Chapter 13. Oral Health Supervision

The condition of children’s teeth and the associated tissues are critical to their well-being. A child with poor dentition may be suffering with chronic pain and thus may have difficulties achieving proper nutrition. He or she may also be at risk of malocclusion and life-threatening infection. Further, dental problems such as early childhood caries can affect the secondary dentition if not addressed, with consequences extending through the life span. Caries are the most common dental problem encountered; the National Health and Nutrition Examination Survey of 1999–2004 showed that 42% of children from ages 2 to 11 have some evidence of decay in their primary teeth, and 21% of children from ages 6 to 11 have evidence of decay in their secondary dentition.2 Unfortunately, a large proportion of these children have untreated caries.1 At higher risk of caries are children living in low-income and moderate-income households, children of color, and children with special health care needs.2,3 However, decay can and does occur in children of all backgrounds. As the health professional most likely to encounter new mothers and their infants at a young age, the pediatric clinician has a unique opportunity to provide anticipatory guidance that may help to prevent or slow the development of caries. Therefore, it behooves the provider to evaluate a child’s current dental status from an early age, to advise the child and the primary caregiver about positive and negative practices that may bear on future dentition, and to assist the family in establishing a dental home.

The evaluation of a child’s current dental status begins with age-appropriate history gathering regarding the child’s current practices. Data should be accumulated to assess risk for caries (see Table 13-1).4 Fixed events such as known decay, special health care needs, low socioeconomic status, and familial history of caries raise the child’s overall assessed risk for developing decay and should be noted in early life. However, mutable practices such as the use of a dental home, exposure to fluoride, exposure to simple sugars, and frequency of brushing are potentially modifiable by behavioral intervention and are critical to assess with every health supervision visit. In addition, sucking habits, including bottle, pacifier, and thumb, should be addressed to evaluate for the risk of malocclusion.

Once historical risk factors for poor dentition have been assessed, the pediatric provider should perform a physical screening as part of the general physical examination. The oral screening is different from a formal dental examination: The former is meant to assess for risk factors; the latter provides specific diagnoses.5 The screening should be conducted with the child feeling comfortable and safe, preferably on the lap of the primary caregiver at younger ages and with the primary caregiver close by for older children. Projection of a calm demeanor and use of distraction techniques will help to smooth the examination. With a gloved hand, the provider should palpate the outside of the mouth and then lift the lips away from the surface of the teeth to examine the teeth and gum line and to palpate the gum line. Using a tongue depressor, or a mirror if available, the provider can encourage the child to open his or her mouth in order to examine the facing surfaces of the molars, if any, and the inner surfaces of the teeth.

Teeth form, erupt, and exfoliate predictably (Fig. 13-1), and the provider should assess this timing. In addition, the provider should be alert for signs of caries, including both overt cavities and the demineralized (chalky white) areas that may form initially. The provider should be on alert for discolored, abnormally shaped, or traumatized teeth; plaque formation; and signs of current infection (such as dental abscess).5

As the enamel is forming, during late pregnancy and early infancy, it is very sensitive to systemic changes in the child, such as temperature changes or nutritional changes. Like the rings of a tree, the enamel records these changes that then become hypoplastic defects or hypocalcified areas within the enamel (Fig. 13-2). Enamel hypoplasia, a defect in the maturation process that results in voids in the enamel structure and predisposes the tooth to dental caries, is common in children with low birth weight or systemic illness in the neonatal period. There is considerable presumptive evidence that malnutrition or undernutrition during this period causes hypoplasia. A consistent association exists between clinical hypoplasia and early childhood caries.6

For further information, consult Chapters 374, 375, 376, 377, 378, 379, and 380.

The provision of oral health anticipatory guidance is a partnership between the pediatrician, the dentist, and the family. The success of this partnership can be measured by good oral hygiene, fluoride exposure, sealants, and the resulting absence of dental caries, as well as trauma prevention in the use of a mouth guard during sports.

The Infant

Every child should begin to receive oral health risk assessments by 6 months of age from a pediatrician or a qualified health professional. Infants identified as having significant risk of caries or assessed to be in one of the high-risk groups (children with special health care needs; children of mothers with high caries rate; children with demonstrable caries, plaque, demineralization, and/or staining; children who sleep with a bottle or breast-feed throughout the night; late-order offspring; children in families of low socioeconomic status) should be entered into an aggressive anticipatory guidance and intervention program provided by a dentist between 6 and 12 months.1

Infancy is perhaps the most important time to discuss risk factors that can be altered by behavior change, such as the vertical and horizontal transmission of Streptococcus mutans. Horizontal transmission is the transmission of bacteria among members of a group, such as among children at day care or between siblings. Vertical transmission, the transfer of bacteria via the saliva from the primary caregiver to the child, occurs when a mother tests the temperature of the bottle with their own mouth, tastes the food on a spoon and then feeds the child with the same utensil, or cleans the pacifier or bottle nipple with her mouth. The mother’s saliva has been shown to be the main reservoir from which infants acquire S. mutans. A mother with a high level of these bacteria continually recolonizes her infant when she employs such practices.

