Caries risk assessment, prevention, and management in pediatric dental care

Abstract

The recent increase in the prevalence of dental caries among young children has highlighted the need for a new approach to prevent caries in children at a younger age. New disease prevention management models call for children to have their first visit to the dentist at age 1 or when their first tooth erupts. This article addresses early childhood caries risk assessment, prevention, and management strategies in young children using the concept of the "dental home" and a simple six-step protocol to conduct an effective and comprehensive infant oral care visit.

Full text

Caries risk assessment, prevention, and
management in pediatric dental care
Francisco Ramos-Gomez, DDS, MS, MPH n Yasmi O. Crystal, DMD n Man Wai Ng, DDS, MPH
Norman Tinanoff, DDS, MS n John D. Featherstone, MSc, PhD
The general dentist is in the
unique position of establishing
a dental care program for preg-
nant women, which is considered
the rst step toward disease preven-
tion for infants and toddlers.
Background
Dental caries remains the most prev-
alent chronic childhood disease in
the U.S., ve times more common
than asthma and seven times more
common than hay fever.1-3 is
disease, known as early childhood
caries (ECC) (formerly termed
nursing bottle caries or baby bottle
tooth decay), is currently dened as
the presence of one or more decayed
(that is, cavitated or noncavitated
lesions), missing (due to caries), or
lled surfaces in any primary tooth
in a child age 6 or younger.4 Among
children under the age of 3, any sign
of smooth-surface caries is indica-
tive of severe early childhood caries
(S-ECC).4 ECC is prevalent among
young children, particularly in
underserved populations and racial/
ethnic minorities.5 Approximately
75% of ECC is found in approxi-
mately 8% of children between the
ages of 2 and 5.6 Compared to other
age groups, where caries rates remain
unchanged, the caries rate among
preschoolers has increased to 28%.7,8
It is well-documented that caries
is a transmissible infectious disease
in which pathogenic risk factors
prevail over protective factors,
producing demineralization of tooth
structure. If the disease is allowed
to progress, surface cavitation and
dental tissue destruction will result.
Mutans streptococci (MS) is con-
sidered one of the most important
pathogens in the cariogenic process
because of its ability to stick to
smooth tooth surfaces and produce
copious amounts of acid. It is rec-
ognized that these micro-organisms
can be transmitted from caregiver
to child through close contact with
or through the exchange of saliva
(vertical transmission)—for example,
through kissing on the mouth,
sharing utensils or cups, and so
forth. Caregivers with high levels of
pathogenic bacteria in their mouths
can communicate these bacteria into
a child’s mouth even before the erup-
tion of the rst tooth. It has been
shown that infants with high levels of
MS or those with early colonization
are more likely to develop ECC.9-13
Establishment of a
dental home
Signs of ECC can be detected soon
after the eruption of the rst tooth.
Its progression is entirely prevent-
able, provided that risk indicators
are identied and preventive oral
health practices are implemented
at a young age.14 For this reason,
the AGD, the ADA, the American
Academy of Pediatric Dentistry, and
the American Academy of Pediatrics
all have recommended that children
should see a dentist by age 1 (or
when the rst tooth erupts) and
that a dental home be established
as soon as possible.4,15,16 e dental
home is dened as the ongoing
relationship between the dentist and
the patient—including all aspects
of oral health care—delivered in a
comprehensive, continuously acces-
sible, coordinated, family-centered
way.16 Establishment of a dental
home (including referral to dental
specialists when appropriate) should
begin by the time the child is 12
months old.16
A dental home should be estab-
lished so that children can make
regular dental visits that include
caries risk assessment, individualized
The recent increase in the prevalence of dental caries among young
children has highlighted the need for a new approach to prevent
caries in children at a younger age. New disease prevention
management models call for children to have their first visit to
the dentist at age 1 or when their first tooth erupts. This article
addresses early childhood caries risk assessment, prevention, and
management strategies in young children using the concept of
the “dental home” and a simple six-step protocol to conduct an
effective and comprehensive infant oral care visit. Age-specific
anticipatory guidance recommendations—including early parental
education, timely intervention, and/or referral—have been
included for counseling parents during early childhood dental visits.
Received: March 30, 2010
Accepted: June 15, 2010
Pediatric Dentistry
www.agd.org General Dentistry November/December 2010 505
CDE
2 HOURS
CREDIT

preventive strategies, and anticipa-
tory guidance.17 Periodic supervision
of care intervals (also known as
periodicity) should be determined
based on the disease risk for each
individual patient.16
Pediatricians, family practitioners,
and other medical providers see
children frequently during infancy
and early childhood. ese practi-
tioners are ideally suited to screen
young children for caries risk and
refer these patients for dental care.
If physicians are to refer children for
their rst dental visit at age 1, the
dental community must be willing
and prepared to accept infants and
pregnant women as patients. Since
general dentists comprise 80%
of practicing dentists and see the
majority of children seeking dental
care, it is important for these den-
tists to embrace the concepts of the
dental home, infant oral health, and
perinatal health.18
Perinatal oral health
Dentists have come to recognize
the critical role that a mother
plays in ensuring her child’s oral
health. However, women often do
not receive oral health care and
education in a timely manner.19
Many women do not know that
they should seek dental care during
their pregnancy, while many others
who do know this are often unable
to nd a dentist who is willing to
provide it.20 Because new mothers
are more likely to be receptive to
ideas that would improve their
ospring’s oral health, dental and
obstetric providers have a prime
opportunity to educate mothers
about the changes that could aect
their children.21 It is important for
general dentists to provide expect-
ant mothers with comprehensive
dental care, as recent studies have
shown that it is safe to provide care
at any point during pregnancy.22-2 4
e benets of prevention, diag-
nosis, and treatment of oral diseases
(including the use of radiographs
and local anesthetics) during preg-
nancy exceed the risks inherent in
treatment or those associated with
not providing care. Improving the
oral health of expectant mothers by
reducing their pathogenic bacteria
levels will postpone the child’s
acquisition of oral bacteria and may
delay the development of ECC.23
Initial infant oral care visit
Infants and parents will benet
from an early infant oral health visit
and the establishment of a dental
home. Explaining exactly what to
expect during this visit may allay
parental fears and concerns. Parents
should be warned that children
might cry during the visit, just as
they would when they are hungry,
tired, or placed in a new situation.
Understanding the benets of this
preventive visit will help parents
cope, even if their child cries and is
uncooperative.
An infant oral care examination
and caries risk assessment follows
a simple six-step protocol, as
described below.
Caries risk assessment
An individualized risk assessment of
an infant or toddler will help both
health care providers and parents/
caregivers identify and understand
the factors associated with ECC, so
that a cooperative and proactive pre-
ventive care plan can be developed.
e specic information gained
from a systematic assessment of
caries risk guides the dentist in the
decision-making process to establish
treatment and preventive protocols
for children with oral disease and
for those deemed to be at risk.
To achieve the best management
and outcomes for good oral health,
the caries risk assessment should be
Pediatric Dentistry
Caries risk assessment, prevention, and management in pediatric dental care
506 November/December 2010 General Dentistry www.agd.org
Fig. 1. An illustration of the caries balance concept.
Caries No caries
Pathological factors
• Acid-producingbacteria
• Frequenteating /drinkingof
fermentable carbohydrates
• Subnormalsaliva owand
function
Protective factors
• Salivaowandcomp onents
• Fluoride:Reminer alization
with calcium and phosphate
• Antibacte rials:Chlorhexidine,
xylitol, and others

done as early as possible—preferably
before the onset of disease. Caries
risk assessment and subsequent
management of the disease in
children is crucial due to the known
fact that caries in the primary denti-
tion is a strong predictor of caries in
the permanent dentition.25,26
e caries balance concept states
that the progression or reversal
of dental caries is determined by
the balance between pathologi-
cal factors and protective factors
(Fig. 1).27-29 ese risk factors are
determined from interviews with
the parent(s) and a clinical assess-
ment. e caries risk assessment
form in Figure 2 provides an easy
way to compile and keep a record
of the information that will aid
the dentist in determining the
infant/child’s caries risk. is form
is broken down into three major
categories: biological risk factors,
protective factors, and disease indi-
cators from a clinical examination.
