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It is important for non-dental health practitioners to understand the basic concepts and historically proven preventive methods that have been available to the profession to decrease the negative outcomes of dental disease. To date, all preventive interventions recommended are based on principles established by early research, and most noteworthy the work of Keyes. Because dental disease is a bacterial infection, all interventions are aimed to affect the causative bacteria, increase the resistance of the host (teeth and gums) and reduce the substrate required by bacteria. This section will address those concepts primarily in the preschool child, where the primary care provider can have an influence in recommending preventive strategies. By five years of age the majority of children will have had a first professional dental intervention and the pediatric dentist or family dentist will be supervising the oral health of the child.
Plaque (biofilm) is a sticky film of many bacteria, food debris and salivary components that adhere to the tooth. General components of plaque are calcium and phosphorus. The cariogenic bacteria produces polysaccharides that improve adherence of the plaque to the tooth enamel. Although plaque can initially protect enamel because of its mineral content, if left undisturbed, it will increase in size and in the number of bacteria. When a substrate is available, such as sugars and other fermentable carbohydrates, an acid is produced that attacks the enamel with loss of calcium and phosphate. This initial demineralized area is referred to as a white spot lesion. Depending on many factors including saliva pH, presence of fluoride, removing plaque and modifying the substrate, this lesion can either become remineralized, or with time can lead to cavitation.
Plaque removal should begin early, as soon as the teeth erupt. Some reports suggest "wiping" the edentulous alveolar ridges with a washcloth or wet gauze. There is no evidence in the literature that would suggest that this is of any preventive value. Cariogenic bacteria requires tooth surfaces to adhere to and do not adhere to tissue. Possibly an advantage of wiping the alveolar ridge would be to begin to develop a habit of oral hygiene. Again, there are no reports to suggest that infants who have had their edentulous alveolar ridges wiped leads to better oral hygiene after the teeth erupt.
Plaque removal is a fine motor activity that infants, toddlers and even preschoolers cannot be expected to perform initially. Therefore, the care provider will be responsible for cleaning the teeth at least until the child enters first grade. With proper positioning and a toothbrush that is comfortable for the caregiver to use, removing plaque can be fun and quickly accomplished. With increasing number of teeth more time will be necessary.
Initial brushing of teeth can be accomplished in the bath, on the changing table or in a setting where two adults sitting knee to knee create a cradle for the infant to lie in. In this supine position there is stability and good access to the oral cavity .With gentle pressure from fingers, the jaws can be spread apart and the brush inserted for cleaning. Minimal, if any, fluoride containing toothpaste should be used and a system developed to try and clean all surfaces of the teeth. (Figure V-I)
With increasing number of teeth, more time will be necessary to clean the teeth. Infants and toddlers will want to hold the brush and mimic this activity. An appropriate size brush with wide handle can be given to the child to use. But this does not replace the caregivers careful brushing. A rotary scrubbing method is the preferred motion to use for brushing teeth. It is recommended to initially brush once a day, preferably before bedtime, to disturb and remove the plaque off the teeth. As children age, learning to brush after meals and/or before going to school is recommended. Most childcare centers will also encourage tooth brushing as one of the many daily personal hygiene activities.
There are hundreds of styles of manual brushes available to choose from. More recently, power brushes have become popular but none are recommended for infants. Select a brush appropriate for the size of the mouth and the brusher. Initially the caregiver is the primary brusher and a brush with a longer handle will be more comfortable. Because of the few teeth and a small oral cavity, a smaller head will be most convenient. Soft bristles should always be selected over coarse or hard ones.
Colors and logos are up to the selection of the caregiver and child. Brushes should be stored properly to dry between brushings. They should also be replaced periodically depending on their use. Flossing is very difficult in young children because of the size of the mouth and the cooperation expected. Preferences are to concentrate on brushing well, with flossing coming much later in the child's development.
Contemporary Use of Fluoride
The beneficial oral health effects of the mineral fluoride are well known and have been documented in thousands of reports in the literature. For the non-dental health professional or practitioner it is important to know fluoride is safe when used appropriately.
The element fluorine is found naturally throughout the world. Early studies demonstrated that when incorporated in the teeth, the demineralizing effects of acids were reduced. With the beginning of water fluoridation in 1945, there began a lengthy series of studies and reports to again show the beneficial effect in reducing cavities and improving oral health.
The effects of fluoride on teeth and the subsequent reduction in cavities has been thought to be the result of the pre-eruptive incorporation of fluoride into the developing tooth enamel. With continuing research and a better understanding of the caries process, it is now believed that the predominant effect is post-eruptive and not pre-eruptive with incorporation of the fluoride into the demineralized tooth surfaces.
There are many products and methods available for the systemic and topical application of fluoride. Some are available for self-application and others for application by a professional. (see Table V-I)
It is the responsibility of the health professional to select the most appropriate fluoride, the right amount and to ensure that it is given at the right time.
Ingestion of an inappropriate amount of fluoride at a time of enamel calcification can adversely effect formation of enamel crystals. This leads to hypomineralization of dental enamel affecting the porosity of the enamel. This is called fluorosis. Clinically it can appear as a very mild chalk like, lacy marking across a tooth surface to a severe form where the enamel is pitted and brittle and heavily stained. (Figure V -2)
Fluorosis occurs only when fluoride is ingested during critical periods of tooth development. It is highly dependent on the dose, duration and the timing of the fluoride intake. The transition and early maturation stages of enamel development appear most susceptible to fluoride. For the anterior permanent teeth, the critical period is estimated at 15-24 months for boys and 21-30 months for girls.
Fluorosis of primary teeth is uncommon. When seen clinically, the second primary molar buccal surfaces are most often involved. Because the second primary molars are calcified post-natal it is suggested that the fluoride is associated with water fluoride concentration and not from fluoride dentifrices or fluoride supplements.
Current recommendations for the optimal oral health effect are based on the risk of the child for oral disease (see Section IV), the known outcome of excessive systemic fluoride in preschool children and the availability of fluoride containing products.
Fluoridation of Community Waters
The most cost-effective method to prevent cavities in populations served by community waters is by addition of fluoride. Note: the effects of the use of bottled and processed waters over community waters and caries prevention is not known. Most bottled and processed waters do not contain fluoride and manufacturers are not required to state the fluoride (if any) content.
Fluoride containing toothpaste
Over 95% of toothpastes for sale in the United States contain fluoride. There are no "child version" fluoride toothpastes with reduced fluoride content. The only way to limit fluoride uptake from toothpaste is to limit the amount placed on the brush.
Present recommendations are for a small pea-sized amount and maybe only a smear of toothpaste to be placed on the child's brush. (Figure V-3)
For preschoolers, the caregiver should place the paste on the brush. Because of inadequate developed control of the swallowing reflex in children under six years, and even less controlled in children under three years, it is possible for preschoolers to swallow as much as 0.8 g of toothpaste per brushing which amounts to 0.8 mg of fluoride. Fluoridated toothpastes should not be used during brushing for children less than two years old.
Children at high risk for dental disease and who drink low or no fluoride water may be prescribed a supplement in the form of a pill or lozenge. Schedules are periodically updated by the ADA, AAP , and AAPD. (Table V -2).
Fluoride Supplementation Schedule -1994
Age <0.3 0.3-0.6 >0.6
Birth < 6 months 0.0 0.0 0.0
6 months < 3 years 0.25+ 0.0 0.0
6 to at least 16 years 1.00 0.50 0.0
*1.0 ppm = 1 mg/liter
+ 2.2 mg sodium fluoride contains 1 mg fluoride ion
Table V -2
used by the family should first
be analyzed for fluoride content
(See Appendix for testing
programs) and then the
appropriate supplement dose
prescribed. It is also suggested
to allow the tablet/lozenge to
dissolve slowly in the mouth for
a topical effect. The preferred
time is after brushing the teeth
and before going to bed at night.
This allows the fluoride rich
saliva to bathe the teeth for an
optimal topical effect.
Application of high concentration fluoride products
The use of topical products containing fluoride are either available for professional applications or for self-application. Professional application of high concentration fluoride should be limited to children at high risk of dental disease and not as a routine intervention for all children.
Most recently, in the United States, the application of a fluoride varnish in preschoolers at high risk or with early signs of dental disease has been promoted. This application is quite simple and fast, and reduces the amount of fluoride that is available to the child for ingestion. Scandinavian studies have shown fluoride varnish to be cost effective in the school dental services.
Fluoride mouth rinses are available over-the-counter without prescription for daily use. Because children under six years may have an uncontrolled swallowing reflex they, are not recommended. But for school aged children who are at high risk, the daily use of a fluoride containing rinse should be considered.
Whatever fluoride regimen is recommended, monitoring is important. As children age and if risk status changes, modifications in fluoride dosage may be needed and further monitoring may be required.
Because dental disease is a complex bacterial disease that requires a susceptible host, cariogenic bacteria and a substrate for the bacteria to survive, a preventive strategy must include monitoring and possibly modifying the child's diet.
Balanced nutrition is important for healthy gums and teeth. It is not the intent of this section to elaborate on the healthy diet for optimal growth and development for children.
All fermentable carbohydrates provide the required nutrients for oral bacteria to metabolize and produce acids that can promote oral diseases. How an individual child is affected by these acids will depend on many factors including the susceptibility of the teeth and the ability of saliva to neutralize the acid. (Table V -3)
Relative Decay Potential of Beverages
Personal communication, P .R. Erikson, 1999; and data from references 5 and 6.
Unfortunately, inappropriate dietary habits begin early in life with parents who are ill prepared in parenting skills and do not use common sense. Even though infants must be fed frequently during their first year, carrying this schedule into the second and third years with frequent bottles and snacks as a substitute for healthy nutritious meals has become common.
It is important for all health practitioners to discuss with parents the prolonged and inappropriate use of the bottle after teeth have erupted. Toddlers do not require a bottle hanging out of their mouths all day long. This bottle, if containing a beverage with a fermentable carbohydrate, will feed the bacteria and set up an unhealthy oral environment placing the child at high risk for oral disease. Guidelines suggest that weaning from the bottle should occur at 12 months of age.
Beverages other than milk and water are inappropriate to feed a toddler on a routine basis. Carbonated beverages are especially troublesome not only because of their carbohydrate content but also due to their low pH. There are no published guidelines that recommend toddlers have soda pop from a bottle.
Fruit juices and drinks can also be a problem not only for oral health but for general health. Juices should not be used in the bottle but only in a cup after a child can hold up the cup and drink in the upright position!
Availability of confectionaries and baked goods should be limited and children can be directed to eat appropriate fruits and vegetables for snacks. Sweets should be reserved for weekly "junk nights" and special occasions. (Table V -6)
Snacks For Oral Health
With increase in age and socialization children will be provided treats at daycare, friends' homes and parties. Parents should be proactive and work to find an appropriate balance between acceptable and unacceptable foods.
Clarkson BH, Fejerskov 0, Ekstrand J, Bart BA. Rational use of fluorides in caries control. In Fejerskov 0, Ekstand J, Burt BA, eds. Fluorides in Dentistry 2 ed. Copenhagen: Munksgaard, 1996; 347-57.
Committee on Nutrition. The Use and misuse of fruit juices in pediatrics. American AcademyofPediatrics. Pediatrics, 2001; 107:1210-1213.
Dean HT, Arnold FA, Jay P and Knutson JW .Studies on mass control of dental caries through fluoridation of public water supply. Public Health Rep, 1950; 65:1403-1408.
Den Besten PK, Thariane H. Biological mechanisms of fluorosis and level and timing of systemic exposure to fluoride with respect to fluorosis. J Dent Res, 1992; 71: 1238-1243.
Erikson PR, Mayhari E: Investigation of the role of human breast milk in caries development. Pediatr Dent. 1999; 21:86-90.
Erickson PR, McClintock K et al: Estimation of the caries risk associated with infant formulas. Pediatr Dent; 1998; 20:395-403.
Horowitz HS, Ismail L. Topical fluoride in prevention. In: Fejerskov 0, Eckstrand J, Burt BA eds. Fluorides in Dentistry 2 ed. Copenhagen: Munksgaard, 1996; pp 311-327.