Th Blackiston

Opportunities for excellence with pediatric patients

March 1, 2005
When a child enters the dental office, he or she presents many opportunities for the dental team to provide preventive intervention and therapy.

When a child enters the dental office, he or she presents many opportunities for the dental team to provide preventive intervention and therapy. Dental professionals and parents together become key partners as they influence a child’s dental experience and perception of oral health. They have the unique opportunity to shape the dental values of future patients. These values include a high level of oral health, oral hygiene self-care, and professional dental care on a regular basis. Oral healthcare for children is the cornerstone of adult oral healthcare.

The United States may presently be a caries-resistant country, but is certainly not caries-immune. Tooth decay is one of the most prevalent diseases during childhood, five times more common than asthma and seven times more common than hay fever. By age 18, more than 81 percent of children have experienced dental caries, and 60 percent have experienced some form of periodontal disease, most of which could have been prevented through early intervention and preventive care.

The potential for dental professionals to improve the oral health of children is a reality and oral health for children is fast becoming a national priority.

Prevention before birth

The earlier the intervention, the greater the impact on the child.

Periodontal disease in “moms to be”

The oral health of a pregnant woman has a tremendous effect on the overall health of the fetus. Recent studies in the United States have identified periodontal disease as a risk factor for preterm delivery. Offenbacher’s 1996 research estimated that as high as 18 percent of all preterm low birth weight may be attributed to periodontal disease in the mother. Recent large-scale studies have demonstrated that women with the most severe periodontal disease are at greatest risk of preterm birth. Preterm babies are at higher risk for serious health problems because they weigh less and have less developed organs. The dental community is well positioned to lower the incidence for preterm delivery.

A recent intervention study demonstrated that a reduction in periodontal inflammatory disease was accomplished through prenatal scaling and root planing and prescribed oral hygiene therapy. Power toothbrushes have been shown to be more effective in removing plaque than manual brushes.

Smoking cessation

The U.S. Public Health Service estimates there would be a 10 percent reduction in infant deaths if all pregnant women in the U.S. stopped smoking. Approximately 20 percent of low birth weight births and 8 percent of preterm deliveries are linked to smoking. Dental professionals are in a unique position to discuss smoking cessation with pregnant women. Regular dental office visits for preventive care during pregnancy should include smoking cessation discussions. The American Dental Hygienists’ Association has established a tobacco cessation initiative.

Ask a patient about smoking status
Advise against smoking and advocate cessation while sending a clear message about the risks associated with smoking
Refer patients to resources such as quit lines (1-877-44U-QUIT)

Prevention after birthFirst tooth, first visit

The American Academy of Pediatric Dentistry recommends that a child see a dentist when the first tooth appears, or no later than the child’s first birthday. Significant damage and detrimental habits, which can be difficult to break, can occur if the child is not seen early. The focus of the first visit is primarily educational; the goals should include:

  • determine if plaque is present on the teeth
  • check eruption
  • check soft tissue for abnormalities
  • look for white spot lesions and cavitations.

Parents are critical to the success of this visit because they are going to be participants. Utilize a “knee-to-knee” exam technique for best results with a young child. Parent and clinician sit facing each other with knees touching. The parent holds the child so the child’s back is facing the clinician. In a calm slow manner, the child is lowered onto the clinician’s and parent’s knees (lap) so the child can always see the parent. In this position, the clinician can complete an oral exam as well as demonstrate oral hygiene to the parent.

Partnering with parents

Pediatric dental care should be built on the foundation of prevention, so begin with the basics when discussing oral hygiene self-care. Parent assistance and supervision is usually required until the age of 6, in some cases even 8, to achieve effective plaque removal; the operative word is effective. A concerted approach gets the job done with 18-month-olds to 4-year-olds; beyond the age of 4 requires close supervision and assessment of results. Some experts say children can brush alone when they can tie their shoes. Toothbrushes designed for children may get them interested in brushing. An older child may brush more effectively with a power brush like the Sonicare Elite. The Sonicare has a two-minute timer that shuts off at the end of two minutes. This tells the child exactly how long to brush.

