Top Ten List of...
Top Ten List of Sound Oral Health Strategies
to Keep Children Pain-Free and Problem-Free
Clinical Professor, Department of Pediatric Dentistry and Director, International Program in Pediatric Dentistry, New York University College of Dentistry
AbstractEmerging information, technology and therapies make it possible for most children today to grow up with good oral health. The most powerful vehicle we have to achieve this goal is informed professionals and parents. All the tools exist to promote oral health and prevent problems in children if we apply what we know and have learned. The challenge is to increase dissemination of this information, and to remind everyone that good oral health contributes significantly to one's overall general well being12.
Parents, non-dental health professionals and dentists alike can benefit by becom- ing aware of the latest science and infor- mation concerning early oral health pro- motion and disease prevention strate- gies (3). Increasingly, the pediatric dental community is looking toward OB-GYN and pediatric medical professionals to disseminate information to expectant mothers and parents of newborns on how to maintain their infant's oral health, recognize common oral lesions, avoid early dental decay, and deal successfully with common problems of childhood such as teething and oral injuries. Additionally, age-specific information (anticipatory guidance)4,5 should be readily available on issues such as pacifier use, digit sucking, fluorides and effective oral hygiene practices.
In pediatric dentistry, relevant issues are pervasive and dominant. The following TOP TEN LIST is presented to address some of the issues that have a serious impact on a child’s oral health status. All are important and are not listed in order of importance. The goal is to make it easy for anyone to understand how to guide parents and their children toward promotion of oral health and prevention of oral disease. The list defines the "whys;" then offers practical strategies to enable anyone to perform the "hows."
Strategy N° 10
Children are not born with MS, but acquire it as teeth erupt into their mouths between 6 months and 2 1/2 years of age (11). By age 5, more than half of all children are infected (12). It has been suspected for a long time that the oral health of the mother impacts the oral health of her children13-15. It has been proven that the organism is nearly always the same genotype as the mother's13, and is probably passed by shared eating utensils, putting fingers in mother's mouth, kissing, mothers licking pacifiers, etc. If present in high enough numbers, the MS infection puts the child at high risk for dental decay16.
Mother must take care of her own oral health during pregnancy
One good way to minimize risk for the child is for the mother to keep her own MS count low17, i.e., to practice good oral hygiene during pregnancy and the post-partum period. For most people, brushing teeth twice daily with a fluoride toothpaste, flossing, and using an over- the-counter fluoride mouth rinse will maintain good oral health and keep MS at a low level.
An expectant mother, experiencing dental problems during pregnancy, such as inflamed, swollen gums (pregnancy gingivitis) or increased dental decay, should seek professional care. A simple in-office test could determine if her MS count is high. In such cases, chlorhexidine rinses may be prescribed to help resolve the soft tissue and decay problems by lowering the bacterial count. Consensus suggests that the second trimester is the best time for non-emergency treatment, as it provides a balance between safety of the fetus and comfort of the mother-to-be.
Strategy N° 9
Visit a dentist when the baby's first tooth erupts or by age 1 to increase the likelihood of a caries-free childhood
Prenatal counselors and pediatric health care providers (obstetricians, pediatri- cians, nurses, midwives, etc.) are well positioned to offer education and guid- ance to pregnant women and new parents on the basics of infant and toddler oral health. Unfortunately, medical education practically ignores oral health issues. Few practicing medical clinicians recognize and acknowledge the impact of oral health on one's general health. With the recent release of the Surgeon General's Report on Oral Health (12), there will hopefully be an increased number of dental referrals for infants, toddlers and preschool children.
The first visit to the dentist of a mother with her infant should be viewed as a "well-baby visit." Visiting the office of a pediatric dentist or a dentist who treats young children is an opportunity for par- ents to learn the ABC's of oral health care specifically tailored to the needs of their child. An informed parent can deal effectively with behavioral and nutritional concerns that are at the root of early dental decay. They will also be prepared to make intelligent choices when it comes to other oral health issues such as proper hygiene practices, good nutrition, feeding frequency, pacifiers and injury prevention. Their child can grow up cavity-free18.
