INFANT ORAL HEALTH CARE

INTRODUCTION

● Promotion of oral health and preventive dental care are fundamental concepts in
dentistry for children. In this context, the Pediatric dentist has a specific responsibility
to children and their parents as well as to the society. The preventive process must begin
early in infancy during the infant’s 1 st year to ensure a successful outcome .The goal is
to provide infants with a pleasant, non threatening introduction to dentistry and
establish and reinforce the foundation of sound dental habits.

● A comprehensive infant oral care program utilizes

(a) oral health assessment at regularly scheduled dental visits,

(b) risk assessments,

(c) counseling sessions with parents during either regular dental visits or additional
visits scheduled if a child is deemed at risk.

(d) Preventive treatment such as the application of fluoride varnish or sealants and

(e) Outreach and incentives to reinforce attendance.

An oral health risk assessment before 1 year of age affords the opportunity to identify
high-risk patients and provide timely referral and intervention for the child, thus
allowing an invaluable opportunity to decrease colonization of bacteria in the infant.

Need for Infant oral health care:

● Oral mucosa is the first in the human body where microorganisms are seen to be
established soon after the birth within 6-8 hrs in an infant. The eruption of teeth is an
event that brings about a qualitative and quantitative change in the microflora.

● Infectious disease of the oral cavity: It has been proven that streptococcus mutans is
a causative factor in the initiation of dental caries. The major route of its transmission
is vertical from mother to child (Berkowitz and Jones, 1985).Children of mothers with
high concentration of salivary mutans streptococci acquire them earlier and in higher
numbers than children with low level. The most critical time for the initial acquisition
of mutans streptococci in children has been suggested to be between the age of 19 and
31 months, a period designated as ‘the window of infectivity’ (Caufield et al., 1993).The
primary molars may be particularly critical for initial mutans streptococci colonization,
because they emerge into oral cavity between 16 and 29 months of age (Lunt and Law
1974) and possess both fissured occlusal surfaces and concave approximal surfaces.
Newly emerged teeth represent a virgin habitat which enables mutan streptococci to
colonize the oral cavity. As infants are more susceptible to acquisition of mutans
streptococci, either from the mother or due to improper feeding habits .Early
intervention by pediatric dentist is required

. ● Oral soft tissue pathology: Early detection of certain soft tissue pathology like
epithelial cyst, congenital epulis, pseudo membranous candidiasis, natal and neonatal
teeth, eruption cyst, and traumatic ulcer called Rega Fede’s disease caused due to
irritation by erupting mandibular incisors is possible due to early intervention.

● Traumatic Injuries: With the lack of motor coordination in infants, trauma to

developing primary teeth may also occur, which has to be detected.

● Child abuse and neglect may also be detected

● Handicapped children, cleft lip and palate cases and other such children requiring
attention may do so right from birth.

● Problems of speech, language would require early detection.

HISTORY

 1984 the Department of Pediatric Dentistry at the University of Iowa College of

Dentistry initiated the Infant Oral Health Program based on the faculty’s belief
that total prevention of dental disease is a realistic possibility.
 The Infant Oral Health Program was designed to provide early dental evaluation
of infants/toddlers and provide parent education regarding their important role
in preventing dental disease in their children. Although the program was
 available for children up to 3 years of age, the preferred age of the first dental
visit was between 6 and 12 months of age.
 In 1986, the American Academy of Pediatric Dentistry (AAPD) adopted the first
infant oral health-care policy statement approach
 Nowak (1997) has stated that “the goal of the 1 st oral supervision visit is to assess
the risk for dental disease, initiate a preventive program, provide anticipating
guidance and decide on the periodicity of subsequent visits

GOALS:

The goals can be summarized by the following six tenets.

1. Break the Cycle of Early Childhood Caries:

early childhood caries, remains a problem for many children, by 5 years of age, many of
the children experience dental caries. In subpopulations of poor and minority children,
the rate is higher and the condition begins earlier. Although the cause of such early-
onset disease remains unknown, the concentration of disease in certain populations
suggests that diet, microflora, and even prenatal factors may be contributory. Of even
more concern is the cyclic nature of early childhood caries in which children afflicted
remain at risk throughout childhood, even when preventive services are available.

