Oral Health Policy and Practice Guidelines for Pediatric Health Care Providers

To ensure a lifetime of good oral health, children need to establish good oral health habits and a dental home early in life. Initially, those steps are the responsibility of a parent or primary caregiver. The first dental visit should occur within six months of the eruption of the first tooth or by age 1 year, whichever comes first. Deciduous teeth are important for eating and speaking, and they play an essential role in socialization, nutrition, and appearance. They also hold the space for the adult teeth. Childhood oral health problems, including dental caries, may have immediate complications as well as cause a lifetime of oral health issues including pain, local and systemic infections, poor eating and growth, poor self-esteem, financial costs, missed school days, and missed work for parents.

Pediatric health care providers, in collaboration with oral health care providers, play an important role in promoting good oral health and reducing the burden of early childhood caries, benefitting children and their families. The Oral Health Prevention Primer was developed by the American Academy of Pediatrics (AAP) and offers many resources needed to help pediatricians and other health professionals who care for children, learn, incorporate, and provide support to achieve optimal oral health. Additional information is available through online modules: Child Oral Health and Caries Risk Assessment, Fluoride Varnish, and Counseling from Smiles for Life, a national oral health curriculum.

The practice guidelines presented below pertain to young children. Families of children with special health care needs may require additional assistance to prepare their child for a dental visit, including communication before the appointment. Children with special health care needs (CSHCN) are children who typically require accommodations and strategies to address their specific physical, behavioral, and/or communication disabilities. Suggested accommodations and strategies may be found in the American Association of Pediatric Dentists’ publication Management of Dental Patients with Special Health Care Needs.

Perform an oral health risk assessment. Ideally, the assessment should include an evaluation of risk factors, such as maternal (or primary caregiver) oral health status, bottle use after the age of 1 year, use of a sippy cup with fluids other than water, frequent snacking, and special healthcare needs. The American Academy of Pediatrics has developed an Oral Health Risk Assessment Tool in English and Spanish that may be useful to providers.

Take oral health history and note findings regarding:

• Habits: digit sucking, pacifier use, bruxism
• Issues to date, including current acute issues
• Professional dental care and home care received to date
• Survey parents on beverage consumption, including use of tap or bottled water
• Perform a caries risk assessment
• Past or current caries experience of siblings, parents, and other household members

Discuss additional oral health topics/recommendations, as appropriate:

• Discuss the recommendation that dental visits for children should begin within six months of the eruption of the first tooth or by age 1
• Encourage patients to establish a dental home for themselves and their young children
• Help the parent/caregiver identify a dental home for themselves and their child at 12 months of age or sooner if dental caries exists or the patient is at high risk for caries
• Answer caregivers’ questions or concerns about dental treatment

For children under age 3 years, consider offering a quick knee-to-knee oral screening to look for white spots or visible decalcifications on teeth, obvious decay (dark or discolored tooth surfaces or missing tooth structure), restorations (fillings), visible plaque accumulation, and gingivitis (swollen or bleeding gums).

Advise and educate parents/caregivers about the importance of healthy eating and beverage consumption habits.

• Choose age-appropriate healthy foods and snacks during planned meals and snacks; limit foods containing added sugar
• Use and frequency of sugary food and drinks, nighttime feedings of anything except water
• Fluoride exposure, including fluoride varnish in other settings, systemic and topical fluoride, and community water fluoridation
• Encourage fruits and vegetables, other healthy snack options, and dairy products (milk, cheese, cottage cheese, unsweetened yogurt) for snacks
• Avoid sugary and sticky foods, such as candy, sugared-based gum, cookies, cakes, fruit roll-ups, and raisins. Foods like crackers and chips tend to get stuck on teeth and lead to cavities, so limit these snacks
• Choose water between meals. Drinks low in sugar (such as white milk) should be limited to less than 4 ounces once a day with a meal
• Advise and educate parents/caregivers about maintaining good oral health for themselves to prevent tooth decay in their infants and children
• Do NOT put infants to sleep with a bottle, sippy cup, or no-spill cup with formula, milk, or juice products. Do not breastfeed to sleep past the eruption of the first tooth
• Do NOT feed infants with a propped-up bottle
• Offer only water from a sippy or no-spill cup
• Only offer juice at mealtime; infants should not consume more than 4 ounces of 100% juice daily. Juice is not necessary for a balanced diet and whole fruit should be prioritized
• Wean infants from the bottle by their first birthday
• The ADA suggests that powdered formula be reconstituted with optimally fluoridated drinking water
• If using honey at bedtime for the treatment of cough in young children, advise parents to wipe or clean mouth before bedtime

