The ABCs of Infant Oral Health

To promote oral health and prevent early childhood caries (ECC), infants need to receive professional dental care.^1,2 Traditionally, young children have first visited a dental office around the age of 3 years, but at this point all 20 primary teeth have most likely erupted, and oral disease or decay may already be present (Figure 1). The American Dental Hygienists’ Association, American Dental Association (ADA), American Academy of Pediatric Dentistry (AAPD), American Association of Public Health Dentistry, American Academy of Pediatrics, and American Dental Education Association all recommend that infants receive an oral health risk assessment and evaluation by age 6 months.

These associations also suggest that a dental home be established for infants by the age of 1 year. Despite these guidelines from leading professional organizations, many dental practitioners are hesitant to incorporate infant care into their private dental practices. A survey of Nebraska general dentists found that the majority of respondents wanted to treat children beginning at age 3 years or 4 years because they did not feel adequately trained to treat infants and therefore weren’t comfortable doing so, and they believed that most infants did not yet need professional dental services.³

In order to ensure that children are establishing a dental home by the age of 1 year and to reduce the risk of ECC, dental professionals need to become well versed in infant oral health assessment. Educational tool kits designed for dental professionals, such as the Baby Oral Health Program (www.bohp.unc.edu) developed at the University of North Carolina, Chapel Hill, can be very helpful. Third-party payers are also taking notice of this need and a new insurance code—D0145—has been instituted for infant oral health assessment. This dental code covers diagnostic and preventive services performed for a child under the age of 3 years, preferably within the first 6 months of the first primary tooth erupting, including recording oral and physical health history; evaluation of caries susceptibility; development of an appropriate preventive oral health regimen; and communication with and counseling of the child’s parent/caregiver.⁴

APPOINTMENT CONSIDERATIONS

The infant oral health assessment is a simple and typically brief procedure—lasting about 30 minutes. The assessment involves a limited armamentarium, including a plastic mirror to avoid injury if an infant should bite down; a child-size toothbrush; and fluoride varnish for patients at moderate to high caries risk.^2,5–7

Caries risk assessment is key in determining children’s future caries activity. Various caries risk assessment tools have been established for infants and adolescents.⁸ Both the ADA and the AAPD provide practical caries risk questionnaires for dental professionals (Figure 2, click here).^8,9 Scheduling for infant oral health assessments should be based on the baby’s routine. Avoid scheduling appointments close to feedings, nap times, or at end of the day. Explaining the sequence of the oral assessment and what is expected of the parent/caregiver during the appointment will help to ensure a positive experience in the dental office.

STEP-BY-STEP GUIDE

The discussion part of the appointment should be conducted first because the examination may cause the infant to cry. Following is an example of appointment sequence for an infant oral health assessment.

1. Medical history review. This includes any prenatal issues or infant illnesses and medication use, including syrup formulas that may contain sugar for flavoring.

2. Systemic fluoride intake. Find out if the infant’s primary water source is fluoridated.⁷ Inquire if fluoride supplementation has been prescribed by his or her pediatrician (fluoride supplementation may begin as early as 6 months).¹⁰ Explain how fluoride makes enamel stronger and more resistant to the bacteria that cause dental caries.¹¹

3. Provide parents/caregivers with education on the following topics:^6,7

• Oral developmental stages. Identify tooth eruption and exfoliation patterns.
• Maternal health. Discuss the relationship between maternal oral health and the baby’s oral health.
• Vertical transmission. Explain how the sharing of eating utensils, prechewing of food, and cleaning a pacifier with the caregiver’s mouth and then giving it to the infant can transmit caries bacteria from parent to child.²
• Nonnutritive sucking. Sucking on a pacifier, thumb, or finger past the first year should be discouraged. Recommend an orthodontic pacifier, and advise caregiver to frequently inspect for tears or cracks.
• Numbing agents. Avoid the use of benzocaine, the main ingredient of many teething pain medications because of the risk, although small, of methemoglobinemia, which can cause discolored skin, shortness of breath, fatigue, confusion, headache, lightheadedness, and increased heart rate.¹² Instead, recommend the use of a cool teething ring or a washcloth to soothe the baby’s gums.
• Injury prevention. As infants become more mobile and begin exploring, the risk of oral trauma and injury increases. Explain the importance of retaining primary teeth and discuss safety-proofing sharp furniture corners and gating stairwells, as well as keeping fluoride toothpaste out of reach to avoid ingestion

4. Discuss the role of nutrition in preventing early childhood caries:¹³

• Juice intake. Avoid juice with added sugars and limit consumption to 100% fruit juice at meal times only to decrease sugar exposure between meals.² Eating whole fruits is preferred. Fluoridated water should be ingested in between meal times.
• Nighttime feeding. Avoid putting baby to bed with a bottle containing anything besides water.
• Extended nursing or bottle feeding. Introduce a cup after the first tooth erupts. Prolonged, on-demand breastfeeding or bottle feeding should be discouraged.
• Teething biscuits. These are highly cariogenic and should be avoided.
• Snacks. Between meals, whole fruits and vegetables should be consumed. They can be puréed if needed

5. Begin the caries risk assessment. The caries risk assessment tool may have questions that can be completed prior to the exam. If the caries risk is determined to be moderate or high, fluoride varnish may be immediately applied in children who are at least 1 year old.

ORAL ASSESSMENT AND INFANT TREATMENT

The assessment requires parent/caregiver participation, as it reduces the infant’s anxiety and teaches the caregiver how to perform a daily infant oral health care regimen. The knee-to-knee method works best with the parent/caregiver facing knee to knee with the dental professional (Figure 3). The infant’s head lays into the dental professional’s lap. While holding the infant’s hands, the parent/caregiver lays his or her forearms gently over the baby to stabilize the legs.⁷ The baby will most likely cry or fuss, but this provides a better opportunity for viewing the oral cavity. Make sure that all necessary armamentarium (plastic mirror, toothbrush, and fluoride varnish) is at hand. Having a distracter nearby, such as a toy, bubbles, or an image on the ceiling, can be very helpful.

Once a mask and gloves are donned and the infant is in position for the assessment, open his or her mouth using thumbs and index fingers. Gently retract the lips and cheeks away from teeth to examine for caries lesions. Early lesions will have a chalky white spotted appearance near the gumline.

Use this opportunity to explain the purpose of lifting the lip away, which is to examine the anterior third of the teeth for signs of demineralization, so the parent/caregiver may perform the same action during daily infant care. Note any primary teeth that have erupted, and assess for any oral malformations.² Once the assessment has been completed, remove visible plaque biofilm via tooth brushing.^2,14

Daily plaque biofilm removal demonstration should be incorporated into the infant oral health assessment. Toothbrushing begins as early as the eruption of the first tooth, and a demonstration of effective brushing methods needs to be included. The various methods, including knee-to-knee if two caregivers are available, laying the infant in the caregiver’s lap while he or she is sitting on the floor or in a chair, and brushing the infant’s teeth from behind while he or she is seated in a highchair, should be demonstrated.

A child-sized toothbrush should be recommended. Advise the parent/caregiver that the brush should be replaced when the bristles become frayed (usually after 2 months to 3 months of use) or after an illness.⁷ Advise the parent/ caregiver that flossing is necessary once the teeth touch each other. Show him or her how to pull the infant’s lip up and away when brushing, which allows the toothbrush to contact the whole tooth, in addition to providing an opportunity to check for ECC lesions. Establishing a routine is essential for ECC prevention, and overall maintenance of oral health.^2,14

POST-ORAL ASSESSMENT AND TREATMENT

Before the conclusion of the appointment, the newly learned oral hygiene techniques should be reviewed to ensure the parent/caregiver is comfortable enough to make the strategies part of the infant’s daily routine. Providing positive feedback to both the infant and the parent/caregiver for completing the first visit is important. Infants at low risk of ECC can be effectively managed on a 6-month recare schedule, while those at higher risk may need to be seen more frequently for professional fluoride application.^2,11

CONCLUSION

The infant oral health assessment should be a positive experience for all of those involved. A protocol for infant oral health care should be implemented in the dental office and needs to involve all team members including the dentist, dental hygienists, dental assistants, and front office personnel. The protocol should be revisited during the morning huddle each day that an infant is scheduled, so the appointment goes as smoothly as possible. The infant oral health assessment appointment is the perfect opportunity to establish the dental office as the foundation for oral health education, as well as facilitate prevention of ECC and promotion of lifelong oral health.

ACKNOWLEDGEMENT

The author would like to thank Ashley Ignatowski, Stephanie Ignatowski, RDH, and Lisa Stapleton, RDH, BS, for their help with the photographs.

REFERENCES

1. American Academy of Pediatrics. Preventive oral health intervention for pediatricians. Pediatrics.2008;122:1387–1394.
2. American Academy of Pediatric Dentistry. Guideline on Infant Oral Health Care. Available at:www.aapd.org/media/Policies_Guidelines/G_infantOralHealthCare.pdf. Accessed September 10, 2012.
3. Salama F, Kebriaei A. Oral care for infants: a survey of Nebraska general dentists. Gen Dent.2010;58:182–187.
4. CDT 2011-2012: The ADA Practical Guide to Dental Procedure Codes. Chicago: American DentalAssociation; 2012.
5. Hale KJ. Oral health risk assessment timing and establishment of the dental home. Pediatrics.2003;111:1113–1116.
6. Kumar J, Samelson R. Oral Health Care during Pregnancy and Early Childhood Practice Guidelines.New York State Department of Health. Available at: www.health.ny.gov/ publications/ 0824/ pda/windows_ mobile/0824_prenatal_care_providers.pdf. Accessed September 4, 2012.
7. California Dental Association Foundation. Oral health during pregnancy and early childhood:evidence-based guidelines for health professionals. J Calif Dent Assoc. 2010;38:391–440.
8. American Academy of Pediatric Dentistry, Council on Clinical Affairs. Policy on use of a cariesriskassessment tool (CAT) for infants, children, and adolescents. Pediatr Dent. 2008–2009;30(Suppl): 29–33.
9. American Dental Association. Caries risk assessment form (age 0-6). Available at: www.ada.org/sections/ professionalResources/pdfs/topics_caries_under6.pdf. Accessed September 4, 2012.
10. Rozier RG, Adair S, Graham F, et al. Evidence-based clinical recommendations on the prescriptionof dietary fluoride supplements for caries prevention: a report of the American Dental AssociationCouncil on Scientific Affairs. J Am Dent Assoc. 2010;141:1480–1489.
11. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride:evidence-based clinical recommendations. J Am Dent Assoc. 2006;137:1151–1159.
12. US Food and Drug Administration. FDA Drug Safety Communication: Reports of a rare, butserious and potentially fatal adverse effect with the use of over-the-counter (OTC) benzocaine gelsand liquids applied to the gums or mouth. Available at:www.fda.gov/drugs/drugsafety/ucm250024.htm. Accessed September 21, 2012.
13. US Department of Agriculture. Health and Nutrition Information for Preschoolers. Available at:www.choosemyplate.gov/preschoolers.html. Accessed September 4, 2012.
14. Ramos-Gomez FJ. Clinical considerations for an infant oral health care program. Compend ContinEduc Dent.2005;26(Suppl):17–23.

 

From Dimensions of Dental Hygiene. October 2012; 10(10): 66-69.