Biological risk factors are
obtained from the caretaker
interview and include biological or
lifestyle factors that contribute to
the development or progression of
caries. ese risk factors include
a mother with active decay or
recently placed dental restorations,
a family with a low socioeconomic
status, a caregiver with low health
literacy, and a child who frequently
intakes fermentable carbohydrates
or sweetened drinks and/or sleeps
with a bottle or sippy cup contain-
ing milk or juice.
Protective factors are also
obtained during the interview.
ese are biological and/or
therapeutic factors, measures, and
behaviors that, when used consis-
tently, could reduce a child’s risk for
ECC. ese factors include optimal
exposure to uoride and access to
regular dental care (for example,
the presence of a dental home).
www.agd.org General Dentistry November/December 2010 507
Child’s name: _______________________________________________________
Biological factors
High risk
factors
Moderate
risk factors
Protective
factors
Mother/primary caregiver has active caries Yes
Parent/caregiver has low socioeconomic status Yes
Childhasmorethanthreesnacksorbeverages
containing sugar per day between meals
Yes
Childisputtobedwithabottlecontaining
natural or added sugar
Yes
Childhasspecialhealthcareneeds Yes
Childisarecentimmigrant Yes
Protective factors
Childreceivesuoridateddrinkingwateror
uoridesupplements
Yes
Child’steetharebrusheddailywithuoridated
toothpaste
Yes
Childreceivestopicaluoridefromhealth
professional
Yes
Childhasdentalhome/regulardentalcare Ye s
Clinical findings
Childhasmorethanonedecayed,missing,or
lledtoothsurface(DMFS)
Yes
Childhasactivewhitespotlesionsorenamel
defects
Yes
Childhaselevatedmutansstreptococci Yes
Childhasplaqueonteeth Yes
Modiedfrom:Ramos-GomezF,CrallJ,SlaytonR,FeatherstoneJD.Cariesriskassessmentappropriate
fortheageonevisit.JCalifDentA ssoc20 07;35(10) :687-702;andADACariesRiskAssessmentFor ms.
Circlingthoseconditionsthatapplytoaspecicpatienthelpsthepractitionerandparent
understand the factors that contribute to or protect against caries. Risk assessment
categorizationoflow,moderate,orhighisbasedonapreponderanceoffactors.However,
clinical judgment may justify the use of one factor in determining overall risk, for instance,
frequentexposuretosugar-containingsnacksorbeverages,ormorethanoneDMFS.
Overall assessment of the child’s dental caries risk:
❑ High ❑ Moderate ❑ Low
Self-management goals:
1 ________________________________ 2 _______________________________
Practitioner signature: _______________________________________________
Date: ______________________________________________________________
Fig.2.Asamplecariesriskassessmentformforchildrenfromages1–5.(©Copyright2010-2011
bytheAmericanAcademyofPediatricDentistry.Reprintedwithpermission.)

Disease indicators are ndings,
obtained during the clinical
examination of the child, that
are proven to have a strong
correlation to the presence of the
disease. ese include cavitated
carious lesions and white spot
lesions/decalcications, recent
restorations, presence of plaque,
gingival bleeding (an indicator of
heavy plaque), and dry mouth.
A risk assessment categoriza-
tion of low, moderate, or high is
based on a preponderance of the
factors circled on the caries risk
Pediatric Dentistry
Caries risk assessment, prevention, and management in pediatric dental care
508 November/December 2010 General Dentistry www.agd.org
Table 1. CAMBRA dental caries treatment protocol guidelines for children up to age 2.
