early infant oral health

Question 1

when does the AAPD and CAPD recommend that the child’s first visit should be?

Answer 1

within 6 months after the eruption of the first tooth or about 1 year of age.

Question 2

What’s the rational for this early visit time?

Answer 2

Health supervision, not disease treatment; (pediatric) dentists as early interventionists
 Old model: caries inevitable; treat effects of disease, then institute preventive (suppressive) care; OK to start at age 3 (when child is cooperative)
 New model: based on well baby clinic model; examine early; risk assessment; anticipatory guidance; true prevention
 Early identification/intervention are cost effective and lead to better outcomes
 Goepferd, S. J Dent Child 53:257-266, 1986.

 Acquisition of S.mutans prior to the eruption of deciduous teeth.
 43-77% is from maternal transmission.
 Horizontal transmission also possible.
 Early recognition of ECC – BBTD, Nursing Caries,
rampant caries
 Feeding management – bottle use and weaning, ad
libitum, through the night breast feeding, sippy cups and juice

Teething
 Non Nutritive Sucking Habits (NNSH)  Trauma prevention
 Identification of pathology

Question 3

what is meant by anticipatory guidance?

Answer 3

 Providing practical, developmentally- appropriate health information to parents
 Alerting parents to impending change; teaching them their role in maximizing child’s development potential, identifying their child’s special needs
 Providing developmentally paced intervention

Question 4

What are the ABC’s of infant oral health care?

Answer 4

 History
 Examination
 Risk Assessment
 Counselling – Anticipatory Guidance
 Cavity Process, OHI, Diet (BBTD)  NNSH
 Teething
 Trauma Prevention

Question 5

What is the caries risk assessment?

Answer 5

 A systematic evaluation of the presence and intensity of etiologic and contributory factors
 Assessment is designed to provide an estimation of disease susceptibility & aid in targeting preventive and treatment strategies

Question 6

what is caries risk assessment from history and examination using demographic data?

Answer 6

 From history and examination  Demographic data:
 Age (S.mutans transmitted orally from mother to infant)  Race/ethnicity
 SES
 Maternal education level
 Diet history >2 sweet drinks/day, >candy 1xweek

Question 7

What is caries risk assessment from history and examination using general health and medications?

Answer 7

From history and examination
 General health – patients at higher risk for caries or sequelae of caries
 Immuno suppression
 Developmental delay
 Neurologically impaired – salivary duct rerouting
 Cardiac
 Medications – alteration of salivary flow

Question 8

What is the caries risk assessment from history and examination using dental history?

Answer 8

 From history and examination  Dental History
 Mothers DMF
 BEST INDICATOR OF FUTURE CARIES
EXPERIENCE – presence of restored/active lesions in child

Question 9

what is the CRA from H and E using behavioural factors?

Answer 9

Behavioural factors
 Self efficacy and locus of control
 “you can lead a horse to water and sometimes you
can make them drink, some horses you can’t lead to
water”
 50% of parents presenting with children with BBTD
were very aware of the risk  Leggot, JDR Abstract

Question 10

what is the CRA from H and E using oral hygiene?

Answer 10

 From history and examination
 Oral hygiene – visible plaque on labial surfaces of maxillary primary incisor teeth in 19 month olds was positively correlated with caries development by age 3 (compared to use of night time nursing bottle)

Question 11

what is CRA from H and E using diet?

Answer 11

Diet: feeding factors
 Breast vs. Bottle, Sippy cups, frequency, night time use, what is in it
 Diet: solid foods, frequency

Question 12

what is CRA from H and E using fluoride exposure?

Answer 12

 Very difficult to quantify – 18% drink bottled water
 Community sources
 Naturally occurring fluoride provides suboptimal,
optimal and above optimal Fl levels, 30% of population has optimal Fl
 Dingle et al, Ca J Comm Dent 12:31-37, 1997
 Fluoride supplements
 Water filtering – reverse osmosis removes Fl, charcoal
filters OK
 Tooth paste use – ingestion

Question 13

what is CRA requiring the use of currently available technologies?

