Protecting All Children’s Teeth Preventive Care www.aap.org/oralhealth/pact

Introduction Used with permission from Melinda B. Clark, MD; Associate Professor of Pediatrics at Albany Medical Center The effective prevention of caries involves understanding the pathogenesis—the triad of teeth, bacteria, and sugar. Fortunately, the development of caries is almost completely preventable through improved nutrition and oral hygiene and regular dental care. This presentation presents an in-depth discussion of each prevention method to assist in oral health counseling and anticipatory guidance. www.aap.org/oralhealth/pact

Learner Objectives Used with permission from Melinda B. Clark, MD; Associate Professor of Pediatrics at Albany Medical Center Upon completion of this presentation, participants will be able to: Accurately counsel families on child oral hygiene practices List nutrition practices that increase the risk of caries development List practices that decrease the transmission of cariogenic bacteria to children and delay oral colonization Recall the recommended timing for establishment of a dental home. Discuss the placement and benefits of dental sealants Provide age-based oral health anticipatory guidance www.aap.org/oralhealth/pact

Used with permission from Diona Reeves Brushing Before teeth erupt, caregivers should wash the gums and tongue with a wet washcloth after feedings. When the first tooth erupts, begin brushing with a soft-bristled, small-head brush. The most important time to brush is at night, after the last feeding. Used with permission from Diona Reeves www.aap.org/oralhealth/pact

Used with permission from ANZ Photography Brushing, continued Parents should brush the child’s teeth at least twice a day (morning and night) by 1 year of age. Children should not be allowed to consume any sugary liquids such as milk or juice after brushing at night (water only). Used with permission from ANZ Photography www.aap.org/oralhealth/pact

Paper permission on file from Diona Reeves Brushing, continued Caregivers should position themselves behind the child. All the surfaces of every tooth should be brushed. Caregivers should lift the lip to brush the top gum line, pull down the lip to brush the bottom gum line, and brush the top of all the molars. Notes: Caregivers can sit the child in their lap facing out or stand behind the child, both facing the mirror. Paper permission on file from Diona Reeves www.aap.org/oralhealth/pact

Used with permission from Guisy Romano-Clarke Brushing, continued Toothbrushing should be performed or assisted by the parent until the child is 7 or 8 years of age. supervised thereafter until the child can do an adequate job of brushing alone. Used with permission from Guisy Romano-Clarke www.aap.org/oralhealth/pact

Paper Permission on file from Andrew Alspaugh Flossing Parents should begin flossing the child’s teeth as soon as the surfaces of the teeth touch one another. Flossing should be done once a day, preferably with the evening brushing. Flossing should be assisted by a parent until the child is 10 years old. Paper Permission on file from Andrew Alspaugh www.aap.org/oralhealth/pact

Used with permission from Rama Oskouian Fluorosis Ingestion of toothpaste increases the risk of enamel fluorosis. Strategies to limit the amount swallowed include limiting the amount placed on the brush, observing the child as they brush, and keeping toothpaste out of reach of young children. Notes: Older children should spit but not rinse. The small amount of fluoride that remains in the mouth by not rinsing will help prevent tooth decay. Once the permanent teeth erupt, a child is no longer at risk for fluorosis. Refer to http://www.aap.org/oralhealth/pact/ch6_intro.cfm for more information about fluorosis. Glossary: Fluorosis: An abnormal condition (as mottled enamel of human teeth) caused by fluorine or its compounds Used with permission from Rama Oskouian www.aap.org/oralhealth/pact

