1. Infant Oral Health Care
Preventing Early Childhood Caries

2. Growth & Development of the Teeth
At birth the primary (baby) teeth have already formed
Permanent teeth are developing or beginning to mineralize (harden)
Most of the baby teeth have already formed by the time a child is born. The front teeth are nearly finished hardening and the roots are starting to develop.
The tooth buds for the permanent teeth are already starting to form at birth.
Courtesy WI Dept. of Health and Family Services

3. Eruption Patterns Courtesy WI Dept. of Health and Family Services
Lower teeth generally come in before the upper teeth that are in their matching position in the opposite jaw.
Matching teeth on either side of the mouth usually erupt at the same time.
The order of eruption is more important than the timing, with the front teeth coming in first, then the others behind them.
Most children have at least 2 teeth by one year of age, but premature infants and children with special health care needs may have a delayed eruption pattern.
Delayed eruption of teeth can sometimes be a sign of other problems, so your dentist will check for this at your child’s first visit.
A baby’s first dental visit should by within 6 months of the eruption of the first tooth or by 1 year of age, whichever comes first.
Courtesy WI Dept. of Health and Family Services

4. Primary teeth (baby teeth) are important for…
Who Wants a $1,000,000 $mile?
Primary teeth (baby teeth)
are important for…
A. Talking and eating
B. Saving room for permanent teeth
C. They aren’t important!
D. Both A and B
This game is a good way to get the group involved in your presentation.
Divide the group into two teams. Each team is to come up with an answer for each question presented. Keep score of the correct answers for each team.
The correct answer here is D. In addition to ensuring proper nutrition, baby teeth are important for learning to speak and help guide the permanent teeth into their correct position.

5. Importance of Primary (Baby) Teeth
Smiling & self-esteem
Chewing and eating
Speech development
Aid proper jaw and face formation
Guide permanent teeth into place
A nice smile helps build a child’s self-esteem and social connectivity, but a child’s teeth and mouth are important for other reasons. Healthy baby teeth are important for chewing and eating, so your child can get the nutrition that he or she needs to grow.
Teeth are also important for learning to speak properly. In addition, baby teeth guide the development of the jaws and help the permanent teeth come in into their proper position.

6. Early Childhood Caries or ECC (Tooth Decay)
1 or more decayed teeth
Child under age 6
Previously known as:
Baby bottle tooth decay
Bottle mouth
Nursing decay
Sippy cup decay
Any tooth decay in children under the age of 6 is now called Early Childhood Caries (ECC for short).
In the past, tooth decay in infants and toddlers was referred to as baby bottle tooth decay, nursing decay, or bottle mouth. This was because it is usually seen in children who continuously suck on a bottle, especially at night.
Courtesy Diann Bomkamp, RDH, BSDH, Missouri

7. ECC Courtesy Proctor & Gamble
Decay often appears as one or two small cavities on some surface of one or two teeth
It usually starts on the upper front teeth, since these are in contact with the formula or milk while the infant is suckling.
Courtesy Proctor & Gamble

8. Severe ECC Courtesy Proctor & Gamble
As the disease gets worse, more teeth become affected, usually the back teeth. The lower front teeth are usually spared, because they are covered by the tongue during suckling.
Courtesy Proctor & Gamble

9. “Early Childhood Caries” is… A. A cavity
Who Wants a $1,000,000 $mile?
“Early Childhood Caries” is…
A. A cavity
B. Caused by drinks with sugar
C. Is only caused by a bottle
D. Both A and B
The correct answer here is D. Early Childhood Caries or ECC is one or more “cavities” in the teeth, and can be caused by beverages that contain sugar, either refined or natural. It is caused by what kind of drink is in the bottle, not the bottle itself.

10. Results of ECC Pain and infection Difficulty eating and sleeping
Affects nutrition and growth
Infants and toddlers who develop early childhood caries (ECC) often experience pain and discomfort that results in disturbed eating and sleeping patterns. The resulting inadequate food intake and poor sleep can cause nutritional deficiency and impair growth and development. Infants and toddlers with ECC are more likely to be below 80 percent of ideal body weight than caries-free children the same age.
The longer ECC-afflicted children go without care, the more likely they are to exhibit decelerated (slowed) growth. Fortunately, the children examined in studies were also likely to exhibit some acceleration in weight velocity (“catch-up” growth) after their oral disease was successfully treated. Loss of primary teeth causes problems with development and loss of function, speech impediments and loss of self-esteem.
Courtesy Diann Bomkamp, RDH, BSDH, Missouri

11. Results of ECC Courtesy Proctor & Gamble
Tooth decay in children can cause extreme pain, swelling, and fever that can develop with little or no warning.
Sometimes dental infections can spread to areas such as the eye or the throat where they can be life-threatening
Courtesy Proctor & Gamble

12. What is a cavity? Who Wants a $1,000,000 $mile?
A. A large hole in the head
B. A disease
C. A hole in the tooth
D. Both B and C
The correct answer is D. Tooth decay is an infectious disease that is caused by bacteria in the mouth. As it progresses it causes a hole in the tooth.

