Early intervention and risk assessment are essential components in assuring that good oral health is an outcome for all children.

As explained in Section II, oral disease is a bacterial infection with an early initiation. The mouths of infants became infected at birth with bacteria and at the time teeth were erupting bacteria colonized on the tooth surfaces. Therefore, the time to initiate preventive strategies is during tooth eruption. By assessing the risk to the infant and providing appropriate recommendations, disruption of the disease process can begin.

Because infants are scheduled generally with the primary care provider at 6, 9 and 12 months of age, these are ideal visits to include a preventive oral health component to the usual medical procedures planned.

Presently there are no diagnostic laboratory tests to order to determine if an infant is at high risk for oral disease. Attempts have been made to use strep mutans (see Section II) levels as an indicator for risks. But in the absence of other factors a high strep mutans count alone does not insure a risk status.

From many reported studies the most noteworthy risk factors for oral disease are:

1. Presence of plaque on infant’s teeth

2. Absence of fluoride exposures

3. Presence of cavities and white spot lesions

4. Parents low Socio-Economic Status

5. High sucrose containing diet

6. Nationality (Ethnicity)

Other risk factors identified are mother’s diet during pregnancy, mother’s oral health status, prolonged and inappropriate use of nursing bottle or breast, family history of oral disease, salivary flow rate, salivary buffering capacity, infants oral medications, and some other medical conditions.

Because of the broad range of risk factors, the primary care provider should consider the infant/toddler at risk until proven otherwise. Once the risk for oral disease has been assessed, interventions and monitoring can be established and maintained unless a change takes place in the child’s health history.

Plaque and debris should be observed on the teeth and demonstrated to the caregiver.  Recommendations for daily removal with the appropriate style toothbrush should be made.

The Oral Screening Examination

Essential to assessing the oral cavity is access and light. A mouth mirror and tongue blade are helpful. Access will vary with the age of the child and cooperation. For infants and toddlers the knee-to-knee position allows for visibility and stability. (Figure III-1) With older toddlers and school aged children the use of the examining table

Oral Exam of the Infant/Toddler

Figure 111-1

with the child in the supine position will work well. A flashlight or an overhead lamp should provide adequate light to illuminate the mouth.

Disposable mouth mirrors and tongue blades will both facilitate observing teeth and tissues as well as guiding the tongue to positions that will not block visibility .

Lips, tongue and mucosa will be the first soft tissues observed. Lips should be intact, soft, pink, and moist (Figure 111-2).

If possible the tongue can be grasped with a small 2x2 gauze. The tongue should be pink, moist and intact. It should be free of deposits on the superior surface. It should not be smooth but should have a pebbly surface. When squeezed it should be firm and without hard lumps. The ventral surface should be smooth and vascular.

The oral mucosa is non-keratnized tissue and covers the insides of the cheeks almost to the teeth. The color can be pink to brown depending on the skin color. The mucosa should be moist, smooth and intact (Figure 111-3).

Healthy Oral Soft Tissues Mucosa

Figure 111-3

In infants and toddlers it will be common to observe strips of tissue from the oral mucosa extending down to and attaching onto the tissues near the teeth. The most common are located in the upper jaw. They are called frena. The most common being in the upper jaw midline between the area of the two front teeth. The other common frenum is on the ventral surface of the tongue and is called the lingual frenum.

The tissue next to the teeth is gingiva and is keratnized. This tissue should also be pink and form a tight smooth collar around each tooth. It too should be moist and not spongy. If pressed it should not bleed. (Figure 111-4). During the transition from the primary teeth to the permanent teeth, the gingival tissues may have rolled edges especially with the anterior teeth until the permanent teeth are fully erupted.

Healthy Oral Soft Tissues Gingiva

Figure 111-4

 

 

To observe the palate, with the child in the supine position, the head must be bent back for better access by the clinician. With the light directed onto the surface of the palate one should observe pink, moist and intact surfaces. Forward and towards the anterior teeth, rows of tissue (rugae) will be present, varying in height. (Figure 111-5) About two thirds back onto the palate will be an area dividing the hard palate from the soft palate. This tissue should be pink, smooth and soft. Hanging from the rear of the soft palate will be the uvula. If 'Y' shaped it is called a bifid uvula.

Healthy Oral Soft Tissues Palate

Figure 111-5

The facial bones should be examined first by observation to check for gross swellings and symmetry .Then they should be palpated for tenderness, irregularities and hardness. Further examination will not be possible without radiographs and are only ordered if there are signs, symptoms or a suspicious history.

The major salivary glands are located in the cheeks (parotid) and the floor of the mouth, submandibular and sublingual glands. The ducts will be raised and pink. Observation and palpation are used to examine the glands. It is common to observe secretions from the glands and they should be clear. Palpation should not elicit discomfort.

Only the crowns of teeth can be observed. Without dental instruments only a gross examination can be performed. Nevertheless, the clinician should be able to observe three of the five crown surfaces and the remaining two (proximal surfaces) partially. (Figure 111-6)

Healthy Teeth

Figure 111-6

The examination should begin by counting teeth. When all erupted, at approximately 24 months of age, there should be twenty primary teeth. The primary teeth are white in color and opaque, with smooth intact surfaces except for the biting surfaces of posterior teeth that will have a series of grooves and pits. Permanent teeth are cream colored and translucent when observed next to primary teeth. In most cases they are also larger. The number visible to the clinician will vary with the child's age and development.

Children that have similar findings to photos C, D, E should have a dental evaluation in the near future. Oral hygiene instruction and review of nursing bottle/breast feeding habits should be reviewed by the primary care provider.

Composite Photo of normal primary dentition And negative findings Figure 2. A, Normal 12 to 14 month old infant's mouth. B, Infants mouth with plaque. C. Decalcification and early cavitation. D, Remineralized decalcified enamel. E, Hypoplastic enamel (no decay). F; Fractured primary teeth.

Figure IV-l