The timing of bacterial transmission is important, because acquisition of S. mutans before age 2 is a significant risk factor for development of early childhood caries and future dental caries.7 The success of the transmission and resultant colonization depends largely on the magnitude of the inoculum.8 During infancy, or better still, during late pregnancy, the mother and other intimate caregivers should be counseled to reduce their S. mutans count by having all their own dental caries restored and by setting up a routine to brush their own teeth twice a day with fluoridated toothpaste and to floss daily. To reduce the S. mutans inoculum, they may wish to rinse every night with an alcohol-free over-the-counter fluoride mouth rinse if they have more than 4 relatively recent fillings in their mouth or if they live in a nonfluoridated community.

Infancy is the optimal time for the family to examine their diet and eating practices. The family should eat foods containing sugar at mealtimes only, as limiting the frequency of consumption of fruit juices, candy, cookies, and cakes to mealtimes will decrease the risk of dental caries. Additionally, the family should be mindful of “sticky” foods that adhere to the teeth and thereby increase the risk of caries, such as dried fruit, rolled dry fruits, and sticky candy. If the carbohydrate sticks to the fingers and hand, it is likely to stick to the teeth and increase the risk of caries. Parents also should wean themselves off carbonated beverages. The pH of most of the soda products sold today is 3; below pH 5, S. mutans thrives.

Predentate children can harbor S. mutans in the mouth at as early as 3 months old.9 The primary caregiver should clean the infant’s gums with a clean, damp cloth after each feeding to develop the habit of oral care and reduce the S. mutans levels. When the first tooth erupts (see Fig. 13-1), the caregiver can move on to a soft-bristled toothbrush with a very small head and plain water. For infants at high risk, the plain water may be replaced with a tiny smear of fluoridated toothpaste. As the child grows, either a standard toothbrush or an electric one may be used; the latter may make it easier for the child to accept dental cleaning due to prior experience with vibratory sensations. The caregiver should not brush the teeth facing the child, but rather turn the child so that they are both facing the same direction with the child either sitting on the caregiver’s lap or standing in front of the caregiver, so that the adult will have a better view of the child’s teeth and better control of the child’s head movements. If the child is particularly squirmy, the caregiver can place the child on his or her lap so that the child is facing up with the top of the head against the adult’s stomach. The caregiver should brush the teeth from the gum line to the top of the tooth, including the backside of the tooth, while rotating the brush in small circles, not horizontally. To see the gum line, the caregiver must lift the child’s lip. While brushing, the caregiver should inspect the teeth for any changes, such as staining, white demineralized areas (white spot lesions), or frank caries, which often look yellow or brown and cavitated.

Infants 6 months of age and older should receive fluoride supplements based on the risk for dental caries and known level of fluoride in the infant’s drinking water (see Table 13-2).10 For families that prefer to drink bottled water, drinking a brand to which fluoride has been added should be considered after the child is 6 months of age. Formula should not be reconstituted with fluoridated water in infants due to a risk of receiving too much fluoride, causing fluorosis.

During this developmental period, teething is a major concern for many parents. Sore gums from teething can be reduced by giving the infant a wet wash cloth to suck on, a chilled teething ring, or using a clean finger to massage the child’s gum (being careful to not get bitten). Benzocaine gels are not recommended for infants.

Once the primary teeth begin to erupt, it is important to discuss not putting the infant to bed with a bottle or sippy cup with anything other than water. Additionally, ad libitum nocturnal breast-feeding should be avoided at this point.11 In addition, frequent or prolonged bottle feedings or sippy cup usage with beverages with high sugar content, such as fruit juices, soda, milk, or formula during the day should be discouraged. These sugary fluids pool around the teeth and increase the risk for dental caries.

Nonnutritive sucking is sucking that extends beyond that needed for nourishment. It provides emotional security and is thought to be a self-calming behavior. Pacifier use is preferable to digital habits because it can be more easily disrupted. Be sure that the pacifier is not tied around the child’s neck and that it is kept clean and not dipped in a sugary substance such as honey to encourage sucking. Again, to discourage colonization of S. mutans, the caregiver should not clean the pacifier by placing it in his or her own mouth.

