1. Children’s Oral Health & the Primary Care Provider
Anticipatory Guidance and Prevention
Module 6

2. Module 6 Objectives Discuss the components of ECC prevention
Discuss specific dietary & hygiene recommendations for target population:
Pregnant women
Infants
Toddlers
Preschoolers
Discuss fluoride recommendations for different ages
Discuss suggestions for parents about brushing strategies

3. Caries Prevention Strategies

4. Caries Prevention Strategies: Targeting: teeth, oral hygiene & diet
Fluoride
Chlorhexidine
Tooth
Bacteria
Oral Hygiene
Caries
In order to prevent ECC; strategies must address:
Protecting the teeth:
fluoride toothpaste
fluoride supplements
fluoride varnish
fluoridated water supply
dental sealants
Minimizing acid-producing bacteria in the mouth
good oral hygiene
antimicrobials such as chlorhexidine for high risk older children or adults
decreasing the risk of transmission of Streptoccus mutans to infants
Limiting the carbohydrate substrate available to the bacteria in the mouth.
dietary modification
limit sugary foods or beverages, especially those offered between scheduled meals or snacks
avoid sticky foods high in carbohydrates
avoid grazing/frequent snacking
Diet Modification
Carbohydrate
Sealants

5. Caries Prevention Strategies
Prenatal care
Parental education
Diet modification
Oral hygiene & brushing
Avoid Streptococcus mutans transmission
Fluoridated toothpaste
Fluoridated water supply
Fluoride varnish
Sealants
These are all components of caries prevention.
Beginning during the prenatal period helps to ensure not only the oral health of the pregnant woman, but also that of the fetus and infant. This is an ideal time to begin to reduce maternal Streptococcus mutans to improve the health of the mother-to-be and to reduce the chances of early transmission to the infant.
Specific parental messages target dietary and oral hygiene recommendations for infants, toddlers and preschoolers.
Fluoride is an effective part of caries prevention, in many forms.

6. ECC is Preventable: Prenatal Care
Advice for Pregnant Women

7. Advice for Pregnant Women
Regular dental care & prevention important during entire pregnancy
Good dietary & oral hygiene habits important to optimize the woman’s own oral health
Reduce risk of bacterial (SM) transmission from mother to child to decrease risk of ECC
Maternal health during pregnancy is about more than weight gain and measuring fundal height.
Regular dental visits are more important than ever.
Pregnant women must be especially careful to maintain good oral hygiene and to eat a healthy, well balanced diet.
This is also a time for the dentist to assess the risk of high Streptococcus mutans levels in the pregnant woman &, if indicated, institute specific preventive measures.

8. Advice for Pregnant Women
Emergency or necessary dental treatment can be provided at any time during pregnancy
Period between 14th and 20th week is
ideal for routine preventive care
To protect the pregnant woman
& fetus, use a lead apron if x-rays
are necessary
The ideal time for routine, preventive dental care is after most of fetus development (especially after organ formation is completed) and before the pregnant woman becomes so large in the 3rd trimester that she struggles with physical discomfort while in the dental chair.
Morning sickness in the 1st trimester may also limit dental treatment.

9. Advice for Pregnant Women
ECC prevention begins in the prenatal period
Optimize nutrition, especially during the third trimester
Risk of preterm & low-birth-weight babies associated with:
inadequate prenatal care
periodontal disease (severe gum disease)
tobacco, alcohol & drug use
As a preventive measure for the future child’s oral health, pregnant women should be advised to optimize nutrition, especially during the third trimester when enamel is undergoing maturation.
Pregnant women with periodontal disease (severe gum disease) are more likely to have preterm, low-birth-weight infants since bacteria present in the gingival tissue (gum) can trigger labor prematurely.
Smoking is a risk to the fetus from a number of perspectives. Smokers also have a higher risk of developing periodontal disease (severe gum disease) so a smoking cessation program should be instituted for any pregnant woman who smokes.
Preterm & low-birth-weight babies are more likely to have problems with their future teeth; such as enamel hypoplasia, a defect in the first layer of the tooth (enamel), which predisposes them to cavities early in life.
Boggess KA, Maternal Oral Health in Pregnancy. Obstetrics & Gynecology 2008;111:

