Oral disease, especially dental
caries, is complicated and multifactorial, and it
often begins to develop during infancy. Caries is a
biofilm (plaque) induced acid demineralization of
enamel or dentin, mediated by saliva(1). The
Mutans streptococci group of microorganisms
has been implicated as the principal bacteria
responsible for the initiation of dental caries in
humans. It has been further shown that dental caries
is an infectious, transmissible disease(2). Recent
evidence suggests that Mutans group of bacteria may
begin to colonize prior to tooth eruption(3,4).
Ideally, steps to prevent caries begin prenatally
and continue with the mother and child, beginning
when the infant is approximately 6 months of age,
with the eruption of the first tooth(5). A healthy
mouth, with a full complement of teeth and a stable,
aesthetic occlusion is a goal that pediatric
dentists seek to achieve through various preventive
and therapeutic measures.
Prevention of Dental Disease
If appropriate measures are
applied early enough, it may be possible to totally
prevent dental caries. Preventive measures can be
divided into various stages:
A. Stage 1 - Pregnancy
Infant oral health begins with
prenatal oral health counseling for parents. The
purpose of this is to generate awareness among
parents about dental disease, its prevention and the
means to provide a suitable environment for the
child to develop.
Prenatal counseling
Evidence supports that both poor
nutrition and low birth weight are risk factors for
the development of early childhood caries (ECC). ECC
is an early arising, potentially devastating and
virulent form of dental caries. Not only does ECC
affect teeth, but it can also leads to malnutrition
and diminished quality of life due to resulting
pain, infection and impairment of oral function.
Under- or malnourished infants
and infants with low birth weight are at risk for
enamel hypoplasia, an incomplete formation of
enamel(6-8). Enamel hypoplasia may cause an
irregular enamel surface or discoloration, which can
result in areas more prone to caries(6,9). Thus,
expectant mothers should be advised to optimize
nutrition during the third trimester and the
infant’s first year, when the enamel is undergoing
maturation. Further, recent studies have reported an
association between maternal periodontitis and
preterm birth(10), between clinical
periodontitis at delivery and preeclampsia(11), and
between Mutans streptococcus levels in
mothers and caries experience in their
children(12).
Prospective parents need to know
that prenatal assessment and education are essential
to the oral health of their child. Prenatal
assessment includes oral health status of the
parent. The parent’s risk of dental caries needs to
be evaluated since uncontrolled caries means that
the parent has a high level of Mutans streptococcus,
which can be transferred to the infant later. If the
parent is at risk, the dentist should provide
preventive treatment and educate the parent on good
plaque control, provide nutritional counseling, and
discuss the transmissi-bility of Mutans
streptococcus to the infant. Parents should be
monitored on a regular basis to ensure effective
oral hygiene and dietary habits have been
established. Improvement of the mother’s oral
hygiene, diet and the use of mouth rinses can have a
significant impact on the child’s caries rate in the
future.
Anticipatory guidance
Anticipatory guidance is the
process of providing practical, developmentally
appropriate information about children’s health to
prepare parents for the significant physical,
emotional and psychological milestones(13).
Anticipatory guidance involves three types of tasks:
(1) gathering information, (2) establishing a
therapeutic alliance, and (3) providing education
and guidance. General anticipatory guidance for the
mother includes the following (14-16):
(a) Education
concerning development and prevention of dental
disease and also demonstration of oral hygiene
procedures.
(b) Counseling to
instill preventive attitudes and motivation.
(c) Providing
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). With
gingivitis, the gums become inflamed, swollen,
sensitive and tend to bleed. Signs of gingivitis
may become evident in the second trimester and
peak during the ninth month of pregnancy(10).
(d) Visiting a dentist
for an examination and restoration of all active
decay as soon as feasible and to decrease chances
of developing pregnancy gingivitis.
(e) Eating
healthy foods such as fruits, vegetables, grain
products (especially whole grain), and dairy
products (milk, cheese) during meals and snacks.
Limit eating between meals.
(f) Eating foods
containing only sugar at mealtimes, and limiting
the amount. Frequent consumption of foods high in
sugar, such as toffees, cookies, cake, sweetened
beverages (e.g fruit juice, soda), increases the
risk for tooth decay. In addition, frequent
consumption of foods that easily adhere to the
tooth surface, such as dried fruit and candy,
increase the risk for tooth decay.
(g) Brushing
teeth thoroughly twice a day (after breakfast and
before bed) with a fluoridated toothpaste and
flossing daily.
(h) Rinsing every
night with an alcohol-free, over-the-counter
fluoridated mouth rinse.
(i) Not smoking
cigarettes or chewing tobacco.
