January 7, 2022
by Yili Wang, DMD, MSc, FRCD(C); Laura Vertullo DMD, MSc, FRCD(C)
Dental and medical professionals have historically kept separate practices. Dentists have struggled to integrate into the medical community outside of the hospital setting. Traditionally, limited information is given to parents by pediatricians and family physicians with regards to infant oral health and general pediatric dentistry. Recently, there has been a trend towards multidisciplinary outpatient clinics that have both pediatricians and pediatric dentists under one roof, with the goal of providing integrated care for children from birth onwards. (Fig. 1)
How do patients and their caregivers benefit from this multidisciplinary model? Pediatricians and physicians are in a unique position because they are able to provide anticipatory guidance to parents during the gestational period as well immediately after birth. Pediatric dentists have a greater likelihood in establishing a dental home early to promote prevention by teaming up with health care workers and providing consistent education to both patients and other healthcare workers. As the health care model evolves to one of multidisciplinary care, families are demanding a more holistic and convenient approach in providing the best care for their little ones. (Fig. 2)
By working with other health care workers, we have various opportunities to help educate our patients and promote optimal infant health. This can start with prenatal education. Pediatric dentists and pediatricians have the opportunity to work together from as early as the first few days of an infant’s life through infant oral assessments. One of the earliest topics discussed with new parents is infant feeding. Exclusive breastfeeding for the first six months of life with continued breastfeeding for at least the first year is recommended by the American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG) and the World Health Organization (WHO). While levels of evidence for the benefits of breastfeeding vary, the general consensus is that breastfeeding exclusively for the first six months of life offers protection against gastrointestinal tract and respiratory tract infections with benefits extending beyond this period.
Throughout most of history, breastfeeding was considered the norm. It was only in the late 19th century that breastfeeding was not well supported by medical and nonmedical groups. Following an increase in infant mortality from unsafe artificial feeding, public health researchers once again recommended breastfeeding and the use of pasteurized cow’s milk. This created a market for commercial formula as a safer alternative to cow’s milk in the early 20th century. There has been a recent resurgence of breastfeeding, however it is important to note that breastfeeding and formula feeding are considered equally beneficial to infants. We should not be passing our own opinions while discussing infant feeding with parents because there is no strong scientific evidence to support that one method is better than the other. Not to mention, this decision is sometimes out of the caregiver’s control as breastfeeding is not just a lifestyle choice. Interestingly, some speculate that the recent increase in tongue-tie diagnoses can be related to the return of breastfeeding recommendations.
With growing interest in tongue-ties, and their effect on infant feeding, pediatricians and pediatric dentists need to be familiar with the topic and be able to work cooperatively with lactation consultants, speech therapists and other healthcare workers in providing the best care. Tethered oral tissues, tongue or lip-ties highlight the importance of an interdisciplinary approach. We believe the solution cannot be provided by a single healthcare worker but by an entire team of professionals that provide a proper assessment of the child, determine the treatment if required and follow-up. (Fig. 3) Involving the parents through education and involving them as a member of the team is crucial. A tongue-tie can be defined as the restricted movement of the tongue caused by the lingual frenulum. This occurs in 5-12 percent of newborns, presenting in various severities. A lip-tie results from a tightening of the membrane attaching the upper lip to the upper gum tissue. Not all ties are problematic and therefore not all require correction or intervention (Olivi et al, 2012).
The baby’s tongue plays a pivotal role in breastfeeding. The cupped tongue forms a trough, guiding the milk flow while the anterior tongue and mandible elevate. The posterior tongue creates a positive intra-oral pressure to move the milk into the pharynx, initiating swallowing. During the first month of development, babies learn the suck-swallow and breath rhythm that allows them to hold and swallow larger amounts of milk. Restrictions on tongue movement can result in uncoordinated suck-swallow patterns, unproductive suctioning, biting of the nipple, spillage during feeding, and decreased milk supply over time. Restrictions to the upper lip can inhibit the seal around the breast during feeding resulting in excess air ingestion. Some babies do not latch long enough for full feeds while others can latch for long periods but with insufficient milk intake. Additionally, some babies will only consume milk when mothers have milk ejection reflex. Compared to breastfeeding, bottle feeding requires a less sophisticated motor plan. Babies do not need to open as wide when bottle feeding and there is greater cheek and lip movement. There are fewer sucking movements and pauses with bottle feeding.