10. Advice for Pregnant Women: Prevention of SM Transmission
Preventive measures may reduce mothers’ levels of Streptococcus mutans (SM)
Earlier colonization with SM
increases risk for ECC
Reducing levels of maternal SM
may either prevent or delay SM
transmission to their children
In a three-phase longitudinal study starting during pregnancy, Günay et al. (1998) also concluded that a pre- and post-natal prevention program significantly improved the oral health of both mother and child. Participants were recalled every 6 months for preventive care (oral hygiene instructions, professional tooth cleaning, topical fluoride varnish application, chlorhexidine mouth rinsing, and dietary counseling) until their children were 4 years of age. The control group consisted of children from various kindergartens. Children from the experimental group demonstrated in the last two phases of the study lower incidence of SM and healthier dentition than children in the control group. A significant improvement of all mothers’ oral health and reduction of their salivary SM colonization were also observed.
Similar results using a combined regimen of fluoride and chlorhexidine were observed in a three-year longitudinal study, where Tenovou et al. (1992) evaluated 151 children for colonization of the primary dentition by Streptococci mutans and for development of dental caries. Mothers of the children in the experimental group were treated with 1% chlorhexidine and 0.2% sodium fluoride gel twice a year for 3 years. Both colonization and caries incidence were higher in the control group that in the experimental group.
Köhler et al. (1983) also implemented a preventive program targeting highly infected mothers of children who were 3-8 months of age at the time of enrollment. Mothers of the experimental group received a one-time basic preventive program (dietary counseling, professional prophylaxis, oral hygiene instructions, fluoride treatment, and excavation of large cavities). In addition, either at baseline or at recall appointments, mothers of the experimental group whose levels of SM were  3 x 105 per ml saliva were also prescribed a 1% chlorhexidine gel to be used once a day for 2 weeks. At 36 months of age, fewer children were infected with SM in the experimental group than in the control group, showing that reduction of SM in the mother prevented or delayed the establishment of SM colonization in their children.

11. ECC is Preventable: The First Year
Early 1st visit (within 6 months of
tooth eruption & not later than
1 year of age)
Establishment of a dental home
Caries risk assessment:
Identify children who are “high risk”
for ECC
Identify caries process before
cavitation
Implement preventive strategies
The American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP) and the American Academy of Pediatric Dentists, all recommend that professional intervention for caries prevention should start no later than 12 months of age. It should be directed at factors affecting the oral cavity, counseling on oral disease risks, and delivery of anticipatory guidance.
Early first oral exam, along with caries risk assessment and anticipatory guidance are effective means of true primary prevention.
“The primary goal for referring all children is to establish a dental home for each child, where they can receive comprehensive diagnostic, preventive, restorative, and emergency care throughout childhood” Kanellis, 2000.
American Academy of Pediatric Dentistry (AAPD) Dental Home: “Encourages parents and other care providers to help every child establish a dental home by 12 months of age” Pediatric Dent 2007;29(7):22-23.
However, the reality is that children ages 1-3 yeas often don’t have a dental home. According to the American Academy of Pediatrics (AAP), 85% of toddlers have had a well-child visit, while only 20% of toddlers have had a dental visit (AAP News 2006;3:20-21). For this reason, primary health care professionals (pediatricians, family physicians, nurse practitioners, physician assistants) become gatekeepers for dental visits and provide a dental home for children who otherwise would not have access to dental care.
Prevention by non-dental professionals targets:
1. Assessment of risk factors
2. Education of parents about dietary & oral hygiene practices
3. Fluoride varnish application.

