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Organizational Principles to Guide and Define the Child

Health Care System and/or Improve the Health of all Children

POLICY STATEMENT

Maintaining and Improving the Oral Health of Young


Children

abstract SECTION ON ORAL HEALTH


KEY WORDS
Oral health is an integral part of the overall health of children. Dental dental, fluoride, oral health, pediatrician, teeth

caries is a common and chronic disease process with significant short- ABBREVIATION
AAP—American Academy of Pediatrics
and long-term consequences. The prevalence of dental caries for the
youngest of children has not decreased over the past decade, despite This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors
improvements for older children. As health care professionals respon-
have filed conflict of interest statements with the American
sible for the overall health of children, pediatricians frequently con- Academy of Pediatrics. Any conflicts have been resolved through
front morbidity associated with dental caries. Because the youngest a process approved by the Board of Directors. The American
children visit the pediatrician more often than they visit the dentist, Academy of Pediatrics has neither solicited nor accepted any
commercial involvement in the development of the content of
it is important that pediatricians be knowledgeable about the disease this publication.
process of dental caries, prevention of the disease, and interventions Policy statements from the American Academy of Pediatrics
available to the pediatrician and the family to maintain and restore benefit from expertise and resources of liaisons and internal
health. Pediatrics 2014;134:1224–1229 (AAP) and external reviewers. However, clinical reports from the
American Academy of Pediatrics may not reflect the views of the
liaisons or the organizations or government agencies that they
represent.
INTRODUCTION The guidance in this statement does not indicate an exclusive
course of treatment or serve as a standard of medical care.
Dental caries is the most common chronic disease of childhood. Variations, taking into account individual circumstances, may be
Twenty-four percent of US children 2 to 4 years of age, 53% of children 6 appropriate.
to 8 years of age, and 56% of 15-year-olds have caries experience (ie, All policy statements from the American Academy of Pediatrics
untreated dental caries, filled teeth, teeth missing as a result of dental automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
caries).1 For children 5 to 19 years of age, children from poor and
racial or ethnic minority families have higher rates of untreated
dental caries than do their peers from nonpoor and nonminority
families.2 For some age groups, the incidence of dental caries has
decreased or stayed the same, but for the youngest children, it has
increased.3 Among 6- to 8-year-olds and 15-year-olds, caries experi-
ence and untreated dental decay remained mostly unchanged be-
tween 1988–1994 and 1999–2004.1 In children 2 to 4 years of age, the
caries experience increased significantly, from 19% to 24%, during
that same time period. The increase in the caries experience and
untreated caries was statistically significant in children from poor www.pediatrics.org/cgi/doi/10.1542/peds.2014-2984

families. doi:10.1542/peds.2014-2984
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
THE ETIOLOGY AND PATHOGENESIS OF DENTAL CARIES Copyright © 2014 by the American Academy of Pediatrics

A dynamic process takes place at the surface of the tooth that involves
constant demineralization and remineralization of the tooth enamel
(the caries balance).4,5 Multiple factors affect that dynamic process
and can be manipulated in ways that tip the balance toward disease
(demineralization) or health (remineralization). These factors include
bacteria, sugar, saliva, and fluoride. Because these factors can be

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FROM THE AMERICAN ACADEMY OF PEDIATRICS

manipulated, it is possible for pedia- and remineralization is fluoride. More remains in the mouth for long periods
tricians and families to prevent, halt, in-depth reviews of fluoride are available of time.13 Thus, key behaviors that place
or even reverse the disease process. elsewhere.8–10 It is important, however, a child at high risk of caries include
Different oral structures and tissues for pediatricians and other child health continual bottle/sippy cup use (especially
have different and distinct microbial care providers to understand how with fluids other than water), sleeping
communities (microbiomes).6 The oral fluoride influences the caries balance. with a bottle (especially with fluids
microbiome at the surface of the Fluoride has 3 key effects on the caries other than water), frequent between-
tooth is referred to as dental plaque. balance: (1) inhibition of demineralization meal snacks of sugars/cooked starch/
During the disease process of dental at the tooth surface; (2) enhancement of sugared beverages, and frequent intake
caries, bacteria that are aciduric and remineralization, which results in a more of sugared medications.
acidogenic predominate in the dental acid-resistant tooth surface; and (3) in- Early acquisition of S mutans is a
plaque. Streptococcus mutans is most hibition of bacterial enzymes.11 The pri- major risk factor for early childhood
strongly associated with dental car- mary effect of fluoride is topical, via caries and future caries experience.14
ies, although other bacterial species fluoridated toothpastes, mouth rinses, Strong evidence demonstrates that moth-
have these capabilities and thus can and varnishes, although there is still ers are a primary source of S mutans
also be pathogenic. When environmen- value in systemic fluoride exposures via colonization for their children.15 Thus, an
tal factors make it possible to select for fluoridated water and supplements.9,11 important factor associated with car-
these pathogenic bacteria in dental ies risk in young children is the recent
plaque, the disease process begins. PREVENTIVE STRATEGIES
or current presence of active dental
A key environmental factor that allows Caries Risk Assessment decay in the primary caregiver. Pre-
for selection and proliferation of these Ideally, primary prevention efforts will vention, diagnosis, and treatment of
pathogenic bacteria is dietary sugar anticipate and prevent caries before oral diseases are highly beneficial, can
intake. Because these pathogenic bac- the first sign of disease. Preventive be undertaken, and should be en-
teria have the ability to ferment sugars, strategies for this multifactorial, chronic couraged during pregnancy with no
produce acid, and decrease the pH of disease require a comprehensive and additional fetal or maternal risk com-
the dental plaque, they make possible multifocal approach that begins with pared with the risk of not providing
the selection of other aciduric, acidogenic caries risk assessment. Assessing each care.16 The most important and pre-
bacteria that will contribute to disease. child’s risk of caries and tailoring pre- dictive risk factor for caries, however,
As more bacteria produce more acid, the ventive strategies to specific risk fac- is previous caries experience. This finding
pH at the surface of the tooth decreases. tors are necessary for maintaining and is not surprising, considering that the
This process causes the demineralization improving oral health. There is no sin- factors which initiated the disease pro-
of the tooth enamel. Unimpeded, these gle test that takes into consideration all cess often continue to exist over time.
long periods of low pH and deminer- risk factors and accurately predicts an Other caries risk factors are associated
alization will result in cavitation. individual’s susceptibility to caries. How- with salivary flow and the status of the
Saliva is an important factor in buff- ever, pediatricians can conduct an ex- teeth. Diseases (eg, diabetes mellitus,
ering the low pH and bringing these cellent risk assessment for caries by Sjögren’s syndrome, cystic fibrosis)
demineralization pressures back to focusing on the key risk factors for and medications (eg, antihistamines,
a balance with remineralization. In ad- dental caries that are associated with anticonvulsants, antidepressants) that
dition to acting as a buffering agent, diet, bacteria, saliva, and status of the result in xerostomia (decreased sali-
saliva also flushes the oral cavity of teeth (both current status and previous vary flow) reduce the availability of
food particles and provides an envi- caries experience). The American Acad- saliva to buffer the acid produced by
ronment rich in calcium and phosphate emy of Pediatrics (AAP)/Bright Futures pathogenic bacteria, thus enhancing
to aid in remineralization. When sali- Oral Health Risk Assessment Tool can be their ability to cause damage to the
vary flow is impeded, the pH is able to found at http://www2.aap.org/oralhealth/ teeth. In addition, the teeth of preterm
decrease to a lower level, tipping the RiskAssessmentTool.html.12 infants, which frequently have enamel
scales toward demineralization (dis- Sugars (but not sugar substitutes) defects, are at increased susceptibility
ease); in addition, the time it takes to are a critical risk factor in the de- for disease. Older children who have
buffer back to a normal pH is longer.7 velopment of caries. The risk of caries deep pits and fissures in their molars
Another important factor that can af- is greatest if sugars are consumed at are also at increased susceptibility for
fect the balance of demineralization high frequency and are in a form that disease.