Risk
category
Diagnostic Preventive intervention Restoration
Periodic
oral
examinations Radiographs
Saliva
test Fluoride Xylitol Sealants Antibacterials
Anticipatory
guidance
/counseling
Self-
management
goals
White spots/
precavitated lesions Existing lesions
Low Annual Posterior bitewings at 12–24 month intervals if
proximal surfaces cannot be examined visually or
with a probe
Optional
baseline
Inofce:no;Home:brusht wiceeachdaywithasmear
ofuoridetoothpaste
Notrequired No No Yes No n/a n /a
Moderate Every six
months
Posteriorbitewingsat6 –12monthintervalsif
proximal surfaces cannot be examined visually or
with a probe
Recom-
mended
Inofce:FVatinitialvisitandrecalls;Home:brush
twiceeachdaywithasmearofuoridetoothpaste ;
Caregiver:OTCsodiumuoridetreatmentrinses
Child:xylitolwipes;
Caregiver:twosticks
of gum or two mints
four times a day
Fluoride-releasing
sealants recom-
mended on deep
pits and fissures
No Yes No Treatwithuoride
products as
indicated to promote
remineralization
n/a
Moderate;
non-
compliant
Every three
to six months
Posteriorbitewingsat6 –12monthintervalsif
proximal surfaces cannot be examined visually or
with a probe
Required Inofce:FVatinitialvisitandrecalls;Home:brush
twiceadaywithasmearofuoridetoothpaste
combined with a smear of 900 ppm calcium phosphate
paste,leaveonatbedtime;Caregiver:OTCsodium
uoridetreatmentrinses
Child:xylitolwipes;
Caregiver:twosticks
of gum or two mints
four times a day
Fluoride-releasing
sealants recom-
mended on deep
pits and fissures
Recommend
for caregiver
Yes Yes Treatwithuoride
products as
indicated to promote
remineralization
n/a
High Every three
months
Anterior( No.2occlusallm)andposterior
bitewingsat6 –12monthintervalsifproximal
surfaces cannot be examined visually or with a
probe
Required Inofce:FVatinitialvisitandrecalls;Home:brush
twiceadaywithasmearofuoridetoothpaste
combined with a smear of 900 ppm calcium phosphate
paste,leaveonatbedtime;Caregiver:OTCsodium
uoridetreatmentrinses
Child:xylitolwipes;
Caregiver:twosticks
of gum or two mints
four times a day
Fluoride-releasing
sealants recom-
mended on deep
pits and fissures
Recommend
for caregiver
Yes Yes Treatwithuoride
products as
indicated to promote
remineralization
Intermediate therapeutic
restoration(ITR )or
conventional restorative
treatment as patient
cooperation and family
circumstances allow
High;non-
compliant
Every one
to three
months
Anterior( No.2occlusallm)andposterior
bitewingsat6 –12monthintervalsifproximal
surfaces cannot be examined visually or with a
probe
Required Inofce:FVatinitialvisitandrecalls;Home:brush
twiceadaywithasmearofuoridetoothpaste
combined with a smear of 900 ppm calcium phosphate
paste,leaveonatbedtime;Caregiver:OTCsodium
uoridetreatmentrinses
Child:xylitolwipes;
Caregiver:twosticks
of gum or two mints
four times a day
Fluoride-releasing
sealants recom-
mended on deep
pits and fissures
Recommend
for caregiver
Yes Yes Treatwithuoride
products as
indicated to promote
remineralization
ITR or conventional
restorative treatment as
patient cooperation and
family circumstances allow
Extreme Ever y one
to three
months
Anterior( No.2occlusallm)andposterior
bitewingsat6 –12monthintervalsifproximal
surfaces cannot be examined visually or with a
probe
Required Inofce:FVatinitialvisitandrecalls;Home:brush
twiceadaywithasmearofuoridetoothpaste
combined with a smear of 900 ppm calcium phosphate
paste,leaveonatbedtime;Caregiver:OTCsodium
uoridetreatmentrinses
Child:xylitolwipes;
Caregiver:twosticks
of gum or two mints
four times a day
Fluoride-releasing
sealants recom-
mended on deep
pits and fissures
Recommend
for caregiver
Yes Yes Treatwithuoride
products as
indicated to promote
remineralization
ITR or conventional
restorative treatment as
patient cooperation and
family circumstances allow
Fig. 3. An example of the knee-to-knee position.