12. Education: Important Component in ECC Prevention
When working with parents:
Give rationale behind recommendations
Be reasonable
Provide options
Build on the established, trusting relationship you have with families
Be open to listen & respond to the challenges parents may have in following recommendations
Oral health education is an important component of caries prevention.
Primary prevention starts with educating parents/caregivers about ECC-risk related factors.
It should be not only a goal but also an ethical obligation for primary health care providers to educate patients about the importance of oral health and motivate them to improve their health and prevent disease.
In order to motivate parents/caregivers to follow recommendations, it is important to provide the rationale behind recommendations, be open to listen and understand the difficulties in following the recommendations, and be reasonable with recommendations.
Anticipatory guidance to prevent Early Childhood Caries (ECC) will help parents:
Understand the importance of oral health & hygiene from early infancy
Gain the skills they need to properly care for their infants teeth
Understand the importance of the first dental visit by age one year
Understand the etiology & risk factors for early childhood caries (ECC)
Understand how to read labels for nutritional content
Understand how to wisely use “fast foods”
Learn how to model healthy eating behavior for their children
Learn how to set limits
Understand the rationale behind recommendations such as fluoride varnish and the timing of the first dental visit
Understand what they can do to prevent ECC
Anticipatory guidance is a positive, teaching experience and should build on the trusted relationship parent(s) have established with you, the child’s primary care provider. Most parents are doing the best that they can with the knowledge & resources they have. In addition to teaching parents about what they can do to prevent ECC, you may be able to help them find resources within the community to make it easier for them to succeed.

13. Anticipatory Guidance: Feeding Infants
Hold infant for feedings
No bottles in bed
No sweetener on pacifier
Introduce cup by 6 months & wean from
bottle by 12 months
Avoid cariogenic foods/beverages between meals or at bedtime
No sweetened beverages
Avoid unrestricted use of bottle or sippy cup for older infants
No juice in bottle
Avoid introducing juice to infants & toddlers
Holding the infant for feedings is best for breast & formula fed infants.
Infants should not be put to sleep with a bottle in bed. In addition to increasing the risk for ECC if sugary substances are offered with the formula, this practice teaches infants that they should always expect to fall asleep while feeding. They become “trained night feeders and expect to nurse or take a bottle whenever they awaken at night.
Juice or sweetened beverages should not be put in a bottle or sippy cup. Sweetened beverages should not be offered to infants at all. These provide empty calories, have no nutritional value and are cariogenic. Many pediatricians now encourage parents to minimize or eliminate juice altogether and to offer children fruit instead.
Infants should be fed on demand. Exclusive breast feeding supplies all the calories needed for growth in the first 6 months. By 9 months of age infants should obtain the majority of their calories from solid foods offered in 3 meals a day. By 12 months infants should receive 3 meals and 2-3 nutritious “snacks” daily. Grazing (consuming small quantities of solid or liquid foods frequently throughout the day) should be discouraged. Grazing may lead to poor weight gain by blunting the infant’s appetite at scheduled meals or snacks or excessive weight gain and obesity by providing substantially more calories than the infant needs for growth. Grazing also exposes the infants teeth to frequent carbohydrate intake and increases the risk of ECC.
Infants old enough to sit at the table or in the high chair for meals and snacks should not be offered food or liquids that they carry around with them. Meals and snacks should be supervised by an adult and should occur with the infant seated. Establish the “family meal time” from an early age. 13

14. Infant Dietary Recommendations
Breastfeeding:
Discourage feedings with any
sugar-containing foods
Perform good daily toothbrushing/oral hygiene, especially before bedtime
Weaning: There is no "right" time to wean. It depends entirely on the desires and needs of the mother and her baby
AAP Policy Statement: Breastfeeding and the Use of Human Milk: Pediatrics Vol 115. No 2; February 2005
There is no upper limit to the duration of breastfeeding. Exclusive breastfeeding is sufficient to meet the caloric needs for growth for the first 6 months of life.

15. Infant Dietary Recommendations
Bottlefeeding:
Avoid mixing milk or cow’s-milk based formulas with other products or sugar
Perform good daily toothbrushing/oral hygiene
No Bottles in bed
Wean by age one
For infants accustomed to sleeping with a bottle of milk/formula in bed, the parents may transition to no bedtime bottle by filling the bedtime bottle with only water and then gradually decreasing the amount of water in the sleeping bottles.

