Infant Oral Health

Chapter 1: INFANT ORAL HEALTH AAPD GUIDELINE:
http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf http://www.aapd.org/media/Policies_ InfantOralHealthCare.pdf Guidelines/G_ http://www.aapd.org/media/Policies_Guidelines/P_CariesRiskAssess.pdf

1. DEFINITION
   
2. RATIONALE
   
3. GOALS
   
4. STEPS INVOLVED IN INFANT ORAL HEALTH
   
5. ANTICIPATORY GUIDANCE (T)
   
6. ORAL HEALTH RISK ASSESSMENT (T)
   
7. CARIES RISK ASSESSMENT (T)
   
8. RESPONSIBILITY OF NON-DENTAL PROFESSIONALS REGARDING INFANT ORAL HEALTH
   
9. ADDITIONAL READINGS
   

J. Lee, K. Weber Gasparoni

Chapter 1: INFANT ORAL HEALTH

I. DEFINITION
Professional intervention within six months after the eruption of the first primary tooth or no later than 12 months of age directed at factors affecting the oral cavity, counseling on oral disease risks, and delivery of anticipatory guidance

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Early intervention aimed at preventing or mitigating common pediatric oral diseases and conditions while initiating a relationship between infant, child, family and the pediatric dental caregiver
Primary prevention of dental disease based on timely family education, instruction and motivation for behavioral changes, appropriate fluoride management, early identification of risks and tailored preventive programs
Foundation upon which prevention of oral injuries, management of oral habits, assessment of oral development, and consideration of other individual and special needs enhance a child’s opportunity for a lifetime free from preventable oral disease
RATIONALE
Early oral exam, along with oral health risk assessment and anticipatory guidance are effective means of true primary prevention
Early identification and intervention of oral health problems are cost effective and lead to satisfactory outcomes
GOALS
Timely delivery of family education on caries etiology/process, appropriate oral hygiene and feeding/dietary habits for caries prevention with ultimate goal of avoiding future surgical intervention (if possible, initiate educational process during pregnancy)
Timely consideration of fluoride management and preventive strategies as the primary dentition erupts based on individualized risk assessment
Provide anticipatory guidance and identify high-risk children for Early Childhood Caries (ECC) at an early age (if possible, identify high-risk mothers during pregnancy)
Establish a dental home by 12 months of age (Refer to “Policy on the Dental Home” at http://www.aapd.org/media/Policies_Guidelines/P_DentalHome.pdf)
STEPS INVOLVED IN INFANT ORAL HEALTH CARE
Record detailed medical and dental histories
Clinical examination of oral structures in parent-assisted (knee-to-knee) position
Counsel about caries risk factors and provide anticipatory guidance in the areas of dental and oral development, fluoride adequacy, teething, non-nutritive habits, injury prevention, dietary and oral hygiene instructions (Refer to Section V)
Counsel about bacteria transmissibility and provide anticipatory guidance directed to the mother or other intimate caregiver in order to avoid or delay colonization

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Assess the infant’s caries risk using AAPD Caries-Risk Assessment Tool (CAT) in order to address current problems, and determine individual preventive strategies and follow-up intervals (Refer to Section VII)
Decide on supplemental procedures which may include caries risk testing, such as assay of salivary mutans streptococci (MS) levels by culture, selected radiographic examination, water fluoride analysis, consultation with other dental and medical providers and other interventions deemed necessary by a child’s individual needs
Follow-up procedures are those indicated in the “Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children”
ANTICIPATORY GUIDANCE

Chapter 1: INFANT ORAL HEALTH

In dental anticipatory guidance, parents are given counseling in infant oral hygiene, home and office-based fluoride therapies, dietary counseling, and information relative
to oral habits and dental injury prevention. Counseling of parents by providers about dental developmental changes expected to occur between their children’s dental visits is an important part of preventive care. Like well-child medical visits, one of the cornerstones of the infant dental visit is to prepare parents and caregivers for future age-specific needs and dental milestones.

