33 Dental and Oral Disorders
The mouth serves many functions, including speech, and is richly endowed with special systems that serve complex needs; it is increasingly recognized as a barometer of health and well-being throughout life. For this reason, good oral health is essential for normal growth and development. Saliva is replacing serum and blood as the vehicle for noninvasive diagnostic tests for systemic diseases in some cases. Many of these tests are already on the market.
In children, microbial infections caused by bacteria, viruses, and fungi cause tooth decay (dental caries), periodontal or gum diseases, herpes labialis, and candidiasis. Moreover, inherited and congenital conditions result in impairments and cosmetic defects that have serious effects on children as they grow and develop. Lifestyle choices such as tobacco and drug use, body art, and piercings create challenges for maintaining oral health.
Dental problems, particularly tooth decay, are much more common than asthma and can restrict normal daily activity. Dental caries are the most common infectious disease of children. The unmet dental needs of children 2 to 17 years in the U.S. over the past nine years have been steady at 6% to 7% (Blackwell, 2010; Bloom et al, 2009; U.S. Department of Health and Human Services [USDHHS], 2010). Increased demand for dental services is compounded by an inadequate supply of dentists and a maldistribution of pediatric dentists, especially in underserved areas. In addition, the dentist-to-population ratio continues to decline (Nash, 2009).
Ensuring an adequate workforce to meet the needs of children requires involvement of primary care providers (PCPs). They are in a unique position to play a critical role in preventing oral disease, identifying and minimizing the effects of disease, and providing guidance to parents and children about oral health. And yet, Danielson and colleagues’ study (2006) found that although 82% of the physician assistants and nurse practitioners recognized the importance of performing an oral examination, less than half expressed confidence in their ability to do so. These results largely reflect similar findings of a study of physicians that revealed that although 84% knew the importance of oral examinations, only 19% performed the examination routinely; 56% expressed lack of confidence in their skills, and 77% felt their training was insufficient (Morgan et al, 2001). In response, this chapter offers information and practical answers for providers in everyday practice to ensure they have basic examination competencies; are able to distinguish between normal and abnormal structures, pathology, and common oral diseases; feel competent to educate regarding oral health and prescribe and apply preventive treatment (e.g., fluoride and fluoride varnish); and know when to refer to dentists (Danielson et al, 2006).
Normal Growth and Development
Anatomy of the Mouth
The structures of the mouth include the mucosa (buccal and gingival), palate, salivary glands, frenula, tongue, and teeth.
The Teeth
Anatomy of a Tooth
Primary and permanent teeth have similar anatomy, differing primarily in the size and external shape of each tooth. Figure 33-1 shows a cross section of the typical tooth including the crown (white part), neck, and root (encased in bone).
Pattern of Tooth Eruption
The first primary tooth (also called baby tooth or deciduous tooth) may be present at birth. Normally the eruption of primary teeth begins with the anterior primary teeth, occurs during the first 6 to 8 months of life, and ends at about 30 to 36 months old with the maxillary second molars. The sequence of eruption and the timing of eruption for each tooth are similar for both sexes. Variability in the age of children at emergence of the individual teeth is small, with a standard deviation of 2 to 3 months. In most children, the 20 primary teeth (10 per arch) erupt in a period spanning about 2 years.
The permanent teeth begin erupting as children reach school age (about 6 years old), and the jaws grow. The eruption of permanent dentition begins with eruption of the mandibular central incisors and ends with the eruption of the maxillary third molars. The primary teeth are shed as the permanent ones erupt. The permanent molars erupt behind the primary molars. The shedding and replacement of the primary molars by permanent premolars is usually complete around the fifth grade or by 12 years of age. This period, when both primary and permanent teeth are present, is called transitional dentition. The total period of eruption of permanent teeth (except for the third molars) spans about 6 years in most children.
In general, the variability in eruption times for the permanent dentition is much greater than the variability observed in the primary dentition, with standard deviation of 8 to 18 months (about five times greater than in the primary dentition). The sequence of permanent tooth eruption is almost identical for both sexes. However, all teeth erupt earlier in girls than in boys. The gender difference in eruption times averages approximately 6 months. The tooth eruption pattern for both the primary and permanent dentitions is listed in Table 33-1.
