BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE/ COUNSELING AND TREATMENT

Periodicity of Examination, Preventive Dental

Services, Anticipatory Guidance /Counseling, and
Oral Treatment for Infants, Children, and Adolescents
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Periodicity
2022 of examination, preventive dental services, anticipatory guidance/
counseling, and oral treatment for infants, children, and adolescents.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2024:293-305.

Abstract
This best practice presents recommendations about anticipatory guidance and timing of other clinical modalities which promote oral health
during infancy, childhood, and adolescence. The guidance, though modifiable to children with special health needs, focuses on healthy,
normal-developing children and addresses comprehensive oral examination, assessment of caries risk, periodontal risk assessment,
professional preventive procedures, fluoride supplementation, radiographic examination, anticipatory guidance, preventive counseling,
sealant placement, treatment of dental disease, trauma, treatment of developing malocclusions, evaluation of third molars, and transition to
adult care. These preventive recommendations may be applied for the following age groups: six to 12 months, 12 to 24 months, 24 months
to six years, six to 12 years, and 12 years and older. The guidance emphasizes the importance of very early professional intervention and
continuity of care based upon the individualized needs of the child.
The document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and recommendations regarding oral health services and counseling for pediatric dental
patients.

KEYWORDS: ADOLESCENT DENTISTRY; ANTICIPATORY GUIDANCE; CARIES-RISK ASSESSMENT; DENTAL REFERRAL; FLUORIDE SUPPLEMENT; ORAL HYGIENE
COUNSELING; PERIODICITY OF EXAMINATION; PREVENTIVE DENTISTRY

Purpose by title and/or abstract. When data did not appear sufficient or
The American Academy of Pediatric Dentistry (AAPD) were inconclusive, recommendations were based upon expert
intends these recommendations to help practitioners make and/or consensus opinion by experienced researchers and
clinical decisions concerning preventive oral health inter- clinicians.
ventions, including anticipatory guidance and preventive
counseling, for infants, children, and adolescents. Background
Professional dental care is necessary to maintain oral health.3
Methods The AAPD emphasizes the importance of initiating profes-
This document was developed by the Clinical Affairs sional oral health intervention in infancy and continuing
Committee, adopted in 19911, and last revised by the Council through adolescence and beyond.4 The periodicity of profes-
on Clinical Affairs in 2018 2. This update used electronic sional oral health intervention and services is based on a
database and hand searches of articles in the medical and dental patient’s individual needs and risk indicators.5-10 Each age
literature using the terms: periodicity of dental examinations, group, as well as each individual child, has distinct develop-
dental recall intervals, preventive dental services, anticipatory mental needs to be addressed at specific intervals as part of a
guidance and dentistry, caries-risk assessment, early childhood comprehensive evaluation.4,11-13 Continuity of care is based on
caries, dental caries prediction, dental care cost effectiveness the assessed needs of the individual patient and assures appro-
and children, periodontal disease and children and adolescents priate management of all oral conditions, dental disease, and
United States (U.S.), pit-and-fissure sealants, dental sealants,
fluoride supplementation and topical fluoride, dental trauma,
dental fracture and tooth, nonnutritive oral habits, treatment of ABBREVIATIONS
developing malocclusion, removal of wisdom teeth, removal of AAPD: American Academy of Pediatric Dentistry. BMI: Body mass
index. CRA: Caries-risk assessment. ECC: Early childhood caries.
third molars; fields: all; limits: within the last 10 years, humans, HPV: Human papilloma virus. PRA: Periodontal-risk assessment.
English, and clinical trials; birth through age 18. From this SHCN: Special health care needs. U.S.: United States.
search, 2,502 articles matched these criteria and were evaluated

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injuries.14-20 The early dental visit to establish a dental home children is less for those seen at an earlier age versus later,
provides a foundation upon which a lifetime of preventive confirming the fact that the sooner a child is seen by a dentist,
education and oral health care can be built.21 The early estab- the less treatment needs they are likely to have in the future.39
lishment of a dental home has the potential to provide more On the other hand, delayed diagnosis of dental disease can
effective and less-costly dental care when compared to dental result in exacerbated problems which lead to more extensive
care provided in emergency care facilities or hospitals.21-25 and costly care.10,35,40-43 Guidance of eruption and development
Anticipatory guidance and counseling are essential components of the primary, mixed, and permanent dentitions contributes
of the dental visit.4,11,12,21,24-29 The dental home also can influ- to a stable, esthetic, and functional occlusion.11,29
ence general health by instituting additional practices related Components of a comprehensive clinical examination
to general health promotion, disease prevention, and screening include:
for non-oral health related concerns. For example, oral health • general health/growth assessment (e.g., height, weight,
professionals can calculate and monitor body mass index BMI calculation, vital signs);
(BMI) to help identify children at risk for obesity and provide • pain assessment;
appropriate referral to pediatric or nutritional specialists.28 • extraoral soft tissues examination;
Collaborative efforts and effective communication between • temporomandibular joint assessment;
medical and dental homes are essential to prevent oral disease • intraoral soft tissues examination;
and promote oral and overall health among children. Medical • oral hygiene and periodontal-risk assessment;
professionals can play an important role in children’s oral • intraoral hard tissue examination;
health by providing primary prevention and coordinated care. • assessment of the developing occlusion;
Equally, dentists can improve the overall health of children • radiographic assessment, if indicated;
not only by treating dental disease, but also by proactively • caries-risk assessment; and
recognizing child abuse, preventing traumatic injuries through • assessment of cooperative potential/behavior of child.44
anticipatory guidance, preventing obesity by longitudinal
dietary counseling, and monitoring of weight status.30 In addi- Based upon the visual examination, the dentist may employ
tion, dentists can have a significant role in assessing immuni- additional diagnostic aids (e.g., photographs, pulp vitality
zation status and developmental milestones for potential testing, laboratory tests, study casts).10,15,44-46
delays, as well as making appropriate referral for further The interval of examination should be based on the child’s
neurodevelopmental evaluations and therapeutic services.31 individual needs or risk status/susceptibility to disease; some
The unique opportunity that dentists have to help address patients may require examination and preventive services at
overall health issues strengthens as children get older since more or less frequent intervals, based upon historical, clinical,
frequency of well-child medical visits decreases at the same and radiographic findings.8-10,18,20,26,47-49 While the prevalence
time the frequency of dental recall visits increases. Research of caries has decreased in primary teeth, the prevalence of
shows that children aged six- to 12-years are, on average, four having no caries in the permanent dentition remains un-
times more likely to visit a dentist than a pediatrician.32,33 changed; caries remains a health problems facing infants,
children, and adolescents in America. 37 Caries lesions are
Recommendations cumulative and progressive and, in the primary dentition, are
This document addresses periodicity and general principles of highly predictive of caries occurring in the permanent denti-
examination, preventive dental services, anticipatory guidance/ tion.6,50 Reevaluation and reinforcement of preventive activities
counseling, and oral treatment for children who have no contribute to improved instruction for the caregiver of the
contributory medical conditions and are developing normally. child or adolescent, continuity of evaluation of the patient’s
Accurate, comprehensive, and up-to-date medical, dental, and health status, and potentially allaying anxiety and fear for the
social histories are necessary for correct diagnosis and effective apprehensive child or adolescent. 51 Individuals with SHCN
treatment planning. Recommendations may be modified to may require individualized preventive and treatment strategies
meet the unique requirements of patients with special health that take into consideration the unique needs and disabilities
care needs (SHCN).34 of the patient.34

Clinical oral examination Caries-risk assessment (CRA)

The first examination is recommended at the time of the Risk assessment is a key element of contemporary preventive
eruption of the first tooth and no later than 12 months of care. CRA should be performed as soon as the first primary
age.4,21,24,25 The developing dentition and occlusion should be tooth erupts and be reassessed periodically by dental and
monitored throughout eruption at regular clinical examina- medical providers.6,27 The goal is to prevent disease by identi-
tions.29 Evidence-based prevention and early detection and fying patients at high risk for caries and developing individual-
management of caries/oral conditions can improve a child’s ized preventive measures and caries management, as well as
oral and general health, well-being, and school readiness.7,26,35-38 determining appropriate periodicity of services.27,52,53 Given
The number and cost of dental procedures among high-risk that the etiology of dental caries is multifactorial and complex,

