pediatric oral health risk assessment training for medical professionals

1. Pediatric Oral Health Risk AssessmentTraining for Medical Professionals

3. Pediatric Oral Health Objectives At the completion of this section, the participant will be able to understand the: Role of the medical professional in pediatric oral health promotion and the prevention of dental diseases Recommendations for infant oral health of the American Academy of Pediatric Dentistry and the American Academy of Pediatrics. Indications for the use of fluoride varnish as a preventive treatment for young children Recommendations for oral health anticipatory guidance during pregnancy.

4. Oral Health in America: A Report of the Surgeon General ��oral health is integral to general health (1)� Oral Health and Dental Public Health in South Carolina Timeline Prior to 2000, Dr. Waddell, SCDHEC Deputy Director of Health Services had been working to re-establish a state dental public health program at DHEC. In 2000, the US Surgeon General�s report on �Oral Health in America� not only recognized the importance of children's oral health but also identified the high incidence of dental cares in this population. In 2000, DHEC brought Dr. Ray Lala, a HRSA federal assignee to South Carolina as the director of the Oral Health Division. In 2002, SC was awarded the RWJF State Action for Oral Health Access Program funding for the More Smiling Faces project More Smiling Faces in Beautiful Places (MSF) is one of six oral health initiatives that are part of the State Action for Oral Health Access (SAOHA) Program that is funded by the Robert Wood Johnson Foundation (RWJ) and managed by the Center for Health Care Strategies. MSF is based upon partnerships under the leadership of the South Carolina Department of Health and Environmental Control (SCDHEC). Components of the program include: Creation of an integrated oral health network of dentists, physicians, nurse practitioners, dental hygienists, public and private health providers, community health centers, and churches to increase access to oral health care Provision of pediatric oral health training programs for medical and dental professionals Establishment of a system to link medical homes with oral health care providers, provide patients with resources, screen for eligibility in Medicaid or other insurance programs, and arrange patient transportation Provision of educational guidance and support to parents and families that enable them to become effective managers of their child�s oral health needs. Oral Health and Dental Public Health in South Carolina Timeline Prior to 2000, Dr. Waddell, SCDHEC Deputy Director of Health Services had been working to re-establish a state dental public health program at DHEC. In 2000, the US Surgeon General�s report on �Oral Health in America� not only recognized the importance of children's oral health but also identified the high incidence of dental cares in this population. In 2000, DHEC brought Dr. Ray Lala, a HRSA federal assignee to South Carolina as the director of the Oral Health Division. In 2002, SC was awarded the RWJF State Action for Oral Health Access Program funding for the More Smiling Faces project More Smiling Faces in Beautiful Places (MSF) is one of six oral health initiatives that are part of the State Action for Oral Health Access (SAOHA) Program that is funded by the Robert Wood Johnson Foundation (RWJ) and managed by the Center for Health Care Strategies. MSF is based upon partnerships under the leadership of the South Carolina Department of Health and Environmental Control (SCDHEC). Components of the program include: Creation of an integrated oral health network of dentists, physicians, nurse practitioners, dental hygienists, public and private health providers, community health centers, and churches to increase access to oral health care Provision of pediatric oral health training programs for medical and dental professionals Establishment of a system to link medical homes with oral health care providers, provide patients with resources, screen for eligibility in Medicaid or other insurance programs, and arrange patient transportation Provision of educational guidance and support to parents and families that enable them to become effective managers of their child�s oral health needs.

