Starting Kids Off on the Path to Oral Health

As health care professionals responsible for prevention on a daily basis, dental hygienists have emerged in the oral health community as leaders in education and prevention in both the private and public health sectors. Dental hygienists can play an important role in the development and implementation of programs that reduce and prevent early childhood caries (ECC). However, research shows that practices vary on when to initiate prevention and what type of prevention efforts should be used.¹

ECC DEFINED

Originally deemed “nursing bottle mouth” by Fass in 1962,² ECC was initially thought to be caused solely by putting an infant or child to bed with a bottle of milk. In Fass’ survey of pediatric patients who were fed bottles at bedtime, caries was noted on all primary maxillary anterior teeth, maxillary and mandibular first molars, and mandibular canines, while the mandibular anterior teeth were unaffected.² Today, ECC is considered a multifactorial disease that affects approximately 18% of American children annually.³ The American Academy of Pediatric Dentistry (AAPD) defines ECC as the “presence of one or more decayed, missing, or filled tooth surfaces in any primary tooth in a child 71 months of age or younger.”⁴ ECC is a rapid and rampant form of disease that can compromise a child’s self-esteem, nutritional intake, and oral development. The Surgeon General cites ECC as one of the most important public health diseases facing our nation.

CAUSES

The caries process includes plaque, acid, and fermentable carbohydrates. Plaque consists of a bacterial biofilm, which when exposed to fermentable carbohydrates, metabolizes and produces acid as its byproduct. The acid begins to dissolve enamel and dentin in the demineralization process.⁵

While caries in enamel can be visualized initially as a white spot lesion, demineralization occurs below the surface of an intact remineralized enamel layer. The minerals lost from demineralization are replaced and redeposited by minerals found in saliva. Saliva also buffers the effects of acid by neutralizing them. Each time a fermentable carbohydrate is introduced into the oral cavity, demineralization can occur.

Furthermore, fermentable carbohydrates such as glucose, sucrose, fructose, or cooked starches are metabolized by acidic bacteria. Mutans streptococci (MS) are the acidogenic bacteria associated with ECC and thrive on these fermentable carbohydrates.⁵ Children with ECC have elevated levels of MS, which combined with a frequent intake of fermentable carbohydrates cause a rapid, rampant form of demineralization.⁶

Research shows a direct correlation between the oral health of the mother or caregiver and the child’s ECC status. If the level of MS in a caregiver or parent is high, MS is more readily transmitted to the child.⁷ Thus ECC, as dental caries, is an infectious, transmissible disease.⁸ The earlier MS is introduced into the oral cavity, the higher the risk for acquiring ECC. MS prefer to colonize on newly erupted teeth in order to avoid competition with other bacterium. As more teeth erupt, MS increases in the oral cavity until full eruption occurs.⁹ Prevention efforts need to be initiated well before the child’s first birthday.

Further evidence for early prevention efforts show that poor nutrition and low birth weight are risk factors for ECC. Infants born prematurely and at a low birth weight are at risk for enamel hypoplasia, an incomplete formation of enamel.^8,10 Enamel hypoplasia may cause an irregular enamel surface, coloring, or formation, which can result in areas more prone to caries.¹⁰ However, the most predictive factor of ECC is low socioeconomic status. ECC occurs at a much higher rate in low income populations.¹¹ The incidence in low income, ethnic minority, and Native American populations is estimated to be as high as 70%. Within these populations, ECC is often considered a normal part of childhood.¹²

Breast-feeding for extended periods of time also contributes to ECC occurrence.¹² Behavioral patterns associated with feeding practices are difficult to change, as most mothers follow feeding patterns that their mothers used, thus carrying on practices such as feeding on demand, either by bottle or breast. Extended feeding on demand creates an oral environment that is conducive for bacteria growth and ECC tends to thrive in the oral cavity of newly erupted teeth, thus encouraging the caries process to proceed at an accelerated rate.⁸

PREVENTION EFFORTS

Dental hygienists can play a significant role in ECC prevention. Disease transmission, nutritional concerns, plaque control, and the need for education should be assessed by the dental hygienist. Prevention efforts need to begin before the first tooth erupts. Thus, approaching the parent prenatally may prove to be the most effective mode of primary prevention.