2. Disrupt the Acquisition of Harmful Microflora

Recent research suggests that children are inoculated with caries-initiating bacteria by
caretakers, primarily mothers If a child’s caretaker harbors virulent organisms, then
transmission via kissing, shared food or other contact can occur and begin the caries
process. On the plus side of this acquisition model is the potential to prevent
transmission, reduce the parent’s bacterial inoculum, or use antibacterial
chemotherapeutic agents to eliminate the infection before it becomes chronic and leads
to dental caries. In a general dental practice, prenatal counseling, maternal oral health,
and infant oral health form the chain for prevention of bacterial acquisition.
3. Manage the Risk/Benefit of Habits Infancy gives risk to many habits.

The development of basic habits and patterns such as likes dislikes and food preferences
occur very early in life. This holds true for such daily routines as tooth cleaning. Finally
prolonged use of bottle beyond 12 months of age can lead to infant becoming overly
dependent on bottle and to eventual development of potentially damaging habits such
as use of the bottle at night and its use as a pacifier during the day. The development of
sound health habits during infancy offers child the greatest potential for avoiding dental
disease. Infant oral health permits the dentist to enter the habit continuum while it still
provides a benefit to the child and work with the family to mitigate deleterious effects
and transitions the child out of the habit.

4. Establish a Dental Home for Health or Harm:

The concept of a dental home has been suggested as a means to focus preventive,
treatment and referral services to optimize oral health .Our physician colleagues
understand the benefits of establishing a doctor-family relationship. Care is begun with
non threatening preventive services; if an emergency occurs, parents know where to
turn; if questions arise, reliable and trusted information is available; if treatment is
needed, a firm foundation of trust has been built. Children who have a dentist are more
likely to receive preventive services. From the standpoint of a general dental practice,
the one-stop, family orientation is a strong factor in success.

5. Impart Optimal Fluoride Protection

Fluoride remains dentistry’s best preventive tool, and optimal fluoride exposure is a
tenet of early intervention. The current concern about fluorosis gives even more
importance to oversight of fluoride exposure during the period when teeth are at
greatest risk, in the first 3 years of life. Physician-driven fluoride supplementation has
not been very effective, and with current recommendations of the Centers for Disease
Control and Prevention that require caries risk to be added to the equation, dentist
involvement is crucial to maximize anticaries benefit and minimize fluorosis risk.
6. Use Anticipatory Guidance to Arm Parents in the Therapeutic Alliance

Parental involvement has become a tenet of child health care. Because infant oral health
is so heavily weighed toward risk assessment and protective factors at home, the parent
becomes a co therapist. In the first 3 years of life, there is no routine preventive message
as the child develops a full primary dentition, becomes mobile, and makes his or her
first forays away from the family in daycare. The dentist must empower the parent to
provide prevention but even more to anticipate the oral health implications in the
rapidly changing child.

7. Establish the importance of periodic dental visit at regular interval:

Periodic dental check up is essential to prevent occurrence of any new dental lesion and
its importance has to be asserted to the parents. Child’s first dental visit should be
during the time of child’s first birth day. Thereafter periodic checkup has to done to
promote oral health.

American Academy of Pediatric Dentistry Recommendations on Infant Oral

Health Care

1.Ideally, infant oral health begins with prenatal oral health counseling for parents. An
initial oral evaluation visit should occur within six months of the eruption of the first
primary tooth in an infant and no later than 12 months of age.

2. At the infant oral evaluation visit, the dentist should do the following: Obtain a
thorough medical and dental history, covering the prenatal, perinatal and postnatal
periods. Perform a thorough oral examination. Assess the infant's risk of developing oral
and dental disease, and determine the appropriate interval for periodic reevaluation
based on the assessment. Provide anticipatory guidance for the parent or caregiver
regarding dental and oral development, fluoride status, nonnutritive oral habits, injury
prevention, oral hygiene and effects of diet on dentition.

3. The dentist who performs these services for an infant should be prepared to provide
therapy when indicated or should refer the infant to an appropriately trained person for
necessary treatment.
Oral Examination and Assessment of Clinical Risk Factors:

 Oral health risk assessment should be received by an infant by 6 months of age

by primary health-care provider or by a qualified health-care provider. Such an
assessment should provide education on infant oral health, evaluate and
optimize fluoride exposure, and assess the patient’s risk of developing oral
diseases of soft and hard tissues
 Infant care represents deviation from routine office practice .It does not routinely
require the same armamentarium that would be used for a dental prophylaxis
and tray delivered fluoride. The site need not be operatory, but a well lit,
comfortable conference room or play area can also be used. Radiograph would
be considered unusual in most infant visits, and patient napkin, cotton rolls and
other trappings of typical dental examination are for the most part absent
according to Paul S Casamassimo.
 Dental professionals must recognize that any dental caries detected in toddlers
began much earlier. Hence efforts should be directed to prevent dental disease
in children prior to its onset i.e., during infancy. Good feeding practices should
be taught to the parents to achieve this. Importance of fluoride therapy has to be
emphasized. All other oral diseases should be recognized early and intervened.

The oral examination of the infant is a quick process but differs from the typical child
examination in several ways:

 Use of a dental chair is unnecessary and the least preferred approach.

 The parent participates as a learner and immobilizer.
 Teaching about the oral cavity occurs during the examination process.
 The child may cry which is desirable and useful.

The preferred approach to infant examination is the knee-to-knee position in which

Parent and dental provider sit facing each other. Their knees should touch and ideally,
mesh slightly, creating a flat surface on which the child can rest. The infant initially is
held facing the parent and then reclined onto the lap of the dentist.
The parent has the infant’s legs straddling the torso and uses elbows to hold the feet in
place. The parent holds the child’s hands and the dentist, looking down, stabilizes the
child’s head. The examination can occur wherever a suitable light source can be found.
The closeness of the parent and provider may concern some parents and should be
explained before the procedure begins.

During the examination, which may take only seconds, the dentist also has the
opportunity to demonstrate oral hygiene, point out oral structures of importance, as
record findings. Most infants will cry briefly during the examination, affording a wide
open mouth. Parents may need to be assured that infants who cry are normal, healthy
babies and the response is expected. At the completion of the examination, the child is
returned to the parent who can cuddle and console as needed.

Children this age are far more likely to see a physician regularly, so delays in gross motor
areas are usually known to parents. The dentist would expect to see a healthy oral cavity
in most infants. But a few may show pathological conditions

Caries-risk assessment

An infant oral health visit and establishment of a dental home by age 1 year offer the
best opportunity to provide risk-based primary prevention and promote sound oral
health practices. An assessment of caries risk during infancy and periodically thereafter
allows for early identification and understanding of a child’s current and changing risk
factors for ECC.

Caries-risk assessment (CRA) allows for a customized preventive plan to be developed

that is appropriate for the child and family. Based on the distribution of risk factors and
protective factors, the health-care provider can make a determination of a child’s caries
risk, explain the caries process and the causative factors to the parent, and develop in
collaboration with the parent self-management goals to prevent or manage their child’s
caries risk.

Establishment of dental home

The American Dental Association, AAPD and AAP recommend that all children have
their first preventive dental visit and establishment of a dental home by age 1 year.
Nowak described the term “dental home.” A dental home is defined as an ongoing,
comprehensive relationship between the dentist and the patient (and parents), inclusive
of all aspects of oral health delivered in a continuously accessible, coordinated, and
family-centered way.

The concept of dental home is derived from the AAP “Medical Home.” The essential
concepts of medical home state that the medical care for children of all the ages is best
managed when there is an established relationship between the practitioner who is
familiar with the child and the child’s family. The medical home is the place where the
child receives the preventive instructions, immunizations, counseling, and anticipatory
guidance. Parents should establish a dental home for infants by 12 months of age.

