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Recent increases in caries prevalence in young children, especially among minorities and the economically disadvantaged, highlight the need for early establishment of dental homes and simple, effective infant oral care preventive programs for all children as part of a medical disease prevention management model.1–3 This article presents an updated approach and practical tools for pediatric dental caries management by risk assessment, CAMBRA, in an effort to stimulate greater adoption of infant oral care programs among clinicians and early establishment of dental homes for young children.
A 2007 publication by the Centers for Disease Control and Prevention reported that although dental caries prevalence had declined significantly among school-aged children since the early 1970s, caries rates in children aged 2–5 years had increased.2 This confirmed early childhood caries (ECC) as the most prevalent chronic childhood disease in the United States; five times more common than asthma and seven times more common than hayfever.3–5 ECC is more prevalent among young children in low socioeconomic populations and among racial/ethnic minorities who are also more likely to face barriers in accessing care.6 Caries is a preventable infectious disease and it is well-documented that one of the best predictors for future tooth decay is the presence of current caries or evidence of prior caries experience.7,8
Despite awareness of an increase in ECC prevalence, infant oral health care, as well as the establishment of a dental home by age 1, or when the first tooth erupts, has not yet become the standard of care in clinical practice. The Dental Health Foundation’s report, Mommy It Hurts to Chew indicated that 28 percent of California third-graders had untreated tooth decay.6,9 It also showed that only 35 percent of reporting families had private dental insurance, 42 percent had some type of government-funded coverage, and nearly a quarter (23 percent) had no dental coverage at all.6
In 2007, a half-million school-aged children missed at least one day of school in California due to dental problems.10 This resulted in $29.7 million of lost revenue to school districts.10 In the National Survey of Children’s Health, California ranked near the bottom in children’s oral health (only Arizona and Texas ranked lower).11
Several reports have shown that preventing the onset of ECC is more cost effective compared to treating advanced caries. Typical costs of comprehensive oral care visits for preschoolers are considerably less than the cost of emergency room treatment or extensive restorations requiring sedation or treatment under general anesthesia.12,13 Early identification of risk indicators and implementation of oral health preventive practices at a young age can reduce or avoid caries progression.14 The American Dental Association, the American Academy of Pediatric Dentistry (AAPD), the American Academy of Pediatrics (AAP),the American Association of Public Health Dentistry (AAPHD), and the Academy of General Dentistry (AGD), all recommend that a child see a dentist to establish a dental home by age 1 or within six months from eruption of the first primary tooth.15–19 A dental home is defined as the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family centered way.20 Establishment of a dental home should include referrals to dental specialists when appropriate.21
Despite widespread support for establishing a dental home by age 1, infant oral health visits have not yet been embraced universally by practicing clinicians. This situation persists even as dental and other health professionals recognize the growing prevalence of early childhood caries.
This article presents an updated pediatric dental caries management by risk assessment (CAMBRA) approach, along with practical tools to use in caring for young children, to stimulate greater adoption of infant oral health care programs by clinicians.14 Age- and risk-specific “care paths” are included as a part of a “disease-prevention management model.”
Caries is a transmissible, infectious disease. When the disease is allowed to progress, surface cavitation and destruction of dental tissue occur over time. Due to their ability to stick to smooth tooth surfaces and produce copious amounts of acid, the mutans streptococci (MS) group of bacteria is considered one of the most important groups of pathogens in the cariogenic process.20
Primary caregivers can transmit these organisms to their children, which results in MS colonization of the child’s oral cavity.21 There is a direct relationship between adult caregiver MS levels and MS levels and dental caries prevalence in their children.21 Factors influencing colonization include frequent sugar exposure in infants and habits that allow salivary transfer from mothers to infants. Maternal factors, such as high levels of MS, poor oral hygiene, low socioeconomic status, and frequent snacking increase the risk of bacterial transmission to their infants.22 Infants have tested with high levels of MS even before the eruption of their first tooth.22
Therefore, it is critical to consider an infant oral care program in the context of a mother-child pair or dyad, which includes comprehensive maternal perinatal oral health care and treatment.
