REVIEW ARTICLE

Oral Health in Children - Guidelines for Pediatricians

PREETIKA CHANDNA AND VIVEK KUMAR ADLAKHA
From the Departments of Pedodontics and Preventive Dentistry, Subharti Dental College, Meerut, UP, India
Correspondence to: Dr. Preetika Chandna, Department of Pedodontics and Preventive Dentistry, Subharti Dental College, NH- 58,
Delhi-Haridwar Bypass, Meerut, UP. India. [email protected]

Dental caries in the primary dentition can have significant damaging effects on a childs growth due to impairment of oral
functions. Since the first encounter of a child to a medical environment is often through pediatricians and medical
practitioners, it is important that they be aware of the prevention of oral disease that begins early in life. The aim of this
article is to diminish the existing ambiguity among pediatricians and medical practitioners regarding oral disease and its
prevention.
Key words: Children, Counseling, Infant, Oral health

rimary care physicians are in a unique

position to ensure that parents and other
caregivers receive information on the
prevention of oral disease in infants and
young children. By working together, pediatricians
and dentists can reinforce each others efforts to
provide excellent preventive oral care.

PREVENTION OF DENTAL DISEASE

Oral disease, especially dental caries, is

complicated and multifactorial, and it often begins to
develop during infancy. Caries is a biofilm (plaque)
induced acid demineralization of enamel or dentin,
mediated by saliva(1). The Mutans streptococci
group of microorganisms has been implicated as the
principal bacteria responsible for the initiation of
dental caries in humans. It has been further shown
that dental caries is an infectious, transmissible
disease(2). Recent evidence suggests that Mutans
group of bacteria may begin to colonize prior to tooth
eruption(3,4). Ideally, steps to prevent caries begin
prenatally and continue with the mother and child,
beginning when the infant is approximately 6
months of age, with the eruption of the first tooth(5).
A healthy mouth, with a full complement of teeth and
a stable, aesthetic occlusion is a goal that pediatric
dentists seek to achieve through various preventive
and therapeutic measures.

Infant oral health begins with prenatal oral health

counseling for parents. The purpose of this is to
generate awareness among parents about dental
disease, its prevention and the means to provide a
suitable environment for the child to develop.

INDIAN PEDIATRICS

If appropriate measures are applied early enough, it

may be possible to totally prevent dental caries.
Preventive measures can be divided into various
stages:
A. Stage 1 - Pregnancy

Prenatal counseling
Evidence supports that both poor nutrition and low
birth weight are risk factors for the development of
early childhood caries (ECC). ECC is an early
arising, potentially devastating and virulent form of
dental caries. Not only does ECC affect teeth, but it
can also leads to malnutrition and diminished quality
of life due to resulting pain, infection and
impairment of oral function.
Under- or malnourished infants and infants with
low birth weight are at risk for enamel hypoplasia, an
incomplete formation of enamel(6-8). Enamel
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hypoplasia may cause an irregular enamel surface or

discoloration, which can result in areas more prone
to caries(6,9). Thus, expectant mothers should be
advised to optimize nutrition during the third
trimester and the infants first year, when the enamel
is undergoing maturation. Further, recent studies
have reported an association between maternal
periodontitis and preterm birth(10), between clinical
periodontitis at delivery and preeclampsia(11), and
between Mutans streptococcus levels in mothers and
caries experience in their children(12).

(c) Providing information to pregnant women about

pregnancy gingivitis (inflammation of the
gingiva caused by an exacerbated response to
dental plaque, related to hormonal changes
during pregnancy). With gingivitis, the gums
become inflamed, swollen, sensitive and tend to
bleed. Signs of gingivitis may become evident in
the second trimester and peak during the ninth
month of pregnancy(10).
(d) Visiting a dentist for an examination and
restoration of all active decay as soon as feasible
and to decrease chances of developing pregnancy
gingivitis.

