Key points

Introduction

This article provides a brief introduction to the oral health of children and the barriers to dental care as well as some discussion on prevention and treatment modalities for dental caries. Also covered is the epidemiology of dental caries, caries risk assessment, and the involvement of pediatricians in advocating for and providing preventive dental care for children. Dental caries, one of the most common dental diseases, is also referred to as tooth decay or cavities by the public. Dental caries is a recognized public health concern that results from the repeated interaction of oral bacteria, primarily mutans streptococci, with fermentable sugars leading to acid production that results in microscopic dissolution of minerals in dental hard tissues and the formation of opaque white (white spot lesions) or brown spots on teeth.

Early childhood caries (ECC) is the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child before the age of 6 years. ECC is considered severe if the smooth surfaces of the teeth are affected in children less than 3 years old. Early and preventive dental care is cost-effective in reducing dental disease burden, as well as in establishing a dental home as a foundation on which a lifetime of preventive education and oral health care can be built. Routine or preventive dental visits are important for early diagnosis, prevention, and treatment of dental caries and for establishing and maintaining good oral health and overall well-being

Introduction

This article provides a brief introduction to the oral health of children and the barriers to dental care as well as some discussion on prevention and treatment modalities for dental caries. Also covered is the epidemiology of dental caries, caries risk assessment, and the involvement of pediatricians in advocating for and providing preventive dental care for children. Dental caries, one of the most common dental diseases, is also referred to as tooth decay or cavities by the public. Dental caries is a recognized public health concern that results from the repeated interaction of oral bacteria, primarily mutans streptococci, with fermentable sugars leading to acid production that results in microscopic dissolution of minerals in dental hard tissues and the formation of opaque white (white spot lesions) or brown spots on teeth.

Early childhood caries (ECC) is the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child before the age of 6 years. ECC is considered severe if the smooth surfaces of the teeth are affected in children less than 3 years old. Early and preventive dental care is cost-effective in reducing dental disease burden, as well as in establishing a dental home as a foundation on which a lifetime of preventive education and oral health care can be built. Routine or preventive dental visits are important for early diagnosis, prevention, and treatment of dental caries and for establishing and maintaining good oral health and overall well-being

Barriers to children’s oral health

Oral health means more than taking care of the teeth; it refers to the health of the oral cavity and its supporting structures. Oral health is integral to general health and it contributes to overall health and well-being. Despite documented improvement in the oral health of most Americans, access to dental care continues to be a problem in the United States. Inadequate access to dental care cuts across age, gender, and socioeconomic and geographic boundaries. Children from racial and ethnic minorities and low-income families, the uninsured, poor inner-city children, and those with special needs are disproportionately affected by dental diseases and have the most inadequate access to dental care. This problem to persists even with the many years of research into the cause and prevention of common dental diseases. Oral health care remains one of the most challenging and prevalent unmet health needs among infants, toddlers, adolescents, and young adults in the United States and developing countries.

Barriers to children’s oral health exist, especially for Medicaid enrollees. These barriers include workforce maldistribution and/or inadequate numbers of dentists, low Medicaid reimbursement rates, and high administrative burden. In addition, there is a severe shortage of minority dentists to serve the growing racial/ethnic minority Medicaid enrollees. As Okunseri and colleagues have reported, minority dentists are more likely to accept new Medicaid patients. Furthermore, studies have documented that children from low-income families have lower odds of receiving comprehensive dental care and higher odds of having acute dental disease than children from middle-income and upper-income families. To remedy these problems, professional organizations and government agencies continue to work towards expanding the workforce and developing various alternatives, such as school-based sealant and fluoride varnish application programs. These programs are usually managed by dental professionals, including dental hygienists and assistants. In addition, pediatricians and family physicians conduct oral health risk assessment and provide preventive care that includes anticipatory guidance in their offices.

Epidemiology of dental caries

Most children are susceptible to dental caries throughout their lives. However, with the knowledge of epidemiology, dental care providers and researchers have a better understanding of the distribution and determinants of dental caries in different population groups. They also have the opportunity to engage in anticipatory guidance and risk assessment, and to use different modalities of caries prevention. Although different classifications and indices of caries have been used in epidemiologic studies, the facts related to who is affected and by how much in different populations still remains easy to comprehend. Understanding dental caries epidemiology is crucial to providing appropriate clinical care and to identifying relevant public health measures to control the disease. However, because of some of the limitations associated with epidemiologic studies, clinicians are encouraged to engage in caries risk assessment.

In the last 20 years or so, epidemiologic studies have documented an overall decline in dental caries prevalence caused by population exposure to fluoride in water, toothpastes, mouth rinses, and in topical products applied in dental offices. In addition, improved oral hygiene, increased awareness of the relevance of dietary influence on caries, and changing patterns of refined sugar consumption have contributed to this decline. Findings from epidemiologic studies continue to be used to support health care planning and resource allocation as well as in the monitoring of Healthy People 2020 objectives related to oral health.

