Anticipatory Guidance

Dental Caries

 The "silent epidemic” of dental and oral diseases...restricts activities in school, work, and home, and often significantly diminishes the quality of life.

Those who suffer the worst oral health are found among the poor of all ages, with poor children and poor older Americans particularly vulnerable. Members of racial and ethnic minority groups also experience a disproportionate level of oral health problems.

Individuals who are medically compromised or who have disabilities are at greater risk for oral diseases, and, in turn, oral diseases further jeopardize their health.

Oral Health in America: A Report of the Surgeon General, 2000


  • Early childhood caries (cavities) is the number 1 chronic disease affecting young children.
  • Early childhood caries are 5 times more common than asthma and 7 times more common than hay fever.
  • An estimated 24-28% of 2-5 year olds have at least one cavity


  • Prevalence rates of dental carries vary by ethnicity as well as socioeconomic status with low income and African American and Hispanic children having higher rates of caries at all ages, compared with white non-Hispanic children
  •  An estimated 51 million school hours a year are lost in the US because of dental-related illness.
  • As a result, this places a significant burden on society in the form of lost days and years of productive work on part of the caregivers of these children
  • Early tooth loss due to dental decay can result in failure to thrive, impaired speech development, absence from and inability to concentrate in school, and reduced self-esteem.
  • Poor oral health has been related to decreased school performance, poor social relationships and less
    success later in life.


National Center for Dental and Craniofacial Research Statistics on Dental Caries- Click Here



  • Bacteria on the teeth, such as Steptococcus mutans (S. mutans) ferments dietary sucrose which in turn produces acids that promote demineralization & eventually tooth decay.
  • S. mutans is also able to produce glycans from sucrose.  Glycans are adhesive polymers that enable the bacteria to stick to the tooth surface causing further decay in the underlying structures.

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Most Common Pediatric Risk Factors

  • Prolonged bottle feeding or bedtime feeding
  • Snacking  (NYTimes article on Dental Caries in PreSchoolers - click here)
  • Low socioeconomic class
  • Increased consumption of sugared beverages
  • Children with special health care needs
  • Gastroesophageal reflux disease
  • Passive smoke exposure
  • Water supplies with limited or no fluoridation

Symptoms and Diagnosis

The most common symptom is tooth pain or sensitivity to temperature extremes, but the child could be asymptomatic or present with visible damage to the teeth.

Significant carries can present with further damage such as:

  • Abscess formation (periapical, alveolar or periodontal)
  • Periodontal disease (gingivitis and periodontitis)
  • Headache or facial pain
  • Suppurative odontogenic infections

Diagnosis is usually made by visual inspection looking for white spots, pitted enamel, stains, fractured or crumbling teeth as well as the overall state of the gingiva and oral mucosa.  Dentists will use other methods such as tactile inspection and x-rays to confirm and localize the extent of involvement.



Preformed metal crowns are preferred over fillings in children due to a lower failure rate and less pain. Partial removal of caries is preferable to complete removal in deep lesions due to preservation of the pulp. A root canal, involving removal of the center of the tooth, nerve, and blood vessel, may be necessary if the tooth has completely decayed. There is insufficient evidence to suggest which fillings are best in primary teeth.

Unfortunately, many of these treatments can be quite frightening to the pediatric patient. Depending on the extent of involvement and work needed, some children need varying levels of pain control and/or sedation to allow the treatment to be performed.  This carries an additional level of risk, but is warranted if the risk of not performing the procedure is worse than the assumed risk.

Subacute Bacterial Endocarditis (SBE) Prophylaxis

Note, childern with certain types of cardiac abnormalities and prosthetic heart valves may require antibiotic prophylaxis prior to dental cleanings in order to prevent SBE.

CLICK HERE to view a summary statment from the American Heart Association's (AHA) 2007 revised indications for prophylaxis, and when in doubt, contact the child's cardiologist to see if it is required.

Once a child is determined to need SBE prophylaxis for procedures such as dental cleaning, parental education is key.  The AHA has provided a wallet card that providers can print out and give to families to remind them of this very important need.  CLICK BELOW on the wallet card below to link to their website resources.

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Prognosis is generally good if the caries are caught early, so close attention to dental health is necessary from birth. Caries in both primary and secondary teeth can cause serious damage to underlying tooth structures if the lesions are not caught early. 



  • From birth, gums should be wiped with a soft, damp cloth after each feeding.
  • Parents should be advised not to let children go to bed with bottles containing anything besides water.
  • Saliva sharing behaviors, like wiping baby’s mouth with saliva or cleaning a pacifier orally, should be avoided.