Some discrepancy exists between the dental and medical communities about when children should begin regular dental check-ups.¹ The American Academy of Pediatric Dentistry (AAPD) recommends that infant oral care begin with prenatal counseling for parents. Recommendations for the first dental visit or the infant oral health visit should begin within 6 months of the beginning of tooth eruption and no later than 1 year of age.¹³ Until recently, the Academy of Pediatrics recommended that the first dental visit begin at age 3.¹⁴ However in 2003, the society changed its recommendations to reflect the AAPD’s policy statement. Both are in agreement that an infant should be seen by a dental professional for evaluation no later than 1 year of age.¹⁵

Prospective parents need to know that prenatal assessment and education are essential to the oral health of their child. Prenatal assessment includes assessing oral health status of the parent. The patient’s risk of caries needs to be evaluated since uncontrolled caries means that the parent has a higher level of MS, which can be transferred to the infant. If the parent is at risk, the dental hygienist should provide preventive treatment and discuss the status with the dentist to assess disease, educate the parent on good plaque control, provide nutritional counseling, and discuss the transmissibility of MS bacteria to the infant. Parents should be monitored on a regular basis to ensure oral hygiene and dietary habits have been established. By identifying at risk parents and establishing an ongoing relationship, the hygienist and parents can work toward achieving optimal oral health for the infant.

On or before the first birthday, an infant oral health visit should be scheduled. The hygienist can use a “knee to knee” examination approach, where a visual examination is done using a mirror and light. The dentition is examined specifically for signs of ECC. The dentist will confirm any active disease. Diet, oral hygiene techniques, and the need for fluoride are discussed with parents.

Photos courtesy of Norman Tinanoff, DDS, MS
Moderate to severe ECC. All maxillary incisors are affected. It appears as a “melting” of the teeth.	Severe ECC. On the first maxillary primary molar, note the chalky white line at the cervical margin.	Severe ECC. All teeth, even the mandibular incisors, are affected.

MOTIVATIONAL INTERVENTION

Weinstein and colleagues suggest that the traditional health education of parents is not effective in changing behavior patterns. Parents may be reluctant to change established, even traditional behaviors, and may reject a health care provider’s best intentions to encourage healthier practices. Parents often don’t see their behavior as a problem and may be unwilling to change it.¹⁶

Instead, educating with counseling sessions can be more effective. Weinstein and colleagues used motivational interviewing techniques, which involve counseling that focuses on establishing rapport, using open-ended questions, carefully listening and encouraging parents to talk, and allowing parents to identify discrepancies in their present behaviors and future goals. The counselor establishes a comfortable relationship where advice is given only after the parent feels comfortable and gives permission for the counselor to provide advice.¹⁶ Weinstein concludes that motivational interviewing has a more positive effect on changing behavior than traditional counseling.¹⁶

NUTRITIONAL COUNSELING

One of the best controls for preventing ECC is changing nutritional habits and alerting parents to the caries potential of foods/drinks. Once a relationship is established through motivational interviewing, AAPD nutritional guidelines should be emphasized. Breast-feeding should be encouraged especially for the first 6 months of life, followed by the addition of iron rich foods between 6 and 12 months of age. Nocturnal bottle-feeding should be avoided after the first primary tooth begins to erupt, at approximately 6 months. Breast-feeding alone is not a factor in ECC, however, at 6 months the infant has begun to consume other foods, such as fermentable carbohydrates, which changes the oral flora and can be a factor in ECC. Also, when formula or juices are used, their acidity creates an environment where MS thrive.

After 6 months of age, only one in four infants are breastfed in the United States,¹⁷ leaving 75% of infants receiving formula. Formulas are acidogenic and increase ECC potential. Parents need to understand the negative effects of bottle-feeding and set up good oral hygiene practices early. Weaning should occur at 1 year, as breast-/bottle-feeding and night-feeding beyond 1 year is associated with ECC.¹⁷

The use of fruit juices should be limited to 4-6 ounces per day and parents should be encouraged to serve mashed or pureed whole fruits instead of using juices. Fruit juices typically contain added sweeteners and replacing formula with juices may enhance the ECC process. Moreover, serving these juices in easily transportable cups tends to create a habit of consuming them throughout the day.¹⁷ When juices are given, they should be with a meal only. Easily transportable cups should contain water only. Drinking water will decrease cariogenic challenges and provide an avenue for fluoride exposure as a primary preventive liquid.