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current caries-risk assessment models entail a combination of (e.g., diet, home care), oral microflora, or physical condition,
factors including diet, fluoride exposure, host susceptibility, risk assessment must be documented and repeated regularly
and microflora analysis and consideration of how these factors and frequently to maximize effectiveness.13,27
interact with social, cultural, and behavioral factors. More
comprehensive models that include social, political, psycho- Periodontal-risk assessment (PRA)
logical, and environmental determinants of health also are Periodontal-risk assessment is an important component of the
available.54-57 CRA forms and caries management protocols routine examination of pediatric patients. The gingival and
aim to simplify and clarify the process.6,27,58,59 periodontal tissues are subject to change due to normal growth
Sufficient evidence demonstrates certain groups of children and development. PRA identifies risk factors that place
at greater risk for development of early childhood caries individuals at increased risk of developing gingival and
(ECC) would benefit from infant oral health care.60-64 Infants periodontal diseases and pathologies, as well as factors that in-
and young children have unique caries-risk factors such as fluence the progression of the disease. Risk factors for peri-
ongoing establishment of oral flora and host defense systems, odontal disease may be biological, environmental (social), and
susceptibility of newly erupted teeth, and development of behavioral.83 Probing assessments should be initiated after the
dietary habits. Because the etiology of ECC is multifactorial eruption of the first permanent molars and incisors as tolerated
and significantly influenced by health behaviors,65 preventive by the child.49 Probing of primary teeth may be indicated
messages for expectant parents and parents of very young when clinical and radiographic findings indicate the presence
children should target factors known to place children at a of periodontal pathology. Bleeding on probing primary teeth
higher risk for developing caries (e.g., early Mutans strepto- during early childhood, even at a low number of sites, is
cocci transmission, poor oral hygiene habits, nighttime feeding, indicative of high susceptibility to periodontal diseases due to
high frequency of sugar consumption).26,36,57,66 Motivational the age-dependent reactivity of the gingival tissues to plaque.84
problems may develop when parents/patients are not interested PRA can improve clinical decision making and allow the
in changing behaviors or feel that the changes require excessive implementation of individualized treatment planning and
effort. Parental attitude, self-efficacy, and intention have a proactive targeted interventions.85 Maintenance of gingival
strong correlation to oral hygiene practices in preschoolers.67 and periodontal health during childhood and adolescence can
Therefore, health care professionals should utilize preventive help assure periodontal health as an adult.49
approaches based on psychological and behavioral strategies.
Moreover, they should communicate their recommendations Prophylaxis and professional topical fluoride treatment
effectively so parents/patients perceive them as behaviors worth The interval for frequency of professional preventive services is
pursuing. Motivational interviewing and self-determination based upon assessed risk for caries and periodontal disease.5,8-10,
theory are examples of effective motivational approaches for 12,13,27,49,58-60
Prophylaxis aids in plaque, stain, and calculus re-
caries prevention that share similar psychological philoso- moval, as well as in educating the patient on oral hygiene
phies.68-74 techniques and facilitating the clinical examination.12 Gingivitis
Studies have reported caries experience in the primary is common in children and adolescents and usually responds
dentition as a predictor of future caries.75,76 Early school-aged to the implementation of therapeutic measures and routine
children are at a transitional phase from primary to mixed maintenance.49 Hormonal fluctuations, including those occur-
dentition. These children face challenges such as unsupervised ring during the onset of puberty and pregnancy, can modify
toothbrushing and increased consumption of cariogenic foods the gingival inflammatory response to dental plaque.86 There-
and beverages while at school, placing them at a higher risk fore, recognizing modifying factors that may result in the
for developing caries.77-79 Therefore, special attention should development of periodontal disease is important.49
be given to school-aged children regarding their oral hygiene Children who exhibit higher risk of developing caries or
and dietary practices. The use of newer technology including periodontal disease would benefit from recall appointments
cellular telephones (e.g., text messaging, apps) may provide at greater frequency than every six months (e.g., every three
an additional intervention to improve adherence to oral hygiene months).5,8,10,12,13,27,49,59 This allows increased professional fluoride
protocols in children and adolescents.80 therapy application, professional assessment of oral hygiene,
Adolescence can be a time of heightened caries activity due and opportunity to foster improvement of oral health by
to an increased number of tooth surfaces in the permanent demonstrating proper oral hygiene techniques, in addition to
dentition and intake of cariogenic substances, as well as low microbial monitoring, antimicrobial therapy reapplication, and
priority for oral hygiene procedures.11,55,56 Risk assessment can reevaluating behavioral changes for effectiveness.5,12,59,87-90 An
assure preventive care (e.g., water fluoridation, professional individualized preventive plan increases the probability of good
and home-use fluoride and antimicrobial agents, frequency oral health by demonstrating proper oral hygiene methods/
of dental visits) is tailored to each individual’s needs and direct techniques and removing plaque, stain, and calculus.8,90
resources to those for whom preventive interventions provide Fluoride contributes to the prevention, inhibition, and
the greatest benefit.11,81,82 Because a child’s risk for developing reversal of caries.91-93 Professional topical fluoride treatments
dental disease can change over time due to changes in habits should be based on caries-risk assessment.21,27,92,94 Plaque and

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the enamel pellicle are not a barrier to topical fluoride uptake.12 visits. This allows parents to quantify any changes such as, but
Consequently, patients who receive rubber cup dental prophy- not limited to, growth delays, traumatic injuries, and poor
laxis or a toothbrush prophylaxis before fluoride treatment oral hygiene or presence of caries lesions. Educating parents
exhibit no differences in caries rates.94,95 Precautionary measures regarding tooth development and chronology of eruption can
should be taken to prevent swallowing of any professionally- help them better understand the implications of delayed or
applied topical fluoride. Children at high caries risk should accelerated tooth emergence. Parents also need to be informed
receive greater frequency of professional topical fluoride appli- about the benefits of topical fluorides for newly erupted teeth
cations (e.g., every three months).91,94,96-98 Ideally, this would which may be at greater risk of developing caries, especially
occur as part of a comprehensive preventive program in a during the posteruption maturation process.102 Assessment of
dental home.21 each child’s developmental milestones (e.g., fine/gross motor
skills, language, social interactions) is crucial for early recog-
Fluoride supplementation nition of potential delays and appropriate referral to therapeutic
The AAPD encourages optimal fluoride exposure for every services.31 Speech and language are integral components of a
child, recognizing community water fluoridation as the most child’s early development.108 Abnormal delays in speech and
beneficial and cost-effective preventive intervention.91 Fluoride language production can be recognized early with referral made
supplementation should be considered for children at moder- to address these concerns. Communication and coordination
ate to high caries risk when fluoride exposure is not optimal.27 of appliance therapy with a speech and language professional
Determination of dietary fluoride sources (e.g., drinking water, can assist in the timely treatment of speech disorders.108
toothpaste, foods, beverages) before prescribing supplements Oral habits (e.g., nonnutritive sucking: digital and pacifier
is required and can help reduce intake of excess fluoride.91 In habits; bruxism; tongue thrust swallow and abnormal tongue
addition, supplementation should be in accordance with the position; self-injurious/self-mutilating behavior) may apply
guidelines recommended by the AAPD91 and the American forces to teeth and dentoalveolar structures. Although early
Dental Association99,100. use of pacifiers and digit sucking are considered normal,
pacifier use beyond 18 months can influence the developing
Radiographic assessment orofacial complex.112 Increased overjet and Class II malocclu-
Radiographs are a valuable adjunct in the oral health care of sion are more strongly associated with a finger habit versus a
infants, children, and adolescents to diagnose and monitor oral pacifier habit.113,114 Children having a nonnutritive sucking
diseases and evaluate dentoalveolar trauma, as well as monitor habit beyond age three have a higher incidence of maloc-
dentofacial development and the progress of therapy.47,48 clusions.29,112 Early dental visits provide an opportunity to
Timing of initial radiographic examination should not be based counsel parents to help their children stop sucking habits before
on the patient’s age, but upon each child’s individual circum- malocclusion or skeletal dysplasias occur.29,112 For school-aged
stances.47,48 The need for dental radiographs can be determined and adolescent patients, counseling regarding any existing
only after consideration of the patient’s medical and dental habits (e.g., fingernail biting, clenching, bruxism), including the
histories, completion of a thorough clinical examination, and potential immediate and long-term effects on the craniofacial
assessment of the patient’s vulnerability to environmental complex and dentition, is appropriate.29 Management of an
factors that affect oral health.47 Every effort must be made to oral habit can include patient/parent counseling, behavior
minimize the patient’s radiation exposure by applying good modification techniques, appliance therapy, or referral to
radiological practices (e.g., use of protective aprons, thyroid other providers including, but not limited to, orthodontists,
collars, rectangular collimation) and by following the as low psychologists, or otolaryngologists.29
as reasonably achievable (ALARA) principle.47,101 Oral hygiene counseling involves the parent and patient.
Initially, oral hygiene is the responsibility of the parent. As the
Anticipatory guidance/counseling child develops, home care can be performed jointly by parent
Anticipatory guidance is the process of providing practical and child. When a child demonstrates the understanding and
and developmentally-appropriate information about children’s ability to perform personal hygiene techniques, the health
health to prepare parents for significant physical, emotional, and care professional should counsel the child. The effectiveness of
psychological milestones.4,11,21,102,103 Individualized discussion home care should be monitored at every visit and includes a
and counseling should be an integral part of each visit. Topics discussion on the consistency of daily oral hygiene preventive
should include oral hygiene practices, oral/dental development activities, including adequate fluoride exposure.5,8,11,27,91,115
and growth, speech/language development, nonnutritive habits, The development of dietary habits and childhood food
diet and nutrition, injury prevention, tobacco/nicotine product preferences appears to be established early and may affect the
use, substance misuse, and intraoral/perioral piercing and oral oral health as well as general health and well-being of a
jewelry/accessories.4,11,17,21,29,102-111 child.116 The establishment of a dental home no later than
Anticipatory guidance regarding the characteristics of a 12 months of age allows dietary and nutrition counseling to
normal healthy oral cavity should commence during infant occur early. This helps parents to develop proper oral health
oral health visits and continue throughout follow-up dental habits early in their child’s life, rather than trying to change

