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Prevention of Dental Caries in Children Younger Than 5 Years Old

Профилактика кариеса зубов у детей в возрасте до 5 лет

 

 

Keywords:

dietary carbohydrates – пищевыеуглеводы

incisors – резцы

first primary molars – первыекоренныезубы

cavities – полости

facial cellulitis – целлюлитлица

the burden of bacteria – бремябактерий

feeding practices – практикавскармливания

behavioral interventions – поведенческиевмешательства

resistance – устойчивость

rinses – полоскания

enamel fluorosis - флюорозэмали

swallowing – глотание

 

Etiology and Natural History

Dental caries is a disease that occurs when bacteria, predominantly Streptococcus mutans, colonize the tooth surface and metabolize dietary carbohydrates (especially refined sugars) to produce lactic and other acids, resulting in demineralization ofteeth. In children age 12 to 30 months, caries typically initially affects the maxillary primary incisors and first primary molars, reflecting the pattern of eruption. Dental caries first manifests as white spot lesions, which are small areas of demineralization under the enamel surface. At this stage, the caries lesion is usually reversible. If oral conditions do not improve, demineralization progresses and eventually results in irreversible cavities, with a loss of the normal tooth shape and contour. Continued progression of the caries process leads to pulpitis and tooth loss, and can be associated with complications such as facial cellulitis and systemic infections.

Risk Factors and Indicators

Risk factors for dental caries in young children include high levels of cariogenic bacterial colonization, frequent exposure to dietary sugar and refined carbohydrates, inappropriate bottle feeding, low saliva flow rates, developmental defects of tooth enamel, low socioeconomic status, previous caries, maternal caries, high maternal levels of cariogenic bacteria, and poor maternal oral hygiene. Other risk factors include lack of access to dental care, low community water fluoride levels, inadequate tooth brushing or inadequate use of fluoride-containing toothpastes, and lack of parental knowledge regarding oral health.

Rationale for Screening and Screening Strategies

Screening for dental caries and risk for caries in young children prior to school entry could identify caries at an earlier and reversible stage, and lead to interventions to treat existing caries, prevent progression of caries, and reduce incidence of future lesions. Screening strategies typically include oral health risk assessment and visual examination to identify high-risk children, including those who already have caries. Primary care clinicians can play an important role in screening for dental caries because many young children routinely see a primary care provider starting shortly after birth but do not see a dentist until they are older.Approximately three-quarters of children under age 6 years did not have at least one visit to a dentist in the previous year, although the proportion with a visit increased from 21 percent in 1996 to 25 percent in 2004. Access to dental care is limited by many factors, including shortages in dentists treating young children, particularly children who are not insured or who are publicly insured. Once children enter school, there are additional opportunities for screening and treatment.

Interventions and Treatment

In young children at risk for dental caries, interventions focus on reducing the burden of bacteria, reducing the intake of refinedsugars, and increasing the resistance of teeth to caries development. Strategies to reduce the burden of bacteria include the use of fluoride, parental counseling to improve oral hygiene, xylitol, and topical antimicrobials such as chlorhexidine or povidone iodine. Educational and behavioral interventions can reduce intake of refined sugars through changes in diet and feeding practices. Children with caries or at risk of caries can also be referred for needed dental care.

Fluoride increases the resistance of teeth to caries development. Fluoride exposure can be topical (fluoride dentifrices, rinses, gels, foams, varnishes) or systemic (dietary fluoride supplements). Effects of fluoridated water are both topical and systemic. After exposure, fluoride is incorporated into dental plaque, saliva, and tooth enamel, and increases tooth resistance to acid decay, acts as a reservoir for remineralization of caries lesions, and inhibits cariogenic bacteria. A potential harm of excessive systemic fluoride exposure is enamel fluorosis, a visible change in enamel opacity due to altered mineralization. The severity of change depends on the dose, duration and timing of fluoride intake, and is most strongly associated with cumulative intake during enamel development. Mild fluorosis manifests as small opaque white streaks or specks in the tooth enamel. Severe fluorosis results in discoloration and pitted or rough enamel. The prevalence of severe enamel fluorosis in the United States was estimated at less than 1 percent in the period 1999 to 2004.

Topical fluoride is typically applied as a varnish in young children. Unlike fluoride gels, which are commonly used in older school-aged children, fluoride varnish does not require specialized dental devices or equipment and can be applied quickly without the risk of the child swallowing large amounts, which can cause transient gastric irritation. Compared with other topical fluoride application methods (such as acidulated phosphate fluoride or sodium fluoride gel), systemic exposure to fluoride is low following application of fluoride varnish. The varnish results in prolonged contact time between the fluoride and the tooth surface, enhancing incorporation into the tooth surface layers and more prolonged release. Fluoride varnish is typically available in the United States as 5-percent sodium fluoride (2.26% fluoride).

Xylitol is a naturally occurring sugar with properties that reduce levels of caries-forming mutans streptococci in the plaque andsaliva. In young children, xylitol can be administered as a syrup or topically via wipes. In older children, xylitol can also be administered in gum, lozenges, or snack foods. Other topical antimicrobials such as chlorhexidine varnish and povidoneiodinerinses are not in common use in young children in the United States or are not available, as in the case of chlorhexidine varnish.

Current Clinical Practice

Since the publication of the Surgeon General's Report on Oral Health in 2000, many organizations have emphasized the importance of preventive oral health care for young children, particularly in the primary care setting. The American Academy of Pediatrics (AAP) has developed an oral health risk-assessment tool for use in primary care settings starting at the 6-month visit, along with suggested interventions for children at risk. The American Academy of Pediatric Dentistry (AAPD) developed the Caries-risk Assessment Tool (CAT), designed for use by dental and nondental personnel. Although the vast majority of pediatricians agree with recommendations on oral health screening, only about half report examining the teeth of more than half of their patients age 0 to 3 years, and few (4 percent) report regularly applying fluoride varnish.

Recommendations of Other Groups

In 2003, the AAP issued a policy statement that encouraged practitioners to incorporate oral-health–related services into their practice by engaging in oral health assessments, anticipatory guidance, and preventive services, including making referrals to dentists. More specifically, an oral health assessment was recommended for all children by age 6 months and a first dental visit by age 1 year. These recommendations were reaffirmed in 2009 and were also endorsed by the Bright Futures program. In a second policy statement, the AAP supported the use of dietary fluoride supplementation and the application of fluoride varnish for children at risk for dental caries. The American Dental Association (ADA) recommends the application of fluoride varnish every 6 months in preschool children at moderate risk of dental caries and every 3 to 6 months in those at high risk. The American Academy of Family Physicians, the ADA, and others recommend that clinicians consider the use of dietary fluoride supplementation in children age 6 months to 16 years who lack access to adequately fluoridated drinking water.Recommended doses of dietary fluoride supplementation range from 0.25 to 1.0 mg per day, depending on age, the level of community or household water fluoridation, and ingestion of other dietary fluoride sources. Dietary fluoride supplementation is not recommended when water fluoridation levels are greater than 0.6 parts per million fluoride (ppm F) or when caries risk is low.

The U.S. Centers for Disease Control and Prevention recommend that clinicians counsel parents about appropriate use of fluoride toothpaste, especially in children under age 2 years; prescribe dietary fluoride supplements in children at high risk of dental carieswhose drinking water lacks adequate fluoride, and limit the use of products with high fluoride concentration, such as varnish and gel, to high-risk individuals. It recommends that clinicians account for overall ingestion of fluoride through diet, drinking water, and other sources and consider the risk of dental fluorosis before prescribing supplements or applying products with high fluoride concentration.

 

The AAPD recommends use of xylitol in age-appropriate formulations for moderate- and high-risk children. The ADA recommends xylitol in children age 5 years or older, recommends against use of chlorhexidine varnish, and found insufficient evidence to determine effectiveness of povidone iodine.