ANTICIPATORY GUIDANCE: SUGGESTED CONTENT GUIDE – BIRTH TO THREE YEARS
Topic	6-12 months	12-24 months	24-36 months
Dental and oral development	milestones patterns of eruption environmental and genetic influences teething infant oral cavity	• occlusion • spacing issues • speech and teeth • tooth calcification	last primary tooth erupted exfoliation future orthodontic needs radiographs
Fluoride supplementation	F mechanisms sources of F choice of F vehicles F and vitamins toxicity issues/ storage formula and F	• F dentifrice use • F in food sources • avoiding excessive ingestion	• F use revisited at every interval • daily access
Non-nutritive habits	• pacifier use and types/safety • mouthing/oral stimulators	• digit habit issues • effect on occlusion	• revisit habit issues

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Chapter 1: INFANT ORAL HEALTH

Injury prevention	signs of trauma child abuse oral signs emergency access instructions implications for permanent teeth car seats	daycare instructions electric cord safety replantation warning Re: primary teeth child proofing	• helmet safety • seat belts • safety network
Diet	nutrition and dental health bottle use and weaning sippy-cup use and content breast feeding caries process	role of carbohydrates (juice) exposures retention of food review caries process revisit sippy-cup issues	snacks frequency issues review caries process role of carbohydrates (juice) exposures revisit sippy-cup issues
Oral hygiene	oral as part of general hygiene acquisition of S. mutans positioning baby for oral hygiene special techniques	• child participation • dentifrice use • Fl dentifrice for high risk	electric brushes/ toddler techniques use of floss continued parental participation

VI. ORAL HEALTH RISK ASSESSMENT
Systemic evaluation of the presence and intensity of etiologic and contributory caries risk factors designed to provide a disease estimation susceptibility and help in determining preventive and treatment strategies

What to address	What to ask
Medical history: pre-/perinatal history (hypoplasia), general health (healthy vs. special needs), medications (some high in sucrose)	Nutritional deficiencies in pregnancy Prematurity (~ < 36 weeks gestational period) Birth weight (~ < 2.5 kg) Medical problems/special health care needs (i.e. compromised salivary flow, compromised oral hygiene due to behavior problems, high- caloric diets, etc.) History of hospitalization and past/current medications
Oral hygiene: visible plaque on maxillary anterior teeth is one of the best predictors of future caries	Age brushing began? Are the child’s teeth brushed daily, once in while or not yet? Who brushes the child’s teeth? When are the child’s teeth brushed: morning, before bedtime, morning and before bedtime and/or after meals? Any problems with positioning, child’s cooperation, etc.?

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Chapter 1: INFANT ORAL HEALTH

Infant Feeding: only formulas, breastmilk or water in infant bottles; milk is not cariogenic, but a vehicle for cariogenic substances (i.e. chocolate powder); breastmilk alone is not cariogenic, prolonged on-demand nighttime feeding associated with increased risk for caries; weaning from the bottle/sippy-cup at age 1 and from the breast as long as the mother and the child desires; breastfeeding in the 1st year of life found to be protective of future obesity	Breastfed/Bottle-fed? Breastfed/Bottle-fed to sleep and/or in the middle of the night? If yes, duration and frequency for each If bottle-fed, content of bottle: formula, milk, milk and sugary substances, juice/sugary drinks and/or water?
Dietary Habits: early introduction of unhealthy foods (i.e. sugary drinks and snacks) can alter taste preferences for foods and beverages and predispose to obesity; high frequency of sugary drinks and snacks between meals (≥ 3 times) increases caries risk; limit juice and sugary drinks daily intake to 4-6 oz and best given in open cups; best to limit sweet foods/drinks at mealtimes	Does the child regularly eat sweets more than 2× a day? What does the child like to snack on and how frequently? What type of container does the child usually use for drinks? Daily amount in oz during meals and/or throughout the day for the following drinks: 100% juice, juice drinks, regular/diet soda and sugary drinks (i.e. Kool-Aid)
Fluoride Adequacy: daily fluoride exposure through water or supplementation, and monitored use of fluoridated toothpaste (no more than a lateral smear) can be effective primary preventive procedures	Main water source from which the child is drinking: city water (unfiltered, Brita/Pur filter), city water (filtered, reverse osmosis), well water or bottle water? Fluoride level in the child’s drinking water? Does the child take fluoride supplements? If yes, dosage and frequency Does the child use fluoridated toothpaste daily, once in a while or not yet? If yes, amount placed on toothbrush
Bacteria Transmission: Mutans streptococci (MS) transmission can be direct or indirect, vertical (usually from mother) or horizontal (within or outside of the family)	Does the child’s mother (intimate caregiver) have any untreated decay? Does the child and mother (intimate caregiver) share the same utensils, foods and cups? Does the mother (intimate caregiver) pre-chew the child’s food or kiss the child on the mouth?
Demographic data: low SES, low maternal educational level, and minority groups are at higher risk for ECC
Teeth characteristics: white spot lesions considered severe ECC in children younger than 3 years of age; inspect for enamel hypoplasia, enamel defects, retentive pits/fissures; stained pits/fissures not common in primary dentition (possible higher risk for future cavitation?)
Iatrogenic factors: use of braces or orthodontic/oral appliances provide hard, non-desquamating surfaces and serve as plaque traps