5. A health problem: tooth decay Significant advances in dentistry have not been equitable to all people. Dental caries is the most common chronic disease affecting children in the United States; five times more common than asthma and seven times more common than hay fever. - On August 26, 2005 the Centers for Disease Control and Prevention (CDC) released a new report in its Morbidity and Mortality Weekly Report (MMWR) surveillance summary titled, Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis�United States, 1988-1994 and 1999- 2002 (available at: http://cdhp.org/newsbytes/newsbytes.asp). Key finding: Dental caries trends are higher among the nation�s youngest children. 28% of Pre-school children ages 2 through 5 years have experienced tooth decay. This findings suggests that over 4 million children are affected nationwide � a jump of over 600,000 additional preschoolers over a decade. South Carolina 2001 Oral Health Needs Assessment- 1 out of 3 children in SC�s kindergartens have experienced untreated tooth decay. Dental disease persists despite the fact that it is preventable. Significant advances in dentistry have not been equitable to all people. Dental caries is the most common chronic disease affecting children in the United States; five times more common than asthma and seven times more common than hay fever. - On August 26, 2005 the Centers for Disease Control and Prevention (CDC) released a new report in its Morbidity and Mortality Weekly Report (MMWR) surveillance summary titled, Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis�United States, 1988-1994 and 1999- 2002 (available at: http://cdhp.org/newsbytes/newsbytes.asp). Key finding: Dental caries trends are higher among the nation�s youngest children. 28% of Pre-school children ages 2 through 5 years have experienced tooth decay. This findings suggests that over 4 million children are affected nationwide � a jump of over 600,000 additional preschoolers over a decade. South Carolina 2001 Oral Health Needs Assessment- 1 out of 3 children in SC�s kindergartens have experienced untreated tooth decay. Dental disease persists despite the fact that it is preventable.

6. Early childhood caries�tooth decay Is defined as the presence of decayed primary teeth Is also known as baby bottle tooth decay Advances rapidly due to the thinness of the enamel Early childhood caries (ECC) occurs in the primary teeth of infants and young children. ECC is often associated with the use of bottles at nap time and bedtime, this is not the exclusive cause.Early childhood caries (ECC) occurs in the primary teeth of infants and young children. ECC is often associated with the use of bottles at nap time and bedtime, this is not the exclusive cause.

7. What are the costs? Children with early childhood tooth decay are more likely to get more decay in their permanent teeth. Goes beyond pain and infection� Affects their speech Affects their ability to eat Affects their ability to learn Affects the way they feel about themselves Dental treatment can be very costly, especially hospitalization for treatment. Oral health disparities impact poor children Low-income children have the greatest odds of having tooth decay, have the most severe experience with tooth decay, and are most likely to have untreated cavities. Children ages 2-11 in families with income under $18,0002 were nearly twice as likely to experience decay as children in families with twice that income level (55% versus 31%). Decay severity was more than twice as great for poor children as their higher income peers. Children in poverty were more than twice as likely to have untreated cavities as their higher income peers. Children of color are more likely to experience tooth decay and have their cavities untreated. Because children of color are the fastest growing subpopulation of children in the U.S., their higher caries experience CDHP Issue Brief Early Childhood Caries Trends Upward http://www.cdhp.org/CDHPPubs/IssuePolicyBriefs.asp Oral health disparities impact poor children Low-income children have the greatest odds of having tooth decay, have the most severe experience with tooth decay, and are most likely to have untreated cavities. Children ages 2-11 in families with income under $18,0002 were nearly twice as likely to experience decay as children in families with twice that income level (55% versus 31%). Decay severity was more than twice as great for poor children as their higher income peers. Children in poverty were more than twice as likely to have untreated cavities as their higher income peers. Children of color are more likely to experience tooth decay and have their cavities untreated. Because children of color are the fastest growing subpopulation of children in the U.S., their higher caries experience CDHP Issue Brief Early Childhood Caries Trends Upward http://www.cdhp.org/CDHPPubs/IssuePolicyBriefs.asp

8. Why begin oral health with the medical provider? First health professional to provide well child care to the infant and continues this care on a regular basis Prevention is a critical component of pediatric care. Today health professionals recognize the importance of oral health as part of total health Opportunity for early intervention Pediatricians, family medicine physicians, nurse practitioners, physician assistants, registered nurses and other health professionals are more likely to reach new mothers and infants on a regular basis during infancy and early childhood than are dentists. Average child visits the medical provider 10 times in the first 3 years to receive both well child and sick care. Pediatric are focuses on preventive care and already has incorporated anticipatory guidance related to pediatric oral health such as diet, feeding practices, fluoride supplementation and injury prevention. Health professionals understand that oral health is part of a child�s overall health and are aware of the impact of dental diseases on a child health and well being. Opportunity for early intervention Pediatricians, family medicine physicians, nurse practitioners, physician assistants, registered nurses and other health professionals are more likely to reach new mothers and infants on a regular basis during infancy and early childhood than are dentists. Average child visits the medical provider 10 times in the first 3 years to receive both well child and sick care. Pediatric are focuses on preventive care and already has incorporated anticipatory guidance related to pediatric oral health such as diet, feeding practices, fluoride supplementation and injury prevention. Health professionals understand that oral health is part of a child�s overall health and are aware of the impact of dental diseases on a child health and well being.