Dental professionals have begun to recognize the critical role a mother plays in ensuring her child’s oral health. Improving expectant mothers’ oral health by reducing pathogenic bacteria levels in their own mouths can delay the acquisition of oral bacteria in their children and may delay the development of early childhood caries.23 Restoring carious lesions, by itself, is insufficient to reduce a mother’s risk of transmitting cariogenic bacteria to her offspring. An effective perinatal program should institute a long-range, pre- and postpartum maternal strategy to reduce maternal MS and lactobacilli levels through therapeutic interventions and counseling on lifestyle modifications.23
Unfortunately, pregnant women often do not receive oral health care and education in a timely manner. Many women do not know they should seek dental care during their pregnancy and for the many others who do, they often encounter dentists unwilling to provide dental care during pregnancy. New mothers are more likely to be receptive to ideas that would improve their offspring’s oral health and both dental and obstetric providers have a prime opportunity to educate mothers on changes that could improve their children’s oral health.24 In 2010, the CDA Foundation published evidence-based guidelines for health profession on oral health for pregnant women and infants, which indicate that perinatal oral health care is not only safe but necessary to the oral and overall health of the pregnant mother but also that of her infant.23
In light of the importance of perinatal oral health in preventing early childhood caries, and the need to intervene early for mother and child in a “dual parallel track” of treatment and disease prevention management, collaborations and partnerships among all health professionals are encouraged to foster early and timely oral health care and referrals for expectant mothers.
The American Academy of Pediatrics has focused in improving children’s oral health through its Oral Health Initiative and Section on Pediatric Dentistry and Oral Health (aap.org/oralhealth). Through these efforts, pediatricians are becoming more educated on oral health and their role in preventing disease and referring to a dental home. However, many continue to be unaware of the AAP’s current oral health recommendations and more work needs to be done to disseminate this policy and raise awareness. Efforts to increase awareness of incorporating oral health evaluations into well-child visits are crucial since pediatricians often see children on an average of up to six times before age 2.
In addition to pediatricians, family practitioners, and other medical providers who see children frequently during infancy and early childhood are also ideally suited to assess young children for caries risk assessment and refer for dental care.25 A partnership between medical and dental professionals is important to increase patient awareness of the importance of establishing a dental home by the child’s first birthday, assessing caries risk, and coordinating care. As an important step in that direction, the AAP’s “Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents,” which focuses on health promotion and prevention for children and their families, not only advocates for a dental home but also provides extensive information, education and training opportunities, and materials on pediatric oral health for a broad range of practitioners. The AAP is currently conducting a Bright Futures Implementation Project, Brightening Oral Health, to pilot test an oral health risk assessment tool for the primary care practitioner. See TABLE 1.25
Infants and parents can benefit from early infant oral health visits and early establishment of a dental home. Infant oral health visits should include caries risk assessment, individualized preventive strategies and anticipatory guidance.27 Periodic supervision of care intervals (periodicity) should be determined based on each patient’s risk of disease and include age-and risk-appropriate “care paths” for management of the disease process.14
Infants and toddlers should not be expected to be cooperative during an oral examination. Crying and movement are developmentally age-appropriate behaviors for young children. Explaining expected behaviors to parents prior to, during and after infant care visits can help allay any fears and concerns they may have.
There is a simple six-step protocol for an infant oral care visit:
An individualized risk assessment of an infant or toddler for developing caries serves as the foundation for health care providers and parents/caregivers to identify and understand the child’s ECC risk factors. The specific information gained from a systematic assessment of caries risk guides the dentist in the decision-making process for treatment and preventive protocols for children already with disease and those deemed at risk. For optimal outcomes, caries risk assessment should be done as early as possible, and preferably, prior to the onset of the disease process. Since caries in the primary dentition is a strong predictor of caries in the permanent dentition, caries risk assessment and therapeutic management of the disease is crucial, as is the subsequent follow-up.28,29
Risk factors are determined from an interview with the parent and from a clinical assessment of the child. Further details, where evidence-based disease indicators, biological risk factors and preventive factors are described, have been previously published by Ramos-Gomez et al. and are accessible via the web at cdafoundation.org/journal.14 The example provided in TABLE 2 is a one-page, practical form for use in the dental office and has been modified from the original form published by Ramos-Gomez et al. based on the collective experience of pediatric dentists using the form and recommendations developed by the NIDCR-PRIME research at the SF NAHC and the CAMBRA coalition committee of West Coast Dental Schools. TABLE 3 in the present article offers further modifications of the original published form that is an alternative currently suggested by the AAPD.
