++
Dental caries may be controlled by enhancing patient protective
factors and suppressing their pathological factors. Although understanding
the underlying risk factors for dental caries will not completely eliminate
the risk factors in most cases, it will allow for an enhanced balance
between the risk factors and protective factors.17
+++
Caries Risk Assessment
++
Although the incidence of dental caries is very high in children,
the majority of decay is concentrated in a small percentage of them.
It would be more efficacious and cost effective to focus strategies
on preventing and managing dental caries based on risk rather than
treating all patients in the same manner. Risk factors are not constant,
and an individual’s risk of caries changes with time. Risk
factors for caries may be physical, biological, behavioral, or lifestyle-related. Table 374-1 provides examples of factors
that are associated with an increase in caries risk for children.18
++
++
In children, the best predictors of caries in primary teeth are
a past history of caries experience, followed by parents’ education
and socioeconomic status.19 Family history of caries,
particularly in the mother, is also an important predictor of caries
in children.20 Children who have low birth weight
or who are premature may require a special diet or may have developmental
enamel defects or disabilities that increase their caries risk.
Many studies have found that sugars are the most important factor
in caries development. Caries risk is greater if sugars are consumed
at high frequency and are in a sticky and retentive form (eg, raisins
and granola bars) that remain in the mouth for longer periods of
time.21 Again, sucrose is the most cariogenic,
but mixtures of heat-treated starch and sucrose are also cariogenic.22
++
The American Academy of Pediatrics recommends that every child
begin to receive oral health risk assessments by 6 months of age
by a qualified pediatric health care professional. Children who
belong to high-risk groups should be referred to a dentist by 12
months of age to establish a dental home.23
+++
Nutritional Counseling
++
Dental caries is a diet-mediated disease, with dietary sugars
being an important part of the process of caries development and
progression.20 Juice and sugar-sweetened beverage
consumption has been linked to caries development.24,25 Sucrose,
glucose, and fructose contained in fruit juices are easily metabolized
by oral bacteria to form acids that slowly dissolve teeth. Bottles
and sippy cups containing juice, milk, or any fermentable carbohydrate
allow frequent or prolonged consumption, which increases the risk
for early childhood caries.
++
Human milk by itself does not promote caries.26 However,
case reports suggest that after the eruption of the first primary
teeth, infants may be at increased risk for caries if they breast-feed
on demand or throughout the night. They are also at increased risk if
they receive sugary liquids in a bottle or are nursing and eating
foods with sugars and fermentable carbohydrates.
++
Parents and caregivers should receive counseling on the importance
of reducing high-frequency or prolonged exposures to obvious and
hidden sugars in foods and drinks. Cariogenic foods, including sugary foods
and drinks, should be limited to meal times. Sugary drinks, including
fruit juice, should be avoided in nursing bottles or sippy cups.
Children should be discouraged from taking a bottle or sippy cup
with milk or juice to bed. During sleep, the flow of saliva is decreased,
resulting in reduced clearance of the sugary liquid from the oral
cavity.
++
Oral hygiene should begin prior to the emergence of the first
tooth. When possible, a dental home should be established for a
child by the first birthday. During this first visit, an oral exam
is performed, a child’s risk and protective factors are
identified, and preventive counseling is given regarding cleaning
of the mouth, toothbrushing, flossing, and using toothpaste.
++
Mechanical removal and dislocation of plaque accumulations, through
simple tooth brushing, is one of the most effective preventive measures
that can reduce the risk of caries. In very young children, the
presence of plaque on the labial or facial surfaces of maxillary
primary incisors is the best predictor of future development of
early childhood caries.27
++
Since the quality of cleaning is most important, young children
require assistance with toothbrushing from an adult caregiver. Toothbrushing
in young children is a simple and fast procedure, although resistance and
a lack of cooperation are normal reactions to oral hygiene measures
in infants, toddlers, and preschoolers. With correct positioning
(such as using a knee-to-knee position with two adults or having
the adult approach brushing from behind the child’s head)
and retraction of the lips and cheeks, it should take no more than
1 minute to brush a young child’s teeth (Fig.
374-2).
++
++
Older children who have adequate manual dexterity (typically
by 6 to 8 years of age) may require only parental supervision. Flossing
is required when teeth develop contacts (usually after 3 to 4 years
of age for posterior teeth) and proximal surfaces cannot be reached
with a brush. Brushing and flossing before bedtime is of paramount
importance, as caries activity is higher at nighttime, when salivary
flow decreases. Brushing more frequently with fluoride toothpaste
can provide added protection from caries. The practice of brushing
twice a day has become a social norm that is convenient for most
daily routines, and it is the basic tenet for preventing caries.28
++
Use of fluorides is the most effective way to prevent caries.28 In
the ongoing dynamic between demineralization and remineralization
at the enamel surface of teeth, fluoride demonstrates its greatest
effects through topical mechanisms by promoting remineralization
and inhibiting bacterial metabolism. Therefore, therapeutic use
of fluoride for children should focus on maximizing topical contact
and using lower dose, higher frequency approaches.29
++
Water fluoridation is considered the most cost effective, most
convenient, and most reliable method of providing optimal fluoride
benefits, because it does not depend on individual compliance. Caries
rate decreases of 18% to 40% are now attributable
to water fluoridation.2 For children who do not
have access to optimally fluoridated drinking water, systemically
administered fluoride supplements are recommended.