TABLE 33-1 Calcification, Crown Completion, and Eruption
Tooth | Age of Eruption |
---|---|
Primary Dentition | |
Maxillary | |
Central incisor | 7½ months |
Lateral incisor | 8 months |
Canine | 16-20 months |
First molar | 12-16 months |
Second molar | 20-30 months |
Mandibular | |
Central incisor | 6½ months |
Lateral incisor | 7 months |
Canine | 16-20 months |
First molar | 12-16 months |
Second molar | 20-30 months |
Permanent Dentition | |
Maxillary | |
Central incisor | 7-8 years |
Lateral incisor | 8-9 years |
Canine | 11-12 years |
First premolar | 10-11 years |
Second premolar | 10-12 years |
First molar | 6-7 years |
Second molar | 12-13 years |
Third molar | 17-21 years |
Mandibular | |
Central incisor | 6-7 years |
Lateral incisor | 7-8 years |
Canine | 9-10 years |
First premolar | 10-12 years |
Second premolar | 11-12 years |
First molar | 6-7 years |
Second molar | 11-13 years |
Third molar | 17-21 years |
Adapted from Logan WHG, Kronfeld R: Development of the human jaws and surrounding structures from birth to age fifteen years, J Am Dent Assoc 20:379, 1993.
Managing Teething
Often, teeth pierce the gums without causing any symptoms. However, some children show local symptoms, such as redness and swelling in the oral mucosa overlying the erupting tooth. These symptoms appear a few days before clinical eruption. The child may also show signs of irritation, drooling, and sometimes slight fever.
Recommended treatments for teething discomfort include topical treatments, such as chewing on a cold teething ring, pacifier, or even ice. Massaging the gums with a wet finger or a cold spoon may also be helpful. Topical analgesics containing benzocaine gel are marketed for this purpose and may be recommended. Exercise caution regarding topical benzocaine because of potential sensitivity. Oral acetaminophen is an effective remedy.
A great number of folk remedies are used, especially in communities without good access to medical care (Smitherman et al, 2005). Rubbing whiskey on the gums or tying a penny on a string around the child’s neck (creates a potential risk of strangulation) are discouraged, as is using a honey-coated pacifier that might cause tooth decay or introduce botulism. At least one case of methemoglobinemia has been reported in a 6-year-old after the use of Baby Orajel for a toothache (had symptoms of cyanosis, vomiting, lethargy, and tachycardia) (Chung et al, 2010). Overuse of topical salicylates can cause burns.
The Oral Examination
Performing an Infant or Child Oral Exam
An infant’s teeth and oral tissues are examined most easily by placing the child on his or her back on an examining table with the head toward the end of the table. Have the parent restrain the legs and hands. Stand at the head of the table and use a tongue blade or toothbrush as a mouth prop. Use a penlight and intraoral mirror for optimal visualization. Tip the head back to see the upper teeth. The examination table approach is also useful for looking at the teeth of older children. Trying to examine the mouth and teeth with the child sitting in the parent’s lap is not recommended because the provider has to bend over to see the upper teeth, and the crying and movement of the child make visibility very poor.
An alternative for examining a small child is the knee-to-knee approach favored by many dentists. In this approach, the provider and parent sit knee to knee. The parent holds the child facing him or her and then lowers the head into the provider’s lap. The child’s legs are wrapped around the parent’s waist. Again the parent restrains the hands. Small children may cry during the examination, but the crying will stop as soon as the examination is completed.
Clinical Findings
An oral and dental examination should be systematic. During the examination, take the opportunity to point out abnormalities (e.g., tooth decay) to the parent.
Oral Mucosa
The soft mucosal tissues are examined before the teeth. This part of the examination should also include an assessment of the tonsils for size and the presence of inflammation or exudate.
Start the examination with the inside of the lips and continue to the mucosa on the inside of the cheeks, including the mucosal surfaces that connect and surround each tooth. Inspect the palate directly by tipping the child’s head backward. Use a mirror to help direct light to the soft palate. Examine the dorsal and ventral mucosal surfaces of the tongue and floor of the mouth by retracting the tongue with a tongue blade, a dental mirror, or by holding the tongue with cotton gauze. Ulcerations, changes in color and surface texture, swelling, or fistulae of any of these tissues should be noted.
When examining the gums, give special attention to any swelling or retraction of the gingiva where the gums meet the tooth surface. Such symptoms can be a notable sign of tooth or gingival abnormality typical of periodontal disease in peripubertal children and adolescents. Note the presence and attachment of frenula, with special emphasis on the possible complicating effects of high insertion of such frenula on the periodontal tissues.