The National Health and Nutrition Examination Survey (NHANES) 1988 to 1994 and 1999 to 2004 shows that the prevalences of untreated dental caries for children 2 to 5 years old and 6 to 11 years old were 19.1% versus 20.1% and 25.5% versus 25.0% in the primary dentition, respectively. Disparities in dental caries burden persisted in all NHANES surveys. For example, NHANES 2009 to 2010 showed that prevalence of untreated caries was significantly higher among non-Hispanic black children (19%), compared with non-Hispanic white children (11%) aged 3 to 5 years. In terms of poverty status, children aged 3 to 5 years and 6 to 9 years living in families at or below 100% of the federal poverty level had a significantly higher number of untreated dental caries compared with those living above the poverty level.

Caries risk assessment

Risk refers to the probability that some unwanted event might occur. Caries risk assessments are as important as the specific diagnosis of the disease. The identification and mitigation of risk is the foundational component of the nonsurgical management of dental caries. According to the guidelines published by the American Academy of Pediatric Dentistry (AAPD) on caries risk assessment for infants, children, and adolescents, risk assessment is considered a part of the standard of care for treating children. Recent initiatives to include members of the medical profession in identifying patients at risk for dental caries have greatly assisted in the mitigation of some of the risk factors and it is hoped will lead to better outcomes for the population. Educating medical colleagues in dental caries prevention, risk assessment, and referral is important to overall reduction in caries incidence and achieving excellent oral health in children.

Numerous researchers have identified caries risk factors documented by AAPD. These risk factors include mother/caregiver with active cavities; parent/caregiver of low socioeconomic status; child with more than 3 between-meal, sugar-containing snacks or beverages per day; child put to bed with a bottle containing natural or added sugar; child with special health care needs; and recent immigrant children. In 1981, Berkowitz and colleagues found similar oral bacteria in a mother and her child, and their research indicated that mothers with high salivary levels of Streptococcus mutans were 9 times more likely than mothers with low levels to transmit their oral bacteria to their children. Kohler , 1988 showed that children colonized by S mutans at an age younger than 2 years had significantly more decayed, filled surfaces (decayed, filled surface of 5.0 vs decayed, filled surface of 0.3) than children who were not colonized at that age. Southward and colleagues showed that parents with abscessed teeth were significantly more likely to have children with urgent oral care needs. Thitasomakul and colleagues also showed that mothers with greater than or equal to 10 decayed teeth had children with higher incidences of cavities.

Parents/caregivers from low socioeconomic backgrounds have consistently been associated with dental caries. Low socioeconomic status can lead to poorer food choices high in sugar content. The classic Vipeholm caries studies show that the frequency and not necessarily the total amount of sugar consumption is more predictive of having dental caries, thus supporting that children with greater than 3 between-meal sugar-containing snacks or beverages per day are at increased risk for dental caries. In addition, putting a child to bed with a bottle containing natural or added sugar has been documented as a risk factor for dental caries. The sugar consumed through a bottle when a child is put to bed tends to remain on the teeth for prolonged periods of time, which allows an extended period of bacterial acid generation with limited oral clearance and poor salivary buffering. The result is a greater amount of mineral dissolution from the teeth, eventually leading to cavity formation.

The AAPD’s 2007 symposium on patients with special health care needs enumerates many reasons why children with special health care needs are considered to be at higher risk for dental caries. These reasons include increased focus on the intensive medical attention required for their overall general health, limited oral muscle coordination and retention of foods in the oral cavity longer than healthy children, difficulty of parents/caregivers in providing adequate oral hygiene, and the requirement for special dietary formulations resulting in more frequent feedings.

Prevention of dental caries

Following caries risk assessment, the treatment of clinically evident dental caries involves both nonsurgical and surgical management. Greater emphasis is placed on nonsurgical management methods before surgical intervention when lesions are not cavitated, which has great potential not only to reduce morbidities associated with the delivery of dental care (local anesthesia, removal of both diseased and sound tooth structure, possible sedation/general anesthesia) but also to reduce the risk of future disease, something that surgical restoration alone does not do.

As part of the nonsurgical approach, dentists have traditionally engaged in the distribution of written information to their patients in the form of brochures/pamphlets, or public dental advertising in magazines, radio, and even television. Some providers also show videos in their offices in an attempt to educate both parents and children. This traditional approach has the expectation of altering the behavior of both parents and children, mostly within the high-risk populations. However, this approach relies on a 1-way communication from the expert (provider) to the patient and has sometimes proved to be unsuccessful.

A different approach has shown promising results: brief counseling. This approach involves brief motivational interviewing with follow-up by phone. This approach relies on a 2-way communication and tries to engage the parent in a healthy discussion. It has been reported that, when the counselor does most of the talking, counseling usually fails. Clinical studies involving brief counseling have reported a potential benefit with the use of this technique. Weinstein and colleagues, in a 2004 study, compared traditional health education (pamphlet and video) with a brief motivational interview counseling intervention (pamphlet and video plus 1 counseling session and 6 follow-up telephone calls from a lay health counselor). Results after 1 and 2 years showed a positive impact for the brief counseling group. At 1 year, children in the counseling group had 0.71 new carious lesions compared with 1.91 in the traditional group. The data were similar for the second year. Motivational interviewing is an approach that has shown promising results in the improvement of the oral health of those children at risk. In 2002, a survey of dental schools in Canada and the United States concluded that instruction in interpersonal communications skills was not adequate. However, some dental schools are already teaching counseling skills similar to motivational interviewing.

Other preventive approaches used both at the dental office and home include pit-and-fissure sealants, fluoride varnish, amorphous calcium phosphates, and xylitol. Sealants are a thin plastic coating placed on the chewing surfaces of posterior teeth and are considered safe, cost-effective, and easy to apply. As long as they remain intact, they have been shown to reduce caries on these surfaces by 40% to 100%, especially in high-risk populations. The American Dental Association (ADA) has published recommendations on the use of sealants as both a preventive and therapeutic service on noncavitated and inactive carious lesions.

Despite strong evidence-based reports about the effectiveness of this caries preventive technique, pit-and-fissure sealants continue to be under prescribed, particularly among those at high risk for experiencing caries. That population include children from lower-income families and certain racial and ethnic groups. The national oral health objectives for dental sealants, as stated in Healthy People 2010, includes increasing the proportion of children who have received dental sealants on their molar teeth to 50%. However, national data collected from 1999 to 2002 indicated that sealant prevalence on permanent teeth among children aged 6 to 11 years was only 30.5%.

Another nonsurgical approach is fluoride application from various sources. Once dietary issues have been adequately addressed, fluoride stabilizes the apatite mineral, has bactericidal properties, and results in the remineralization of new tooth minerals, making it significantly more resistant to further decay. The mineral apatite is the base mineral in the structure of teeth. It can exist in multiple forms, but in the human body chiefly exists in 3 forms: carbonated apatite, hydroxyapatite, and hydroxyfluorapatite. The major apatite present in a newly erupted tooth is carbonated apatite, which has a critical pH (the pH at which the mineral is saturated with respect to the solution) of approximately 6.5. The normal pH of the saliva is close to the normal physiologic pH of the body: between 7 and 7.4. On fermentation of carbohydrates, the cavity-causing families of bacteria (mutans streptococci and lactobacilli) cause a shift in the plaque pH to less than 4.5, resulting in dissolution of the tooth mineral. Hydroxyapatite is a much more stable crystal than carbonated apatite at pHs of less than 6.5. This process results in a preferential reformation of hydroxyapatite mineral. Hydroxyapatite’s critical pH is approximately 5.5. Thus, this maturation of the enamel, the replacement of carbonate ions with hydroxide ions, results in a mineral that requires 10 times as much acid to dissolve it than the original mineral.

Fluoride’s ability to replace other ions in the hydroxyapatite mineral of which teeth are composed results in increased resistance to the dissolution of the teeth in the oral cavity. Fluoride incorporation into the tooth structure, either pre-eruptively or post-eruptively greatly helps in reducing the risk of caries in individuals, but post-eruptive fluoride incorporation seems to provide the greatest benefit. However, if the fluoride ion is present in the plaque and saliva, the substitution of hydroxide with fluoride is a significantly more stable mineral than hydroxyapatite, and hydroxyfluorapatite is preferentially reformed in the tooth. The critical pH of hydroxyfluorapatite is approximately 4.8. Therefore, with fluoride incorporation, it takes almost 100 times more acid to dissolve the hydroxyfluorapatite than the original carbonated apatite. With the demineralization and remineralization process continuing throughout the day, the maintenance of low levels of fluoride in the plaque and oral fluids throughout the day has the greatest effect at reducing caries incidence. If the patient lives in a location with nonfluoridated public water supplies (either municipally provided or via a private well) the AAPD and the American Academy of Pediatrics (AAP) recommend supplementation with fluoride tablets.

Xylitol is another product routinely prescribed in dental offices for caries prevention. Xylitol is a natural sweetener that is obtained from birch wood, corn stalks, and other sources. Multiple studies have suggested that this sugar alcohol assists in the arrestment of the caries process and can reduce the transmissibility of mutans streptococci. Difficulties in compliance with the required daily dosage (5–10 g/d in 3–5 divided doses) contribute to the lack of effectiveness with this product. In addition, concerns with osmotic diarrhea also reduce the frequency of recommendation. Dosages of up to 45 g/d for children 7 to 16 years old resulted in no significant increase in gastrointestinal disturbances compared with no xylitol consumption. Compliance with the dental benefits of 5 to 10 g/d has a very low risk of gastrointestinal distress.

Amorphous calcium phosphates have been shown to both decrease demineralization and increase remineralization of early carious lesions, most likely because of the common ion effect on the equilibrium of the apatite crystal. Other reports indicate that the calcium phosphopeptide–amorphous calcium phosphate (CPP-ACP) also affects the bacteria related to dental caries. However, a more recent report indicates that long-term low levels of fluoride are more effective at caries prevention than CPP-ACP.