assessment form. ese specic
patient conditions will help both
the practitioner and the parent(s)
understand the factors that con-
tribute to or protect the patient
from caries.
Proper positioning
Proper positioning of the child is
critical to conducting an eective
and ecient clinical examination.
Knee-to-knee positioning (Fig. 3)
allows the child to see the parent
throughout the examination, while
the parent can directly observe
ndings and receive hygiene
instructions while gently helping
to stabilize the child during the
examination. In general, the knee-
to-knee position should be used
for children between the ages of 6
months and 3 years, or up to age 5
for children with special health care
needs. Children over the age of 3
may be able to sit forward on their
caregiver’s lap or sit alone in a chair.
Examiners and caregivers need
to work together to ensure that
the transition from the interview
to the examination runs smoothly
for the child. e clinician should
explain what will happen prior
to starting the examination and
anticipate that young children
might cry, which is developmen-
tally appropriate behavior.
Toothbrush prophylaxis
For most young children, a
toothbrush prophylaxis is ecient
for removing plaque. It is also
non-threatening to young children
and serves to demonstrate the
proper technique of brushing to the
caregiver.30,31
www.agd.org General Dentistry November/December 2010 509
Table 1. CAMBRA dental caries treatment protocol guidelines for children up to age 2.
Risk
category
Diagnostic Preventive intervention Restoration
Periodic
oral
examinations Radiographs
Saliva
test Fluoride Xylitol Sealants Antibacterials
Anticipatory
guidance
/counseling
Self-
management
goals
White spots/
precavitated lesions Existing lesions
Low Annual Posterior bitewings at 12–24 month intervals if
proximal surfaces cannot be examined visually or
with a probe
Optional
baseline
Inofce:no;Home:brusht wiceeachdaywithasmear
ofuoridetoothpaste
Notrequired No No Yes No n/a n /a
Moderate Every six
months
Posteriorbitewingsat6 –12monthintervalsif
proximal surfaces cannot be examined visually or
with a probe
Recom-
mended
Inofce:FVatinitialvisitandrecalls;Home:brush
twiceeachdaywithasmearofuoridetoothpaste ;
Caregiver:OTCsodiumuoridetreatmentrinses
Child:xylitolwipes;
Caregiver:twosticks
of gum or two mints
four times a day
Fluoride-releasing
sealants recom-
mended on deep
pits and fissures
No Yes No Treatwithuoride
products as
indicated to promote
remineralization
n/a
Moderate;
non-
compliant
Every three
to six months
Posteriorbitewingsat6 –12monthintervalsif
proximal surfaces cannot be examined visually or
with a probe
Required Inofce:FVatinitialvisitandrecalls;Home:brush
twiceadaywithasmearofuoridetoothpaste
combined with a smear of 900 ppm calcium phosphate
paste,leaveonatbedtime;Caregiver:OTCsodium
uoridetreatmentrinses
Child:xylitolwipes;
Caregiver:twosticks
of gum or two mints
four times a day
Fluoride-releasing
sealants recom-
mended on deep
pits and fissures
Recommend
for caregiver
Yes Yes Treatwithuoride
products as
indicated to promote
remineralization
n/a
High Every three
months
Anterior( No.2occlusallm)andposterior
bitewingsat6 –12monthintervalsifproximal
surfaces cannot be examined visually or with a
probe
Required Inofce:FVatinitialvisitandrecalls;Home:brush
twiceadaywithasmearofuoridetoothpaste
combined with a smear of 900 ppm calcium phosphate
paste,leaveonatbedtime;Caregiver:OTCsodium
uoridetreatmentrinses
Child:xylitolwipes;
Caregiver:twosticks
of gum or two mints
