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G PerinatalOralHealthCare1
G PerinatalOralHealthCare1
Latest Revision
2016
Purpose previous surveys, but the filled component (fs) has greatly
The American Academy of Pediatric Dentistry (AAPD) recog- increased indicating that more treatment is being provided.3
nizes that perinatal and infant oral health are the foundations ECC and the more severe form of ECC (i.e., S-ECC)
upon which preventive education and dental care must be begin soon after tooth eruption, developing on all surfaces of
built to enhance the opportunity for a child to have a lifetime primary teeth, progressing rapidly, and having a lasting detri-
free from preventable oral disease. Recognizing that dentists, mental impact on the dentition.4,5 This disease affects the
physicians, allied health professionals, and community organi- general population, but is 32 times more likely to occur in
zations must be involved as partners to achieve this goal, the infants who are of low socioeconomic status, who consume a
AAPD proposes guidelines for perinatal and infant oral health diet high in sugar, and whose mothers have a low education
care, including caries risk assessment, anticipatory guidance, level.6-8 The consequences of ECC often include higher risk
preventive strategies, and therapeutic interventions, to be of new carious lesions in both the primary and permanent
followed by the stakeholders in pediatric oral health. dentitions5,9,10 hospitalizations and emergency room visits,11,12
high treatment costs,13 loss of school days,14 diminished ability
Method to learn,15 and reduced oral health-related quality of life.16
The Guideline on Infant Oral Health Care was originally devel- It has been reported that 89 percent of children age one
oped by the Infant Oral Health Subcommittee of the Clinical year had an office-based physician visit, compared with only
Affairs Committee and adopted in 1986. The Guideline on 1.5 percent who had a dental office visit.17 In a recent study,
Perinatal Oral Health Care was originally developed by the 99 percent of Medicaid-enrolled children had well baby visits
Infant Oral Health Subcommittee of the Council on Clinical before age one, whereas only two percent had a dental visit.18
Affairs and adopted in 2009. This guideline is a merger and Since medical health care professionals see new mothers and
an update of the previous versions, revised in 2014 and 2011 infants earlier and more often than dentists, it is essential that
respectively. This revision included a search of the PubMed
electronic database using the terms: infant oral health, in-
® they be aware of the multifactorial etiology and associated risk
factors of ECC, give appropriate counseling regarding ECC
fant oral health care, early childhood caries, perinatal, perinatal prevention to pregnant women and caregivers, and facilitate
oral health, and early childhood caries prevention; fields: all; the establishment of a dental home.19
limits: within the last 10 years, humans, English, and clinical Because restorative care to treat ECC often requires the
trials. Papers for review were chosen from the resultant list of use of sedation and general anesthesia with associated high
articles and from references within selected articles and hand costs and possible health risks,20 and because there is high recur-
searches of the literature. When data did not appear sufficient rence of lesions subsequent to the procedures,21 there is now
or were inconclusive, recommendations were based upon ex- more emphasis on prevention and arrestment of the disease
pert and/or consensus opinion by experienced researchers and processes to manage ECC. Approaches include methods that
clinicians. have been referred to as (1) chronic disease management, which
includes parent engagement to facilitate preventive measures
Background and temporary restorations to postpone advanced restorative
Dental caries, consequences, and management care,22 (2) active surveillance, which emphasizes careful moni-
The Centers for Disease Control and Prevention reports that toring of caries progression and establishment of a prevention
dental caries is the most prevalent chronic disease in our na- program in children with incipient lesions,23 and (3) interim
tion’s children.1 More than 28 percent of children have caries
by the time they reach kindergarten.2 Epidemiologic data
from a 2011-2012 national survey clearly indicate that early ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ECC: Early child-
childhood caries (ECC) remains highly prevalent in poor and
hood caries. S-ECC: Severe early childhood caries. dfs: Decayed
near poor U.S. preschool children. For the overall population and filled tooth surfaces. ITR: Interim therapeutic restorations.
of preschool children, the prevalence of ECC, as measured MI: Motivational interviewing.
