Optimizing Infant and Toddler Oral Health The Importance of Early Intervention

Dentistry Today


What is the appropriate age for a child’s first dental visit? Parents attempting to make an initial visit for their child would probably receive different responses if they called a number of dental offices to ask that question. Traditionally, age 3 was thought to be the proper age. Some dentists may suggest that the first visit occur even later, perhaps when the child will not be a management problem. However, if the goal is to prevent disease rather than treat the result of disease, early intervention is needed.
During the last several decades, remarkable progress has been made in improving the oral health of children. However, many children still suffer from dental caries and periodontal disease, and malocclusion remains a common problem. Dental caries is the single most common chronic childhood disease, with an incidence 5 times that of asthma and 7 times that of common hay fever.1 More than half of 5 to 9yearold children have at least one carious lesion or restoration.1 The social impact of oral diseases in children is significant. Pain due to untreated disease can lead to problems in eating, speaking and attending to learning.2

•Isolate area with cotton rolls or gauze sponges. Usually one quadrant can be
treated at a time, but this may vary.
•Apply a thin layer of varnish to all surfaces of the teeth. A cotton applicator
or disposable brush may be used. Avoid getting varnish on soft tissue.
•Fluoride varnish will set quickly in the presence of moisture.
•Post-application instructions*:

-Advise parents that any change in tooth color is temporary. (Varnish will set as a yellowish coating that might last till the next day.)
-Patient should avoid eating for at least 1 hour and eat a soft, nonabrasive diet for the rest of the day.
-Parents should be instructed not to brush until the next morning

Fluoride varnishes commonly used in the United States include the following:
•Duraphat—Colgate-Palmolive Co.
•Duraflor—A.R. Medicom.
•CavityShield—Omnii Oral Pharmaceuticals.
•Fluor Protector—Ivoclar Vivadent, Inc.

*Be advised that individual manufacturer’s instructions will vary.

Figure 1. General protocol for application of fluoride varnish.

The American Academy of Pediatric Dentistry (AAPD) recommends that an initial oral evaluation visit should occur within 6 months of the eruption of the first primary tooth and no later than 12 months of age.3 The AAPD is not alone in recommending a dental visit before the child’s first birthday. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents4 is a document that was developed with support of the US Department of Health and Human Services Maternal and Child Health Bureau. It is based on an extensive review of scientific literature and best practices. It represents a consensus of more than 100 multidisciplinary experts and was reviewed by over 1,000 health professionals. This report has been supported by many organizations, including the American Medical Association and the American Academy of Pediatrics. These guidelines suggest that an appointment be made for the toddler’s first dental examination and risk assessment at 1 year of age. The purpose of this visit is to assess individual risk and to educate the parent in reducing such risk.

Performing a risk assessment offers the dentist the opportunity to tailor the frequency of the visits and oral health supervision to the individual’s level of risk for specific diseases and conditions. This assessment involves identifying both risk factors that might negatively impact a child’s oral health and factors that potentially will promote oral health for that child. This process allows the dentist to individualize intervention by focusing resources and education on specific components of oral health.5 Fluoride history, dietary habits, socioeconomic status, Streptococcus mutans (SM) counts, family oral health, and the clinical examination are areas that may be included in performing a risk assessment for dental caries in the infant and toddler. In this age group, dental caries is often referred to as early childhood caries (ECC), which has been defined as “the presence of one or more decayed (noncavitated or cavitated lesions), missing (because of caries), or filled tooth surfaces” in any primary tooth in a child 71 months of age or younger.6


Table 1. Dietary fluoride supplementation schedule (age and level of water fluoridation)
Patient Age
Less than 0.3 ppm fluoride
0.3 to 0.6 ppm fluoride Greater than 0.6 ppm fluoride
Birth to 6 months
6 months to 3 years
3 years to 6 years


6 years to at least 16 years
1 mg

Figure 2. The knee-to-knee position.

