Maintaining and Improving Oral Health in Young Children

Oral health is an integral part of children’s overall health. Dental caries is a common and chronic pathological process with important short and long term consequences.

The prevalence of dental caries continues to be greater than 40% between 2 and 19 years of age.

Although dental visits have increased across all age, race, and geographic categories in the United States, disparities remain and a significant portion of children have difficulty accessing dental care.

As health professionals responsible for the overall health of children, pediatricians frequently face the morbidity associated with dental caries.

Because younger children visit the pediatrician more frequently than the dentist, it is important for pediatricians to understand the disease process of dental caries, disease prevention, interventions to maintain and restore health, and social determinants. of children’s oral health.

Tooth decay is the most common chronic childhood disease, despite increases in dental visits.1 23% of American children ages 2 to 5, 52% of children ages 6 to 8, and 57% of young people between 12 and 19 years of age have cavities.2

The overall prevalence of dental caries in youth ages 2 to 19 between 2015 and 2017 was 45.8%.3 Significant disparities persist in the receipt of childhood preventive dental care, with young children, uninsured children, children living In poverty, non-Hispanic black children, children from non-English speaking homes, including immigrants and refugees, and children with special health care needs are less likely to receive preventive oral health care than they would. need.2–5

American Indian/Alaska Native children have the highest rates of dental decay in the United States.6 The reasons for these disparities are multifactorial and are explained in more detail in the Indian Health Service Data Summary “Oral Health of American Indian and Alaska Native Children Aged 1–4 Years: Results from the IHS Oral Health Survey” 2018–19 and in the American Academy of Pediatrics (AAP) policy statement “Early Childhood Caries in Indigenous Communities” , which focuses on specific challenges within this population.6,7 There were slight improvements over time.

A 10 percentage point decrease in untreated dental caries was evident in the primary teeth of children ages 2 to 5 and 6 to 8 years and in the permanent teeth of adolescents ages 12 to 19 when comparing data from 2011–2016. with 1999–2004. Mexican American children, children near the poverty line, and children below the poverty line saw improvements in untreated dental cavities; however, disparities continue to persist.2

A dynamic process takes place on the surface of the tooth that involves constant demineralization and remineralization of the tooth enamel (the balance of caries).8,9 Multiple factors affect this dynamic process and it can be manipulated in a way that tips the balance towards disease ( demineralization) or health (remineralization). These factors include bacteria, sugar, saliva and fluoride. Because these factors can be manipulated, pediatricians and families can prevent, stop, or even reverse the disease process. Different oral structures and tissues have different and distinct microbial communities (microbiomes).10

The oral microbiome on the surface of the tooth is known as dental plaque.

During the pathological process of dental caries, aciduric and acidogenic bacteria predominate in dental plaque. Streptococcus mutans is most commonly associated with dental caries, although a larger pathogenic community exists.11 When environmental factors allow selection of these pathogenic bacteria in dental plaque, the disease process begins.

A key environmental factor that allows the selection and proliferation of these pathogenic bacteria is dietary sugar intake. Because these bacteria have the ability to ferment sugars, produce acid, and lower the pH of dental plaque, they make possible the selection of other aciduric and acidogenic bacteria that will contribute to the disease. As more bacteria produce more acid, the pH on the tooth surface decreases. This process causes the demineralization of tooth enamel. Unhindered, these long periods of low pH and demineralization will result in cavitation.

Saliva is an important factor in buffering low pH and balancing these demineralization pressures with remineralization.12

In addition to acting as a buffering agent, saliva also removes food particles from the oral cavity and provides an environment rich in calcium and phosphate to aid in remineralization and includes proteins that have antimicrobial activity. When salivary flow is impeded (e.g., by disease, iatrogenic), the pH can decrease to a lower level, tipping the balance toward demineralization (disease). Additionally, the time it takes to return to a normal pH is longer.12 Another important factor that can affect the balance of demineralization and remineralization is fluoride.

More detailed reviews on fluoride are available elsewhere.13–15 However, it is important for pediatricians and other children’s healthcare providers to understand how fluoride influences the balance of tooth decay.

Caries Risk Assessment Ideally, primary prevention efforts will anticipate and prevent caries before the first sign of disease. Preventive strategies for this multifactorial chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment. It is necessary to evaluate each child’s caries risk and adapt preventive strategies to specific risk factors to maintain and improve oral health.