four times a day
Fluoride-releasing
sealants recom-
mended on deep
pits and fissures
Recommend
for caregiver
Yes Yes Treatwithuoride
products as
indicated to promote
remineralization
Intermediate therapeutic
restoration(ITR )or
conventional restorative
treatment as patient
cooperation and family
circumstances allow
High;non-
compliant
Every one
to three
months
Anterior( No.2occlusallm)andposterior
bitewingsat6 –12monthintervalsifproximal
surfaces cannot be examined visually or with a
probe
Required Inofce:FVatinitialvisitandrecalls;Home:brush
twiceadaywithasmearofuoridetoothpaste
combined with a smear of 900 ppm calcium phosphate
paste,leaveonatbedtime;Caregiver:OTCsodium
uoridetreatmentrinses
Child:xylitolwipes;
Caregiver:twosticks
of gum or two mints
four times a day
Fluoride-releasing
sealants recom-
mended on deep
pits and fissures
Recommend
for caregiver
Yes Yes Treatwithuoride
products as
indicated to promote
remineralization
ITR or conventional
restorative treatment as
patient cooperation and
family circumstances allow
Extreme Ever y one
to three
months
Anterior( No.2occlusallm)andposterior
bitewingsat6 –12monthintervalsifproximal
surfaces cannot be examined visually or with a
probe
Required Inofce:FVatinitialvisitandrecalls;Home:brush
twiceadaywithasmearofuoridetoothpaste
combined with a smear of 900 ppm calcium phosphate
paste,leaveonatbedtime;Caregiver:OTCsodium
uoridetreatmentrinses
Child:xylitolwipes;
Caregiver:twosticks
of gum or two mints
four times a day
Fluoride-releasing
sealants recom-
mended on deep
pits and fissures
Recommend
for caregiver
Yes Yes Treatwithuoride
products as
indicated to promote
remineralization
ITR or conventional
restorative treatment as
patient cooperation and
family circumstances allow

For this step, the examiner
retracts the child’s lips and cheeks
and demonstrates brushing along
the gingival margins. e spongy
handle of an age-appropriate
toothbrush can be used to prop
open the child’s mouth. During
this Tell-Show-Do encounter,
caregivers should be encouraged
to brush both their own teeth and
the child’s at least twice a day,
especially before bedtime. Fluoride
toothpaste is one of the most eec-
tive tools for caries prevention and
it is safe for children to use as soon
as the rst tooth erupts.32 ,33
A pea-sized amount of toothpaste
is recommended for children
between the ages of 2 and 6, while a
“smear” is appropriate for children
under the age of 2.34
Clinical examination
During this examination, the exam-
iner counts the child’s teeth aloud,
using the toothbrush handle to
prop open the mouth if necessary.
Many providers make a game of this
task, singing songs, engaging the
child’s attention, and, if all else fails,
distracting the child with a brightly
colored toothbrush or toy. Praise
the child at each step for his or her
cooperation and/or good behavior.
If the child is able to cooperate, the
examiner should also inspect the
soft tissues, hard tissues, and occlu-
sion at this time.
Data from the clinical examina-
tion should be combined with
data from the caregiver interview
to determine the child’s overall
caries risk and formulate an indi-
vidualized treatment plan. Visible
plaque and its locations should
be documented, as should white
spot lesions, brown spots (which
may indicate caries on the occlusal
Pediatric Dentistry
Caries risk assessment, prevention, and management in pediatric dental care
510 November/December 2010 General Dentistry www.agd.org
Table 2. CAMBRA dental caries treatment protocol for children from ages 3– 6.
