Oral Health in Pediatric Population: Prevention and Risk

Introduction to Oral Health in Children

Dental caries is a chronic disease that affects over 40% of U.S. children by the time they reach school age. Although caries has significantly decreased for most Americans over the past four decades, it continues to be the most common chronic ailment in children. Childhood caries, or tooth decay, is an avoidable and infectious disease caused by bacteria such as Streptococcus mutans or Streptococcus sobrinus, which form plaque on the exterior of teeth. The bacterium interacts with sugars found in food and drinks, converting them into acids that break down tooth enamel (Pierce, Rozier, Vann, Jr., & Vann, Jr., 2002).

The general health and well-being of children is considerably affected by their oral health. Oral health encompasses a wide array of health promotion and disease prevention concerns, including dental caries and tooth decay, periodontal health, oral diseases and conditions, appropriate growth and positioning of facial bones and teeth, and injury to the mouth and teeth. Oral disease is progressive and becomes more complex over time. Such issues can affect a child's capacity to eat, food choices, appearance, and communication abilities. Notably, dental decay in children is five times more frequent than asthma and seven times more frequent than hay fever (U.S. Department of Health and Human Services, 2010).

Anticipatory guidance is the process of providing practical, developmentally appropriate information about children's health to prepare parents for important physical, emotional, and mental milestones. It is well established among physicians that utilizing anticipatory guidance during routine medical appointments is an effective way of informing parents on how to ensure the best possible health outcomes for children. Recently, the American Academy of Pediatrics has adopted new recommendations regarding the inclusion of oral health in anticipatory guidance during well-child appointments. These recommendations state that the first dental risk evaluation should occur at six months of age and that the establishment of a dental home should take place by one year of age for children considered at risk for dental caries (Savage, Lee, Kotch, and Vann, Jr., 2004).

Anticipatory Guidance and Early Risk Assessment

Pediatricians and family physicians have a unique opportunity to influence the oral health of children due to their early and frequent contact through well-child and chronic illness appointments. Children five years of age often visit a physician more frequently than they visit a dentist. Two effective methods of preventing caries in children are ensuring they receive the recommended amount of dietary fluoride and arranging regular dental visits. Pediatricians must expand their knowledge base to conduct oral health risk evaluations on all children starting at six months of age (Roberts, Keels, Sharp and Lewis, Jr., 1998).

Children determined to be at risk of dental caries or who belong to a documented risk group should be referred to establish a dental home six months after the first tooth erupts or by one year of age, whichever comes first. The best prevention of early childhood decay is the establishment of the dental home, tailored to the child's specific needs. Although not always possible due to workforce and engagement limitations, best practice standards recommend that, whenever feasible, all children should have a complete dental assessment by a dentist in the early toddler years (Oral Health Risk Assessment Timing and Establishment of the Dental Home, 2003).

The Dental Home Concept

The dental home is the continuing relationship between the dentist and the patient, encompassing all aspects of oral health care provided in a comprehensive, continuously accessible, coordinated, and family-focused manner. The dental community is unified in supporting families to establish a dental home by the time their child is one year old (Bright Futures in Practice: Oral Health Pocket Guide, 2004).

Disparities in Oral Health Outcomes

Incidence rates of caries often differ by ethnicity and socioeconomic status. African American and Hispanic children have higher incidences of caries at all ages compared with white non-Hispanic children. Data indicate that American Indian and Alaska Native children have among the highest incidences of decay. Limited information is available for children with special health care needs, but as a group they face elevated risk for concurrent conditions including decay (Oral Health Assessment: Training for Pediatricians and Other Health Care Professionals, n.d.).

Limited information about oral hygiene and difficulty accessing preventive dental care are thought to contribute to the racial and income disparities in caries incidence. Underprivileged and minority children are more likely to have untreated dental decay compared with more affluent white children. In a recent analysis of national survey data, the General Accounting Office found that underprivileged children had five times more untreated decay than children from higher-income families. Untreated decay can result in difficulties with eating and drinking, speaking, and academic performance. Children from disadvantaged backgrounds experience twelve times the number of limited activity days caused by dental problems compared with more affluent children (Lewis, Grossman, Domoto and Deyo, 2000).

Etiology and Timing of Early Childhood Caries

Primary teeth begin to erupt at varying ages throughout a child's first year of life. A child becomes vulnerable to tooth decay almost immediately after the first teeth erupt, if adequate bacteria are present in the mouth and teeth are exposed to carbohydrates for prolonged periods. Chalky or white spots on the teeth are the primary signs of early dental problems. Both inadequate oral hygiene and inappropriate feeding practices that expose teeth to natural or refined sugars for extended periods contribute to the development of early childhood caries (Bright Futures in Practice: Oral Health Pocket Guide, 2004).

Although a child's teeth do not begin to erupt until the middle of the first year of development, oral health remains a concern since caries can develop throughout the early years. Before a baby is born, parents must ensure their own mouths are as healthy as possible to reduce transmission of caries-causing bacteria to the newborn's mouth. Health care providers should instruct families and caregivers in the following strategies to prevent transmission of harmful bacteria: