Oral Hygiene

Over the past few decades, the oral health of infants and children has improved significantly.1 However, there are segments of the population where this improvement is not seen, and children continue to suffer with pain and discomfort from untreated dental disease. The sight of an 18- to 24-month-old child presenting for the first dental visit with multiple carious lesions on several teeth is not an uncommon site in many pediatric dental practices. In 1989 the American Academy of Pediatric Dentistry (AAPD) published the recommendation that infants should be seen by a dental professional no later than the age of 12 months or at least 6 months after the eruption of the first primary tooth.2 The recommendations were reviewed in 1994 and revised in 2001. The current guidelines are provided in the Table.3 Although these guidelines have been available for more than a decade, the dental and medical communities, as well as the general population, have not fully appreciated the importance of infant oral health as it relates to the general health of the child. Studies have shown that systemic health and oral health are closely related.4

Table. Guidelines for Infants’ First Dental Visit

1. Infant oral healthcare begins ideally with prenatal oral health counseling for parents. 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.

2. At the infant oral evaluation visit, the dentist should:

  • Record a thorough medical and dental history, covering the prenatal, perinatal, and postnatal periods.
  • Complete a thorough oral examination.
  • Assess the patient’s risk of developing oral and dental disease, and determine an appropriate prevention plan and interval for periodic reevaluation based on that assessment.
  • Discuss and provide anticipatory guidance regarding dental and oral development, fluoride status, non-nutritive oral habits, injury prevention, oral hygiene, and effects of diet on the dentition.

3. Dentists who perform such services for infants should be prepared to provide therapy when indicated, or should refer the patient to an appropriately trained individual for necessary treatment.

Unfortunately, many parents hold on to fears and myths that have been prevalent for years. When visible signs of decay are evident on anterior teeth, some parents avoid seeking treatment until their child experiences pain. Dentists are confronted daily with sayings like, “The child’s baby teeth are going to fall out anyway. So, why should they be fixed?” Another refrain that is commonly heard is, “My mother never took me to the dentist this young.” And finally, “My baby is too young to sit still for the dentist. What can be done at this age?”

The goal of the dental and medical professionals who treat children is to prevent the onset of dental disease. If prevention is not possible, early intervention becomes the next goal. Because education appears to be the missing item in the discussion of infant oral healthcare, this article explores the connection between risk factors, prevention, and intervention for the oral health of infants.


The first dental examination is particularly important to:

(1) determine the risk status of the infant based on information obtained from the parents and to perform a screening examination of infants’ mouths5,6

(2) assess fluoride needs5,6

(3) assess transmission of Streptococcus mutans5,6

(4) assess diet

(5) assess risk factors3

(6) teach proper care for the child’s teeth

(7) provide guidance for injury prevention3 and

(8) prepare to provide preventive, interceptive, or restorative services, or refer the patient to an appropriately trained individual for necessary treatment.3

Examination of the infant 6 months after the first tooth erupts and no later than 12 months of age allows the dentist to intervene before oral health is compromised by poor oral hygiene or improper feeding habits. Also, once the teeth begin to erupt, the mouth becomes colonized by S mutans. The acquisition of the bacteria can be from siblings or the child’s mother.1 Therefore, infants should receive early intervention, before the established window of infectivity, and parents should be given appropriate recommendations concerning oral healthcare for their infants. Many family physicians and pediatricians are recommending the first dental visit at 24 months despite the current AAPD recommendations. Therefore, it is imperative that a consensus be reached on the guidelines for pediatric preventive dental care.1


The following are risk factors for dental caries in infants1:

(1) mothers with poor dental health

(2) mothers with limited education

(3) poor prenatal nutrition

(4) maternal illness during pregnancy

(5) poor feeding habits:

  • baby bottles that are used to put a child to sleep (Figure 1)
  • sugared soft drink and fruit drink snacks
  • continuous use of sippy cups (vessels with bill-shaped extensions)7

(6) shape of the teeth, including cusp and groove anatomy

(7) poor oral hygiene.

Because of the fact that the AAPD recognizes that caries risk assessment is an essential element of contemporary clinical care for infants, children, and adolescents, the Council on Clinical Affairs has developed a policy statement on the use of a Caries Risk Assessment Tool (CAT).8 This CAT has been developed as a first step to assist both dental and non-dental healthcare providers in assessing levels of risk for caries development. The CAT:

(1) provides an assessment at a point in time.

(2) is intended to be used when clinical guidelines call for caries-risk assessment.

(3) allows the assessor to obtain reliable clinical, environmental, and general health information.

(4) cannot provide a diagnosis.