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established unhealthy habits later. During infancy, counseling sale of tobacco products from 18 to 21 years.130 Children may
should focus on breastfeeding, bottle or no-spill cup usage, be exposed to opportunities to experiment with other sub-
concerns with nighttime feedings, frequency of in-between stances that negatively impact their health and well-being.
meal consumption of sugar-sweetened beverages (e.g., sweet- Practitioners should provide education regarding the serious
ened milk, soft drinks, fruit-flavored drinks, sports drinks) health consequences of tobacco use and exposure to secondhand
and snacks, as well as special diets.28,117 Excess consumption of smoke.104,130 The practitioner may need to obtain information
carbohydrates, fats, and sodium contribute to poor systemic regarding tobacco use and alcohol/drug misuse confidentially
health.118-120 Dietary analysis and the impact of dietary choices from an adolescent patient.11,107 When tobacco or substance
on oral health, malnutrition, and obesity121,122, as well as abuse has been identified, practitioners should provide brief
quality of life, should be addressed through nutritional and interventions for encouragement, support, and positive rein-
preventive oral health.28,123 The U.S. Departments of Health forcement for avoiding substance use.104,107 If indicated, dental
and Human Services and Agriculture provide dietary guidelines practitioners should provide referral to primary care providers
for Americans two years of age and older every five years to or behavioral health/addiction specialists for assessment and/
promote a healthy diet and help prevent chronic diseases.123 or treatment of substance use disorders.107
Traumatic dental injuries in the primary and permanent Human papilloma virus (HPV) is associated with several
dentition occur with great frequency with a prevalence of types of cancers, including oral and oropharyngeal cancers.131,132
one-third of preschool children and one-fourth of school-age Seventy percent of oropharyngeal cancers in the U.S. are caused
children.20,124 Facial trauma that results in fractured, displaced, by HPV, and the number of oropharyngeal cancers is increasing
or lost teeth can have significant negative functional, esthetic, annually.132 Evidence supports the HPV vaccine as a means to
and psychological effects on children.125 Practitioners should lessen the risk of oral HPV infection.131,133 The vaccine provides
provide age-appropriate injury prevention counseling for oro- the greatest protection when administered at ages nine through
facial trauma. 17,103 Initial discussions should include advice 12. 132 As adolescent patients tend to see the dentist twice
regarding play objects, pacifiers, car seats, and electrical cords. As yearly and more often than their medical care provider, this
motor coordination develops and the child grows older, the is a window of opportunity for the dental professional to
parent/patient should be counseled on additional safety and counsel patients and parents about HPV’s link to oral cancer
preventive measures, including use of protective equipment (e.g., and the potential benefits of receiving the HPV vaccine.134
athletic mouthguards, helmets with face shields) for sporting Complications from intraoral/perioral piercings can range
and high-speed activities (e.g., baseball, bicycling, skiing, four- from pain, infection, and tooth fracture to life-threatening
wheeling). Dental injuries could have improved outcomes not conditions of bleeding, edema, and airway obstruction.106 Edu-
only if the public were aware of first-aid measures and the need cation regarding pathologic conditions and sequelae associated
to seek immediate treatment, but also if the injured child had with piercings should be initiated for the preteen child and
access to emergency care at all times. Caregivers report that, parent and reinforced during subsequent periodic visits. The
even though their children had a dental home, they have AAPD strongly opposes the practice of piercing intraoral and
experienced barriers to care when referred outside of the dental perioral tissues and use of jewelry on intraoral and perioral
home for emergency services.126 Barriers faced by caregivers tissues due to the potential for pathological conditions and
include availability of providers and clinics for delivery of sequelae associated with these practices.106
emergency care and the distance one must travel for treatment.
Therefore, primary care providers should inform parents about Treatment of dental disease/injury
ways to access emergency care for dental injuries and provide Health care providers who diagnose oral disease or trauma
telephone numbers to access a dentist, including for after- should either provide therapy or refer the patient to an
hours emergency care.110 Teledentistry may serve as an adjunct appropriately-trained individual for treatment.135 Immediate
with time-sensitive injuries or when unexpected circumstances intervention is necessary to prevent further dental destruction,
result in difficulties accessing care.127 as well as more widespread health problems. Postponed treat-
Smoking and smokeless tobacco use almost always are ini- ment can result in exacerbated problems that may lead to the
tiated and established in adolescence. 111,128,129 In 2020, 6.7 need for more extensive care.24,36,37,42 Early intervention could
percent of middle school students and 23.6 percent of high result in savings of health care dollars for individuals, com-
school students reported current tobacco product use. 130 The munity health care programs, and third-party payors.23,31,32,36
most common tobacco products used by middle school and
high school students were reported to be e-cigarettes, cigarettes, Treatment of developing malocclusion
cigars, smokeless tobacco, hookahs, pipe tobacco, and bidis Guidance of eruption and development of the primary, mixed,
(unfiltered cigarettes from India).130 E-cigarette decreased from and permanent dentitions is an integral component of com-
27.5 to 19.6 percent among high school students and from prehensive oral health care for all pediatric dental patients.29
5.3 to 4.7 percent among middle school students from 2019 Dentists have the responsibility to recognize, diagnose, and
to 2020.130 The recent decline reversing previous trends may be manage or refer abnormalities in the developing dentition as
attributable to multiple factors including increasing the age of dictated by the complexity of the problem and the individual

