Pediatric Clinics of North America

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PREVENTION OF DENTAL DISEASE The Role of the Pediatrician

Pediatric Clinics of North America - Volume 47, Issue 5 (October 2000)  -  Copyright © 2000 W. B. Saunders Company  -  About This Journal



The Role of the Pediatrician
Tara E. Schafer 1 DMD, MS

Steven M. Adair 1 2 DDS, MS

1 Departments of Pediatric Dentistry (TES, SMA)
2 Oral Biology and Maxillofacial Pathology (SMA), Medical College of Georgia, Augusta, Georgia

Address reprint requests to
Tara E. Schafer, DMD, MS
Department of Pediatric Dentistry
School of Dentistry
1459 Laney Walker Boulevard
Medical College of Georgia
Augusta, GA 30912-1210

Oral and dental health are integral parts of good overall health, and dental caries is the most common chronic infectious disease of childhood. A child with severe dental caries may experience chronic oral pain and infection, be malnourished, frequently absent from school, and suffer from low self-esteem because of missing or defective teeth. Evidence in the dental literature increasingly suggests that, to be successful in preventing dental disease, clinicians must begin risk-factor determination, preventive counseling, and preventive interventions within the first year of life (infant oral health care is discussed in detail in the article by Nowak and Warren later in this issue). Pediatricians are well positioned to begin this process as they see their patients for well-baby visits and as they provide anticipatory guidance to parents and other caregivers. Pediatricians are also in a good position to see that every child has a dental home in addition to the medical home. This article provides information to pediatricians that will enable them to provide practical, targeted, and effective advice to parents about preventing dental disease. A full review of the pathogenesis of dental caries can be found in the article by Caufield and Griffen earlier in this issue. This article focuses on reviews of etiologic factors, the evidence to support preventive measures for each factor, and recommendations that can be made to parents. Risk factors for dental disease are presented to enable pediatricians to identify infants and toddlers at high risk for caries. The role of fluoride in caries prevention is discussed, with emphasis on dietary fluoride supplements, which are often prescribed by pediatricians. Finally, this information is brought together in a section on anticipatory guidance and other interventions that enable pediatricians to begin the process of dental disease prevention before referral for an initial dental evaluation.

As explained elsewhere in this issue, transmission of the bacterial etiologic agent for caries, mutans streptococci (MS), occurs in infancy. Thus, true prevention can occur only in infants who have not yet been infected. When the transmission of MS has occurred, pediatricians and dentists must consider ways to suppress the caries activity through the medical management of dental caries. [15] Medical, or nonsurgical, management can be used up to and including the point at which tooth caviation occurs. As illustrated in Table 1 , surgical management (i.e., excavation and replacement of carious tooth structure) must be used at some point to deal with the symptoms of dental caries, that is, cavities. [14] This schema also indicates that treatment becomes more expensive as it becomes more invasive. Prevention and early diagnosis are just as important in managing dental caries as in managing any disease.


Cost of Intervention

Status of Child/Carious Lesion


Less expensive

Predentate; dentate, not infected; dentate, infected, no active caries


Active caries

Suppressor, medical management

Decalcification/white spot lesion

More expensive

Cavity present

Medical/surgical management

Infection of dental pulp; pain, alveolar or facial infection

Surgical management

Adapted from Edelstein BL: Medical management of infant and toddler dental caries. In Pinkham JR (ed): Pediatric Dentistry: Infancy Through Adolescence. Philadelphia, WB Saunders, 1999, p 181.


Dental caries is a dietary carbohydrate-modified infectious disease. It is the most common chronic infectious disease of childhood, with a prevalence of more than 40% by age 6 years in the primary dentition and more than 85% by age 17 years in the permanent dentition. [12] [32] Caries typically is described as a multifactorial process, involving specific oral microflora, diet, and a susceptible host. Prevention of dental caries therefore is aimed at (1) reducing cariogenic microbes in the oral cavity; (2) reducing the exposure of these microbes to a cariogenic substrate; and (3) increasing the decay resistance of the tooth. A combination of dietary advice, coupled with mechanical plaque removal (e.g., brushing and flossing) and adequate fluoride exposure, is sufficient to control dental disease in most patients.

Control of Microflora

As detailed in the article by Caufield and Griffen earlier in this issue MS are transmitted vertically from parents (usually the mother) to infants at an early age. The presence of MS is a necessary, but not solely sufficient, condition for dental caries. The primary antimicrobial approach to caries prevention traditionally has been the removal of plaque through oral hygiene practices. The relationship between oral hygiene practices and caries prevention, however, is not strong. Bacteria are harbored in niches where caries often initiates, such as the pits and fissures on the biting surfaces of posterior teeth, the protected environment between teeth, and the microscopic crevices at the margins of dental restorations. These niches may not be cleansible with standard brushing and flossing techniques. Thus, the suppression of MS by chemotherapeutic means is beginning to find favor. [62]


Topical treatment with chlorhexidine has been shown to reduce the number of MS in the saliva of highly infected patients, [40] and it is used in dentistry in various forms. The best result has been obtained with the use of chlorhexidine gel (not yet available in the United States) in custom-fitted trays. In younger children, application of a gel by toothbrush may be more easily managed. [64] A significant decrease in the number of MS in the saliva of preschool-aged children has been reported after daily brushing with chlorhexidine gel, and this decrease was still evident 1 month after the termination of the 2-week study. [64] In some experiments, chlorhexidine was more effective than was fluoride, whereas other studies demonstrated an additive effect of the two agents. [52] A 0.12% chlorhexidine mouthrinse (Peridex, PerioGard) is available with prescription in the United States.

Other studies have attempted with some degree of success to delay or prevent the transmission of MS from mothers to their children. [22] [34] The decrease of maternal salivary MS at the time of tooth emergence may delay or prevent the colonization of MS in the child's primary dentition, with a concomitant decrease in caries prevalence. [61] The influence of the age of infection with MS on the subsequent development of caries has been demonstrated in numerous animal studies [56] and in humans. [5] Children who become infected at younger ages are at a higher risk for caries. To date, no specific guidelines exist for prescribing chlorhexidine or other topical antimicrobials, but clinicians may choose to use these agents as adjuncts to standard oral hygiene practices in children who are at high risk for early childhood caries. Also, because patients with xerostomia are at increased risk for caries, twice-daily chlorhexidine mouthrinse use should be considered for individuals who have received radiotherapy in the region of the salivary glands and for patients who are on long-term medications that suppress salivary flow (see section on host factors).

Oral Hygiene

Young children require assistance with their oral hygiene routine, and parents should integrate oral hygiene into children's daily schedules. Before age 1 year, it is sufficient to clean the child's oral tissues and teeth with a soft cloth or gauze pad. Parents may wish to use a fluoride-free dentifrice, though this may be difficult to find. At least one product, First Teeth (Nu-Tec Health Products, Carlsbad, CA) is marketed as a "baby toothpaste" for children as young as 5 months of age. Fluoride-containing toothpaste typically is not recommended until children gain some control of the swallowing reflex, typically at approximately 3 years of age. Young children swallow as much as 60% of the toothpaste that is dispensed, or up to 0.8 g per brushing [8] [9] which provides 0.8 mg of fluoride ion. This may lead to systemic overexposure to fluoride and subsequent mild discoloration of the developing teeth. Some practitioners, however, may wish to recommend the use of a fluoridated dentifrice at a young age (18-24 mo) for children at high risk for dental caries. Whenever the use of fluoride-containing toothpaste is begun, parents should use a pea-sized amount of dentifrice on a soft-bristled toothbrush. Parents can adopt various techniques to aid in brushing their children's teeth, including standing behind the child or having the child place his or her head in the parent's lap. Whatever method is selected, parents should initiate oral hygiene measures at least once daily just before bedtime. Gradually, the child can become a more active participant in the process, and parents may elect to alternate brushing with the child, in a my-turn, your-turn fashion.

Recommendations to parents include:

Clean the oral cavity after feedings. A moist cloth is sufficient for infants.

Begin toothbrush cleanings at approximately age 1 year, using a moist, soft-bristled toothbrush. A nonfluoridated dentifrice, if available, can be introduced as tolerated by the infant. The teeth should be cleaned at least once daily just before bedtime. Twice-daily cleanings are preferable.

Introduce fluoride-containing dentifrice when the child can control the swallowing reflex, or earlier for high-risk children. Use a small amount of toothpaste. Children who wish to brush can do so with a moist toothbrush; fluoride dentifrice should be applied to the teeth by parents. The child should be encouraged to expectorate freely at the end of the brushing.

Older, high-risk patients should be evaluated by their dentists for the possible need for other antimicrobial regimens.

Dietary and Medication Factors of Caries Promotion and Protection

Cariogenic bacteria metabolize fermentable carbohydrates, resulting in periodic production of organic acids and subsequent loss of the mineral components of tooth structure. Dietary interactions with the other factors necessary for caries are complex. Total carbohydrate consumption and the frequency of intake are associated with dental caries. [11] [21] [35]

More than any other carbohydrate, sucrose has been associated with the formation of carious lesions. The relationship between the sucrose content of the individual food or of the total diet and the resulting caries describes a sigmoid curve, which rises steeply when sucrose-containing foods are eaten on a frequent basis, when newly erupted teeth are at high risk, and when the immune response is immature, as is found in young children. After this initial increase in caries, the curve levels off, indicating that increases in the sucrose content of the diet beyond a certain level do not increase caries development to any significant extent. [48]

Despite extensive research, foods unlikely can be reliably ranked on the basis of cariogenicity. The Toothfriendly labeling system, popular in some European countries, has not found favor in the United States. The US Food and Drug Administration (FDA) allows Does not promote tooth decay labels for products containing sugar alcohols known to be noncariogenic, but concerns over testing models have led to resistance to subscribing to more lenient labeling. The following recommendations may be of value: (1) parents should be informed of the known association between frequent consumption of fermentable carbohydrates and dental caries; (2) parents should be encouraged to promote balanced, low-caries-risk diets; (3) parents should be encouraged to limit their children's frequency of exposure to highly cariogenic foods; and (4) parents should have various dentally healthful snacks on hand to promote healthier snacking.

Between-meal snacks should be low in fermentable carbohydrates or contain nonfermentable sweeteners, of which the FDA has approved four: saccharin, aspartame, acesulfame K, and sucralose. The consistency of the food may be equally important in the overall scheme. Sticky or adhesive foods that can maintain high sugar levels in the mouth for a prolonged time are more cariogenic than are foods that are rapidly cleared. The minimal sucrose content required for cariogenicity varies with the stickiness, rate of oral clearance, and the frequency of ingestion. Some foods, such as cheese, have anticariogenic effects. [13] [23] [31] These effects of cheese may be related to the presence of calcium lactate and various fatty acids. Calcium and phosphates may be retained by salivary micelles and therefore serve as slow-release units for mineral components needed for tooth-surface remineralization and the prevention of demineralization. Also, the physical form of various cheeses may promote salivary flow, which, in turn, buffers decreases in pH and aids in cleansing and clearance of food particles. Various other foods and food components have been investigated as caries-protective agents, including chocolate, nuts, licorice, and phosphopeptides from milk. Milk has been reported to have some cariostatic properties and is thought to contribute little to the production of caries when ingested under normal dietary conditions. [53] Foods with protective actions, those that are hypoacidogenic in plaque pH studies, and those made with nonfermentable carbohydrates, such as xylitol, can be recommended, though conclusive data are lacking in this area.

A child's use of a bottle containing juice, formula, milk, or liquids sweetened with fermentable carbohydrates can increase the risk for early childhood caries (ECC) caused by prolonged contact of sugars in the beverage with cariogenic bacteria present on the teeth. [57] The contents of the bottle and the frequency and duration of bottle use contribute to potentially dramatic decay. The risk for ECC also exists for at-will breastfed children and is related to frequency of exposure to breast milk that is allowed to pool on the teeth, especially if the child falls asleep while nursing. This exposure, coupled with less-than-effective oral hygiene practices, can have deleterious effects on the teeth, leading to pain, infection, growth retardation, [2] and early loss of teeth. The American Academy of Pediatric Dentistry offers the following suggestions to aid in the prevention of ECC. First, infants should not be put to sleep with a bottle containing any liquid other than water. Prolonged, at-will breastfeeding should be avoided after eruption of the first tooth. Second, parents should be encouraged to have infants drink from a cup as they approach their first birthday. Weaning from the bottle should occur between 12 and 14 months of age in most cases. Thirdly, oral hygiene measures should be implemented by the time of eruption of the first primary tooth. Lastly, an oral health consultation visit within 6 months of eruption of the first tooth is recommended for evaluation of the child's dental condition and to educate parents and provide anticipatory guidance for prevention of dental disease. [6]

Information released in 1984 from the National Pharmaceutical Association indicated that nearly 100% of pediatric medicine contained sucrose. [47] Some formulations contain as much as 80% sucrose on a weight-volume basis ( Table 2 (Table Not Available) ). [25] Children receiving sucrose-containing medications demonstrated a higher incidence of caries and gingivitis than did children not receiving medication. [54] Frequency of administration coupled with the chronic dosing and pH of the sucrose-containing medication contribute to the caries susceptibility of these children. The cariogenic potential of children's medications can be reduced in various ways, perhaps most simply by educating parents about the need for cleaning the teeth after each dose of medication. Bedtime dosages of medications should be given before the child's nightly oral hygiene ritual. A more effective strategy would be to substitute sugar-free formulations when available.


(Not Available)

Adapted from Hill EM, Flaitz CM, Frost GR: Sweetener content of common pediatric oral liquid medications. American Journal of Hospital Pharmacy 45:135, 1988; with permission.

Recommendations to parents include:

Do not put the infant to sleep with a bottle containing any liquid other than water.

Infants who fall asleep while breastfeeding may be at higher risk for caries.

Wean the infant from the bottle by 14 months of age.

Avoid prolonged consumption of sweetened beverages or low-pH fruit juices from a bottle or "tippy" cup.

Do not dip pacifiers in sweetened solutions or honey (also carries a risk for infant botulism [67] ).

Monitor the child's diet for the amount and frequency of exposure to fermentable carbohydrates. Restrict intake of sweets to mealtimes, when salivary flow is greater. Substitute less-cariogenic foods as snacks.

Clean the child's teeth after the intake of medications flavored with sucrose.

Host Factors

Individuals with teeth are susceptible to some degree to dental caries. This susceptibility can be lowered if the teeth are structurally sound, if salivary flow and composition are normal, and if sufficient ambient fluoride is present in the oral environment. Whole saliva, the mixture of secretions in the oral cavity derived from major and minor salivary glands plus the gingival exudate, is the host's greatest defense against caries. Saliva significantly influences the carious process, as evidenced by a myriad of animal experiments in which the salivary glands are surgically removed [17] ; however, even in desalivated animals, a cariogenic substrate is still a necessary factor for caries, underscoring the multifactorial causes of the disease process.

Saliva is supersaturated with respect to calcium and phosphate. The pH at which these ions precipitate is referred to as the critical pH, thought to be approximately 5.5. At any pH less than this value, tooth structure may begin to dissolve.

The effects of saliva can be partly explained by its ability to wash away food debris and bacteria. Saliva also possesses a buffering capacity, and some studies suggest that it has antibacterial properties. Salivary IgA antibodies prevent colonization of streptococci on epithelial cells, [68] but the role of salivary IgA in regulating colonization of MS on tooth surfaces is controversial. [44] Secretory IgA constitutes the main specific immune defense mechanism in saliva and may have an important role in the homeostasis of the oral micobiota. [41] Protection against bacterial agents of caries may be conferred by salivary IgA antibodies by stimulation of the common mucosal immune system, which produces protective antibodies on mucosal surfaces, including those in the oral cavity. Serum-derived antibodies of the IgG type also exist in whole saliva and are at detectable levels within the first year of life. Nonimmune factors found in saliva include myeloperoxidase, lysozyme, lactoferrin, and cystatins. These antimicrobial agents may interact with each other and with the immune factors in an additive or synergistic manner. [61] The antimicrobial agents produced by oral peroxidases may be protective in the early phases of dental caries. [51] Dentifrices and mouthrinses that generate the hydrogen peroxide necessary to drive the production of hypothiocyanate from oral peroxidases are already commercially available, and these products may be beneficial in patients with xerostomia. Further research into the development of products containing nonimmune or immune agents may yield important new ways to battle oral infections, including tooth decay. The use of a sugar-free chewing gum after meals stimulates salivary flow and has documented beneficial effects. [16] Gums sweetened with xylitol may provide additional antimicrobial effects. [58]

Physiologic xerostomia occurs during sleep, when the salivary glands do not secrete spontaneously. With no saliva to buffer pH and wash away fermentation products of plaque during sleep, the most important time for plaque removal is just before bedtime. Also, many medications can produce xerostomia as a side effect, including antispasmodics, antidepressants, antihistaminics, anticonvulsants, and others. Individuals on these medications long term may benefit from increased oral hygiene measures, more frequent fluoride exposure, and saliva substitutes to reduce the damaging effects of reduced salivary flow.

Enamel is the hardest material in the body and, as such, is the first line of defense against decay. Developmental defects that reduce its hardness or alter its morphology can diminish its protective nature. Hypomineralization, a relatively rare phenomenon, results in enamel that is softer than normal and may be easily lost from the tooth. Hypoplastic enamel results from various conditions, including prematurity and very low birthweight. In hypoplasia, the enamel has normal hardness but is pitted, appears creased, or lacks normal thickness. Evidence shows that the hypoplastic defects associated with prematurity are subclinical but sufficient to allow for the development of ECC.

Ambient fluoride in the oral environment can promote remineralization of early enamel demineralization lesions. The mechanisms of action of fluoride and the appropriate use of fluoride modalities are discussed later.

The occlusal (biting) surfaces of molar and premolar teeth are the most caries-susceptible tooth surfaces. This is true of permanent first (6-y) molars, which can have deep pits and fissures that may be impenetrable by toothbrush bristles. Consequently, pit and fissure sealants have been advocated for teeth that are susceptible to decay, such as those with deep, non-coalesced pits and fissures. A sealant is a clear or shaded resin material that may be bonded to the chewing surfaces of caries-susceptible posterior teeth. The sealant forms a coating or barrier to protect these surfaces from decay ( Fig. 1 ). Numerous studies have confirmed that sealants effectively prevent occlusal caries. [28]

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