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Our Youngest Patients

Promoting oral health in infants and young children.

PURCHASE COURSE
This course was published in the July 2009 issue and expires July 31, 2012. The author has no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated. 

EDUCATIONAL OBJECTIVES
After reading this course, the participant should be able to:

  1.  Provide an effective infant oral health visit and basic management techniques for young children.
  2. Assess the causative and protective factors in an oral health risk assessment.
  3. Discuss basic preventive strategies and restorative options with parents.

While the prevalence of dental caries has been significantly reduced during this past decade, dental disease remains a major health concern among young children with primary dentition. Prevention is the most cost-effective and least invasive method of treating dental disease. Effective dental care, oral health risk assessment, and early intervention are all factors in promoting oral health among our youngest patients. The dental practitioner—particularly as an educational resource for parents—is integral to the process of establishing good oral health in infants and young children.

THE DENTAL VISIT

All primary teeth should be erupted by 2 years to 3 years of age. By this time the child should have an established, consistent oral health care routine as well as periodic evaluations with a dental practitioner. The frequency of the dental evaluation is determined by an oral health risk assessment.

At each dental visit, oral hygiene practice should be reassessed and its importance emphasized. Parents should continue to assist and supervise their child’s oral hygiene technique up to 9 years of age or until the child is able to perform effective oral hygiene independently. When the interproximal contacts between teeth are closed, flossing is essential to dislodge food debris and bacterial plaque. However, flossing may be challenging for a child, especially between tight contacts in the posterior teeth, and parental assistance may be needed.

Bitewing radiographs are indicated to evaluate interproximal tooth surfaces with closed contacts. After the eruption of all primary teeth, the dental practitioner can assess the occlusal and arch relationships. Early detection of dental or skeletal malocclusion provides an opportunity for diagnosis and coordinated therapeutic intervention. If a child presents with tooth crowding or rotation, space analysis may be performed to identify potential space deficiency and to plan for coordinated care or monitoring.

Dietary counseling should be included in the dental appointment and needs to focus on restricting snacking (no more than once per day) and limiting sweetened food and beverages between meal times. A high frequency of snacking is associated with increased caries rates due to constant exposure of teeth to an acidic environment. Healthy snack choices should be discussed with parents. The presence of dental erosion may necessitate a referral to a specialist to rule out any potential systemic issues such as gastroesphogeal reflux disease.

Non-nutritive oral habits, such as abnormal tongue thrusts, bruxism, use of pacifiers, and digit sucking, may have negative effects on oral and facial development.1 Although the use of pacifiers and digit sucking are considered normal at early ages, prolonged habits with high frequency and intensity could lead to undesirable effects. Early parental counseling may help in the elimination of sucking habits by the time the child reaches 3 years of age. Functional appliances may be required to modify these oral habits. Delay or deficiency in language development should be recognized and discussed with parents. Early referral to a speech pathologist and coordinated treatment effort with an appropriate functional appliance can assist in timely intervention for this developmental problem.

As a child learns how to walk and develops motor coordination, there is an increased incidence of oral and/or facial trauma. The greatest incidence of trauma in the primary dentition occurs at 2 years to 3 years of age.2 Children at this age are curious and active, and they may sustain injuries from falls or play with sharp objects, toys, pacifiers, and electrical cords. Trauma prevention, appropriate courses of action after trauma, and other safety issues (eg, use of car seats) should be discussed with parents/caregivers. The outcome of treatment and prognosis of the injured tooth are greatly enhanced with immediate care and an appropriate course of action at the scene of the injury.

BEHAVIOR MANAGEMENT DURING THE DENTAL VISIT

Caring for children provides a unique opportunity to evaluate their behavior and emotional and psychological development. Oral health practitioners should evaluate a child as a whole person and observe his or her body language. A child is not a small adult, and every child is different. Practitioners should recognize these differences and provide appropriate guidance to help children cope with the potentially stressful environment of the dental setting.

Understanding children’s developmental status and their relatively short attention spans are critical in planning treatment procedures for children. Common behavior management techniques, such as tell-showdo, should be used routinely when caring for children. Age appropriate language should be used to communicate and help children relate to procedures and objects in the dental setting. For children who present with challenging coping skills, dental practitioners should determine a method of behavior modification to assist these children and discuss these techniques with the parents. A child’s behavior and coping strategies should be documented on the treatment record.

ORAL HEALTH RISK ASSESSMENT

Effective clinical decision making is based on a thorough oral health risk assessment that includes social, behavioral, microbiologic, environmental, and clinical variables.3-5 Caries risk assessment is a useful tool to determine the likelihood of caries development during a defined time period and to determine the likelihood that existing caries activity will change. Children who have a high risk of developing dental caries are thereby identified, and specific preventive and treatment regimens can be designed based on the underlying etiologies and variables. The ultimate outcome is optimization of the protective factors, such as fluoride exposure and reduction of bacterial counts, plaque accumulation, and other causative factors.6

Caries incidence approaches epidemic proportions in certain populations of children. Approximately 70% of dental caries are found in 20% of children in the United States.7Children in families of low socio economic status or who acquire mutans streptococci at an early age are at high risk of developing caries.8,9 Key variables in the risk assessment are derived from the dental history and clinical evaluation. Dental practitioners should consider an intensive preventive regimen if the child has impaired salivary gland function, special health care needs, is snacking more than three times per day, has poor oral hygiene practices, or wears an orthodontic appliance. Studies show that the best risk predictor for caries is the child’s previous caries experience followed by parental education level.10,11 The presence of gingivitis, visible plaque accumulation, areas of enamel demineralization (chalky white spot lesions), enamel defects, and deep pits and fissures are other clinical signs indicating high caries risk.

Children who have existing cavitated carious lesions should be treated with dental restorations, and preventive strategies should be implemented to stabilize any existing caries activity and to prevent further caries development. The use of fluoridated toothpaste, consumption of fluoridated water, and toothbrushing two to three times per day provide protective mechanisms. Radiographic examination and bacterial level testing provide supplemental information to assess caries risk.

One of the common etiologies leading to early bacterial colonization in infants is vertical transmission of microbes from mother to infant.9-11 Mothers with high caries risk should be identified. Studies show that identical genotypes of mutans streptococci are found in approximately 71% of mother-infant pairs, and children are at high risk of developing caries when their mothers have a high caries rate.12,13 Therefore, the mother’s oral health and risk level should also be considered when planning an effective preventive regimen. Modification of the mother’s oral hygiene and dietary habits with the use of supplemental topical fluoride or antimicrobial rinse may alter and reduce the level of the mother’s dental flora. The mother should thus maintain optimal oral health because of its significant impact on the child’s caries rate.

In the pediatric oral health risk assessment, several unique features pertaining to infants and young children should be considered, such as susceptibility of newly erupted teeth, newly acquired dietary habits, and ongoing establishment of oral flora and host defense. An infant should have an oral health risk assessment done as early as 6 months of age to afford an invaluable opportunity to identify high-risk subjects and to allow implementation of appropriate preventive strategies as the first tooth begins to erupt. Infants who consume sugary foods and whose mothers have low education levels and low socioeconomic status are 32 times more likely to have caries by 3 years of age compared to infants without these risk factors.14

Although risk assessment is an effective tool, it may not be able to identify all infants who are at risk of developing early childhood caries (ECC). Since a child’s risk may change over time due to the alteration of oral flora, dietary habits, and other factors, an oral health risk assessment should be performed at regular and timely intervals to re-evaluate and update the child’s risk status. An appropriate preventive regimen and intervention should be provided at the time of assessment to maintain optimal oral health.

STRATEGIC DISEASE PREVENTION AND EARLY INTERVENTION

Dental caries is a preventable disease. The progression of caries is accelerated in an ideal medium of abundant fermentable carbohydrates and an increased quantity of cariogenic bacteria surrounding the teeth. As the condition persists, a cavitated lesion develops over time. Based on the aggressive nature of ECC, areas of decalcification and enamel hypoplasia can rapidly develop into a cavitated lesion.

Recognizing the early signs of tooth decay and the associated risk factors, practitioners can provide an effective and minimally invasive intervention in a timely manner with the opportunity to reverse or arrest the course of caries progression and avoid further destruction of dental structure. Caries management by risk assessment (CAMBRA) effectively identifies causative variables and provides a true evidence-based preventive regimen based on specific underlying etiologies. To foster a favorable environment for oral health, protective factors, such as topical fluoride exposure, should be optimized. Children should also receive routine professional dental cleaning. Topical fluoride is applied after dental prophylaxis in the form of gel, foam, or varnish. Due to its easy application and prolonged retention on the enamel surface, fluoride varnish has gained popularity among practitioners and is especially effective for infants who need immobilization for care, children who are not able to tolerate the fluoride tray, and patients who have special health care needs.

Teeth with deep anatomical grooves will benefit from sealant placement.15,16 Well-placed sealants provide a protective coating to minimize the occurrence of pit and fissure caries and are efficacious and cost-effective in caries prevention when properly maintained. A poorly placed or defective sealant may facilitate plaque retention and caries development.

Once a cavitated lesion develops, surgical intervention may be required to remove the diseased tooth structure and to restore the tooth to its original anatomical form and contour to promote physiological function and ease of maintenance. A cavity may serve as a food trap, retain plaque, or simply be a difficult area to clean, and therefore can lead to further progression of caries activity and destruction of tooth structure. The consequences of untreated dental decay of primary teeth can affect children’s growth, lead to malocclusion and interproximal space loss, and result in significant pain and potentially life-threatening swelling.17-22

Restoring primary dentition in a young child provides a unique challenge for practitioners. Therapeutic intervention should be provided by a practitioner who has training, experience, and expertise in managing children and the disease process. Due to the aggressive nature of ECC and the relatively thin enamel of primary teeth, carious lesions may extend to dentin and pulp by the time parents seek care. Extensive treatment involving pulp therapy and full coverage restoration, such as a stainless steel crown, may be required to treat and restore the diseased tooth. For children who are at high risk of developing secondary or recurrent caries, placement of a stainless steel crown may be more cost-effective and provide a more definitive treatment option for ECC than other available restorations because the stainless steel crown will reduce the number of surfaces at risk of developing future caries.23-25

When planning for restorative treatment on a young child, practitioners must carefully evaluate the patient’s developmental level and comprehensive skills. For young children who are not able to cope with the stress of dental treatments, behavior modification, advanced behavior guidance techniques, and other management modalities, such as sedation or general anesthesia, may be required to perform treatment effectively and efficiently. Risks and benefits for children undergoing general anesthesia should be assessed and communicated with parents. The extent and severity of ECC should be considered. For example, if only one or two teeth have cavitated lesions or if the lesions are incipient, a noninvasive approach of aggressive topical fluoride treatment, meticulous oral hygiene, reduction of cariogenic diet, and possibly interim therapeutic restorations should be offered as a treatment option.

The desirable properties of an interim therapeutic restoration should be anticariogenic, such as glass ionomer sealants, and easy to place using the atraumatic restorative technique.26,27 The practitioner removes the bulk of soft, demineralized tooth structure and places the restoration in an interim basis. Glass ionomers release fluoride, prevent caries progression, and provide an effective interim restoration until the child is able to tolerate dental care and return for definitive treatment. Parents should be informed of all potential treatment options and have the opportunity to discuss the proposed plan.

Options for surgical intervention in treating carious primary dentition in a precooperative child may be limited and parental expectations can be unrealistic. Oral disease prevention is perhaps the most cost-effective and the least traumatic way of managing ECC. Early access to care and early intervention are critical in timely management of this opportunistic, rapidly progressing disease. Oral health counseling should be initiated as early as during the prenatal visit. An aggressive approach to intervention in the early stages of ECC provides an effective means of maintaining dental health.

