THE CE ANSWER SHEET APPEARS ON PAGE 37 ETIOLOGY AND RISK ASSESSMENT Caries occurs when cariogenic bacteria colonize a susceptible tooth surface in the presence of carbohydrates.14 have been found in dental plaque,15–17 ciated with caries are Streptococcus mutans, Lactobacilli, Streptococcus sobrinus, and Bifidobacteria.18 When carbohydrates and fermentable sugars are ingested, the pH of the oral cavity decreases, dropping from a neutral pH of 7.0 to an acidic pH of approximately 5.0 to 5.5.19 This increased acidity is also found within the biofilm fluid. If cariogenic bacteria are already present, the carbohydrates and fer- mentable sugars are metabolized by these acid-producing bacteria.19 bohydrate exposure has ended.19 Acid pro- duced at the biofilm level diffuses into the enamel, causing structural demineralization.19 However, the enamel can remineralize once the car- These cycles of demineralization/ remineralization continue as long as cariogenic bacteria, fermentable car- bohydrates and saliva are present. If this cycle occurs frequently, the dem- ineralization eventually surpasses saliva’s remineralizing abilities, creating initial white-spot or incipient lesions that may progress to cavitation.14,19,20 A child’s risk of developing caries lesions is influenced by many factors and can change over time.14 Dietary patterns of carbohydrate consump- Identifying a child’s caries risk is an effective and evidence-based approach to disease prevention and management. Caries management by risk assessment enables oral health professionals to recommend individually tailored therapeutic, restorative, oral hygiene, educational and nutritional approaches for pediatric patients and their parents or caregivers.21 This chair- side assessment measures each child’s disease indicators, risk factors and protective factors, which help providers determine current and future caries disease status and risk.21 Through risk assessment, clinicians can identify cariogenic feeding pat- terns, assess the child’s use of fluoride toothpaste and frequency of fluoride varnish applications, and communicate to parents/caregivers the presence of active lesions or plaque. A caries risk assessment evaluation can be per- formed during any routine dental examination or prophylaxis. ESTABLISH A DENTAL HOME The AAPD defines a dental home as, “the ongoing relationship between the dentist and patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and family-centered way. The dental home should be established no later than age 12 months and includes referral to specialists when appropriate.”22 An anticipatory approach emphasizing oral health promotion through guidance and parental/caregiver education is likely to have the greatest impact on chil- dren’s oral health.3,23 necessity and importance of maintaining routine dental examinations and prophylaxes. They also provide an opportunity to educate parents/care- givers about proper oral hygiene techniques, as well as behavioral and social risk factors.8 Preventive care visits can be used to reinforce the tion and other genetic, personal and social factors — such as oral hygiene habits, socioeconomic status and ethnicity — all affect caries develop- ment.2,6,7,20 While more than 800 species of bacteria the four primary oral bacteria asso- DEATH Infection Sedation analgesics provided at discharge Misuse of emergency department resources from general anesthesia Costs of hospital admission Costs of antibiotics and HOSPITAL COSTS Morbidity resulting FAMILY ASSOCIATED MORBIDITY Parental and family stress Loss of work time and employment Child’s loss of school hours, attentiveness, and academic performance Costs associated with travel and child care Eating and sleeping dysfunctions Disturbed pain perception COSTS ASSOCIATED WITH EARLY CHILDHOOD CARIES Days missed from school Days missed from work Morbidity associated with treatment Chewing of lip or cheek Inappropriate use of over-the-counter pain medications Courtesy of the American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatr Dent. 2015;37(Special Issue):123–131. According to the AAPD, care within a dental home should include compre- hensive assessment, individualized preventive care based on caries risk, anticipatory guidance related to growth and development (including care of the child’s soft and hard tissues), education of parents/caregivers about management of acute dental trauma; nutritional assessment and counsel- ing, and referral to specialists, if needed.22 A recent cross-sectional study explored the association of an established dental home on ECC prevalence and cariogenic feeding practices in high- risk populations.24 The caries disease status (dmft score), incidence of plaque and gingivitis, and the practice of high-risk dietary behaviors were compared among two groups of children (age 24 months to 60 months) differentiated by the presence of an established dental home. The study demonstrated significant relationships between higher dmft scores and frequent consumption of sticky snacks and sugary drinks, as well as pro- longed drinking sessions of sugary beverages.24 Children with an estab- lished dental home had a lower prevalence of caries and lower rates of biofilm and gingivitis than children who did not have an established dental home. These findings add further evidence to support the effectiveness of ERIN A. KIERCE, RDH, BA, MS, MPH, is director of quality assurance for New England Family Dentistry and Family Orthodontics in Marlborough, Massachusetts. Her professional areas of interest include caries risk assessment, early childhood caries, oral care during pregnancy and clinical compliance. She can be reached at [email protected]. Nutritional education should be provided in order to ensure cariogenic feeding practices are avoided and proper dietary guidelines that support optimal oral and systemic heath are followed. The goal of providing anticipatory guidance for parents/caregivers is to modify or eliminate practices and behaviors known to increase caries risk.3,24 DecisionsInDentistry.com LORI RAINCHUSO, RDH, MS, DHSc, is an associate professor and graduate program director at the Forsyth School of Dental Hygiene, MCPHS University in Boston, as well as a public health dental hygienist in Massachusetts. Rainchuso is an active member of the Better Oral Health for Massachusetts Coalition. The authors have no commercial conflicts of interest to disclose. December 2017 • Decisions IN DENTISTRY 35 FIGURE 1. The wide-ranging costs of early childhood caries.
