I've had the opportunity to associate with a few executives from the American Association of Pediatric Dentistry at a Kellogg School of Business leadership training program. A few years ago, we were at a dinner function with 6 or 7 of us at the table when the subject of bottle-mouth syndrome came up. All the doctors at the table were pediatric dentists except for me. However, with my roots a great portion of my patients have been children. We were all sharing challenges of working with little ones that had bottle mouth syndrome. One of the doctors was a wonderful lady dentist named Patty Lewis. (Bottle-mouth syndrome is difficult to deal with, as you know. The corrective treatment can be most challenging to the Pediatric Dentist because it often means that the little patient has to be put down on general anesthesia. Certainly, they've lost their smile and it's difficult to regain it completely, even with corrective treatment.) The men at the table were discussing the subject with some level of understanding and conviction and the consensus was that it was necessary to prevent the syndrome by having mothers keep the bottle away from the children after one year of age. Patty sat quietly and listened at first but then provided a fabulous education (women have brought such a fabulous dimension to dentistry. They see, hear and feel things that many times males may just "gloss" over. Additionally, it's exciting when these younger dentist giving us older dentists a chance to learn something new and exciting. It reminds us that the torch will keep going up the mountain after we're gone.) Patty told us that she practices in the Bronx and that she serves a very diverse segment of Americans there. She shared the idea of looking past just the oral cavity. She said something that I'd never thought of before and I think is relevant to every clinician in the world. She discussed how she has patients who wake up crying at 2:00 a.m. like all little ones. In most families, the father and/or mother will wake up to help the little one. Tragically, there are a few families where if the mother can't calm the baby by placing a bottle in their mouth to stop the screaming, the dad might beat the baby! We think we've got all of this figured out at times, even as professionals, and then, lo and behold, it turns out there can be more to the picture than what is on the surface. Certainly, we can't separate the oral cavity from the gray matter but more importantly we can't separate it from the family, culture and the like. Patty went on to share that she and others had done quite a bit of research (Patty works part-time at Stony Brook). The research shows that if one can get a high risk patient in the office by one year of age and their teeth are erupted at that time, application of fluoride varnish as often as two times per month can eliminate bottle-mouth syndrome. This is clinically and humanly relevant! This is why the AAPD released their recommendations of up to six treatments a year for the high risk child and the ADA recommends 4 times per year for children starting at one year of age. It would obviously be next to impossible to get a fluoride tray into a little one-year-old's mouth, and if you did, it would be dangerous. The logic behind the varnish is that it's a higher percentage concentration than the gel, but the volumes used are much lower. Fluoride simply provides a thin film that’s applied against enamel. It prevents the chance of volumes being swallowed. Fluoride varnish facilitates a rapid way to deliver a small quantity, volume-wise, of fluoride, which can remain in the oral cavity for multiple hours and/or days, releasing small quantities over and extended time period. Compare this to the systemic route where the fluoride is dispersed throughout the body, simply to have small percentages of it delivered back through the saliva to the teeth or compare it to when high concentration gels are applied but for only up to 4 minutes and the benefits derived from "duration to exposure" become obvious. Fluoride varnish presents a fabulous opportunity. The AAPD has taken a position on fluoride varnish. They have made a public announcement and have invited their membership to get their little patients in at one year of age and, where indicated, apply the fluoride varnish. Patty and others of this leadership group shared that they do try to customize the treatment to the needs of the patient. For example, with the more rampant caries such as the bottle-mouth syndrome, they apply fluoride varnish as often as every other month. For the moderate risk patient, application will be quarterly or semi-annually. Otherwise, it should be an annual application. It's fun when you can see even old ideas, such as fluoride, used in new ways to bring about such important solutions to these kinds of needs. It has become a great enough need in many states that it has been legalized for pediatricians to provide this treatment. Some states are even paying for such treatment through their welfare dentistry program. Certainly, the more we can get ahead of this program and cover the bases as dentists the better. This is "Dentistry" after all. For sure, we must be responsive to the needs of the population we serve. Dan