Prospective parents need to know that prenatal

assessment and education are essential to the oral
health of their child. Prenatal assessment includes
oral health status of the parent. The parents risk of
dental caries needs to be evaluated since
uncontrolled caries means that the parent has a high
level of Mutans streptococcus, which can be
transferred to the infant later. If the parent is at risk,
the dentist should provide preventive treatment and
educate the parent on good plaque control, provide
nutritional counseling, and discuss the transmissibility of Mutans streptococcus to the infant. Parents
should be monitored on a regular basis to ensure
effective oral hygiene and dietary habits have been
established. Improvement of the mothers oral
hygiene, diet and the use of mouth rinses can have a
significant impact on the childs caries rate in the
future.

(e) Eating healthy foods such as fruits, vegetables,

grain products (especially whole grain), and
dairy products (milk, cheese) during meals and
snacks. Limit eating between meals.
(f) Eating foods containing only sugar at mealtimes,
and limiting the amount. Frequent consumption
of foods high in sugar, such as toffees, cookies,
cake, sweetened beverages (e.g fruit juice, soda),
increases the risk for tooth decay. In addition,
frequent consumption of foods that easily adhere
to the tooth surface, such as dried fruit and candy,
increase the risk for tooth decay.
(g) Brushing teeth thoroughly twice a day (after
breakfast and before bed) with a fluoridated
toothpaste and flossing daily.

Anticipatory guidance
(h) Rinsing every night with an alcohol-free, overthe-counter fluoridated mouth rinse.

Anticipatory guidance is the process of providing

practical, developmentally appropriate information
about childrens health to prepare parents for the
significant physical, emotional and psychological
milestones(13). Anticipatory guidance involves three
types of tasks: (1) gathering information, (2)
establishing a therapeutic alliance, and (3) providing
education and guidance. General anticipatory
guidance for the mother includes the following
(14-16):

(i) Not smoking cigarettes or chewing tobacco.

Dental treatment of women during pregnancy
Often, pediatricians are asked for advice regarding
dental problems. Relevant information regarding the
type of dental treatment that can be undertaken may
be summarized as follows(14,17):

(a) Education concerning development and

prevention of dental disease and also
demonstration of oral hygiene procedures.

First trimester: It is the most crucial period for

growth of fetus. Only emergency dental treatment
should be undertaken in consultation with the
patients physician.

(b) Counseling to instill preventive attitudes and

motivation.

Second and third trimester: Emergency as well as

elective dental treatment can be provided.

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Radiographs essential for diagnosis can be obtained

with adequate protection (e.g. lead shields).

environment that enhances the development of

early tooth decay. Infants should be weaned from
the bottle at 12 to 14 months of age.

Throughout pregnancy: Plaque diet control

programs are initiated for mother. Local anesthetics
are to be preferred for dental procedures.

Dental home concept

The dental home concept(14,24) was developed
analogous to the concept of medical home. The
dental home is inclusive of all aspects of oral health
that result from the interaction of the patient, parents,
nondental professionals, and dental professionals.
The dental home concept fits well with the emphasis
on comprehensive care that exists in pediatric
dentistry programs. Establishing a dental home
should be done within 6 months of eruption of the
first tooth and no later than 12 months of age.

B. Stage 2 - Infancy (0-1year)

Children experiencing dental caries as infants or
toddlers have a much greater probability of
subsequent caries in primary or permanent
dentition(18,19). The major reservoir from which
infants acquire Mutans streptococcus is their
mothers (vertical transmission). Mothers with dense
salivary reservoirs of Mutans streptococcus are at
high risk for infecting their infants early in life.
Horizontal transmission (between members of a
family or group) can also occur(12). Eliminating
saliva sharing activities can thus reduce the
development of caries in infants. Moreover, highrisk dietary practices are developed early, probably
by 12 months of age and are maintained throughout
childhood(20,21). Frequent bottle-feeding at night,
breast feeding on demand and extended use of a nospill training cup are associated with development of
early childhood caries (ECC) (22). Oral hygiene
maintenance in this phase includes(23):

