when it gets into the dentin that’s usually the point in time where we’re treating so that everything below this water line is not being treated with most correct techniques. I’ve got a few dentist who do treat but by large we’re just treating the [inaudible 00:30:18] above here but not below [inaudible 00:30:21]. The system to classify called the ICDAS or ICCMS, International Classification Disease Assessment Systems as well as the International Classification Management System for Caries.

 

 

This shows that ... I don’t see this pretty well but the subclinical lesions are at the very, very bottom, again and they’re pretty large. There’s a large number of these but this is the dynamic state where these subclinical lesions which are only in enamel could be reversed with the proper [inaudible 00:31:04]. Then you see the visible enamel decay some of which could be remineralized some of which are beyond the point of remineralization and these also can be treated. Then you start to look at visible dental decay and that’s usually again the area that we’re treating and then pulpal decay. These are the ones that patients usually complain about over [inaudible 00:31:36]. Because near this whole other area the bottom of the pyramid so that’s why I think this new system, this ICDAS which uses a 0 to 6 point or 7 point scale.

 

 

I don’t want to get into the measurement issues so much today but just to point out that this huge area below of the subclinical decay where we can remineralize is what I want to focus on because we as dentists know how to take care of these things. Wouldn’t it be nice since we have so many people who don’t know about reversing oral decay and preventing we’ve got a lot of work that we can do to prevent decay. That we can take care of more patients who we help fight cavitation and decay later on. I just want to say that the FDI, the Federation Dentaire Internationale have a global peers initiative and they have really lifted some of these systems too for assessment.

 

 

G.V. Block everyone knows this but the disadvantage is it’s 100 years old and underestimates caries, there’s no way to address progression which is part of the biology. If you look at the WHO systems it's accepted but it underestimates caries and I think that when we listen to Professor Fitz from Kings College in London who has really spearheaded the ICCMS efforts and ICDAS systems at both Kings College and with Dr. Ismael [inaudible 00:33:19] University here in the US. I think that you’ll see that education about oral lesions has really been under-recorded. I think that we need to focus more on that but ADA has come up with a caries classification system which collapses some of the [inaudible 00:33:41] for ICDAS but again these haven’t been validated.

 

 

Now him he has some clinical standards which some of us like and it’s a clinician I like it but there’s limited data about its affecting this. Then there’s the [inaudible 00:33:53] use of sight stage classification system. I think that none of these systems have really been validated but I think we need more work to validate caries particularly in light of the efforts that come out of both Mota and Portugal. I’m just going to leave the whole issue of assessment and say that we can do better and I think the best right now is the ICDAS/ICCMS. We need more work on validation for the US. There’s a lot of remineralization agents and I didn’t include all of them. Some of them you know and know well which is fluoride.

 

 

We’ve been using fluoride but we’re probably not using all the fluoride that we need to use and at early enough stages. Because we know that caries is a process that also it’s an infectious disease process let’s think about that and that’s something that is of interest to me. It starts pretty early after birth. We don’t talk about that very much but it is transmitted from mother or caregiver to this very early life. Also there’s been lots of studies that shows that there are what we call horizontal transmission which is transmission from say siblings or other children in a daycare center who transmit the bacteria that cause caries to other children. Mothers transmit the caries bacteria to their children what we call vertical transmission very early in an infant's life.

 

 

Then there’s also horizontal transmission which is siblings or other children transmit the bacteria to children very early in life. We know that preventing caries in primary teeth is very important and we know that fluoride varnish provided very early in life say 1 year old or afterwards can be very, very helpful in preventing decay at the very early stages. There’s also a lot of other remineralizing agents and I don’t really have time to go into all of those. That’s another hour long lecture. ACP has been ... Amorphous Calcium Phosphate has been shown to be pretty effective. Tricalcium phosphate and Clinpro and some others, Xylitol has been ... I’m not going into all of them but there's some evidence on Xylitol [inaudible 00:36:38] it to be helping in preventing a carie.