In practice, the caries risk assessment would begin in the dental office with an initial interview with the parent or caregiver. The assessment interview should explore biological or lifestyle predisposing risk factors that contribute to the development or progression of caries. Examples of these risk factors include recently placed dental restorations or active caries in the mother, low health literacy of caregiver, frequent intake of fermentable carbohydrates by the infant, sleeping with a bottle that contains liquids other than water, prolonged use of a sippy cup containing milk, juice, or a sweetened beverage. The practitioner can simply circle “Yes” beside the risk or protective factors that apply in order to make a judgment as to whether the risk factors outweigh the protective factors or vice versa, thereby determining a risk status of low, moderate, or high. The risk level will then dictate which care path to be used, as described below.
Protective factors are indicators of preventive activities that may reduce a child’s risk for the onset extension of ECC and should be assessed during the parental interview. These factors include optimal exposure to fluoride, access to regular dental care (e.g., the presence of a dental home), and consistent daily brushing with fluoride toothpaste.
Disease indicators are indications of current and active caries and are obtained from the clinical examination of the child and include cavitated carious lesions, white spot lesions/ decalcifications, and recent restorations. Biological risk factors are also observed at the clinical examination and include the presence of plaque, gingival bleeding (an indicator of inadequate oral hygiene), and dry mouth. In older children, the presence of dental or orthodontic appliances increases plaque retention and the risk for caries.
The caries balance concept (FIGURE 1) states that the progression or reversal of dental caries is determined by the balance between pathological factors and caries protective factors.30–33 A risk assessment categorization of low, moderate, or high is based on a preponderance of the factors circled as “Yes” on the caries risk assessment form. When risk factors outweigh the protective factors, it indicates an increased likelihood for the development of caries, which would place the child in a high-risk category. When protective factors prevail and risk factors are controlled, the child can be considered low risk. The clinician’s experience, expertise, and personal historical experience with his patient and the child’s caregivers, is of vital importance in determining a child’s risk, which serves as the basis for an individualized treatment plan for each infant/caregiver. These specific patient conditions and risks will help the practitioner and the parents understand the factors that contribute to or protect the patient from caries.
Proper positioning of the child is critical to conducting an effective and efficient clinical exam in a young child. In general, the knee-to-knee position should be used with children ages 6 months to 3 years, or up to age 5 with children who have special health care needs. Children older than 3 may be able to sit forward on their caregiver’s lap or sit alone in a chair. Examiners and caregivers need to work together to transition the child smoothly from the interview to the exam. The clinician should explain what will happen (“Tell-Show-Do”) prior to starting and anticipate that young children may cry since crying is developmentally appropriate for children at this age. If the child can perceive a friendly and comfortable interaction between the clinician and caretaker, a positive tone is frequently set for the visit. Knee-to-knee positioning allows the child to see the parent throughout the exam. It also allows the caregiver to observe clinical findings and hygiene demonstrations directly, while gently helping to stabilize the child safely for the clinical examination.