Answer 13

 Salivary S.mutans assays
 Study of 148 3-5 year old children
 In 2 years dmfs scores were 1 for low S. mutans levels,
1.7 for moderate and high MS levels
 S. mutans can be a predictor for caries in young
children
 Thibodeau, E. Caries Res 29:148-53, 1995
 Salivary buffering capacity
 Salivary flow rate

Question 14

How do you exam the infant and toddler?

Answer 14

on parents knee
 Comfort for infant, toddler
 Decrease separation anxiety  Parent participation
 Parental restraint if necessary

Question 15

for examination of the I and T, what is normal and variation of nomral?

Answer 15

Extraoral –
 Intraoral –
 Mucous membranes and gum pads  Bohn’s nodules, Epstein’s pearls
 Natal and neonatal teeth
 Eruption pattern and sequence
 Eruption haematoma

Question 16

for examination of the I and T what is the cavity process?

Answer 16

 Cavity process
 Explanation of cavities as an infection
 Factors we don’t control – shape of teeth
 Factors we control - # of bugs, fluoride
 Bugs and sugar
 Bugs don’t read labels – sugar is sugar
 It’s not the amount but the # of times in the day
 If conceptual understanding is there you can talk further remineralization/demineralization, saliva’s
role

Question 17

For OHI for the I, T, child and parent, what about infant and toddlers?

Answer 17

 Infants & Toddlers
 Start when the first tooth erupts
 Encourage use of brush, but may wipe teeth
initially with gauze or cloth to remove surface plaque and food debris
 This will not arouse the child who has fallen
asleep on the breast or the bottle
 As more teeth emerge encourage utilization of brush
Minimum twice daily, consistency
 Encourage play and imitation for development of habit
 HABITS DEVELOP EARLY
 Encourage independence
 Have family brush-ins
 Parental brushing of infants teeth minimum once a day, bedtime preferable, establish routine, times 2 minutes

Question 18

For OHI for the child?

Answer 18

 Developmental milestones used to assess teachability and dexterity
 Shoelaces, colouring between the lines
 Times 2-3 minutes
 Supervision and check by caregiver for a good job
 Flossing
 Spaced vs. non-spaced arches, dexterity, habit development
 Children can’t floss effectively till they can write their own names (not print)

Question 19

For bottle use and weaning, what are the recommendations?

Answer 19

 Convenience of feeding
 Bottle as a soother
 Bottle as a symbol of infancy
 Cultural “norms”
 What we preach is not what is practised!
 Feeding position to encourage bonding  Attempt clearance with water
 Never to bed with a bottle
 Caries is not the only risk – Choking/Aspiration
 Milk or water in the bottle, no juice (unsweetened or sweetened).Wean by 10- 12 months of age if developmentally normal

Question 20

What is the cautionary note for infant oral health care?

Answer 20

Cautionary note – Ad libitum night time breast feeding with child in bed and mother on side does lead to ECC.
 Choking risk
 Want to encourage proper feeding technique

Question 21

For breast feeding and nursing caries what about breast feeding to be where feasible encouraged?

Answer 21

 Nutritionally superior – iron better absorbed, superior ratio of Calcium phosphate, superior absorption, protein
 Immunological benefit – secretory IgA, IgG
 Psychological – bonding and nurturing benefit
 Physiological – encourages uterus involution  Lactobacillus – enhances normal gut flora
 Economic – cheap
 Safety – no sterilization

Question 22

IS human breast milk (HBM) associated with nursing caries?

Answer 22

 HBM does not cause a significant pH drop in plaque
 HBM supports moderate bacterial growth
 The buffer capacity of HBM is very poor
 HBM is not cariogenic in an in vitro model, unless another carbohydrate source is available for bacterial fermentation, then it is highly cariogenic
 Erickson, PR & Mazhari, E. Investigation of the role of
human breast milk in caries development, Ped Dent 21:86-90, 1999.

Question 23

What does prolonged breast-feeding do for caries?

Answer 23

 Dental caries and prolonged breast-feeding in 18 month old children
 Hallonsten, A.L., Int J Paed Dent 5:149-155, 1995.
 Found that prolonged breast feeding was a
risk factor for caries development because these children have a higher food intake than non-breast-fed children

Question 24

What about solids and snacks?