FLUORIDE VARNISHES

Historically, fluoride has been a highly effective agent for the remineralization of enamel. In addition to water fluoridation and oral hygiene procedures, in-office and home fluoride gels should be encouraged. Fluoride varnish is highly recommended for ECC control. Fluoride varnish has been used extensively in Europe since the 1960s. It consists of 5% sodium fluoride in an alcohol solution and is applied directly to the teeth with a brush. Varnish is 22,000 ppm as compared to acidulated phosphate gel, which is 12,500 ppm. Varnish is easily applied for 30-60 seconds and doesn’t require a continuous dry field. The varnish hardens on contact with saliva and forms a yellow or white film on the teeth. Children can rinse immediately but should refrain from eating solid foods for a few hours. After 6 hours, the teeth can be brushed and the yellow or white film will disappear.¹¹

Because of its ease of application, lengthy retention time, and low ingestion potential, fluoride varnish is an excellent agent of choice for ECC prevention and control in infants and young children.^18,19 Unfortunately, results from a study of Maryland dental hygienists revealed that varnish is not being used to its fullest potential for ECC control.¹ The survey found that only 25% of the hygienists polled were using varnish for caries control.¹ This may be attributed to the fact that varnish has not been approved in the United States as an anticaries application by the Food and Drug Administration. It has been approved as a desensitizing agent and as a cavity liner in operative procedures.²⁰ As such, the dental health community, based on historical studies of fluoride and its aid in the control of caries, uses varnish as an off label designation for use in caries control. 4 Such labeling allows fluoride varnish to be considered the standard of care regarding caries prevention because of its common use and clinical evidence for effectiveness and safety.²¹

Dental hygienists need to be aware that ECC currently affects 18% of American children.⁴ Healthy People 2010’s goal is to reduce ECC’s incidence to 11%.⁴ Dental hygienists are uniquely positioned to assess, plan, implement, and evaluate programs to prevent this rampant and destructive disease.

REFERENCES

1. Manski MC. Early Childhood Caries: Knowledge, Attitudes and Practice Behaviors of Maryland Dental Hygienists [master’s thesis]. Baltimore, Md: University of Maryland; 2004.
2. Fass EN. Is bottle-feeding of milk a factor in dental caries? J Dent Child . 1962;24:245-251.
3. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General . Rockville, Md: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
4. The American Academy of Pediatric Dentistry. Definition of early childhood caries. Pediatr Dent . 2005;27(suppl):13.
5. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc. 2000;131:887-899.
6. Tinanoff N, O’Sullivan DM. Early childhood caries: overview and recent findings. Pediatr Dent . 1997;19:12-16.
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14. American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. Available at: http://pediatrics.aappublications.org/content/early/2017/02/15/peds.2017-0254. Accessed June 29, 2006.
15. American Academy of Pediatrics. Oral Health Risk Assessment Timing and Establishment of the Dental Home. Available at: www.aap.org/commpeds/dochs/oralhealth/policy.cfm. Accessed June 26, 2006.
16. Weinstein P, Harrison R, Benton MA. Motivating parents to prevent caries in their young children: one-year findings. J Am Dent Assoc. 2004;135:731-738.
17. Nainar SM, Mohummed S. Diet counseling during the infant oral health visit. Pediatr Dent . 2004;26:459-461.
18. Holm AK. Effect of fluoride varnish (Duraphat) in preschool children. Community Dent Oral Epidemiol . 1979;7:241-245.
19. Seppa L, Leppanen T, Hausen H. Fluoride varnish versus acidulated phosphate fluoride gel: a 3-year clinical trial. Caries Res . 1995;29:327-330.
20. FDA status of fluoride varnish. Available at: www.fda.gov/cdrh/pdf3/k031932.pdf. Accessed June 26, 2006.
21. Goodman HS, DePaola LG, Alqueza-Vernon MB. A review of fluoride varnish efficacy and use in dental practice. American Dental Institute of Continuing Education . 2003;81(2):2-10.

From Dimensions of Dental Hygiene. July 2006;4(7): 18-21.