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clinician’s training, knowledge, and experience.135 Early diag- Referral for regular and periodic dental care
nosis and successful treatment of developing malocclusions As adolescent patients approach the age of majority, educating
can have both short-term and long-term benefits, while the patient and parent on the value of transitioning to a dentist
achieving the goals of occlusal harmony and function and who is experienced in adult oral health can help minimize
dentofacial esthestics.136 Early treatment is beneficial for many disruption of high-quality, developmentally-appropriate health
patients but is not indicated for every patient. When there is care. At the time agreed upon by the patient, parent, and
a reasonable indication that an oral habit will result in un- pediatric dentist, the patient should be referred to a specific
favorable sequelae in the developing permanent dentition, any practitioner in an environment sensitive to the adolescent’s
treatment must be appropriate for the child’s development, individual needs.11,148 Until the new dental home is established,
comprehension, and ability to cooperate. Use of an appliance the patient should maintain a relationship with the current
is indicated only when the child wants to stop the habit and care provider and have access to emergency services. For the
would benefit from a reminder. 29 At each stage of occlusal patient with SHCN, in cases where it is not possible or desired
development, the objectives of intervention/treatment include: to transition to another practitioner, the dental home can
(1) managing adverse growth, (2) correcting dental and skeletal remain with the pediatric dentist, and appropriate referrals
disharmonies, (3) improving esthetics of the smile and the for specialized dental care should be recommended when
accompanying positive effects on self-image, and (4) improving needed.148 Proper communication and records transfer allow
the occlusion.29 for consistent and continuous care for the patient.44

Sealants Recommendations by age

A 2016 systematic review concluded sealants are effective in Six to 12 months
preventing and arresting pit-and-fissure occlusal caries lesions 1. Complete the clinical oral examination with adjunctive
of primary and permanent molars in children and adolescents diagnostic tools (e.g., radiographs as determined by child’s
and can minimize the progression of noncavitated occlusal history, clinical findings, and susceptibility to oral disease)
caries lesions.137 They are indicated for primary and permanent to assess oral growth and development, pathology, and/or
teeth with pits and fissures.137 At-risk pits and fissures should injuries; provide diagnosis.
be sealed as soon as possible. Because caries risk may increase 2. Complete a caries-risk assessment.
at any time during a patient’s life due to changes in habits 3. Provide oral hygiene counseling for parents, including
(e.g., dietary, home care), oral microflora, or physical condi- the implications of the oral health of the caregiver.
tion, unsealed teeth subsequently might benefit from sealant 4. Clean teeth and remove supra- and subgingival stains or
application. 138 The need for sealant placement should be deposits as indicated.
reassessed at periodic preventive care appointments. Sealants 5. Assess the child’s exposure to systemic and topical fluorides
should be monitored and repaired or replaced as needed.138-140 (including type of infant formula used) and exposure to
fluoridated toothpaste and provide counseling regarding
Third molars fluoride.
Panoramic or periapical radiographic assessment is indicated 6. Assess appropriateness of feeding practices, including
during late adolescence to assess the presence, position, and bottle and breastfeeding, and provide counseling as
development of third molars.47,48 Impacted third molars are indicated; provide dietary counseling related to oral
potentially pathologic; a 2016 study found the incidence of health.
cysts or tumors associated with impacted mandibular third 7. Provide age-appropriate injury prevention counseling for
molars to be 0.41-0.71 percent in patients younger than 30 orofacial trauma.
years.141 A decision to remove or retain third molars should 8. Provide counseling for nonnutritive oral habits (e.g.,
be made before the middle of the third decade. 142,143 Con- digit, pacifiers).
sideration should be given to removal when there is a high 9. Provide required treatment or appropriate referral for any
probability of disease or pathology or the risks associated oral diseases or injuries.
with early removal are less than the risks of later removal.29, 10. Provide anticipatory guidance.
143,144
Treatment should be provided before pathologic condi- 11. Assess overall growth and development, and make appro-
tions adversely affect the patient’s oral or systemic health.142,143 priate referral to therapeutic services if needed.
Postoperative complications for removal of impacted third 12. Consult with the child’s physician as needed.
molars are low when performed at an early age.145 A Cochrane 13. Determine the interval for periodic reevaluation.
review in 2012 reported no difference in late lower incisor
crowding with removal or retention of asymptomatic im- 12 to 24 months
pacted third molars.146 When a decision is made to maintain 1. Repeat the procedures for ages six to 12 months every
disease-free impacted wisdom teeth, clinical and radiographic six months or as indicated by the child’s individual needs
monitoring is appropriate to prevent undesirable outcomes.147 or risk status/susceptibility to disease.

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2. Assess appropriateness of feeding practices (including 3. At an age determined by patient, parent, and pediatric
bottle, breastfeeding, and no-spill training cups) and dentist, refer the patient to a general dentist for continuing
provide counseling as indicated. oral care.
3. Review patient’s fluoride status and provide parental
counseling. References
4. Provide topical fluoride treatments every six months or 1. American Academy of Pediatric Dentistry. Periodicity of
as indicated by the child’s individual needs or risk examination, preventive dental services, and oral treat-
status/susceptibility to caries. ment for children. Reference Manual 1991-1992.
Chicago, Ill.: American Academy of Pediatric Dentistry;
Two to six years 1991:38-9.
1. Repeat the procedures for 12 to 24 months every six 2. American Academy of Pediatric Dentistry. Periodicity
months or as indicated by the child’s individual needs of examination, preventive dental services, anticipatory
or risk status/susceptibility to disease, including peri- guidance/counseling, and oral treatment for infants,
odontal conditions. Provide age-appropriate oral hygiene children, and adolescents. Pediatr Dent 2018;40(6):
instructions. 194-204.
2. Assess diet and body mass index to identify patterns 3. U.S. Department of Health and Human Services. Office
placing patients at increased risk for dental caries or of the Surgeon General. A National Call to Action to
obesity. Provide counseling or appropriate referral to a Promote Oral Health. Rockville, Md.: U.S. Department
pediatric or nutritional specialist as indicated. of Health and Human Services, Public Health Service,
3. Scale and clean the teeth every six months or as indicated National Institutes of Health, National Institute of
by individual patient’s needs. Dental and Craniofacial Research; 2003. Available at:
4. Provide pit-and-fissure sealants for caries-susceptible “https://www.ncbi.nlm.nih.gov/books/NBK47472/”.
anterior and posterior primary and permanent teeth. Accessed March 2, 2022.
5. Provide counseling and services (e.g., mouthguards) as 4. American Academy of Pediatric Dentistry. Perinatal and
needed for orofacial trauma prevention. infant oral health care. The Reference Manual of Pediatric
6. Assess developing dentition and occlusion and provide Dentistry. Chicago, Ill.: American Academy of Pediatric
assessment/treatment or referral of malocclusion as Dentistry; 2022:277-81.
indicated by individual patient’s needs. 5. Pienihakkinen K, Jokela J, Alanen P. Risk-based early
7. Provide required treatment or appropriate referral for any prevention in comparison with routine prevention of
oral diseases, habits, or injuries as indicated. dental caries: A 7-year follow-up of a controlled clinical
8. Assess speech and language development and provide trial; clinical and economic results. BMC Oral Health
appropriate referral as indicated. 2005;5(2):1-5.
6. Fontana M, González-Cabezas C. The clinical, environ-
Six to 12 years mental, and behavioral factors that foster early childhood
1. Repeat the procedures for ages two to six years every caries: Evidence for caries risk assessment. Pediatr Dent
six months or as indicated by child’s individual needs. 2015;37(3):217-25.
2. Complete a periodontal-risk assessment that may include 7. Fontana M. Noninvasive caries risk-based management
radiographs and periodontal probing with eruption of in private practice settings may lead to reduced caries ex-
first permanent molars. perience over time. J Evid Based Dent Pract 2016;16(4):
3. Provide substance abuse counseling (e.g., smoking, 239-42.
smokeless tobacco) and referral to primary care providers 8. Beil HA, Rozier RG. Primary health care providers’ advice
or behavioral health/addiction specialists if indicated. for a dental checkup and dental use in children. Pediatrics
4. Provide education and counseling regarding HPV and the 2010;126(2):435-41.
benefits of the HPV vaccine. 9. Patel S, Bay C, Glick M. A systematic review of dental
5. Provide counseling on intraoral/perioral piercing. recall intervals and incidence of dental caries. J Am Dent
Assoc 2010;141(5):527-39.
12 years and older 10. Pahel BT, Rozier RG, Stearns SC, Quiñonez RB. Effec-
1. Repeat the procedures for ages six to 12 years every six tiveness of preventive dental treatments by physicians for
months or as indicated by the child’s individual needs young Medicaid enrollees. Pediatrics 2011;127(3):682-9.
or risk status/susceptibility to disease. 11. American Academy of Pediatric Dentistry. Adolescent oral
2. During late adolescence, assess the presence, position, and health care. The Reference Manual of Pediatric Dentistry.
development of third molars, giving consideration to Chicago, Ill.: American Academy of Pediatric Dentistry;
removal when there is a high probability of disease or 2022:282-91.
pathology or the risks associated with early removal are
less than the risks of later removal. References continued on the next page.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 299

BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE/ COUNSELING AND TREATMENT

12. American Academy of Pediatric Dentistry. Policy on the 25. American Academy of Pediatrics. Maintaining and im-
role of dental prophylaxis in pediatric dentistry. The proving the oral health of young children. Pediatrics 2014;
Reference Manual of Pediatric Dentistry. Chicago, 134(6):1224-9.
Ill.: American Academy of Pediatric Dentistry; 2022: 26. American Academy of Pediatric Dentistry. Policy on early
67-9. childhood caries (ECC): Consequences and preventive
13. Ramos-Gomez FJ, Crystal YO, Ng MW, Crall JJ, Feath- strategies. The Reference Manual of Pediatric Dentistry.
erstone JD. Pediatric dental care: Prevention and manage- Chicago, Ill.: American Academy of Pediatric Dentistry;
ment protocols based on caries risk assessment. J Calif 2022:90-3.
Dent Assoc 2010;38(10):746-61. 27. American Academy of Pediatric Dentistry. Caries risk
14. American Academy of Pediatric Dentistry. Pediatric assessment and management for infants, children, and
restorative dentistry. The Reference Manual of Pediatric adolescents. The Reference Manual of Pediatric Dentistry.
Dentistry. Chicago, Ill.: American Academy of Pediatric Chicago, Ill.: American Academy of Pediatric Dentistry;
Dentistry; 2022:401-14. 2022:266-72.
15. American Academy of Pediatric Dentistry. Acquired tem- 28. American Academy of Pediatric Dentistry. Policy on
poromandibular disorders in infants, children, and ado- dietary recommendations for infants, children, and
lescents. The Reference Manual of Pediatric Dentistry. adolescents. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:442-50. 2022:96-100.
16. American Academy of Pediatric Dentistry. Management 29. American Academy of Pediatric Dentistry. Management
considerations for pediatric oral surgery and oral pathol- of the developing dentition and occlusion in pediatric
ogy. The Reference Manual of Pediatric Dentistry. dentistry. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; Chicago Ill.: American Academy of Pediatric Dentistry;
2022:484-94. 2022:424-41.
17. American Academy of Pediatric Dentistry. Policy on pre- 30. Tseng R, Vann WF Jr, Perrin EM. Addressing childhood
vention of sports-related orofacial injuries. The Reference overweight and obesity in the dental office: Rationale and
Manual of Pediatric Dentistry. Chicago, Ill.: American practical guidelines. Pediatr Dent 2010;32(5):417-23.
Academy of Pediatric Dentistry; 2022:121-6. 31. Scharf RJ, Scharf GJ, Stroustrup A. Developmental
18. Bourguignon C, Cohenca N, Lauridsen E, et al. Interna- milestones. Pediatr Rev 2016;37(1):25-37.
tional Association of Dental Traumatology guidelines for 32. Brown E, Jr. Children’s Dental Visits and Expenses, United
the management of traumatic dental injuries: 1. Fractures States, 2003. Statistical Brief #117. March, 2006. Agency
and luxations. Dent Traumatol 2020;36(4):324-30. for Healthcare Research and Quality, Rockville, Md.
19. Fouad AF, Abbott PV, Tsilingaridis G. International Asso- Available at: “http://meps.ahrq.gov/mepsweb/data_files/
ciation of Dental Traumatology guidelines for the publications/st117/stat117.shtml”. Accessed March 2,
management of traumatic dental injuries: 2. Avulsion of 2022.
permanent teeth. Dent Traumatol 2020;36(4):331-42. 33. Selden TM. Compliance with well-child visit recommen-
20. Day PF, Flores MT, O’Connell AC, et al. International dations: Evidence from the Medical Expenditure Panel
Association of Dental Traumatology guidelines for the Survey, 2000-2002. Pediatrics 2016;118(6):e1766-78.
management of traumatic dental injuries: 3. Injuries in the 34. American Academy of Pediatric Dentistry. Management
primary dentition. Dent Traumatol 2020;36(4):343-9. of dental patients with special health care needs. The
21. American Academy of Pediatric Dentistry. Policy on the Reference Manual of Pediatric Dentistry. Chicago, Ill.:
dental home. The Reference Manual of Pediatrc Dentistry. American Academy of Pediatric Dentistry; 2022:302-9.
Chicago, Ill.: American Academy of Pediatric Dentistry; 35. American Academy of Pediatric Dentistry. Policy on early
2022:21-2. childhood caries (ECC): Unique challenges and treatment
22. Kempe A, Beaty B, Englund BP, et al. Quality of care and options. The Reference Manual of Pediatric Dentistry.
use of the medical home in a state-funded capitated Chicago, Ill.: American Academy of Pediatric Dentistry;
primary care plan for low-income children. Pediatrics 2022:94-5.
2000;105(5):1020-8. 36. Clarke M, Locker D, Berall G, Pencharz P, Kenny DJ,
23. American Academy of Pediatrics Council on Children Judd P. Malnourishment in a population of young chil-
with Disabilities. Care coordination: Integrating health dren with severe early childhood caries. Pediatr Dent
and related systems of care for children with special health 2006;28(3):254-9.
care needs. Pediatrics 2005;116(5):1238-44. 37. Dye BA, Mitnik GL, Iafolia TJ, Vargus CM. Trends in
24. Berg JH, Stapleton FB. Physician and dentist: New initi- dental caries in children and adolescents according to
atives to jointly mitigate early childhood oral disease. poverty status in the United States from 1999 through
Clin Pediatr 2012;51(6):531-7. 2004 and from 2011 through 2014. J Am Dent Assoc
2017;148(8):550-74.

300 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE/ COUNSELING AND TREATMENT