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Anticipatory Guidance  Foster eating patterns that are cost-effective means of preventing den-
With a clear understanding of the eti- consistent with guidelines from the tal caries, with the lifetime cost per
ology of dental caries and the risk fac- US Department of Agriculture. person equaling less than the cost of
tors that lead to and facilitate the spread 1 dental restoration.20,21 Most bottled
of this disease, pediatricians can target Oral Hygiene waters do not contain an adequate
anticipatory guidance to assist families The value of good oral hygiene lies in amount of fluoride.
in preventing it. Because the disease of controlling the levels and activity of Fluoride toothpaste is an important way
dental caries is multifocal, the antici- disease-causing bacteria in the oral to deliver fluoride to the surface of the
patory guidance should also be multi- cavity and delivering fluoride to the tooth. Fluoride toothpaste has been
focal. Pediatricians should concentrate surface of the tooth. It is important shown to be effective in reducing dental
their anticipatory guidance on topics to remember that pathogenic bacteria caries in both primary and permanent
that can affect the risk of disease. can be passed from caregiver to child.18 teeth.22,23 It is important to limit the
Thus, anticipatory guidance for both amount of toothpaste used to a smear
Dietary Counseling parent and child is important. Key an- or a grain-of-rice–sized amount for young
Because sugar intake is such an im- ticipatory guidance points regarding children and no more than a pea-sized
portant risk factor for dental caries, oral hygiene are as follows: amount for children older than 3 years.24
pediatricians can incorporate antici-  Parents/caregivers should be en- Fluoride supplements should be pre-
patory guidance associated with pre- couraged to model and maintain scribed for children whose primary
venting dental caries into discussions good oral hygiene and a relationship source of drinking water is deficient
with families about dietary habits and with their own dental provider. in fluoride.25
nutritional intake. Pediatricians should
counsel parents and caregivers on the
 Parents/caregivers, especially those Fluoride varnish is a professionally
with significant history of dental de- applied, sticky resin of highly concen-
importance of reducing the frequency
cay, should be cautioned to avoid trated fluoride. Two or more applica-
of exposure to sugars in foods and tions of fluoride varnish per year are
sharing with their child items that
drinks. To decrease the risk of dental effective in preventing caries in chil-
have been in their own mouths.
caries and ensure the best possible dren at high risk of all ages.8 In most
health and developmental outcomes,  The child’s teeth should be brushed states, pediatricians can apply and be
pediatricians should recommend that twice a day as soon as the teeth
paid for application of fluoride varnish
parents do the following: erupt with a smear or a grain-of-
to the teeth of young children. Appli-
rice–sized amount of fluoridated
 Exclusively breastfeed infants for cation of fluoride varnish is even more
6 months and continue breastfeeding toothpaste. After the third birthday,
effective when coupled with counsel-
as complementary foods are intro- a pea-sized amount should be used.
ing.26 The US Preventive Services Task
duced for 1 year or longer, as mutu-  Parents/caregivers should help/ Force recently published a new rec-
ally desired by mother and infant.17 supervise a child brushing his or her ommendation that primary care clini-
 Discourage putting a child to bed teeth until mastery is obtained, usu- cians apply fluoride varnish to the
with a bottle. Establish a bedtime ally at around 8 years of age. primary teeth of all infants and chil-
routine conducive to optimal oral dren starting at the age of primary
health (eg, brush, book, and bed). Fluoride tooth eruption (B recommendation).25
 Wean from a bottle by 1 year of age. The delivery of fluoride to the teeth More details and recommendations on
includes community-based options (water fluoride can be found in the AAP clinical
 Limit sugary foods and drinks to fluoridation), self-administered modalities report “Fluoride Use in Caries Pre-
mealtimes.
(fluoride toothpaste and supplements), vention in the Primary Care Setting.”10
 Avoid carbonated, sugared bever- and professional applications (fluoride
ages and juice drinks that are varnish). Each of these delivery mecha- Other Important Anticipatory
not 100% juice. nisms is useful in preventing dental caries. Guidance Topics
 Limit the intake of 100% fruit juice Water fluoridation is a community-based A frequent topic of discussion with
to no more than 4 to 6 oz per day. intervention that optimizes the level of parents is nonnutritive oral habits,
 Encourage children to drink only fluoride in drinking water, resulting in such as use of pacifiers and thumb
water between meals, preferably preeruptive and posteruptive protection sucking. AAP policy states that parents
fluoridated tap water. of the teeth.19 Water fluoridation is a consider offering a pacifier at naptime

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FROM THE AMERICAN ACADEMY OF PEDIATRICS