C. Stage 3 - First Dental Visit

The American Academy of Pediatric Dentistry
recommends that the first oral examination should
occur within 6 months of the eruption of the first
primary tooth, and no later than age 12 months of
age(24). Thereafter the child should be seen
according to a schedule recommended by the dentist,
based on the childs individual needs and
susceptibility to disease.
D. Stage 4 Care of the Deciduous Dentition

1. Reducing the mothers and sibling(s) levels of

Mutans Streptococcus (ideally during the
prenatal period) to decrease transmission of
cariogenic bacteria. This can be accomplished
through regular toothbrushing, use of fluoridated
mouthrinses and treatment of all decayed teeth.

Oral hygiene measures must be implemented no later

than the time of eruption of the first primary tooth.
These measures include the following(23,25):

If an infant falls asleep while feeding, the teeth

should be cleaned before placing the child in bed.

2. Minimizing saliva-sharing activities between an

infant or toddler and his/her family. Avoiding
testing of the temperature of the bottle with the
mouth and sharing utensils (e.g., spoons). This
practice helps to prevent transmission of bacteria
that cause tooth decay.

Toothbrushing of all dentate children should be

performed twice daily with a fluoridated
toothpaste and a soft, age-appropriate sized
toothbrush.

Parents should use a smear of toothpaste to

brush the teeth of a child less than 2 years of age
and perform or assist with their childs
toothbrushing.

For the 2-5 years old child, parents should

dispense a pea-size amount of toothpaste and
perform or assist with their childs toothbrushing.
Children should be taught to never swallow the
toothpaste.

3. Prior to eruption of teeth, wrap a moistened gauze

square or washcloth around the index finger of
the hand and gently massage the teeth and
gingival tissues. Do not use a dentifrice
(toothpaste) containing fluoride, because
fluoride ingestion is possible.
4. Prolonged bottle or breast feeding provides an
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Dental flossing should be initiated when adjacent

tooth surfaces cannot be cleansed by a
toothbrush.

Brushing should be supervised and assisted until

age 8. A small, circular scrubbing motion is
recommended for children.

GUIDELINES FOR ORAL HEALTH IN CHILDREN

Caries-promoting feeding behaviors that must be

avoided are(1,23):

Infants should not be put to sleep with a bottle

containing fermentable carbohydrates.

At-will breast-feeding should be avoided after

the first primary tooth begins to erupt and other
dietary carbohydrates are introduced.

Parents should be encouraged to have infants

drink from a cup as they approach their first
birthday. Infants should be weaned from the
bottle at 12 to 14 months of age.

Repetitive consumption of any liquid containing

fermentable carbohydrates from a bottle or
training cup should be avoided.

Between-meal snacks and prolonged exposures

to foods and juice or other beverages containing
fermentable carbohydrates should be avoided.

Contributors: Both authors contributed to concept, review

of literature and drafting of the manuscript.
Funding: None.
Competing interests: None stated.

5.

Gomez SS, Weber AA. Effectiveness of a caries

preventive program in pregnant women and new
mothers on their offspring. Int J Paediatr Dent
2001; 11: 117-122.

6.

Seow WK, Humphrys C, Tudehope DI. Increased

prevalence of developmental dental defects in low
birth-weight, prematurely born children: a
controlled study. Pediatr Dent 1987; 9: 221-225.

7.

Davies GN. Early childhood cariesa synopsis.

Community Dent Oral Epidemiol 1998; 26 (1
Suppl): 106-116.

8.

Seow WK. Biological mechanisms of early

childhood caries. Community Dent Oral Epidemiol
1998; 26 (1 Suppl): 8-27.

9.

Horowitz HS. Research issues in early childhood

caries. Community Dent Oral Epidemiol 1998; 26
(1 Suppl): 67-81.

10.

