TABLE 1. Oral Health Risk Assessment for Nondental Health Care Providers Factors High Risk Biological Mother/primary caregiver has active cavities Parent/caregiver has low socioeconomic status Child has > three between meal sugar-containing snacks or beverages per day Child is put to bed with a bottle containing natural or added sugar Child has special health care needs Child is a recent immigrant Protective Child receives optimally fluoridated drinking water or fluoride supplements Child has teeth brushed daily with fluoride toothpaste Child receives topical fluoride from health care professionals Child has dental home/regular dental care Clinical Findings Child has white spot lesions or enamel defects Child has visible cavities or fillings Child has plaque on teeth Yes Yes Yes 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. oral hygiene education and anticipatory guidance in the prevention of adverse oral health outcomes.24 On the other hand, a recent study examining early prevention in the reduction of dental caries among Medicaid-enrolled children in Alabama did not find any benefits to the practice.25 Results showed that children who received preventive dental care before age 2 were more likely to need treat- ment for dental caries over several years. However, the study had significant limitations, including the use of claims data that did not consider quality of life improvement. Another was the lack of accounting for oral health behav- iors that may have contributed to the increased need for follow-up dental care. Lastly, the investigators were not able to account for community water fluoridation, which may have impacted caries rates.25 Yes Yes Yes Yes Moderate Risk Protective Yes Yes Yes Yes Yes Yes Some children may be placed on “active surveillance,” a nonsurgical approach in which providers carefully monitor the progression of lesions through a specific plan of follow-up and behavior change. This approach includes active parental/caregiver engagement, fre- quent recare appointments with fluoride varnish appli- cations, and consistent self-care measures, including brushing with fluoride toothpaste and improving dietary behaviors.30–32 If a pediatric patient requires restorative treatment, per- manent restorations or interim therapeutic restorations — such as glass ionomer or resin-modified glass ionomer cement — can be considered.28 Silver diamine fluoride is a topical agent that has been shown to arrest caries; it can be used to address lesions in primary teeth.33–35 INTERPROFESSIONAL CARE The role of pediatricians and allied medical providers in children’s oral health continues to grow as the oral/systemic connection becomes better understood. In response, schools are creating programs that incorporate oral/systemic health content, as well as clinical competen- cies, into nurse practitioner curricula; an example of this approach is New York University’s Rory Meyers College of Nursing’s Oral Health Nursing Edu- cation and Practice Program. Considering that nurse practitioners in pedi- atric settings have more frequent access to new mothers and infants than oral health professionals, improved oral health training can help them more efficiently recognize oral disease and identify high-risk cariogenic behav- iors.36–38 Reasons as to why the study found no evidence supporting early prevention in caries reduction may be that more children sought early care simply because they had a dental home. In contrast, the rate of undiagnosed and untreated caries in children who did not receive early preventive care may be high. According to the Alabama Department of Public Health, approximately 20% of Alabama’s children aged 6 to 9 have untreated dental caries.26 THERAPEUTIC AND RESTORATIVE APPROACHES Protective modalities, specifically topical fluoride, should be employed to inhibit demineralization, promote remineralization, and obstruct the forma- tion of cariogenic plaque — especially in high-risk patients. The AAPD rec- ommends that all children use fluoride toothpaste twice daily, regardless of caries risk.27 For children age 36 months and younger, no more than a “smear or rice-sized” amount should be used. For children between the ages of 36 months and 60 months, a pea-size amount is indicated. Using more than the recommended amount can increase the risk of fluorosis.27 The frequency of fluoride varnish (5% NaF) application is determined by the child’s caries risk; application intervals for pediatric patients at high-caries risk are typically every three to six months. Multiple factors should be considered when determining restorative treatment for pediatric patients with ECC. Clinicians need to consider the child’s age and future caries risk, engagement of parents/caregivers, and severity of the lesions to determine an evidence-based course of action.28–32 36 Decisions IN DENTISTRY • December 2017 According to the Medical Expenditure Survey, 89% of children younger than age 1 had routine physician visits annually, while only 1.5% of these children had dental visits.37 Medicaid-enrolled children had well-baby visits before age 1, compared with only 2% who had a dental visit.36 Another study indicates that 99% of Therefore, medical professionals need to incorporate oral health assessments into their preventive appointments (Table 1) to reinforce oral health-promoting behaviors, apply fluoride var- nish, and facilitate the establishment of a dental home.36–38 In support of this, the majority of states reimburse nondental professionals for caries-pre- vention services performed during the medical appointment.39 The American Academy of Pediatrics recommends the first oral health risk assessment be performed by age 6 months, and continue at nine months, 18 months, 24 months, 30 months, 3 years and 6 years.40 The objective of Risk assessment also enables medical providers to identify high-risk patients and refer them to oral health professionals. A growing body of evidence suggests oral health is essential to systemic health. Considering that family, economic and social statuses significantly impact the development of ECC, emphasizing oral health-promoting behaviors is likely to have the greatest effect on children’s oral health.6,42,43 performing caries risk assessment in the medical home is to prevent disease by identifying and decreasing contributory factors, while optimizing protec- tive factors — specifically, fluoride exposure, proper oral hygiene and sealant placement.29,38,41 Dental professionals, as well as medical providers, play a critical role in identifying high-risk behaviors and providing patient-specific education and counseling that will prevent or mitigate caries lesions. For high-risk pediatric patients, educating parents/caregivers about the known risk factors associated with ECC is imperative.5,6,8–11 D DecisionsInDentistry.com
