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
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
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
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.
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.
13-2. Daily Recommended Dietary Fluoride
Supplementation Depending on Drinking Water Content
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
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).
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
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”).
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
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
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.
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
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