16. Infant Dietary Recommendations
During early infancy:
On-demand feeding encourages
bonding & food security
Stomach is too small to hold sufficient
formula/feeding for structured meals
Beyond infancy:
3 meals and 2-3 snacks are frequent enough to assure food security and adequate intake for growth
Snacks: Avoid high-frequency sugar consumption
Snacks should be healthy & nutritious, structured like small meals.
The child should be seated at the table or in a high chair for all meals and snacks.
Milk or water (rarely juice and never sugary beverages or pop) should be offered in a cup.
Healthy snacks may consist of fruits, vegetables, cheese and crackers, sandwiches or cereal that are age and developmentally appropriate.
Do not offer “children’s” breakfast cereals (those with a high sugar content and that are often highly colored and advertised directly to children).

17. Anticipatory Guidance: Feeding Toddlers
Discontinue bottle by 12 months
Avoid unrestricted use of sippy cup
Avoid excessive juice
Avoid cariogenic snacks between meals
Avoid soda, candy and sweets
Use sweets for special occasions & give with meals/snacks
Sweets, if offered, should be given infrequently and with scheduled meals or snacks rather than between meals.
Do not offer sweets as a reward.
Avoid sweetened beverages such as soda and sports drinks. Candy and other sweets should be infrequent treats. Children should not be offered a “dessert” after meals on a routine basis.
Offer cheese, veggies or fruit instead of sweets.
Avoid grazing
If children are thirsty between scheduled meals or snacks offer water unless the child’s physician specifically recommends otherwise.
Juice is an unnecessary beverage and contains more concentrated carbohydrate than fresh fruit. Some juices have additional fructose or sucrose added. Fresh fruit or canned fruit packed in its own juice is a better nutritional offering.
If juice is offered, it should be given with scheduled meals or snacks and limited to not more than 4-6 oz./day. 17

18. Toddler Dietary Recommendations
Juice:
Should be consumed as an occasional treat with scheduled meals & snacks
No juice before 6 months
For children 6 months to 1 year:
limit juice to <4oz with snacks or meals
For children 1 to 6 years:
limit juice to < 6 oz with snacks or meals
Many pediatricians now recommend delaying the introduction of juice.
Although there is no specific recommendation that advises entirely against juice, juice is completely unnecessary in the diets of most children.
Juice contains significant carbohydrate (as fructose and often as added sucrose), and excess calories compared with consumption of fruit.
By limiting juice to an occasional treat given with meals or snacks, the caries risk is limited by avoiding more frequent exposure of teeth to carbohydrates, which are metabolized to acid that can then demineralize the teeth.
Frequent offering of juice may also blunt the child’s appetite for more nutritious foods offered at meals or scheduled snacks.

19. Dietary Recommendations
No juice at bedtime or throughout the night
Never put juice or sugary beverages in a bottle
Do not allow ad-lib access to juice
It is preferable to offer juice from a cup rather than a sippy-cup to avoid
high consumption
throughout the day

20. Anticipatory guidance: Feeding Preschoolers
Avoid excessive juice
Offer fresh fruits, vegetables and whole grain snacks
Avoid cariogenic snacks between meals
Limit sweetened beverages & foods to special treats given occasionally with a meal or snack
Children > 5 yrs can also be offered nuts & popcorn as a nutritious snack.
Remember that even nutritious snacks such as raisins or other dried fruits are cariogenic because they contain high levels of concentrated carbohydrates and stick to the teeth. 20

21. Dietary Recommendations: Preschoolers
Soda & Sugared Beverages:
Avoid regular soda, flavored sugar-containing powders added to water, sports drinks & other sugared beverages
Older children may have occasional diet & sugar-free beverages
Younger children should be offered milk or water
Artificial Sweeteners include:
Aspartame (NutraSweet, Equal)
Saccharin (Sweet'N Low, SugarTwin)
Acesulfame K (Sunett, Sweet One)
Sucralose (Splenda)

22. Diet: Soda & Sugared Beverages
Flavored/carbonated waters with sugar sweeteners (i.e., honey, sucrose, or high fructose corn syrup) should be considered sugared beverages
Flavored/carbonated waters without sweetener or with an artificial sweetener (i.e., nutrasweet, acesulfame K) should be considered sugar-free beverages

