Anticipatory Guidance in Infant Oral Health: Rationale and Recommendations



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If appropriate measures are applied early enough, it may be possible to totally prevent oral disease. The American Academy of Pediatric Dentistry recommends that infants be scheduled for an initial oral evaluation within six months of the eruption of the first primary tooth but by no later than 12 months of age. The rationale for this recommendation is provided, although the recommendation itself is not universally accepted. Specific recommendations include elimination of bottles in bed, early use of soft-bristled toothbrushes (with parental supervision) and limitation of high-carbohydrate food intake after teeth have been brushed.

The oral health of children in industrialized countries has improved considerably during the past four decades. Yet, a significant number of children still present with oral disease at the first dental visit. Oral disease, especially dental caries, is complicated and multifactorial, and it often begins to develop during infancy. Although certain risk factors are associated with the development of oral disease in children, it has been difficult to consistently identify infants at greatest risk for oral disease later in life.1 For this reason, contemporary guidelines on the management of oral disease recommend that more emphasis be placed on primary prevention.2,3

The American Academy of Pediatric Dentistry (AAPD) recommends that infants (and parents) be scheduled for an initial oral evaluation visit within six months of the eruption of the first primary tooth but by no later than 12 months of age.3 This article provides information to help health care professionals understand the rationale behind this recommendation. Specific clinical recommendations concerning bottle use, brushing technique and preventive oral health are also discussed.

Health Supervision vs. Disease Treatment

For many years, the approach to oral disease (dental caries, periodontal disease and acquired or hereditary oral conditions) has been to treat destructive effects and then initiate a preventive program. Contemporary guidelines recommend more emphasis on early professional intervention consisting of an oral examination, risk assessment of infants and anticipatory guidance for parents.2,3 The goal of primary prevention is to stop the onset of disease or to interfere with its progression before treatment becomes necessary. With early professional intervention, it may be possible to reduce or even eliminate oral disease.2,3  The AAPD recommendations for infant oral health care are summarized in Table 1.4

TABLE 1

American Academy of Pediatric Dentistry Recommendations on Infant Oral Health Care

Ideally, infant oral health begins with prenatal oral health counseling for parents; a postnatal initial oral evaluation should be performed within six months of the eruption of the first primary tooth in an infant but by no later than 12 months of age.

At the infant oral evaluation visit, the dentist should do the following:

Obtain a thorough medical and dental history, covering the prenatal, perinatal and postnatal periods. Perform a thorough oral examination.

Assess the infant's risk of developing oral and dental disease, and determine the appropriate interval for periodic reevaluation based on the assessment.

Provide anticipatory guidance for the parent or other caregiver regarding dental and oral development, fluoride status, nonnutritive oral habits, injury prevention, oral hygiene and effects of diet on dentition.

The dentist who performs these services for an infant should be prepared to provide therapy when indicated or should refer the infant to an appropriately trained person for necessary treatment.


Adapted with permission from Oral health policies. American Academy of Pediatric Dentistry. Pediatr Dent 1999;21:18–37. More detailed information can be obtained by contacting the Web site of the American Academy of Pediatric Dentistry (http://www.aapd.org).

TABLE 1   American Academy of Pediatric Dentistry Recommendations on Infant Oral Health Care

View Table

TABLE 1

American Academy of Pediatric Dentistry Recommendations on Infant Oral Health Care

Ideally, infant oral health begins with prenatal oral health counseling for parents; a postnatal initial oral evaluation should be performed within six months of the eruption of the first primary tooth in an infant but by no later than 12 months of age.

At the infant oral evaluation visit, the dentist should do the following:

Obtain a thorough medical and dental history, covering the prenatal, perinatal and postnatal periods. Perform a thorough oral examination.

Assess the infant's risk of developing oral and dental disease, and determine the appropriate interval for periodic reevaluation based on the assessment.

Provide anticipatory guidance for the parent or other caregiver regarding dental and oral development, fluoride status, nonnutritive oral habits, injury prevention, oral hygiene and effects of diet on dentition.

