Infant Care

Feb. 1, 1998
The medical community now believes that children should visit the dentist before age 3. Can dental hygiene help detect risks for caries at such an early age?

The medical community now believes that children should visit the dentist before age 3. Can dental hygiene help detect risks for caries at such an early age?

Cathleen Terhune Alty

How many times have you been besieged with questions from family and friends about their children`s primary teeth? The top 10 list of most-asked questions might include:

- "Is this normal?"

- "Should I clean them?"

- "How do I know which teeth should be coming in?"

- "Is there enough room?"

- "Should I be concerned about thumb-sucking?"

- "When should I take the baby for his first visit to the dentist?"

There`s a whole new world of thought in research circles these days about infant oral health and evidence that caring for the primary dentition in infants could be a new role for dental hygienists.

Infant (ages 0 to 3 years) oral-health concerns came about from disturbing statistics. Dr. Paul Casamassimo, professor and chair of pediatric dentistry at Ohio State University College of Dentistry, says that even though 50 percent of children are caries-free, most recent caries surveys indicate decay in primary teeth has not declined.

"Over the last 10 years, there has not been any reduction in primary caries in the USA and some other developed countries," he notes. "This indicates the traditional approach is not working."

As most hygienists are aware, the traditional ap-proach always has been for a child`s first dental visit to occur at age three. Until this age, the child was considered under the primary care of the physician. The problem is that the medical community is largely uninformed about oral health.

"We have given the medical community the responsibility, but not the knowledge," says Casamassimo. "There have been several studies that show the lack of knowledge in the medical community about oral health. They [physicians] have no knowledge of the science and the best preventive approach."

He also notes, "In the past, the dental team has been reluctant or unwilling to get involved. Dentists generally do not see children until they are older and can sit in the dental chair. All factors for dental caries are in place three or more years before a child ever sees a dental professional. The medical community is becoming convinced that children need to be seen by a dental professional before age three, but many dental professionals will not see them because of the lack of reimbursement for preventive techniques, the stress of handling a crying child or they don`t understand what can be done. Therefore, dentists are reluctant to see these children until they are older."

Another problem with the traditional "wait until age three" approach is that factors that impact primary-dentition decay occur early in the child`s life. Prevention of the deterious effect of habits and educating the parent or caregiver through the predictable steps of childhood development is critical.

"Some habits begun at an early age may damage the child`s teeth and be difficult to break," Casamassimo points out. "For example, a baby who has grown accustomed to going to bed with a bottle of milk or juice may find it difficult to fall asleep without it. Studies indicate that once caries begin in the mouth of a young child (age two to three years), they tend to reoccur throughout childhood, despite preventive measures.

"If we can see children right at the moment teeth are erupting," Casamassimo continues, "we can institute mechanisms to prevent primary decay. There is growing evidence that suggests you can identify risk factors that lead to dental caries at a particular period in life. So, if you can identify when a child is most susceptible to dental caries flora or stop serious habits - like bottle use - you can remove or minimize the risk factors. All of this can take place in the first 18 months of life, using preventive counseling and a process of risk assessment."

Dental-caries reduction is the emphasis of infant oral health, but also it includes the prevention of traumatic injuries, beginning effective oral-hygiene routines, nutrition, fluoride supplements and habit-management. These items form the basis of counseling that we should provide the parents or caregivers of the infant.

"Preventive counseling and risk assessment are not procedures done to look for disease, but for behavior that could lead to caries," Casamassimo points out.

So, how does this work in a practical way? Dr. Casamassimo will take us through a step-by-step example below.

First, the mother or father brings in the child. The history taken is, by nature, more focused on prenatal and perinatal events around habits and behaviors. Infant oral health begins prenataly. Preliminary research suggests that decreasing the mother`s prenatal bacterial load by assisting the mother with her dental hygiene may benefit the child. We believe that there is something beyond decay in children`s mouths that make them carriers.

