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Pediatric Oral Health. Bob Selvester, MD LCDR MC USN Family Physician Interservice Physician Assistant Program. Prevalence of Dental Caries. 5 times more common than asthma 7 times more common than hay fever Caries Rate 18% aged 2 to 4 years 52% aged 6 to 8 years 67% aged 12 to 17 years.

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Pediatric Oral Health

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pediatric oral health

Pediatric Oral Health

Bob Selvester, MD


Family Physician

Interservice Physician Assistant Program

prevalence of dental caries
Prevalence of Dental Caries
  • 5 times more common than asthma
  • 7 times more common than hay fever

Caries Rate

  • 18% aged 2 to 4 years
  • 52% aged 6 to 8 years
  • 67% aged 12 to 17 years
learning objectives
Learning Objectives
  • State the key components of a primary care oral health history and physical examination.
  • State the recommended intervals for examination by a Dental Health professional.
  • Recognize indications for referral
aapa paea nccpa arc pa
  • Do not address expectations for oral health except to say there must be training in all body systems
  • Dietary fluoride supplements should be considered for children from ages 6 months through 16 years when drinking water levels are suboptimal.
  • The AAFP recognizes avoidance of tobacco products by children and adolescents is desirable.
    • The effectiveness of physician advice and counseling in this area is uncertain.
uspstf recommendations
USPSTF Recommendations
  • Evidence is insufficient to recommend for or against routine risk assessment of preschool children by primary care clinicians for the prevention of dental disease (Rating I)
  • Primary care clinicians prescribe oral flouride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in flouride. (Rating B)

Prior to 2000, initial exam by Dentist was recommended at age of 3.

the american academy of pediatrics oral health initiative

The American Academy of Pediatrics Oral Health Initiative

The American Academy of Pediatrics Oral Health Initiative

Wendy Nelson

Manager Oral Health Initiative

January 25, 2008

brief pathophysiology
Brief Pathophysiology
  • Cariogenic Bacteria
  • Frequency of exposure
  • Contact time
  • Acidity
oral flora how does infection occur
Oral Flora: How Does Infection Occur?
  • Transmitted mainly from mother or primary caregiver to infant
  • Window of infectivity is first 2 years of life
  • Earlier child colonized, the higher the risk of caries
substrate you are what you eat
Substrate: You Are What You Eat
  • Caries is promoted by carbohydrates, which break down to acid.
  • Acid causes demineralization of enamel.
  • Frequent snacking promotes acid attack.
  • Foods with complex carbohydrates (breads, cereals, pastas) are major sources of “hidden” sugars.
  • High sugar content in sodas is a source of these substrates.
fluoride s influence on oral flora
Fluoride’s Influence on Oral Flora
  • Promotes remineralization of enamel, and may arrest or reverse early caries
  • Decreases enamel solubility
  • Inhibits the growth of cariogenic organisms, thus decreasing acid production
  • Concentrated in dental plaque
  • Primarily topical even when given systemically
not just what you eat but how often
Not Just What You Eat, But How Often
  • Acids produced by bacteria after sugar intake persist for 20 to 40 minutes.
  • Frequency of sugar ingestion is more important than quantity.
substrate environmental influences
Substrate: Environmental Influences
  • Saliva inhibits bacterial growth.
  • Unremoved plaque promotes the caries process.

Red disclosing tablet reveals plaque

aap recommendations for an oral health risk assessment
AAP Recommendations for an Oral Health Risk Assessment
  • Assess mothers’/caregiver’s oral health.
  • Assess oral health risk of infants and children.
  • Recognize signs and symptoms of caries.
  • Assess child’s exposure to fluoride.
  • Make timely referral to a dental home.
  • Provide anticipatory guidance including oral hygiene instructions (brush/floss).
high risk groups for caries
High-Risk Groups for Caries
  • Children with special health care needs
  • Children from low socioeconomic and ethnocultural groups
  • Children with suboptimal exposure to topical or systemic fluoride
  • Children with poor dietary and feeding habits
  • Children whose caregivers and/or siblings have caries
fluoride exposure
Fluoride Exposure
  • Determine fluoride exposure: systemic versus topical
  • Fluoridated water
    • 58% of total population
    • Optimal level is 0.7 to1.2 ppm
    • Significant state variability
    • CDC fluoridation map
positioning child for oral examination
Positioning Child for Oral Examination
  • Position the child in the caregiver’s lap facing the caregiver.
  • Sit with knees touching the knees of caregiver.
  • Lower the child’s head onto your lap.
  • Lift the lip to inspect the teeth and soft tissue.
aapd caries risk assessment tool cat
AAPD Caries Risk Assessment Tool (CAT)