The dentist who performs these services for an infant should be prepared to provide therapy when indicated or should refer the infant to an appropriately trained person for necessary treatment.


Adapted with permission from Oral health policies. American Academy of Pediatric Dentistry. Pediatr Dent 1999;21:18–37. More detailed information can be obtained by contacting the Web site of the American Academy of Pediatric Dentistry (http://www.aapd.org).

Onset of Dental Caries

The prevalence of dental caries among children has declined steadily since the 1940s. However, dental caries remains the single most common disease of childhood that is not self-limited or amenable to a course of antibiotics.5 By the age of nine years, 56 percent of U.S. schoolchildren have dental caries.6 Even though a continuing decline in the prevalence of dental caries in permanent teeth has been shown,7 there has been no decline in its prevalence in the primary teeth of children living in industrialized countries.8 In addition, the incidence of tooth decay appears to vary considerably in different ethnic and socioeconomic populations.8

By the age of 12 months, infants begin to establish an oral environment that places them at risk for dental caries. It has been shown that dental caries is an infectious, transmissible disease.9 The mutans streptococci (i.e., Streptococcus mutans and Streptococcus sobrinus) have been implicated as the principal bacteria responsible for the initiation of dental caries in humans.10 Because colonization requires the presence of a hard, nondesquamating surface, infants do not harbor these organisms until sometime after teeth emerge.11

Infants acquire mutans streptococci primarily from their mothers.12 The initial acquisition of these bacteria appears to occur during a well-delineated age range (window of infectivity), estimated to be 19 to 31 months of age.11 Earlier acquisition of the bacteria has been associated with certain risk factors, including sibling caries, maternal caries, feeding habits, dietary habits, fluoride exposure and oral hygiene practices.13 Therefore, infants should receive early intervention before the established window of infectivity, and parents should be given appropriate recommendations concerning oral health care for their infants.

Feeding Practices

To cause dental caries, oral bacteria require the presence of a particular environment. Prolonged bottle or breast feeding provides the substrate (i.e., the presence of fermentable carbohydrates) that produces an oral environment favorable to bacterial proliferation and the formation of acidogenic plaque.14 This plaque environment lowers oral pH, promoting demineralization of dental enamel, and can eventually lead to caries formation.15

Early childhood caries, also termed “nursing caries,” “baby-bottle tooth decay” and “bottle caries,” is a specific dental disease occurring in very young children. This disease affects primary dentition, is characterized by rapid and extensive dental caries and is often associated with prolonged bottle or breast feeding.16 Early childhood caries affects an estimated 1 to 11 percent of infants in the urban population.17

To reduce the incidence of dental caries, parents and other caregivers should be counseled about proper feeding practices during infancy and the preschool years. One such measure is limiting the intake frequency of foods and liquids that promote acid production (Table 2).4

TABLE 2

American Academy of Pediatric Dentistry Recommendations on the Prevention of Early Childhood Caries

Infants should not be put to sleep with a bottle. Ad libitum nocturnal breast feeding should be avoided after the first primary tooth begins to erupt.

Parents should be encouraged to have infants drink from a cup as they approach their first birthday; infants should be weaned from the bottle at 12 to 14 months of age.

Consumption of juice from a bottle should be avoided; when juice is offered, a cup should be used.

Oral hygiene measures should be implemented by the time the first primary tooth erupts.

An oral health consultation visit within six months of the eruption of the first tooth is recommended as an opportunity to educate parents and provide anticipatory guidance for the prevention of oral disease.


Adapted with permission from Oral health policies. American Academy of Pediatric Dentistry. Pediatr Dent 1999;21:18–37.

TABLE 2   American Academy of Pediatric Dentistry Recommendations on the Prevention of Early Childhood Caries

View Table

TABLE 2

American Academy of Pediatric Dentistry Recommendations on the Prevention of Early Childhood Caries

Infants should not be put to sleep with a bottle. Ad libitum nocturnal breast feeding should be avoided after the first primary tooth begins to erupt.