38. Jackson SL, Vann WF, Kotch J, Pahel BT, Lee JY. Impact 52. Crall JJ, Quiñonez RB, Zandona AF. Caries risk assess-
of poor oral health on children’s school attendance and ment: Rationale, uses, tools, and state of development. In:
performance. Amer J Publ Health 2011;10(10):1900-6. Berg JH, Slayton RL, eds. Early Childhood Oral Health,
39. Nowak AJ, Casamassimo PS, Scott J, Moulton R. Do 2nd ed. Hoboken, N.J.: John Wiley & Sons, Inc.; 2016:
early dental visits reduce treatment and treatment costs 193-220.
for children? Pediatr Dent 2014;36(7):489-93. 53. Fontana M, Zero DT. Assessing patients’ caries risk. J
40. Davis EE, Deinard AS, Maiga EW. Doctor, my tooth Am Dent Assoc 2006;137(9):1231-9.
hurts: The costs of incomplete dental care in the emergency 54. American Academy of Pediatric Dentistry. Policy on
room. J Pub Health Dent 2010;70(3):205-10. social determinants of children’s oral health and health
41. Kobayashi M, Chi D, Coldwell SE, Domoto P, Milgrom disparities. The Reference Manual of Pediatric Dentistry.
P. The effectiveness and estimated costs of the access to Chicago Ill.: American Academy of Pediatric Dentistry;
baby and child dentistry programs in Washington State. 2022:29-33.
J Am Dent Assoc 2005;136(9):1257-63. 55. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Influences
42. Lee JY, Bouwens TJ, Savage MF, Vann WF Jr. Examining on children’s oral health: A conceptual model. Pediatrics
the cost-effectiveness of early dental visits. Pediatr Dent 2007;120(3):e510-20.
2006;28(2):102-5, discussion 192-8. 56. Lee JY, Divaris K. The ethical imperative of addressing
43. American Academy of Pediatrics. Early childhood caries oral health disparities: A unifying framework. J Dent Res
in indigenous communities. Pediatr Dent 2011;127(6): 2014;93(3):224-30.
1190-8. 57. Seow KW. Environmental, maternal, and child factors
44. American Academy of Pediatric Dentistry. Recordkeeping. which contribute to early childhood caries: A unifying
The Reference Manual of Pediatric Dentistry. Chicago, conceptual model. Int J Paediatr Dent 2012;22(3):
Ill.: American Academy of Pediatric Dentistry; 2022: 157-68.
521-8. 58. Domejean S, White JM, Featherstone JD. Validation of
45. Yepes JF, Dean JA. Examination of the mouth and relevant the CDA CAMBRA caries risk assessment: A six year
structures. In: Dean JA, ed. McDonald and Avery’s Den- retrospective study. J Calif Dent Assoc 2011;39(10):
tistry for the Child and Adolescent. 11th ed. St. Louis, 709-15.
Mo.: Elsevier Co; 2020:3-19. 59. Ramos-Gomez F, Ng MW. Into the future: Keeping
46. Fontana M. Patient evaluation and risk assessment. In: healthy teeth caries free: Pediatric CAMBRA protocols. J
Little JW, Falace DA, Miller CS, Rhodus, NL eds. Den- Calif Dent Assoc 2011;39(10):723-33.
tal Management of the Medically Compromised Patient. 60. Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors
9th ed. St. Louis, Mo.: Elsevier; 2018:2-17. for dental caries in young children: A systematic review of
47. American Academy of Pediatric Dentistry. Prescribing the literature. Community Dent Health 2004;21(suppl):
dental radiographs for infants, children, adolescents, and 71-85.
individuals with special health care needs. The Reference 61. Ramos-Gomez FJ. A model for community-based pedi-
Manual of Pediatric Dentistry. Chicago, Ill.: American atric oral health: Implementation of an infant oral care
Academy of Pediatric Dentistry; 2022:273-6. program. Int J Dent 2014;2014:156821.
48. American Dental Association, U.S. Department of Health 62. Southward LH, Robertson A, Edelstein BL. Oral health
and Human Services. Dental Radiographic Examinations: of young children in Mississippi Delta child care centers.
Recommendations for Patient Selection and Limiting A second look at early childhood caries risk assessment. J
Radiation Exposure. Revised 2012. Available at: “https:// Public Health Dent 2008;68(4):188-95.
www.fda.gov/media/84818/download”. Accessed June 22, 63. Nunn ME, Dietrich T, Singh HK, Henshaw MM, Kres-
2022. sin NR. Prevalence of early childhood caries among very
49. American Academy of Pediatric Dentistry. Risk assessment young urban Boston children compared with U.S.
and management of periodontal diseases and pathologies children. J Public Health Dent 2009;69(3):156-62.
in pediatric dental patients. The Reference Manual of 64. Weber-Gasparoni K, Kanellis MJ, Qian F. Iowa’s public
Pediatric Dentistry. Chicago, Ill.: American Academy of health-based infant oral health program: A decade of
Pediatric Dentistry; 2022:466-83. experience. J Dent Educ 2010;74(4):363-71.
50. Tagliaferro EP, Pereina AC, Meneghin MDC, Ambrosono 65. Jiang S, McGrath C, Lo E, Ho S, GaoX. Motivational
GBM. Assessment of dental caries prediction in a seven- interviewing to prevent early childhood caries: A random-
year longitudinal study. J Pub Health Dent 2006;66(3): ized control trial. J Dent 2020;97(6):1-7.
169-73. 66. Plutzer K, Keirse MJ. Incidence and prevention of early
51. American Academy of Pediatric Dentistry. Behavior childhood caries in one- and two-parent families. Child
guidance for the pediatric dental patient. The Reference Care Health Dev 2011;37(1):5-10.
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:321-39. References continued on the next page.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 301

BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE/ COUNSELING AND TREATMENT

67. Smith S, Kroon J, Schwarzer R, Hamilton K. Parental 83. Elangovan S, Novak KF, Novak MJ. Clinical risk assess-
social cognitive correlates of preschoolers’ oral hygiene ment. In Newman MG, Takei HH, Klokkevold PR,
behavior: A systematic review and meta-analysis. Soc Sci Carranza FA. eds. Newman and Carranza’s Clinical Peri-
Med 2020;264:113322. odontology. 13th ed. Philadelphia, Pa.: Elsevier 2019:
68. Halvari AEM, Halvari H, Bjørnebekk G, Deci EL. Self- 410-2.
determined motivational predictors of increases in dental 84. Bimstein E, Huja Pe, Ebersole JL. The potential lifespan
behaviors, decreases in dental plaque, and improvement impact of gingivitis and periodontitis in children. J Clini
in oral health: A randomized clinical trial. Health Psychol Pediatr Dent 2013;38(2):95-9.
2012;31(6):777-88. 85. Douglass CW. Risk assessment and management of
69. Harrison RL, Veronneau J, Leroux B. Effectiveness of periodontal disease. J Am Dent Assoc 2006;137(Suppl):
maternal counseling in reducing caries in Cree children. J 7S-32S.
Dent Res 2012;91(11):1032-7. 86. American Academy of Pediatric Dentistry. Oral health
70. Ismail AI, Ondersma S, Jedele JM, Little RJ, Lepkowski care for the pregnant pediatric dental patient. The
JM. Evaluation of a brief tailored motivational interven- Reference Manualof Pediatric Dentistry. Chicago, Ill.:
tion to prevent early childhood caries. Community Dent American Academy of Pediatric Dentistry; 2022:292-301.
Oral Epidemiol 2011;39(5):433-48. 87. Clerehugh V. Periodontal diseases in children and adoles-
71. Miller WR, Rollnick S. Meeting in the middle: Motiva- cents. Br Dent J 2008;204(8):469-71.
tional interviewing and self-determination theory. Int J 88. Anderson MH, Shi W. A probiotic approach to caries
Behav Nutr Phys Act 2012;2(9):25. management. Pediatr Dent 2006;28(2):151-3.
72. Riedy C, Weinstein P, Manci L, et al. Dental attendance 89. Featherstone JDB. Caries prevention and reversal based
among low-income women and their children following a on the caries balance. Pediatr Dent 2006;28(2):128-32.
brief motivational counseling intervention: A community 90. Clerehugh V, Tugnait A. Periodontal diseases in children
randomized trial. Soc Sci Med 2015;144:9-18. and adolescents: 2. Management. Dent Update 2001;28
73. Weber-Gasparoni K, Reeve J, Ghosheh N, et al. An effec- (6):274-81.
tive psychoeducational intervention for early childhood 91. American Academy of Pediatric Dentistry. Fluoride
caries prevention: Part I. Pediatr Dent 2013;35(3):241-6. therapy. The Reference Manual of Pediatric Dentistry.
74. Weber-Gasparoni K, Warren JJ, Reeve J, et al. An effective Chicago, Ill.: American Academy of Pediatric Dentistry;
psychoeducational intervention for early childhood caries 2022:317-20.
prevention: Part II. Pediatr Dent 2013;35(3):247-51. 92. Adair SM. Evidence-based use of fluoride in contem-
75. Mejàre I, Axelsson S, Dahlén D, et al. Caries risk-assessment: porary pediatric dental practice. Pediatr Dent 2006;28
A systematic review. Acta Odontol Scand 2014;72(2): (2):133-42.
81-91. 93. Tinanoff N. Use of fluoride. In: Early Childhood Oral
76. Lin Y, Chou C, Lin Y. Caries experience between primary Health. Berg JH, Slayton RL, eds. Hoboken, N.J.: John
teeth at 3-5 years of age and future caries in the permanent Wiley & Sons, Inc.; 2016:104-19.
first molars. J Dent Sci 2021;16(3):899-904. 94. Weyant RJ, Tracy SL, Anselmo TT, et al. Topical fluoride
77. American Academy of Pediatric Dentistry. Policy on for caries prevention: Executive summary of the updated
snacks and sugar-sweetened beverages sold in schools. clinical recommendations and supporting systematic
The Reference Manual of Pediatric Dentistry. Chicago, review. J Amer Dent Assoc 2013;144(11):1279-91.
Ill.: American Academy of Pediatric Dentistry; 2022: 95. Azarpazhooh A, Main PA. Efficacy of dental prophylaxis
101-2. (rubber-cup) for the prevention of caries and gingivitis:
78. Marshall TA, Levy SM, Broffitt B, et al. Dental caries A systematic review of the literature. Br Dent J 2009;
and beverage consumption in young children. Pediatrics 207(7):E14.
2003;112(3Pt1):e184-e191. 96. Featherstone JD, Adair SM, Anderson MH, et al. Caries
79. Chankanka O, Marshall TA, Levy SM, et al. Mixed denti- management by risk assessment: Consensus statement,
tion cavitated caries incidence and dietary intake fre- April 2002. J Calif Dent Assoc 2003;331(3):257-69.
quencies. Pediatr Dent 2011;33(3):233-40. 97. Axelsson S, Söder B, Norderam G, et al. Effect of com-
80. Sharif M, Newton T, Cunningham S. A systematic review bined caries-preventive methods: A systematic review of
to assess interventions delivered by mobile phones in controlled clinical trials. Acta Odontol Scand 2004;62
improving adherence to oral hygiene advice for children (3):163-9.
and adolescents. Br Dent J 2019;227(5):375-82. 98. Källestål C. The effect of five years’ implementation of
81. Featherstone JDB, Chaffee B. The evidence for caries caries-preventive methods in Swedish high-risk adoles-
management by risk assessment (CAMBRA). Adv Dent cents. Caries Res 2005;39(1):20-6.
Res 2018;29(1):9-14. 99. Rozier RG, Adair, S, Graham F, et al. Evidence-based
82. Warren JJ, Van Buren JM, Levy SM, et al. Dental caries clinical recommendations on the prescription of dietary
clusters among adolescents. Community Dent Oral fluoride supplements for caries prevention. J Am Dent
Epidemiol 2017;45(6):538-44. Assoc 2010;141(12):1480-9.