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VII. CARIES RISK ASSESSMENT

Chapter 1: INFANT ORAL HEALTH

Salivary assays for MS: Ivoclar Vivadent CRT system (www.ivoclarviva.com), MSKB agar plates

Perceived risk by dental professional is reliable

AMERICAN ACADEMY OF PEDIATRIC DENTISTRY CARIES-RISK ASSESSMENT*
RISK FACTORS TO CONSIDER (For each item below, circle the most accurate response found to the right under “Risk Indicators”.)	RISK INDICATORS
	HIGH	MODERATE	LOW
Part 1 – History (determined by interviewing the parent/primary caregiver)
Child has special health care needs	Yes		No
Child has condition that impairs salivary flow/composition	Yes		No
Child’s use of dental home	None	Irregular	Regular
Time lapsed since child’s last cavity	<12 months="" span="">	12 to 24 months	>24 months
Child wears braces or orthodontic/oral appliances	Yes		No
Child’s mother has active decay present	Yes		No
Socioeconomic status of child’s caregiver	Low	Mid-level	High
Frequency of exposure to between meal sugars/cariogenic foods (include ad lib use of bottle/sippy cup containing juice or carbonated beverage)	>3	1 to 2	Mealtime only
Child’s exposure to fluoride	Does not use fluoridated toothpaste; drinking water is not fluoridated; not taking fluoride supplement	Uses fluoridated toothpaste; usually does not drink fluoridated water and does not take fluoride supplement	Uses fluoridated toothpaste; drinks fluoridated water or takes fluoride supplement
Part 2 – Clinical evaluation (determined by examining the child’s mouth)
Visible plaque on anterior teeth	Present		Absent
Gingivitis		Present	Absent

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VIII.

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1. 2. 3. 4. 5.

RESPONSIBILITY OF NON-DENTAL PROFESSIONALS REGARDING INFANT ORAL HEALTH CARE
Since health care professionals (i.e. physicians, nurses) are more likely to serve new mothers and children in their first three years of life compared to dental professionals, it is important they understand their role in providing parent/ caregiver oral health education, and be aware of the infectious and transmissible nature of bacteria that cause ECC, associated ECC risk factors, methods of oral health risk assessment (CAT), anticipatory guidance, and appropriate decisions regarding timely and effective intervention, as well as appropriate referral
ADDITIONAL READINGS
O’Connor TM, Yang SJ and Nicklas TA. Beverage Intake Among Preschool Children and it’s effect on Weight Status. Pediatrics 118:e1010-e1018, 2006.
Nowak A J and Warren J J. Infant Oral Health and Oral Habits. Ped Clinics NA 47:1043-1066, 2000.
Nowak AJ. Rationale for the timing of the first oral evaluation. Pediatr Dent 19:8-11, 1997.
Nowak AJ and Casamassimo PS. Using anticipatory guidance to provide early dental intervention. JADA 126:1156-1163, 1995.
Nowak AJ and Casamassimo PS. The Dental Home: A primary oral health concept. JADA 133:93-98, 2002.

Chapter 1: INFANT ORAL HEALTH

Areas of demineralization (white spot lesions)	More than 1	1	None
Enamel characteristics; hypoplasia, defects, retentive pits/fissures	Present		Absent
Part 3 – Supplemental assessment (Optional)
Radiographic enamel caries	Present		Absent
Levels of mutans streptococci	High	Moderate	Low

* Based on AAPD Policy on Use of Caries-risk Assessment Tool (CAT) for Infants, Children, and Adolescents. Pediatr Dent 2004:26(7) 25
Each child’s overall assessed risk for developing decay is based on the highest level of risk indicator circled above (i.e. a single risk indicator in any area of the “high risk” category classifies a child as being “high risk”).

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