Saliva
Salivary flow does not appreciably change over the life span. Note the quantity and quality of the saliva; thick or ropy saliva or a dry mouth may be abnormal. Decreased salivary flow and changes in sensation in the area of the facial nerve can result from infection or tumor in the parotid space or facial musculature, or can be a side effect of dehydration or medications.
Teeth
Examine the teeth systematically by beginning with the upper right buccal or facial surfaces and moving around to the left. Then from left to right, examine the lingual surfaces of the upper teeth. Then examine the biting surfaces in the same systematic manner. After this, move to the lower jaw. The number and types of teeth erupted, color changes, irregularities, and asymmetries should be noted.
Variations in number, morphology, color, and surface structure should be observed under good light after drying the teeth with cotton gauze. Primary teeth may be malformed or have incompletely formed, chalky, or pitted enamel due to other systematic conditions, such as ectodermal dysplasia. In the case of traumatically injured teeth, the color and translucency of the injured tooth or teeth should be evaluated. Slight color changes are often found as one of the first signs of intrapulpal damage after trauma and may lead to an abscessed tooth.
Early tooth decay can be detected most effectively by cleaning the teeth with a toothbrush and then drying them with gauze. Note any surface roughness or loss of surface continuity.
Aberrations in Primary Tooth Eruption
Natal and Neonatal Teeth
The prevalence of natal or neonatal teeth is estimated to be 1:2000 to 3000 births and is equally common in boys and girls. The teeth usually erupt in pairs. Natal and neonatal teeth have been shown to occur in about 50 different syndromes, of which about 10 are associated with chromosomal aberrations. More than 90% of these prematurely erupting teeth are mandibular central incisors belonging to the normal dentition, with normal shape and color. Supernumerary teeth may be abnormal in shape and color and only loosely attached to the gingiva. Natal or neonatal teeth can lead to gingivitis, self-mutilation of the tongue, and trauma to the mother’s breast. However, they should be extracted only if they are loose enough to involve risk of aspiration or if feeding is severely disturbed. Most will develop normally with normal root structure (Leung and Robson, 2006).
Delayed tooth eruption
Delayed tooth eruption can result from either systemic or local factors. These include prematurity, low birthweight, genetic syndromes (e.g., Down and Turner syndromes), a diet low in protein, children born to mothers with severe goiter (iodine deficiency), hereditary gingival fibromatosis, and adjacent supernumeraries or dental tissue tumors (odontomes) (Crawford and Aldred, 2005; Hayes and Thornton, 2007). In general, children with chronic diseases who show delay in both physical and dental development experience delayed but otherwise normal tooth eruption. Parents may need reassurance if there is some delay. Once the child is old enough to tolerate dental x-rays, no earlier than 4 years old and often later, diagnostic films can be taken to provide a better assessment of the developing dentition.
Other Gum Events
Preeruption Cysts
When a tooth starts erupting through the gingival tissue, a blood-filled cyst may precede it. Alarmed parents may report a purple, reddish, black, or blue bump or bruise in their child’s mouth. If the enlargement is on the alveolar ridge, reassurance is all that is required. The symptom will resolve as the tooth erupts (Fig. 33-2).
Congenital Epulis
Congenital epulis is a fibrous, pedunculated, soft-tissue enlargement that occurs on the maxillary alveolar ridge at birth (Fig. 33-3). This condition is more common in female babies. It typically regresses with time, but large lesions should be excised.
Bohn Nodules
Bohn nodules are present at birth and appear as firm nonpainful nodules on the buccal surface of the alveolar ridge (Fig. 33-4). They are remnants of dental lamina connecting the developing tooth bud to the epithelium of the oral cavity. No treatment is required because they will resolve spontaneously. If they appear in the midline of the palate, they are referred to as Epstein pearls.
Professional Dental Care
Access To Dental Care
Numerous studies report considerable disparities in oral health and access to care, with the greatest burden experienced by low-income, ethnic minority children in households with low child or parental education, and in smokers (Beltrán-Aguilar et al, 2005; Edelstein and Chinn, 2009; Klein, 2009; Tinanoff and Reisine, 2009; USDHHS, 2003). Those without insurance are four times as likely to have unmet dental needs as those with some form of public insurance (Bloom et al, 2009). Although Medicaid-enrolled children have better access to dental care than uninsured children (Bloom et al, 2009), they continue to exhibit low dental utilization rates (less than 60%) (Chi and Milgrom, 2009). This could be due to dentists’ unwillingness to accept Medicaid insurance (because of low reimbursements rates) and high no-show rates (Al Agili et al, 2007; Iben et al, 2000). Low preventive care utilization rates can result in a cycle of emergency care with less comprehensive treatment, pain, and then more symptomatic care.