The mineral fluoride occurs naturally on earth and is released from rocks into the soil, water, and air. Fluoride protects teeth from decay. All water contains some fluoride but, in many communities, the fluoride level in water is not enough to prevent tooth decay. Consumption of fluoride through water and foods is important for the growing child. During tooth development, fluoride is incorporated into the developing tooth and strengthens the primary and permanent dentitions. Community water fluoridation, available to more than 95% of the Illinois population, is the process of adjusting the amount of fluoride found in water to achieve optimal prevention of tooth decay.

As summarized by the CDC Community Water Fluoridation program, fluoride benefits children and adults throughout their lives and irrespective of income, race, or ethnicity Because of the widespread adoption of community water fluoridation in Illinois, that benefit extends across geographic regions of the state. For children younger than age 8, fluoride helps in the development of stronger secondary teeth. For adults, drinking water bathes teeth with low levels of fluoride that helps prevent cavities from forming and supports remineralization of tooth enamel. The optimal fluoride concentration indrinking water, as established by the U.S. Public Health Service, is 0.7 parts per million. In 2018, the CDC reported that 98.2% of Illinois’ 12.8 million residents on 1,800 community water systems receive fluoridated drinking water.

It is important to educate adults and children on the importance of drinking fluoridated water and determine whether they live in a fluoridated or non-fluoridated community. This is important because living in a non-fluoridated community may increase the risk of dental caries. Fluoride concentration of specific water systems information by county can be found on the Illinois page of CDC’s My Water’s Fluoride.

The International Bottled Water Association maintains a list of bottled water brands containing fluoride. However, most bottled waters contain a less-than-optimal concentration of fluoride, and the fluoride content varies among brands. Bottled-water products that are marketed as “purified,” “distilled,” “deionized,” “demineralized,” or “produced through reverse osmosis” typically have concentrations of fluoride much lower than those of products marketed without these claims. For children living in areas without optimal levels of fluoride in their community drinking water, consider the child’s ingestion of water from other sources from the home such as at school, day care, or other sources and encourage drinking of water supplied by their local water system.

For children under 6 years of age, apply fluoride varnish to the primary teeth starting at the age of primary tooth eruption regardless of the levels of fluoride in their water. Fluoride varnish is recommended by the U.S. Preventive Services Task Force for children through the age of 5, and, therefore, is a mandated service covered by insurers. Based on risk, discuss, and provide an application of fluoride varnish every three to six months. The following non-oral health providers should consider adding the use of fluoride varnish to their clinical practice:

• Dentists
• Dental Hygienists
• Dental Assistants (with dentist supervision)
• Physicians
• Physician Assistants
• Nurse Practitioners
• Registered Nurses
• Licensed Practical Nurses
• Medical Assistants

The Illinois Department of Healthcare and Family Services reimburses physician providers for applying fluoride varnish. Although physicians must perform the oral health assessment themselves, fluoride varnish application maybe delegated to ancillary medical staff that has been trained to provide the services. This effort reaches high-risk children up to 3 years of age in primary care settings. Refer to Handbook for Providers of Healthy Kids Services, Procedures for Health Care for Children Chapter HK-200 for detailed protocol.

Discuss health promotion and self-care practices, home oral hygiene, decreasing the risk of dental disease using fluoride, appropriate diet, and nutrition, eating and sugar-sweetened beverage drinking behaviors, and the importance of professional preventive dental visits. Remember to emphasize that bacteria from untreated dental caries from caregiver/parent can pass on to the baby through sharing toothbrushes, pre-chewing food, and cleaning a pacifier with caregiver/parent saliva.These bacteria then can start the caries process in the child.

