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pediatric dentistry.

  1. 1. Contents General Information in Pediatric Dentistry.....3 Fluoride........................................................ 3 Public Health Dentistry................................. 4 Restorative Materials..................................... 5 New Trends in Pediatric Dentistry.................6 Oral Pathology.............................................. 6 Special Needs Children..................................6 Child Abuse and Neglect...............................8 Age-Specific Information: P EDIATRIC DENTISTRY IS AN AGE-DEFINED SPECIALTY that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with Birth to Three Years, Three to Six Years, Six to 12 Years, and Adolescence...................... 8 special health care needs.”1 Today, Birth to Three Years.......................................8 pediatric dentistry is prevention Growth and Development......................... 8 oriented. Many changes have evolved Examination..............................................9 Fluoride...................................................10 since the years when dental care for Early Childhood Caries............................10 children was predominately secondary Home Oral Health Care...........................11 Nonnutritive Sucking.............................. 11 and tertiary care. The dental hygienist Three to Six Years........................................12 is a valuable resource in promoting, Dental Disease......................................... 12 Examination............................................ 12 establishing, and maintaining oral Behavior Management............................. 12 health in infants, children, and Fluoride.................................................. 13 Radiology................................................ 14 adolescents. Home Oral Health Care.......................... 14 This brief overview of pediatric Nonnutritive Sucking.............................. 14 Six to 12 Years............................................. 15 dentistry is in two parts. The first part Oral Diseases........................................... 15 contains information about pertinent Examination............................................ 15 Fluoride...................................................16 topics in pediatric dentistry that are Home Oral Health Care.......................... 16 not necessarily age specific. The Sealants................................................... 16 second part concerning pediatric Mouth Guards......................................... 17 Tobacco...................................................18 patients is divided into age groups. Adolescence.................................................. 18 This segmenting allows for the Growth and Development........................18 Oral Diseases........................................... 18 dissemination of oral health care issues Examination............................................ 18 that occur at various developmental Home Oral Health Care.......................... 18 stages. This supplement touches upon Eileen Olderog-Hermiston, RDH, BS, is an a vast amount of information that is assistant in instruction and codirector of preventive dentistry in the Pediatric Dentistry available in the field of pediatric Department, College of Dentistry, University of dentistry. For more in-depth Iowa, in Iowa City, Iowa. information, refer to the list of ADHA is the publisher and is solely responsible for the editorial content. Oral-B Laboratories, Inc., is the additional readings at the end of this exclusive advertiser in this supplement. supplement. 2 Special Supplemental Issue—Access
  2. 2. General Information in Pediatric Dentistry Fluoride forms of f luoride are meant for community is consuming the com- ingestion: f luoridated water; f luoride munity water. With the popularity of Fluoride is regarded as one of the supplements; and foods and beverages bottled water and water filtration main contributing factors in the containing f luoride. Topical f luorides systems, many patients are drinking reduction of dental caries. In 1990, include toothpaste, prophy pastes, from these alternative water sources. the National Institute of Dental and gels, foams, varnishes, and Reverse osmosis water purification Craniofacial Research estimated the mouthrinses. Fluoride products vary systems remove 90% to 95% of the savings to Americans in reduced need in concentration. The concentrations f luoride content in water. Bottled for restorations at $3 billion per year, of common f luoride products are water varies in f luoride content with which was largely attributed to found in Table I and Table II. a majority below optimal f luorides.2 Research suggests that Water f luoridation is a primary concentration. If the f luoride content f luoride’s primary anticariogenic source of systemic f luoride. Over is unknown in a child’s primary action is its role in the reminerali- 50% of the U. S. population currently drinking water source, the water zation of demineralized enamel.3 To has access to drinking water should be analyzed to determine the understand how f luoride intervenes containing a level of f luoride greater amount of f luoride present. State in the reduction of dental caries, than 0.7 ppm (parts per million).4 departments of public health or knowledge of tooth structure and Usually, the state department of schools of dentistry are resources for development is necessary. public health has a record of each information on where f luoride assays Enamel is composed of apatite- community water system’s level of can be obtained. A child not like crystals arranged in rod-like f luoride. However, the dental consuming optimally f luoridated structures. Fluoride can be hygienist must not assume that a water should be assessed for a dietary incorporated into the enamel surface patient living in a f luoridated f luoride supplement. before and after a tooth erupts. Before eruption, a f luid-filled sac bathes the Table I. Topical Fluoride Preparations for Home Use developing tooth. Fluoride received systemically, by ingestion, becomes a Type of Active Percent Usual Total mg component of this f luid and enters Product Ingredient Fluoride Ion Dose Fluoride the maturing enamel. Post-eruptively, Dentifrice 0.22% NaF 0.1% (w/w) 0.1– 0.1– f luoride continues to enter the 0.76% MFP 0.15% w/v) 1 gm 1 mg enamel surface, causing a new Gels 0.4% SnF2 0.1% 1 gm 1 mg f luoride-enhanced apatite crystal that 1.1% NaF 0.5% 1 gm 5 mg is less soluble than the original apatite 1.1% APF crystal. The f luoride-rich tooth Daily Rinses 0.05% NaF 0.02% 10 ml 2 mg becomes more resistant to plaque- Weekly Rinses 0.2% NaF 0.1% 10 ml 10mg acid attacks. Another role that f luoride plays in the prevention of dental caries is Table II. Topical Fluoride Preparations for Professional Use dependent on its presence in plaque. When plaque becomes acidic, Type of Active Percent Usual Total mg Product Ingredient Fluoride Ion Dose Fluoride f luoride ions which have become incorporated into the plaque through Foam APF 1.23% 1 gm 12 mg topical exposures are released into the 2% NaF 0.9% 1 gm 9 mg plaque f luid. The f luoride and Gel APF 1.23% 5 ml 60–62 mg hydrogen ions combine, enter the 2% NaF 0.9% 5 ml 45 mg plaque bacteria, and inhibit the Varnish 5% NaF 2.3% 0.1–0.5 ml 2–11 mg metabolism of carbohydrates. Prophy Paste 1.23% APF 1.23% 2 gm 25 mg Fluoride can be classified as 2% NaF 0.9% 2 gm 18 mg either systemic or topical. Systemic Access—Special Supplemental Issue 3