The initial visit should include thorough medical (infant) and dental (parent and infant)
histories, a thorough oral examination, performance of an age appropriate
toothbrushing demonstration, and prophylaxis and fluoride varnish treatment if
indicated. In addition, CRA for infant and determining a prevention plan and interval
for periodic reevaluation should be done. Infants should be referred to the appropriate
health professional, if specialized intervention is necessary. Providing anticipatory
guidance regarding dental and oral development, fluoride status, nonnutritive sucking
habits, teething, injury prevention, oral hygiene instruction, and the effects of diet on
the dentition is also important components of the initial visit.

An initial visit with thorough medical (infant) and dental (parent and infant) histories,
a thorough oral examination, performance of an age-appropriate tooth and gum
cleaning demonstration, and fluoride varnish treatment if indicated.

• Assessing the infant’s risk of developing caries and determining a prevention plan,
anticipatory guidance regarding the effects of diet on the dentition, use of fluoride, and
interval for periodic re-evaluation.

• Caries management of infants and toddlers with known risk factors for ECC. This
should be provided by practitioners who have the training and expertise to manage both
the young child and the disease process.
• Injury prevention counseling to prevent orofacial trauma. Discussions should include
play objects, pacifiers, car seats, and electric cords.

• Counseling regarding teething. While many children have no apparent difficulties,

teething can lead to intermittent localized areas of discomfort, irritability, and excessive
salivation. Treatment of symptoms includes oral analgesics and chilled teething rings
for the child.

Use of topical anesthetics, including over-the-counter teething gels, to relieve

discomfort should be avoided due to potential toxicity of these products in infants.

• Discussion regarding atypical frenum attachments that may be associated with

problems with breast-feeding. In some cases, frenuloplasty or frenectomy may be a
successful approach to facilitate breast-feeding; however, there is a need for more
evidence-based research to determine indications for treatment.

• Counseling regarding non-nutritive oral habits (e.g., digit or pacifier sucking, bruxism,
abnormal tongue thrust) which may apply forces to teeth and dentoalveolar structures.
It is important to discuss the need for early sucking and the need to wean infants from
these habits before malocclusion or skeletal dysplasias occur.

Teething

The appearance of the first tooth is most eagerly awaited, significant developmental
landmarks by most parents.

Signs and symptoms of teething

Teething can lead to intermittent localized discomfort in the area of erupting primary
teeth, inflammation of the mucous membrane overlying the tooth, pain, general
irritability/malaise, disturbed sleep, facial flushing/circumoral rash,
drooling/sialorrhea, gum rubbing/biting/sucking, bowel upset(ranging from
constipation to loose stools and diarrhea), loss of appetite/alteration in volume of fluid
intake, and ear rubbing on the same side as the erupting tooth; however, many children
have no apparent difficulties.

Treatment
Various treatments are advocated for the relief of the discomfort or pain associated with
teething. Many of these have their origins in methods used for centuries.

The management of teething includes:

• Teething rings (chilled)

• Hard sugar-free teething rusks/bread-sticks/oven-hardened bread

• Cucumber peeled

• Pacifier (even frozen)

• Frozen items (anything from ice cubes to frozen bagels, frozen banana, sliced fruits,
vegetables)

• Rub gums with clean finger, cool spoon, wet gauze

• Reassurance

• Analgesics/antipyretics

• Topical anesthetics.

Oral hygiene

Oral hygiene measures should be implemented no later than the time of eruption of the
first primary tooth. Cleansing the infant’s teeth as soon as they erupt with a soft
toothbrush will help reduce bacterial colonization. Toothbrushing should be performed
for children by a parent twice daily, using a soft toothbrush of age-appropriate size

Diet counseling during infant oral health visit

AAPDs preventive pediatric dental care recommendation suggests that at the initial
examination and at every recall appointment, pediatric dentist should discuss the role
of refined carbohydrates and the impact of snacking frequency.

