You saw Jay for his 12-month well-child visit in 2019. He arrived drinking juice from a baby bottle, and oral exam revealed white spot lesions (incipient cavities) along the gumline of his primary incisors (photo 1). You explained to his mom that Jay had early signs of tooth decay that could be reversed with proper care. You recommended stopping the bottle, avoiding sugary drinks, brushing his teeth twice daily with fluoride toothpaste and making his first dentist appointment. You also applied fluoride varnish and recommended re-application in three months.
You do not see Jay again until his 30-month well-child visit. His mother explains that they missed many visits due to fear of COVID-19. He is drinking juice in a sippy cup, and exam reveals severe early childhood caries (photo 2). You ask whether Jay complains of mouth pain, and his mom says, “Whenever I try to brush his teeth, he shuts his mouth and turns away. Maybe his teeth hurt?”
How would you manage Jay’s severe caries?
a) Discuss concerns about Jay’s tooth decay, and schedule a dental appointment from your office.
b) Recommend water only (no juice) in sippy cups.
c) Advise toothbrushing twice daily with a smear of fluoride toothpaste. Suggest a toothbrushing video (e.g., Elmo from Sesame Street).
d) Apply fluoride varnish with appropriate personal protective equipment (PPE), and schedule a follow-up visit in three months.
e) All of the above.
Jay is not alone. Routine preventive care and dental visits stopped when the pandemic began. From March through May 2020, child Medicaid and Children’s Health Insurance Program dental claims declined by 69% (https://go.cms.gov/35YjmOH). Clinicians also are reporting worsening oral health during the COVID-19 pandemic.
Burden of disease
Dental caries, or tooth decay, is one of the most common chronic diseases of childhood, affecting nearly half of U.S. children ages 2-19 years. The highest rates are in children whose families have low income and children who are ethnic minorities.
Untreated dental caries can cause chronic infections, abscesses, mouth pain, problems eating and sleeping, growth delay, school absence and poor well-being. In rare cases, it can cause sepsis and death.
Dental caries is caused when dietary sugars are metabolized by oral cariogenic bacteria, producing acid that demineralizes the tooth enamel. During the COVID-19 pandemic, children’s screen time, unhealthy snacking and food insecurity have increased, leading to greater caries risk.
Caries is largely preventable, and pediatricians play a critical role. For the past decade, AAP Bright Futures/Periodicity Schedule and the U.S. Preventive Services Taskforce have recommended that well-child visits from birth onward include caries risk assessment, oral health promotion and counseling, fluoride varnish application and referral to a dental home.
During the COVID-19 pandemic, the AAP recommends that children continue in-office well-child visits and provided guidelines for PPE use when applying fluoride varnish (https://bit.ly/36kjk51). When suspicion for SARS-CoV-2 is low, standard PPE (face shield, surgical mask and gloves) is recommended. Telehealth visits also can incorporate oral risk assessment and anticipatory guidance.
Improving children’s oral health
Pediatricians can take the following steps to address oral health at all well-child visits:
- Promote good nutrition: breastfeeding, healthy bottle-feeding when needed (only breastmilk or formula, no bottle in bed, stop bottle at 1 year), consuming non-sugary snacks and beverages, and drinking fluoridated water. Check families’ food security and refer to food assistance programs as needed.
- Emphasize good oral hygiene: Brush children’s teeth twice daily with fluoride toothpaste (a smear for those younger than 3 years and pea size for those 3 and older), with adult assistance until age 8.
- Assess caries risk through a targeted history and tooth exam.
- Teach parents the “lift the lip” method to look at the teeth.
- Engage families in healthy behaviors with motivational interviewing techniques.
- Apply fluoride varnish every three to six months based on risk.
- Refer children to a dental home by age 1 year, with warm handoffs when needed. Reassure families that dental offices take precautions to ensure safety from COVID-19.
Pediatricians also can build and maintain collaborative relationships with local dental professionals. Advocate together for policies, health systems and environmental changes to improve the social determinants of child nutrition and oral health.
Drs. Sokal-Gutierrez and Braun are members of the AAP Section on Oral Health Executive Committee.