  3. 3. Table III. Fluoride Supplementation in Dosage Schedule Many children with caries have a difficult time obtaining access to oral Fluoride Level in Drinking Water (ppm) health care. This is especially true for Age <0.3 ppm 0.3–0.6 ppm >0.6ppm very young children and for children enrolled in Medicaid. One study 6 months–3 years 0.25 mg/day none none found that only 26% of dentists are 3 years–6 years 0.50 mg/day 0.25 mg/day none willing to provide exams to children 6 years–16 years 1.00 mg/day 0.50 mg/day none age three to five years.11 The U.S. Department of Health and Human 1 ppm = 1 mg/liter 2.2 mg sodium f luoride = 1 mg f luoride Services’ Office of the Inspector General reported that only 18% of American Dental Association Council on Scientific Affairs Recommendations: April 1994. Medicaid-eligible children received a single preventive oral health care service during the course of a year.12 Before a f luoride supplement is enamel ranging in severity from small To increase access to dental care, prescribed, a history of a child’s white specks to brown stain with a Children’s Health Insurance f luoride sources needs to be obtained, pitting. The critical time period Program (CHIP) was established with including daycare and school water. during which maxillary permanent the passage of the Balanced Budget Other issues that should be incisors are at risk for f luorosis has Act of 1997. The program targets considered are the child’s caries risk been determined to be during a four- working, low-income families who do and the halo effect from food and month time period beginning around not have health insurance coverage beverages processed with f luoridated age 22 months.7 and offers low cost or free health water. Evidence suggests a strong Acute toxicity can result from the insurance for children through 18 association between f luorosis and the ingestion of excessive amounts of fluor- years of age. This insurance plan is a inappropriate use of f luoride ide. The amount of fluoride needed to state-by-state operated effort to supplements during early childhood.5 cause a toxic reaction is directly related provide health coverage for children. Along with each patient’s f luoride to the weight of the child. The While dental coverage is not a history, the f luoride dosage chart probable toxic dose is 5 mg of fluoride mandated benefit, many states have found in Table III can assist the per kilogram of body weight.4 Early incorporated oral health benefits into practitioner in prescribing f luoride symptoms of fluoride poisoning their CHIP programs. supplements. include nausea, vomiting, and diarrhea, School-based dental sealant If f luoride is administered in and can begin to occur at 1 mg fluoride programs are another means of excessive amounts, it can produce per kilogram of body weight.8 All reaching children who lack access to f luorosis and even acute toxicity. fluoride products should be stored out dental care. These programs usually Recent surveys conducted in the U.S. of reach of young children. target schools with a high percentage have shown that the prevalence and of low-income children. The number severity of f luorosis is increasing of students who qualify for free and among school-age children.6 Enamel Public Health Dentistry reduced meals is one of the indicators f luorosis is the discoloration of of a school’s neediness. Specific Dental decay is still a serious grades are selected to participate in public health problem for U.S. sealant programs in accordance with The critical time period children and is one of the most eruption of permanent molars. When common diseases of childhood.9 More areas of tooth decay are identified during which maxillary than one half of children age six to during screenings for sealant permanent incisors are at eight years, and over 66% of all 15- placement, referrals for dental care year-old adolescents continue to can be coordinated through area risk for fluorosis has been experience tooth decay. Furthermore, dentists, public health agencies, or determined to be during a one-third of the decayed teeth in school based dental clinics. Other four-month time period children age six to eight years have services that can be provided in not been repaired.10 Children of low schools are f luoride rinsing programs beginning around age socioeconomic status and from in areas devoid of water f luoridation, 22 months. minority groups experience higher dental screenings, and oral health caries rates and at an earlier age.9 education. Dental hygienists are often 4 Special Supplemental Issue—Access
  4. 4. the integral professionals in these the acid-etch technique. The resin amalgam margins and enamel defects, school-based oral health care programs. composite is a strong, yet polishable blocking out undercuts, and as liners, “Healthy People” is the nation’s restorative material. Disadvantages of and pit and fissure sealants. prevention agenda for health. In 1990, resin composites include technique Recently, compomers have been Healthy People 2000 was released as a sensitivity, material shrinkage, and introduced into the restorative dental resource that identified areas of marginal leakage. Although resin materials arena. Compomers are light significant preventive threats to composites have greater wear resistance cured, f luoride releasing, high- health. One of the 22 priority areas in and can better replicate the appearance of strength materials with adhesive “Healthy People 2000” was oral enamel, resin modified glass ionomers properties. The material combines the health. The oral health objectives are more practical when wear and technology of glass ionomer cements contained several aims at preventing appearance are not as critical.15 with light cured composites. oral disease in children. The final data Resin modified glass ionomer, a A majority of dental sealant accumulated on the Healthy People tooth-colored adhesive, was introduced material is formed by the reaction of 2000 objectives is being compiled and in 1992.16 The formulation consists of bisphenol A with Glycidyl methacrylate, analyzed. January 2000 is the release about 80% glass ionomer material date for the Healthy People 2010 combined with 20% visible light objectives. Information concerning polymerized resin component.17 Healthy People can be accessed on the Unlike the self-hardening glass There is no clinically web page < ionomer cements, resin modified glass controlled research indicating healthypeople>. Dental hygienists can ionomers cure in 30 to 60 seconds by that mercury from amalgam use this as a tool for promoting oral light activation. Advantages of resin health activities and community modified glass ionomer material restorations has any initiatives to improve oral health. include f luoride releasing, toxic effects. conservative preparation, aesthetic appearance, and ease in application.15 Restorative Materials Preventive resin restorations preserve tooth structure since they do also known as BIS-GMA.20 Concerns Restorative materials in dentistry not require extensive removal of tooth have been raised regarding the are continuing to change as new devel- structure. With preventive resin estrogenic potential of bisphenol A opments in product function, applica- restorations, only caries are removed, from sealants. Nathanson conducted tion, durability, strength, and appear- followed by placement of a composite extensive analysis of sealants and ance emerge. This section will highlight resin, and sealing the remaining concluded that the levels of bisphenol a few of the common and/or newer caries-susceptible pits and fissures on A were below the level of detectibility. materials used in pediatric dentistry. the tooth. This method is an alternative However, other components leached The amalgam restoration continues to the “extension for prevention” from the different dental sealant to be an effective restorative material method used when placing amalgam materials tested. Further studies may in pediatric dentistry. Dental amalgam restorations. A retrospective study of be needed to assess the other leached is one of the least technique-sensitive 2,000 preventive resin restorations components that were detected in the restorative materials.13 Because of the concluded that more than 80% of the study.21 No adverse health effects have negative public attention amalgams sealant remained intact and 98% of been attributed to the placement of have received due to their mercury the composite remained intact over a dental sealants.22 When selecting