There is no single tool that takes into account all risk factors and accurately predicts an individual’s susceptibility to cavities. However, pediatricians can monitor oral health, both in-office and via telehealth, focusing on key risk factors for tooth decay associated with diet, bacteria, saliva, and tooth condition (i.e. that is, current and previous caries experience).

According to Bright Futures guidelines , pediatricians can perform an oral health screening exam of the mouth at every well-child visit to look for signs of cavities. Each visit is an opportunity to assess risk, discuss risk reduction, modify behaviors, and identify goals to improve oral health. The AAP/Bright Futures Oral Health Risk Assessment Tool, which includes photographs of clinical findings on oral cavity examination, can be found at https://downloads. aap.org/AAP/PDF/oralhealth_RiskAssessmentTool.pdf.18

Sugars (but not sugar substitutes) are a critical risk factor in the development of cavities.19, 20

This does not include natural sugars and they are present in whole fruits and vegetables or dairy products. The risk of cavities is greater if sugars are consumed with high frequency (and therefore in large quantities) and are in a form that remains in the mouth for long periods of time), sleeping with a bottle (with liquids other than water), frequent snacking between meals of sugars/cooked starches/sweetened beverages, sticky foods (raisins, fruit snacks, and gummy vitamins, for example), and frequent intake of sugary medications.

The most important and predictive risk factor for cavities is previous experience with cavities. This finding is not surprising, considering that the factors that initiated the disease process often continue to exist over time. Early acquisition of S. mutans is also an important risk factor for early childhood caries and future caries experience.21

Strong evidence demonstrates that mothers are a primary source of S. mutans colonization for their children (e.g., sharing utensils, cleaning pacifiers with mouth).22 Therefore, an important factor associated with caries risk in young children it is the recent or current presence of active dental caries in the parent/primary caregiver. Because bacteria are likely to be transmitted vertically, prevention, diagnosis, and treatment of oral diseases in the child’s parents/caregivers are very beneficial, especially during pregnancy.

Dental care and treatment can be provided and is recommended during pregnancy. There is no additional maternal or fetal risk compared to the risk of not providing dental care.23

Abnormalities in salivary flow and tooth structure are associated with the development of cavities.

Diseases (eg, diabetes mellitus, Sjogren’s syndrome, cystic fibrosis) and medications (eg, antihistamines, anticonvulsants, antidepressants) cause xerostomia (decreased salivary flow). Xerostomia causes reduced availability of saliva to buffer the acid produced by pathogenic bacteria, increasing their ability to damage tooth enamel.

Variations in the anatomical structure of teeth can also increase the risk of cavities. For example, teeth with enamel defects, frequently found in premature children, are more susceptible to disease, as are molars with deep pits and fissures. Finally, there is increasing evidence of an association between exposure to secondhand smoke and dental caries in children.24, 25

> Advance guidance

Pediatricians can focus on early counseling to help families prevent tooth decay by having a clear understanding of its etiology and the risk factors that lead to and facilitate the spread of this disease. Because dental caries disease is multifactorial, anticipatory counseling may also be multifaceted, with a focus on decreasing disease risk.

> Diet advice

Because sugar intake is such a major risk factor for dental caries, pediatricians can incorporate anticipatory guidance associated with dental caries prevention into conversations about dietary habits and nutritional intake. The risk of cavities may be lower with exclusive breastfeeding for 6 months and continued breastfeeding as complementary foods are introduced for 1 year or longer, as mutually desired by the baby and breastfeeding mother.26

To decrease the risk of tooth decay and increase the chances of better possible health and developmental outcomes, pediatricians can educate and provide guidance to families on how to establish a bedtime routine that leads to optimal oral health (p (e.g., the AAP Brush, Book, Bed program for parents).27,28 Do not put a child to bed with a bottle to limit the sugars on the teeth after brushing and encourage them to stop taking the bottle by one year of age. Parents/caregivers can be counseled on the importance of reducing the frequency of exposure to added sugars in foods and beverages.29

By limiting the amount and frequency of eating foods with added sugars, as well as avoiding sugary drinks and juices, the risk of cavities is reduced. Pediatricians can encourage children to drink only water between meals, preferably fluoridated tap water, while also discouraging 100% juice intake before age 1, limiting juice to 4 ounces daily for children 1 to 3 years of age and 4 to 6 ounces daily for children 4 to 6 years of age.30 Finally, providers can counsel families to encourage eating patterns consistent with USDA guidelines. UU.31

> Oral hygiene

The value of good oral hygiene lies in controlling the levels and activity of bacteria in the oral cavity and providing fluoride to the tooth surface.