 

 

I think that there’s a lot of information that’s continued to come out and looking at the evidence again looking at clinical trials evidence and looking at the reviews on these remineralizing agents is pretty important to reverse an early decay. That’s the message I want to get across is that we as dentists can reverse this we have been doing that anyway with fluoride. Most of us have delivered fluoride treatments for a long time and we’ll continue to do so. It’s really thinking about this in a new way in terms of reversing oral decay. I just want to say that in summary that oral caries can be reversed and actually with remineralization. The new methods of managing caries [inaudible 00:37:37] and as has been summarized in December 2014 ICCMS from Dr. Preston and Dr. Ismael and I would encourage people to go take a look at that.

 

 

They were a number of secondary authors including myself with a very small role but this is an important document. It’s too big to be summarized. There were many people who were much better experts on ICCMS than I am. I believe that this is the new way in which to manage to caries for the future and we need to think to about how to translate this into clinical practice and also get the reverse for it because it’s important in terms of saving money, the patient saving time and saving tooth structure. Patients are not aware of remineralization. They may be aware of fluoride from some of the advertisements on televisions but generally they are not aware of the capability that we have to actually save teeth and save teeth structure.

 

 

I think that that’s something that is a new message for the future and that is real prevention. You can help patients prevent early cavitations, you can help to prevent decay. I know that [inaudible 00:38:59] are skilled in treating decay once it has been … It’s into dentin and we’ve got a lot of techniques and we’ve got a lot of focus on that. I think we’ve been missing the mark in that in terms of the early caries. When I see some of our colleagues in the other health professions like pediatricians and physician's assistants and nurse practitioners who are starting to work on diagnosis and treatment of oral decay in young children. I think that it’s something that we can take a lesson from and utilize this with all of our patients.

 

 

Including adults to remineralize teeth so it can be managed just like any other infectious disease so that it doesn’t become chronic. That we can interrupt not only the transmission issues at some point in time but also to remineralize teeth and actually save teeth structure. I wonder if you have any question for me.

 

Dr. Farran:

Well that was an outstanding presentation and the most obvious takeaway is that we’ve been treating dentin decay and pulpal decay with root canals and we need to start trying to treat enamel decay.

 

Dr. Scarlett:

Yeah exactly and we haven’t even been measuring this. I think that that’s the real important takeaway message because we’ve been using an outmoded system that doesn’t really make sense. I think it’s time that we look at very earliest stages that we’re tweaking reverse decay help to get more of those 40 or 50% of the population who never makes it to the dentist in a given year. Let them know that we can actually prevent early decay or reverse early decay in an, hour how about that? That’s a new message, that’s real prevention.

 

Dr. Farran:

A couple of times you said there were other experts in this field and then another time you said to talk about that would take an hour. Would you ever consider creating an online CE course for Dentaltown? We have 210,000 dentists from every single country on earth. We put up 350 courses and they’ve been viewed over half a million times. Do you think that you or the CDC could ever go into more detail with an online course on Dentaltown?

 

Dr. Scarlett:

Sure, I can’t say I can say about CDC but I can say for myself that I would be happy to really talk a little bit more about ICDAS too, the measuring system as well as the clinical issues around early detection and early remineralization. I think it would be important and we could do it in a couple of different ways. 1 is to look at the evidence on some of these things. If you think about the detection device and we’ve done this in other areas and I’ve done this with [inaudible 00:42:08]. We get 2 things which you call sensitivity and specificity. Sensitivity is 1 part of it and specificity is another part of looking at the devices that we want to be able to use. You want both high sensitivity and high specificity, that means that the number of false negatives and false positives are very, very low.

 

 

We could go over some of the science as long as you look at the clinical data the clinical trials data from remineralization agents. I don’t think many people have looked at. I looked on the literature there’s couple of reviews, there's been some international conferences that looked at this but hasn’t been related to the assessment of where the caries was [inaudible 00:43:01] enamel. They were different. They were exaggerating it, there was lack of consistency, the studies were really small. I think that I could help guide people to how to think about evaluating whether to use these agents in their practices or not. Yeah, sure.

