With all the changes and challenges we have faced as a society in the past year with the current pandemic, pediatricians should not lose sight of their important role in promoting oral health in children. While it was easy for me to note how the changes in eating habits that came with quarantine affected my clinic patients in terms of weight, I often missed an opportunity to address its potential effect on the development of the most common chronic disease of childhood, dental caries. As many as 24% of children ages 2-4, 53% of children ages 6-8, and 58% of 15-year-olds have had dental caries, and the incidence for the youngest children has only been increasing.¹ As pediatricians, we can use recommended preventative strategies in our clinic and telehealth visits.

First, we need to understand what puts patients at risk of developing dental caries. Previous history of caries is a very important risk factor, but a history of current or recent caries in the parent/primary caregiver plays a role, because pathogenic bacteria can be passed to children early in age. Dietary risk factors include intake of sugars, frequent snacking of sugary foods or beverages, continual use of a sippy cup or bottle with fluids other than water, and sleeping with a sippy cup or bottle. The frequent exposure to sugars caused by these habits allows for the flourishment of pathogenic bacteria that break down the sugars into acids that can lower pH and result in demineralization of the tooth enamel. Saliva works to offset these changes in multiple ways, so, conditions or medications that reduce salivary flow can increase the risk of caries.

While it may seem time-consuming to collect all this information, it doesn’t have to be.  The American Academy of Pediatrics (AAP) published this helpful Oral Health Risk Assessment Tool to aid clinicians during their office visits.

Second, after identifying risk factors, clinicians can take preventative measures in the form of counseling and the use of fluoride. The specific dietary and hygiene recommendations to review during the clinic visit are outlined in this article published by the American Academy of Pediatrics.¹

Dietary

• Exclusively breastfeed infants for 6 months and continue breastfeeding as complementary foods are introduced for 1 year or longer, as mutually desired by mother and infant
• Discourage putting a child to bed with a bottle. Establish a bedtime routine conducive to optimal oral health (e.g., brush, book, and bed)
• Wean from a bottle by 1 year of age
• Limit sugary foods and drinks to mealtimes
• Avoid carbonated, sugared beverages and juice drinks that are not 100% juice
• Limit the intake of 100% fruit juice to no more than 4 to 6 oz per day
• Encourage children to drink only water between meals, preferably fluoridated tap water
• Foster eating patterns that are consistent with guidelines from the US Department of Agriculture

Oral hygiene

• Encourage parents/caregivers to model and maintain good oral hygiene and a relationship with their own dental provider
• Caution parents/caregivers, especially those with significant history of dental decay, to avoid sharing with their child items that have been in their own mouths
• Teach parents/caregivers to brush the child’s teeth twice a day as soon as the teeth erupt, using only a smear or a grain-of-rice–sized amount of fluoridated toothpaste. After the third birthday, a pea-sized amount should be used.
• Encourage parents/caregivers to help/supervise a child brushing his or her teeth until mastery is obtained, usually at around 8 years of age

The anticipatory guidance discussed during the visit may also be supplemented with the use of helpful handouts as provided by the Healthy Teeth Healthy Children program of the AAP, available in English and Spanish, in addition to other languages. Additional family resources can be found at healthychildren.org like the Brush, Book, Bed message promoted by AAP. 

Finally, the use of fluoride is known to aid in the prevention of dental caries. In addition to the use of fluoride toothpaste and fluoridated water, clinicians can take one further step in the prevention of dental caries with the use of fluoride varnish in their clinics. In many states, physicians may complete certification and bill insurance to provide this helpful service known to be safe and effective in children as early as 6 months of age. ² In fact, it is a grade B recommendation by the US Preventative Services Task Force. However, in one 2009 survey of pediatricians, only 4% regularly applied fluoride varnish for their patients.³ Thus, there is room for improvement in our rates of fluoride varnish use to further reduce the risk of caries development in our patients. For more information regarding fluoride use, please see this article published by the American Academy of Pediatrics.

A patient population of particular concern are those with developmental disabilities. Pediatricians should take care to screen and provide preventative counseling to this subset of patients, because they may have unique risk factors or barriers to care that affect their overall oral health. For example, children that are exclusively tube fed are known to have increased risk of tartar and gingivitis likely due to lack of routine clearance of the oral cavity. Patients with limitations in their activities of daily living are dependent on their caregivers, who may not prioritize oral health in the setting of other complex needs. Some of those complex needs may require the use of medications high in sugar or that reduce saliva, which also increases risk of caries.  Frequent exposure to acid from reflux is another direct risk factor many children face. Barriers to care include limited number of dental providers able to care for patients with special needs, other health needs frequently taking precedence over oral health, and oral aversions to name a few.⁴ Thus, it is particularly important for pediatricians to routinely implement screening and preventative services for these patients in addition to their healthy patients.

Iba Iyegha, MD

References

1. Kroll, D. M. (2014). Maintaining and Improving the Oral Health of Young Children. Pediatrics, 134(6), 1224-1229. doi:10.1542/peds.2014-2984
2. Clark, M. B., & Slayton, R. L. (2014). Fluoride Use in Caries Prevention in the Primary Care Setting. Pediatrics, 134(3), 626-633. doi:10.1542/peds.2014-1699
3. Lewis, C. W., Boulter, S., Keels, M. A., Krol, D. M., Mouradian, W. E., Oconnor, K. G., & Quinonez, R. B. (2009). Oral Health and Pediatricians: Results of a National Survey. Academic Pediatrics, 9(6), 457-461. doi:10.1016/j.acap.2009.09.016
4. Norwood, K. W., & Slayton, R. L. (2013). Oral Health Care for Children With Developmental Disabilities. Pediatrics, 131(3), 614-619. doi:10.1542/peds.2012-3650

http://www.healthyteethhealthychildren.org/docs/default-source/healthy-teeth-healthy-children/healthy-mouth-healthy-body-eng.pdf?sfvrsn=2

http://www.healthyteethhealthychildren.org/docs/default-source/healthy-teeth-healthy-children/hthc-8-5×11-spanish3613.pdf?sfvrsn=2

https://www.healthychildren.org/English/healthy-living/oral-health/Pages/Brush-Book-Bed.aspx