Recommendations for Fluoridated Toothpaste The American Dental Association (ADA), American Academy of Pediatric Dentistry (AAPD), and the American Academy of Pediatrics (AAP) now all recommend a “smear” of toothpaste for children younger than 3 and a “pea-sized” amount for children ages 3 to 6. Fluoride toothpaste is recommended from emergence of the first tooth for all children, not a decision based on risk of caries. References: Clark MB, Slayton RL; AAP Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2014 Sep;134(3):626-33. http://pediatrics.aappublications.org/content/134/3/626 American Dental Association Council on Scientific Affairs. Fluoride Toothpaste for Young Children. J Am Dent Assoc. 2014;145(2):190-1. Wright JT, Hanson N, Ristic H, et al. Fluoride toothpaste efficacy and safety in children younger than 6 years. J Am Dent Assoc. 2014; 145(2):182-9. American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy. Updated 2014. Reference Manual 36(6): 171-74. Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry University of North Carolina www.aap.org/oralhealth/pact

Feeding and Nutrition Practices Eating and drinking supply cariogenic bacteria in the oral biofilm with the carbohydrates they need to grow and produce acid that can destroy tooth enamel. The types of food chosen and the pattern of ingestion can significantly alter a child’s risk for the development of caries. Notes: Refer to http://www.aap.org/oralhealth/pact/ch4_intro.cfm for more information about the caries process. Used with permission from ANZ Photography www.aap.org/oralhealth/pact

Feeding and Nutrition Practices, continued The goal is to decrease the time that the teeth are exposed to sugars. This can be done by: Decreasing the frequency and duration of sugar intake Promptly removing carbohydrates from the teeth Choosing less cariogenic foods Notes: Refer to http://www.aap.org/oralhealth/pact/ch4_intro.cfm for more information about the caries process. Paper Permission on file from J. Ho www.aap.org/oralhealth/pact

Anticipatory Guidance Include the following recommendations in anticipatory guidance:  Try to stop night feedings once the teeth erupt. Use methods other than feeding to calm a crying child.  If a child needs a bottle to fall asleep, it should contain plain water.  Breastfeeding should be encouraged along with good oral hygiene and age appropriate, healthy, complementary foods. Discourage ad-libitum breast or bottle feeding. For infants who continue to feed on demand at night, parents should wipe the teeth clean after feedings. Notes: Most children are physiologically able to tolerate a prolonged fast around 6 months of age, when the teeth typically begin to erupt.  Methods to calm a child include providing a transitional object such as a small blanket or stuffed toy, offering a pacifier, rocking, or singing. Although controversy on the subject remains, human breastmilk is probably less cariogenic than formula, with frequent and nocturnal feedings posing a smaller risk for ECC. Given the proven medical benefits of breastfeeding, according to the AAP policy, breastfeeding should be continued through at least the first year of life and beyond as long as mutually desired by mother and child. www.aap.org/oralhealth/pact

Anticipatory Guidance, continued Never prop a bottle and always remove it promptly once the infant is done feeding.  Discourage prolonged and frequent use of a bottle or sippy cup during the day unless the cup contains plain water.  Limit drinking of sugary fluids to meals and snack times.  Introduce a cup as soon as the child can sit unsupported (around 6 months of age). Try to eliminate the bottle by 1 year of age. www.aap.org/oralhealth/pact

Nutrition Practices: Infants and Children Never dip pacifiers in sweeteners like honey, corn syrup, or sugar.  Encourage planning of 3 meals with 2 snacks.  Limit the consumption of foods high in sugar and eat them only at mealtimes.  Avoid foods that stick to the surface of the teeth and are difficult to remove. Notes: Planning 3 meals a day with 2 snacks helps to limit constant eating or “grazing” throughout the day. “Sticky” foods include fruit roll-ups, dried fruit (raisins), and certain candies (caramel). Used with permission from Melinda B. Clark, MD; Associate Professor of Pediatrics at Albany Medical Center www.aap.org/oralhealth/pact

Nutrition Practices: Infants and Children Encourage families to choose fresh fruits, vegetables, and whole grain snacks.  Minimize juice consumption and allow juice drinking only from a cup (not a bottle or sippy cup). Notes: The AAP recommends no juice for children younger than 1 year of age. It also recommends limiting fruit juice to 4-6 oz/day for children 1 to 6 years of age and 8-12 oz/day for children ages 7-18. Used with permission from Diona Reeves www.aap.org/oralhealth/pact