A toothbrush prophylaxis is efficient in removing plaque in most young children. It is also nonthreatening to young children and serves to demonstrate the proper technique of brushing to the caregiver. The examiner retracts the child’s lips and cheeks and demonstrates brushing along the gingival margins (FIGURE 2). The spongy handle of an age-appropriate toothbrush can be used to prop open the child’s mouth. The handle of a second toothbrush can be used as a mouth prop. During this “Tell-Show-Do” encounter, the caregiver should be encouraged to brush their child’s teeth at least twice a day, especially before bedtime. The use of fluoride toothpaste should be emphasized since fluoride has been shown to be effective both systemically and topically to prevent caries. Parents and caregivers should be instructed to use a “pea-sized” amount of fluoride toothpaste for children age 2–6 and a “smear” for children under age 2.34 (FIGURE 3) Children should be taught to spit out excess toothpaste during and after brushing.
Clinical examination can be accomplished while counting the child’s teeth aloud, using the toothbrush handle as a mouth prop, if necessary. Many providers make a game of this task, singing songs, engaging the child’s attention, and, if all else fails, distracting the child with a brightly colored toothbrush or toy. Praise the child at each step for their cooperation and good behavior. While counting the teeth, the examiner also inspects the soft tissues, hard tissues, and occlusion, if the child is able to cooperate. Data from the clinical exam results should be combined with data from the caregiver interview to determine the child’s overall caries risk, establish an oral diagnosis, and formulate an individualized treatment plan.
The following information should be documented:
Fluoride is an important and cost-effective prevention method to strengthen tooth enamel and prevent decay. The ADA recommends that high caries risk children receive a full-mouth topical fluoride varnish application with reapplication consistently at three months intervals.35 A minimum of every six months is recommended for children at moderate caries risk, even if the child lives in a community that already receives the benefits of water fluoridation34 (FIGURE 3). Practitioners should also be aware that fluoridation of public water supplies can vary greatly by community and by the water source. Only 27.1 percent of Californians have access to optimally fluoridated community (tap) water.9 Providers should reiterate the cumulative benefit of the fluoride varnish, even if it has been mentioned earlier in the visit.40 Following the fluoride application, the caregiver should be reminded not to allow brushing of the child’s teeth or eating crunchy/sticky foods for the rest of the day to maximize the effect of the fluoride varnish.
An individualized treatment plan (TABLES 4 and and5)5) for each infant/caregiver is determined by the risk determined from the parent interview and the clinical examination of the child. A dual treatment plan approach is essential for moderate and high caries risk children and their parent/caregivers. Strategies need to be employed to modify the maternal transmission of cariogenic bacteria to infants through the potential use of chlorhexidine rinse and xylitol products for caregivers, and fluoride varnish for both the caregiver and the child.36 Additionally, the necessary changes in the child’s diet, toothbrushing, and fluoride application can be identified from the risk analysis. Expected parental compliance to recommended treatment protocols is essential for moderate and high caries risk children.
Parents should be given additional information and anticipatory guidance on the prevention of dental disease that is specific to the their child’s needs and caries risk factors, e.g., information on oral hygiene, growth and development, teething, digit or pacifier habits, oral habits, diet and nutrition, and injury prevention (FIGURE 4). The anticipatory guidance approach is designed to take advantage of time-critical opportunities to implement preventive health practices and reduce the child’s risk of preventable oral disease.37
An important component of the visit is to counsel parents to change specific risk factors, which may contribute to caries activity or the child’s caries risk. Traditionally, general recommendations to parents such as “brush your teeth twice a day and don’t eat candy,” have had very limited success. Research shows that family-centered approaches and individualized recommendations are more promising in engaging parents to change specific practices.
Motivational interviewing is a counseling technique that relies on two-way communication between the clinician and the patient or parent and establishes a therapeutic alliance (rapport and trust).38 In this process the clinician asks questions to help parents identify problems; listens to their concerns; encourages self-motivational statements; prepares them for change (discussing the hurdles that interfere with action); sets attainable specific self-management goals; responds to resistance; schedules follow-up appointments; and prepares the parent for their family’s specific and unique difficulties, which inevitably arise when instituting a consistent, lifetime dental care program for their child.39
Following the brief motivational interviewing (counseling), the parent/caregiver is asked to select two self-management goals or recommendations as their assignments before the next re-evaluation dental visit and to commit to the two goals selected, and is informed that the oral health care providers will follow-up on those goals with them at the next appointment (FIGURE 4).