Strategy N° 8
Breastfeeding is preferable to bottle- feeding because it provides both devel- opmental and immunological advan- tages for the child. However, breast- feeding on demand throughout the night can trigger the onset of early den- tal decay in the same manner as bottle- feeding.
Breast and bottle-feeding must be accompanied by sound oral hygiene interventions
Ideally, feeding patterns should be planned and be on some sort of sched- ule. In particular, nocturnal feeding increases the risk of dental decay, as lit- tle saliva is produced during sleep19. The oral bacteria can be extremely active during this time. Nutrients remain in the mouth longer and demineralization of enamel continues uninterrupted. Even during the day, continuous long-term exposure of dental enamel to acid, resulting from frequent snacking and eating results in demineralization, cavi-
An important intervention in very young children is to simply keep their teeth clean to counteract acid attack and eventual cavity formation. Without the plaque matrix to which to adhere, the harmful bacteria do not colonize and will not harm the teeth. Caretakers should use a piece of moistened gauze or a soft washcloth as often as possible, prefer- ably after each exposure to food, to wipe off plaque and debris from the teeth. A tiny amount of fluoridated toothpaste may be introduced after 6 months of age, but applied no more than once a day. Older children, age 2 and up, should use a soft toothbrush and a pea-size portion of fluoridated toothpaste at least twice a day (super- vised, of course).
Strategy N° 7
Teething can be difficult even for the heartiest of babies. All indications are that the pain and discomfort associated with initial tooth eruption can be quite severe. Teething symptoms usually man- ifest as irritability, loss of appetite, fret- ful/intermittent sleep, drooling, finger/fist biting or sucking, and sponta- neous episodes of crying22. Fever and diarrhea, commonly associated with teething, are more likely attributable to an opportunistic infection due to low- ered resistance during periods of active eruption of teeth. The stress and strain on the entire family from an infant expe- riencing severe teething should not be underestimated.
Use cold/pressure for teething; avoid commercial preparations
The topical application of cold to the affected area is the most effective rem- edy for teething22. Accompanied by bit- ing on a hard object, this is the best way to help the infant through difficult spells. Commercial teething rings, filled with sterile water, offer an effective and safe way to bring cold to the area causing discomfort. Just as effective, and less expensive, are refrigerated washcloths. They are large and coarse in texture, both desirable characteristics that get the job done safely and well. In both cases, a few spares should be kept ready, cold and clean, so that applica- tions continue uninterrupted by rotating them.
Most commercial preparations are inef- fective, as they are short-acting topical anesthetics. They also tend to mix with saliva and spread over the entire mouth, decreasing their effectiveness and toler- ance by the child. Definitely avoid "tradi- tional" or "folk" remedies such as rub- bing whiskey or paregoric on the gums; no doubt we'd all agree that alcohol and narcotics are not appropriate by today's standards.
Strategy N° 6
It used to be that oral health guidance from your dentist consisted of "don't eat sweets and brush twice a day," but it is somewhat more complicated on the "sweets issue." While sugar and carbo- hydrates are metabolized by MS, the thinking these days is that it is not so much what you eat that matters regard- ing the formation of cavities, but rather how often you eat16.
When frequency of eating decreases, oral clearance increases, discourag- ing MS activity
Reduction in the frequency of eating, in the form of regular meals and a few snacks per day, provides the healthiest nutrition and a reduced likelihood of enamel demineralization. Lowering the nutrient supply for MS and a subsequent acid reduction is achieved by minimiz- ing the number of food exposures each day. Saliva can then clear residual food- stuffs from the mouth efficiently, increas- ing the likelihood that cavities will not develop.
