|Year : 2016 | Volume
| Issue : 3 | Page : 183-186
Infant oral health care: An invaluable clinical intervention
Kanika Singh Dhull1, MD Indira2, Rachita Singh Dhull3, Bhavya Sawhney4
1 Department of Pedodontics and Preventive Dentistry, Kalinga Institute of Dental Sciences, KIIT University, Bhubaneswar, Orissa, India
2 Department of Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, JSS University, Mysore, Karnataka, India
3 Department of Pediatric Nephrology, Detroit Medical Centre, Detroit, Michigan, USA, India
4 Private Consultant, Esthetica Dental Care, Gurgaon, India
|Date of Web Publication||7-Oct-2016|
Kanika Singh Dhull
Department of Pedodontics and Preventive Dentistry, Kalinga Institute of Dental Sciences, KIIT University, Bhubaneswar, Orissa
Source of Support: None, Conflict of Interest: None
Dental assessments and evaluations for children during their 1st year of life have been recommended by the American Academy of Pediatric Dentistry and the American Association of Pediatrics. Early dental intervention evaluates a child's risk status based on parental interviews and oral examinations. These early screenings present an opportunity to educate parents about the medical, dental, and cost benefits of preventive rather than restorative care and may be more effective in reducing early childhood caries than traditional infectious disease models. A comprehensive infant oral care program includes: (1) risk assessments at regularly scheduled dental visits, (2) preventive treatments such as fluoride varnishes or sealants, (3) parental education on the correct methods to clean the baby's mouth, and (4) establishment of dental home and use of anticipatory guidance. The present article highlights the important guidelines of infant oral health care.
Keywords: Anticipatory guidance, dental home, early childhood caries, infant oral health, teething
|How to cite this article:|
Dhull KS, Indira M D, Dhull RS, Sawhney B. Infant oral health care: An invaluable clinical intervention. Indian J Dent Sci 2016;8:183-6
|How to cite this URL:|
Dhull KS, Indira M D, Dhull RS, Sawhney B. Infant oral health care: An invaluable clinical intervention. Indian J Dent Sci [serial online] 2016 [cited 2019 May 19];8:183-6. Available from: http://www.ijds.in/text.asp?2016/8/3/183/191736
| Introduction|| |
The Centers for Disease Control and Prevention reports that caries is the most prevalent infectious disease and more than 40% of children have caries by the time they reach kindergarten. Dental caries is five times more common than asthma and seven times more common than hay fever in children. Early childhood caries (ECC) and the more severe form of ECC can be particularly virulent forms of caries, beginning soon after tooth eruption, developing on smooth surfaces, progressing rapidly, and having a lasting detrimental impact on the dentition.
Caries in primary teeth can affect children's growth, result in significant pain and potentially life-threatening infection, and diminish overall quality of life.,, Since medical health-care professionals are far more likely to see new mothers and infants than are dentists, it is essential that they be aware of the infectious etiology and associated risk factors of ECC, make appropriate decisions regarding timely and effective intervention, and facilitate the establishment of the dental home.,
A historical perspective on oral health care for infants shows that there is a need to move away from the surgical approach of managing oral disease and embrace the concept of primary care right from perinatal period. In 1986, the American Academy of Pediatric Dentistry (AAPD) adopted the first infant oral health-care policy statement approach. It has been 25 years since the inception of this policy. This paper collectively reviews the guidelines adopted for infant oral health and the role of the nondental health-care professional in achieving the goals of infant oral health.
| American Academy of Pediatric Dentistry Recommendations for Infant Oral Health|| |
Oral health risk assessment
Oral health risk assessment should be received by an infant by 6 months of age by primary health-care provider or by a qualified health-care provider. Such an assessment should provide education on infant oral health, evaluate and optimize fluoride exposure, and assess the patient's risk of developing oral diseases of soft and hard tissues.
Risk assessment procedures used in medical practice normally have sufficient data to accurately quantify a person's disease susceptibility and allow for preventive measures. Even though caries-risk data in dentistry still are not sufficient to quantify caries, the risk assessment is component enough in the making accurate clinical decision. Risk assessment fosters the treatment of the disease process instead of treating the outcome of the disease; gives an understanding of the disease factors for a specific patient and aids in individualizing preventive discussions; individualizes, selects, and determines frequency of preventive and restorative treatment for a patient; and anticipates caries progression or stabilization.