• Wipe gums/teeth twice daily with a soft cloth or baby toothbrush
• The use of fluorides in toothpaste, rinses, or water is safe when used appropriately
• Limit food and utensil sharing between caregivers and infants/children to reduce the transmission of bacteria that can cause dental caries
• Encourage parents/caregivers to practice and set an example of good oral health habits like flossing and brushing
• Avoid cleaning a dropped pacifier or toy with the caregiver’s mouth. This will transmit bacteria between caregiver and child
• Do not dip the pacifier in sweetened foods, such as honey, syrup, or sugar
• Do not ingest any food or beverages other than water after the nighttime brushing
• Encourage caregivers to brush their children’s teeth with the appropriate amount of toothpaste until age 7 or 8 years, depending on the maturity of the child
• Advise parents on oral health protective factors, including establishing a dental home, fluoride usage (toothpaste, drinking water), low cariogenic diet, and twice-daily tooth brushing
• Advise parents on age-appropriate prevention of oral-facial injuries (e.g., mouth guards)

In addition to providing advice on tooth brushing and flossing, evaluate the child’s sources and estimated levels of fluoride intake. Although fluoride provides protection against dental caries, ingestion of higher than recommended levels of fluoride is associated with increases in mild dental fluorosis in developing permanent teeth. Encourage caregivers to have children avoid rinsing with water after using toothpaste at night to leave some protective fluoride on teeth.

Health care providers should develop a comprehensive management plan including assistance in establishing a dental home, a source for ongoing prevention and treatment. In addition, trained primary care providers can assess risk in young children and apply fluoride varnish to prevent and control the dental caries process. Providers are also encouraged to talk with parents/caregivers to access the barriers to oral health care for young children. Ask about:

• Transportation and financial issues
• Competing health issues, especially for those with special needs
• Fear and fatalistic attitudes, such as “they are only baby teeth.”
• Health providers’ awareness of the recommendation to begin dental visits by age 1

It is important to document and follow-up on recommendations. Parents listen to what you have to say, and the recommendations you make, so use your influence to motivate and to institute health behaviors at home and to promote professional care.

Pediatricians must work with oral health care providers to establish effective oral health care for infants and children. According to the AAP policy statement, pediatricians should support families in identifying a dental home for all children. A dental home should be identified within six months of the eruption of the first tooth and before their first birthday.

• For children who do not have a dental home, help the family to locate one in their community. Develop a referral list by calling area dental offices or by using the Find a Dentist function on insurekidsnow.gov. Be sure to determine whether they accept adult Medicaid and other insurance plans or have sliding fee schedules for uninsured patients
• Establish relationships with oral health professionals who see children in the community to facilitate your referrals. Consider developing a formal referral process with oral health professional offices to facilitate timely appointments
• Consider providing to the parent/caregiver a written referral to collaborating oral health care provider
• Consult with oral health providers for patients with high-risk conditions, including those with heart disease, complex medical conditions, or taking multiple medications
• As needed, make referrals to other health professionals, such as nutritionists
• Assist families with applications for insurance or other sources of coverage, social and nutrition services, or other needs such as transportation and translation

• Discourage saliva-sharing behaviors between parent and child, such as sharing of spoons and cleaning pacifiers in the mouth. Inform parent/caregiver that such behaviors are the source of cariogenic bacteria in the baby’s mouth
• Discuss teething remedies, such as cold teething rings and the use of acetaminophen/ibuprofen only as needed; discourage topical anesthetic products due to the risk of toxicity and ease of overdose
• Discuss non-nutritive oral habits, such as a digit, pacifier, or toy sucking; bruxism; or abnormal tongue thrust. Although most children stop these behaviors on their own between ages 2 and 4, they should be weaned from these habits by age 5 to prevent long-term dental effects
• Provide age-appropriate injury prevention counseling (e.g., mouth guards, childproofing home)

Useful Medications for Pediatric Oral Conditions: The American Academy of Pediatric Dentistry has produced a guideline on useful medications to address pediatric oral health concerns.