a content, some parents may request period ranging from one to eight dental sealant material, many that other dental materials be used. years.18 Preventive resin restorations properties must be considered There is no clinically controlled are used widely in pediatric dentistry. including the following: research indicating that mercury from Flowable composites have essentially amalgam restorations has any toxic the same chemistry as conventional Fluoride versus Nonfluoride effects.14 However as research and composites, except they are made The clinical significance of the development continue to enhance the thinner.19 The material has the ability release of f luoride from dental sealants properties of adhesive tooth-colored to f low into the smallest micro- has yet to be proven.23 The f luoride materials, the traditional silver structural defects and then become release may help remineralize adjacent amalgam wanes in popularity. mechanically locked there. Indications tooth structure and provide a f luoride The resin composite binds for use include small and conservative rich layer that should be more caries adhesively to enamel and dentin via restorations, repair of defective resistant. Access—Special Supplemental Issue 5
  5. 5. Opaque versus Clear technique is less sensitive to moisture To apply f luoride varnish for the Opaque or tinted sealants are control due to the use of glass prevention of dental caries the follow- easier to detect, which allows for ionomer filling material. Michael ing steps are recommended. monitoring of the sealant for Kanellis, DDS, MS, a pediatric dentist 1. Dispense 0.5 ml or less into a retention. A study has shown that the at The University of Iowa, states, “ dappen dish. error rate in identifying the presence The ART technique procedure can 2. Remove excess moisture on or absence of sealants is 1.4% for help stabilize the caries process in teeth with cotton rolls or opaque and 22.8% for clear.24 young children until they are old gauze squares. enough to cooperate for definitive 3. Apply f luoride varnish with a Light-polymerized versus Autopolymerized care.” disposable brush or cotton tip Light-polymerized sealants offer In 1994, fluoride varnish became applicator to all teeth or some advantages over autopolymerized available for use in the United States.27 selected teeth. (Note: sealants. Light-polymerized sealants Fluoride varnish is 5% sodium f luoride varnish adheres and set in 15 seconds and require no f luoride in a varnish base that sets in the presence of saliva.) provides an adhesive, waterproof 4. Instruct patient to refrain coating against saliva. Clinical studies from brushing and f lossing have shown caries reduction as great Patient ingestion of fluoride as 75% from the use of f luoride for 12 hours to allow varnish to remain in contact with varnish occurs over a varnishes, with most studies tooth surfaces. demonstrating caries reduction of relatively long period of time 25%–45%.28 Other noteworthy because of the varnish’s findings include that prophylaxis is Oral Pathology ability to adhere to the not required before f luoride varnish is applied,29 f luoride uptake appears to enamel surface. have significantly increased when Oral pathological conditions and applied to dry enamel surfaces anomalies in children are too numerous compared to water and saliva coated to be covered inclusively in this mixing. The disadvantages of light surfaces,30 and reduction of caries is supplement. However, a few of the polymerized sealants are the expense achieved on both smooth and occlusal more common pathological condi- and maintenance of the light curing surfaces.31 The recommended tions are highlighted in Table IV. units. Studies have concluded the frequency of application for f luoride retention rates of both autopolymerized varnish is typically twice a year, with and light-polymerized are comparable.25 some studies suggesting more Special Needs Children frequent applications of f luoride varnish for children at moderate to Providing dental care for the child New Trends in Pediatric Dentistry high risk for caries. Documented patient with special health care needs intervals for high-risk patients include can be both challenging and The atraumatic restorative three applications in 10 days,32 and rewarding. A child with special needs technique (ART) was first introduced one application every three months.33 can have mental, physical, medical by the World Health Organization for Patient ingestion of f luoride and/or social conditions that interfere the restoration of carious lesions in varnish occurs over a relatively long with normal functioning. Treating underdeveloped countries.26 The period of time because of the special needs children requires a technique uses only hand instruments, varnish’s ability to adhere to the knowledge base of medical conditions no local anesthesia, and f luoride enamel surface. When 0.5 ml of 5.0% and the oral health implications of the releasing adhesive material for f luoride varnish is used, existing conditions. For instance, restorations. Caries are removed using approximately 5 mg is ingested. children with Down’s syndrome have a spoon excavator. The use of this Ekstrand noted that plasma f luoride a high chance of also having a cardiac technique for young precooperative concentrations after treatment were defect. Furthermore, children with children with caries has been far below toxic levels.34 The one Down’s syndrome have a higher proposed in the U.S. The advantages disadvantage with the application of incidence of periodontal disease and a of this technique include less noise f luoride varnish is the yellowish color lower incidence of dental caries. The and vibration because no handpieces of the varnish that is present on the combination of periodontal disease or suction are used, and that the teeth while the varnish is intact. and certain cardiac defects should 6 Special Supplemental Issue—Access
  6. 6. Table IV. Condition Clinical Findings Significance Treatment Ankyloglossia present at birth, short lingual may interfere with if indicated a frenectomy (tongue tied) frenum or anterior attachment speech and swallowing of frenum to tip of tongue angular cheilitis deep fissures at commissures of occurs with mouth breathing antifungal ointment mouth, may bleed and ulcerate, and chronic licking of lips develops superficial crust, dryness, and sometimes burning congenital epulis present at birth, female predilection may cause bleeding or excisional biopsy, located on anterior gingiva, localized respiratory problems occasionally spontaneous spongy nodule, smooth surface, pink regression to red in color dental and palatal present at birth, solitary or multiple found in 75% of newborns no treatment necessary lamina cysts discrete papules with smooth translucent usually the cysts slough to white surface, firm, usually 1-3 mm within 3 months in size eruption cyst localized dome-shaped, f luctuant tender if inf lamed no treatment necessary hematoma enlargement, translucent to bluish in uncover tooth if symptomatic color, overlying an erupting tooth hemangioma usually detected within first year of life, hemorrhage from trauma surgical excision, laser female predilection, localized to diffuse, ablation red to blue lesion, soft and compressible, blanches, most common sites are lips, tongue, and buccal mucosa mucocele localized, compressible f luid-filled most common lip excisional biopsy nodule with smooth, translucent swelling in children to blue surface, f luctuates in size, may be tender periapical abscess primary dentition is most frequently can progress to cellulitis endodontic treatment affected in children; nonvital, mobile or extraction tooth, tender to percussion; soft tissue swelling with purulent exudate; painful; widening of the periodontal ligament space or poor defined radiolucency primary herpetic fever, irritability, pain, lymphadenopathy, self-limiting infectious antipyretics, analgesics, gingivostomatitis drooling, halitosis, diffuse oral and disease caused by palliative oral