Caries Risk Indicators

Chart based on the AAPD Caries-Risk Assessment Tool. For more information on using the tool, refer to

initial screening by child dental professional
Initial Screening by Child Dental Professional
  • By 12 months of age or 6 months after eruption of first tooth (whichever is sooner)—even natal teeth . . .
    • All children at “High Risk”—as early as 6 months of age. (earlier)
    • Any child with visible caries, plaque, or decay (right away)
referral establishment of dental home
Referral: Establishment of Dental Home

What is a dental home?

When to refer?

  • Refer high-risk children by 6 months.
  • Refer all children by 1 year.
anticipatory guidance37
Anticipatory Guidance
  • Minimize risk of infection.
  • Optimize oral hygiene.
  • Reduce dietary sugars.
  • Remove existing dental decay.
  • Administer fluorides judiciously.
xylitol for mothers children
Xylitol for Mothers/Children

Xylitol gum or mints used 4 times a day may prevent

transmission of cariogenic bacteria to infants.

  • Helps reduce the development of dental caries
  • A “sugar” that bacteria can’t use easily
  • Resists fermentation by mouth bacteria
  • Reduces plaque formation
  • Increases salivary flow to aid in the repair of damaged tooth enamel
substrate contributing dietary and feeding habits
Substrate: Contributing Dietary and Feeding Habits
  • Frequent consumption of carbohydrates, especially sippy cups/bottles with fruit juice, soft drinks, powdered sweetened drinks, formula, or milk
  • Sticky foods like raisins/fruit leather (roll-ups), and hard candies
  • Bottles at bedtime or nap time not containing water
  • Dipping pacifier in sugary substances
optimizing oral hygiene flossing
Optimizing Oral Hygiene: Flossing

When to Use Floss

  • Once a day (preferably at night)
  • Whenever any 2 teeth touch
toothpaste and children
Toothpaste and Children
  • Children ingest substantial amounts of toothpaste because of immature swallowing reflex.
  • Early use of fluoride toothpaste may be associated with increased risk of fluorosis.
  • Once permanent teeth have mineralized (around 6-8 years of age), dental fluorosis is no longer a concern.

A small pea-sized amount of toothpaste weighs 0.4 mg to 0.6 mg fluoride, which is equal to the daily recommended intake for children younger than 2 years.

example of fluorosis
Example of Fluorosis

Mild Fluorosis

Severe Fluorosis

recommended fluoride supplement schedule

Fluoride Concentration in Community Drinking Water


<0.3 ppm

0.3–0.6 ppm

>0.6 ppm

0–6 months




6 mo–3 yrs

0.25 mg/day



3 yrs–6 yrs

0.50 mg/day

0.25 mg/day


6 yrs–16 yrs

1.0 mg/day

0.50 mg/day


Recommended Fluoride Supplement Schedule

MMWR: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the US:

cme credit
CME Credit

Take this training online to earnContinuing Medical Education credit! about this training?E-mail

photo credits
Photo Credits

Special thanks to the following individuals and

organizations for contributing to this training:

AAP Breastfeeding Initiatives

American Academy of Pediatric Dentistry

American Dental Association

ANZ Photography

Suzanne Boulter, MD

George Brenneman, MD

Content Visionary

Melinda Clark, MD

Joanna Douglass, BDS, DDS

Rani Gereige, MD

Donald Greiner, DDS, MSc

Indian Health ServiceMartha Ann Keels, DDS

Sunnah Kim

Cynthia Neal, DDS

Rama Oskouian, DMD

P&G Dental ResourceNet

Michael San Filippo

Gregory Whelan, DDS


Primary Authors

Suzanne Boulter, MD, FAAP

Paula Duncan, MD, FAAP

Kevin Hale, DDS

Martha Ann Keels, DDS, PhD

David Krol, MD, MPH, FAAP

Wendy Mouradian, MD, MS, FAAP

Wendy Nelson, ACCE

Additional Contributors

Betty Crase, IBCLC, RLC

Martin J Davis, DDS

Adriana Segura Donly, DDS, MS

Rocio B Quinonez, DMD, MS, MPH

Kathleen Marinelli, MD, IBCLC, FAAP

Special thanks to the following individuals for contributing to the development of this training: