January 1, 2010
by Fehmida Z. Dosani DDS, Trang D. Nguyen DDS and David R. Farkouh BSc, DMD, MSc, FRCD(C)
Establishment of a dental home during infancy provides an opportunity to make a meaningful impact on the oral and general health of a patient. Early dental assessment assists in the prevention of dental disease and helps to optimize oral health over a lifetime. Furthermore, implementing early dental visits is a practice builder not only by providing a new patient source, but through retention of patients by encouraging lifelong care.
Although it was previously recommended that the first dental visit should be scheduled for age three unless a pediatrician recommended an earlier assessment, dental disease can arise much earlier. Eight per cent of children aged two have at least one decayed or filled tooth and over 40 per cent of children are affected by caries by the age of five.1 Early childhood caries (ECC) is a disease that when severe can affect growth, cause pain and infection and have lasting detrimental effects on the quality of life of patients and parents.2 In these cases, a dental visit at age three is often too late for prevention and the interventions required to treat ECC are both expensive and invasive.3
The Canadian Dental Association (CDA) recommends that the first dental visit take place within six months of eruption of the first tooth or by one year of age.4 The timing of this visit not only allows an opportunity for screening for dental caries, but also for preventive counseling and anticipatory guidance with regard to oral hygiene techniques, diet, fluoride exposure, non-nutritive sucking habits and injury prevention. Though the need for an early examination has been advocated, the protocol is not routinely practiced because parents are largely unaware of it and many dentists have limited experience or interest in performing an infant oral exam.
The establishment of the dental home during infancy consists of two components: the history and physical examination followed by caries risk assessment and preventive counseling.
Taking maternal and infant medical/dental histories is a good opportunity to develop rapport with parents and to learn about their dental knowledge and expectations. Pertinent questions should assess demographics, medical history including complications during pregnancy or delivery, and the child’s medical conditions including allergies, medications, hospital stays and immunization status. In addition, a dental history should include oral home care routine, diet and presence of oral habits, history of dental trauma, fluoride use and prior dental visits. The dentist may also address specific concerns of the parent at this time.
A convenient and safe way to accomplish the physical examination is in the knee-to-knee position (Figures 1 and 2). The parent is instructed to sit sideways on the dental chair facing the dentist, who sits in the operator chair knee-to-knee with the parent. The infant is positioned on the parent’s lap facing the parent, with one leg wrapped around each side of the parent. This allows the parent to use his/her elbows to restrain the child’s legs, while having his/her hands available to hold the child’s hands. The child’s head is lowered on to a pillow on the operator’s lap for the examination. This position offers the dentist good stability of the child’s head, while the parent is responsible for the arms and legs (Figure 3). It is important to note that proper stability of both head and body is necessary to carry out a safe oral examination on an infant, and the parent must be aware of his/her role for this to occur.
Before beginning the examination it is important to counsel the parents that their child will likely cry and to reassure them that this is expected and normal. In fact, if the baby does cry, his/her open mouth will facilitate the intraoral examination. If the child will not open his/her mouth, a finger can be placed high and posterior to the most posterior tooth (in the lateral pterygoid region) to facilitate a jaw-opening reflex.
The dentist should thoroughly assess the infant’s overall growth and development, extra-oral tissues and intra-oral soft tissues and teeth. Presence of plaque, gingivitis, decalcifications or white spot lesions, as well as any carious lesions or evidence of trauma should be noted.
With information regarding the patient’s history, oral hygiene routine, diet and dental status, it is then possible to conduct a caries risk assessment and provide patient-specific recommendations.
A caries risk assessment should be performed at each visit. Risk factors for infants include but are not limited to existing decay, socioeconomic status, education level of the parents, number and type of between-meal exposures to fermentable carbohydrates (including on-demand/prolonged nursing and oral liquid medications), the habit of storing food in the mouth by not swallowing, sleep disturbances, systemic diseases, poor oral hygiene, poor family dental health, enamel defects, cariogenic bacteria, genetic abnormalities, and low fluoride exposure.5-9 Results of the caries risk assessment will help determine the need and extent of preventive measures or interventions required.