rinses, perioral vesicles and ulcers, herpes simplex virus, force f luid consumption, inf lamed gingiva high fever and dehydration resolves 7–10 days are serious complications soft tissue abscess localized or diffuse enlargement, smooth caused by pupal or eliminate source of infection red to yellow surface, expression of periodontal disease or purulent exudate, soft, f luctuant, tender entrapment of a foreign body, may progress to cellulitis traumatic fibroma localized, pedunculated or sessile most common tumor- excisional biopsy if nodule, pale, smooth surface, firm, like lesion in the oral cavity, indicated found on buccal and labial mucosa, represents hyperplastic border of tongue and gingiva scar tissue traumatic ulcer solitary lesion, variable in most common oral symptomatic relief shape with irregular margins, ulcer, may indicate removal of cause, shallow or deep, red or yellow child abuse heals within 2-3 days psuedomembranous surface, painful verruca vulgaris usually multiple, sessile lesions caused by human excisional biopsy, with white, rough surface and papilloma virus, auto- may spontaneously finger-like projections, asymptomatic inoculation from sucking resolve on fingers and nailbiting Modified from Flaitz CM: Pediatric Dentistry: Infancy Through Adolescence. W.B. Saunders, Philadelphia 1999. Access—Special Supplemental Issue 7
  7. 7. increasing the risk of acid production patterned marks, human bite marks, in the caries process. adult hand imprints, or bilateral After identifying a suspected Depending on the child’s physical injuries are indicators for suspicion of abilities, plaque removal may require abuse. If a questionable injury is case of abuse or neglect, partial to full assistance. With a observed, the parent and child should the next step is to report it severely disabled child, a mouth prop be asked how the injury occurred. to the Department of can help secure the mouth in an open Conf licting answers or uneasiness in position for cleansing. Toothbrushes providing an analysis of the injury Human Services, Child with extra large handles, and sonic may indicate that abusive behavior Protective Service Agency. and electric toothbrushes, may help occurred. facilitate brushing. Child neglect is defined as not Special needs children may be at providing adequate care, support, higher risk for dental disease due to nutrition, or medical or surgical care alert the dental care professional to health conditions, diet and feeding for a child. After identifying suspected the prevention of infective patterns, access to dental care, and abuse or neglect, the next step is to endocarditis. It would be important to possible limited ability to provide oral report it to the Department of develop a plaque control program for home care. The dental hygienist can Human Services, Child Protective this type of patient and monitor oral assist the special needs child and Service agency. The dental hygienist conditions on a regular basis, along parents or caregiver in developing a is not to pursue investigation, but is with providing recommended preventive oral health plan. responsible for notifying the proper antibiotic prophylaxis to prevent authorities who will then determine if subacute bacterial endocarditis for child abuse or neglect occurred. If children with a cardiac defect. Child Abuse and Neglect intervention does not occur, 50% of Children with developmental the time abuse will recur and be more disabilities may require diet Dental hygienists are mandatory severe.36 If a mandatory reporter fails modifications because of their health reporters of child abuse and neglect. to report suspected child abuse or conditions. Diets may be supple- More than 65% of all cases of physical neglect, he or she may face legal mented with high-calorie beverages, abuse involve injuries to the head, penalties. pureed foods, or frequent feedings, all neck, or mouth.35 Injuries that exhibit Age-Specific Information: Birth to Three Years, Three to Six Years, Six to 12 Years, and Adolescence Birth to Three Years burgeons to 1,000 words by three to a three-year-old who has good years of age.38 control of his body. Toddlers’ large Growth and Development Emotions in the infant and young muscles are more developed than child are often formulated by adults those that control smaller movements, From birth to three years, a child observing a child’s behavior. Crying such as finger and hands.40 Therefore, experiences remarkable changes in might be labeled as fear, smiling as toddlers still have great difficulty in growth and development. joy. Oral health care practitioners fine motor skills. Cognitively, most of the intellectual especially have to deal with the Tooth development begins at achievements of the child during this emotion of fear. Fear of strangers is seven weeks in utero. During period result from interactions almost universal after seven to 12 pregnancy, many factors can inf luence between the child and their months of age. Between 13 and 18 the developing teeth: illness, environment.37 Language months of life, the feeling of fear medications, and metabolic development in the form of peaks, and then begins to decline.39 deficiencies. At six to seven months expression starts with an average of 10 Physical abilities change from a of age, the first primary teeth begin to words in an 18-month-old and newborn that has modest musculature erupt. Table V can be used as a guide 8 Special Supplemental Issue—Access
  8. 8. for eruption sequence. By age three, Table V. generally all the primary teeth have erupted. Considering the vast growth Primary dentition Hard tissue Enamel Eruption changes, behavior, and oral develop- formation begins complete ment that occurs in the first three years Maxillary of life, oral health care is important. central incisor 4 mo in utero 1 1/2 mo 7 1/2 mo lateral incisor 4 1/2 mo in utero 2 1/2 mo 9 mo cuspid 5 mo in utero 9 mo 18 mo first molar 5 mo in utero 6 mo 14 mo Examination second molar 6 mo in utero 11 mo 24 mo Mandibular In the past, a child’s first dental central incisor 4 1/2 mo in utero 2 1/2 mo 6 mo visit was recommended around three lateral incisor 4 1/2 mo in utero 3 mo 7 mo years of age. Fortunately, today the cuspid 5 mo in utero 9 mo 16 mo recommendation for the first dental first molar 5 mo in utero 5 1/2 mo 12 mo visit is by a child’s first birthday. second molar 6 mo in utero 10 mo 20 mo (American Academy of Pediatric Dentistry, American Academy Permanent Hard tissue Enamel Pediatrics) The benefits of seeing dentition formation begins complete Eruption the child by one year of age are Maxillary establishing a place to receive oral central incisor 3-4 mo 4-5 yr 7-8 yr health care, assessing risk factors that lateral incisor 10-12 mo 4-5 yr 8-9 yr cuspid 4-5 mo 6-7 yr 11-12 yr may result in dental disease, and first bicuspid 1 1/2 yr 5-6 yr 10-11 yr stressing the importance of second bicuspid 2 yr 6-7 yr 10-12 yr continuing oral health care. first molar at birth 2 1/2-3 yr 6-7 yr The oral health care visit can be second molar 2 1/2-3 yr 7-8 yr 12-13 yr divided into three parts. First, a Mandibular parent interview and risk assessment central incisor 3-4 mo 4-5 yr 6-7 yr is conducted. Next, an examination lateral incisor 3-4 mo 4-5 yr 7-8 yr is performed, followed by preventive cuspid 4-5 mo 6-7 yr 9-10 yr and treatment recommendations. first bicuspid 1 3/4 yr 5-6 yr 10-12 yr When interviewing parents about second bicuspid 2 1/4 yr 6-7 yr 11-12 yr their child’s health history, oral first molar at birth 2 1/2-3 yr 6-7 yr second molar 2 1/2-3 yr 7-8 yr 11-13 yr home care, and other related dental issues, it is important to gather Modified from Pinkham JR et al.: Pediatric Dentistry: Infancy Through Adolescence information in a private, W.B. Saunders, Philadelphia 1999. nonthreatening environment. As a result, communication and partnership begin to build among An oral examination of an the child, parent and oral health care infant or toddler is usually team. Conducting a risk assessment accomplished through the help will help provide the oral health care of a parent. The knee to knee team with possible factors that may position allows for the parent to negatively impact the child’s oral help restrain a child, and health. Risk assessment allows health provides the dental hygienist as professionals to individualize inter- well as the parent with good vention by focusing resources and vision of the child’s oral cavity education on identified risk factors. (Figure 1). Along with the oral Risk assessment factors to address examination, the head and neck Figure 1. include prenatal/natal history, family region should be evaluated for caries history, diet and feeding size, shape, and symmetry. The dental Following the examination and methods, f luoride adequacy, oral hygienist should be alerted if signs of prophylaxis, preventive habits, injury and trauma prevention, bruising are present during the recommendations should be and home oral health care. examination. formalized based on the risk Access—Special Supplemental Issue 9