Saliva Decreased saliva production is a risk factor for caries development. Because xerostomia is most commonly medication a side effect, prescribers should avoid medications that inhibit saliva whenever possible. Children at risk or who are known to have xerostomia should be more closely screened for caries. These children should also be referred to a dentist early. Notes: The protective effects of saliva are detailed online at http://www.aap.org/oralhealth/pact/ch4_sect2d.cfm. Causes of limited saliva production include systemic diseases (eg, Sjogren’s, other autoimmune disorders) and salivary gland damage (eg, surgery, radiation therapy). Medications responsible for decreased saliva include Glycopyrrolate and other anticholinergics, as well as some medications that treat depression, anxiety, seizures, and hypertension. Glossary: Xerostomia: Abnormal dryness of the mouth due to insufficient saliva production www.aap.org/oralhealth/pact

Paper Permission on file from Jamie Zaleski Delay Colonization Dental caries has a microbial, infectious component. Delaying colonization of a child’s mouth with cariogenic bacteria may also delay the development of dental caries. Notes: Delaying colonization can be achieved through improved parental oral hygiene and the decrease of bacterial transmission, both of which can be encouraged by physicians. Paper Permission on file from Jamie Zaleski www.aap.org/oralhealth/pact

Delay Colonization, continued Modifying the oral flora of the primary caregiver can significantly affect a child’s caries risk. General anticipatory guidance for new and prospective parents before and during the colonization process is recommended. www.aap.org/oralhealth/pact

Delay Colonization, continued Parents should be encouraged to:   Brush their teeth at least twice daily with a fluoridated toothpaste Floss daily Rinse nightly with a fluoridated mouth rinse  Visit a dentist for a cleaning and have all dental disease treated  Consume fruit juices only at meals Avoid carbonated beverages for the first 30 months of an infant’s life  Use Xylitol chewing gum 4 times per day Notes: Chlorhexidine-based mouth rinse are available over the counter. Xylitol chewing gum reduces the number of bacteria in the mouth and decreases the rate of transmission to children. Reference for xylitol recommendation: Isokangas P, Soderling E, Pienihakkinen K, Alanen P. Occurrence of dental decay in children after maternal consumption of xylitol chewing gum, a follow-up from 0 to 5 years of age. J Dental Res; 2000; 79: 1885-1889. Glossary: Xylitol: A crystalline alcohol C5H12O5 that is a derivative of xylose, used as a sweetener www.aap.org/oralhealth/pact

Delay Colonization, continued Parents can theoretically minimize transmission of cariogenic bacteria via saliva transfer in the following ways:   Do not allow children to place fingers into the parent’s mouth  Avoid sharing utensils or toothbrushes Do not taste an infant’s food or drink and then place that food into the child’s mouth  Avoid “cleaning” a dropped pacifier with their saliva Notes: Children’s fingers that are placed in the parents’ mouth will likely eventually end up back in the child’s mouth, therefore spreading the cariogenic bacteria. Used with permission from Melinda B. Clark, MD; Associate Professor of Pediatrics at Albany Medical Center www.aap.org/oralhealth/pact

Dental Visits The American Academy of Pediatrics and the American Academy of Pediatric Dentistry recommend that all children be seen by a dentist within 6 months of eruption of the first tooth or 12 months of age, whichever comes first. In communities with limited pediatric dental resources, children at risk for caries should be prioritized for establishment of a dental home by age 1. Notes: Krol D. Maintaining and Improving the Oral Health of Young Children. AAP Policy Statement. Pediatrics. 2014.; 134: 1224-1229. Paper Permission on file from Michael SanFilippo www.aap.org/oralhealth/pact