Parents should be encouraged to have infants drink from a cup as they approach their first birthday; infants should be weaned from the bottle at 12 to 14 months of age.

Consumption of juice from a bottle should be avoided; when juice is offered, a cup should be used.

Oral hygiene measures should be implemented by the time the first primary tooth erupts.

An oral health consultation visit within six months of the eruption of the first tooth is recommended as an opportunity to educate parents and provide anticipatory guidance for the prevention of oral disease.


Adapted with permission from Oral health policies. American Academy of Pediatric Dentistry. Pediatr Dent 1999;21:18–37.

Fluoride Supplementation

Systemic or topical fluoride supplementation is one of the most effective measures for reducing dental caries.1820 Ingested fluoride is incorporated into the dentin and enamel of unerupted teeth. As a result, the teeth are more resistant to acid demineralization. Furthermore, systemic fluoride is secreted in saliva and is bacteriostatic. It accumulates in plaque, where it decreases microbial acid production and enhances enamel remineralization. Topical fluoride therapy is also highly effective, especially in children. It increases the fluoride content of the enamel of newly erupted teeth, thereby increasing the resistance of these teeth to caries.

Although appropriate fluoride ingestion is beneficial for tooth development, fluoride supplements should be prescribed only when the fluoride concentration of the drinking water supply has been tested and determined to be suboptimal.21  The AAPD recommendations for fluoride supplementation are provided in Table 3.4

TABLE 3

American Academy of Pediatric Dentistry Recommendations on Fluoride Supplementation*

Age of the child Supplementation based on fluoride concentration of water supply
< 0.3 ppm 0.3 to 0.6 ppm > 0.6 ppm

Birth to six months

0

0

0

Six months to three years

0.25 mg

0

0

Three to six years

0.5 mg

0.25 mg

0

Six to at least 16 years

1 mg

0.5 mg

0


ppm = parts per million.

*—Fluoride supplementation should be considered for any child whose drinking water is deficient in fluoride (i.e., water that contains less than 0.6 ppm of fluoride). Thus, before fluoride supplementation is prescribed, it is essential to know the fluoride concentration of the child's drinking water. Once the fluoride level has been determined, by contacting public health officials or by water analysis (as well as evaluation of other sources of fluoride and/or its removal through use of in-house filtration systems), a daily dosage schedule can be recommended.

Adapted with permission from Oral health policies. American Academy of Pediatric Dentistry. Pediatr Dent 1999;21:18–37.

TABLE 3   American Academy of Pediatric Dentistry Recommendations on Fluoride Supplementation*

View Table

TABLE 3

American Academy of Pediatric Dentistry Recommendations on Fluoride Supplementation*

Age of the child Supplementation based on fluoride concentration of water supply
< 0.3 ppm 0.3 to 0.6 ppm > 0.6 ppm

Birth to six months

0

0

0

Six months to three years

0.25 mg

0

0

Three to six years

0.5 mg

0.25 mg

0

Six to at least 16 years

1 mg

0.5 mg

0


ppm = parts per million.

*—Fluoride supplementation should be considered for any child whose drinking water is deficient in fluoride (i.e., water that contains less than 0.6 ppm of fluoride). Thus, before fluoride supplementation is prescribed, it is essential to know the fluoride concentration of the child's drinking water. Once the fluoride level has been determined, by contacting public health officials or by water analysis (as well as evaluation of other sources of fluoride and/or its removal through use of in-house filtration systems), a daily dosage schedule can be recommended.

Adapted with permission from Oral health policies. American Academy of Pediatric Dentistry. Pediatr Dent 1999;21:18–37.