For mothers, breastfeeding struggles cause emotional, physiological and mental anguish. Mothers feel blamed for their infant’s inability to feed and may give up breastfeeding early. We must be mindful that all conversations are conducted in a culturally and socially sensitive manner. Not everyone is able to breastfeed. Often times, mothers have trouble locating calm places in public or at work to breastfeed or breast pump. (Fig. 4) Our roles are to encourage families to be informed about the benefits of breastfeeding and to seek support groups during the prenatal period. Families need to feel supported. Medical providers need to follow-up within days of birth for breastfeeding babies and their families because there are often challenges. If needed, a Board-Certified Lactation Consultant should be included in an infant’s management.
From a dental perspective, the knowledge mentioned above is crucial to know, particularly if providers are recommending tethered tissue releases. Understanding the mechanics of breastfeeding, and ensuring that caregivers are guided pre and postoperatively is critical for success. Offices should be breastfeeding-friendly by creating a quiet corner or designated lactation rooms. Tethered tissue assessments and releases is one of many areas where early collaboration between the relevant providers is important. Dentists can also utilize the opportunity of being involved early on in infancy by educating caregivers on caries prevention methods and establishing a dental home.
The opportunity to collaborate with medical professionals does not end in early infancy. Dental professionals have read and heard it many times that early childhood caries is one the most common chronic diseases in children, however our medical colleagues may not be as aware of this statistic and far too often, will not recommend early dental visits to their youngest patients. Pediatric dentists frequently encounter situations where advice given by a physician with regards to feeding and oral hygiene differs from what they would recommend. Educating other medical professionals and working with them can help get a clear message across regarding the importance of early dental care. We can empower families by outlining the risk factors for early childhood caries including diet and oral hygiene practice.
When discussing caries prevention with parents, it is easy to promote healthy diets by listing foods that promote caries and those that do not. Unfortunately, these good and bad food lists fail to consider the biggest variable, which are the children’s eating habits and possible medical comorbidities. For example, hypotonia or tethered oral tissues can lead to poor and/or slow eating habits. Prolonged periods of food in the mouth increases the risk of caries. There may be a discrepancy of opinions between pediatricians and dentists regarding then duration of infant feeding or types of food. In children who are underweight or growing slowly, pediatricians often recommend PediaSure. Unfortunately, this calorie dense drink is also thick and high in sugar, promoting early childhood decay. Sugars in breast milk and infant formulas act as substrates for dental caries. At birth, the oral cavity and GI tract are sterile but become colonized by different microbes within the first two years of life (Costello et al, 2009). There are two types of formula: cow’s milk-based and non-cow’s milk-based. All formula when prepared has between 60-70kcal of energy per 100mL (Walker, 2015). Lactose, sucrose, maltose and/or glucose make up the carbohydrate content in infant formula. Alternatives to lactose-containing milk-based formulas have the highest sucrose content. There is approximately 1.3-12 grams of total sugars per serving (More et al, 2018). Breast milk, a source of lactobacilli, has shown to inhibit growth and attachment of cariogenic bacteria especially S. mutants. One study concluded that infants who were breastfed had higher lactobacilli species compared to infants who were formula fed. However, there’s more at play to caries risk than bacterial count and not all infant formulas are created equal. Formula with sucrose is more cariogenic than lactose-containing formulas. Dentists and pediatricians can work together in promoting breast feeding but also realize there are multiple reasons as to why infants are exclusively breastfed or supplemented with formula. Healthcare providers should also take into consideration the composition of infant formula that is best for growth and development and minimizing dental caries risk.
As dentists, we should strive to be more collaborative with other healthcare workers and our patients. We have all learnt the caries process in school, the demineralization of tooth enamel from acid producing bacteria that breakdown carbohydrates. However, this process means little to our patients and us because we have not given it context. Even before a baby’s first tooth erupts we need to work with their doctors and auxiliary professionals to ensure we have equipped the family with all the tools in not just caries prevention but overall health, growth and development. We believe this approach will build the foundation for lifelong patients. (Fig. 5)
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About the Authors
Dr. Yili Wang and Dr. Laura Vertullo are pediatric dentists in private practice in Oakville, Ontario. They work in a multidisciplinary pediatric clinic alongside pediatrician, Dr. Alexandra Hernandez.