(5) can be used by clinicians with various levels of experience.

Figure 1. Baby bottle caries.
Figures 2 and 3. Early childhood caries.


The type of decay that occurs soon after eruption of the primary teeth has been defined as early childhood caries (ECC) (Figures 2 and 3). It is defined as the presence of one or more decayed surfaces in a primary tooth in children under 3 years of age. This disease process progresses much more rapidly than caries in older children or adults. If decay appears in a child younger than 3 years, it is termed severe early childhood caries (S-ECC) or baby bottle tooth decay (BBTD).9

ECC is a lifestyle disease with biologic, behavioral, and social determinants.10 For the above reasons, prevention must take a multifocused approach. Early screening leads to early detection of risk factors and risk indicators that may increase the possibility of prevention. Therefore, preventive care must be coordinated with definitive operative treatment.10

Prevention can be viewed on three levels. Each of these levels should be of concern to medical and dental professionals. The primary level (prepathogenesis) should be managed by the pediatrician and nurse practitioners. The secondary level (early pathogenesis) is initially identified by the pediatrician or the nurse practitioner, and then referred to the dental professional for prompt treatment to prevent the progression of disease. The tertiary level (advanced pathogenesis) is strictly managed by the dental professional for complete rehabilitation with the objective of limiting disabilities, ie, loss of teeth.11

Because mothers are in constant contact with nurses and physicians during the early part of the child’s life, nurses can help promote good oral health for children by educating and training expectant and new mothers in preventing ECC or BBTD.


There is strong evidence that the frequency of intake of sugar-containing substances increases the likelihood of developing caries. However, a direct relationship does not exist because caries formation is multifactorial. Diets that contain sugary foods, soft drinks, and fruit juices are most likely to promote caries.12 Saliva cannot buffer acid after the pH drops below 5.5. It is at this point that the process of demineralization begins. If sustained intake of carbohydrates continues, the surface enamel eventually develops a chalky texture known as a “white spot lesion.” At this stage, if plaque removal and topical fluoride is encouraged, the tooth will experience remineralization. However, demineralization and cavitation will result without intervention.5,6

The frequency of food ingestion is an important factor in caries development, and it has been recommended that the number of snacks consumed each day be minimized.13 Griffen and Goepferd14 state the same warning but add that prevention is most effective when begun early.

Malnutrition in the United States should be ruled out as a causative factor. In the United States chronic malnutrition is rare. However, unbalanced nutrition is more common.13 Because ECC has a strong link to diet, the next logical step is to investigate diet modification. How should the diet and eating patterns of children be modified to prevent and limit the occurrence of dental caries? The following outline has been proposed13:

(1) Maintain optimal levels of the micronutrient fluoride in community water levels.

(2) Follow the “Dietary Guidelines for Americans,” published in Nutrition and Your Health (February 1980) by the US Department of Agriculture and the US Department of Health and Human Services.

(3) Limit the frequency of fermentable carbohydrate intake and the consumption of snacks containing fermentable carbohydrates.

(4) Limit the duration of time the teeth are exposed to retentive foods.

(5) Rinse with water after eating when it is not possible to brush and floss.

The question that usually follows is, “What is an appropriate snack?” Fruits are offered as an alternative to high carbohydrate, sugary substances. Fruits contain sugars, but the capacity of many fruits to promote saliva flow probably reduces their cariogenic potential.12


After brushing, there is more visible plaque on the teeth of children who brush alone compared to those children whose teeth are cleansed by their parents.15 For that reason, it has long been recommended that parents brush their children’s teeth until the child is 7 to 9 years of age. During this period, if the parent brushes at night then the child can be allowed to brush in the morning and at other times of day. Parents should allow the child to watch them brush their own teeth, thereby teaching the child to brush properly.

There are several environmental factors that are associated with improper toothbrushing behavior16:

(1) low appreciation of the benefits of oral hygiene on the part of rural populations because of lack of oral hygiene instructions and education

(2) lack of support for young mothers—personal dental care support and support with the child’s dental healthcare

(3) inadequate counseling of expectant parents

(4) insufficient involvement of the health provider in the formation of oral health habits.

Drinks highly supplemented with sugars, eg, certain fruit juices, should only be provided with meals. They should not be given in a bottle or at bedtimes.17 Drinks that have a high sugar content and therefore can be fermented by oral bacteria will lead to demineralization of the teeth. Therefore, the amount of calcium and phosphorus that is removed from the teeth can provide an indication of the drink’s erosiveness rather than cariogenicity. The importance of the acids in infant fruit drinks outweighs the dissolving effects of microbial fermentation. (As previously stated, saliva cannot buffer acid after the pH drops below 5.5.) However, the acidity and demineralization potential of infant fruit drinks are generally less than those of adult drinks.18


Prenatal counseling can improve oral health of both the mother and the child. Maternal diet, self-care, and lifestyle can affect the offspring’s oral health. Casamassimo19 found that pregnant mothers were unclear about the relationship of diet and dental caries as well as the relationship between fluoride levels in the water and fluoride supplements. Because of fears of dental treatment during pregnancy, most mothers did not receive dental care during this time. One half of those mothers who were aware of acute dental needs still refused to seek treatment.20

Dentists are soliciting the help of obstetricians, nurses, and pediatricians to inform pregnant mothers of the effect that medications and illnesses may have on the child’s teeth, ie, tetracycline, excessive iron intake in infancy, illnesses associated with high fever during developmental stages that can lead to hypoplasia, smoking, alcohol, and radiation.11

Obstetricians and nurses should continue to analyze the diet of the pregnant mother to determine if the proper amount of calcium, phosphorous, and vitamins A, C, and D are being ingested. Calcium and phosphorous are major mineral components of teeth. Vitamins C and D aid in the absorption and deposition of calcium and phosphorous. Vitamin A is required for the differentiation and maintenance of the cells that form enamel and dentin. Both vitamins A and C are needed for healthy gingival tissues.11


Because of the willingness to treat children between the ages of 6 months and 12 months, pediatric dentists are in a position to counsel parents on diet, pit and fissure caries in toddlers, fluoride in water levels, and appropriate feeding and dietary recommendations. By beginning before the onset of disease, parents can be advised about how to rear children who are caries-free.21


Prevention of transmission of maternal oral microflora and use of fluorides are important in a baby’s oral health early in life.19 Many new mothers have a superficial knowledge of infant dental health, and demonstrate inadequate brushing behavior for their children.22 Brown23 determined that dental health education of new mothers met with only limited success in changing attitudes, and achieved only short-term gains in knowledge of dental issues. However, Gomez and co-workers24 concluded that information regarding preventive dentistry that was given to pregnant mothers, and then continued until the children were 5 to 6 years of age, showed significant long-term benefits in reduction of dental caries in these children.


Intervention first requires information. Answers to important questions must be obtained from the parent, including:

(1) Does your child need a bottle or something to drink to go to sleep?

(2) Does your child get up in the middle of the night? If so, do you give them something to drink? What do you give them to drink? If not, does your child have a cup beside their bed? (Can they drink or eat at will throughout the night?)

(3) How many snacks does your child eat each day? (Stress that juice alone is counted as a snack.)

(4) Does your child have a sippy cup that they drink from at will throughout the day?

(5) Who brushes your child’s teeth and when?

(6) Do you give your child something to eat or drink after you finish brushing at night?

(7) Does your child have a regular bedtime?

(8) Have you ever looked closely at all of your child’s teeth (front and back of anterior teeth as well as posterior teeth).

(10) Is your city’s drinking water fluoridated?

(11) Has your child ever fallen and hit the front teeth? Did you take him to a dentist?

(12) For how long do you think you should brush your child’s teeth?

(13) Is your child taking medications for a chronic condition?

(14) Does your child vomit/regurgitate often?


The most cost-effective way to reduce caries on the smooth surfaces of teeth is fluoride. Fluoride incorporates into the tooth in two different ways. It can be absorbed into the bloodstream and incorporated into developing teeth via the systemic circulation. Or, it can be absorbed directly into the enamel through topical application.10

Therefore, water fluoridation continues to be the most cost-effective preventive measure. Supplemental fluoride is available for those patients who do not have access to fluoridated water.14 Recently, bottled water companies have added fluoride to their products. The use of topical fluoride products (dentifrices, gels, and rinses with fluoride) at home and professionally will significantly reduce caries on the smooth surfaces of the teeth.14


The pits and fissures are the most common place for caries in children. The pits and fissures are protected by sealants as well as preventive resin restorations in which tooth preparation exposes the depths of the fissures to eliminate potential traps for bacteria.14


The objectives of restorative treatment are to prevent or limit the damage from dental caries, protect and preserve the remaining tooth structure, reestablish adequate function, restore aesthetics (where applicable), and provide ease in maintaining good oral hygiene. Pulp vitality should be maintained whenever possible.25 Dentists who perform such services for infants should be prepared to provide therapy when indicated, or should refer the patient to an appropriately trained individual for necessary treatment.3