  9. 9. assessment factors, family and health • recommending forbidding pea-size amount, .25 grams of history, and results of the oral exami- continuous snacking, offering toothpaste, being used. dentally healthful snacks nation. Anticipatory guidance, a guide • discussing preventing dental on what to expect as the child enters injuries due to trauma during the next developmental stage, can be toddler stage Early Childhood Caries provided to the parent and family.41 • educating parent on child’s frequent use of sippy cup with Baby bottle tooth decay (BBTD) For example: Matthew, 18 months apple juice and its possible dental was described 37 years ago as a caries old, presents for his first dental visit. effects • informing parent that second pattern affecting all the primary upper During the parental interview and risk assessment the following risk factors primary molars may be erupting in anterior teeth, upper and lower primary were noted: the next six months first molars, and lower primary canines. • child was born one month Recall interval: three months due The lower four anterior teeth are prematurely to identified risks and initial either unaffected or are very slightly •well water is primary drinking formation of caries carious. It was noted that children water source with this caries pattern had been put •sippy cup is being used indiscriminately to bed with a nursing bottle of milk.42 •mom brushes once a day most of Fluoride In the past decade, new theories the time and discoveries have led to the renaming •snacks between meals include apple Receiving an optimal amount of of the disease to “early childhood juice and dry cereals systemic f luoride is important during caries” (ECC). The window of •six year old brother has a moderate the child’s early developmental stage. infectivity theory describes the acquisi- history of caries Oral examination findings: If it is determined that, after six tion of the caries-causing bacteria •areas of hypoplasia on first primary months of age, the child is not Streptococcus mutans in children to molars consuming an optimal amount of occur through the transmission of the •“white spot” decalcified lesions on f luoride in the drinking water, a bacteria from mother to child. The S. maxillary incisors f luoride supplement should be mutans being isolated from the child •plaque covering two-thirds of maxillary incisors and along considered. The supplementation has the same genotype as the child’s gumline throughout rest of mouth dosage schedule will help practitioners mother, and is present in the child’s Treatment: prescribe systemic f luoride in plaque at around the age of 14 months.43 • prophylaxis appropriate amounts. Liquid f luoride Other areas of investigation include • f luoride varnish application supplements are available for children that sleeping with a bottle does not Anticipatory guidance and who are unable to chew. To obtain cause dental decay in all children, and preventive recommendations may include: both a topical and systemic effect, the that the cariogencity of milk and • testing well water to determine liquid f luoride drops can be placed infant formulas remains unclear.44 amount of f luoride directly on a child’s teeth and then Management of early childhood • parent brushing the child’s teeth swallowed. For children who can caries can be accomplished through with pea-size amount of toothpaste chew, tablets should be masticated and different types of intervention, both morning and nighttime. then swished throughout the mouth depending on the progression of the before swallowing. disease, age of the child, and social, Young children who present with behavioral, and medical history of the Young children who present structural defects in their teeth, child. Examining a child by his or her with structural defects in their decalcified teeth, or have experienced first birthday is ideal in the prevention dental caries should be considered for and intervention of early childhood teeth, decalcified teeth, or a professionally applied f luoride caries. At this initial visit, conducting have experienced dental caries treatment. Fluoride varnish is ideal for a risk assessment can provide baseline should be considered for a precooperative patients because of its data necessary to counsel the parent ease of application, and may be placed about preventing dental decay. In professionally applied fluoride on selected tooth surfaces. addition, if white spot decalcified treatment.Fluoride varnish is In regard to f luoridated areas are observed, f luoride varnish toothpaste, inadvertent ingestion is a may be applied. A clinical study on ideal for precooperative concern for a child up to three years applying f luoride varnish to decalci- patients. of age. An adult should monitor fied maxillary incisors demonstrated a toothpaste use, with no more than a reduction in white spot lesions after 10 Special Supplemental Issue—Access
  10. 10. six months.45 Recall appointments experience are brushing to a song, proteins versus carbohydrates, should be based upon the risk assess- counting brushing strokes, developing consistency of the food (chewy and ment and examination outcomes. a hide-and-seek game with the plaque sticky versus a food that clears the In advanced stages of early child- germs, and using brushing calendars. mouth readily); consumption rate; hood caries, the management of caries An infant’s diet is primarily milk, and amount of salivary stimulation. becomes extremely expensive and whether breast milk or formula. Both Parents have control over their child’s difficult to treat because such young breast milk and formula can diet, and need to establish healthy children lack the ability to cope with contribute to acid production in the eating behaviors at an early age. extensive restorative care. General caries process. However, controversy anesthesia cases are often recommended exists regarding the cariogenic and can cost thousands of dollars. potential of milk and formula. Nonnutritive Sucking In light of the theories and trends Prolonged feeding and sleeping with regarding early childhood caries, the bottle or nursing may in some Nonnutritive sucking is the evolving management therapies are children lead to early childhood sucking of a digit or pacifier for the being investigated. Culturing for cario- caries. A survey conducted at a purpose of comfort and is not related genic f lora in mothers to determine if general pediatric clinic determined high S. mutans counts are present, and that 90% of the patients were bottle- then reducing the S. mutans counts feeding past 12 months of age.46 When addressing healthful through chlorhexidine mouthrinses is Children should be weaned from the one approach. Another is educating bottle by their first birthday. snacking in terms of the mother about oral transmission of As the infant turns to a toddler, oral health, emphasize S. mutans. For the high-risk child, snacking becomes a daily routine. inhibiting the transmission of the When addressing healthful snacking to the parent eliminating cariogenic bacteria by applying a in terms of oral health, emphasize to continuous eating throughout bactericidal product to the child’s the parent eliminating continuous the day and providing snacks teeth is being investigated.39 eating through the day and providing snacks that are healthy. Evaluate the that are healthy. snack food for content; fats and Home Oral Health Care The infant/toddler’s home oral health care is the responsibility of the parent. Once teeth erupt, plaque begins to form. Because of the toddler’s limited dexterity, the parent needs to perform toothbrushing. The caregiver can access a young child’s mouth by having the child lie on a bed or by cradling the child’s head in the caregiver’s arms (Figure 2). Toothbrushes with soft bristles and a small head are recommended for infants and toddlers. If toothpaste is used, only a pea size amount is needed. Flossing is not necessary until interdental contacts become present. Developing a daily routine in the child’s plaque removal is crucial to the establishment of a regular tooth- brushing habit. A child is more likely to object to brushing if it is an occasional activity. Suggestions for making brushing a favorable Figure 2. Access—Special Supplemental Issue 11
  11. 11. to feeding and nutrition. Sucking is a Oral Health Care for dietary patterns, dietary content, natural ref lex in an infant. An infant’s absence of optimal f luoride, and a sucking need is met by the use of his or Children Three to Six susceptible host—the tooth. Individual her fingers, thumb, or pacifier. Finger Years tooth susceptibility is determined to a sucking is seven times less likely to large extent by tooth anatomy and occur when the child is introduced to During the preschool stage, position. Primary first molars have a the pacifier.47 The benefits of a pacifier between the ages of three and six years, lower decay rate than primary second include that it is easier to discontinue the child’s bone and musculature molars because of the lack of deep pits a pacifier habit, most pacifier habits growth significantly increase. Preschool and fissures present in primary first stop between ages two to three years children are extremely active, and molars. Furthermore, interproximal of age,47 and pacifier use has been have fairly good control of their decay in the primary dentition occurs associated with a decreased risk of bodies. Handedness is established most frequently between the primary sudden infant death syndrome.48 during this time period, with 90% of first and second molars because of the The following safety recommenda- children being righthanded.40 larger contact area. tions for parents with children using a A dramatic emotional change that Gingivitis occurs in 50% of the pacifier should be provided: select a begins to emerge in the child is the four to five year olds, and continues pacifier with a wide shield to prevent development of self-control.39 Because to increase in prevalence with age.50 the child from fitting the entire pacifier fear of strangers is diminishing, the Younger children tend to be less in the mouth, have ventilation holes child becomes more willing to under- reactive to the same amount of plaque in the pacifier guard, do not put take new experiences. as older children. This can be related anything sweet on the pacifier, Cognitively, the child’s ability to to the differences in bacterial periodically examine the pacifier for reason is growing substantially. At the composition of plaque and the oral health care visit, the professionals changes in inf lammatory responses as will be able to make several requests the child develops. Other factors of the child. In addition, a child is able affecting gingival tissue are crowding Parents may be concerned with to produce mental imagery and of teeth making plaque removal more fantasy play. difficult, mouth breathing, and the difference in color between By age three years, the primary eruption and exfoliation of teeth. the deciduous and permanent dentition has completed root develop- Gingivitis is reversible and can be ment. In terms of change in dentition, treated by improved oral hygiene. teeth, with the permanent the next few years are passive. Around teeth being yellowish or five and a half years of age, the mandi- darker in color. Primary teeth bular primary incisors begin to exfoliate, Examination and soon, the eruption of first permanent appear lighter because of the molars begins. Parents may be concerned The oral health care appointment thinner, more translucent with the difference in color between the for the preschool age patient deciduous and permanent teeth, with continues with health history review layer of enamel on them. the permanent teeth being yellowish or and risk assessment of the patient. As darker in color. Primary teeth appear the child grows and life situations and lighter because of the thinner, more styles change, new risks and health wear and tear, and do not tie the translucent layer of enamel on them. issues may emerge or diminish. pacifier around the child’s neck. Most oral examinations in the Pacifier and digit habits can create preschool patient take place in an similar changes in the dentition and jaw Dental Disease operatory unit with the child in the relationship. There is some scattered dental chair. A majority of the behavior evidence that pacifier use may be less Dental caries in the primary management techniques are directed harmful in its effects, but this is not dentition remains a problem, with towards the preschool age patient. supported across all studies.49 Inter- higher prevalence in economically vention of the sucking habit in children disadvantaged populations. Many less than three years of age is not factors contribute to the risk of dental Behavior Management indicated. In many young patients, caries besides socioeconomic status. once the sucking habit ceases, Predisposing factors include amount Fear, stress, emotional conditions, malocclusion spontaneously corrects. of cariogenic microf lora present, personality traits, parenting, and other 12 Special Supplemental Issue—Access
  12. 12. factors inf luence children’s behaviors singing a song. The goal is to get the used daily can facilitate the at the dental visit. Management of patient to focus on something other remineralization process. children’s behaviors in the dental than the procedure. Professionally applied topical office ranges from communication Voice control is a method of f luorides are commonly available in management to several techniques gaining the patient’s attention, foam, gels, and varnish. In determining that require informed consent such as establishing authority, and discouraging if a child patient needs a high- hand-over-mouth, conscious sedation, negative behaviors. The technique concentration f luoride treatment, the nitrous oxide, physical restraint, and works in part by the practitioner practitioner needs to evaluate the general anesthesia.39 Discussing raising and lowering his or her voice patient’s caries risk, other f luoride management techniques with parents volume and directing the voice tone exposures including water, and the and knowing the parents’ expectations according to the child’s behaviors. cost/benefit of the professional builds a relationship and leads to wise Conveying body language is a f luoride treatment. choices. The following behavior nonverbal communication technique. The tray method of applying management techniques will focus on The dental hygienist can strengthen professional f luoride gels and foam communication management. positive behavior or discourage should have one to four minutes of Communication by both the parents negative behavior by posture and contact time with the teeth.51 For and oral health care professionals is a expressions. For example, a six-year- patients not demonstrating good oral key component for establishing old who is not cooperating for dental control and ability to keep f luoride rapport with the patient. sealants, the dental hygienist might trays in position, the