by decayed and filled tooth surfaces (dfs), is unchanged from
therapeutic restorations (ITR) that temporarily restore teeth Anticipatory guidance to reduce the risk of dental caries
in young children until a time when traditional cavity prepara- should include counseling regarding brushing of child’s teeth
tion and restoration is possible.24 twice daily with the appropriate amount of fluoridated tooth-
paste, diet analysis, and counseling to reduce the consumption
The Perinatal Period and Anticipatory Guidance of sugar containing beverages.38 The use of fluoride for the
The perinatal period is defined as the period around the time prevention and control of caries is documented to be both
of birth, beginning with the completion of the 20th to 28th safe and effective.46,47 Optimal exposure to fluoride is important
week of gestation and ending one to four weeks after birth. to all dentate infants and children.48 Systemically-administered
The perinatal period plays a crucial role for the well-being of fluoride should be considered for all children who do not
pregnant women.25 Also, it is essential for the health and well- receive fluoride by consuming fluoridated water (less than
being of their newborn children. Yet, many women do not 0.7 ppm) in after determining all other dietary sources of
seek dental care during their pregnancy, and those who do fluoride exposure.47 The correct amount of fluoridated tooth-
often confront unwillingness of dentists to provide care.26-29 paste should be used twice daily by all children regardless of
Many expectant mothers are unaware of the implications of risk. No more than a smear or rice-sized amount of fluoridated
poor oral health for their pregnancy and/or their unborn toothpaste should be used for children under age three.49
child.28,30,31 Professionally-applied fluoride varnish should be considered for
Identifying mothers with high levels of dental caries and children at risk for caries.23
poor oral health and educating them on the importance of Practitioners should counsel parents that high frequency
their own oral health and the future health of their unborn consumption of sugars by bottle-feeding, sippy cup use, or
child can help change their trajectory of oral health. Timely between meal consumption of sugars increases the risk of
delivery of educational information and preventive therapies caries.50 The American Academy of Pediatrics has recommended
to these parents may reduce the incidence of ECC, prevent children one through six years of age consume no more than
the need for dental rehabilitation, and improve the oral health four to six ounces of 100 percent fruit juice per day, from a
of their children.32-34 Physicians, nurses, and other health care cup (i.e., not a bottle or covered cup).51 Epidemiological re-
professionals are far more likely to see expectant or new moth- search shows that human milk and breast-feeding of infants
ers and their infants than are dentists. Therefore, it is essential provide general health, nutritional, developmental, and
that these providers be aware of oral anomalies and associated psychological advantages while significantly decreasing risk for
risk factors of dental caries in order to make appropriate deci- a large number of acute and chronic diseases.52 Frequent
sions regarding timely and effective interventions for pregnant night-time bottle-feeding with milk and ad libitum breast-
women and facilitate the establishment of a dental home for feeding are associated, but not consistently implicated, with
the child.35-37 ECC.53
Caries-risk assessment for infants determines the patient’s Parents also should be counseled that prolonged non-
relative risk for dental disease and allows for the institution of nutritive oral habits may contribute to deleterious changes in
appropriate strategies as the primary dentition begins to erupt. the child’s occlusion and facial development and that there
Its goal is to prevent disease by identifying and minimizing are serious health consequences of tobacco use and exposure
causative factors (e.g., dietary habits, plaque accumulation, lack to secondhand smoke.38 Furthermore, practitioners should
of topical or systemic fluoride, frequent use of sugar contain- provide age-appropriate injury prevention counseling for oro-
ing medications) and optimizing protective factors (e.g., fluor- facial trauma.38
ide exposure, oral hygiene practices, sealants).38 Caries-risk
assessment also allows health care professionals to identify Management of perinatal and infant oral health
and refer high caries-risk patients for appropriate dental man- Oral health care for pregnant and lactating women. The peri-
agement.23 natal period is an opportune time to educate and perform
Even the most judiciously designed and implemented dental treatment on expectant mothers.54-56 Pregnancy care
caries-risk assessment can fail to identify all infants at risk visits provide a teachable moment for physicians, dentists, and
for developing ECC. The early establishment of a dental nurses to educate women about the following:
home, including ECC prevention and management, is the • Diet including the adequate quality and quantity of
ideal approach to infant oral health care.39,40 The inclusion of nutrients for the mother-to-be and the unborn child.
oral health education into the curriculum of medical, dental, This education also should include information regard-
nursing, and allied health professional programs can facilitate ing the caries process and food cravings that may increase
the acceptance of the age one dental visit.41,42 Recent studies, the mother’s caries risk.
noting that a majority of pediatricians and general dentists • Comprehensive oral examination, dental prophylaxis, and
were not advising patients to see a dentist by one year of age, treatment during pregnancy. Dental treatment during
point to the need for increased infant oral health care educa- pregnancy, including dental radiographs with proper
tion in the medical and dental communities.43-45 shielding and local anesthetic, is safe in all trimesters
and optimal in the second trimester. Due to possible
patient discomfort, elective treatment sometimes may be haviors.61 MI is a personalized approach that raises caregiver
deferred until after delivery. and child awareness of the problems, setting oral health goals,
• Proper oral hygiene, using a fluoridated toothpaste, and co-evaluating if current behaviors are consistent with
chewing sugar-free gum, and eating small amounts of the goals.
nutritious food throughout the day to help minimize
their caries risk. References
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