The clinician must consider each child’s individual needs to determine the appropriate interval and frequency for oral examination; some infants and toddlers with high caries risk should be re-evaluated on a monthly basis.37 Most children at high risk need to be seen on a three-month interval for re-evaluation, additional counseling and clinical preventive services (e.g., fluoride varnish). Children in the moderate-risk category usually are placed on a six-month interval, while low-risk children can be re-evaluated at six- to 12-month intervals.
Parents who have demonstrated compliance with recommendations for three to six months should be scheduled back for a follow-up visit with their child for reassessment of risk. Parents need encouragement early on when new behavioral change is required and should be questioned regarding any difficulties with following recommendations. Reassessment of risk factors and monitoring the progress of improvements in established self-management goals are essential elements of infant oral care visits. Modifications of recommendations or positive reinforcement for successful changes are necessary to achieve and sustain successful risk modification. Parents should be reminded that changing risk factors and lifestyles do not happen overnight and require persistence.
Pediatric dentists and general dentists have a critical role in preventing and reducing the severity of early childhood caries. Embracing the concepts of caries risk assessment, early establishment of a dental home, medical home with their recommendations integrated within the family home practices are essential. Perinatal and infant oral health and implementation of the techniques, protocols, and care paths highlighted in this paper in a clinical practice can help break the cycle of dental disease in high-risk families and reduce burden of disease. Caries risk assessment, individualized counseling, clinical preventive services such as fluoride varnish applications, xylitol use, and referral of high-risk infants and children to dental homes are increasingly being recognized as important elements of efforts to engage other pediatric health care providers in reducing the prevalence and severity of early childhood caries.
Many providers adapt caries risk assessment tools to meet their individual practice needs. For example, the Western CAMBRA group uses and recommends the forms presented in TABLE 2. AAPD has endorsed and adapted as their 2010 Risk Assessment the guideline presented in TABLE 3. Also, some pediatricians have been using an AAP-recommended sticker version of caries risk assessment tools on their charts (TABLE 1). Whatever form is chosen, what remains critical is the process of assessing caries risk on a routine basis in an individualized and age-specific manner that can empower practitioners and parents/caregivers in identifying each child’s risk and protective behaviors for a targeted “age- and risk-specific” approach to lower their risk for ECC.
The authors wish to acknowledge NIDCR — R21DE018650-01 for providing support for research and the PRIME team and staff at the San Francisco Native American Health Center for development of the CAMBRA 0-5 instrument. They also thank Dr. Norman Tinanoff for contributing his support and knowledge to this project; CSPD and Dr. Paul Reggiardo for their invitation to contribute for this publication; Ms. Debra Tom for her editorial assistance; and in addition, to HRSA — Oral Health Disparities Collaborative for implementation of the CAMBRA instrument and development of the self-management goal instrument through High Plains Health Center. The authors also wish to acknowledge the Western CAMBRA coalition and the American Academy of Pediatric Dentistry for its support and leadership on development of the caries risk assessment tool, and the committee and staff of the American Academy of Pediatrics and their project, “Brightening Oral Health: Implementing Oral Health Risk Assessments in Pediatric Care.”
FRANCISCO J. RAMOS-GOMEZ, Professor at the University of California, Los Angeles, School of Dentistry, Section of Pediatrics, and a researcher for the University of California, San Francisco, Center to Address Disparities in Children’s Oral Health — CANDO.
YASMI O. CRYSTAL, Maintains a clinical practice, Comprehensive Pediatric Dentistry, in New Jersey.
MAN WAI NG, Dentist-in-chief and assistant professor, Oral and Developmental Biology at the Harvard School of Dental Medicine.
JAMES J. CRALL, Professor of pediatric dentistry at the University of California, Los Angeles, and project director for the American Academy of Pediatric Dentistry Head Start Dental Home Initiative.
JOHN D.B. FEATHERSTONE, Dean and a professor at University of California, San Francisco, School of Dentistry.