dental hygienist The tell-show-do technique can look eye to eye at the patient with a should consider using a f luoride help reduce stress caused by fear of look of disapproval, while leaning varnish product. the unknown. The technique begins close to the child. The following precautions should with an explanation of the procedure, Many pediatric patients can be always be employed when providing a followed by a demonstration, and managed by these communication professional tray method f luoride then performance of the procedure. techniques. However, every child treatment: always seat the child upright, For example: reacts in his or her own individual way. use suction during and after treat- What works for one child may not ment, fill approximately one third of Julie, I am going to clean your teeth help another patient. Professionals the tray with f luoride product, use with this special toothbrush that has a should continually assess how the rubber cup and spins around on your child is responding to the manage- teeth. Let me show you how it works on your fingernail. Do you feel how ment technique being employed. Every child reacts in his or soft it is? When my toothbrush spins around it makes a sound. Do you hear her own individual way. the sound? I am going to put a little Fluoride What works for one child toothpaste in the cup to help make your teeth shine. Julie, can you smell the may not help another patient. bubble gum f lavor toothpaste? Now, Fluoride plays a key role in the open up, so I can clean your teeth. prevention of decay in preschool age Professionals should children. For children whose primary continually assess how the Positive reinforcement promotes drinking water is unf luoridated, an evaluation for fluoride supplementation child is responding to the desired behaviors. The communication can be through the form of a facial should be considered. By age three, management technique being expression or praise. For example: most children are able to use the tablet employed. form of fluoride supplements. Although John, you are opening your mouth so the risk for developing fluorosis has wide for me. You are doing an excellent decreased, the practitioner needs to job. Thank you for being a good helper. gather information about other appropriately fitting trays, and have possible sources of systemic f luoride the patient expectorate after the The distraction technique diverts before prescribing a supplement. procedure. If one teaspoon or 5 ml of the patient’s attention from a perceived Once the child demonstrates the APF gel is used in the tray method, unpleasant procedure. For instance, a oral musculature control needed to the total amount of f luoride entering child receiving an injection may be expectorate, topically applied the child’s mouth is 61.5 mg. An distracted by the oral health care f luorides may be administered. Over- alternative vehicle for administering professional jiggling the cheek or by the-counter f luoride mouthrinses f luoride professionally is the foam Access—Special Supplemental Issue 13
  13. 13. f luoride. Researchers presence and degree of malocclusion concluded that only one fifth is related to several parameters: dura- the amount of foam f luoride tion, frequency, and intensity of the is required for a tray method sucking habit. Also, how the thumb, treatment when compared to finger, or pacifier is placed in the oral a gel f luoride.52 cavity can affect tooth placement. Several different approaches are available to assist in the cessation of a Radiology sucking habit. Counseling the patient is one of the most common and Children in the three to Figure 3. Snap-A-Ray. simple methods. One point to stress six years age range can have Manufactured by Rinn Corporation with the child is how the sucking difficulties in cooperating habit has affected the child’s with the taking of begin to close. Flossing, a fine motor appearance. David Decides by Susan radiographs. In the primary dentition, skill, needs to be performed by the Heitler, published by Reading if contacts are not present and parent. If accessibility is a problem, Matters, is a story about a boy trying interproximal surfaces can be f loss handles can help reach posterior to quit a thumb habit. The parent examined clinically bitewing interproximal areas. could find a quiet time with the child radiographs may not be needed. If As the preschool child becomes to read and discuss the story. This radiographs are indicated, the more aware of food and beverage method can include weekly phone following suggestions may assist the products, they want more input in calls by the dental hygienist to receive dental hygienist with the radiographic their food and drink choices. Advertise- feedback and provide support. procedures: select a film size that will ments can greatly inf luence children’s Reminder therapy can be used for fit comfortably in the child’s mouth, desire for certain foods. Snacking is children who want to stop the habit, usually a size 0 for the preschool age often a favorite pastime for a but need additional help. Placing an child; bend the corners of the film preschooler. Selecting dentally adhesive bandage around the finger, slightly if they are impinging on the healthful snacks and limiting the covering the hand with a mitten or lingual mucosa; place the film number of times a day snacking is sock, and painting a bitter substance vertically if the film will not fit allowed needs to be reinforced to on the digits being sucked are ways of horizontally; and have the settings and parents and caregivers with children of reminding the child. radiographic equipment positioned this age group. The Food Guide Another type of treatment is the before placing the film. The Snap-A- Pyramid that has been adapted for reward system. A contract is agreed Ray device by Rinn Corporation can young children, two to six year olds, upon between the parent and child. be used to help position the film can help provide nutritional informa- When the contract is met, the child (Figure 3). tion (Figure 4). This version of the will receive a reward. Making a daily Food Guide Pyramid is designed to calendar for the child to record target preschool-age children. If a achievements increases the child’s Home Oral Health Care child presents with moderate to high involvement in the therapy. caries at the oral health care visit, the If the above therapies are not Even though the child is dental hygienist should conduct a diet providing results, and more aggressive becoming more independent, the history to evaluate the child’s food therapy is indicated; an alternative parent still needs to be the primary and beverage intake. treatment is adjunctive therapy. plaque remover. Using only a pea- Adjunctive therapy consists of sized amount of f luoridated physically interrupting the sucking toothpaste is recommended. Studies Nonnutritive Sucking habit. This may include an intraoral have shown that some preschoolers appliance that interferes with finger swallow large amounts of toothpaste During the years of three to six, placement and ability to suck. The that may increase the risk of most nonnutritive sucking habits have fabrication of the appliance will f luorosis.53 Together, the parent and ceased. However, if a sucking habit require a dental appointment. child can take a team approach to continues past the age that coincides The elastic bandage method is a toothbrushing. with the eruption of permanent nighttime therapy. Before the child goes Contacts between the teeth maxillary incisors, intervention to bed, the arm that is used for sucking appear as the spaces between the teeth techniques may be indicated. The should be wrapped with an elastic 14 Special Supplemental Issue—Access