Fear of the Dentist
Parents’ and caregivers’ own fear of the dentist can have a negative effect on the oral health of children. As many as one in five adults in North America profess such fear (Smith and Heaton, 2003). Many of the parents of children with whom primary care providers interact may have this fear and consequently avoid dental visits themselves.
Early and consistent primary prevention is the best way to avoid the development of fear and avoidance (Weinstein and Milgrom, 2006). Allowing tooth decay to go untreated until a child is school age results in extensive restorative intervention—a traumatic experience for any child. Dental restorative care is the only area of medicine in which children are expected to endure extensive surgery while they are awake. Hospitalizing children and performing reparative services under general anesthesia is a scarce, expensive, and risky option. Moreover, the majority of children experience recurrence of disease within 6 months because the surgical treatment does not address the underlying problem.
Choosing a Dentist
The choice of a dentist is critical, especially for children who have had poor previous experiences. Many general dentists are skilled at working with children, so the absence of a pediatric specialist is not a huge barrier. A dentist new to the child should be told about any prior dental experiences. Parents of dentally naive children should be counseled to choose a dentist known to like and work well with children. Parents should be encouraged to ensure that their child has had a good night’s sleep and is fed before a visit. The child’s teeth should be brushed before any visit to the dentist. A parent or caretaker should accompany the child into the treatment room; avoid dentists who are adverse to such. Counsel parents to avoid dentists who rely only on pharmacology to manage behavior, such as using nitrous oxide, oral antihistamines, or narcotics. The most effective strategies are behavioral. Combinations of behavioral and pharmacologic methods—such as distraction and nitrous oxide—can be effective, whereas the drug alone may not be.
Preparation should focus on helping the child develop coping skills and ways to gain control. Children gain control when the dentist briefly explains procedures and allows them to signal any discomfort. An example of a coping skill is relaxation breathing. Finding a dentist who tells stories and riddles, sings to the children, or otherwise distracts them (e.g., with videos, music, or games) is particularly effective. Directed guidance strategies—specific kinds of direction followed by praise—are also very effective in managing children’s behaviors. For fearful children, practitioners can be successful by using structured rehearsals, in which procedures are broken into small steps, and teaching coping strategies. Dentists and parents who rely solely on authoritarian approaches or who are permissive are likely to fail with a fearful child (Weinstein and Milgrom, 2006).
Parents should be cautious about dentists with laser-based diagnostic devices. These devices are often marketed to dentists as being capable of detecting “invisible” cavities. They are being misused to justify unnecessary fillings, often called “preventive resins.” The standard method of examination of the teeth is visual, using strong light and transillumination (shining light through the tooth) without using sharp probes, which can damage teeth and transfer potential pathogenic bacteria from one groove or surface to another. Most tooth decay in permanent teeth in children occurs on the biting surface, and x-rays are of limited diagnostic value in such cases. Parents should be urged to seek second opinions whenever eight or more fillings (two for each quadrant of the child’s mouth) are recommended.
Dental Health Education
Dental health education is a crucial preventive strategy. Tailoring health education messages and instruction to an individual’s capacity to “obtain, process, and understand” reflects a health literacy approach to oral health education. Low parental health literacy is most often associated with early childhood caries, low income, and inadequate maternal education. Low reading literacy, combined with low health literacy, is of particular concern given the dual role a parent plays as decision-maker for self and child. The potential negative consequences for health and safety escalate.
Health information that is accessible to individuals with limited literacy is just beginning to influence dentistry. A review of dental education materials for parents found many required reading skills above the seventh to ninth grades. Additionally, many materials included dental jargon and unnecessarily difficult words (Alexander, 2000). The same study found that more than 80% of secondary school children (spanning a reading level equivalent to that of adults) were unsure of many dental terms, such as “fluoride tablets” and “gum disease.” The advice given in published materials often is inconsistent. In addition, there are many oral health myths that should be dispelled by the PCP during conversations on oral health (e.g., caries in baby teeth aren’t important since they eventually fall out anyway; it is “impossible” to brush children’s teeth; fluoride is unsafe; pregnant women shouldn’t see the dentist).
