Basics
Description
- Dental health and prevention is the practice of maintaining proper oral health to prevent the initiation or progression of oral disease. It is composed of effective oral hygiene, appropriate dietary practices, fluoride exposure, and the establishment of a dental home.
- Dental caries is a disease that generally is preventable. Early risk assessment allows for identification of parent-infant groups who are at risk for early childhood caries (ECC) and would benefit from early preventive intervention. The ultimate goal of early assessment is the timely delivery of educational information to populations at high risk for developing caries in order to prevent the need for later surgical intervention.
Epidemiology
- 42% of children 2-11 years old have had dental caries in their primary teeth.
- 23% of children 2-11 years old have untreated dental caries.
- Children 2-11 years old have an average of 1.6 decayed primary teeth and 3.6 decayed primary surfaces.
- 21% of children 6-11 years old have had dental caries in their permanent teeth.
- Tooth decay is five times more common than asthma and seven times more common than hay fever.
- More than 51 million school hours are lost due to dental-related illness each year.
Risk Factors
- Poor oral hygiene
- Poor dietary practices
- Frequent nighttime bottlefeeding with milk or juice
- Breastfeeding >7 times daily after 12 months of age
- Ad libitum breastfeeding after introduction of other dietary carbohydrates
- A diet high in natural or added sugars
- Frequent sugar-containing snacking between meals
- Delayed establishment of dental home
- Previous caries
- Lack of exposure to fluoride
- Low socioeconomic status
- Immigrant status
- Poor salivary flow
- Special health care needs or chronic conditions
General Prevention
Establishment of a dental home no later than the child's 1st birthday allows the dental practitioner to educate and promote the use of caries-preventing strategies such as dietary recommendations and appropriate oral hygiene.
- The American Academy of Pediatrics (AAP) recommends children 1-6 years of age consume no more than 4-6 oz of fruit juice per day from a cup (i.e., not a bottle or covered cup) and as part of a meal or snack.
- Dietary guidelines include the following:
- Eating a variety of nutrient-dense foods and beverages
- Balancing foods eaten with physical activity to maintain a healthy body mass index
- Maintaining a caloric intake adequate to support normal growth and development
- Choosing a diet with plenty of vegetables, fruits, and whole grains and low in fat
- Using sugars and salt (sodium) in moderation
- Oral hygiene measures should be implemented no later than the time of eruption of the first primary tooth.
- Brushing the infant's teeth after eruption with a toothbrush will help reduce bacterial concentrations. Brushing should be performed for children by a parent twice daily.
- Flossing should be initiated when adjacent tooth surfaces touch. Parents and caregivers should help or watch over their kids' tooth brushing abilities until they're at least 8 years old.
- Optimal exposure to fluoride is an important preventive measure for children. The use of fluoride for the prevention and control of caries is documented to be both safe and effective.
- When determining the risk-benefit of fluoride, the key issue is mild fluorosis versus preventing devastating dental disease. In children considered at moderate or high caries risk younger than the age of 2 years, a "smear"¯ of fluoridated toothpaste should be used. In all children ages 2-5 years, a "pea-size"¯ amount should be used.
- Professionally applied topical fluoride, such as fluoride varnish, should be considered for children at risk for caries. Systemically administered fluoride should be considered for all children at caries risk who drink fluoride-deficient water (<0.6 ppm) after determining all other dietary sources of fluoride exposure.
Alert
- 54% of U.S. preschool children were given some form of over-the-counter medications, most commonly as analgesics, antipyretics, and cough and cold medications. Numerous oral liquid medications contain a high sugar content to increase palatability and acceptance by children. Frequent ingestion of sugar-sweetened medications has demonstrated a higher incidence of caries in chronically ill children.
- To motivate children to consume vitamins, numerous companies have made "gummy"¯ vitamin supplements. Cases of vitamin A toxicity have been reported as a result of excessive consumption. The AAP recommends that the optimal way to obtain adequate amounts of vitamins is to consume a healthy and well-balanced diet.
Alert
Dental caries is a common chronic infectious and transmissible disease resulting from primarily mutans streptococci (MS) that metabolize sugars to produce acid which, over time, demineralizes and cavitates tooth structure (enamel). MS colonization of an infant may occur from the time of birth by "vertical transmission"¯ from mother to infant. The higher the levels of maternal salivary MS, the greater the risk of the infant being colonized, the greater risk for caries. Along with salivary levels of MS, mother's oral hygiene, periodontal disease, snack frequency, and socioeconomic status also are associated with infant colonization. The initial acquisition of MS occurs at the median age of 26 months during the "window of infectivity."¯ Mothers are recommended to minimize or eliminate saliva-sharing habits such as sharing spoons.
Pathophysiology
The oral cavity contains a diverse microbiota that is essential for maintaining normal physiology in the oral cavity. Oral bacteria metabolize sugar and produce lactic acid. Lactic acid is responsible for the demineralization of tooth structure and may lead to cavitation and the advancement of caries through the various dental structures. Furthermore, lactic acid alters the oral environment to a more acidic one and thus disrupts the balance of the oral microbiota, causing the appearance of more pathogenic organisms, thereby enhancing the process.