Dental treatment of women during pregnancy
Often, pediatricians are asked
for advice regarding dental problems. Relevant
information regarding the type of dental treatment
that can be undertaken may be summarized as
follows(14,17):
First trimester: It is the
most crucial period for growth of fetus. Only
emergency dental treatment should be undertaken in
consultation with the patient’s physician.
Second and third trimester:
Emergency as well as elective dental treatment
can be provided. Radiographs essential for diagnosis
can be obtained with adequate protection (e.g. lead
shields).
Throughout pregnancy:
Plaque diet control programs are initiated for
mother. Local anesthetics are to be preferred for
dental procedures.
B. Stage 2 - Infancy (0-1year)
Children experiencing dental
caries as infants or toddlers have a much greater
probability of subsequent caries in primary or
permanent dentition(18,19). The major reservoir from
which infants acquire Mutans streptococcus is their
mothers (vertical transmission). Mothers with dense
salivary reservoirs of Mutans streptococcus are at
high risk for infecting their infants early in life.
Horizontal transmission (between members of a family
or group) can also occur(12). Eliminating saliva
sharing activities can thus reduce the development
of caries in infants. Moreover, high-risk dietary
practices are developed early, probably by 12 months
of age and are maintained throughout
childhood(20,21). Frequent bottle-feeding at night,
breast feeding on demand and extended use of a
no-spill training cup are associated with
development of early childhood caries (ECC) (22).
Oral hygiene maintenance in this phase includes(23):
1. Reducing the mother’s and
sibling(s) levels of Mutans Streptococcus (ideally
during the prenatal period) to decrease
transmission of cariogenic bacteria. This can be
accomplished through regular toothbrushing, use of
fluoridated mouthrinses and treatment of all
decayed teeth.
2. Minimizing saliva-sharing
activities between an infant or toddler and
his/her family. Avoiding testing of the
temperature of the bottle with the mouth and
sharing utensils (e.g., spoons). This practice
helps to prevent transmission of bacteria that
cause tooth decay.
3. Prior to eruption of teeth,
wrap a moistened gauze square or washcloth around
the index finger of the hand and gently massage
the teeth and gingival tissues. Do not use a
dentifrice (toothpaste) containing fluoride,
because fluoride ingestion is possible.
4. Prolonged bottle or breast
feeding provides an environment that enhances the
development of early tooth decay. Infants should
be weaned from the bottle at 12 to 14 months of
age.
Dental home concept
The dental home concept(14,24)
was developed analogous to the concept of ‘medical
home’. The dental home is inclusive of all aspects
of oral health that result from the interaction of
the patient, parents, nondental professionals, and
dental professionals. The dental home concept fits
well with the emphasis on comprehensive care that
exists in pediatric dentistry programs. Establishing
a dental home should be done within 6 months of
eruption of the first tooth and no later than 12
months of age.
C. Stage 3 - First Dental
Visit
The American Academy of Pediatric
Dentistry recommends that the first oral examination
should occur within 6 months of the eruption of the
first primary tooth, and no later than age 12 months
of age(24). Thereafter the child should be
seen according to a schedule recommended by the
dentist, based on the child’s individual needs and
susceptibility to disease.
D. Stage 4 – Care of the
Deciduous Dentition
Oral hygiene measures must be
implemented no later than the time of eruption of
the first primary tooth. These measures include the
following(23,25):
• If an infant falls asleep
while feeding, the teeth should be cleaned before
placing the child in bed.
• Toothbrushing of all dentate
children should be performed twice daily with a
fluoridated toothpaste and a soft, age-appropriate
sized toothbrush.
• Parents should use a ‘smear’
of toothpaste to brush the teeth of a child less
than 2 years of age and perform or assist with
their child’s toothbrushing.
• For the 2-5 years old child,
parents should dispense a ‘pea-size’ amount of
toothpaste and perform or assist with their
child’s toothbrushing. Children should be taught
to never swallow the toothpaste.
• Dental flossing should be
initiated when adjacent tooth surfaces cannot be
cleansed by a toothbrush.
• Brushing should be supervised
and assisted until age 8. A small, circular
scrubbing motion is recommended for children.
Caries-promoting feeding
behaviors that must be avoided are(1,23):
• Infants should not be put to
sleep with a bottle containing fermentable
carbohydrates.
• At-will breast-feeding should
be avoided after the first primary tooth begins to
erupt and other dietary carbohydrates are
introduced.
• 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.
• Repetitive consumption of any
liquid containing fermentable carbohydrates from a
bottle or training cup should be avoided.
• Between-meal snacks and
prolonged exposures to foods and juice or other
beverages containing fermentable carbohydrates
should be avoided.
Contributors: Both authors
contributed to concept, review of literature and
drafting of the manuscript.
Funding: None.
Competing interests: None
stated.
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