13. Causes of ECC Diet (Sugar in Food) Bacteria (Plaque) Tooth Time
Four factors must be present for tooth decay to occur:
A tooth that is not well protected by saliva
Acid-producing bacteria or “germs” (shown on the figure as “Microbes” i.e., S. mutans, Lactobacilli).
Sugary or starchy foods (fermentable carbohydrates) in the mouth (shown in the figure as “Substrate”)
Repeated exposure to bacteria and starches (shown in the figure as “Time”)
All of these are needed for Tooth Decay

14. ECC Causes - Bacteria Passed from caregiver to child
food/drink
utensils
toothbrushes
Blowing on or pre-chewing food
More likely if mother has decay
Early spread increases decay risk
The bacteria that cause decay (S. mutans) are be passed from the primary caregiver to the infant, especially through the mother or another female relative.
Mothers or caregivers may infect their children with S. mutans by sharing:
food/drink
utensils
toothbrushes
food after blowing or pre-chewing it first
saliva in any other way
The chances of transmission are greater if the mother already has untreated decay herself.
The more decay the mother has, the more bacteria she has in her mouth to give to the baby.
The earlier the infant gets exposed to the decay-causing bacteria, the more likely the child is to develop tooth decay.
Courtesy Proctor & Gamble

15. How to Reduce Bacteria
Mothers or primary care givers should have all cavities treated
Wipe baby’s mouth from birth
Brush preschool child’s teeth using a smear of toothpaste

16. ECC Causes - Diet Food type Starchy foods Added or natural sugar
Pacifier dipped in sweetener
Liquid medicine
Snacking on foods high in added sugar and starches can cause decay, as can sugar-containing beverages. Milk and fruit juice, while healthy for the body, contain natural sugars. Bacteria can use both added sugar and natural sugar to cause decay.
Use of pacifier dipped in honey, syrup or other sugary substance will promote tooth decay.
Many liquid medicines for children contain up to 50% sugar. Oral antibiotics may also have a lot of sugar. If your child takes oral medicine for more than a week or so, there could be at risk for decay. Clean your child’s teeth after giving a sugar-containing medicine.
Courtesy Proctor & Gamble

17. How to Reduce Sugar in Diet
NO bedtime bottles
If bedtime bottle is used, WATER is the only safe liquid to put in the bottle
Limit juice to 4-6 ounces a day
Use water for an “anytime drink”
Limit sweet snacks

18. ECC Causes - Time Courtesy Proctor & Gamble
This shows what happens when the previous factors (the tooth, the bacteria, the food) come together over time.
The carbohydrate (starch or sugar) in foods are turned into acids by bacteria in the mouth, shown as the orange peaks over time.
Acids attack the teeth approximately 20 minutes after a meal. Each exposure can damage the teeth.
The more often we eat food, the more “acid attacks” our teeth are exposed to, and the more likely we are to develop a cavity.
Courtesy Proctor & Gamble

19. ECC Causes - Time Frequency and length of feeding Bedtime bottle
“At will” nighttime nursing
“Carry along” bottle or no-spill training cup
Frequent snacking
Putting a child to bed with a bottle containing anything but water, can be especially damaging to teeth. During sleep, saliva flow decreases greatly, so any liquids in the mouth remain on the teeth for a long time and are more likely to cause decay.
Breast milk has natural sugars and can also cause tooth decay. Babies who sleep with their mother and suckle repeatedly throughout the night expose their teeth to these sugars and can get decay.
How frequently a baby drinks from a bottle/cup or snacks on sugary or starchy foods plays a large part in the development of tooth decay. The more frequently sugars come into contact with the tooth surface, the more damage they can cause. Babies that carry a bottle or no-spill training cup around with them and sip from it constantly or that eat snacks every 30 minutes are more likely to develop decay.
Courtesy Proctor & Gamble

20. ECC Causes - Teeth Enamel Hypoplasia Lack of fluoride
Deformed, weak enamel
Causes:
Fever or virus
Low birth weight
Lack of fluoride
Enamel is more vulnerable to acids
There is no such thing as “soft teeth.” Sometimes teeth can have defects in the enamel that can become decayed more easily. One example is Enamel Hypoplasia, which is caused when something disrupts the cells that are forming the teeth. Common causes are untreated fevers during pregnancy or premature birth/ low birth weight.
The affected areas can be deformed or weakened or even missing altogether. These areas of the teeth can develop cavities very easily.
Teeth that are not exposed to adequate amounts of fluoride after they erupt into the mouth are more likely to develop decay. Their enamel (the hardest outer portion) is easier for bacterial acids to dissolve. Fluoride also helps saliva to repair damaged enamel.
Courtesy Diann Bomkamp, RDH, BSDH, Missouri

21. How to Make Teeth Stronger
Ask your physician to check teeth at each well baby/well child visit and apply fluoride varnish
Take your child to the dentist by Age 1
Use a small amount of fluoride toothpaste daily
Smear for a preschool child
Pea size dab for older children

22. Which of the following can cause ECC?
Who Wants a $1,000,000 $mile?
Which of the following can cause ECC?
A. Pepsi
B. 100% fruit juice (example: Juicy-Juice)
C. Milk
D. All of the above
The correct answer here is D, all of the above. Even the natural sugars in juice and milk can cause decay or ECC if they are sipped throughout the day or night.