If early intervention becomes the rule for dental disease, the dental and medical professions, working in concert, will further reduce the oral disease burden for future generations.21

Dentists have a responsibility to encourage physicians to identify abnormalities in the oral cavity that might be attributable to disease or be a compromising factor in the health, growth and development, or functioning of children. Physicians should be encouraged to make referrals. Overall good health for children depends upon a close cooperation between dentists and physicians.4

Furthermore, greater attention should be paid to the oral health needs of pregnant women. This responsibility should be shared and coordinated between the dental and obstetric communities. Guidelines are needed that would benefit both maternal oral health and the future dental health of the child.20


1. Sanchez OM, Childers NK. Anticipatory guidance in infant oral health: rationale and recommendations. American Fam Physician. 2000;61:115-120,123-124.

2. Clinical Guideline on Infant Oral Health Care. American Academy of Pediatric Dentistry. Pediatr Dent. 1989-1990.

3. Clinical Guideline on Infant Oral Health Care. American Academy of Pediatric Dentistry. Pediatr Dent. 2001-2002;23:31.

4. Casamassimo PS. Relationships between oral and systemic health. Pediatr Clin North Am. 2000;47:1149-1157.

5. Nowak AJ, Warren JJ. Infant oral health and oral habits. Pediatr Clin North Am. 2000;47:1043-1066,vi.

6. Vogel LD, Cerda SP. Parental education and infant health. NY State Dent J. 1999;65:24-25.

7. Behrendt A, Szlegoleit F, Muler-Lessmann V, et al. Nursing: bottlesyndrome caused by prolonged drinking from vessels with bill-shaped extensions. ASDC J Dent Child. 2001;68:47-54.

8. Policy Statement on the Use of a Caries-Risk Assessment Tool. American Academy of Pediatric Dentistry. Annual Report 2002: 143-149.

9. Clinical Guideline on Baby Bottle Tooth Decay/Early Childhood Caries/Breastfeeding/Early Childhood Caries: Unique Challenges and Treatment Options. Pediatr Dent. 2001-2002;23:29-30.

10. Twetman S, Garcia-Gogoy F, Goepferd SJ. Infant oral health. Dent Clin North Am. 2000;44:487-505.

11. Charonko CV, DeBiase CB. Dental health for children: an adult responsibility. J Pract Nurs. 1984;34:44-54.

12. Burt BA, Eklund SA, Landis R, et al. Diet and dental health, a study of relationships: United States. 1971-1974. Vital Health Stat II. 1982;11:1-85.

13. Burt BA. Diet nutrition, and oral health: a rational approach for the dental practice. J Am Dent Assoc. 1984;109:20-32.

14. Griffen AL, Goepferd SJ. Preventive oral health care for the infant, child, and adolescent. Pediatr Clin North Am. 1991 Oct;38(5):1209-1226.

15. Habibian M, Roberts G, Lawson M, et al. Dietary habits and dental health over the first 18 months of life. Community Dent Oral Epidemiol. 2001;29:239-246.

16. Paunio P, Rautava P, Helenius H, et al. Children’s poor toothbrushing behavior and mothers’ assessment of dental health education at well-baby clinics. Acta Odontol Scand. 1994;52:36-42.

17. Holt RD, Moynihan PJ. The weaning diet and dental health. Br Dent J. 1996;181:254-259.

18. Grenby TH, Mistry M, Desai T. Potential dental effects of infants’ fruit drinks studied in vitro. Br J Nutr. 1990;64:273-283.

19. Casamassimo PS. Maternal oral health. Dent Clin North Am. 2001;45:469-478, v-vi.

20. Gaffield ML, Gilbert BJ, Malvitz DM, et al. Oral health during pregnancy: an analysis of information collected by the pregnancy risk assessment monitoring system. J Am Dent Assoc. 2001;132:1009-1016.

21. Goepferd SJ. Infant oral health: a rationale. ASDC J Dent Child. 1986;53:257-260.

22. Blinkhorn AS, Wainwritght-Stringer YM, Holloway PJ. Dental health knowledge and attitudes of regularly attending mothers of high-risk, pre-school children. Int Dent J. 2001;51:435-438.

23. Brown LF. Research in dental health education and health promotion: a review of the literature. Health Educ Q. 1994;21:83-102.

24. Gomez SS, Weber AA, Emilson C-G. A prospective study of a caries prevention program in pregnant women and their children 5 and 6 years of age. ASDC J Dent Child. 2001;68:191-195

25. Clinical Guideline on Pediatric Restorative Dentistry. American Academy of Pediatric Dentistry. Pediatr Dent. 2001-2002;23:56-57.


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