++
The most recent recommendations for fluoride supplementation
(Table 374-2)—approved in 1994 by
the American Dental Association, the American Academy of Pediatrics,
and the American Academy of Pediatric Dentistry—emphasize
initial supplementation at 6 months of age and continuing to age
16. This supplementation schedule was developed with the intention
of minimizing fluorosis while maximizing the topical cariostatic
effects after teeth erupt. This schedule assumes the regular use
of fluoridated toothpaste.
++
++
Before recommending fluoride supplementation, the fluoride content
of water, whether it be well water or bottled water, should be tested.
Testing of private wells is available through local and state public health
departments and through some private laboratories. If the fluoride
concentration is not listed on the label of bottled water, the bottler
can be contacted directly to obtain this information. If multiple
water sources are used, determining the total fluoride exposure
becomes difficult. Instead of purchasing bottled water, filtering
tap water may be considered. However, some reverse osmosis systems
do not allow fluoride to pass through.
++
For self-administered care, fluoride toothpaste is the most powerful
intervention for caries prevention, because it has high clinical
effectiveness and social acceptability.30 The current
perspective is that regardless of caries risk, all age groups should
use commercially available fluoridated toothpaste at least two times
per day.31 To minimize the risk of fluorosis, children
younger than 2 years of age should limit the amount to a small smear
applied onto a soft toothbrush by an adult caregiver, while older
preschoolers may use a pea-size amount.32
++
Children who are at increased risk for caries may be prescribed
topical fluoride in the form of gels or rinses to be used at home. For
example, in high caries–risk children who are able to rinse
and expectorate, 0.2% or 0.05% sodium fluoride
rinse may be used. Additionally, professional applications of fluoride
treatment every 6 months or more may also be recommended. These
may be in the form of gels, foam, and varnishes. Fluoride varnish
is a sticky substance that is easily applied onto the teeth and
hardens quickly on contact with saliva. Fluoride varnish is well
accepted by young children.
+++
Delaying the
Transmission of Streptococcus Mutans
++
Early acquisition of Streptococcus mutans (SM)
is a major risk factor for early childhood caries and future caries
experience. Preventing and delaying the acquisition and transmission
of SM involves reducing the bacteria in the mother, siblings, and other
caregivers; altering saliva-sharing activities; brushing two times
per day with fluoride toothpaste; avoiding caries-promoting feeding
behaviors; and having an oral health evaluation by a dental professional
by the first birthday.5
++
The pits and fissures on the chewing surfaces of teeth are the
most susceptible to caries. A sealant is a plastic material that
is usually applied to the chewing surfaces of the posterior teeth,
molars, and premolars. This plastic resin bonds into the depressions
and grooves (pits and fissures) of the chewing surfaces of back
teeth. The sealant acts as a barrier, protecting enamel from plaque
and acids. Both primary and permanent teeth that are judged at risk
for caries would benefit from sealants.33
+++
Xylitol and Antimicrobials
++
Xylitol is a sugar substitute that is part of the polyol family
and includes sorbitol, mannitol, and maltitol. It is produced from
birch trees and other hardwood trees containing xylan. It is approved
by the FDA and safe to use in children. Sugar alcohols have been
shown to be noncariogenic, and xylitol exhibits protective effects
from dental caries. Studies indicate that xylitol can reduce Streptococcus
mutans (SM) in plaque and saliva, which can reduce dental
caries in young children and their mothers and can decrease the
vertical transmission of SM from mother to child.34
++
Xylitol use is attractive, because, as a sugar substitute, it
can reduce the overall consumption of other sugars in the diet.
Xylitol is commonly available in chewing gum; however, a range of
6 to 10 grams divided into at least three consumption periods per
day is necessary for xylitol to be effective with chewing gum as
the delivery system.34 Unfortunately, chewing gum
is not a suitable product for toddlers and preschoolers, and presently
there is no safe xylitol substitute available for this age group.34
++
Antimicrobial rinses can reduce the number of cariogenic bacteria
and can be useful in high caries–risk individuals. Presently,
the most effective antibacterial rinse is 0.12% chlorhexidine
gluconate. To avoid the possibility of swallowing, these rinses
are recommended only for children who can spit and rinse.4