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Evidence-Based Strategies for Common Clinical Questions

June, 2018

Oral health: An opportunity to plug a hole in pediatric care


Primary Author: Evan Weber, MD

Column Editor: Rupal Gupta, MD | Medical Director, Operation Breakthrough Clinic | General Academic Pediatrics | Assistant Professor, UMKC 

A hallmark of primary care is the prevention and treatment of infectious disease, yet in the process of offering vaccines and other preventive treatments, primary care providers must not forget the most common chronic disease of childhood: dental caries. In young children, newly forming teeth may become colonized with cavity-causing bacteria. In the presence of carbohydrates, bacteria in the mouth produce acid, which slowly destroys tooth enamel, and ultimately, the pulp below it.1

According to the 1999-2004 National Health and Nutrition Examination Survey, about 42 percent of children ages 2-11 years have had dental caries in their primary teeth.2 Over half of these children have not had these cavities treated, and a disproportionate number of children with dental caries come from socioeconomic and ethnic minorities.

Despite reductions in caries prevalence among older children, young children carry an increasing burden of this chronic disease. In the most recent national surveys on oral health status, dental caries among 2-to-4 year-olds had increased from 19 to 24 percent.3 Because early dental caries serves as the highest risk factor for poor dentition in adulthood, this statistic is concerning. Dental caries can lead to missed school days secondary to pain and associated infections, as well as tooth loss and missed caregiver workdays due to appointments.1

Fortunately, dental caries is preventable. Primary prevention across the life span is essential to ensuring the oral health of children, especially those in high-risk communities. This includes aiming to reduce caregiver colonization with cariogenic bacteria such as Streptococcus mutans, which can easily transfer to children and become colonized once primary teeth erupt.4 Caregivers who have had fillings and proper dental hygiene are less likely to transfer harmful bacteria to their children. Thus, primary care providers should ask routinely whether caregivers have had untreated dental caries within the past year. Families should be also encouraged to reduce consumption of sugar, which directly influences development of caries.
   
Fluoride plays a critical role in primary prevention of childhood dental caries. This mineral improves oral health by promoting enamel remineralization, reducing enamel demineralization, and inhibiting bacterial metabolism to acid production, ultimately preventing formation of dental caries.1 

Community water fluoridation has been shown to reduce tooth decay by 19 percent.1 An AAP policy statement in 2015 supported the use of fluoridated tap water to prepare meals and for drinking.5 The consumption of fluoridated water maintains a low concentration of fluoride in saliva and plaque that enhances remineralization of enamel.6 While systemic fluoride exposure has been linked to enamel fluorosis, the risk is small and primarily cosmetic.2 As a public health measure, water fluoridation has been effective for a large population of people, including those families that face barriers to accessing dental care.

The AAP and the U.S. Preventive Services Task Force (USPSTF) currently recommend brushing teeth with fluoride-containing toothpaste twice daily. The use of fluoride-containing toothpaste should begin with eruption of the first tooth.1 In children less than 3 years of age, no more than a smear of fluoridated toothpaste is recommended; a pea-sized amount is recommended for children age 3 and older.1 

When used at least twice a year, fluoride varnish can reduce dental decay in primary teeth by up to 37 percent.7,9 The AAP and USPSTF recommend that primary care providers apply fluoride varnish to all infants and children every 6 months beginning at the age of primary tooth eruption to age 5 years old, until a dental home has been established.1,2,7 The AAP and the American Academy of Pediatric Dentistry (AAPD) recommend that children establish a dental home by 1 year of age.2,4,8 

Fluoride varnish is painted on the teeth with a small brush or applicator. It hardens after coming in contact with saliva. In general, children should be instructed to eat soft foods and not to brush teeth for at least four to six hours to maximize contact time of the varnish to the teeth.1 Hot foods should be avoided during the six hours after treatment. Depending on the brand of varnish applied, specific instructions may vary. The following day, the child should resume brushing twice daily with fluoridated toothpaste.

When barriers delay the establishment of a dental home, pediatric providers can play an important role in improving the oral health of children. Pediatricians should guide parents on proper brushing technique, discuss the role of sugary food and drinks in the development of dental caries, and follow recommendations for fluoride administration and supplementation. 

References: 

1. Fluoride Use in Caries Prevention in the Primary Care Setting. Clark MB, Slayton RL, and Section on Oral Health. Pediatrics. 2014; 134(3):626-631.
2. Prevention of Dental Caries in Children from Birth Through Age 5 years: US Preventative Services Task Force Recommendation Statement. Moyer VA. Pediatrics. 2014; 133:1102-1111.
3. Trends in Oral Health by Poverty Status as Measured by Healthy People 2010 Objectives. Dye, BA, Thornton-Evans, G. Public Health Rep. 2010; 125(6):817-30.
4. The Role of the Pediatrician in the Oral Health of Children: A National Survey. Lewis CW, Grossman DC, Domoto PK, Deyo, RA. Pediatrics. 2000; 106(6):1-7.
5. American Academy of Pediatrics Supports HHS Fluoride Recommendations for Drinking Water. Hassink, S. AAP Policy Statement. April 2015. 
6. U.S. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries. Gooch et al. Public Health Reports. 2015; 130:318-329.
7. Effects of Physician-Based Preventative Oral Health Services on Dental Caries. Kranz AM, Preisser JS, Rozier RG. Pediatrics. 2015; 136(1):107-113.
8. Maintaining and Improving the Oral Health of Young Children. Krol, DM. Pediatrics. 2014; 134(6): 1224-1229.
9. Fluorides and Other Preventive Strategies for Tooth Decay. Horst, JA, et al. Dental Clinics of North America. 2017; 62(2): 207-234.