The systemic and topical use of fluoride is the most effective measure to prevent dental caries.7 The patient’s exposure to both systemic and topical fluoride must be evaluated. Over one third of the US population has no access to community water fluoridation.8 Water fluoride content should be evaluated if the fluoride content of the child’s drinking water is unknown. This can be accomplished by contacting the local public health officials, or if necessary, by analysis of a water sample. It is important to review all potential sources of drinking water, including home, day care and school. Recommendations for fluoride supplementation can then be made based on the fluoride content of the water, the child’s age, and the child’s caries risk. The dietary fluoride supplementation schedule is shown in Table 1 (p. 124). This dosage schedule was revised in 1994 and is approved by the American Dental Association, the American Academy of Pediatrics, and the American Academy of Pediatric Dentistry.

It is important to note that ingestion of higherthanrecommended levels of fluoride by children has been associated with an increase in mild dental fluorosis in unerupted developing teeth.9 Children may ingest fluoride from food, beverages other than water, and especially dentifrice. The use of a fluoridated toothpaste in children who cannot expectorate consistently carries an increased risk of fluorosis.10 Therefore, the risk of fluorosis must be weighed against the benefit of caries prevention when considering the use of a fluoridated dentifrice by a lowrisk child. Caregivers should be counseled on the frequency of tooth brushing and the use of no more than a small amount of fluoridecontaining toothpaste, roughly approximating the size of a pea.11
he use of fluoride varnish should be considered as a preventive adjunct in children identified at risk for early childhood caries. Clinical trials have confirmed the efficacy of 5% sodium fluoride in the reduction of dental caries in primary teeth.12,13 In Europe, fluoride varnish has been used for many years and has become the standard of care. In the United States, fluoride varnish is currently approved by the Food and Drug Administration (FDA) as a cavity liner and desensitizing agent, but is used “offlabel” as a topical fluoride treatment. Fluoride varnish is easy to use, generally well accepted by young patients, and carries less potential for ingestion of excessive fluoride. A general protocol for the use of fluoride varnish is outlined in Figure 1.

It is important to consider dietary habits of the infant or toddler when determining caries risk. Improper feeding practices in this age group can lead to baby bottle tooth decay (BBTD), a severe form of ECC. BBTD can result from a child going to bed with the bottle or drinking at will from the bottle during the day. AAPD guidelines state that infants should not be put to sleep with a bottle.14 The guidelines also recommend that if a child is breastfed at will, nocturnal breastfeeding should be avoided after the first primary tooth begins to erupt. In the event that an infant is using a bottle at night, it should contain only water. A cup should be introduced at about 6 months of age, and the child should be weaned from the bottle at about 12 months of age. Frequent consumption of any fermentable carbohydrate is a major dietary risk factor for ECC. Parents should limit the amount of snacks and beverages that are offered between meals.

According to the Surgeon General’s report on oral health, there are striking disparities in dental disease as related to income. Poor children suffer twice as much dental caries as children of higher socioeconomic status, and this disease is more likely to be untreated.2 Children ages 2 through 5 from families with low incomes are 5 times more likely to have untreated dental caries than children from families with higher incomes.15 Low socioeconomic status should be considered a significant risk factor for dental caries.

It is generally accepted that SM is the microorganism associated with ECC. Studies have shown that salivary levels of SM may be used to identify and to predict future caries in preschool children.16,17

A patient’s salivary SM level is easily obtainable and can offer useful information when determining risk for dental caries in the young child.

As previously mentioned, preschool children with high salivary levels of SM demonstrate higher caries prevalence and are at increased risk of new lesions than are those with low levels of SM. The most likely source of inoculation of an infant’s oral cavity is the primary caregiver, usually the mother.18 Children of mothers with a high caries rate are at greater risk of dental caries. Furthermore, reduction of the mother’s SM levels can significantly lower the child’s caries rate.19

Parents and caregivers should be educated about the infectious nature of dental caries. It is important to emphasize to mothers that their good oral health can help reduce the chances that their child will experience dental caries. To prevent the early colonization of SM, caregivers should also be educated about avoiding the sharing of utensils with their infants.20

The clinical examination is an essential part of the child’s first dental visit and is an important part of risk assessment. Dentists who lack experience in treating infants and toddlers are often concerned that the child will cry during the examination and that this will reflect poorly on their patient management skills. Crying during an examination is normal behavior for an infant, and parents are generally accustomed to seeing that behavior during visits to the pediatrician.