A good source of reference material on the Internet is www.medlineplus.gov, the consumer side of PubMed from the National Library of Medicine. Access is free, and materials are often in multiple languages. The site includes brochures that can be freely downloaded and copied.
Reducing Disparities Through Preventive Intervention and management
Weinstein and colleagues (2004) have shown that parents of young children are willing and able to change home preventive oral health practices. Using an intervention based on the transtheoretical “stages of change” model of Prochaska and Norcross, individuals overcome self-identified barriers to change, setting goals that are attainable and of personal value (Weinstein and Milgrom, 2006; Weinstein et al, 2004) (see Chapter 9 for discussion of this model).
Beil and Rozier’s study (2010) evaluated whether a recommendation by a PCP to see a dentist resulted in more dental checkups in children. They found that children 2 to 5 years who received such a recommendation were more likely to have a dental examination, whereas children from 6 to 11 years of age showed no increase. This supports the efficacy of the recommendation that primary care providers refer children to a “dental home” at an early age.
Bacterial Diseases of the Mouth
Tooth Decay (Cavities, Dental Caries)
Description and Epidemiology
The Centers for Disease Control and Prevention (CDC) notes that of the approximately 50% of children who have had decay, two thirds of these children are in the 12- to 19-year-old range (CDC, 2010a); about one quarter are from 2 to 5 years old. Tooth decay is a bacterial disease that can result in irreversible damage and potential loss of teeth. The decay is caused by lactic acid demineralization of the tooth subsurface enamel. The acid is produced by an alpha hemolytic streptococcus (mutans streptococci), in older literature referred to as Streptococcus mutans, after metabolism of carbohydrates in the diet. Unless neutralized and buffered by saliva (remineralized), the demineralization process will lead to cavitation. Active cavities are also frequently infected with lactobacilli. The bacterial species are part of the biofilm adherent to the teeth. The bacteria are usually transmitted when saliva is shared between the child, caregivers, or other children (California Dental Association Foundation, 2010). Infection and colonization peak around the time of the eruption of the primary teeth, but may occur before.
In infants the carbohydrates may be present in the form of prolonged exposure to formula or breast milk, especially if the infant is allowed to sleep with the nipple in his or her mouth (Azevedo et al, 2005; van Palenstein Helderman et al, 2006). Before and after weaning, carbohydrates may also come from milk sweetened with honey or sugar or from juices in baby bottles or training cups, especially when given at bedtime, naptime, or when a child is allowed to take swigs of the fluid throughout the day. In older children, the source of the carbohydrates may be Tang, Kool-Aid, sports drinks, and/or soda. This frequent carbohydrate exposure keeps the pH of mouth fluid near the tooth surface below 5 and results in an environment conducive to demineralization. The neutralization process does not have enough time to increase the mouth pH to a level that would allow remineralization. In patients undergoing chemotherapy or radiation to the head and neck and in patients who are immunocompromised, normal salivary flow and salivary buffering of acids is disrupted. Cavities result. Box 33-1 provides a list of risk factors associated with dental caries in children.
BOX 33-1 Factors That Increase a Child’s Risk for Developing Dental Caries
Health and Personal History
Adapted from American Academy of Pediatric Dentistry (AAPD): Reference manual 2009-2010: policy on use of a caries-risk assessment tool (CAT) for infants, children, and adolescents, Pediatr Dent 31(special issue):29-33, 2009a.
Clinical Findings
Clinical findings can include the following:
• Early caries lesions. These appear as horizontal white or brown lines or spots along the upper central gumline or gingival margin, more commonly in populations using baby bottles because the cavity-causing fluids pool in these areas of the mouth (breastfed babies are not necessarily excluded from such lesions). In cultures where bottle use, especially at night or naptime, is less common the damage may occur in back teeth first as a function of other dietary patterns. When white lesions occur, the dentin is initially damaged. Then, as the lesion progresses, the hard enamel breaks, and a clinical cavity is evident (see Color Plate). Baby teeth are important for chewing food, serve an aesthetic function, and hold space in the mouth so that the permanent teeth can erupt properly. Therefore, it is critical to prevent cavities and intervene early in any decay.
• Advanced tooth decay. This appears as cavitations in the teeth. Nearly all cavities in permanent teeth in children in the U.S. begin on the biting surface of the molars. The initial lesion appears as a pinhole surrounded by a white, opaque halo. As the lesion enlarges greater damage to the enamel becomes apparent. Lesions typically appear about 1 year after the eruption of the tooth and frequently begin while the tooth is still erupting. A gumboil may form if the tooth becomes abscessed (Fig. 33-5).