23. Dietary Recommendations
Sippy cup:
May contain formula, milk, water or (rarely) 100% juice at meals and snacks
Only water between meals/scheduled snacks and at bedtime
The improper use of “sippy-cups” and its possible relationship with an increased risk of developing ECC has become a great concern among many researchers and dental practitioners (Tinanoff & Palmer, 2000; Updyke, 2002; Marshall, 2003).
Historically, oral health education has emphasized early transition to drinking from a cup to limit exposure time associated with bottle-feeding. Unfortunately, many closed-cups currently in use are not significantly different from a bottle.
The caries risk is not associated with the container used to provide beverages, but rather the type of beverage provided. The risk associated with the use of “sippy-cups” lies in the fact that the closed-cup system prevents spills & often increases the child’s intake frequency of beverages throughout the day. In today’s culture, children are often allowed ad lib use of a sippy cup throughout the day. If the cup is filled with sugared beverages or juice the child’s teeth are exposed to carbohydrate on a very frequent basis.

24. Dietary Recommendations
Limit sweet foods to mealtimes, as occasional desserts, to encourage proper eating habits
Avoid sticky foods that may be retained in the mouth for prolonged periods of time
Choose non-cariogenic snacks: i.e. cheese, veggies, popcorn for children over 5 yrs. (as developmentally appropriate)
Sticky foods may include candies, dried fruits, fruit rollups, granola bars and sugared cereals.
Young children should not be given hard, uncooked fruits or vegetables or popcorn as these constitute a choking hazard.

25. Transmission of Streptococcus mutans
Advise parents/caregivers:
Avoid activities that exchange saliva
Keep their own teeth healthy to prevent high levels of bacteria that increase risk of transmission
Streptococcus mutans infection in infants & children usually occurs as a result of transmission from the mother to the child.
High rates of Streptococcus mutans in other family members also increases the risk of transmission to the infant.
Factors that increase the risk of transmission of Streptococcus mutans bacteria to the child include:
Frequent sugar exposure in infants
Caregiver behaviors that permit saliva transfer from mother to infant
Tasting or pre-chewing food
Sharing food, utensils or drinking glasses/cups
“Cleaning” pacifiers by putting them in the mother’s mouth
Having the infant put her fingers or teething objects into the mothers mouth and then into her own mouth
High maternal bacteria levels
Poor maternal oral hygiene
Low socioeconomic status
Frequent maternal snacking
The dietary preferences and oral hygiene habits of the mother are passed to the child at an early age. If the mother has a “sweet tooth” or snacks frequently, this is a concern as the children are likely to follow her example.

26. Streptococcus mutans Transmission
Advise parents:
Avoid activities that could result in transfer of their saliva to their child’s mouth:
Don’t share a toothbrush with your child
Don’t share spoons, forks and cups
Don’t lick or suck on your child’s pacifier or bottle
Don’t pre-chew food your child will eat
Keep their own teeth healthy to prevent
high levels of bacteria that are more likely
to be transmitted to children
This advice applies to any caretaker of the child and other family members, including siblings.

27. Toothbrushing & Fluoridated Toothpaste
Little evidence to support the efficacy of toothbrushing alone in reducing caries
Convincing evidence for decay-preventing benefit of toothbrushing with fluoride-containing toothpaste
Longer contact of fluoridated toothpaste during brushing is better (brush 2 minutes; use a timer)
After brushing with fluoridated toothpaste, rinsing should be kept to a minimum to maximize the beneficial effect of the fluoride
Little evidence to support the notion that toothbrushing alone reduces caries.
Instructional programs designed to reduce caries incidence by supporting oral hygiene have failed. On the other hand, there is convincing evidence for decay-preventing benefit of toothbrushing when fluoride-containing toothpaste is used. Studies have shown that daily brushing with fluoridated toothpaste among 3 to 6 years old children was linked with a significant reduction in caries incidence (Holtta & Alaluusua, 1992; and Sjögren et al, 1995; Scharwartz et al, 1998)
When to start fluoridated toothpaste:
Fluoride toothpaste (smear amount) should start with eruption of first tooth. Use of small amounts fluoride from
toothpaste on a daily basis is the most effective way to prevent caries, especially for high-caries risk children.

