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Title: Preventive dental care and counseling for infants and young children

INTRODUCTION — Many oral health problems, including dental caries, malocclusion, and fluorosis, begin in childhood and can be prevented through regular preventive dental care and counseling . Despite the decrease in prevalence of dental caries among school-aged children from approximately 75 percent in the 1970s to 42 percent in 1999 to 2002 , caries continues to be one of the most common chronic diseases . A Centers for Disease Control and Prevention report confirmed that tooth decay in primary teeth of children aged two to five years increased from 24 to 28 percent between 1988 to 1994 and 1999 to 2004 . The oral health goals for Healthy People 2020 include :

●Decrease the proportion of three- to five-year-olds with caries in the primary dentition from 33 percent (1999 to 2004) to 30 percent
●Decrease the proportion of six- to nine-year-old children with caries in the mixed dentition from 54 percent (1999 to 2004) to 49 percent
●Decrease the proportion of adolescents with caries in the permanent dentition from 54 percent (1999-2004) to 48 percent
The provision of preventive dental care and counseling at regularly scheduled health maintenance visits is essential to the achievement of these goals and will be discussed below. Oral health habits are discussed separately.

RISK ASSESSMENT — Dental risk assessment before one year of age can help to identify children who are at risk for development of dental disease . Risk factors for the development of dental disease have been identified in several prospective studies and include findings from both the history and examination.
Children with the following risk factors should be referred for early dental evaluation, preventive care, and counseling:

●Mother/primary caregiver with active cavities
●Parent/caregiver with low socioeconomic status
●Prolonged breast-feeding or bottle-feeding (>12 months)
●Frequent consumption of sugary beverages and snacks
●Prolonged use of a training cup (sippy cup) throughout the day
●Use of a bottle at bed time, especially with sweetened beverages
●Use of liquid medication for longer than three weeks
●Exposure to passive tobacco smoke
●Children with special health care needs
●Insufficient fluoride exposure (see \'Fluoride\' below)
●Visible plaque on upper front teeth
●Enamel pits or defects
SCREENING EXAMINATION — Pediatric primary care providers should begin performing a dental screening examination as soon as the first teeth erupt, usually when the child is between five and eight months of age . With adequate training, primary care clinicians can appropriately identify children who require dental referral (eg, those with cavities, soft tissue pathology, tooth or mouth trauma) .

Recommended equipment for this examination includes a light source, disposable mouth mirror, and a soft-bristled toothbrush. The examination may be conducted on the examination table or in the \"knee-to-knee\" position. In the \"knee-to-knee\" position, the child is well supported and stable, the child\'s mouth is visible and accessible to the examiner, and the parent can support and distract the child.

The goals of the screening dental examination include:

●Evaluation for abnormalities of teeth and oral mucosa (
●Assessment for dental plaque
●Assessment for white spots and/or cavities
With gloved hands and a good light source, the examiner should lift the child\'s upper lip to inspect the teeth for plaque. The teeth should be cleaned with a gauze square or a wet toothbrush, using a gentle scrubbing motion to remove plaque if it is present. After cleaning, the front surfaces of the teeth should be inspected for white spots, pitted enamel, stains, and cavities . The back surfaces of the front teeth should be checked with a mouth mirror.

If obvious decay, abscess, or other significant disease is noted during screening, the child should have an immediate referral to a dentist experienced in caring for children.

Oral health assessment by six months of age is recommended by the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry . The AAP recommends repeat oral health assessment at 12, 18, 24, and 30 months of age if the child has not yet established a dental home . Studies evaluating the effectiveness of these recommendations in preventing caries are lacking , but there is little risk of harm.

DENTAL REFERRAL — All children should receive a dental referral at or near their first birthday . However, if dental providers in the area are unwilling to see children who are younger than three years of age, the pediatric health-care provider may continue to provide preventive dental care and counseling for infants and children who are at low risk of developing dental disease and have no abnormalities on screening examination. Children with risk factors for caries and/or abnormalities on screening examination should be referred preferably to a pediatric dentist who accepts infants and toddlers. The American Academy of Pediatric Dentistry (AAPD) provides a website to help find a pediatric dentist.

Making a dental referral provides the pediatric care provider with an opportunity to explain the concept of the dental home and encourage the parents to establish one as soon as possible after the first birthday, and certainly by the time the child is three years of age. Once the referral is made, pediatric and dental care providers should communicate regarding the child\'s diagnosis and treatment plans. The pediatric care provider should verify that the child kept the initial appointment and continues to be seen by the dentist at least annually. The pediatric care provider should continue to provide oral health anticipatory guidance at regularly scheduled health maintenance visits. 