302 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE/ COUNSELING AND TREATMENT

100. American Dental Association Council on Scientific 114. Cenci VS, Marciel SM, Jarrus ME, et al. Pacifier-sucking
Affairs. Professionally-applied topical fluoride: Evidence- habit duration and frequency on occlusal and myofunc-
based clinical recommendations. J Am Dent Assoc 2006; tional alterations in preschool children. Braz Oral Res
137(8):1151-9. 2015;29(1):1-7.
101. Campbell RE, Wilson S, Zhand Y, Scarfe WC. A survey on 115. American Academy of Pediatric Dentistry. Policy on use
radiation exposure reduction including rectangular col- of fluoride. The Reference Manual of Pediatric Dentistry.
limation for intraoral radiography by pediatric dentists in Chicago, Ill.: American Academy of Pediatric Dentistry;
the United States. J Am Dent Assoc 2020;151(4):287-96. 2022:70-1.
102. Casamassimo PS, Nowak AJ. Anticipatory guidance. In: 116. Kranz S, Smiciklas-Wright H, Francis LA. Diet quality,
Berg JH, Slayton RL, eds. Early Childhood Oral Health, added sugar, and dietary fiber intakes in American pre-
2nd ed. Hoboken, N.J.: John Wiley & Sons, Inc.; 2016: schoolers. Pediatr Dent 2006;28(2):164-71.
169-92. 117. Lott M, Callahan E, Walker Duffy E, Story M, Daniels
103. Sigurdsson A. Evidence-based review of prevention of S. Consensus statement. Healthy beverage consumption
dental injuries. Pediatr Dent 2013;35(2):184-90. in early childhood: Recommendations from key national
104. American Academy of Pediatric Dentistry. Policy on health and nutrition organizations. September, 2019.
tobacco use. The Reference Manual of Pediatric Dentistry. Available at: “https//healthyeatingresearch.org/wp-
Chicago Ill.: American Academy of Pediatric Dentistry; content/2019/09/HER-HealthyBeverage-Consensus
2022:103-7. Statement.pdf ”. Accessed March 16, 2022.
105. American Academy of Pediatric Dentistry. Policy on 118. Drewnowski A. The cost of U.S. foods as related to their
electronic nicotine delivery systems (ENDS). The Reference nutritive value. Am J Clin Nutr 2010;92(5):1181-8.
Manual of Pediatric Dentistry. Chicago, Ill.: American 119. Ervin RB, Kit BK, Carroll MD, Ogden CL. Consump-
Academy of Pediatric Dentistry; 2022:108-11. tion of added sugar among U.S. children and adolescents,
106. American Academy of Pediatric Dentistry. Policy on 2005-2008. NCHS Data Brief 2012;3(87):1-8.
intraoral/perioral piercing and oral jewelry/accessories. 120. Mobley C, Marshall TA, Milgrom P, Coldwell SE. The
The Reference Manual of Pediatric Dentistry. Chicago, contribution of dietary factors to dental caries and dis-
Ill.: American Academy of Pediatric Dentistry; 2022: parities in caries. Acad Pediatr 2009;9(6):410-4.
119-120. 121. Davidson K, Schroth R, Levi J, Yaffe A, Mittermuller B,
107. American Academy of Pediatric Dentistry. Policy on Sellers C. Higher body mass index associated with severe
substance misuse in adolescent patients. The Reference early childhood caries. BMC Pediatrics 2016;16(137):
Manual of Pediatric Dentistry. Chicago, Ill.: American 1-8.
Academy of Pediatric Dentistry; 2022:112-6. 122. Schroth R, Levi JA, Sellers EA, Friel J, Kliewer E, Moffatt
108. American Speech-Language-Hearing Association. How M. Vitamin D status of children with severe early child-
Does Your Child Hear and Talk? Available at: “http:// hood caries: A case control study. BMC Pediatrics 2013;
www.asha.org/public/speech/development/chart/”. 13(174):1-8.
Accessed March 2, 2022. 123. U.S. Department of Health and Human Services, U.S.
109. Lewis CW, Grossman DC, Domoto PK, Deyo RA. The Department of Agriculture. 2020-2025 Dietary Guide-
role of the pediatrician in the oral health of children: A lines for Americans, 9th ed. Washington, D.C.: U.S.
national survey. Pediatrics 2000;106(6):E84. Department of Health and Human Services and U.S. De-
110. American Academy of Pediatric Dentistry. Policy on emer- partment of Agriculture; 2020.
gency oral care for infants, children, adolescents, and 124. Glendor U. Epidemiology of traumatic injuries - A 12
individuals with special health care needs. The Reference year review of the literature. Dent Traumatol 2008; 24(6):
Manual of Pediatric Dentistry. Chicago, Ill.: American 603-11.
Academy of Pediatric Dentistry; 2022:66. 125. Lee JY, Divaris K. Hidden consequences of dental trauma:
111. American Lung Association. Stop Smoking. Available at: The social and psychological effects. Pediatr Dent 2009;
“http://www.lung.org/stop-smoking/”. Accessed March 2, 31(2):96-101.
2022. 126. Meyer BD, Lee JY, Lampiris LN, Mihas P, Vossers S,
112. American Academy of Pediatric Dentistry. Policy on Divaris K. “They told me to take him somewhere else”:
pacifiers. The Reference Manual of Pediatric Dentistry. Caregivers’ experiences seeking emergency dental care
Chicago, Ill.: American Academy of Pediatric Dentistry; for their children. Pediatr Dent 2017;39(3):209-14.
2022:86-9. 127. American Academy of Pediatric Dentistry. Policy on
113. Bishara SE, Watten JJ, Broffitt B, et al. Changes in the teledentistry. The Reference Manual of Pediatric Dentis-
prevalence of nonnutritive sucking patterns in the first 8 try. Chicago, Ill.: American Academy of Pediatric
years of life. Am J Orthod Dentofacial Orthop 2006;130 Dentistry; 2022:50-1.
(1):31-6.
References continued on the next page.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 303

BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE/ COUNSELING AND TREATMENT