• Sensitivity. Cavities can be hot, cold, or sweet sensitive.
• Localized pain. Lesions that progress can begin to hurt all the time, disrupting normal activity, sleeping, and eating.
• Inflammation and abscesses. Bacterial invasion of the pulpal tissue in the tooth causes inflammation and necrosis. In severely decayed primary teeth, a gumboil or draining fistula will form on the gum tissue above the root end of the tooth. This also occurs in permanent teeth, but is a late stage (see Fig. 33-5).
• Methamphetamine use (“meth mouth”) can cause accelerated tooth decay on the facial surfaces of the teeth and between the teeth. In later stages the teeth are blackened, stained, and appear to be crumbling. There may be signs of severe grinding and dry mouth (Klasser and Epstein, 2005). See the discussion on the use of 12% chlorhexidine gluconate oral rinse for this condition.
• Cavities may spontaneously arrest. This is thought to occur, for example, when cavities are exposed to saliva high in fluoride or when the diet changes (such as after weaning). Arrested caries appear as open cavities that are black or dark brown. If the child has such open cavities, is asymptomatic, the teeth are primaries, and access to dental care is problematic, these teeth can be left alone and allowed to shed normally. Ideally, these children should receive dental care. The discoloration also may be the result of previous topical treatment by a dentist with diamine silver fluoride or silver nitrate that was used in an attempt to arrest and prevent carious lesions.
Management and Prevention Strategies in Primary Care
Fluoride Varnish
Early white spot lesions in primary and permanent teeth can be remineralized using topical fluoride varnish. In many states, PCPs and nurses are permitted to apply fluoride. Marketed fluoride varnish preparations contain from 1000 parts per million (ppm) (0.1% silane fluoride) to 22,600 ppm (sodium fluoride, 5%). Typically the 5% varnish preparations are used for children. All of the 5% varnishes for sale in the U.S. are essentially similar, varying in flavor or color. Twice-yearly applications have been shown to reduce tooth decay by about one third. A recent study suggested that four treatments given at the same time as well-child visits before 24 months reduced tooth decay in high risk children (Holve, 2008). Frequent application of fluoridated toothpaste also promotes repair (Do and Spencer, 2007). Plasma fluoride levels following applications of varnish are low and are not associated with toxicity or fluorosis. Fluoride varnish is the agent of choice for young children and has been shown to be more effective than the fluoride gels that are still widely used in the U.S. Fluoride gels are dangerous and difficult to apply in preschool children and are not recommended because of the risk of acute toxicity.
1. Dispense approximately 0.5 mL of varnish into a small well. Prepackaged individual-dose systems come with their own well that is filled with varnish.
2. Lightly dry the teeth with air or gauze to remove moisture.
3. While keeping the teeth isolated from further moisture contamination, paint the varnish onto the teeth with a brush or another type of applicator (Fig. 33-6). The varnish sets on contact with the slightly moist teeth.
A short training video on the technique for applying varnish is available from the National Maternal and Child Oral Health Resource Center at www.mchoralhealth.org/highlights/flvarnish.html..
Topical Iodine
Polyvinylpyrrolidone iodine (10% PVP-I or povidone-iodine) can be painted on the teeth before the application of fluoride varnish for an additive effect to depress the tooth decay-causing mutans streptococci in children at high risk for dental problems (Milgrom et al, 2011). Application of topical iodine alone at 3-month intervals over 12months has been shown to cause a significant reduction in the rise of flora from a baseline measurement (Singh et al, 2010).
Fluoride Therapy
The most effective preventive measure against dental caries is optimizing the fluoride content of communal water supplies (a new proposal recommends the optimal level be reset to 0.7 ppm [USDHHS, 2011]). However, only about 50% of children in the U.S. drink fluoridated water. Children who consume fluoride-deficient water supplies and who are at risk for caries will benefit from dietary fluoride supplementation (CDC, 2010b).The fluoride level of public water supplies can usually be ascertained by calling the local health department. If the patient uses a private water supply, the fluoride level should be tested before prescribing fluoride supplements. To prevent potential overdoses, no prescription should be written for more than a total of 120 mg of fluoride. See Table 33-2 for adjusting the dose of fluoride supplements in relation to that found in the community water supply.

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