The clinical examination should be conducted efficiently and gently. If the child is hesitant, it is not necessary for the very young patient to sit in the dental chair. The dentist and caregiver should sit kneetoknee facing each other. The child’s legs should be placed around the caregiver’s waist, and the child’s head placed in the cradle formed by the dentist’s and caregiver’s knees. In this position (Figure 2), the caregiver can help support the child, and the dentist can gain excellent access to the oral cavity. If necessary, prophylaxis and application of fluoride varnish also can be performed in this position. Older children can be seen in the dental chair either alone or sitting in the caregiver’s lap, depending on their level of cooperation and the dentist’s preference. A dialogue with the caregiver should generally take place before and/or after the examination, because the caregiver is likely to focus on the child during the examination and might not give full attention to the dentist.
During the examination, special attention should be given to identifying plaque accumulations and white spot incipient carious lesions. Visible plaque on primary teeth has been shown to be a risk factor for caries.21 If visible plaque is detected on the infant’s teeth, it should be revealed to the parents, and oral hygiene instructions should be reinforced. Whitespot lesions represent the early clinical manifestation of the caries process. These white spots become apparent on enamel surfaces before cavitation occurs. They represent decalcified enamel and are most often detected close to the gingival margin. If these white spots are detected, the patient should be considered at high risk for future caries.22 
Anticipatory guidance is another element that should be incorporated into the child’s dental visit. Anticipatory guidance refers to sharing with the parents or caregivers information about the child’s current oral health status as well as preparing them for what to expect as their child grows. This guidance should be modified based on the child’s risk assessment and should be provided throughout childhood and adolescence. Fluoride status, diet, and oral hygiene should be addressed when providing anticipatory guidance to the parent of an infant or toddler. Topics not directly related to dental caries should also be discussed. The dentist should review dental eruption patterns as well as facts and myths regarding the teething process. When needed, pacifier use and safety, and digit habits should also be addressed.
If ECC does develop and is allowed to progress, it can dramatically affect the quality of life of the patient and his or her family. It is estimated that 51 million school hours are lost each year because of dental related illness.23 Children with severe ECC weigh significantly less than their peers.24 The financial costs of this disease also can be great. The average Medicaid cost for providing restorative dental care for early childhood caries under general anesthesia is $2,000 per case.25 The effects of ECC can be longlasting because children experiencing caries as infants and toddlers have a much greater probability of subsequent caries in both the primary and permanent dentitions.26

As healthcare professionals, our ultimate goal should be preventing disease whenever possible, and in patients where disease has begun, we should aim to minimize its effects. To prevent dental caries in children, we must identify those most at risk, educate parents, and focus aggressive preventive strategies on those children most in need. To effectively take these steps and to ensure optimal oral health for our nation’s children, dental practitioners must be willing to embrace the philosophy of the yearone dental visit.