Next, we develop a risk profile on the child. Are his teeth being cleaned? Is there a high caries rate in the family? Does he get a bottle at night to take to bed with him? Some are indirect. Studies correlate low income or immigrant status with higher caries rates. Then, we look at the child. You don`t need a dental chair for this. Have the parent hold the child. Sit in a knee-to-knee position with the parent, with the head of the child in the clinician`s lap. Most children will begin to cry at this point, which is good because both you and the parent can see in the child`s mouth.

We want the parent to see what the child`s mouth looks like. We show them teeth erupting, ruggae, frenum, what looks right and what doesn`t look right. Now, look at the child`s teeth. Is there plaque present? The evidence we`ve seen says that if you see plaque on the teeth, the child is at a greater risk to develop tooth decay. Is there hypoplasia? A greater proportion of children with these characteristics will get tooth decay. Using historical and clinical findings, you can make a "guesstimate" for this child`s caries risk: low risk, great risk, etc. We`re still working on this terminology. It is important to see what groups of factors will give us about an 80 percent chance of getting dental caries. Risk-profiling is done often on an adult population with less information than we have on children.

Once the risk profile is completed, the parent is instructed, based on the information. We institute appropriate preventive behaviors to try to address the risk factors. The goal is to put the child back on a no-caries route.

Clinicians should be keenly aware and knowledgeable about the stages of child development, habits and behaviors. We call this "anticipatory guidance." We can offer age-appropriate kinds of preventive information to parents about their child. You anticipate what is going to happen with their child from a dental standpoint. Prepare them for eruption patterns, teething, walking, etc. We need to prepare them for what will happen between now and their next visit. We look at the age of the child and make our recommendations age-specific. For example, a 12-month old child will be coming off the bottle, so we will need to discuss finger foods, system fluoride intake and parent techniques for brushing the child`s teeth. At each interval, there will be different counseling and age-specific procedures. You look at the different areas, determine what the preventive approach is, design a preventive plan and instruct parents about what they can do and what the dental professional can do for the child.

Effectiveness can be measured by looking in the child`s mouth. "We have a nice way to check the outcome of the program," says Casamassimo. "If you have a risk factor, in many cases, it`s behavioral. Clearly describe to the parent what needs to be done. For example, tell the parent, `You need to get the plaque off your baby`s teeth every day. If you brush your child`s teeth every day, we will have no gingiva problems. If there are no caries and no gingivitis, then you`ve a healthy mouth.`"

The outcomes are obvious to the parent and the clinician. If you show a healthy mouth and say that this is where we`re going, you both can agree on what you want. We want to minimize the likelihood of caries and get prompt treatment if they do occur. For the vast majority, you can achieve these outcomes with these techniques.

Dr. Casamassimo sees infant oral-health promotion as a perfect role for a dental hygienist. "This process is all preventive-oriented and involves patient education, which dental hygienists are skilled and trained to do. Except for its focus on early childhood, it doesn`t require any particular training above and beyond what hygienists already are educated to do, so it is really right down their alley."

For more information about infant oral health, parent-education materials and sources of information about child development, contact the following organizations:

- The American Academy of Pediatrics, Elk Grove Village, IL; (847) 228-5005.

- The American Academy of Pediatric Dentistry (AAPD), Chicago, IL; web-site address:; (312) 337-2169.

- The American Society of Dentistry for Children, Chicago, IL; (312) 943-1244.

- The American Dental Association, Chicago, IL; (800) 621-8099.

Cathleen Terhune Alty is a consulting editor for RDH.

The best places to find a baby

If you want to institute an infant oral-health program, the office will want to get the word out to parents of infants. Here are a few ideas:

Supply local hospital birthing centers, Ob-gyn offices, Lamaze-training groups, day-care centers and pediatricians with information that can be given to parents. This information could include:

- How to care for the infant`s teeth

- Advice about the first dental visit

- Infant mouth-cleaner swabs

- Teething concerns

- Preventing toddler tooth and mouth injuries