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Road map for oral health: AAP report outlines pediatricians’ role in prevention

December 19, 2022

Pediatricians should be knowledgeable about the disease process of dental caries, the principles of good oral hygiene practices and the social determinants of children’s oral health.

Those are among the recommendations in an updated AAP clinical report that reminds pediatricians to perform a caries risk assessment and offer anticipatory guidance on oral health during well-child visits. They also can help identify problems that require prompt referral to a dentist.

The report Maintaining and Improving the Oral Health of Young Children, from the Section on Oral Health, is updated from 2014. It is available at https://doi.org/10.1542/peds.2022-060417 and will be published in the January issue of Pediatrics.

“Because dental caries is such a common and consequential disease process in the pediatric population and such an integral part of the overall health of children, it is essential that pediatricians include oral health in their daily practice of pediatrics,” the report states.

Curtailing caries

Multiple factors influence the progression toward dental caries, including the presence of bacteria, sugar, saliva and fluoride.

The risk of caries is greatest if sugars are consumed at high frequency and in a form that remains in the mouth for long periods. Examples in children are continual bottle or sippy cup use with fluids other than water, frequent between-meal snacking of sugars/cooked starch/sugary beverages, consumption of sticky foods (raisins, fruit snacks, gummy vitamins), frequent intake of sugared medications and sleeping with a bottle.

“We still see multiple kids a year having to undergo anesthesia for their dental caries, many caused by prolonged bottle use at night,” said Kaitlin Whelan, M.D., FAAP, a lead author of the clinical report. “That’s something that we continue to educate families on — just as their teeth come in … to limit nighttime exposures.”

Her practice outside of Denver has families fill out a screening instrument, and the providers discuss oral health during the well visit. The office also provides fluoride treatments.

Application of fluoride varnish is associated with a substantial reduction in caries. In most states, pediatricians are paid for applying varnish on the teeth of young children. Recommendations are to apply the varnish two to four times a year to the primary or permanent teeth.

Pediatricians also should be aware of silver diamine fluoride, which is used to arrest caries lesions and will stain the surface black. More patients may have had this treatment at their dentist’s office.

Counseling about dental hygiene extends to parents, since the presence of active dental decay in the primary parent or caregiver is a risk factor for caries in young children. Pediatricians can urge caregivers to maintain regular dental visits and model good oral hygiene.

Strong evidence reveals that mothers are a primary source of Streptococcus mutans colonization for their children through behaviors such as utensil-sharing or cleaning the child’s pacifier with their mouths.

Disparities in dental care

The AAP and other organizations recommend a dental visit for all children by the time they are a year old.

Disparities persist in preventive dental care, however, with young children, those from non-English-speaking households including immigrants and refugees, and children with special health care needs less likely to receive such care. American Indian/Alaska Native children have the highest rates of dental caries in the U.S.

An approach to children’s health — including dental health — must address social determinants such as poverty, racism, education, access to healthy foods, culture and physical environment, as well as access to medical and dental care. Pediatricians can consider and address determinants of oral health at the child, family and community levels.

It helps if pediatricians know the dental resources in their community and the barriers to care, Dr. Whelan said.

Recommendations

The report includes the following guidance:

  • Counsel parents, caregivers and patients on ways to reduce exposure to sugars in foods and drinks.
  • Encourage parents, including pregnant mothers, to maintain their own oral health, and advise them to brush a child’s teeth at least twice a day as soon as teeth erupt using a smear or grain of rice-sized amount of fluoride toothpaste. Increase to a pea-sized amount when the child turns 3 years old.
  • Advise parents to assist and monitor children’s brushing until they reach age 10.
  • Keep abreast of dental consultation/referral sources in the community, and establish relationships with local dental providers.
  • Promote policy, system and environmental changes that address social determinants of children’s oral health.
  • Advocate for insurance coverage for fluoride varnish as a preventive service.

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