  1. Third National Health and Nutrition Examination Survey (NHANES III). Hyattsville, Md: National Center for Health Statistics, US Dept of Health and Human Services; 1996.
  2. Oral Health in America: A Report of the Surgeon General. Rockville, Md: National Institute of Dental Research, US Dept of Health and Human Services; 2000.
  3. American Academy of Pediatric Dentistry. Guideline on infant oral health care. Pediatr Dent. 2002;24(special issue):47.
  4. Green M, Palfrey JS, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health; 1994.
  5. Casamassimo P. Bright Futures in Practice: Oral Health. Arlington, Va: National Center for Education in Maternal and Child Health; 1996.
  6. Drury TF, Horowitz AM, Ismail AI, et al. Diagnosing and reporting early childhood caries for research purposes. A report of a workshop sponsored by the National Institute of Dental and Craniofacial Research, the Health Resources and Services Administration, and the Health Care Financing Administration. J Public Health Dent. 1999;59:192197.
  7. Nowak AJ. Rationale for the timing of the first oral evaluation. Pediatr Dent. 1997;19:811.
  8. Fluoridation census, 1992. Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, US Dept of Health and Human Services; 1993.
  9. Lalumandier J, Rozier G. The prevalence and risk factors of fluorosis among patients in a pediatric dental practice. Pediatr Dent. 1995;17:1925.
  10. Pang DT, Vann WF Jr. The use of fluoridecontaining toothpastes in young children: the scientific evidence for recommending a small quantity. Pediatr Dent. 1992;14:384387.
  11. American Academy of Pediatric Dentistry. Guideline on fluoride therapy. Pediatr Dent. 2002;24(special issue):6667.
  12. Seppa L, Leppanen T, Hausen H. Fluoride varnish versus acidulated phosphate fluoride gel: a 3year clinical trial. Caries Res. 1995;29:327330.
  13. Weinstein P, Domoto P, Wohlers K, et al. MexicanAmerican parents with children at risk for baby bottle tooth decay: pilot study at a migrant farmworkers clinic. ASDC J Dent Child. 1992;59:376383.
  14. American Academy of Pediatric Dentistry. Policy on baby bottle tooth decay (BBTD)/early childhood caries (ECC). Pediatr Dent. 2002;24(special issue):23.
  15. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 19881994. J Am Dent Assoc. 1998;129:12291238.
  16. O’Sullivan DM, Thibodeau EA. Caries experience and mutans streptococci as indicators of caries incidence. Pediatr Dent. 1996;18:371374.
  17. Thibodeau EA, O’Sullivan DM. Salivary mutans streptococci and dental caries patterns in preschool children. Community Dent Oral Epidemiol. 1996;24:164168.
  18. Li Y, Caufield PW. The fidelity of initial acquisition of mutans streptococci by infants from their mothers. J Dent Res. 1995;74:681685.
  19. Kohler B, Andreen I, Jonsson B. The effect of cariespreventive measures in mothers on dental caries and the oral presence of the bacteria Streptococcus mutans and lactobacilli in their children. Arch Oral Biol. 1984;29:879883.
  20. Hale KJ, American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003;111:11131116.
  21. Alaluusua S, Malmivirta R. Early plaque accumulation: a sign for caries risk in young children. Community Dent Oral Epidemiol. 1994;22:273276.
  22. Tinanoff N, Kanellis MJ, Vargas CM. Current understanding of the epidemiology, mechanisms, and prevention of dental caries in preschool children. Pediatr Dent. 2002;24:543551.
  23. Gift HC. Oral health outcomes research: challenges and opportunities. In: Slade GD, ed. Measuring Oral Health and Quality of Life. Chapel Hill, NC: Department of Dental Ecology, University of North Carolina; 1997:2546.
  24. Acs G, Shulman R, Ng MW, et al. The effect of dental rehabilitation on the body weight of children with early childhood caries. Pediatr Dent. 1999;21:109113.
  25. Kanellis MJ, Damiano PC, Momany ET. Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia. J Public Health Dent. 2000;60:2832.
  26. Proceedings of the Conference on Early Childhood Caries. Bethesda, Maryland, USA. October 1997. Community Dent Oral Epidemiol. 1998;26(suppl):1119.

Dr. Chussid is currently director of the division of pediatric dentistry and associate professor of clinical dentistry at Columbia University School of Dental and Oral Surgery. He is also presently the chief of the dental service at Blythedale Children’s Hospital. He is a graduate of the University of Buffalo School of Dental Medicine and received his certificate in pediatric dentistry from Children’s Hospital of Buffalo. He has been on the faculty at New York University and the Albert Einstein College of Medicine and has served as program director and director of the division of pediatric dentistry at Montefiore Medical Center in New York. He can be reached at (212) 3051040.