REFERENCES

  1. American Academy of Pediatric Dentistry Council on Clinical Affairs. Policy on oral habits. Pediatr Dent. 2005-2006;27(7 Suppl):40-41.
  2. Flores MT. Traumatic injuries in the primary dentition. Dent Traumato. 2002;18:287-298.
  3. Weinstein P. Provider versus patient-centered approaches to health promotion with parents of young children: what works/does not work and why. Pediatr Dent. 2006;28:172-176.
  4. Shiboski CH, Gansky SA, Ramos-Gomez F, Ngo L, Isman R, Pollick HF. The association of early childhood caries and race/ethnicity among California preschool children. J Public Health Dent. 2003;63:38-46.
  5. Beck JD, Kohout F, Hunt RJ. Identification of high caries risk adults: attitudes, social factors and diseases. Int Dent J. 1988;38:231-238.
  6. Fontana M, Zero DT. Assessing patients’ caries risk. J Am Dent Assoc. 2006;137:1231-1239.
  7. Kaste LM, Selwitz RH, Oldakowski JA, Brunelle JA, Winn DM, Brown LJ. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, 1988-1991. J Dent Res. 1996;75:631-641.
  8. Berkowitz RJ. Mutans streptococci: acquisition and transmission. Pediatr Dent. 2006;28:106-109.
  9. Harris R, Nichol AD, Adair PM, Pine CM. Risk factors for dental caries in young children: a systematic review of the literature. Community Dent Health. 2004;21(suppl):71-85.
  10. Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicators of risk in caries management. J Dent Educ. 2001;65:1126-1132.
  11. Demers M, Brodeur JM, Mouton C, Simard PL, Trahan L, Veilleux G. A multivariate model to pre – dict caries increment in Montreal children aged 5 years. Community Dent Health. 1992;9:273-281.
  12. Li Y, Caufield PW. The fidelity of initial acquisition of mutans streptococci by infants from their mothers. J Dent Res. 1995;74:681-685.
  13.  Klein H. The family and dental disease IV. J Am Dent Assoc. 1946;33:735.
  14. Nowak AJ, Warren JJ. Infant oral health and oral habits. Pediatr Clin North Am. 2000;47:1043- 1066.
  15. Feigal RJ. The use of pit and fissure sealants. Pediatr Dent. 2002;24:415-422.
  16. Feigal RJ, Donly KJ. The use of pit and fissure sealants. Pediatr Dent. 2006;28:143-150.
  17. Sheiham A. Dental caries affects body weight, growth and quality of life in pre-school children. Br Dent J. 2006;201:625-626.
  18. Ast D, Allaway N, Draker H. The prevalence of malocclusion, related to dental caries and lost first permanent molars, in a fluoridated city and a fluoridated-deficient city. Am J Orthod. 1962;48:106- 113.
  19. Northway W, Wainright R. D E space—a realistic measure of changes in arch morphology: space loss due to unattended caries. J Dent Res. 1980;59:1577-1580.
  20. Slade G. Epidemiology of dental pain and dental caries among children and adolescents. Community Dent Health. 2001;18:219-227.
  21. Douglass A, Douglass J. Common dental emergencies. Am Fam Physician. 2003;67:511-516.
  22. Amponsah E, Donkor P. Life-threatening oro-facial infections. Ghana Med J. 2007;41:33-36.
  23. Randall RC, Vrijhoef MM, Wilson NH. Efficacy of preformed metal crowns vs. amalgam restorations in primary molars: a systematic review. J Am Dent Assoc. 2000;131:337-343.
  24. Eidelman E, Faibis S, Peretz B. A comparison of restorations for children with early childhood caries treated under general anesthesia or conscious sedation. Pediatr Dent. 2000;22:33-37.
  25. Almeida AG, Roseman MM, Sheff M, Huntington N, Hughes CV. Future caries susceptibility in children with early childhood caries following treatment under general anesthesia. Pediatr Dent. 2000;22:302-306.
  26. American Academy on Pediatric Dentistry Clinical Affairs Committee-Restorative Dentistry Subcommittee; American Academy on Pediatric Dentistry Council on Clinical Affairs. Guideline on pediatric restorative dentistry. Pediatr Dent. 2008-2009;30(7 Suppl):163-169.
  27. van’t Hof MA, Frencken JE, van Palenstein Helderman WH, Holmgren CJ. The Atraumatic Restorative Treatment (ART) approach for managing dental caries: a meta-analysis. Int Dent J. 2006;56:345-351.

From Dimensions of Dental Hygiene. July 2009; 7(7): 40-43.

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