First dental visit — The AAPD, the American Dental Association (ADA), the American Public Health Association, and the American Academy of Pediatrics (AAP) recommend that the first dental visit occur at or near one year of age . We support the recommendation for initiation of dental care as soon as possible after the child\'s first birthday, particularly for children who are at risk for development of oral health problems.

The rationale for the early dental visit centers on the early initiation of preventive care and counseling, including evaluation of dental risks (ie, caries, malocclusion) and anticipatory guidance regarding dental hygiene, fluoride, diet, dietary habits, and oral habits . In addition, early dental referral can provide a pleasant, nonthreatening introduction to the dentist.

The potential benefits of early initiation of dental care were demonstrated in one study in which an oral examination and comprehensive preventive dental program (including monitoring of oral bacteria and referral for dental treatment if needed) were provided to 36 pregnant women who delivered 47 children . After delivery, the mothers were instructed on how to care for their infants\' teeth (eg, brushing, use of fluoride toothpaste, dietary habits), and professional examinations were provided to the mothers and children every six months until the children were four years of age. When the children were three and four years of age, the study group was compared with an age-matched control group who received neither pre- nor postnatal dental care. The oral health of the study group at four years of age was better than that of the control group, as indicated by the following parameters:

●Naturally healthy dentition (91 versus 58 percent in the study and control groups, respectively)
●Presence of caries (9 versus 42 percent)
●Mean decayed, missing, filled teeth score (DMF-s) (1.5 versus 7.0)
●S. mutans score ≥2 (>105 colony-forming units (cfu)/mL) (21 percent versus 60 percent)
The number of children with a first dental visit at 12 months of age has improved since 2003 (when the AAP lowered the recommended age for the first visit from three years to 12 months [1]), but continues to be suboptimal. Although surveys indicate that dentists are increasingly willing to see children at or before 12 months of age , persistent barriers include lack of reimbursement, busy schedules, and inexperience in providing dental care to young children.

Dental home — The dental home, similar to the medical home that is recommended by the AAP [30-32], should be established at the initial dental examination.

●Initial dental visit at 12 to 18 months of age
●Risk assessment for dental disease
●Evaluation of fluoride needs
●Demonstration of appropriate teeth-cleaning method
●Discussion of the benefits and risks of nonnutritive sucking
●Monitoring of the child\'s oral health care on a schedule that is individualized to the child\'s risk for dental disease
●Treatment (or referral for treatment) of dental caries
●24-hour availability for acute dental problems
●Recognition of the need for specialty consultation and referrals
●Provision of continuing, comprehensive dental care for all children, including those with special health care needs
ANTICIPATORY GUIDANCE — The pediatric care provider should provide and reinforce dental anticipatory guidance at regularly scheduled health maintenance visits . Before the eruption of the child\'s primary dentition, the provider can discuss nonnutritive sucking and the teething process. The need for fluoride supplementation should be evaluated before the six-month check-up so that, if it is necessary, it can be initiated at the six-month visit (table 2). Feeding habits, the use of the bottles and cups, and cleaning the teeth become more important as the primary dentition erupts.

Studies evaluating the effectiveness of specific educational or counseling interventions are lacking. However, there is some evidence that education combined with other interventions (eg, provision of toothbrushes and toothpaste, additional training of primary care providers) is associated with decreased caries in high-risk children younger than five years .

Nonnutritive sucking — Nonnutritive sucking is a normal part of early development; it is self-soothing behavior that occurs in 70 to 90 percent of infants in various populations . The frequency of sucking on digits or pacifiers decreases with increasing age; by the age of four to five years, nonnutritive sucking is usually replaced by other coping mechanisms . Compared with pacifier sucking, digit sucking is more likely to persist into the fourth or fifth year of life . If it persists into the period of permanent tooth eruption, nonnutritive sucking may contribute to the development of malocclusion . The dental effects and recommendations for the discontinuation of sucking habits are discussed separately. 
Teething — It is normal for infants whose primary teeth are erupting to be cranky, chew on objects, and have excessive drooling. Parents frequently report that their teething infants have fever, diarrhea, or other systemic symptoms; however, no proven association exists between these symptoms and teething. The management of teething symptoms is palliative (eg, chewing on a chilled (not frozen) teething ring or other teething device, systemic analgesia). 