28. Fluoridated Toothpaste: When & How Much?
smear
½ pea-sized
Young children can’t spit; so some, most or all of the toothpaste used may be swallowed. The amount of toothpaste applied to the toothbrush is key.
1. Children’s toothbrushing should be done and/or supervised by an adult.
2. Dispensing of fluoridated toothpaste should be done by an adult and should follow the recommendations below for the amount of toothpaste applied:
“smear” amount for children 6 to 24 months; (begin brushing with fluoridated toothpaste after the first tooth is fully erupted)
pea-sized amount for children older than 24 months of age
Brushing is recommended twice daily; in the morning and prior to bed in the evening.
According to Warren and Kanellis, fluoride toothpastes (Warren, JJ & Kanellis, MJ. Fluoride. In: The Handbook of Pediatric Dentistry. American Academy of Pediatric Dentistry. 3rd Edition, pp , 2007):
Best topical application for compliance;
Ingestion ( mg can be swallowed by pre-school aged children when brushing twice a day);
Begin use with eruption of first tooth (minimal, smear amount);
Very small, pea-sized amount in pre-school aged children.
Use of a pea-sized amount (approximately 0.25 mg) of fluoride toothpaste <2 times per day by children aged <6 years is reported to sharply reduce the importance of fluoride toothpaste as a risk factor for enamel fluorosis (Pendrys, 1995).
pea-sized
Amount of Fluoridated Toothpaste Recommended

29. Fluorosis Caused by ingestion of high concentrations of fluoride
More often related to systemic fluoride supplements rather than topical use of fluoridated toothpaste
If the amount of fluoridated toothpaste dispensed is carefully controlled, the amount of fluoride ingested is relatively low
According to Kanellis (2000):
Scientific findings lead to the conclusion that preventive programs involving toothbrushing, especially when conducted with children at high risk for dental caries, should be carried out using a fluoride toothpaste, followed by minimal or no rinsing.
If brushing with this protocol takes place with young children, ingestion of fluoride and the potential for dental fluorosis (which may cause esthetically objectionable discoloration of the permanent teeth) must be taken into consideration.
A study by Bently et al. (1999) reported that 30-month-olds will ingest 72 percent of the toothpaste applied to a toothbrush. Other studies with young children have found that an average of 59 percent and 65 percent of toothpaste applied to the brush is ingested (Simard et al., 1989; Naccache et al., 1992).
If the amount of toothpaste dispensed is carefully controlled, the amount of fluoride ingested will be relatively low, however. For example, if a pea-sized amount of toothpaste is used when brushing, the amount of fluoride contained on the toothbrush will be 0.25 mg or less. It could still be a contributing factor to fluorosis, however, for children ingesting more than the average amount, or for children ingesting significant amounts of fluoride from other sources.
The critical time period during which maxillary permanent central incisors are at highest risk for fluorosis is during a four-month period beginning around age 22 months (Evans & Stamm, 1991). The risks for fluorosis must be weighed against the risk for caries, however, and in vulnerable populations including children served by Head Start and WIC, the potential benefits of daily brushing with tooth­paste may outweigh any potential risk for fluorosis.
Dental fluorosis: permanent, intrinsic stain caused by excessive fluoride ingestion during tooth development; staining is usually white, but can be dark brown or orange

30. Cleaning the Teeth: Washcloth or Toothbrush?
Before tooth eruption: clean gums and tongue with a clean wet washcloth once daily, either at bedtime or at bath time. Cleaning the baby’s mouth even before tooth eruption helps the child become accustomed to the parent manipulating her mouth. Most importantly, it helps the parent to establish a daily oral hygiene routine in their schedule that will be crucial after the eruption of the child’s teeth.
After eruption of the first tooth: instead of using a washcloth, begin brushing with a small, soft toothbrush designed especially for young children. The washcloth will not clean and remove plaque from teeth as well as the toothbrush. Most children’s toothbrushes have soft bristles that will not hurt the child’s gums or other oral structures. Ideally, brushing should be done twice daily; in the morning and prior to bed in the evening.
Help parents understand that (similar to the routine use of carseats) if brushing becomes a daily routine from a very early age, children are more likely to accept having the parent wiping or brushing at these routine, expected times. Children are less likely to resist parental efforts and brushing does not become battle.
Linking brushing with a preferred activity that follows brushing, such as snuggling while a parent reads a book, can make this a positive, enjoyable experience for the child and the parent.
Before Tooth Eruption
After Tooth Eruption