  14. 14. bandage. The wrap should be secure, Localized juvenile but not hinder circulation. The wrap periodontitis occurs in should extend from the middle of the one percent of the U.S. forearm to the middle of the upper population.39 Localized arm. As the child relaxes, the bandage juvenile periodontitis is will straighten the arm and bring the characterized by its fingers out of the mouth. unique pattern of The success of quitting a sucking attachment and bone habit depends on the willingness of loss, occurring around the child to want to quit the habit. permanent incisors and Parents should not scold or punish a first molars. Another child for the habit, but rather offer closely related encouragement. periodontal disease is localized prepubertal periodontitis. The Figure 4. Food Guide Pyramid for young children two attachment and bone Oral Health Care for to six years old. loss occurs in the Children 6 to 12 Years United States Department of Agriculture Center for Nutrition Policy and Promotion. primary dentition, usually around the The transitional dentition years molar area. are a period of change for children six early elementary years, children are still to 12 years of age. As the deciduous extremely active and general fidgeting teeth exfoliate, the permanent teeth may be noticed. Also, the child may Examination begin to emerge. By the end of the become fatigued after extended periods 12th year, usually all the permanent of activity. Towards the age of 12, girls Examination of the child in the teeth have erupted, except for third begin to experience growth spurts and transitional period focuses on molars. changes associated with puberty. Because bringing the child from primary During the elementary school girls mature earlier than boys, about dentition through mixed dentition to years, the child’s cognitive abilities two to three years, girls may be taller the permanent dentition. In inter- greatly expand. Communication and and larger than boys of the same age. viewing the child in this age group knowledge strengthen with each year. and his or her parents at the oral The capability of thinking health care appointment, additional operationally and mentally reversing Oral Diseases risk assessment factors need to be actions is acquired during this time addressed. These include sports period.40 Children in this stage of Even with the decline in decay that trauma, tobacco products, the child operations move freely from one has occurred over the years in school- making diet choices, and the child’s point of view to another; thus they age children, dental caries continues ability to provide his or her own are able to be rather objective in to be a common problem. A 1963–1965 home oral health care. evaluating events.37 This cognitive nationwide survey conducted by the The intraoral examination of the milestone allows the child to evaluate National Center for Health Statistics school-age child should include perio- the requests made by the oral health found a mean decayed, missing, and dontal evaluation. Keep in mind that care practitioners, and if deemed filled tooth (DMFT) rate for six-to erupting teeth may have a deeper sulcus reasonable, respond appropriately. 11-year-olds to be 1.4 DMFT.54 The because of the associated inflammation. Between ages six and 12, children National Institute of Dental and Children are less likely to brush begin to accept societal norms. Craniofacial Research also surveyed around exfoliating and erupting teeth Temper tantrums and crying as a six- to 11-year-olds in 1986–1987 and because of the discomfort and means of expressing dissatisfaction discovered a mean 0.71 DMFT, a difficulty of brushing these areas. diminish. Being socially accepted by 50% decline.55 Radiographic evaluation of the their peers is emotionally satisfying to The prevalence of gingivitis peaks mixed dentition may require additional school-age children. during the prebupertal and pubertal types of radiographs. Identifying Physically, as the child progresses period.50 Increased hormonal activity missing teeth, supernumerary teeth, through the school years, fine motor and poor plaque control during this and developmental status of the development becomes quite good. In period may further aggravate gingivitis. dentition may entail a panoramic Access—Special Supplemental Issue 15
  15. 15. radiograph. A variety of combinations primary remover of plaque in his or nutritionally empty foods may lead to of radiographs may be necessary to reveal her mouth, the parent should obesity and nutritional deficiencies. tissue areas, pathology, and develop- periodically evaluate the child’s oral After school tends to be a time mental problems. Radiographs should care. Using disclosing tablets can help when the child snacks. Counseling the always be justified to keep X-ray a child and parent assess thoroughness child and parent on healthful snack exposure to a minimum. of plaque removal. choices and avoiding continuous Around the age of eight to nine eating needs to be reinforced. The years, the child’s fine motor skills Food Guide Pyramid can be used as a Fluoride usually have developed enough to resource in developing healthy eating begin f lossing. Because f lossing is a practices (Figure 5). Both topical and systemic time consuming technique, the f luoride intake is important in the bathroom area may not be the most prevention of dental decay in school- conducive place to f loss. Recom- Sealants age children. Enamel formation mending f lossing while watching a continues in developing permanent television program could provide the Tooth surfaces with deep pits and teeth until around eight years of age. time needed to f loss. fissures are especially susceptible to Fluorides applied to erupting teeth Children in orthodontic treatment dental caries. In the permanent provide greater protection to these will need to modify brushing and dentition, a majority of caries are susceptible teeth. Since the child is flossing to clean around brackets, wires, found on the occlusal surfaces. The becoming increasingly responsible for and appliances. Around 50% of patients discovery of the acid etch technique, his or her oral health, sometimes with banding and bonding develop etching enamel with phosphoric acid, home oral health care becomes poor. demineralized white spot lesions.56 An led to the development of sealant Plaque, inadequately removed during orthodontic patient could include a application. When deciding to place a brushing and f lossing, can act as a daily f luoride mouthrinse to help dental sealant, the following factors reservoir for f luoride. High-caries- with remineralization of potential should be considered: if dental caries risk children may require a daily white spot lesions. are present, if the tooth can be application of a more concentrated Healthful eating practices become adequately isolated, if there is a prescription f luoride. more challenging as the child grows. history of caries, and if the pit and School activities, sports, and social fissure morphology is deep or events may begin to disrupt regular smooth. The first step in the Home Oral Health Care meal times. Many families choose fast placement of sealant is to clean the foods and convenience meals. Also, tooth surface to remove organic Parents need to remain a presence soft drink consumption becomes a debris. The surface can be debrided in their child’s oral home care. matter of concern. A daily diet filled with a prophy cup, toothbrush, or Although the child is becoming the with high-calorie, high-fat, and explorer tip. Using a f luoridated paste while cleaning the surface will not reduce shear bond strengths.57 Keeping the tooth isolated is the most challenging and most critical procedure in the success of the sealant. A simple yet effective step in achieving isolation is placing the patient’s head back, with his or her chin pointing towards the ceiling. When isolating mandibular molars, using cotton roll holders and bending a triangular salivary shield to fit next to the alveolar ridge and over the dorsum of the tongue will help prevent the tongue from contaminating the tooth surface (Figure 6). For Figure 5. Food Guide Pyramid. maxillary molars, keeping the mouth United States Department of Agriculture Center for Nutrition Policy and Promotion. mirror to the lingual of the tooth 16 Special Supplemental Issue—Access