Optimizing Infant and Toddler Oral Health The Importance of Early Intervention

What is the appropriate age for a child’s first dental visit? Parents attempting to make an initial visit for their child would probably receive different responses if they called a number of dental offices to ask that question. Traditionally, age 3 was thought to be the proper age. Some dentists may suggest that the first visit occur even later, perhaps when the child will not be a management problem. However, if the goal is to prevent disease rather than treat the result of disease, early intervention is needed.
During the last several decades, remarkable progress has been made in improving the oral health of children. However, many children still suffer from dental caries and periodontal disease, and malocclusion remains a common problem. Dental caries is the single most common chronic childhood disease, with an incidence 5 times that of asthma and 7 times that of common hay fever.1 More than half of 5 to 9yearold children have at least one carious lesion or restoration.¹ The social impact of oral diseases in children is significant. Pain due to untreated disease can lead to problems in eating, speaking and attending to learning.²

The American Academy of Pediatric Dentistry (AAPD) recommends that an initial oral evaluation visit should occur within 6 months of the eruption of the first primary tooth and no later than 12 months of age.³ The AAPD is not alone in recommending a dental visit before the child’s first birthday. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents⁴ is a document that was developed with support of the US Department of Health and Human Services Maternal and Child Health Bureau. It is based on an extensive review of scientific literature and best practices. It represents a consensus of more than 100 multidisciplinary experts and was reviewed by over 1,000 health professionals. This report has been supported by many organizations, including the American Medical Association and the American Academy of Pediatrics. These guidelines suggest that an appointment be made for the toddler’s first dental examination and risk assessment at 1 year of age. The purpose of this visit is to assess individual risk and to educate the parent in reducing such risk.

THE USE OF FLUORIDE

Figure 2. The knee-to-knee position.

The systemic and topical use of fluoride is the most effective measure to prevent dental caries.⁷ The patient’s exposure to both systemic and topical fluoride must be evaluated. Over one third of the US population has no access to community water fluoridation.⁸ Water fluoride content should be evaluated if the fluoride content of the child’s drinking water is unknown. This can be accomplished by contacting the local public health officials, or if necessary, by analysis of a water sample. It is important to review all potential sources of drinking water, including home, day care and school. Recommendations for fluoride supplementation can then be made based on the fluoride content of the water, the child’s age, and the child’s caries risk. The dietary fluoride supplementation schedule is shown in Table 1 (p. 124). This dosage schedule was revised in 1994 and is approved by the American Dental Association, the American Academy of Pediatrics, and the American Academy of Pediatric Dentistry.

DIETARY HABITS
It is important to consider dietary habits of the infant or toddler when determining caries risk. Improper feeding practices in this age group can lead to baby bottle tooth decay (BBTD), a severe form of ECC. BBTD can result from a child going to bed with the bottle or drinking at will from the bottle during the day. AAPD guidelines state that infants should not be put to sleep with a bottle.¹⁴ The guidelines also recommend that if a child is breastfed at will, nocturnal breastfeeding should be avoided after the first primary tooth begins to erupt. In the event that an infant is using a bottle at night, it should contain only water. A cup should be introduced at about 6 months of age, and the child should be weaned from the bottle at about 12 months of age. Frequent consumption of any fermentable carbohydrate is a major dietary risk factor for ECC. Parents should limit the amount of snacks and beverages that are offered between meals.

SOCIOECONOMIC STATUS
According to the Surgeon General’s report on oral health, there are striking disparities in dental disease as related to income. Poor children suffer twice as much dental caries as children of higher socioeconomic status, and this disease is more likely to be untreated.2 Children ages 2 through 5 from families with low incomes are 5 times more likely to have untreated dental caries than children from families with higher incomes.15 Low socioeconomic status should be considered a significant risk factor for dental caries.

STREPTOCOCCUS MUTANS COUNT
It is generally accepted that SM is the microorganism associated with ECC. Studies have shown that salivary levels of SM may be used to identify and to predict future caries in preschool children.^16,17

FAMILY ORAL HEALTH
As previously mentioned, preschool children with high salivary levels of SM demonstrate higher caries prevalence and are at increased risk of new lesions than are those with low levels of SM. The most likely source of inoculation of an infant’s oral cavity is the primary caregiver, usually the mother.¹⁸ Children of mothers with a high caries rate are at greater risk of dental caries. Furthermore, reduction of the mother’s SM levels can significantly lower the child’s caries rate.¹⁹

CLINICAL EXAMINATION
The clinical examination is an essential part of the child’s first dental visit and is an important part of risk assessment. Dentists who lack experience in treating infants and toddlers are often concerned that the child will cry during the examination and that this will reflect poorly on their patient management skills. Crying during an examination is normal behavior for an infant, and parents are generally accustomed to seeing that behavior during visits to the pediatrician.

CONCLUSION
As healthcare professionals, our ultimate goal should be preventing disease whenever possible, and in patients where disease has begun, we should aim to minimize its effects. To prevent dental caries in children, we must identify those most at risk, educate parents, and focus aggressive preventive strategies on those children most in need. To effectively take these steps and to ensure optimal oral health for our nation’s children, dental practitioners must be willing to embrace the philosophy of the yearone dental visit.

References

1. Third National Health and Nutrition Examination Survey (NHANES III). Hyattsville, Md: National Center for Health Statistics, US Dept of Health and Human Services; 1996.
2. Oral Health in America: A Report of the Surgeon General. Rockville, Md: National Institute of Dental Research, US Dept of Health and Human Services; 2000.
3. American Academy of Pediatric Dentistry. Guideline on infant oral health care. Pediatr Dent. 2002;24(special issue):47.
4. Green M, Palfrey JS, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health; 1994.
5. Casamassimo P. Bright Futures in Practice: Oral Health. Arlington, Va: National Center for Education in Maternal and Child Health; 1996.
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Dr. Chussid is currently director of the division of pediatric dentistry and associate professor of clinical dentistry at Columbia University School of Dental and Oral Surgery. He is also presently the chief of the dental service at Blythedale Children’s Hospital. He is a graduate of the University of Buffalo School of Dental Medicine and received his certificate in pediatric dentistry from Children’s Hospital of Buffalo. He has been on the faculty at New York University and the Albert Einstein College of Medicine and has served as program director and director of the division of pediatric dentistry at Montefiore Medical Center in New York. He can be reached at (212) 3051040.