31. Brushing Children’s Teeth: Frequency, Timing & Technique
The more times teeth are brushed during the day, the better.
However, the most important time for brushing is right before bedtime. Brushing teeth before bedtime is extremely important since there is a significant reduction of salivary flow during sleep. The chemical and physical properties of saliva help to fight off bacteria that cause cavities.
Toothbrushing in the morning and before bedtime is ideal.
Brushing twice a day improves plaque removal from teeth when compared with only once a day brushing.
However, if brushing will occur only once a day, the best time is right before going to bed in the evening.

32. Who Should be Doing the Brushing?
An adult should brush the child’s teeth until the child is in approximately the 1st or 2nd grade. It is not until children are 6 to 7 years of age that most children have the necessary motor skills to brush their teeth effectively. Remember, this is a matter of developmental attainment rather than simply chronologic age. Some children still do not have the motor dexterity or skill to brush their teeth at age 8 or 9 or even later.
An egg timer is useful to remind children that they should continue to brush for a full 2 minutes. Children often overestimate the amount of time they spend brushing their teeth.
An electric toothbrush facilitates tooth brushing for children & may be especially helpful for those children lacking the motor skills to brush manually. Some models also have an electronic timer to cue children that they need to keep brushing for a full 2 minutes.
After the child is in 1st or 2nd grade, and able to effectively brush their own teeth, adults should continue to supervise the toothbrushing. Adults should motivate young children to learn how to brush their own teeth.
Making a “deal” between the child and the parent about brushing is a good way to form a great partnership and help ensure that the child will have fun while learning how to brush his teeth, and also that the parent will be the one responsible for cleaning the child’s teeth. For younger children the “deal” might be: “First you brush & then mommy will brush!” or “After we brush your teeth, then we will read a story.”
Some families make it a routine to have all of the younger children brush their teeth at the same time. It becomes a routine expectation for all children at that time and eliminates the individual child’s concern that they might be “missing something fun”.
Important tip: place the fluoridated toothpaste on the toothbrush only when it is the time for the adult to brush the child’s teeth.

33. Positioning the Young Child for Toothbrushing
Make it comfortable for the child and effective for the adult to brush. Adults need to restrain the child’s body and head movements during toothbrushing.
Advise parents to be creative and gentle. Make brushing an enjoyable experience for the child & a way to spend positive time with a parent.
Important tip: Lift the child’s lip during brushing to brush the upper front teeth better and pull the cheeks away to better brush the outside (buccal) surfaces of the back upper and lower teeth.

34. Brushing the Teeth of an Uncooperative Child
Establish a partnership between adult & child
Distract the child
Allow the child some control
Be creative but firm & consistent
The problem with toothbrushing and children is the restraint necessary during brushing and the child’s desire to be independent and do things by themselves.
In terms of the sense of independence, establish a partnership between the adult and the child.
In terms of the restraint, try to make brushing fun by distracting the child with a story, songs, games, movies, cartoons, etc.
Allow the child some control: “Do you want to brush first or do you want mommy to brush first?” ; “Do you want to stand on your own to brush your teeth or sit in my lap?”
Advise the parent to be creative during brushing and find out what works best for the child and, very importantly, to be consistent with brushing day after day.
Pair brushing with a preferred activity that follows. The “after (this), then (that)” parenting tool works well for brushing. “After we brush your teeth, then we can play a game.” “After we brush your teeth, then we can snuggle and read a story.”