Anticipatory guidance in infancy also includes placing the dentist’s emergency telephone contact information in a highly visible place. As infants become mobile, tooth trauma is a common result of falls. Avulsed primary teeth should not be reimplanted (see Chapter 376).

The Preschooler

Anticipatory guidance at this developmental age includes all the relevant recommendations for infancy if they have not been reviewed with the family at prior visits. At age 2, the child can begin to use a small smear of fluoridated toothpaste if not introduced to it previously because of high risk. Monitoring the use of fluoride-containing products, including toothpaste, may help prevent ingestion of excessive amounts of fluoride that cause fluorosis. The child’s teeth should be brushed twice a day, after breakfast and before bed, because S. mutans can recolonize every 24 hours. Infants and preschool children should have their teeth brushed by an adult. Young preschool children do not have the fine motor skills necessary to brush, nor do they have the object permanence to brush back teeth that they cannot visualize in the mirror. The rule of thumb is that if a child can tie his own shoelaces, he can independently brush his teeth.

Fluoride supplementation based on risk of developing tooth decay and on the known level of fluoride in the child’s drinking water should be reexamined during this period (see Table 13-2). The family’s diet should be reviewed again for frequency of juice and soda consumption as well as for frequent consumption of foods high in sugar, especially candy, cookies, cake, and sticky carbohydrates, such as dried fruits and rolled dried fruits. The child should be encouraged to drink from a cup at this age.

Injury prevention should be reviewed with parents of preschoolers. They should be aware that injuries to the face and mouth are common at this age. Because of the risk of harm to the permanent tooth, they should never reimplant a primary tooth (see Chapter 376, “Dental Occlusion and Its Management”).

The School-Aged Child

At this age, anticipatory guidance for oral health includes discussion with the child. The child should be well entrenched in a dental home by now and should be seeing the dentist twice a year or more frequently depending on their risk factors for dental caries. At this age, the child may experience the discomfort of tooth eruption as the permanent teeth erupt and primary (baby) teeth begin to exfoliate. The dentist will begin to place sealants on the permanent molars as they erupt into the mouth.

The child should be brushing his or her own teeth twice a day, after breakfast and before bed, with a pea-sized amount of fluoridated toothpaste. If the child cannot tie shoelaces at this age, the parent should continue to brush the child’s teeth until those fine motor skills have developed. The child may be placed on a supplemental fluoride rinse if they found to be at high risk for dental caries. Oral fluoride supplementation still depends on the fluoride content of the water that the child drinks, whether it is from a community water source or from bottled water (see Table 13-2).

The dietary recommendations from infancy and preschool development are still important, but school vending machines become an important discussion point. The child should be encouraged to choose water or milk rather than sweetened fruit drink or soda.12 If the child enjoys chewing gum, xylitol (sugar substitute) gum has been shown with varying results to reduce dental caries by lowering the plaque index scores.13

Most children will have discontinued nonnutritive sucking on their own by this age. The eruption of the anterior permanent teeth makes nonnutritive sucking less enjoyable. If the child has not stopped nonnutritive sucking by the time the permanent anterior teeth are erupting, discussions about helping the child discontinue the habit should begin. If the child wants help to stop the habit, a positive reinforcement system can be used, such as stars on a calendar for every night the child does not suck her thumb before bed. On the first night, the child gets a star for 1 minute of not sucking her thumb; every 3 nights, the duration is increased by 1 minute. The reward for a week of consecutive stars should be something motivating to the child. Usually, by the time the child has reached 5 minutes of non–thumb sucking, she will have stopped the habit if the parent has been consistent in the criteria for awarding the star. If a reward system does not work and the child and family wish additional help, an orthodontic appliance can be fabricated. In severe and very prolonged cases of nonnutritive sucking, a psychological consult may be necessary.

Discussions about preventive orthodontics may be introduced as a form of injury prevention. Very protrusive maxillary incisors place the child at great risk for dental trauma. Interceptive or phase I orthodontics may be indicated to reduce the protrusion, known as overjet (see Chapter 376). The parent should know how to handle oral injuries. At this age, fractured anterior teeth are very common (see Chapter 375). The use of mouth guards when participating in all contact sports and physical activities that could result in trauma to the mouth must have occurred by this age. A boil and bite type of mouthguard can be used, or the dentist can fabricate a custom-made mouth guard for the child. In 2005, the National Youth Sports Safety Foundation estimated the cost to treat an avulsed permanent tooth and provide follow-up care to be from $5000 to $20,000 over a lifetime.14

Infants and children exposed to environmental tobacco smoke have higher rates of caries in the primary dentition. Thus, the dangers of cigarette smoking and chewing tobacco should be discussed with the child and parents.

