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
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
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DEFINITION
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RATIONALE
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GOALS
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STEPS INVOLVED IN INFANT ORAL HEALTH
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ANTICIPATORY GUIDANCE (T)
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ORAL HEALTH RISK ASSESSMENT (T)
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CARIES RISK ASSESSMENT (T)
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RESPONSIBILITY OF NON-DENTAL
PROFESSIONALS REGARDING INFANT ORAL
HEALTH
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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
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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III.
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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
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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The Handbook of Pediatric Dentistry
IV.
V.
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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
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.
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.
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ANTICIPATORY GUIDANCE: SUGGESTED CONTENT GUIDE
– BIRTH TO THREE YEARS
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Topic
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6-12 months
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12-24 months
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24-36 months
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Dental and oral
development
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• occlusion
• spacing issues • speech and teeth • tooth calcification |
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Fluoride
supplementation
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• F dentifrice use
• F in food sources • avoiding excessive ingestion |
• F use revisited at
every interval
• daily access |
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Non-nutritive
habits
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• pacifier use and
types/safety
• mouthing/oral stimulators |
• digit habit issues
• effect on occlusion |
• revisit habit issues
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The Handbook of Pediatric Dentistry 3
Chapter 1: INFANT ORAL HEALTH
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Injury prevention
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• helmet safety
• seat belts
• safety network |
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Diet
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Oral hygiene
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• child participation
• dentifrice use
• Fl dentifrice for high risk |
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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
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
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What to address
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What to ask
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Medical history: pre-/perinatal history
(hypoplasia), general health (healthy vs.
special needs), medications (some high in
sucrose)
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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 |
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Oral hygiene: visible plaque on
maxillary anterior teeth is one of the
best predictors of future caries
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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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The Handbook of Pediatric Dentistry
Chapter 1: INFANT ORAL HEALTH
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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
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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? |
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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) |
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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 |
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Bacteria Transmission: Mutans
streptococci (MS) transmission can be
direct or indirect, vertical (usually from
mother) or horizontal (within or outside of
the family)
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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? |
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Demographic data:
low SES, low maternal educational level, and minority groups are at higher risk for ECC |
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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?) |
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Iatrogenic factors:
use of braces or orthodontic/oral appliances provide hard, non-desquamating surfaces and serve as plaque traps |
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The Handbook of Pediatric Dentistry 5
VII. CARIES RISK ASSESSMENT
Chapter 1: INFANT ORAL HEALTH
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Salivary assays for MS: Ivoclar Vivadent CRT system (www.ivoclarviva.com), MSKB
agar plates
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Perceived risk by dental professional is reliable
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AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
CARIES-RISK ASSESSMENT*
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RISK FACTORS TO
CONSIDER (For each item below,
circle the most accurate response
found to the right under “Risk
Indicators”.)
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RISK INDICATORS
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HIGH
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MODERATE
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LOW
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Part 1 – History (determined by
interviewing the parent/primary
caregiver)
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Child has special health care needs
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Yes
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No
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Child has condition that impairs
salivary flow/composition
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Yes
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No
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Child’s use of dental home
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None
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Irregular
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Regular
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Time lapsed since child’s last cavity
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<12 months="" span="">
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12 to 24 months
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>24 months
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Child wears braces or orthodontic/oral
appliances
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Yes
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No
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Child’s mother has active decay present
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Yes
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No
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Socioeconomic status of child’s
caregiver
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Low
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Mid-level
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High
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Frequency of exposure to between meal
sugars/cariogenic foods (include ad lib
use of bottle/sippy cup containing juice
or carbonated beverage)
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>3
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1 to 2
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Mealtime
only
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Child’s exposure to fluoride
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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
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Uses
fluoridated
toothpaste;
drinks
fluoridated
water or
takes fluoride
supplement
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Part 2 – Clinical evaluation (determined by examining the child’s mouth)
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Visible plaque on anterior teeth
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Present
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Absent
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Gingivitis
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Present
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Absent
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The Handbook of Pediatric Dentistry
VIII.
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IX.
1. 2. 3. 4. 5.
IX.
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.
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
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Areas of demineralization (white spot
lesions)
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More than
1
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1
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None
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Enamel characteristics; hypoplasia,
defects, retentive pits/fissures
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Present
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Absent
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Part 3 – Supplemental assessment (Optional)
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Radiographic enamel caries
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Present
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Absent
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Levels of mutans streptococci
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High
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Moderate
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Low
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* 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”).
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”).
The Handbook of Pediatric Dentistry