McGaw T. Periodontal disease and preterm

delivery of low-birth-weight infants. J Can Dent
Assoc 2002; 68: 165-169.

11.

Contreras A, Herrera JA, Soto JE, Arce RM,

Jaramillo A, Botero JE. Periodontitis is associated
with preeclampsia in pregnant women. J
Periodontol 2006; 77: 182-188.

12.

Berkowitz RJ. Mutans streptococci: acquisition and

transmission. Pediatr Dent 2006; 28: 106-109.

13.

Lewis CW, Grossman DC, Domoto PK, Deyo RA.

The role of the pediatrician in the oral health of
children: A National survey. Pediatrics 2000; 106:
E84.

14.

Pinkham J, Casamassimo P, Fields H, McTigue D,

Nowak A. Pediatric Dentistry: Infancy through
Adolescence. 4th Ed. Philadelphia: Saunders;
2005.

15.

Brambilla E, Felloni A, Gagliani M, Malerba A,

Garca-Godoy F, Strohmenger L. Caries prevention
during pregnancy: results of a 30-month study. J
Am Dent Assoc 1998; 129: 871-877.

16.

Nowak AJ, Casamassimo PS. Using anticipatory

guidance to provide early dental intervention. J Am
Dent Assoc 1995; 126: 1156-1163.

17.

American Academy of Pediatric Dentistry.

Guideline on oral health care for the pregnant
adolescent. Pediatr Dent 2008; 30: 102-106.

18.

Peretz B, Ram D, Azo E, Efrat Y. Preschool caries

as an indicator of future caries: a longitudinal study.
Pediatr Dent 2003; 25: 114-118.

REFERENCES
1.

2.

3.

4.

American Academy of Pediatric Dentistry. Policy

on Early childhood caries (ECC): Unique
challenges and treatment options. Pediatr Dent
2008; 30: 44-46.
Loesche WJ. Role of Streptococcus mutans in
human dental decay. Microbiol Rev 1986; 50: 353380.
Wan AK, Seow WK, Purdie DM, Bird PS, Walsh
LJ, Tudehope DI. Oral colonization of
Streptococcus mutans in six-month-old predentate
infants. J Dent Res 2001; 80: 2060-2065.
Tanner AC, Milgrom PM, Kent R Jr, Mokeem SA,
Page RC, Riedy CA, et al. The microbiota of young
children from tooth and tongue samples. J Dent Res
2002; 81: 53-57.

INDIAN PEDIATRICS

326

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CHANDNA AND ADLAKHA

19.

20.

21.

GUIDELINES FOR ORAL HEALTH IN CHILDREN

Foster T, Perinpanayagam H, Pfaffenbach A, Certo

M. Recurrence of early childhood caries after
comprehensive
treatment
with
general
anesthesia and follow-up. J Dent Child 2006; 73:
25-30.
Douglass JM. Response to Tinanoff and Palmer:
Dietary determinants of dental caries and dietary
recommendations for preschool children. J Public
Health Dent 2000; 60: 207-209.
Kranz S, Smiciklas-Wright H, Francis LA. Diet
quality, added sugar, and dietary fiber intakes in
American preschoolers. Pediatr Dent 2006;
28: 164-171.

INDIAN PEDIATRICS

327

22.

Reisine S, Douglass JM. Psychosocial and

behavioral issues in early childhood caries.
Community Dent Oral Epidemiol 1998; 26: 32-44.

23.

American Academy of Pediatric Dentistry. Policy

on Early childhood caries (ECC): Classifications,
consequences and preventive strategies. Pediatr
Dent 2008; 30: 39-40.

24.

American Academy of Pediatric Dentistry. Policy

on the dental home. Pediatr Dent 2008; 30: 22-23.

25.

McDonald R, Avery D, Dean J Mosby. Dentistry

for the Child and the Adolescent. 8th Ed St. Louis,
Missouri: Mosby; 2004.

VOLUME 47__APRIL 17, 2010