It is important to remember that pathogenic bacteria can be transmitted from parents/caregivers to children.22 Therefore, anticipatory guidance is important for both the parents/caregivers and the child.

Pediatricians can encourage parents/caregivers to model and maintain good oral hygiene, including regular brushing, flossing, and a relationship with their own dental provider. Parents/caregivers should be advised to brush a child’s teeth twice a day as soon as the teeth erupt with a bean-sized amount of fluoride toothpaste.

After the third year, a pea-sized amount can be used. Pediatricians can also encourage parental/caregiver assistance and supervision in brushing children’s teeth until mastery is achieved, usually around 10 years of age.32, 33

> Fluoride

Fluoride delivery to teeth includes community-based options (water fluoridation), self-administered modalities (fluoride toothpaste, rinses, and supplements), and professional applications (fluoride varnish and silver diamine fluoride). Fluoride is a critically important primary care preventive measure for families, especially those without consistent early and/or ongoing dental care. As part of early well-child counseling, pediatricians can assess fluoride intake at each well-child visit, including consumption of fluoridated tap water, and encourage families to protect their children’s teeth with regular fluoride administration. oral and topical.

Water fluoridation is a community-based intervention that optimizes the level of fluoride in drinking water, resulting in protection before and after tooth eruption.34 Water fluoridation is a cost-effective means of preventing tooth decay. , with a lifetime cost per person equivalent to less than the cost of 1 dental restoration.35, 36 Most bottled waters do not contain an adequate amount of fluoride.

Many families at increased risk for tooth decay primarily consume bottled water, reducing potential exposure to fluoridated tap water . Fluoride supplements may be prescribed for children 6 months and older whose primary source of drinking water is deficient in fluoride.16

Fluoride toothpaste is an important way to deliver fluoride to the tooth surface. Fluoride toothpaste has been shown to be effective in reducing tooth decay in both primary and permanent teeth.37, 38

Fluoride mouthwashes are another strategy for topical fluoride application and are associated with reducing caries in permanent teeth in children and adolescents, most particularly in a school setting.39

Fluoride varnish is a professionally applied highly concentrated fluoride tacky resin. Applying fluoride varnish 2 to 4 times a year, to either primary or permanent teeth, is associated with a substantial reduction in dental caries.40, 41 In most states, pediatricians can apply fluoride varnish. fluoride on young children’s teeth and charge for the service The U.S. Preventive Services Task Force recommends that primary care physicians apply fluoride varnish to the primary teeth of all infants and children starting at age of primary tooth eruption (recommendation B). More details and recommendations on fluoride can be found in the AAP clinical report "Use of Fluoride in Caries Prevention in the Primary Care Setting."14

Silver diamine fluoride is a colorless ammonia solution containing silver and fluoride ions that is applied to the tooth. It is used to stop caries lesions in primary and permanent teeth, including those that have already cavitated into the dentin, and has been shown to be effective in stopping cavities in children.42 When applied to the tooth or any surface , stains the surface black. Pediatricians may see more children with this type of staining and should know its origin.

Silver diamine fluoride treatment is best used as part of an ongoing cavity management plan with the goal of optimizing individualized patient care according to the goals of a dental home. A dental home is the ongoing relationship between dentist and patient, including all aspects of oral health care provided in a comprehensive, continually accessible, coordinated, and family-centered manner.43

> Other important early guidance topics

A frequent topic of discussion with parents/caregivers is non-nutritive oral habits, such as pacifier use and thumb sucking.