Brushing (or gauzing) a child's teeth at least twice a day is still the ideal. This interrupts plaque formation and mini- mizes sites where MS can colonize. Use of a fluoride toothpaste helps maintain a "constant low level" of fluoride in the saliva necessary to keep the mineral equilibrium in favor of remineralization of the tooth surface23.
Strategy N° 5
Without a doubt, adequate fluoride ingestion is the single most important factor in the striking 65% reduction of dental decay that has occurred in the U.S. over the past 50 years. The wide- spread availability of fluoride through drinking water and fluoridated tooth- paste has greatly enhanced the oppor- tunity for most children to remain cavity- free during their childhood years (24).
To ensure a cavity-free childhood, it is essential to receive the proper amount of fluoride
Strategy N° 4
Many parents are fearful that oral habits are harmful to their children. In fact, dur- ing infancy, children learn much about the taste, texture and shape of objects by putting things in their mouths. Little or no harm is done by sucking on fin- gers or pacifiers25. As with most habits, extreme cases may result in problems such as a malocclusion, open bite, palatal constriction or protruding front teeth. However, experts agree that important emotional needs are satisfied by these habits; sucking helps children feel safe and secure.
Thumbsucking and pacifiers should not be discouraged for young children
Children are born with a need to suck, which diminishes at different rates with different children. If a child sucks his/her thumb or finger, or uses a pacifier, do not be overly concerned about lasting effects - most children give the habit up themselves by age 426. Intervention should not even be considered until the permanent teeth begin to erupt, gener- ally about age 627.
Strategy N° 3
In an area where the water supply is flu- oridated, take advantage of the benefits afforded by utilizing it whenever possi- ble. Using local, fluoridated water to prepare foods and drinks is a great way to keep fluoride available in small doses over extended periods of time, and reduce the chances that teeth will decay. It is important to carefully consid- er all dietary and environmental sources of fluoride in determining how to achieve an optimum level for the child30. Low, constant delivery of fluoride into the body is the most effective and safest way to keep tooth enamel resistant to demineralization and decay.
Use fluoridated tap water to prepare formula, juices or cereals for infants and toddlers
In a non-fluoridated area, or when bot- tled water is used, consider the use of supplemental fluoride for children. Taken systemically, ingested fluoride contributes to one's overall fluoride pro- file and adds to the topical effect23. A dentist can assess how much fluoride your child is actually receiving, and can make recommendations to optimize the protective dose without risk of fluorosis - the result of excessive fluoride intake.
Strategy N° 2
Injury prevention awareness begins at birth and requires a safe environment and the use of protective gear. From the time that children begin to crawl and learn to walk, there is an increased risk that they will fall and injure their teeth. Serious oral and dental injuries include fracture, displacement and avulsion of teeth, as well as fractures and displace- ment of bones or joints of the head and neck. During infancy and toddlerhood, there is little protection to be offered other than the watchful eye of the care-taker. For the parent, there is a delicate balance between protecting the young child from injury and providing enough freedom to venture away and explore their environment.
Encourage the use of mouthguards when children are older and involved in physical activities and contact sports
and the N° 1 Strategy
Plaque does not form in the oral cavity 28,29 until teeth are present , but experts suggest that cleaning the mouth should begin immediately after the baby is born. Some feel that teething difficulties can be either eliminated or reduced in severity by massaging the gumpads beginning at birth, before the eruption of teeth. Certainly, if for no other reason, it makes good sense to get the child into the routine of regular cleaning, and to get used to the fact that this is some- thing essential to their well-being and for their entire life.
Strategy to keep children pain-free and problem-free - Cleaning of the mouth and teeth should begin at birth
This is best accomplished with a new- born or toddler by using the knee-to- knee position (see inset). Two adults sit opposite each other, knees touching. The child is placed with the head in the lap of one, the feet in the lap of the other. While one gently holds the arms and legs of the child to restrict movement, the other cradles the head, looks directly down into the mouth, and cleans the baby's oral cavity effortlessly and efficiently.
- American Academy of Pediatric Dentistry. Infant Oral Health Care Policy Statement, May,
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