Dental Visits, continued It is recommended that all children be referred to a dentist by 12 months of age whenever possible. To facilitate referrals, consider creating a list of local pediatric dentists and use this as a handout for families. It is important to create working relationships with local pediatric and general dentists to allow for “emergent” referrals. Notes: Because the initial risk assessment may still miss at-risk children, the AAP policy statement further states that “the ideal approach to early childhood caries prevention and management is the early establishment of a dental home.” The following national agencies may be helpful in finding local dentists: American Academy of Pediatric Dentistry at 312/337-2169 or http://www.aapd.org/finddentist; or American Dental Association at 312/440-2500 or http://www.ada.org (click on "Find an ADA Member Dentist"). www.aap.org/oralhealth/pact

Dental Sealants Sealants are a plastic material applied to the chewing surface of permanent molars that provide a physical barrier to bacterial invasion of pits and fissures. Sealants are effective because 90% of caries lesions in school-aged children occur in the pits and fissures of molars, the place a sealant seals and protects. Used with permission from David A. Clark, MD; Chairman and Professor of Pediatrics at Albany Medical Center www.aap.org/oralhealth/pact

Dental Sealants, continued The first permanent molars erupt at age 6 and the second permanent molars erupt around age 12. Sealants can be applied at any time based on caries risk assessment performed by the dental professional. A properly applied sealant is virtually 100% effective in preventing a cavity at the site of the sealant. Notes: Sealants are only effective as long as they remain on the tooth. Glossary: Cavity: An area of decay in a tooth www.aap.org/oralhealth/pact

Dental Sealants, continued Using sealants is cost-effective. One sealant costs less than half the cost of a single filling. Sealants need to be used in addition to fluoride. Fluoride primarily benefits the smooth surfaces of teeth, whereas sealants protect the grooved surfaces. Notes: Sealants typically last 5 to 10 years. Sealants should be applied to all high-risk children around the ages of 6 and 12. For more information about sealants, access Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis - United States, 1988-1994 and 1999-2002 at http://www.cdc.gov/MMWR/preview/mmwrhtml/ss5403a1.htm. Used with permission from ANZ Photography www.aap.org/oralhealth/pact

Used with permission from Suzanne Boulter, MD Fluoride Fluoride is effective in the prevention of caries and can be delivered through many modalities. The most important effect of fluoride is the topical effect. Fluoride varnish materials Notes: Fluoride can be provided topically through toothpaste, mouth rinses, gel, or varnish. Fluoride can be provided systemically through drinking water or dietary supplementation. Refer to http://www.aap.org/oralhealth/pact/ch6_intro.cfm for more information about fluoride. Used with permission from Suzanne Boulter, MD www.aap.org/oralhealth/pact

Anticipatory Guidance For children younger than 6 months: Strongly encourage breastfeeding Counsel parents on methods of delaying colonization with cariogenic bacteria.  Delay introduction of juice, preferably until 1 year of age. Recommend drinking juice only from a cup, never from a bottle. Clinician anticipatory guidance should also include age-based oral trauma and injury prevention. For a complete review of this topic, please see http://www2.aap.org/ORALHEALTH/pact/ch10_intro.cfm about oral injury. Paper Permission on file from Raynel Gonzales www.aap.org/oralhealth/pact

Anticipatory Guidance: Late Infancy For children 6 months to 1 year of age: Counsel parents to begin brushing once teeth erupt.  Provide anticipatory guidance on teething care.   Counsel parents that infants should be held when bottle-fed. Bottles should not be propped with infants in cribs or car seats. Notes: Parents should not sweeten pacifiers. If a bottle is given with anything other than water at nap time or bedtime, parents should use a cloth to wipe the baby’s mouth prior to laying the baby down. Children who drink bottles while lying down may be more prone to ear infections. Prolonged and frequent exposure to sugary liquids contributes to the caries process Clinician anticipatory guidance should also include age-based oral trauma and injury prevention. For a complete review of this topic, please see PACT Course 10: Oral Injury. Used with permission from ANZ Photography www.aap.org/oralhealth/pact