9. American Academy of Pediatric Dentistry Clinical Guideline on Infant Oral Health Care Recognizes that allied health professionals and community organizations must be involved as partners to achieve a lifetime of freedom from preventable oral diseases. Tooth decay in primary teeth predicts future tooth decay in permanent teeth as the child grows older. With the increase in tooth decay in preschool age children, we can expect and increase in tooth decay in their permanent teeth as the children get older. To keep this from happening, it is critical to identify children at greatest risk for caries as early as possible and initiate comprehensive dental treatment that is consistent with professional �age one dental visit� policies and establishment of the �dental home.� The challenge to the dental care system is significant as pre-school age children have the lowest rates of dental care of all age groups in the US and therefore currently miss an important and timely opportunity for effective prevention. Tooth decay in primary teeth predicts future tooth decay in permanent teeth as the child grows older. With the increase in tooth decay in preschool age children, we can expect and increase in tooth decay in their permanent teeth as the children get older. To keep this from happening, it is critical to identify children at greatest risk for caries as early as possible and initiate comprehensive dental treatment that is consistent with professional �age one dental visit� policies and establishment of the �dental home.� The challenge to the dental care system is significant as pre-school age children have the lowest rates of dental care of all age groups in the US and therefore currently miss an important and timely opportunity for effective prevention.

10. AAP and AAPD Recommendations Oral risk assessment including a visual oral screening Anticipatory Guidance Preventive strategies Establishment of the dental home by age one Policies: American Academy of Pediatrics, Section of Pediatric Dentistry. 2003. Oral health risk assessment timing and establishment of the dental home. Pediatrics 3(5):1113-1116. American Academy of Pediatric Dentistry. 2002. Policy on the use of a caries-risk assessment tool (CAT) for infants, children and adolescents. Pediatric Dentistry 24(7):15-17. Policies: American Academy of Pediatrics, Section of Pediatric Dentistry. 2003. Oral health risk assessment timing and establishment of the dental home. Pediatrics 3(5):1113-1116. American Academy of Pediatric Dentistry. 2002. Policy on the use of a caries-risk assessment tool (CAT) for infants, children and adolescents. Pediatric Dentistry 24(7):15-17.

11. Caries begins as a streptococcal infection. In order to progress, Bacteria , predominately streptococcus mutans metabolize fermentable carbohydrates including sugars and starches to produce acid and therefore a low pH. Acid deminterializes or dissolves the tooth If the demineralization continues, the surface enamel is weakened with eventual cavitation or breakdown of the tooth surface As the demineralization continues, the decay spreads farther into the tooth Caries begins as a streptococcal infection. In order to progress, Bacteria , predominately streptococcus mutans metabolize fermentable carbohydrates including sugars and starches to produce acid and therefore a low pH. Acid deminterializes or dissolves the tooth If the demineralization continues, the surface enamel is weakened with eventual cavitation or breakdown of the tooth surface As the demineralization continues, the decay spreads farther into the tooth

12. Parent Sheet: The Bottle and Your Infant�s Dental Health

13. Tooth decay and infants Oral flora colonize the mouth soon after birth Current belief that cariogenic bacteria colonize only after the tooth erupt Tooth decay can begin as soon as the teeth erupt at 6-10 months of age Exactly why an early oral assessment is so important.Exactly why an early oral assessment is so important.