Fluorosis is a condition caused by the ingestion of excessive amounts of fluoride. During the past 10 years, the incidence of fluorosis has increased somewhat in the pediatric population. In children, this condition has been associated with fluoride supplements, formulas containing fluoride and fluoride dentrifices.22 Because enamel formation in primary dentition is complete by the time an infant is 11 months of age and begins at birth for permanent dentition, parents should receive early supervision and counseling regarding the use of fluoride (i.e., prenatally to before the infant is 12 months old).23

Education on Oral Hygiene and Dietary Habits

Poor oral hygiene and poor dietary habits are associated with the development of caries in infants and young children.1,18 Because children are not able to control these factors, their dental health is greatly influenced by the amount of education and subsequent practices of parents and other caregivers.24

Mothers appear to be the primary source of a child's dental knowledge. Therefore, failure to adequately educate mothers at an early stage can lead to subsequent dental problems in chilren. Nutritional and lifestyle counseling (i.e., alcohol and tobacco use), medication warnings and advice concerning breast feeding and postnatal care can also have a positive influence on oral health in children. The AAPD age-specific home oral hygiene instructions are provided in Table 4.4

TABLE 4

American Academy of Pediatric Dentistry Age-Specific Instructions on Home Oral Hygiene

Prenatal counseling

Counsel parents about their own oral hygiene habits and their effect as role models.

Provide information to pregnant women about pregnancy gingivitis (inflammation of the gingiva caused by an exacerbated response to dental plaque related to hormonal changes during pregnancy).

Review infant dental care.

Infants (birth to 1 year of age)

Counsel parents to clean the infant's gums daily before eruption of the first primary tooth to help establish a healthy oral flora, using the following procedure*:

Cradle the infant with one arm.

Wrap a moistened gauze square or washcloth around the index finger of the hand of the other arm and gently massage the teeth and gingival tissues.

Introduce a soft-bristled toothbrush during this age only if parents feel comfortable using the toothbrush.

Do not use dentifrice containing fluoride, because fluoride ingestion is possible.

Toddlers (1 to 3 years of age)

Introduce a toothbrush into the plaque-removal procedure (if not done earlier).

Use dentifrice beginning around the age of 2 years; use only a pea-sized amount of toothpaste (apply across the narrow width of the toothbrush, rather than along its length, to decrease the chance of applying an excessive amount).

Encourage the child to begin rudimentary brushing; however, parents should remain the primary caregiver in oral hygiene procedures.

Preschool-age children (3 to 6 years of age)

Remind parents to continue their responsibility as primary providers or supervisors of oral hygiene procedures. Continue to use only a pea-sized amount of toothpaste on the child's toothbrush.

Use daily flossing if any interproximal area has tooth-to-tooth contact.


* —Recommended by some, but not all, dentists.

Adapted with permission from Oral health policies. American Academy of Pediatric Dentistry. Pediatr Dent 1999;21:18–37.

TABLE 4   American Academy of Pediatric Dentistry Age-Specific Instructions on Home Oral Hygiene

View Table

TABLE 4

American Academy of Pediatric Dentistry Age-Specific Instructions on Home Oral Hygiene

Prenatal counseling

Counsel parents about their own oral hygiene habits and their effect as role models.

Provide information to pregnant women about pregnancy gingivitis (inflammation of the gingiva caused by an exacerbated response to dental plaque related to hormonal changes during pregnancy).

Review infant dental care.

Infants (birth to 1 year of age)

Counsel parents to clean the infant's gums daily before eruption of the first primary tooth to help establish a healthy oral flora, using the following procedure*:

Cradle the infant with one arm.

Wrap a moistened gauze square or washcloth around the index finger of the hand of the other arm and gently massage the teeth and gingival tissues.

Introduce a soft-bristled toothbrush during this age only if parents feel comfortable using the toothbrush.

Do not use dentifrice containing fluoride, because fluoride ingestion is possible.

Toddlers (1 to 3 years of age)

Introduce a toothbrush into the plaque-removal procedure (if not done earlier).

Use dentifrice beginning around the age of 2 years; use only a pea-sized amount of toothpaste (apply across the narrow width of the toothbrush, rather than along its length, to decrease the chance of applying an excessive amount).

Encourage the child to begin rudimentary brushing; however, parents should remain the primary caregiver in oral hygiene procedures.

Preschool-age children (3 to 6 years of age)

Remind parents to continue their responsibility as primary providers or supervisors of oral hygiene procedures. Continue to use only a pea-sized amount of toothpaste on the child's toothbrush.

Use daily flossing if any interproximal area has tooth-to-tooth contact.


* —Recommended by some, but not all, dentists.

Adapted with permission from Oral health policies. American Academy of Pediatric Dentistry. Pediatr Dent 1999;21:18–37.

Timing of the First Dental Visit

Because all children do not receive primary prevention, secondary measures such as early diagnosis and treatment can eliminate pain, infection and oral diseases. Traditionally, the recommended time for the first dental visit has been at three years of age. The rationale for choosing this later age was that children were more manageable, and treatment was more efficient.24

By three years of age, however, poor oral hygiene or improper feeding habits may already have compromised oral health (Figure 1). Therefore, the AAPD recommends that the first oral examination occur within six months of the eruption of the first primary tooth but by no later than 12 months of age.4 Conversely, the American Academy of Pediatrics currently recommends that children be referred for an initial dental evaluation at 24 months of age.25

FIGURE 1.

Extensive carious lesions and abscesses in the mouth of a toddler who did not benefit from early preventive intervention.

View Large


FIGURE 1.

Extensive carious lesions and abscesses in the mouth of a toddler who did not benefit from early preventive intervention.


FIGURE 1.

Extensive carious lesions and abscesses in the mouth of a toddler who did not benefit from early preventive intervention.

Early dental intervention provides an opportunity to supplement oral health education for parents in areas such as proper oral hygiene, prevention of dental injuries and prevention of nursing caries. Such intervention may also allow children to become comfortable in the dentist's office.26 Unfortunately, the provision of early and regular dental care among children is uncommon. In 1986, it was estimated that only 25 percent of two-year-old children had ever visited a dentist.27 By five years of age, 75 percent of children had seen a dentist, and by seven years of age, 89 percent of children had received a dental examination.27

Traditionally, family physicians and pediatricians have provided information on preventive oral health in infants because of the early age at which children are brought to their offices and because parents accept their recommendations.28 Although physicians know that they play an important role in caries prevention,29 most estimate that they received less than two hours of oral health education during medical school and residency training.30 With the exception of feeding practices and fluoride supplementation, some of these physicians may not be informed about the relative worth of other measures to prevent caries, such as pit and fissure sealants and plaque-removal activities.30,31

Final Comment

Despite the current AAPD recommendations, it has been difficult to achieve uniformity among health care professionals regarding timing for the provision of preventive oral information as well as who should provide it. Consensus on guidelines for pediatric preventive dental care is also lacking. Because even healthy children visit physicians frequently, beginning at an early age, physicians who provide primary care for children are in a unique position to help ensure that parents and other caregivers receive information on the prevention of oral disease in infants and young children. By working together, physicians and dentists can reinforce each others' efforts to provide excellent preventive oral care.

The Authors

OLGA M. SANCHEZ, D.M.D., M.S., is a resident in the Department of Orthodontics at the University of Alabama School of Dentistry, Birmingham. Dr. Sanchez graduated from the University of Puerto Rico School of Dentistry, San Juan, and completed a pediatric dental residency at the University of Alabama School of Dentistry, where she served as a chief resident.

NOEL K. CHILDERS, D.D.S., M.S., PH.D., is a professor in the Department of Pediatric Dentistry at the University of Alabama School of Dentistry. Dr. Childers received his doctor of dentistry degree from Emory University School of Dentistry, Atlanta, where he also completed a pediatric dental residency. In addition, he completed doctoral studies in the immunology of dental caries at the University of Alabama.

Address correspondence to Noel Childers, D.D.S., M.S., Ph.D., Department of Pediatric Dentistry, University of Alabama School of Dentistry, 1919 7th Ave. S., SDB Box 89, Birmingham, AL 35294-0007. Reprints are not available from the authors.

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