Dietary habits — Anticipatory guidance regarding diet and dietary habits can play a major role in the prevention of caries . The acid that is produced when the bacteria in plaque metabolize carbohydrates decreases the pH of the oral cavity. Saliva is able to buffer the acid until the oral pH is less than 5.5; at this pH, demineralization of the dental enamel occurs. With continued exposure to pH <5.5 (eg, from constant snacking or grazing), the surface enamel develops a chalky texture, known as the white spot lesion (picture 2). At this stage, teeth cleaning, plaque removal, and the use of topical fluoride promote remineralization; without intervention, cavitation will result.

In vitro, human breast milk, formula, and other beverages differ in their ability to support bacterial growth, dissolve enamel mineral, reduce plaque pH, buffer acid, and decalcify enamel and dentin . Compared with water, breast milk and most infant formulas reduce plaque pH, have variable buffering capacity, and may support bacterial growth and dissolve enamel mineral when exposure is prolonged [49,50]. Other beverages, such as juices that are commonly given to infants and toddlers in bottles or training cups, have high cariogenic potential (table 3). These beverages should not be consumed in bed, should be offered only from a training cup, and should not be sipped throughout the day. 

Cariogenic potential is increased in foods that have a high carbohydrate content, decrease the pH of the oral cavity, and are slowly cleared from the mouth (eg, raisins, peanut butter). Avoiding such foods altogether may not be necessary provided the teeth are cleaned appropriately after their ingestion. Moderation is the key word, followed by frequency, and finally duration. It is commonly suggested that children ingest sugary foods with a meal as desserts, rather than being allowed to snack or \"graze\" on such food throughout the day.

The American Academy of Pediatrics recommends that infants be breast-fed exclusively for the first six months of life, that breastfeeding continue until the child is one year of age, and that solid foods be introduced at approximately six months of age . The use of a training cup for juice and other beverages can begin as soon as the child is able to drink from one (at approximately six months of age), and bottles should be discontinued as soon as possible after the child reaches one year of age . Fruit juice should be consumed only at meals, and carbonated beverages, particularly those sweetened with sugar or corn syrup, should be avoided for the first 30 months of life.

Breast-feeding has been suggested to reduce the risk of malocclusion. However, few studies have evaluated the effects of infant feeding method on dental arch development. Those that have been performed are inconclusive because they relied on parental report or cursory assessment of malocclusion, rather than actual measurements . Thus, the effects of breast- or bottle-feeding on dental arch development are largely unknown.

Oral hygiene — The parents should be encouraged to clean the child\'s teeth twice daily . The teeth may be cleaned with a small soft toothbrush. Parents should supervise brushing until the child is about eight years of age and can tie shoelaces (a marker of the manual dexterity necessary for effective brushing, including spreading fluoride-containing toothpaste on all surfaces of the teeth) . Supervision may be necessary beyond attainment of this skill to ensure that the proper amount of toothpaste is used and that the child does not swallow the toothpaste.  Flossing should be initiated when the space between teeth becomes too small to clean adequately with a toothbrush. Toothpaste containing fluoride is recommended, but to avoid fluorosis, fluoride-containing toothpaste should be used in very small amounts. 

Fluoride — To avoid the risk of dental caries from too little fluoride or fluorosis from too much, fluoride should be used judiciously, particularly during the critical months of enamel maturation (up to 48 months), when the developing anterior permanent teeth are most vulnerable to excessive fluoride that can cause fluorosis. This is especially true for daily-use fluoride products, such as fluoride toothpaste.

Fluoride toothpaste — We suggest that all children with teeth have their teeth brushed twice daily with small amounts of fluoride-containing toothpaste. The appropriate amount of toothpaste for infants and toddlers (younger than three years) is a “smear” or the size of a grain of rice . The amount of toothpaste should be increased to no more than a “pea-sized” (picture 4) amount at age three years; older preschoolers can use slightly more than a “pea-sized” amount. It is important to provide counseling to caregivers to ensure that the appropriate amount of toothpaste is used. To avoid swallowing fluoride toothpaste, young children should not be given water to rinse after brushing .

There is no clear consensus among pediatric and dental groups as to when use of fluoride toothpaste should be initiated . The American Academy of Pediatrics (AAP) and the American Dental Association (ADA) recommend fluoride toothpaste “for all children with teeth” ,  whereas the American Academy of Pediatric Dentistry (AAPD) recommends fluoride toothpaste “for children less than two years of age at risk for dental caries” . All three organizations agree that use of fluoride toothpaste should be closely supervised by caregivers, and that very small amounts should be used for infants and toddlers to reduce the risk of fluorosis in the permanent teeth. Given the cost and complexity of treating caries in young children and the lack of caries risk assessment tools that have been validated in this population, we suggest that all children with teeth should have their teeth brushed daily with small amounts of fluoride toothpaste.

In a 2014 systematic review, pooled analysis of eight studies (4187 patients) found that brushing with fluoride versus nonfluoride toothpaste reduced the risk of caries in children younger than six years who were at high risk of developing caries (standardized mean difference -0.25, 95% CI -0.36 to -0.14) . The systematic review found limited evidence from observational studies that ingesting more than a pea-sized amount of fluoride toothpaste can lead to fluorosis , but that most cases of fluorosis associated with fluoride toothpaste are mild . To maximize the benefits and minimize the risks of fluoride toothpaste, we suggest that children younger than three years begin brushing with fluoride toothpaste as soon as they develop teeth, but that they use only a “smear” of toothpaste.

Topical fluoride application — We suggest that prescription strength topical fluoride be provided based on the results of a caries risk assessment , rather than universal application of topical fluoride beginning at primary tooth eruption. Prescription strength home-use topical fluoride agents are indicated only for patients at increased risk of developing dental caries . Patients at low risk of developing caries can receive sufficient fluoride through fluoridated water and over-the-counter fluoridated toothpaste.

For children at increased risk of dental caries, topical application of fluoride can be achieved in a number of way:

●Professionally applied by healthcare practitioners (in the United States, all states permit dentists and physicians to apply fluoride varnish; some states also allow other healthcare practitioners [eg, nurses, medical assistants] to do so as well) :
•For children <6 years – 2.26% fluoride varnish applied at least every three to six months
•For children 6 to 18 years old – 1.23% acidulated phosphate fluoride (APF) gel for 4 minutes at least every three to six months; or 2.26% fluoride varnish at least every three to six months
Information and resources related to fluoride varnish application in primary care practice are available through the American Academy of Pediatrics.
●Self-applied at home (by prescription)
•For children 6 to 18 years old – 0.09% fluoride mouth rinse at least weekly; or 0.5% fluoride gel or paste twice daily
Systematic reviews and meta-analyses have found that over-the-counter fluoride rinse does not provide any benefit beyond that of fluoride toothpaste for children at low risk of caries, but may be beneficial in preventing caries in children (>6 years) at high risk .

There is a lack of consensus among professional groups regarding universal or risk-based topical fluoride application. The American Dental Association and the American Academy of Pediatric Dentistry recommend risk-based application to avoid unnecessary use of resources in children who are at low risk of dental caries . The United States Preventive Services Task Force (USPSTF) and the American Academy of Pediatrics (AAP) recommend universal application of fluoride varnish beginning at primary tooth eruption and continuing through age five years (USPSTF) or establishment of a dental home (AAP) to avoid missed opportunities for caries prevention . Although, we suggest a risk-based approach, we recognize that it is not always practical to perform individualized caries risk assessments.

In a 2013 meta-analysis, fluoride varnish reduced the risk of decayed, missing, or filled primary teeth by 37 percent (95% CI 24-51 percent; 10 trials, 3804 children) and the risk of decayed, missing, or filled permanent teeth by 43 percent (95% CI 30-57 percent; 13 trials, 6478 children) . Evidence suggesting that a particular frequency (eg, every three versus every six months) or regimen (eg, single application versus multiple applications over a two-week period) is superior to another is limited .

The safety of fluoride varnish was assessed in a pharmacokinetic study in six toddlers (12 to 15 months of age) in whom urinary fluoride was measured for five hours after application of 5% sodium fluoride (2.26% fluoride) varnish . The average estimated retained fluoride was 20 mcg/kg, well below the “probable toxic dose” of 5 mg/kg .

Fluoride supplementation — Fluoride supplementation, if indicated based upon fluoride intake and caries risk (table 1), should begin at six months of age . Fluoride supplementation is only necessary if the child is at high risk for caries, other fluoride vehicles (eg, fluoride toothpaste, mouth rinse, varnish, gel) have proved to be inadequate, and the family is using nonfluoridated water, bottled or processed waters, or water from a rural well .