14. Tooth decay is an infectious, transmissible disease Tooth decay bacteria is transmitted from mom or other primary caregiver to baby through Fingers Sharing eating utensils Cleaning pacifier with mother�s saliva The children of mothers with higher caries rate are at higher risk for dental caries Modification of mother�s oral flora at the time the infant�s colonization can significantly impact the child�s caries rate. Oral health risk assessment before 1 year of age offers an opportunity to identify high risk patients and provide timely referral and intervention for the child. Acquisition of S. mutans appears to take place through mouth-to-mouth transmission between caretaker and child. Transmission can be delayed/prevented by the initiation of a prevention program including meticulous oral hygiene, especially in caretakers who demonstrate a high-risk level of S. mutans www.dentalcare.comThe children of mothers with higher caries rate are at higher risk for dental caries Modification of mother�s oral flora at the time the infant�s colonization can significantly impact the child�s caries rate. Oral health risk assessment before 1 year of age offers an opportunity to identify high risk patients and provide timely referral and intervention for the child. Acquisition of S. mutans appears to take place through mouth-to-mouth transmission between caretaker and child. Transmission can be delayed/prevented by the initiation of a prevention program including meticulous oral hygiene, especially in caretakers who demonstrate a high-risk level of S. mutans www.dentalcare.com

15. Caries-risk assessment Child�s History History of dental decay in mother, child and other family members Family is of low economic status Child consumes a high sugar/complex carbohydrate diet Child has special health care needs Child was premature/low birth weight Child routinely is prescribed medications that are sugar based or that reduce salivary flow Information adapted from the Policy on Use of a Caries-risk Assessment Tool (CAT) for Infants, Children and Adolescents. American Academy of Pediatric Dentistry Information adapted from the Policy on Use of a Caries-risk Assessment Tool (CAT) for Infants, Children and Adolescents. American Academy of Pediatric Dentistry

16. Tools for a visual oral screening Light Tongue depressor Long handled cotton swab/toothpick 2x2 gauze Toothbrush

17. Knee to knee position The child is initially held by mother and slowly lowered into health professional�s lap. Child may cry, but that will allow you to see their teeth better. Some medical providers prefer positioning the child on the exam table and working from behind the head or have older children sit on the table. Ask mother to hold the child�s hands The child is initially held by mother and slowly lowered into health professional�s lap. Child may cry, but that will allow you to see their teeth better. Some medical providers prefer positioning the child on the exam table and working from behind the head or have older children sit on the table. Ask mother to hold the child�s hands

18. Visual oral screening Lift the lip Check for presence of plaque and food on teeth Check gums and soft tissues�look for abscesses For more information on Oral Development: http://www.mchoralhealth.org/PediatricOH/mod2_1.htm Common oral conditions and abnormalities: http://www.mchoralhealth.org/PediatricOH/mod3.htmFor more information on Oral Development: http://www.mchoralhealth.org/PediatricOH/mod2_1.htm Common oral conditions and abnormalities: http://www.mchoralhealth.org/PediatricOH/mod3.htm

19. Examine the teeth Observe the teeth from the Outside surfaces Look for �White Spots� Look for obvious signs of tooth decay such as brown spots or breaks in the tooth surface Look from the inside of the upper front teeth Healthy teeth are shiny and smooth. Arrows point to �white spots� or areas of demineralized enamel. Earliest signs of decay may appear as white spots or like frosted glass or flat paint. �White spots� can be remineralized with the use of fluoride varnish Brown or yellow spots or carious lesions on the teeth are more obvious signs of tooth decay The inside of the upper front teeth is where the baby bottle nipple rests. Once the disease is established and the decay goes through the enamel into the dentin, restorative care is required. Once a child has experienced tooth decay, follow ups is very important.Healthy teeth are shiny and smooth. Arrows point to �white spots� or areas of demineralized enamel. Earliest signs of decay may appear as white spots or like frosted glass or flat paint. �White spots� can be remineralized with the use of fluoride varnish Brown or yellow spots or carious lesions on the teeth are more obvious signs of tooth decay The inside of the upper front teeth is where the baby bottle nipple rests. Once the disease is established and the decay goes through the enamel into the dentin, restorative care is required. Once a child has experienced tooth decay, follow ups is very important.