and bedtime because of a protective though 1 study found that children 2 SUGGESTIONS FOR PEDIATRICIANS
effect of pacifiers on the incidence of to 5 years of age who received a rec-
1. Administer an oral health risk as-
sudden infant death syndrome after ommendation from their health care
sessment periodically to all children.
the first month of life.27 Both finger- and provider to visit the dentist were more
pacifier-sucking habits will only cause likely to have a dental visit,33 the US 2. Include anticipatory guidance for oral
problems with dental structures if they Preventive Services Task Force found health as an integral part of compre-
go on for a long period of time. Evalu- no study that evaluated the effects of hensive patient counseling.
ation by a dentist is indicated for non- referral by a primary care clinician to 3. Counsel parents/caregivers and
nutritive sucking habits that continue a dentist on caries incidence.34 It is patients to reduce the frequency
beyond 3 years of age.28 also noteworthy that preschool-aged of exposure to sugars in foods and
Dental injuries are common. Twenty- children covered by Medicaid who had drinks.
five percent of all schoolchildren ex- an early preventive dental visit by 1 4. Encourage parents/caregivers to
perience some form of dental trauma.29 year of age were more likely to use brush a child’s teeth as soon as
Pediatricians can help prevent such subsequent preventive services and to teeth erupt with a smear or a
trauma by encouraging parents to cover have lower dental expenses.35 grain-of-rice–sized amount of fluo-
sharp corners of household furnishings With early referral to a dental provider, ride toothpaste and a pea-sized
at the level of walking toddlers, rec- there is an opportunity to maintain amount at 3 years of age.
ommend use of car safety seats, and be good oral health, prevent disease, and 5. Advise parents/caregivers to moni-
aware of electrical cord risk for mouth treat disease early. Establishing such tor brushing until 8 years of age.
injury. Pediatricians can also encourage collaborative relationships between 6. Refer to the AAP clinical report,
mouthguard use during sports activi- physicians and dentists at the com- “Fluoride Use in Caries Prevention
ties in which there is a significant risk munity level is essential for increasing in the Primary Care Setting,” for
of orofacial injury.30 More information access to dental care for all children fluoride administration and supple-
on dental trauma is available in the and improving their oral and overall mentation decisions.
AAP clinical report “Management of health.
7. Build and maintain collaborative
Dental Trauma in a Primary Care
relationships with local dentists.
Setting.”31 CONCLUSIONS
8. Recommend that every child has
Oral health is an integral part of the a dental home by 1 year of age.
COLLABORATION WITH DENTAL
overall health and well-being of chil-
PROVIDERS
dren.36 A pediatrician who is familiar LEAD AUTHOR
The AAP, the American Academy of Pe- with the science of dental caries, capable David M. Krol, MD, MPH, FAAP
diatric Dentistry, the American Dental of assessing caries risk, comfortable with
Association, and the American Asso- applying various strategies of prevention SECTION ON ORAL HEALTH EXECUTIVE
ciation of Public Health Dentistry all COMMITTEE, 2012–2013
and intervention, and connected to dental Adriana Segura, DDS, MS, FAAP, Chairperson
recommend a dental visit for children resources can contribute considerably Suzanne Boulter, MD, FAAP
by 1 year of age. Although pediatricians to the health of his or her patients. Melinda Clark, MD, FAAP
have the opportunity to provide early This policy statement, in conjunction Rani Gereige, MD, FAAP
assessment of risk for dental caries David M. Krol, MD, MPH, FAAP
with the oral health recommendations Wendy Mouradian, MD, FAAP
and anticipatory guidance to prevent of the third edition of the AAP’s Bright Rocio Quinonez, DMD, MPH, FAAP
disease, it is also important that chil- Futures: Guidelines for Health Supervi- Francisco Ramos-Gomez, DDS, FAAP
dren establish a dental home. A dental sion of Infants, Children, and Adolescents, Rebecca Slayton, DDS, PhD, FAAP
home is the ongoing relationship be- Martha Ann Keels, DDS, PhD, FAAP, Immediate
serves as a resource for pediatricians Past Chairperson
tween the dentist and the patient, in- and other pediatric primary care pro-
clusive of all aspects of oral health care viders to be knowledgeable about LIAISONS
delivered in a comprehensive, contin- addressing dental caries.37 Because den- Joseph Castellano, DDS – American Academy of
uously accessible, coordinated, and tal caries is such a common and conse- Pediatric Dentistry
family-centered way.32 Sheila Strock, DMD, MPH – American Dental
quential disease process in the pediatric Association Liaison
Unfortunately, little is known about population, it is essential that pedia-
pediatric health care providers’ dental tricians include oral health in their daily STAFF
referral behaviors and patterns. Al- practice of pediatrics. Lauren Barone, MPH

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Maintaining and Improving the Oral Health of Young Children
SECTION ON ORAL HEALTH
Pediatrics 2014;134;1224
DOI: 10.1542/peds.2014-2984 originally published online November 24, 2014;

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Maintaining and Improving the Oral Health of Young Children
SECTION ON ORAL HEALTH
Pediatrics 2014;134;1224
DOI: 10.1542/peds.2014-2984 originally published online November 24, 2014;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/134/6/1224

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