An infant oral health visit and establishment of a dental home by age 1 year offer the best opportunity to provide risk-based primary prevention and promote sound oral health practices. An assessment of caries risk during infancy and periodically thereafter allows for early identification and understanding of a child's current and changing risk factors for ECC. Caries-risk assessment (CRA) allows for a customized preventive plan to be developed that is appropriate for the child and family.
Based on the distribution of risk factors and protective factors, the health-care provider can make a determination of a child's caries risk, explain the caries process and the causative factors to the parent, and develop in collaboration with the parent self-management goals to prevent or manage their child's caries risk.
Establishment of dental home
The American Dental Association, AAPD, and AAP  recommend that all children have their first preventive dental visit and establishment of a dental home by age 1 year. Nowak described the term “dental home.” A dental home is defined as an ongoing, comprehensive relationship between the dentist and the patient (and parents), inclusive of all aspects of oral health delivered in a continuously accessible, coordinated, and family-centered way.
The concept of dental home is derived from the AAP “Medical Home.” The essential concepts of medical home state that the medical care for children of all the ages is best managed when there is an established relationship between the practitioner who is familiar with the child and the child's family. The medical home is the place where the child receives the preventive instructions, immunizations, counseling, and anticipatory guidance.
Parents should establish a dental home for infants by 12 months of age. The initial visit should include thorough medical (infant) and dental (parent and infant) histories, a thorough oral examination, performance of an age appropriate toothbrushing demonstration, and prophylaxis and fluoride varnish treatment if indicated. In addition, CRA for infant and determining a prevention plan and interval for periodic reevaluation should be done. Infants should be referred to the appropriate health professional, if specialized intervention is necessary. Providing anticipatory guidance regarding dental and oral development, fluoride status, nonnutritive sucking habits, teething, injury prevention, oral hygiene instruction, and the effects of diet on the dentition is also important components of the initial visit.
The appearance of the first tooth is most eagerly awaited, significant developmental landmarks by most parents. Teething Latin term “Dentitio difficili” was coined, literally meaning difficult dentition.
Signs and symptoms of teething
Teething can lead to intermittent localized discomfort in the area of erupting primary teeth, inflammation of the mucous membrane overlying the tooth, pain, general irritability/malaise, disturbed sleep, facial flushing/circumoral rash, drooling/sialorrhea, gum rubbing/biting/sucking, bowel upset (ranging from constipation to loose stools and diarrhea), loss of appetite/alteration in volume of fluid intake, and ear rubbing on the same side as the erupting tooth; however, many children have no apparent difficulties.
Various treatments are advocated for the relief of the discomfort or pain associated with teething. Many of these have their origins in methods used for centuries. The management of teething  includes:
- Teething rings (chilled)
- Hard sugar-free teething rusks/bread-sticks/oven-hardened bread
- Cucumber peeled
- Pacifier (even frozen)
- Frozen items (anything from ice cubes to frozen bagels, frozen banana, sliced fruits, vegetables)
- Rub gums with clean finger, cool spoon, wet gauze
- Topical anesthetics.
Oral hygiene measures should be implemented no later than the time of eruption of the first primary tooth. Cleansing the infant's teeth as soon as they erupt with a soft toothbrush will help reduce bacterial colonization. Toothbrushing should be performed for children by a parent twice daily, using a soft toothbrush of age-appropriate size.
Diet counseling during infant oral health visit
AAPDs preventive pediatric dental care recommendation suggests that at the initial examination and at every recall appointment, pediatric dentist should discuss the role of refined carbohydrates and the impact of snacking frequency. Based on the accepted guideline following recommendations regarding diet counseling can be made:
- Infants should be exclusively breastfed during first 6 months of life followed by addition of iron-enriched solid food between 6 and 12 months of age. However, ad libitum nocturnal breastfeeding should be discouraged after the first primary tooth erupts. Infant formulas are acidogenic and possess cariogenic potential 
- Parents should be counseled about no to put their children to sleep with the bottle. They should also be made aware of the deleterious effects of inappropriate bottle usage and the need for good oral hygiene practice upon the first primary teeth eruption 
- Breastfeeding for over 1 year and at night beyond eruption of teeth may be associated with ECC. Hence, AAPD suggests that children should be weaned from breast or bottle by 12–14 months of age and should drink from cup as they approach their first birthday 
- Infants older than 6 months and with exposure to <0.3 ppm fluoride in their drinking water need dietary fluoride supplement of 0.25 mg fluoride per day. For infants under the 6 months of age, irrespective of fluoride exposure in water dietary supplements should not be prescribed 
- Parents should be counseled to reduce their child sugar consumption frequency. AAP suggests that infants should consume only 4–6 oz of fruit juice per day. Mashed/pureed whole fruit consumption should be encouraged rather than fruit juice. They should not be given powdered beverages or soda pop as these drinks pose increased risk for dental caries. Only iron-fortified infant cereals along with breast milk or infant formula should be given to infants who are older than 6 months of age. Cow's milk should be completely avoided in the 1st year of life and restricted to 24 oz per day in the 2nd year of life 
- Parents should also be counseled on the potential of various foods that constitute choking hazard to infants. Infants should be given food only when they are seated and are supervised by an adult.
Optimal exposure to fluoride is important to all dentate infants and children. Decisions concerning the administration of fluoride are based on the unique needs of each patient. The use of fluoride for the prevention and control of caries is documented to be both safe and effective. When determining the risk-benefit of fluoride, the key issue is mild fluorosis versus preventing devastating dental disease. In children with moderate or high caries risk under the age of 2, a “smear” of fluoridated toothpaste should be used. In all children aged 2–5 years, a “pea-size” amount should be used. Professionally applied topical fluoride, such as fluoride varnish, should be considered for children at risk for caries.
Systemically-administered fluoride should be considered for all children at caries risk who drink fluoride deficient water (<0.6 ppm) after determining all other dietary sources of fluoride exposure. Careful monitoring of fluoride is indicated in the use of fluoride-containing products. Fluorosis has been associated with cumulative fluoride intake during enamel development.
Practitioners should provide age-appropriate injury prevention counseling for orofacial trauma. Initially, discussions would include play objects, pacifiers, car seats, and electric cords.
The use of properly fitted mouth guards in other organized sporting activities that carry the risk of orofacial injury should be mandatory. The coaches/administrators of organized sports should consult a dentist with expertise in orofacial injuries before initiating practices for a sporting season, for recommendations for immediate management of sports-related injuries (e.g, avulsed teeth). The dentists should prescribe, fabricate, or provide referral for mouth guard protection for patients at increased risk for orofacial trauma. Pediatric dentists should partner with other dentists and child health professionals, school administrators, legislators, and community sports organizations to promote the broader use of mouth guards.
Nonnutritive oral habits (e.g, digit or pacifier sucking, bruxism, and abnormal tongue thrust) may apply forces to teeth and dentoalveolar structures. It is important to discuss the need for early sucking and the need to wean infants from these habits before malocclusion or skeletal dysplasias occur.
| Recommendations for Pediatricians in Preventive Oral Health|| |
American Academy of Pediatric offers several recommendations on expanding the role of pediatricians in preventive oral health
- Pediatricians will require adequate training in oral health in medical school, residency, and in continuing education courses. AAP recommends adding a module on oral health and dental care to the undergraduate medical school, physical examination skills courses, and an oral health rotation to pediatric residency curriculums. Having dental professionals provide such instruction would enhance acquisition of hands-on skills and could encourage future professional collaboration and cross-referrals 
- Pediatricians will require current information and guidelines on preventive dental care. With the exception of bright futures: guidelines for health supervision of infants, children, and adolescents, very little is available to guide pediatricians in the promotion of oral health in their practices 
- Pediatricians must be ensured that all of their patients, Medicaid and uninsured included, can receive timely preventive and restorative dental care. Pediatricians can expand their involvement in oral health prevention, but they can never replace the care that dental professionals provide. Further dialog with our dental colleagues and joint advocacy efforts by the AAP and AAPD are needed to address the serious problem of disparities in access to dental care 
- Pediatricians will require sufficient resources to successfully assume greater involvement in oral health-related activities. Time pressures and inadequate staffing will make it difficult for pediatricians to devote the attention to oral health that all children deserve.
| Conclusion|| |
As our society for pediatric dentistry strives to achieve the goal that “every child has a fundamental right to his or her total oral health,”; it is the responsibility of the health-care professional involved with children to provide comprehensive care for the child. Preventive dental assessment and treatment program can be incorporated into the well-baby visits provided by pediatricians. By examining the infant for oral problems and by providing early preventive counseling, it is possible to prevent many forms of dental disease and thus promote the total health of child patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
U.S. Department of Human and Health Services. Oral health in America: Report of Surgeon General. NIH Publication No. 00-4713. Bethesda. National Institute of Dental and Craniofacial Research, National Institute of Health; 2000.
Nowak AJ, Warren JJ. Infant oral health and oral habits. Pediatr Clin North Am 2000;47:1043-66, vi.
Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatr Dent 1992;14:302-5.
Ayhan H, Suskan E, Yildirim S. The effect of nursing or rampant caries on height, body weight and head circumference. J Clin Pediatr Dent 1996;20:209-12.
Low W, Tan S, Schwartz S. The effect of severe caries on the quality of life in young children. Pediatr Dent 1999;21:325-6.
American Academy of Pediatrics, Section on Pediatric Dentistry and Oral Health. A policy statement: Preventive intervention for pediatricians. Pediatrics 2008;122:1387-94.
American Academy of Pediatrics. Policy on oral health risk assessment timing and establishment of the dental home. Pediatrics 2003;111 (5 Pt 1):1113-6.
Nowak AJ, Quiñonez RB. Visionaries or dreamers? The story of infant oral health. Pediatr Dent 2011;33:144-52.
American Academy of Pediatric Dentistry. Guideline on infant oral health care. Pediatr Dent 2013;34:132-6.
Lauer MS, Fontanarosa PB. Updated guidelines for cholesterol management. JAMA 2001;285:2508-9.
Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicators of risk in caries management. J Dent Educ 2001;65:1126-32.
American Academy of Pediatric Dentistry. Guideline on assessment and management for infants, children, and adolescents. Pediatr Dent 2013;34:118-25.
American Dental Association. Statement on Early Childhood Caries. Available from: http://www.ada.org/2057.aspx
. [Last accessed on 2013 Apr 12].
American Academy of Pediatric Dentistry. Guideline on infant oral health care. Pediatr Dent 2011;33:124-8.
Section on Pediatric Dentistry and Oral Health. Preventive oral health intervention for pediatricians. Pediatrics 2008;122:1387-94.
American Academy of Pediatric Dentistry. Definition of dental home. Pediatr Dent 2011;33:12.
Ashley MP. It's only teething. A report of the myths and modern approaches to teething. Br Dent J 2001;191:4-8.
American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies. Pediatr Dent 2011;33:47-9.
American Academy of Pediatric Dentistry. Recommendations for preventive pediatric dental care. Pediatr Dent 2002;24:53.
American Academy of Pediatric. Breast feeding and use of human milk. Pediatrics 1997;100:1035-9.
American Academy of Pediatric Dentistry. Policy on baby bottle tooth decay (BBTD)/early childhood caries (ECC). Pediatr Dent 2002;24:23.
Bowen WH, Pearson SK, Rosalen PL, Miguel JC, Shih AY. Assessing the cariogenic potential of some infant formulas, milk and sugar solutions. J Am Dent Assoc 1997;128:865-71.
Valaitis R, Hesch R, Passarelli C, Sheehan D, Sinton J. A systematic review of the relationship between breastfeeding and early childhood caries. Can J Public Health 2000;91:411-7.
American Academy of Pediatric Dentistry. Guideline on Fluoride therapy Guideline on fluoride therapy. Pediatr Dent 2012;34:162-5.
Committee on Nutrition. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics 2001;107:1210-3.
Kazal LA Jr. Prevention of iron deficiency in infants and toddlers. Am Fam Physician 2002;66:1217-24.
Milgrom PM, Huebner CE, Ly KA. Fluoridated toothpaste and the prevention of early childhood caries: A failure to meet the needs of our young. J Am Dent Assoc 2009;140:628, 630-1.
American Academy of Pediatric Dentistry. Policy on prevention of sports-related orofacial injuries. Pediatr Dent 2015;37:71-5.
American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatr Dent 2010;32:93-100.
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.