20. Looking at the back teeth Look for Dark spots and stains Breaks in the tooth surface

21. Show parent how to do a Smile Check Gently lift your child�s upper lift Look at the outside and the inside of the upper front teeth If you observe any signs of tooth decay, you can show them to the parent. Show parent how to lift the child�s upper lip while brushing the upper teeth and to routinely check the teeth for chalky white or brown spots, being sure to look at both the front and back of the teeth and near the gumline. White spots=early signs of decay. Child needs to see a dentist!If you observe any signs of tooth decay, you can show them to the parent. Show parent how to lift the child�s upper lip while brushing the upper teeth and to routinely check the teeth for chalky white or brown spots, being sure to look at both the front and back of the teeth and near the gumline. White spots=early signs of decay. Child needs to see a dentist!

22. Referral for dental care The findings�are provided below: Needs regular dental examination Needs dental treatment within one month Needs dental treatment immediately

23. Needs regular dental examination Slides from: www.dentalcare.com Slides from: www.dentalcare.com

24. Needs treatment within 1 month Slides from: www.dentalcare.com Slides from: www.dentalcare.com

25. Immediate dental treatment Signs or symptoms that include pain, infection, swelling or soft tissue ulceration of more than 2 weeks duration determined by questioning.

26. Needs immediate treatment Slides from: www.dentalcare.comSlides from: www.dentalcare.com

27. Establish a Dental Home Refer high risk children by 6 months Refer all children by the age of one Dental home: provides care of infants and children ideally that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.  Dental home: provides care of infants and children ideally that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.

28. Children with Special Health Care Needs Refer early referral for dental care (before or by age 1) Collaboration with dentist is especially important Emphasize with parents the importance of oral health to CSHCN

29. Considerations for CSHCN Medications for asthma and allergies often reduce salivary flow which increases risk for tooth decay Children who are preterm or low birth weight have a higher rate of enamel defects and are at increased risk for tooth decay Infants with feeding problems are often placed on special high carbohydrate diets Other considerations are: May not be receiving adequate home care due to competing medical needs. Most babies and young children with SHCN are considered to be at �high risk� for tooth decay. Dilantin, medication for epilepsy and medications used to prevent transplant rejection can lead to gingival overgrowth (hypertrophy) which makes hygiene difficult and increases risk for gum disease.Other considerations are: May not be receiving adequate home care due to competing medical needs. Most babies and young children with SHCN are considered to be at �high risk� for tooth decay. Dilantin, medication for epilepsy and medications used to prevent transplant rejection can lead to gingival overgrowth (hypertrophy) which makes hygiene difficult and increases risk for gum disease.

30. Oral Hygiene After feeding, an infant's teeth and gums shall be wiped with a moist cloth to remove any remaining liquid that coats the teeth and gums Sit your baby on your lap, facing to one side Support the health with your arm and hand Use the index finger or thumb of your supporting hand to open the mouth and support the lower jaw Wrap the wet cloth around the index finger of your other hand Wipe the roof of the mouth, tongue, cheeks and gums Once teeth appear, clean with cloth or small soft toothbrush Breastfeeding should be encouraged and mothers should be advises that removing their baby from the breast and wiping their baby�s gums reduces the risk of tooth decay in baby teeth. Sit your baby on your lap, facing to one side Support the health with your arm and hand Use the index finger or thumb of your supporting hand to open the mouth and support the lower jaw Wrap the wet cloth around the index finger of your other hand Wipe the roof of the mouth, tongue, cheeks and gums Once teeth appear, clean with cloth or small soft toothbrush Breastfeeding should be encouraged and mothers should be advises that removing their baby from the breast and wiping their baby�s gums reduces the risk of tooth decay in baby teeth.