128. Albert DA, Severson HH, Andrews JA. Tobacco use by 138. Sasa I, Donly KJ. Dental sealants: A review of the
adolescents: The role of the oral health professional in materials. Calif Dent Assoc J 2010;38(10):730-4.
evidence-based cessation program. Pediatr Dent 2006; 139. Ignelzi M. Pit and fissure sealants - An ongoing com-
28(2):177-87. mitment. Calif Dent Assoc J 2010;38(10):725-8.
129. U.S. Department of Health and Human Services. Pre- 140. American Academy of Pediatric Dentistry. Policy on
venting Tobacco Use Among Youth and Young Adults: A third-party reimbursement of fees related to dental
Report of the Surgeon General. Atlanta, Ga.: U.S. De- sealants. The Reference Manual of Pediatric Dentistry.
partment of Health and Human Services, Centers for Chicago, Ill.: American Academy of Pediatric Dentistry;
Disease Control and Prevention, Office on Smoking and 2022:163-4.
Health; 2012. Available at: “http://www.cdc.gov/tobacco 141. Shin S, Choi E, Moon S. Prevalence of pathologies re-
/data_statistics/sgr/2012/index.htm”. Accessed March 2, lated to impacted mandibular third molars. Springerplus
2022. 2016:5(1):915.
130. Centers for Disease Control and Prevention. Tobacco use 142. Lieblich SE, Dym H, Fenton D. Dentoalveolar surgery.
among middle and high school students – United States, J Oral Maxillofac Surg 2017;75(8):250-73.
2020. MMWR Morb Mortal Wkly Rep 2020;69(50): 143. American Association of Oral and Maxillofacial Surgeons.
1881-8. Advocacy white paper on third molar teeth (2016). Avail-
131. Jiang S, Dong Y. Human papillomavirus and oral squa- able at: “https://www.aaoms.org/docs/govt_affairs/
mous cell carcinoma: A review of HPV-positive oral advocacy_white_papers/management_third_molar_ white_
squamous cell carcinoma and possible strategies for paper.pdf ”. Accessed March 2, 2022.
future. Curr Probl Cancer 2017:41(5):323-7. 144. Klene CA, Ferneini EM, Bennett JD. Oral surgery in
132. National Cancer Institute. HPV and Cancer. Reviewed the pediatric patient. In: Dean JA, ed. McDonald and
October 25, 2021. Available at: “https://www.cancer.gov/ Avery’s Dentistry for the Child and Adolescent. 11th ed.
about-cancer/causes-prevention/risk/infectious-agents/ St. Louis, Mo: Elsevier; 2020:659-72.
hpv-and-cancer”. Accessed March 9, 2022. 145. Blondeau F, Daniel NG. Extraction of impacted mandibu-
133. National Cancer Institute. Oral Cavity, Oropharyngeal, lar third molars: Postoperative complications and their
Hypopharyngeal, and Laryngeal Cancers Prevention risk factors. J Can Dent Assoc 2007;73(4):325.
(PDQ®)–Health Professional Version. Updated October 146. Mettes TD, Ghaeminia H, Nienhuijs ME, Perry J, van
15, 2021. Available at: “https://www.cancer.gov/types/ deer Sanden WJ, Plasschaert A. Surgical removal versus
head-and-neck/hp/oral-prevention-pdq#_223_toc”. retention for the management of asymptomatic impacted
Accessed March 9, 2022. wisdom teeth. Cochrane Database Syst Rev 2012;13(6):
134. American Academy of Pediatric Dentistry. Policy on CD003879. Available at: “https://repository.ubn.ru.nl/
human papilloma virus vaccinations. The Reference bitstream/handle/2066/109646/109646.pdf;jsessionid=2F
Manual of Pediatric Dentistry. Chicago, Ill.: American 32C887B9A7DF553B2B555F3522DBDB?sequence=1”.
Academy of Pediatric Dentistry; 2022:117-8. Accessed March 6, 2022.
135. American Academy of Pediatric Dentistry. Policy on ethi- 147. Ghaeminia H, Toedtling V, Tummers M, Hoppenreijs T,
cal responsibilities in the oral health care management Van der Sanden W, Mettes T. Surgical removal versus
of infants, children, adolescents, and individuals with spe- retention for the management of asymptomatic disease-
cial health care needs. The Reference Manual of Pediatric free impacted wisdom teeth. Cochrane Database Syst Rev
Dentistry. Chicago, Ill.: American Academy of Pediatric 2020;5:CD003879. Available at: “https://www.cochrane
Dentistry; 2022:184-5. library.com/cdsr/doi/10.1002/14651858.CD003879.pub5/
136. Dean JA, Walsh JS. Managing the developing occlusion. epdf/full”. Accessed March 6, 2022.
In: Dean JA, ed. McDonald and Avery’s Dentistry for the 148. American Academy of Pediatric Dentistry. Policy on
Child and Adolescent. 11th ed. St. Louis, Mo.: Elsevier; transitioning from a pediatric to an adult dental home
2020:467-530. for individuals with special health care needs. The Refer-
137. Wright JT, Tampi MP, Graham L, et al. Sealants for ence Manual of Pediatric Dentistry. Chicago, Ill.: American
preventing and arresting pit-and-fissure occlusal caries in Academy of Pediatric Dentistry; 2022:172-5.
primary and permanent molars. Pediatr Dent 2016;38
(4):282-308. Erratum in Pediatr Dent 2017;39(2):100.

304 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 Recommended Dental Periodicity Schedule for Pediatric Oral Health Assessment, Preventive Services,
and Anticipatory Guidance/Counseling
Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally. These recommendations will need to be
modified for children with special health care needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric Dentistry emphasizes the importance of very early professional
intervention and the continuity of care based on the individualized needs of the child. Refer to the text of this best practice for supporting information and references.

AGE
®

6 TO 12 MONTHS 12 TO 24 MONTHS 2 TO 6 YEARS 6 TO 12 YEARS 12 YEARS

AND OLDER

1
Clinical oral examination • • • • •
20
Assess oral growth and development • • • • •
30
Caries-risk assessment • • • • •
4
Radiographic assessment • • • • •
3,4
Prophylaxis and topical fluoride • • • • •
Fluoride supplementation 5 • • • • •
680
Anticipatory guidance/counseling • • • • •
3,7
Oral hygiene counseling Parent Parent Patient/parent Patient/parent Patient
3,8
10
Dietary counseling • • • • •
9 • • • • •
Counseling for nonnutritive habits
10
12
Injury prevention and safety counseling • • • • •
11
Assess speech/language development • • •
121
Assessment developing occlusion • • •
13
Assessment for pit and fissure sealants • • •
Periodontal-risk assessment 3,14
• • •
Counseling for tobacco, vaping, and
• •
substance misuse
Counseling for human papilloma virus/ • •
vaccine
Counseling for intraoral/perioral piercing • •
10
Assess third molars •
Transition to adult dental care •

1 First examination at the eruption of the first tooth and no later than 12 months. Repeat every six months or as indicated 10 Initially pacifiers, car seats, play objects, electric cords; secondhand smoke; when learning to walk; with sports
by child’s risk status/susceptibility to disease. Includes assessment of pathology and injuries. and routine playing, including the importance of mouthguards; then motor vehicles and high-speed activities.
2 By clinical examination. 11 Observation for age-appropriate speech articulation and fluency as well as achieving receptive and expressive
3 Must be repeated regularly and frequently to maximize effectiveness. language milestones.
4 Timing, types, and frequency determined by child’s history, clinical findings, and susceptibility to oral disease. 12 Identify: transverse, vertical, and sagittal growth patterns; asymmetry; occlusal disharmonies; functional status
5 Consider when systemic fluoride exposure is suboptimal. Up to at least 16 years. including temporomandibular joint dysfunction; esthetic influences on self-image and emotional development.

6 Appropriate discussion and counseling should be an integral part of each visit for care. 13 For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and
fissures; placed as soon as possible after eruption.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

7 Initially, responsibility of parent; as child matures, jointly with parent; then, when indicated, only child.
14 Periodontal probing should be added to the risk-assessment process after the eruption of the first permanent
8 At every appointment; initially discuss appropriate feeding practices, then the role of refined carbohydrates and frequency
molars.
of snacking in caries development and childhood obesity. Monitor body mass index beginning at age two.
9 At first, discuss the need for nonnutritive sucking: digits vs. pacifiers; then the need to wean from the habit before mal-

305
BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE/ COUNSELING AND TREATMENT

occlusion or deleterious effect on the dentofacial complex occurs. For school-aged children and adolescent patients,
counsel regarding any existing habits such as fingernail biting, clenching, or bruxism.