 

Dr. Farran:

That would be so exciting and it would be so prestigious for our online CE course to have someone of your stature creating a course for us. That would just be completely amazing.

 

Dr. Scarlett:

You're kind, I would be pleased to do and really help give people some rulers about evidence and how they can make assessments about evidence for themselves and their practice.

 

Dr. Farran:

I want to ask you 1 question before I let you go regarding water fluoridation. I’ve been involved with that my entire career. I was on the Water Fluoridation Campaign in Phoenix originally in '89. I had to do it again 20 years later when it expired. It just seemed to me that the growing force of people that are just so against this and I mean they seem to get louder and louder. It seems like there’s more anti-community water fluoridationist today in 2016 than there was in 1989 when I first got involved with it. Do you agree with that or do you disagree with that? Do you think it’s still worth the fight to stand up to all these people? I mean it’s a conspiracy, it’s a government plot, this stuff is so toxic they have no idea where to get rid of it.

 

 

They bribed government officials to pour it into the public water supply. They take a blog from ... They find studies [inaudible 00:44:45] in China and Iran. They didn’t get picked up on any other, PopMed that are showing that it’s toxic things like these. What is your view of water fluoridation all these years later?

 

Dr. Scarlett:

Well it’s highly effective at reducing early decay and remineralizing teeth when decay is at the very early stages. It’s also a cost income level so that poor kids benefit as much as well to do children so that it’s across the population, again it's backing population health. It’s very, very low cost. It’s not as expensive as a visit to the dentist and it has been shown to reduce decay significantly in study after study after study. Now I’m always a proponent that we need more studies the early studies in Kingston and Newburgh are pretty outdated. We really need another study like Kingston and Newburgh because we get other sources of fluoride. I think the government has reduced the standards from 1 part per million point 7 parts per million it's [inaudible 00:46:02].

 

 

There haven’t been great messages and the communication about the benefits of community water fluoridation but they are pretty clear. In studies especially in other countries we see in fluoridation is highly effective at reducing decay. We need to get to get that message out yes worth the fight because it can reduce decay, reduce that early decay. I think that there’s a lot of misinformation out in the airwaves but I think all that presents us with an opportunity to educate people because they are interested in what's in their water. We’ve seen horrible situations like in Flint where people didn’t know what was happening. I think the more people educate themselves about knowing what’s in their water, what's in their air and in their environment it’s important.

 

 

We can honestly say looking at the science that fluoridation in the water is highly effective in reducing decay and so I think it’s important but we also need to continue to study that.

 

Dr. Farran:

Well Scarlett thank you. Is that why the CDC hired you because they wanted after Scarlett O'Hara in The Gone With The Wind when you applied for the job at CDC they said Atlanta, Georgia wants another Scarlett?

 

Dr. Scarlett:

Perhaps so, you’ll have to ask them.

 

Dr. Farran:

Margaret seriously than you so much for giving me an hour your time today and I would so love to have this online CE course on Dentaltown. The neat thing about Dentaltown and the internet is many kids would be watching this in Kathmandu or Malaysia or Singapore or Ethiopia as they would in Atlanta, Georgia. It would just be a great … You have a great message from a great career in infectious diseases and everything and I would look so forward to that.

 

Dr. Scarlett:

Well I’ll be very happy to do it and I’m looking forward to it thanks very much Dr. Farran.

 

Dr. Farran:

All right, thank you Margaret and I hope to meet you in person someday.

 

Dr. Scarlett:

Me too.

 

Dr. Farran:

Okay bye-bye.

 

Dr. Scarlett:

Bye-bye.

 

Dr. Farran:

We’ll have a glass of fluoridated water together.

 

Dr. Scarlett:

Yeah maybe in Shinagawa where it’s fluoridated.

 

Dr. Farran:

Okay. Bye-bye.

 



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