31. Oral Hygiene: Infant to Toddler� When teeth appear you can use a small, soft toothbrush As baby gets bigger, you can trying sitting on the floor with the baby�s head in your lap As baby gets bigger, you can trying sitting on the floor with the baby�s head in your lap

32. Oral Hygiene: Supervised Brushing Young children have not developed good coordination, so you will need to help them until about age 8.The caregiver will evaluate the child�s motor activity to assess the child�s capabilities to brush effectively. The care giver should brush the child�s teeth after the child has completed brushing. Note: Caregiver�s hand is over the child�s hand. This allows the caregiver to teach the child proper brushing technique. This is an important part of teaching the child how to brush properly. Young children have not developed good coordination, so you will need to help them until about age 8.The caregiver will evaluate the child�s motor activity to assess the child�s capabilities to brush effectively. The care giver should brush the child�s teeth after the child has completed brushing. Note: Caregiver�s hand is over the child�s hand. This allows the caregiver to teach the child proper brushing technique. This is an important part of teaching the child how to brush properly.

33. Diet and Oral Health If the baby goes to bed with a bottle, only use water. Baby should begin using a cup by 6 months Wean from bottle to cup by age 1 Avoid letting baby walk around with a bottle or sippy cup with milk, juice or sweet liquid Any liquid except water � even milk and juice � can cause cavities. Some other ways to calm baby: Favorite blanket or toy Pacifier Holding, patting, rocking Softly singing or talking to babyAny liquid except water � even milk and juice � can cause cavities. Some other ways to calm baby: Favorite blanket or toy Pacifier Holding, patting, rocking Softly singing or talking to baby

34. Encourage Good Food Choices With obesity and diabetes on the rise in SC� children, we have a responsibility to counsel families to limit both sugar intake and the frequency of exposures per day to enhance both general overall health as well as oral health.With obesity and diabetes on the rise in SC� children, we have a responsibility to counsel families to limit both sugar intake and the frequency of exposures per day to enhance both general overall health as well as oral health.

35. Medicines Children�s medication often contain sugar Some decrease the child�s salivary flow Be sure to inform parents or caregivers to brush the child�s teeth after giving him or her their medication. The bacteria in the mouth use the sugar to make acids that can demineralize the tooth surface.The bacteria in the mouth use the sugar to make acids that can demineralize the tooth surface.

36. Fluoride�the Tooth Protector Water that may contains fluoride: Community water systems Well water with naturally occurring fluoride Fluoride in the water helps slow down the loss of the tooth surface---by replacing the lost minerals with fluoride, a process called remineralization Check local water systems for fluoridation information at: CDC�s My Water�s Fluoride website: http://www.scdhec.net/hs/mch/dental/WaterFlou.html Optimal fluoride concentration of water systems should be in the .7 to 1.2 parts per million

37. ADA Recommended Supplements Children should receive supplements based on this table only after a determination of the FL content of their primary water source.Children should receive supplements based on this table only after a determination of the FL content of their primary water source.

38. Fluoride Toothpaste Small, pea sized amount beginning at age 2 Under age 2, water only Supervised use under age 8 years ADA approved FL containing toothpaste is recommended for children age two and over. Very small amount (pea sized) should be smeared on brush for use with very young children.ADA approved FL containing toothpaste is recommended for children age two and over. Very small amount (pea sized) should be smeared on brush for use with very young children.

39. Injury Prevention Parent Information Booklet: Is Your Home Safe?, page 20 Safety: Toys and Dental Health, page 21 Home for the Holidays, page 22 Keeping Your Child�s Smile Safe When Riding in a Car, page 25 Keeping Your Child�s Smile Safe At Home and In School, page 26 Keeping Your Child�s Smile Safe When Shopping, page 27 How to Respond to a Dental Emergency, page 28

40. Why do we recommend fluoride varnish for very young children? To prevent dental caries and in some cases reverse early dental caries Children with early childhood decay are more likely to get more decay Baby teeth are in a child�s mouth until about age 11 or 12 Fluoride varnish helps reverse early demineralization that has already started. Fluoride varnish helps reverse early demineralization that has already started.

