Children’s Oral Health & the Primary Care Provider
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Children’s Oral Health & the Primary Care Provider. Oral Screening Exam Module 3. Module 3 Objectives:. Learn to perform a knee-to-knee oral screening exam for infants & toddlers

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Module 3 objectives
Module 3 Objectives:

  • Learn to perform a knee-to-knee oral screening exam for infants & toddlers

  • Learn helpful tips to gain access to a child’s mouth & restrain a child’s body movements during an oral screening exam

  • Learn to identify clinical findings predictive of high caries risk for infants & toddlers

  • Learn to identify caries in its different stages

    (non-cavitated (white spots) vs. cavitated lesions)


Knee to knee oral screening exam
Knee-to-Knee Oral Screening Exam

Step 1: Child is held facing caregiver

in a straddle position

Step 2: Child leans back onto examiner while caregiver holds child’s hands and legs

Step 3: Provider performs exam while caregiver effectively restrains child’s hands and legs


Equipment for the oral screening exam
Equipment for the Oral Screening Exam

  • Disposable gloves

  • Good light source

  • Disposable mirror (optional)

  • Toothbrush or gauze (for plaque removal)


Performing an oral screening exam
Performing an Oral Screening Exam

  • Place the child in the knee-to-knee position

  • Restrain child’s head and body movements

  • Lift the child’s upper lip and lower child’s lower lip

Lift-the-Lip Procedure


Knee to knee position dental setting
Knee-to-Knee Position: Dental Setting

Double-click the picture to begin the video clip


Knee to knee position medical setting
Knee-to-Knee Position: Medical Setting

Double-click the picture to begin the video clip



Previous caries experience
Previous Caries Experience

  • One of best predictors of future caries

  • For children under age 5, a history of decay should automatically classify a child as high risk

  • Not useful caries-risk predictor

    for infants and toddlers

    (insufficient time for ECC

    to be expressed)


Visible plaque

Dental Plaque

Dental Plaque

Visible Plaque

  • One of the best predictors of future caries risk in young children

  • Screening for visible plaque is easy and inexpensive


White spot lesions
White Spot Lesions

  • Also referred to as non-cavitated lesions

  • Initial stage (precursor) of the caries process

  • Equivalent to caries for infants and toddlers

Chalky, white spots on primary teeth are demineralized areas and are considered early decay


White spot lesions1
White Spot Lesions

Are often:

  • Observed next to the gum line

  • Accompanied by plaque

  • Accompanied by bleeding gums (gingivitis)

Chalky, white spots on primary teeth are demineralized areas and are considered early decay


From white spots to frank caries

Figure 1

Figure 2

Figure 3

From White Spots to Frank Caries




  • All pictures show advanced frank cavities (cavitated lesions) that have reached the nerve (pulp) of the teeth. These children are in pain and need immediate and/or emergency dental treatment

  • Green arrow shows the presence of an abscess due to a necrotic tooth


Enamel defects stained pits and fissures

Enamel Hypoplasia lesions) that have reached the nerve (pulp) of the teeth. These children are in pain and need immediate and/or emergency dental treatment

Stained Pits

and Fissures

Enamel Defects & Stained Pits and Fissures

  • Enamel hypoplasia

  • Stained pit and fissure surfaces of primary teeth

  • Consider these indicative of increased caries risk


Presence of braces and oral appliances
Presence of Braces lesions) that have reached the nerve (pulp) of the teeth. These children are in pain and need immediate and/or emergency dental treatment and Oral Appliances


Caries risk assessment and management
Caries Risk Assessment lesions) that have reached the nerve (pulp) of the teeth. These children are in pain and need immediate and/or emergency dental treatment and Management

  • Any observable decay or demineralization (white spots):

    - Refer for dental care as soon as possible

  • Any factors on the oral screen (or parent interview) that increase the child’s risk for caries:

    - Refer for dental care

  • Uncertain caries risk:

    - Refer for dental care

  • Refer to your I-Smile Coordinator for care, assistance with referrals & to ensure dental care is established

  • Re-assess to ensure the child has been evaluated by a dentist & has established regular dental care


I smile coordinators
I-Smile Coordinators lesions) that have reached the nerve (pulp) of the teeth. These children are in pain and need immediate and/or emergency dental treatment

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. I-Smile Coordinators 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.

I-Smile Coordinator contact information can be found at: www.idph.state.ia.us/hpcdp/oral_health.asp or

I-Smile hotline 1-866-528-4020


Summary oral screening exam
Summary: Oral Screening Exam lesions) that have reached the nerve (pulp) of the teeth. These children are in pain and need immediate and/or emergency dental treatment

Use the knee-to-knee position for oral screening exams

Clinical findings predictive of high caries risk for infants and toddlers:

previous caries experience

visible plaque

white spot lesions

enamel defects

stained pits and fissures

oral appliances


Summary: Oral Screening Exam lesions) that have reached the nerve (pulp) of the teeth. These children are in pain and need immediate and/or emergency dental treatment

  • During an oral screening exam remember to:

    • Restrain the child’s head and body movements

    • “Lift-the-lip”: lift the upper lip & pull down the lower lip to examine the child’s teeth

    • Dry the child’s teeth to examine for white spot lesions

    • Remove plaque using a toothbrush or gauze to examine for possible white spot lesions under plaque


Summary: Oral Screening Exam lesions) that have reached the nerve (pulp) of the teeth. These children are in pain and need immediate and/or emergency dental treatment

  • Refer a child for dental care as soon as possible if any caries or white spot lesions are observed

  • Refer for dental care if any of the clinical findings predictive of high caries risk are observed and/or if you are uncertain of the child’s caries risk

  • Refer to your I-Smile Coordinator for care & to ensure dental care is established


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