Parents should be advised that putting their child to bed with a bottle that contains sugars, either naturally occurring or added, is one of the greatest risk factors for ECC.5Ad libitum breastfeeding, where the child is in bed with the mother and allowed to breastfeed on demand, has also been implicated in the development of ECC.9 By six to eight months of age, many children who are being breastfed have also begun consuming other foods, and breast milk when combined with other sources of carbohydrates has been found to be cariogenic.10-11 This increased risk during sleep is due to decreased salivary flow, the retention of cariogenic food or liquid in the mouth and a lower frequency of swallowing that results in teeth being exposed to fermentable carbohydrates for prolonged periods. Other dietary habits associated with ECC include prolonged use of a sippy or spout cup with juice or milk that allows a child easy access and consumption, and frequent snacking on fermentable carbohydrates. Infants should be allowed to consume only four to six ounces of fruit juice per day and powdered beverages or soda pop should be avoided as they increase the risk of dental caries and have poor nutritional value.12 Parents should also be aware that chronic use of sugar-containing oral liquid medications increases caries risk.13 High-risk dietary practices are commonly established by approximately 12 months of age,14-15 and this further reinforces the importance of diet counseling at the first visit.
Parents should be advised that good oral hygiene begins prior to the eruption of the first tooth by wiping the gums after feeding to help accustom the child to oral care. Regardless, oral hygiene should begin no later than the eruption of the first primary tooth. When only incisors are present, teeth can be cleaned with a soft toothbrush with water to help reduce plaque accumulation. Once all incisors have erupted, toothpaste can be introduced, in the form of a light smear on the toothbrush bristles. Teeth should be brushed at least twice daily. Parents frequently express that they are having difficulty brushing due to their infant’s inability to cooperate, and often benefit from a demonstration. For infants, a safe and stable position is to have the parent sit with the baby’s head in his/her lap (Figure 4). Once the child is able to
stand up, parents can position themselves behind the child and have the child tilt the head upward (Figure 5). In these positions, the parent has good control over the child’s head, and can use one hand to reflect the lips and retract the cheeks while brushing. Flossing should be encouraged for children who have closed contacts, and the use of floss picks is often helpful (Figure 6).
The CDA now recognizes the use of topical fluoride as a safe and effective means of caries prevention in patients of all ages. Before age two, it is recommended that only a light smear of fluoridated toothpaste should be used for brushing (Figure 7), and excess toothpaste can be wiped off the teeth with a soft cloth. Fluoride containing toothpaste should be used judiciously as excessive ingestion of fluoride in young children may lead to dental fluorosis.16 Prior to prescribing fluoride supplements, dentists should consider possible alternate sources of systemic fluoride to optimize prevention and minimize risk.
Parents often have questions concerning non-nutritive sucking, including thumb sucking and the use of pacifiers. Early use of pacifiers or digit sucking is normal. Parents should be informed that these habits generally cease by two to four years of age and that children should be encouraged to stop these habits prior to the eruption of permanent teeth to prevent distortion of the dental arches.17
As babies become toddlers, risk of dental injury increases. Most injuries are due to falls or less frequently collisions and usually have no long-term consequences. Parents are more comfortable if dental office contact information is made available and they have some understanding of what constitutes a dental emergency.
The infant oral visit establishes the dental office as the dental home of the infant. A comprehensive exam at this age allows for both early detection of dental disease and early prevention through education of the caregiver. At the completion of this appointment regular visits can be arranged to continue to ensure the optimum oral health. By incorporating the infant dental visit into their practice, dentists can truly have a lasting impact on the oral and general health of their patients. oh
Dr. Fehmida Z. Dosani is a dental resident in the Department of Dentistry at The Hospital for Sick Children, Toronto, Ontario.
Dr. Trang D. Nguyen is a dental resident in the Department of Dentistry at The Hospital for Sick Children, Toronto, Ontario.
Dr. David R. Farkouh is a staff pediatric dentist in the Department of Dentistry at The Hospital for Sick Children, Toronto, Ontario.
Oral Health welcomes the original article.
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