Based on the accepted guideline following recommendations regarding diet counseling

can be made:

i. Infants should be exclusively breastfed during first 6 months of life followed

by addition of iron-enriched solid food between 6 and 12 months of age.
 However, ad libitum nocturnal breastfeeding should be discouraged after the
first primary tooth erupts. Infant formulas are acidogenic and possess
cariogenic potential
ii. ii. Parents should be counseled about no to put their children to sleep with
the bottle. They should also be made aware of the deleterious effects of
inappropriate bottle usage and the need for good oral hygiene practice upon
the first primary teeth eruption
iii. iii. Breastfeeding for over 1 year and at night beyond eruption of teeth may be
associated with ECC. Hence, AAPD suggests that children should be weaned
from breast or bottle by 12–14 months of age and should drink from cup as
they approach their first birthday
iv. iv. Infants older than 6 months and with exposure to less than 3 ppm fluoride
in their drinking water need dietary fluoride supplement of 0.25 mg fluoride
per day. For infants under the 6 months of age, irrespective of fluoride
exposure in water dietary supplements should not be prescribed
v. Parents should be counseled to reduce their child sugar consumption
frequency. AAP suggests that infants should consume only 4–6 oz of fruit
juice per day. Mashed/pureed whole fruit consumption should be encouraged
rather than fruit juice. They should not be given powdered beverages or soda
pop as these drinks pose increased risk for dental caries. Only iron-fortified
infant cereals along with breast milk or infant formula should be given to
infants who are older than 6 months of age. Cow’s milk should be completely
avoided in the 1st year of life and restricted to 24 oz per day in the 2nd year
of life
vi. Parents should also be counseled on the potential of various foods that
constitute choking hazard to infants. Infants should be given food only when
they are seated and are supervised by an adult

Fluoride

Optimal exposure to fluoride is important to all dentate infants and children. Decisions
concerning the administration of fluoride are based on the unique needs of each
patient.The use of fluoride for the prevention and control of caries is documented to be
both safe and effective. When determining the risk-benefit of fluoride, the key issue is
mild fluorosis versus preventing devastating dental disease. In children with moderate
or high caries risk under the age of 2, a “smear” of fluoridated toothpaste should be used.
In all children aged 2–5 years, a “pea-size” amount should be used. Professionally
applied topical fluoride, such as fluoride varnish, should be considered for children at
risk for caries.[24] Systemically-administered fluoride should be considered for all
children at caries risk who drink fluoride deficient water

Nonnutritive habits

Nonnutritive oral habits(e.g, digit or pacifier sucking, bruxism, and abnormal tongue
thrust) may apply forces to teeth and dentoalveolar structures. It is important to discuss
the need for early sucking and the need to wean infants from these habits before
malocclusion or skeletal dysplasias occur.

The perinatal period and anticipatory guidance

Oral health care for pregnant and lactating women.

The perinatal period is an opportune time to educate and perform dental treatment on
expectant mothers.Pregnancy care visits provide a teachable moment for physicians,
dentists, and nurses to educate women about the following:

• Diet including the adequate quality and quantity of nutrients for the mother-to-be and
the unborn child. This education also should include information regarding the caries
process and food cravings that may increase the mother’s caries risk.

• Comprehensive oral examination, dental prophylaxis, and treatment during

pregnancy. Dental treatment during pregnancy, including dental radiographs with
proper shielding and local anesthetic, is safe in all trimesters and optimal in the second
trimester. Due to possible patient discomfort, elective treatment sometimes may be
deferred until after delivery.

• Proper oral hygiene, using a fluoridated toothpaste, chewing sugar-free gum, and
eating small amounts of nutritious food throughout the day to help minimize their
caries risk.
• Continued breast-feeding along with complementary foods for a period of one year or
longer.The transfer of drugs and therapeutics into breastmilk should be considered,
especially in infants younger than six months of age.

The perinatal period is defined as the period around the time of birth, beginning with
the completion of the 20th to 28th week of gestation and ending one to four weeks after
birth. The perinatal period plays a crucial role for the well-being of pregnant women.

Also, it is essential for the health and wellbeing of their newborn children. Yet, many
women do not seek dental care during their pregnancy, and those who do often confront
unwillingness of dentists to provide care.

Many expectant mothers are unaware of the implications of poor oral health for their
pregnancy and/or their unborn child.

Identifying mothers with high levels of dental caries and poor oral health and educating
them on the importance of their own oral health and the future health of their unborn
child can help change their trajectory of oral health.