Older infants/children

  • When teeth come in, they should be brushed twice daily (by the parents initially) with a soft children's toothbrush.
  • A pea-sized amount of fluoride toothpaste (or the size of the child’s pinky nail) should be used.
  • Fluoridated water should be used for mixing formula and for routine drinking, as other sources such as bottled water, "Nursery Water", and filtered water may have may sub-optimal and variable levels.  
    • Additional amouts of flouride may be required depending on the level of fluoride in the drinking water.

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  • Families can ask their local water utility how much fluoride is contained in their drinking water supply, or for residents of Chicago, information may be obtained by CLICKING BELOW:


  • Fluoride varnishes applied every 4 to 6 months between the ages of 6 months and 5 years can reduce tooth decay in primary teeth by 30 to 60% in studies.

Fluoride application to the teeth takes less than a minute and involves painting on a yellowish resin onto the teeth.  Note, the color fades within approximately  1 day.

  • Fluorinated toothpaste should be used, but the addition of another form of topical fluoride has been shown to be helpful. These include mouthwash, gel, or varnishes, each of which work equally well.

The Dental Home

For all children, the AAP recommends establishing a dental home. CLICK HERE  to read the AAP Policy Statement on Oral Health Risk Assessment and the Dental Home. The early establishment dental home helps ensure coordinated care between pediatricians and pediatric dentists.

Oral health risk assessments should begin by age 6 months for all children, with particular focus on high risk infants, with aggressive anticipatory guidance and intervention programs. A dentist should be established within 6 months of the first tooth erupting, or by 1 year, whichever comes first.


CLICK BELOW for additional information on pediatric oral health:


AAP website with links to education, training, practice tools as well as family resources and infromation on local oral health sections and resources.

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Local educational program by the AAP Illinois Chapter to provide physician, dental and family resources on oral health as well as how to incorporate it into health visits.


CDC website with information for families & providers on prevention & promotion of oral health.


American Academy of Pediatric Dentristy website with links on resources for parents & providers.


  1. Hale KJ; American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003 May;111(5 Pt 1):1113-6. PubMed PMID: 12728101.
  2. Khadra-Eid J, Baudet D, Fourny M, Sellier E, Brun C, François P. [Development of a screening scale for children at risk of baby bottle tooth decay]. Arch Pediatr. 2012 Mar;19(3):235-41. doi: 10.1016/j.arcped.2011.12.022. Epub 2012 Feb 3. French. PubMed PMID: 22305088.
  3. Mouradian WE, Slayton RL, Maas WR, Kleinman DV, Slavkin H, DePaola D, Evans C Jr, Wilentz J. Progress in children's oral health since the Surgeon General's Report on Oral Health. Acad Pediatr. 2009 Nov-Dec;9(6):374-9. doi: 10.1016/j.acap.2009.09.023. PubMed PMID: 19945070.
  4. Palmer C, Wolfe SH; American Dietetic Association. Position of the American Dietetic Association: the impact of fluoride on health. J Am Diet Assoc. 2005 Oct;105(10):1620-8. PubMed PMID: 16183366.
  5. Edelstein, B. Racial and Income Disparities in Pediatric Oral Health. Children's Dental Health Project. 1998. Washington, DC: Children's Dental Health Project, 7 pp.
  6. Gift HC. 1997. Oral Health Outcomes Research: Challenges and Opportunities. In Slade GD, ed., Measuring Oral Health and Quality of Life (pp. 25-46). Chapel Hill, NC: Department of Dental Ecology, University of North Carolina.
  7. Office of Disease Prevention and Health Promotion. 2000. Healthy People 2010. In Office of Disease Prevention and Health Promotion [Web site]. Cited January 15, 2001; available at
  8. U.S. General Accounting Office. 2000. Oral Health: Dental Disease is a Chronic Problem Among Low-Income and Vulnerable Populations. Washington, DC: U.S. General Accounting Office.
  9. MMWR Recommendations for Using Fluoride to Provent and Control Dental Caries in the United States, August 17, 2001, Vol 50
  10. U.S. Preventive Health Services Task Force, Physicians’ Roles in Preventing Dental Caries in Preschool Children: Summary of the Evidence (2004).
  11. Marinho, V., et al. One topical fluoride (toothpastes, or mouth rinses, or gels, or varnishes) versus another for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2004;(1):CD002780.
  12. Marinho, V. Substantial caries-inhibiting effect of fluoride varnish suggested. Evid Based Dent. 2006;7(1):9-10.
  13. Seppa, L., et al. Fluoride varnish versus acidulated phosphate fluoride gel: A 3 year clinical trial .Caries Res. 1995;29(5):327-30.
  14. Ismail, A.I. Prevention of early childhood caries. Community Dent Oral Epidemiol. 1998;26(1 Suppl):49-61. Review