The value of topical fluoride

The 2001 Centers for Disease Control and Prevention (CDC) report “Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States” states that children under the age of 3 swallow up to 60 percent of the toothpaste that is dispensed. The American Academy of Pediatric Dentists recommends that practitioners evaluate each child’s risk for caries. If a child is determined to be at high risk for dental caries following a risk assessment, daily fluoride may be recommended. If fluoride toothpaste is recommended before the age of 3, parents should be in full control of the amount used, wiping the excess and teaching kids to spit as early as possible. Use of a pea-sized amount of fluoride toothpaste no more than two times per day by children under the age of 6 is recommended in the CDC report. Fluoride works in several ways to help control dental caries. Fluoride in saliva inhibits the demineralization of enamel, enhances the remineralization of enamel, inhibits the process of cariogenic bacteria metabolizing carbohydrates to produce acid, and affects bacterial production of adhesive polysaccharides. Frequent exposure to small amounts of fluoride will best reduce the risk for dental caries in all age groups. The CDC work group recommends that all persons drink water with optimal fluoride concentration and brush their teeth twice daily with fluoride toothpaste.

Xylitol - a noncariogenic sweetener

Over the last 25 years, clinical studies on xylitol have been conducted, and the studies strongly indicate that it reduces dental caries. Xylitol is a naturally occurring sweetener not fermentable by cariogenic bacteria. In one study, more than 1,000 schoolchildren were tracked for decay over a three-and-a-half-year period. The groups included sugar gum and three types of sugar-free gum, including xylitol gum. In all but the xylitol group, caries increased. In fact, the xylitol group had less decay than when it started; some of the decay actually healed itself. In another study, chewing xylitol gum two to three times a day significantly increased the protection against caries in 10-11 year olds. Xylitol interferes with the metabolism and adherence of S. mutans and possibly lactobacillus. Xylitol has a long history of safety and could be viewed as another tool in the defense of dental decay in children.

Orthodontic evaluation

The American Association of Orthodontists recommends that all children have an orthodontic evaluation no later than age 7. This early evaluation advises parents if a problem is apparent. The orthodontist can suggest to the parent an appropriate time to begin treatment. Orthodontic patients can be a challenge when it comes to oral hygiene compliance. The Sonicare toothbrush is the toothbrush most recommended by orthodontists. An in vivo study done at the Harvard School of Medicine concluded that the Sonicare toothbrush is superior to a manual toothbrush in improving periodontal health in adolescent orthodontic patients. In addition, a significant decrease in subgingival gram-negative bacteria in the Sonicare group was observed. Some orthodontists are now including a Sonicare toothbrush as part of an oral hygiene packet that is given to patients at the beginning of treatment.

Beyond disease prevention

Approximately 65 percent of all child abuse has some type of head or neck injury. Therefore, it is likely that a dental professional may be one of the first people to recognize an abused child. By state law, dentists in every state are required to report suspected cases of child abuse. P.A.N.D.A. (Prevent Abuse and Neglect through Dental Awareness) is a coalition that provides educational programs to the dental team to improve recognition of child maltreatment. According to P.A.N.D.A., some of the signs of child abuse include unexplained bruises and welts on the face, lips and mouth, bruises in various stages of healing, unexplained lacerations or abrasions to the mouth, lips, gingiva and eyes, torn frenula, fractured teeth, neglected oral disease, constant hunger, poor hygiene, and oral signs of sexually transmitted disease. If abuse is suspected, P.A.N.D.A. recommends obtaining more than one health history, one from the child and one separately from the adult. Carefully document any suspected findings in the patient’s chart, have another individual witness the exam, note and cosign the records, then call the appropriate child protective services in the area. Reporting child abuse and neglect may prevent a child from continued abuse or even save a child’s life.


Treating the pediatric patient can be challenging, but the office visit offers many opportunities for the dental team to assist in the development of lifetime quality oral health. Dental professionals should take advantage of the opportunities that are presented to them before a child is born and as the child grows and develops. Early prevention and intervention are the keys to pediatric care. When a child enters the dental office, opportunities abound for the dental team.

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Linda Blackiston received her bachelor’s degree in Dental Hygiene from the Baltimore College of Dental Surgery, University of Maryland, Dental School. She has presented CE courses to numerous audiences on the etiology and management of periodontal diseases, specifically related to the host response mechanism.