Timely delivery of educational information and preventive therapies to these parents

may reduce the incidence of ECC, prevent the need for dental rehabilitation, and
improve the oral health of their children.

Physicians, nurses, and other health care professionals are far more likely to see
expectant or new mothers and their infants than are dentists. Therefore, it is essential
that these providers be aware of oral anomalies and associated risk factors of dental
caries in order to make appropriate decisions regarding timely and effective
interventions for pregnant women and facilitate the establishment of a dental home for
the child.

Advantages of infant oral health care:

The Main Benefit of early involvement in Oral health care of infants is the opportunity
to intercept behaviors that are potentially damaging to children’s oral health and to
provide valuable preventive information to parents, which is structured to meet the
individual needs of each family situation.
The specific advantages of Infant Oral Health Program are

 Intercept and modify detrimental feeding habits

 Assist parents in establishing snacking and dietary patterns that are favorable for
dental health
 Education of parents regarding their role in tooth cleaning for their
infants/toddlers
 Determination of the fluoride status and recommendations for an optimum
fluoride program
 Introduction of dentistry to the child in a pleasant non threatening manner
 Opportunity to promote a positive image for dentistry.

The early evaluation of Infants and Preventive counseling offer the dental profession
the opportunity to improve the image of dentistry when approximately 50% of the
population avoids dentistry, with fear being one of the reasons, a pleasant no
threatening introduction to dentistry can only advance dentistry’s image.

Recommendations for Pediatricians in Preventive Oral Health

American Academy of Pediatric offers several recommendations on expanding the role

of pediatricians in preventive oral health

1. Pediatricians will require adequate training in oral health in medical school, residency,
and in continuing education courses. AAP recommends adding a module on oral health
and dental care to the undergraduate medical school, physical examination skills
courses, and an oral health rotation to pediatric residency curriculums. Having dental
professionals provide such instruction would enhance acquisition of hands-on skills and
could encourage future professional collaboration and cross-referrals

2. Pediatricians will require current information and guidelines on preventive dental

care. With the exception of bright futures: guidelines for health supervision of infants,
children, and adolescents, very little is available to guide pediatricians in the promotion
of oral health in their practices
3. Pediatricians must be ensured that all of their patients, Medicaid and uninsured
included, can receive timely preventive and restorative dental care. Pediatricians can
expand their involvement in oral health prevention, but they can never replace the care
that dental professionals provide. Further dialog with our dental colleagues and joint
advocacy efforts by the AAP and AAPD are needed to address the serious problem of
disparities in access to dental care

4. Pediatricians will require sufficient resources to successfully assume greater

involvement in oral health-related activities. Time pressures and inadequate staffing
will make it difficult for pediatricians to devote the attention to oral health that all
children deserve.

Conclusion:

Despite the current AAPD recommendations, it has been difficult to achieve uniformity
among health care professionals regarding timing for the provision of preventive oral
information as well as who should provide it. Some dentists are still reluctant to see
these children because of expectations of negative behavior and a lack of understanding
of preventive opportunities. Time and again, measures initiated before the onset of the
disease have proven to be effective. Hence dental professionals have a growing role in
early intervention, with prenatal oral health counseling for parents and child’s oral care
beginning during infancy. At no other point in life will the dentist have same level of
parental concern, attention and compliance. This has to be understood by every infant
oral health care provider and can be used for their benefit to raise children free of oral
diseases. Dentist who provides primary care for children are in a unique position to help
ensure that parents and other caregivers receive information on the prevention of oral
disease in infants and young children. Dentists can work together with the physicians
and can reinforce each others' efforts to provide excellent preventive oral care to
children.

As our society for pediatric dentistry strives to achieve the goal that “every child has a
fundamental right to his or her total oral health,”; it is the responsibility of the
health-care professional involved with children to provide comprehensive care for the
child. Preventive dental assessment and treatment program can be incorporated into
the well-baby visits provided by pediatricians. By examining the infant for oral problems
and by providing early preventive counseling, it is possible to prevent many forms of
dental disease and thus promote the total health of child patients.

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