23. ECC Prevention Diet Reduce bacteria Protect the teeth with fluoride
Brush daily
Treat mother’s cavities
Protect the teeth with fluoride
Regular dental visits
There are three principles to preventing ECC in infants. They have to do with limiting sugar exposure, reducing the amount of bacteria that the child has, protecting the teeth with fluoride, and visiting the dentist.

24. ECC Prevention – Diet & Time
Watch sugar/starch exposure
Limit night beverages
Provide healthy snacks
Avoid pacifier dipping
Wean from bottle/breast by one year
Ask for sugar-free medication
To decrease the chances of tooth decay:
Sugar-containing drinks like juices, milk or other beverages should be limited to mealtime or snack time.
Never put a child to bed with a bottle containing anything but water.
Offer your child healthy snacks rather than high-sugar foods.
Pacifiers should never be dipped in sweeteners.
Infants should be encouraged to drink from a cup as they approach their first birthday. Children should be weaned off the bottle/breast at 12 to 14 months.
If your child has to take any medicine for more than a few weeks, you can ask for sugar-free medications. Prevent decay by cleaning children’s teeth after they take their medicine.

25. ECC Prevention – Reduce Bacteria
Toothbrushing should begin with the eruption of the first tooth.
When brushing the sides of teeth, tilt the brush so that the bristles come in at an angle, pointed partially toward the gums. This will allow the bristles to clean the tooth all the way down to the gums. Use gentle pressure and a circular motion, since the area where the tooth meets the gum is rounded.
Courtesy Proctor & Gamble

26. ECC Prevention – Reduce Bacteria
Once the back teeth start to come in, you may need to pull the lips and cheeks back to reach all of the areas of the teeth.
Be sure to clean the chewing surfaces of back teeth also. The fissures (grooves) on these surfaces are best cleaned with a scrubbing motion .
Courtesy Proctor & Gamble

27. What does fluoride do? Who Wants a $1,000,000 $mile?
A. Is what causes the flu
B. Protects the teeth
C. Helps repair early stages of decay
D. Both B and C
The correct answer is D. Fluoride can protect the teeth from becoming decayed by making the enamel resistant to acids. It can also help repair early damage to the tooth enamel, before an actual cavity forms.

28. ECC Prevention - Dental Visits
12 months old or 6 months after 1st tooth
Early morning appointment
Build excitement
Be calm
Your child should visit the dentist within 6 months of the appearance of the first primary (baby) tooth, or by 12 months of age, whichever comes first.
Try to schedule the first visit early in the day when the child is alert and rested. When you make the appointment, you should talk to the office manager or dentist about what will happen. Then you can prepare the child for the visit and build excitement about new discoveries. Treat the visit to the dentist just like a visit to the Post Exchange (PX), Shopette, etc.
On the day of the visit say, “Today we get to go to the dentist! The dentist will use a special little mirror and a light to ‘count’ your teeth and to make sure that they are all nice and healthy.”
It is important that you be calm, patient, and reassuring.
You may need to sit in the dental chair and hold the child during the examination. Another position that works well is for the parent to sit knee to knee with the dentist, and hold the child’s hands while the child’s head is in the dentist’s lap, as seen here.
Courtesy University of Washington School of Dentistry

29. First Dental Visit Dentist will: Check: Ask questions Give information
Face and Jaws
Gums, Tongue, Tissues
Teeth and Bite
Ask questions
Give information
There are several things that will happen during the visit. The dentist will examine the child’s teeth, jaws, bite, gums, and oral tissues for any problems with development or disease. The dentist will ask questions about your child’s diet, sucking habits and hygiene.
A dentist or hygienist can show you how you brush your child’s teeth properly and discuss whether or not your child needs to use fluoride. This mother is practicing brushing her son’s teeth.
The dentist may also talk to you about your child’s sucking habits. Sucking on fingers or a pacifier should be discontinued by the age of 2, or the child’s bite will become disrupted.
Courtesy University of Washington School of Dentistry

30. Acknowledgements MAJ Georgia delaCruz Dental Staff Officer
Directorate of Health Promotion & Wellness
US Army Center for Health Promotion & Preventive Medicine
Additional graphics or information provided by the following:
University of Washington School of Dentistry
Diann Bomkamp, RDH, BSDH, Missouri
Dr. Dietmar Kennel
USC School of Dentistry
Marquette University School of Dentistry
WI Dept. of Health and Family Services
Cathy Hollister, RDH, MSPH, PhD, Nashville Area Dental Support Center