Children and Caries
Specific Recommendations for ages 0-5
Early childhood caries has increased significantly in children, particularly those aged 2–5 years.[1] The disease progression in this age group has been the subject of numerous recent headline media reports. Caries Management by Risk Assessment (CAMBRA) is recommended by the American Academy of Pediatric Dentistry as a primary method of intervention and education. Many parents and caregivers are unaware of several important issues regarding the dental caries risk of children. For example, caregivers play a role in the bacterial transmission to their child. Caregivers pass organisms and bacterial species responsible for dental decay through close contact and the sharing of saliva in a process termed vertical transmission.[2] Caregivers are often surprised to learn that there are specific risks associated with childhood caries and that therapy recommendations made in order to lower the child’s risk and symptoms of dental disease include home care therapy recommendations for the caregiver as well.[3] Furthermore, during pregnancy, women often fail to recognize the critical importance good oral health and regular dental visits may have on the long-term oral health of their children.[4]
CAMBRA is designed to systematically assess each child’s and their caregiver’s caries risks, tailor a specific therapeutic management plan in conjunction with a restorative plan, and provide guidance for appropriate periodic reassessment based on the individual risk of the patient.[5] Due to the speed with which children and their habits change between the ages of 0 and 5, risk assessment should be performed at an initial appointment as well as at all subsequent appointments. While the evidence and effectiveness of preventive and treatment methods continues to grow, children’s risks and specific needs differ widely and standardized protocols are limited.[5] Therefore, both patients and practitioners should expect to modify the patients’ caries therapy plan regularly based on risk and therapies available.
In order to prevent and manage the disease, it is recommended that dental visits begin early, and children should have a comprehensive oral exam by age 1.[4] During the exam, the practitioner performs a caries risk assessment, looking specifically at risk factors for the disease, bacterial biofilm challenge (if applicable), and disease indicators. Dental exams for children are similar to those experienced by adults, and there are five straightforward steps involved.
Step 1. Through a short interview with the caregiver, the practitioner gathers information regarding the child’s specific risk factors for the disease. Risk factors for the disease include those risk factors already discussed for adults, but other risk factors specific to children are also assessed. At this time, if applicable, a bacterial screening test is also performed to assess the patient’s and the caregiver’s bacterial biofilm challenges.
Step 2. The practitioner then performs a prophylaxis cleaning of the child’s teeth and possibly demonstrates proper cleaning techniques for the caregiver.
Step 3. The dentist then performs a clinical examination. During the examination, the dentist looks for disease indicators such as current decay, white spot lesions, decalcifications of the enamel, or the presence of restorations indicating past caries experience.
Step 4. Based on the patient’s caries risk assessment, the ADA recommends that a fluoride varnish be applied every 3 to 6 months to help prevent decay.[1]
Step 5. Based on the risk assessment and clinical examination, the caregiver and the dental professional work to determine mutually agreed-upon oral health goals for the child and the family. Ideally, one or two home management goals are established for reassessment at the next appointment to reduce the risk factors for dental disease and increase the protective factors.
Risk factors for ages 0–5
In order to identify if a child is at risk for cavities, the caregiver and the dental practitioner must identify if the child has any risk factors for the disease. A risk factor is simply something that increases the child’s risk for a disease. Because children may have very little dental history due to their age, risk factors by themselves can place a child at high risk for dental decay. The best method of lowering a child’s caries risk is to reduce any and all modifiable risk factors. If unmodifiable risk factors exist, or patients would prefer, professional/prescription home care therapy products should be dispensed.
Risk factors for children aged 0–5 [3, 5]
- Elevated levels of ATP by CariScreen and/or cavity-causing bacteria by culture.
- Mother/caregiver(s) has elevated levels of ATP as determined by CariScreen.
- Mother/Caregiver(s) has had dental decay in the last 12 months (family history of decay).
- Takes bottle or drinks liquid other than water or milk/formula/breastfed.
- Frequent/continual bottles/drinks other than water.
- Child sleeps with bottle/drinks other than water or nurses on demand.
- Frequent snacking between meals (three or more times daily other than meals).
- Saliva-reducing factors present (medications, medical condition, genetic factors).
- Cariogenic diet (sugars, sugared/acidic beverages, starch foods, fermentable carbohydrates).
- Child has developmental problems (special needs).
- Low socioeconomic status and/or caregiver has low health literacy.
Disease indicators for ages 0–5 [3, 5]
Disease indicators are signs and symptoms of the disease, and the presence of one disease indicator places the child at high risk, and based on the risk factors present, professional/prescription therapy should be dispensed.
- Current decay, white spot lesions, decalcification/defects of the enamel.
- Restorations present (past caries/decay experience).
- Plaque is obvious on teeth or gums bleed easily.
- Visually inadequate saliva flow.
Therapy recommendations for ages 0–5 [3, 5]
Low risk
Low-risk patients’ caregivers should be aware of the risks associated with dental disease and share the information with other family members and caregivers, maintaining good home care habits with preventive dental care products such as tooth wipes for infants and toddlers and gels (CTx3 Gel) and sprays (CTx2 Spray) for all ages. Preventive products should contain pH neutralization, xylitol, and remineralization agents such as nanohydroxyapatite whenever possible. The dental practitioner will advise on the use of fluoride-containing oral care products based on the age and risk of the child. Caregivers should be aware if they live in a water-fluoridated community as drinking fluoridated water is a protective factor.