41. Who should receive fluoride varnish? Children are at risk for developing dental caries. Risk assessment based on the Caries Risk Assessment

42. Risk factors for dental caries are: History History of dental decay in mother, child and other family members Family is of low economic status Child consumes a high sugar/complex carbohydrate diet Child has special health care needs Child was premature/low birth weight Child routinely is prescribed medications that are sugar based or that reduce salivary flow Clinical evaluation Visible plaque, white spots and/or decay Gingivitis�gums appear red, swollen, report bleeding when brushing White spots/demineralization

43. How does fluoride varnish work? The lacquer-based product adheres to the dental enamel forming a depot from which fluoride is slowly released A dry tooth surface allows the uptake of the fluoride into the tooth surface Saliva actually sets the varnish

44. Advantages of fluoride varnish easy to apply teeth do not need professional prophylaxis children can eat and drink following applications potential ingestion of fluoride is low due to the sticky form of the varnish and the small amount used prevents tooth decay and reverses early decay

45. White spots White spots are areas of demineralization and considered early decay�Indication for fluoride varnish applications.White spots are areas of demineralization and considered early decay�Indication for fluoride varnish applications.

46. Knee to knee position Child is examined in a knee-to-knee position with parent. Child is examined in a knee-to-knee position with parent.

47. Fluoride varnish application 1. Dry teeth with gauze square Remember to clean and dry the teeth. It is critical to dry the teeth with a gauze before applying the varnish.Remember to clean and dry the teeth. It is critical to dry the teeth with a gauze before applying the varnish.

48. Post application instructions for parents Varnish will set on contact with saliva and look like a yellowish film Child can eat or drink right after application but should try to eat soft foods Instruct parent not to brush their child�s teeth until the next day. The first toothbrushing will remove the yellow film on the teeth.

49. When fluoride varnish is used to remineralize white spot lesions these are the results. Acknowledgement: The fluoride varnish section was adapted wit permission from the work of Dr. Michael Kanellis, Department of Pediatric Dentistry, University of Iowa. When fluoride varnish is used to remineralize white spot lesions these are the results. Acknowledgement: The fluoride varnish section was adapted wit permission from the work of Dr. Michael Kanellis, Department of Pediatric Dentistry, University of Iowa.

50. You can make a difference!! Integrate oral health assessment into well child visits Provide patient education regarding oral health Document findings and follow up Train office staff in oral assessment Identify dentists in your area who accept new patients and Medicaid patients. Take a dentist to lunch to establish a referral relationship Investigate fluoride content in area water supply Oral Health Risk Assessment Training for Pediatricians and Other Child Health Professionals Developed by American Academy of Pediatrics Pediatrics Collaborative Care (PedCare) Program Supported by the Maternal and Child Health Bureau, Health Resources and Services Administration Department of Health and Human Services U93MC0 Oral Health Risk Assessment Training for Pediatricians and Other Child Health Professionals Developed by American Academy of Pediatrics Pediatrics Collaborative Care (PedCare) Program Supported by the Maternal and Child Health Bureau, Health Resources and Services Administration Department of Health and Human Services U93MC0

51. At the completion of this section, the participant will be able to describe anticipatory guidance for the mother both before the baby is born and following the infant�s birth.

52. Water Ask your doctor or your dentist if your water has fluoride in it. Fluoride is a safe, easy way to protect your teeth from tooth decay. If you buy bottled water, check the label for fluoride. Fluoride prevents tooth decay by inhibiting the demineralization of the tooth surface-enamel, enhancing remineralization and inhibiting the bacteria in plaque. Water fluoridation is considered to one of the greatest public health advances of the 20th century. Fluoride prevents tooth decay by inhibiting the demineralization of the tooth surface-enamel, enhancing remineralization and inhibiting the bacteria in plaque. Water fluoridation is considered to one of the greatest public health advances of the 20th century.

53. Anticipatory guidance for mother Or other intimate caregiver before and during colonization process Brush and floss daily to disturb cariogenic bacteria and reduce bacterial plaque levels Use toothpaste with fluoride Fluoride toothpaste is effective at preventing dental caries.Fluoride toothpaste is effective at preventing dental caries.