Anticipatory Guidance: Late Infancy, continued Introduce a cup as soon as the infant can sit unsupported (around 6 months of age). Try to eliminate the bottle by 1 year of age. Consider fluoride supplements at 6 months if drinking water is non-fluoridated. Provide dental referral around 12 months (approximately 6 months after eruption of the first tooth. Provide dental referral as soon as possible if caries are identified. Notes: High-risk categories include children with special health care and children whose mothers have a high caries rate. A chair side guide to fluoride supplementation is available online from the American Dental Association at http://ebd.ada.org/contentdocs/6327_Fluoride_Chairside_Tool.pdf. More information about high-risk groups is available online at http://aap.org/oralhealth/pact/ch3_sect4.cfm. Clinician anticipatory guidance should also include age-based oral trauma and injury prevention. For a complete review of this topic, please see http://www2.aap.org/ORALHEALTH/pact/ch10_intro.cfm about oral injury. www.aap.org/oralhealth/pact

Anticipatory Guidance: Toddlers For children 1 to 3 years of age:   Recommend brushing at least twice daily.  Discontinue bottle use by 12 months of age. If a sippy cup is offered between meals, it should contain only milk or water. Restrict juice to mealtimes (max 4 ounces per day).   Limit snacks to one time between meals. Notes: Sippy cups containing fruit juices, soft drinks, sweet teas, formula, or milk should not be given to the child at bedtime or nap time. Clinician anticipatory guidance should also include age-based oral trauma and injury prevention. For a complete review of this topic, please see http://www2.aap.org/ORALHEALTH/pact/ch10_intro.cfm about oral injury. Used with permission from Lauren Barone www.aap.org/oralhealth/pact

Anticipatory Guidance: Preschool and School-Age Children Review brushing and flossing.  Encourage regular dental visits.  Review fluoride sources and prescribe fluoride if indicated.  Limit cariogenic snacks between meals. Encourage families to choose fresh fruits, vegetables, and whole grain snacks.  Recommend dental sealants for all high-risk patients. Notes: Review both systemic and topical fluoride sources. Especially limit soda, juice, sweets, and “sticky” foods between meals. Clinician anticipatory guidance should also include age-based oral trauma and injury prevention. For a complete review of this topic, please see http://www2.aap.org/ORALHEALTH/pact/ch10_intro.cfm about oral injury. Paper Permission on file from Sunnah Kim www.aap.org/oralhealth/pact

Question #1 Which statement about flossing is true? A. It should begin when the teeth surfaces touch  B. It typically does not require supervision   C. It is only necessary for adults   D. It is recommended twice a day for children   E. It should begin at 4 years of age in all children www.aap.org/oralhealth/pact

Answer Which statement about flossing is true? A. It should begin when the teeth surfaces touch  B. It typically does not require supervision   C. It is only necessary for adults   D. It is recommended twice a day for children   E. It should begin at 4 years of age in all children www.aap.org/oralhealth/pact

Question #2 What is the recommended age for complete weaning from a bottle to a cup? A. 6 months B. 9 months  C. 12 months D. 18 months   E. 24 months www.aap.org/oralhealth/pact

Answer What is the recommended age for complete weaning from a bottle to a cup? A. 6 months B. 9 months C. 12 months  D. 18 months  E. 24 months www.aap.org/oralhealth/pact

Question #3 Which of the following statements about dental sealants is true? A. Sealants are more expensive than just repairing the cavities  B. Sealants are recommended for all children, regardless of caries risk  C. Sealants should be applied to the primary molars after eruption D. Sealants are applied to the secondary molars at ages 6 and 12 E. Sealants replace the need for fluoride use if applied properly www.aap.org/oralhealth/pact

Answer Which of the following statements about dental sealants is true? A. Sealants are more expensive than just repairing the cavities.  B. Sealants are recommended for all children, regardless of caries risk.  C. Sealants should be applied to the primary molars after eruption.  D. Sealants are applied to the secondary molars at ages 6 and 12.  E. Sealants replace the need for fluoride use if applied properly. www.aap.org/oralhealth/pact

Question #4 Ideally, all children should have their first visit to a dentist by what age? A. Only after the pediatrician identifies a problem during an office visit B. 1 year  C. 2 years D. 3 years  E. 4 years www.aap.org/oralhealth/pact

Answer Ideally, all children should have their first visit to a dentist by what age? A. Only after the pediatrician identifies a problem during an office visit  B. 1 year C. 2 years  D. 3 years E. 4 years www.aap.org/oralhealth/pact

Question #5 Children should be assisted in brushing their teeth until approximately what age? A. 1 B. 2 C. 4 D. 5 E. 7 www.aap.org/oralhealth/pact

Answer Children should be assisted in brushing their teeth until approximately what age? A. 1  B. 2  C. 4 D. 5  E. 7 www.aap.org/oralhealth/pact

References Ahovuo-Saloranta A, Hiiri A, Nordblad A, Worthington H, Mäkelä M. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD001830. DOI: 10.1002/14651858.CD001830.pub2 American Academy of Pediatric Dentistry. Guideline on Infant Oral Health Care. Council on Clinical Affairs. Reference Manual 2011. 33(6):124-128. American Academy of Pediatric Dentistry. Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies. Pediatr Dent 2011. 33(6): 47-49. American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy. Updated 2014. Reference Manual 36(6): 171-74. American Academy of Pediatrics Policy Statement. Oral health Risk Assessment Timing and Establishment of the Dental Home. Pediatrics. 2003; 111(5): 1113-1116. Available online at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/5/1113. American Academy of Pediatrics Committee on Nutrition. The Use and Misuse of Fruit Juice in Pediatrics. Pediatrics. May 2001; 107 (5): 1210-1213. www.aap.org/oralhealth/pact

References, continued American Dental Association Council on Scientific Affairs. Fluoride Toothpaste for Young Children. J Am Dent Assoc. 2014;145(2):190-1. Brambilla E et al. Caries prevention during pregnancy: results of a 30-month study. J Am Dent Assoc. 1998; 129(7): 871-7. Caring for Your Baby and Young Child: Birth to Age 5. American Academy of Pediatrics publication. Bantam Books, 3rd edition; Shelov SP and Hannemann RE (eds); 1998. Clark MB, Slayton RL; AAP Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2014 Sep;134(3):626-33. http://pediatrics.aappublications.org/content/134/3/626 Dental Sealants. JADA. 1997; 128 (4): 485-48. Isokangas P et al. Occurrence of dental decay in children after maternal consumption of xylitol chewing gum, a follow-up from 0-5 years of age. J Dental Res. 2000; 79(11):1885-9. Kaste LM et al. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: US J Dent Res. 1996; 75: 631-641. www.aap.org/oralhealth/pact

References, continued Kohler B, Andreen I. Influence of caries-preventative measures in mothers on cariogenic bacteria and caries experience in their children. Arch Oral Biol. 1994; 39(10): 907-11. Krol D. Maintaining and Improving the Oral Health of Young Children. AAP Policy Statement. Pediatrics. 2014.; 134: 1224-1229 Pang D, Vann WF. The use of fluoride-containing toothpastes in young children: the scientific evidence for recommending a small quantity. Pediatr Dent. 1992; 14(6): 384-387. Siegal MD et al. Dental Sealants: Who needs them? Public Health Reports. 1997; 112(2): 98-106. Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis – United States, 1988-1994 and 1999-2002. MMWR. August 25, 2005. Vol 54 (SS3;1). Truman BI, Gooch BF et al and The Task Force on Community Preventive Services Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. Am J Prev Med. 2002; 23(1):21-54. Wright JT, Hanson N, Ristic H, et al. Fluoride toothpaste efficacy and safety in children younger than 6 years. J Am Dent Assoc. 2014; 145(2):182-9. http://www.aap.org/oralhealth/pact