Moderate risk
Moderate risk patients’ caregivers should be aware of the risks associated with dental disease and share the information with other family members and caregivers. If possible, caregivers should consider the benefit of eliminating the risk factor placing the child at risk. Maintaining good home care habits with preventive dental care products such as tooth wipes for infants and toddlers and gels and sprays for all ages. Preventive products should contain pH neutralization, xylitol, and remineralization agents such as nano hydroxyapatite whenever possible. The dental practitioner will advise on the use of fluoride containing oral care products based on the age and risk of the child. Caregivers should be aware if they live in a water-fluoridated community as drinking fluoridated water is a protective factor.
High risk
High-risk patients’ caregivers should be aware of the risks associated with dental disease and share the information with other family members and caregivers. If possible, caregivers should consider the benefit of eliminating the risk factor(s) placing the child at risk. For high-risk patients aged 0–2, caregivers should brush the child’s teeth/gums at least 2 times daily with a gel that contains pH neutralization, xylitol, and nanoparticles of hydroxyapatite. Such products are safe to swallow. Caregivers should also use xylitol wipes infused with pH neutralization 3–4 times daily after every meal/bottle. Based on the clinician’s judgment, a small smear of gel that contains a small amount of fluoride can be used along with pH neutralization, xylitol, and nanoparticles of hydroxyapatite as a toothpaste replacement for the gel which does not contain fluoride.[3] Use caution when using fluoride products on infants and toddlers. A smear of gel with pH neutralization, xylitol, and nanoparticles of hydroxyapatite should also be applied and left on at bedtime.[3] Fluoride varnish should be performed at initial dental visits and at 3-month recalls.
Caregivers of patients aged 0–2 should also consider adding products with 0.05% neutral sodium fluoride, antibacterials (0.2% sodium hypochlorite), pH neutralization, and xylitol, along with toothpaste/gel with pH neutralization, fluoride (1.1% NaF), xylitol, and nanoparticles of hydroxyapatite to their home care regimen. A change to professional/prescription home care therapy products for the caregiver(s) may reduce the risk of vertical transmission of the cavity-causing bacterial species.[3]
High-risk patients’ caregivers should be aware of the risks associated with dental disease and share the information with other family members and caregivers. If possible, caregivers should consider the benefit of eliminating the risk factor(s) placing the child at risk. For high-risk patients aged 3–5, caregivers should brush the patients’ teeth/gums at least 2 times daily with a small smear of gel that contains a small amount of fluoride (0.243%), along with pH neutralization, xylitol, and nanoparticles of hydroxyapatite as a toothpaste. Use caution when using fluoride products on infants and toddlers. Caregivers should also use oral wipes and mouth sprays infused with xylitol and pH neutralization, 3–4 times daily after every meal/bottle. A smear of gel with pH neutralization, xylitol, and nanoparticles of hydroxyapatite should also be applied and left on at bedtime.[3] Fluoride varnish should be performed at initial dental visits and recalls.[6]
Caregivers of patients aged 3–5 should also consider adding products such as 0.05% neutral sodium fluoride, antibacterials (0.2% sodium hypochlorite), pH neutralization, and xylitol, along with toothpaste/gel with pH neutralization, fluoride (1.1% NaF), xylitol, and nanoparticles of hydroxyapatite, to their homecare regimen. A change to professional/prescription home care therapy products with xylitol for the caregiver(s) may reduce the risk of vertical transmission of the cavity-causing bacterial species.[3]
Other recommendations
Depending on the severity of the patient’s risk and the clinical judgment of the dentist, some clinicians have also added additional recommendations to those above for children aged 3–5. The FDA recommends that all 0.05% neutral sodium fluoride rinses be prescribed only to children aged 6 and up.[7] Antibacterial rinses such as the 0.2% sodium hypochlorite and 0.05% fluoride also fall under this category. But for children that are capable of rinsing and spitting, some practitioners have recommended adding such rinses for a patient in the 3–5 age group home care regimen. In order to reduce the risk of swallowing, it is sometimes recommended that the caregiver brush the rinse on with a toothbrush and have the child spit every 5 to 10 seconds. Clinicians will only make these types of other recommendations when they feel the benefit outweighs the risk. Children that have had to undergo anesthesia in a hospital setting in order to have dental treatment due to decay may fit this category.
Sealants
Clinicians should follow all ADA and AAPD guidelines on sealants, and glass ionomer–based materials are recommended on all deep pits and fissures. [3]
- B. A. Dye, O. Arevalo, and C. M. Vargas, “Trends in Pediatric DentalCaries by Poverty Status in the United States, 1988–1997 and 1994–2004,” Int J Paediatric Dent 20, no. 2 (2010): 132–43.
- American Academy of Pediatric Dentistry, “Policy on the DentalHome,” AAPD Reference Manual 31, no. 6: 22–3.
- Francisco Ramos-Gomez and Man-Wai Ng, “Into the Future: KeepingHealthy Teeth Caries Free: Pediatric CAMBRA Protocols,” J Calif DentAssoc 39, no. 10 (2011): 723–33.
- S. Gajendra and J. V. Kumar, “Oral Health and Pregnancy: A Review,”NY State Dent J 70, no. 1 (2004):40–4.
- American Dental Association Council on Scientific Affairs,“Professionally Applied Topical Fluoride: Evidence-Based ClinicalRecommendations,” JADA 137, no. 8 (August 2006 ): 1151–1159.
- J. L. Sintes, C. Escalante, B. Stewart, et al., “Enhanced AnticariesEfficacy of a 0.243% Sodium Fluoride/10% Xylitol/Silica Dentifrice:3 Year Clinical Results,” Am J Dent 8, no. 5 (1995): 231–5.
- “Anticaries Drug Products for Over-the-Counter Human Use,” Codeof Federal Regulations, title 21, vol. 5, 21 CFR 355.