54. Eat healthy foods Chose foods low in sugar. Eat healthy snacks like fruit, cheese and vegetables. Get enough calcium for you and your baby�s healthy teeth and bones. Calcium is in milk, cheese, dried beans and leafy green vegetables. Avoid carbonated drinks It is important to address the limiting the frequency of simple carbohydrates including sugary foods and drinks, and foods like potato chips. It is the frequency of fermentable carbohydrate intake that contributes to tooth decay. For more information: http://ohioline.osu.edu/mob-fact/0001.html Nutritional information for pregnancy and for the child up to age three. Into the Mouths of Babes: A Nutritional Guide to Age Three Nutritional Needs of PregnancyIt is important to address the limiting the frequency of simple carbohydrates including sugary foods and drinks, and foods like potato chips. It is the frequency of fermentable carbohydrate intake that contributes to tooth decay. For more information: http://ohioline.osu.edu/mob-fact/0001.html Nutritional information for pregnancy and for the child up to age three. Into the Mouths of Babes: A Nutritional Guide to Age Three Nutritional Needs of Pregnancy

55. Dental care for mother Refer to dentist to: To maintain or to restore to health the oral tissues which includes not only healthy teeth but also gums and the supporting tissues or the oral cavity. If dental caries are present, removal of decay and restoration of teeth Serious gum disease has been linked to premature and low birth weight babies. This visit gives the dental team the opportunity to assess the mother�s caries risk and subsequently the caries risk for her child.Serious gum disease has been linked to premature and low birth weight babies. This visit gives the dental team the opportunity to assess the mother�s caries risk and subsequently the caries risk for her child.

56. Mother chewing xylitol gum Recent evidence suggests that chewing xylitol gum kills cariogenic bacteria Chew 1 piece of gum for 5 minutes 3-5 times a day decreases the child�s caries rate. Xylitol is a naturally occurring sugar. An over the counter brand is Carefreee Koolerz (1.6 grams piece). When purchasing over the counter xylitol products, one should look to see if xylitol is listed as the first ingredient. A therapeutic dose is 5-10 grams per day. Xylitol is a naturally occurring sugar. An over the counter brand is Carefreee Koolerz (1.6 grams piece). When purchasing over the counter xylitol products, one should look to see if xylitol is listed as the first ingredient. A therapeutic dose is 5-10 grams per day.

57. Now is the time for mom to learn How to keep her child cavity-free! Get her mouth healthy�see her dentist Learn how to do a Smile Check on a baby Learn how to clean a baby�s teeth Learn how to prevent baby bottle tooth decay by not putting the baby in bed with a bottle at night or naptime. Be prepared to ask her doctor or dentist to check you�re the baby�s teeth by age one. Talk to her doctor or dentist about fluoride. Get regular dental care because cavity germs in your mouth can be passed to your baby by sharing spoons, forks and cups. Learn how to do a Smile Check to check for white spots or stains on the teeth by lifting the baby�s upper lip. Learn how to clean your baby�s teeth by wiping the baby�s mouth and teeth with a clean, soft cloth or a baby toothbrush. To prevent baby bottle tooth decay do not put your baby in bed with a bottle at night or naptime. If you do use a bottle at night or naptime, fill it with water only. Teach you child how to use a cup around age one. Ask you doctor or dentist to check your child�s teeth by age one. Fluoride drops are important for babies starting at 6 months of age. Talk to your doctor or dentist about fluoride. Get regular dental care because cavity germs in your mouth can be passed to your baby by sharing spoons, forks and cups. Learn how to do a Smile Check to check for white spots or stains on the teeth by lifting the baby�s upper lip. Learn how to clean your baby�s teeth by wiping the baby�s mouth and teeth with a clean, soft cloth or a baby toothbrush. To prevent baby bottle tooth decay do not put your baby in bed with a bottle at night or naptime. If you do use a bottle at night or naptime, fill it with water only. Teach you child how to use a cup around age one. Ask you doctor or dentist to check your child�s teeth by age one. Fluoride drops are important for babies starting at 6 months of age. Talk to your doctor or dentist about fluoride.