Most bottled water products contain negligible levels of fluoride, although the content varies. In one study, the fluoride concentration in bottled water ranged from <0.1 to 0.94 mg/L . Only 6 of the 54 brands tested contained more than 0.25 mg/L of fluoride.

The treatment of water before drinking may affect the fluoride concentration. Faucet water filters that use reverse osmosis systems and distillation units reduce the fluoride content by more than 80 percent [77,78]. Some, but not all, studies of \"pour-through\" devices using activated carbon filters demonstrate a reduction of fluoride content [78,79]. Water and conditioning softener systems do not alter fluoride content [77,80,81].

Fluorosis — Excess fluoride consumption (generally greater than 0.05 mg/kg per day) can cause fluorosis or hypomineralization of the dental enamel . According to data from the National Health and Nutrition Examination Survey, the prevalence of fluorosis among persons aged 6 to 39 years was 23 percent during 1999 to 2002 .

The dental effect of mild fluorosis is limited to surface appearance . A 2010 systematic review found that mild fluorosis is not a cosmetic concern . Mild fluorosis is indicated by a white flecked or lacy appearance to the enamel; moderate fluorosis has an opaque white appearance (picture 6); severe fluorosis is indicated by a brown discoloration. Severe fluorosis is much less common than mild fluorosis, but it can make the teeth more susceptible to wear and breakage . The mechanism by which excessive fluoride consumption causes fluorosis appears to be a direct effect on the rate of mineral formation by ameloblasts, resulting in disruption of the enamel matrix . Fluorosis can be prevented by limitation of excessive fluoride consumption (eg, through the swallowing of fluoridated toothpaste or mouth rinses) early in life and appropriate fluoride supplementation.

A prospective study found that using optimally fluoridated water to reconstitute powdered infant formula concentrate increased the risk of dental fluorosis . As a result of this and other similar observations, the American Dental Association’s Council on Scientific Affairs recommends that clinicians be cognizant of this risk in counseling parents regarding the use of infant formulas .

Trauma — Nearly one-half of children sustain some type of dental injury during childhood. Many of these injuries are preventable through anticipatory guidance regarding prevention of falls, particularly when the child is learning to walk. As the child begins to participate in sports and recreation activities that are associated with a risk of dental trauma, parents and children should be counseled about the use of protective gear (eg, facemasks and mouth guards) . In addition, parents should be instructed regarding the proper management of avulsed primary and permanent teeth, as well as the importance of regular dental care and maintenance. 

DENTAL RESOURCES — The following resources may provide useful oral health information:

●The American Academy of Pediatric Dentistry provides information and resources including help finding a pediatric dentist
●The American Academy of Pediatrics
●American Dental Association
●Office of Maternal and Child Health (DHHS)
●National Institute of Dental and Craniofacial Research
●Maternal and Child Health Library
●A Health Professional\'s Guide to Pediatric Oral Health Management

SUMMARY AND RECOMMENDATIONS

●Dental risk assessment  before one year of age can help to identify children who are at risk for development of dental disease. Children with the following risk factors should be referred for early dental evaluation, preventive care, and counseling (see \'Risk assessment\' above):
•Mother/primary caregiver with active cavities
•Parent/caregiver with low socioeconomic status
•Prolonged breast-feeding or bottle-feeding (>12 months)
•Frequent consumption of sugary beverages and snacks
•Prolonged use of a training cup (sippy cup) throughout the day
•Use of a bottle at bed time, especially with sweetened beverages
•Use of liquid medication for longer than three weeks
•Exposure to passive tobacco smoke
•Children with special health care needs
•Insufficient fluoride exposure
•Visible plaque on upper front teeth
•Enamel pits or defects
●Pediatric primary care providers should begin performing a dental screening examination for abnormalities of the teeth and oral mucosa (including dental plaque, white spots, and cavities) as soon as the first teeth erupt. If obvious decay, abscess, or other significant disease is noted during screening, the child should have an immediate referral to a dentist experienced in caring for children. 
●All children should receive a dental referral at or near their first birthday. However, if dental providers in the area are unwilling to see young children, the pediatric clinician may continue to provide preventive dental care and counseling for infants and children who are at low risk of developing dental disease and have no abnormalities on screening examination.
●The pediatric care provider should provide and reinforce dental anticipatory guidance at regularly scheduled health maintenance visits. Topics to be discussed include nonnutritive sucking, the teething process, oral hygiene, feeding habits (ie, the use of bottles and cups), the need for fluoride supplementation, and dental trauma.

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