The AAP recommends that parents/caregivers consider offering a pacifier at naptime and bedtime due to the protective effect of pacifiers on the incidence of sudden infant death syndrome after the first month of life.44 The evaluation by a dentist is indicated for non-nutritive sucking habits that continue beyond 3 years of age. Those children who use pacifiers are less likely to develop malocclusions (i.e., overhang) compared to those who suck their fingers; However, longer duration of thumb or pacifier sucking is associated with a higher risk of developing malocclusions.45 Breastfeeding also decreases the risk of malocclusions.46

Dental injuries are common, with twenty-five percent of all school-age children experiencing some type of dental trauma.47 Pediatricians can help prevent such trauma by encouraging parents/caregivers to cover sharp corners on household furniture when level of walking toddlers, recommend the use of car safety seats, and be careful and aware of the risk of oral injuries from electrical cords Pediatricians may also recommend the use of mouth guards during sports activities where there is a risk of orofacial injuries (basketball, field hockey, and baseball, for example).48,49 More information on dental trauma is available in the AAP clinical report "Management of Dental Trauma in a Primary Care Setting."50

The AAP, the American Academy of Pediatric Dentistry, the American Dental Association, the American Association of Dental Hygienists, and the American Association of Public Health Dentistry recommend a dental visit for children 1 year of age. Although pediatricians have the opportunity to provide early tooth decay risk assessment and early guidance to prevent disease, it is also important for children to establish a dental home.

Depending on where a pediatrician’s office is located, there are different members of the dental team with whom they may need to coordinate care and may even be included as part of their office staff.51 In addition to dentists, dental hygienists, and dental assistants, some of States have expanded the scope of practice or even developed new oral health professionals. Such professionals include expanded function dental assistants, allied dental health therapists, dental therapists, advanced dental therapists, independent practice dental hygienists, community dental health coordinators, alternative practice registered dental hygienists, public health dental hygienists, expanded practice and others.

There is emerging data on the dental referral behaviors and patterns of pediatric healthcare providers. One study found that children ages 2 to 5 who received a recommendation from their healthcare provider to visit the dentist were more likely to have a dental visit.52

Another study found that children with more well-baby visits between ages 1 and 2 and ages 2 and 3 were more likely to have earlier first dental exams than children with fewer well-baby visits. 53,54 However, the number and timing of well-baby visits before one year of age were not significantly related to first dental examinations.

The US Preventive Services Task Force found no studies evaluating the effects of referral by a primary care physician to a dentist on the incidence of cavities.55 Early dental visits have been associated with a decreased costs in most,56–58 but not all studies.59

With early referral to a dental provider, there is an opportunity to maintain good oral health, prevent disease, treat disease early, and potentially reduce costs. Establishing such collaborative relationships between doctors and dentists at the community level is essential to increasing access to dental care for all children and improving their oral and overall health.

The determinants of oral health, like oral health itself, are multifaceted . The driving determinants of oral health include genetic and biological factors, health behaviors, access to care, physical environment, and social environment.60

The focus of this clinical report, to this point, has been on biological factors, health behavior, and access to oral health services. However, the AAP also recommends screening for risk factors related to social determinants of health during all patient encounters.61

It is important for pediatricians to understand that an approach to children’s oral health must also address social determinants. These social determinants, such as poverty, racism, education, access to healthy foods, culture and physical environment, as well as access to medical and dental care, influence oral health status and inequalities in oral health. oral health in the same way that they influence general health and health inequity.

Pediatricians can consider and address determinants of oral health at the child, family, and community levels.62 With a solid understanding of how social determinants influence oral health, pediatricians can advocate for changes in policy, system and the environment that generate comprehensive and sustainable improvements in oral health. Adequate payment for social determinant screening is necessary to facilitate implementation of screening in pediatric practices.

Oral health is an integral part of children’s overall health and well-being.63 Pediatricians who are familiar with the science of dental caries, capable of assessing caries risk, comfortable with applying various prevention strategies and intervention, connected to dental resources, and familiar with the social determinants of childhood health can contribute considerably to the health of their patients.

This clinical report, along with oral health recommendations from the fourth edition of AAP Bright Futures: Guidelines for Health Monitoring of Infants, Children, and Adolescents, serves as a resource for pediatricians and other pediatric primary care providers. informed about how to address dental cavities.64

Because dental caries is such a common disease and consequential disease process in the pediatric population and such an integral part of children’s overall health, it is essential that pediatricians include oral health in their daily pediatric practice.

• Oral health is a fundamental aspect of children’s overall health. Caries is a common and chronic pathological process with important short and long term consequences.
   
• Pediatricians are capable of assessing caries risk and are familiar with multiple effective prevention and intervention strategies.
   
• This report offers extensive coverage and serves as a resource for pediatricians and other primary care providers to be informed about how to address their patients’ dental health.