35. Fluoride Varnish Application
Ideally suited for young children
Caries reduction of 25-40% with biannual applications
Recommended every 3 months for children with white spot lesions on any teeth or those at high risk for ECC
Fluoride varnish is an ideal topical regimen for young children for many reasons:
1. Potential ingestion of fluoride is low, especially when compared to gel or foam fluoride applications * (see
comment below)
2. Teeth don’t need professional cleaning (prophylaxis) prior to use
3. Prevents caries on smooth & pit and fissure sites
4. No need to be in a dental office for this application
5. Can be applied by trained non-dental professionals; physicians, physicians’ assistants, nurses, nurse practitioners etc.
Fluoride concentrations in gels, foams and varnishes:
1.23% APF (Acidulated Phosphate Fluoride) = 1.23% fluoride
The two most common professionally applied fluoride treatments are gels and foams, which are delivered by the tray method for both dental arches:
1. A tray application of fluoride gel is approximately 5ml per arch (10 ml both arches) for a total of 123mg of fluoride.
2. A tray application of fluoride foam provides the same therapeutic concentration as the gel; however, the usual treatment dose of foam is only ¼ the amount of total fluoride, for a total of 30.8 mg of fluoride. The reason for this difference in fluoride concentration is that the fluoride is suspended in low density foam instead of high density gel.
5% NaF Varnish (Sodium Fluoride) = 2.26% fluoride
An application of fluoride varnish is applied using a disposable brush. A prepackaged unit-dose of fluoride varnish contains up to 0.5 ml, which corresponds to 11.3 mg of fluoride. The usual child dose is .25 ml, which equates to 5.65 mg of fluoride.
The bottom line:
Although, fluoride varnish is twice as concentrated as fluoride gels and foams; the amount of fluoride exposure is considerably less (up to 10 times).

36. Dental Sealants Effective in caries prevention
Despite effectiveness, use of sealants is low
Relatively expensive:
Sealants on primary teeth not reimbursed by most dental insurance
Sealants are reimbursed by Iowa Medicaid for children classified as high-caries risk
Dental sealant is a plastic, professionally-applied material that is placed on the chewing surfaces of back teeth to prevent cavities.
Dental sealants provide a physical barrier so bacteria cannot invade the pits and fissures on the chewing surfaces of teeth.
Studies show effectiveness when placed on primary molars of 3 to 4 year olds (Hardison et al, 1986; Hotunam et al, 1998).
Use of sealants is low, especially for primary teeth.
As a caries preventive measure, sealants are more costly than other preventive regimens like fluoride varnish. However, when targeted to high-caries risk children (i.e., children with white spot lesions and/or stained pits and fissures), sealants may be more cost-effective when compared to tooth fillings.
Sealants on primary teeth are not reimbursed by most dental insurance. However, sealants are reimbursed by Iowa Medicaid for children classified as high-caries risk.
Dental insurance pays for sealants only once. Dentists monitor the sealants they place and, in case of any sealant displacement from the tooth grooves, most dentists replace them at no charge to the patient.

37. Summary: ECC Preventive Strategies
Target pregnant women in the last 3 months of pregnancy & the child in the 1st year of life
Chemotherapeutic agents for high-risk pregnant & nursing women to reduce SM
Fluoride varnish for high-caries risk children
Train parents & caregivers about caries prevention & risk reduction
Teach parents to identify early signs of ECC
High risk pregnant and nursing women would include those with poor oral health, periodontal disease, multiple treated or untreated caries and missing teeth due to decay.

38. Summary: ECC Preventive Strategies
Encourage parents & caregivers to adopt feeding & hygiene practices & procedures to prevent development & progression of ECC
Screen infants & toddlers in dental & medical settings
Employ preventive measures such as fluoride varnish application

39. I-Smile Coordinators
I-Smile coordinators are dental hygienists who serve as prevention experts and liaisons between families, health care professionals, and dental offices to ensure completion of dental care. Coordinators are located in regional public health agencies and provide local community support throughout Iowa. A coordinator can:
Assist with dental referrals for young children.
Provide Medicaid dental billing information.
Offer education for healthcare professionals regarding children’s oral health, including screening and fluoride varnish training.
Another important component of ECC prevention is the partnership among the family and medical and dental professionals that can be nurtured and facilitated by the local I-Smile Coordinator.
I-Smile Coordinator contact information can be found at: or
I-Smile hotline

40. Summary: Oral Health Module 6
Dental caries develop in the presence of teeth, bacteria & sugars
Prevention by non-dental professionals targets:
Assessment of risk factors
Parent education regarding diet & oral hygiene
Fluoride varnish application
Dental screening by non-dental professionals must occur at every well child visit
Oral health preventive care can be efficiently incorporated into primary care practice
Ideally, 1st dental visit no later than 12 months of age 40