Diagnosis
History
- Poor oral hygiene
- Poor dietary practices
- Frequent nighttime bottlefeeding with milk or juice
- Breastfeeding >7 times daily after 12 months of age
- Ad libitum breastfeeding after introduction of other dietary carbohydrates
- A diet high in natural or added sugars
- Frequent sugar-containing snacking between meals
- Delayed establishment of dental home
- Previous caries
- Lack of exposure to fluoride
- Low socioeconomic status
- Immigrant status
- Poor salivary flow
- Special health care needs or chronic conditions
- Maternal caries
- Dental pain
Physical Exam
- Visible plaque buildup
- "Chalky"¯ teeth
- Cavitated teeth
- Gingivitis
- Red, swollen gingival
- Spontaneous bleeding
- Abscessed teeth
- Lymphadenopathy
- Pain
Alert
- Caries risk assessment is a key element of preventive care. Its goal is to prevent disease by identifying and minimizing causative factors and optimizing protective factors.
- Causative factors include maternal caries, low socioeconomic status, frequent sugar snacking, nighttime bottle use, special health care needs.
- Protective factors include brushing twice daily with fluoride toothpaste, proper diet, and having a regular dental home. However, the best predictor of future caries is previous caries.
Diagnostic Tests & Interpretation
- Oral swabbing to assess MS bacterial load
- Plaque index
- Use of disclosing tablets to highlight plaque and score teeth
- Caries risk assessment
Imaging
- Dental x-rays
- As needed at discretion of the pediatric dentist
Differential Diagnosis
- Viral infections such as primary herpetic gingivostomatitis, hand-foot-and-mouth disease, herpangina
- Gingivitis
- Periodontal disease
Treatment
Medication
Treatment of dental caries does not involve medication but rather the restoration of decayed teeth along with the establishment of a dental home. Proper oral hygiene and dietary measures need to be introduced to the patient and the parent.
Additional Therapies
- Probiotics
- Probiotics are living microbes that beneficially influence the health of the host when used in adequate numbers. Dental probiotics have been shown to act as antagonists toward pathogenic bacteria by a variety of different mechanism. Restoring the oral health to a more balanced one creates a more suitable environment for the prevention of dental caries and proper oral health.
- Increased fluoride exposure
- When used appropriately, fluoride is both safe and effective in preventing and controlling dental caries.
- Topically, low levels of fluoride in plaque and saliva inhibit the demineralization of sound enamel and enhance the remineralization of demineralized enamel.
- Sealant application
- Sealants reduce the risk of pit and fissure caries in susceptible teeth and are cost-effective when maintained. They are indicated for primary and permanent teeth with pits and fissures that are predisposed to plaque retention. At-risk pits and fissures should be sealed as soon as possible.
- Xylitol chewing gum
- Xylitol is a five-carbon sugar alcohol derived primarily from forest and agricultural materials. Xylitol reduces plaque formation and bacterial adherence (i.e., is antimicrobial), inhibits enamel demineralization (i.e., reduces acid production), and has a direct inhibitory effect on MS.
Ongoing Care
Follow-up Recommendations
The most common interval of examination is 6 months; however, some patients may require examination and preventive services at more or less frequent intervals based on historical, clinical, and radiographic findings.
Prognosis
The practice of pediatric dentistry is based on prevention. If a dental home is established early, a pediatric dentist can guide the parent and the child on proper oral hygiene and diet, minimizing the risk for the development of caries.
Additional Reading
- American Academy of Pediatric Dentistry. 2014-15 Definitions, oral health policies, and clinical guidelines. http://www.aapd.org/policies/. Accessed September 2013.
- American Academy of Pediatric Dentistry. Symposium on the prevention of oral disease in children and adolescents. Chicago, Ill; November 11-12, 2005: Conference papers. Pediatr Dent. 2006;28(2):96-198.
- Dye BA, Shenkin JD, Ogden CL, et al. The relationship between healthful eating practices and dental caries in children aged 2-5 years in the United States, 1988-1994. J Am Dent Assoc. 2004;135(1):55-66. [View Abstract]
- Dye BA, Shenkin JD, Ogden CL, et al. The relationship between healthful eating practices and dental caries in children aged 2-5 years in the United States, 1988-1994. J Am Dent Assoc. 2004;135(1):55-66. [View Abstract]
- U.S. Department of Health and Human Services, Office of the Surgeon General. A National Call to Action to Promote Oral Health. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial Research; 2003.
Codes
ICD09
- 521.00 Dental caries, unspecified
- 523.10 Chronic gingivitis, plaque induced
- 523.9 Unspecified gingival and periodontal disease
ICD10
- K02.9 Dental caries, unspecified
- K05.10 Chronic gingivitis, plaque induced
- K05.6 Periodontal disease, unspecified
SNOMED
- 80967001 Dental caries (disorder)
- 66383009 Gingivitis (disorder)
- 2556008 Periodontal disease (disorder)
FAQ
- Q: It's just a baby tooth. Isn't it going to fall out?
- A: Untreated dental caries in children can lead to pain and infection and affect speech and communication, eating and dietary nutrition, sleeping, learning, playing, and quality of life, even into adulthood.
- Q: My child cannot spit yet and swallows the toothpaste. Can I use a fluoride-free "safe-to-swallow"¯ toothpaste?
- A: Latest research has strongly and unequivocally supported the safety and efficacy of fluoride toothpaste in children. The benefit of fluoride far outweighs any potential risks of toxicity. However, use of fluoride should be based on individual risk factors. In children considered at moderate or high caries risk younger than the age of 2 years, a smear of fluoridated toothpaste should be used. In all children ages 2-5 years, a pea-size amount should be used.