Answer 24

 Nutritionally and dentally acceptable snacks – read labels
 Moderation is the spice of life
 Timing and caries risk, cariogenecity
 Good – carrots, celery, cheese, meat sticks, fresh fruits,
popcorn
 Sugar free gum
 Not so good – fruit snacks, dried fruits, chips
 All kids get junk, make “junk” a special occasion as dessert or once a week at a special time

Question 25

What about in between meal drinks?

Answer 25

 Sip n play and apple juice
 Naturally acidic
 GI issues
 SIPPY CUPS-important when child allowed to
wander about with cup clenched between teeth
 Sit down to drink
 Purpose – hydration, filling up on milk and or juice provides false caloric intake, and poor appetite, iron deficient anaemia
 Water is the BEST
 Aspartame – as an alternative sweetened drinks
 Avoid in phenylketonuria – pin prick in heel at birth
 Allergies

 Aspartame
 Toxicity – Health Canada guidelines – 40 mg/kg daily average: 15 kg child = 600 mg = 11 cups of crystal lite!
 Sugar free Koolaid 56 mg/8 oz serving
 Diet pop 35 mg/kg/8 oz serving (beware of carbonic acid)

Question 26

What about teething?

Answer 26

•  Inform parents of signs and symptoms
   Biting > drooling > gum rubbing > irritability (disruption of eating and sleeping patterns) > sucking
   Low fevers may occur but High fever or serious illness is not associated with teeth
   If fever present rule out other sources of infection
•  Supportive and Symptomatic  Chilled teething ring or cloth
   Health Canada warning re: PVC teething rings & DINP
   Push fluids
   Acetaminophen product for pain/fever
•  Do not recommend topical teeth gels
   Benzocaine
   Meth-haemoglobinaemia ( not with lidocaine)
   Anaesthetize epiglottal region

Question 27

What is NNSH?

Answer 27

Non-nutritive sucking habits
 Sucking is an innate reflex necessary for survival
 NNSH can be noted in utero
 No intervention required until just prior to eruption of permanent teeth

Question 28

For NNSH what about ignoring, dental effects, occlusal development, and pacifier safety?

Answer 28

 Ignore
 Children seek reinforcement be it positive or negative
 50% stop on own by age 3
 Another 45% stop on own by 5 with peer group
pressure
 Only 5% continue past age of 5 – intervene if
dental affects
 Burlington studies, Popovitch.

 Dental Effects
 AOB (anterior open bite) – whether passive or active sucking
 Self correction if ceased before eruption of
permanent teeth
 Posterior crossbite – dependent on intensity and
duration of habit
 No correlation with Class II development
 Burlington studies, Popovitch.  Swedish studies, Larsen.

 With respect to occlusal development no difference between digit and pacifier habit
 Pacifiers linked with an increased risk for developing acute otitis media in children aged 2-3 years
 Niemela, M. Pediatrics 96:884, 1995.

 Pacifier Safety
 One piece construction, no separable parts, examine daily
 If child chewing (teething) use a teething ring
 Large oral shield, at least 2 vent holes
 Non-toxic material: latex, plastic, rubber,
change if discoloured
 Do not tie around child’s head or pin to child with a cord, remove when running and playing

Question 29

What about trauma prevention for children?

Answer 29

 Car seats
 Carry seats
 Child proofing your home
 Baby walkers
 Stairs
 Coffee tables
 Electrical cords
 What to do if child sustains an oral facial injury

Question 30

Upon completion of infant visit what should you have completed?

Answer 30

 Upon completion of infant visit:
 Anomalies noted and managed
 Oral health care prevention established
 Care plan for future established based on risk assessment
 Parents educated
 Should be able to prevent tooth decay in infant and establish life-long preventive habits

Question 31

Are these early visits effective?

Answer 31

 Dental visits every 6 months beginning before birth were helpful
 Data from before birth to 4 years of age show these visits reduced caries incidence and delayed S. mutans colonization
 Improvements in oral health of mothers
 Gunay, H et al, Effect of caries experience of a long-term preventive program for mothers and children starting during pregnancy. Clin Oral Investigation 2(3):137-142, 1998.