The Adolescent

At this age, the discussion may involve only the adolescent or may include the parents. All of the previously mentioned anticipatory guidance issues still should be discussed as necessary, but the use of mouth guards should be reinforced at this age for contact sports or for any physical activity that could result in trauma to the mouth. The frequent intake of soda and/or sports drinks throughout the day is seen frequently in this age group and accounts for a spike in dental caries formation. Early adolescence is also the time when many children engage in active orthodontic treatment, increasing their risk for developing caries. Good oral hygiene during this period is of utmost importance. Supplemental fluoride is often prescribed during active orthodontic treatment as a preventive modality (see Chapter 377). The adolescent can also benefit from continuing oral fluoride supplementation throughout the teenage years and into early adulthood as part of the framework of positive youth development.

The adolescent should be counseled on the dangers of oral piercings, which can damage the tongue and gums. It is not unusual to see lingual gingival recession in an adolescent with tongue piercing when the adolescent rolls the pierced object against the lower front teeth. Thus, tongue piercing may predispose the adolescent to future localized gingival disease on the lingual aspects of the mandibular incisors. Additionally, oral piercings of the tongue, lips, cheeks, and uvula have been associated with pathological conditions of pain, infection, scar formation, tooth fractures, metal hypersensitivity reactions, speech impediment, and nerve damage.15

Through news stories and advertisements, adolescents are becoming more aware of the advances in cosmetic dentistry and may request information on whitening or dental bleaching of the teeth. Dental whitening may be achieved by using either professional or at-home (gels, whitening strips, or brush-on agents) bleaching modalities. Most of the research on bleaching has been performed on adult patients; very little data has been accumulated using child or adolescent patients. The more common side effects associated with bleaching vital (non–root canalled) teeth are tooth sensitivity and tissue irritation. Sensitivity affects 8% to 66% of patients and often occurs during early stages of treatment. Both sensitivity and tissue irritation are temporary and cease with the discontinuation of treatment. If tooth whitening is initiated too early, when the teeth are still erupting, the result may be mismatched coloration. The adolescent should consult with the dentist before using any bleaching product to determine the right product and timing of dental whitening.16

Smoking and smokeless tobacco use almost always are initiated during adolescence. Oral consequences of smoking and using smokeless tobacco include oral cancer, periodontal disease, and poor wound healing.17 Avoidance or cessation of all forms of tobacco use, including cigarettes, pipes, cigars, smokeless tobacco, and alternative nicotine delivery systems (ANDS) such as nicotine lozenges, nicotine water, nicotine lollipops, or “heated tobacco” cigarette substitutes, should be discussed with adolescents.

If the adolescent has been seeing a pediatric dentist, discussions about transitioning to an adult or family dentist should begin during late adolescence. This transition can be difficult for both the provider and the patient after a multiyear relationship. This is especially true for children with special health care needs, when there may be few providers who feel comfortable dealing with persons with special health care needs and a dearth of providers willing to accept state-funded dental insurance.

In-office treatment by pediatric providers is limited. If the child is between 6 months and 16 years of age, and is not regularly exposed to fluoridated water, then fluoride supplementation should be prescribed using published guidelines.10 Pediatric providers in some areas have been trained to administer 5% sodium fluoride varnish to infants and children at moderate or high risk for caries. Administration of fluoride varnish by a pediatric provider is not, however, a substitute to referral to a dentist for establishment of a dental home.

Every infant, child, adolescent, and child with special health care needs should have a dental home. The American Academy of Pediatric Dentistry has adopted the concept of a dental home, derived from the American Academy of Pediatrics’ definition of a medical home.18 A dental home is a comprehensive, individualized preventive dental health program based on risk assessment, established by 12 months of age, that provides periodic supervision, anticipatory guidance, plans for acute dental trauma, and referrals to dental specialists when care cannot be provided within the dental home. Strong clinical evidence exists for the efficacy of early professional dental care complemented with caries-risk assessment, anticipatory guidance, and periodic supervision.19 Children should be referred to a dental home as early as 6 months of age, 6 months after the eruption of the first tooth, and no later than 1 year of age.19 Although trained dentists generally see children in their offices, many defer the first visit until 3 years of age. In contrast, a pediatric dentist has undergone a minimum of 2 years of specialty training in an accredited program with a standardized curriculum and will see children of any age. Care frequency will be at the discretion of the dentist, will depend on the caries risk assessment and need for treatment, and will be no less than twice per year.