Risk
categor y
Diagnostic Preventive intervention Restoration
Periodic
oral
examinations Radiographs
Saliva
test Fluoride Xylitol Sealants Antibacterials
Anticipatory
guidance/
counseling
Self-
management
goals
White spot/
precavitated
lesions Existing Lesions
Low Annual Posterior bitewings at 12–24 month intervals if
proximal surfaces cannot be examined visually
or with a probe
Optional
baseline
In office : no; Home: brush twice a day with a
pea-sized amount of fluoride toothpaste
Not required No No Yes No n/a n/a
Moderate Every six
months
Posterior bitewings at 6–12 month inter vals if
proximal surfaces cannot be examined visually
or with a probe
Recom-
mended
In office : FV at initial visit and recalls; Home:
brush twice a day with a pea-sized amount of
fluoride toothpaste; Caregiver: OTC sodium fluoride
treatment rinses
Child: xylitol wipes/ products
to substitute for sweet treats
or when unable to brush;
Caregiver: two sticks of gum
or two mints four times a day
Fluoride-releas-
ing sealants
recommended
on deep pits and
fissures
No Yes No Treat with fluoride
products as indi-
cated to promote
remineralization
n/a
Moderate;
non-
compliant
Every three
to six months
Posterior bitewings at 6–12 month inter vals if
proximal surfaces cannot be examined visually
or with a probe
Required In office: FV at initial visit and recalls ; Home: brush
twice a day with a pea-size of fluoride toothpaste
combined with a pea-size of 900 ppm calcium
phosphate paste, leave on at bedtime ; Caregiver:
OTC sodium fluoride treatment rinses
Child: xylitol wipes/ products
to substitute for sweet treats
or when unable to brush;
Caregiver: two sticks of gum
or two mints four times a day
Fluoride-releas-
ing sealants
recommended
on deep pits and
fissures
Recommend
for caregiver
Yes Yes Treat with fluoride
products as indi-
cated to promote
remineralization
n/a
High Every three
months
Anterior ( No. 2 occlusal film) and posterior
bitewings at 6–12 month intervals if proximal
surfaces cannot be examined visually or with
a probe
Required In office: FV at initial visit and recalls ; Home: brush
twice a day with a pea-size of fluoride toothpaste
combined with a pea-size of 900 ppm calcium
phosphate paste, leave on at bedtime ; Caregiver:
OTC sodium fluoride treatment rinses
Child: xylitol wipes/ products
to substitute for sweet treats
or when unable to brush;
Caregiver: two sticks of gum
or two mints four times a day
Fluoride-releas-
ing sealants
recommended
on deep pits and
fissures
Recommend
for caregiver
Yes Yes Treat with fluoride
products as indi-
cated to promote
remineralization
ITR or conventional
restorative treatment
as patient coop-
eration and family
circumstances allow
High; non-
compliant
Every one to
three months
Anterior ( No. 2 occlusal film) and posterior
bitewings at 6–12 month intervals if proximal
surfaces cannot be examined visually or with
a probe
Required In office: FV at initial visit and recalls ; Home: brush
twice a day with a pea-size of fluoride toothpaste
combined with a pea-size of 900 ppm calcium
phosphate paste, leave on at bedtime ; Caregiver:
OTC sodium fluoride treatment rinses
Child: xylitol wipes/ products
to substitute for sweet treats
or when unable to brush;
Caregiver: two sticks of gum
or two mints four times a day
Fluoride-releas-
ing sealants
recommended
on deep pits and
fissures
Recommend
for caregiver
Yes Yes Treat with fluoride
products as indi-
cated to promote
remineralization
ITR or conventional
restorative treatment
as patient coop-
eration and family
circumstances allow
Extreme Every one
to three
months
Anterior ( No. 2 occlusal film) and posterior
bitewings at 6–12 month intervals if proximal
surfaces cannot be examined visually or with
a probe
Required In office: FV at initial visit and recalls ; Home: brush
twice a day with a pea-size of fluoride toothpaste
combined with a pea-size of 900 ppm calcium
phosphate paste, leave on at bedtime ; Caregiver:
OTC sodium fluoride treatment rinses
Child: xylitol wipes/ products
to substitute for sweet treats
or when unable to brush;
Caregiver: two sticks of gum
or two mints four times a day
Fluoride-releas-
ing sealants
recommended
on deep pits and
fissures
Recommend
for caregiver
Yes Yes Treat with fluoride
products as indi-
cated to promote
remineralization
ITR or conventional
restorative treatment
as patient coop-
eration and family
circumstances allow

surface), tooth defects, deep pits/s-
sures, tooth anomalies, missing and
decayed teeth, existing and defec-
tive restorations, gingivitis or other
soft tissue abnormalities, occlusion,
and indications of trauma.
Fluoride treatment
e ADA recommends that
children categorized as high caries
risk receive a full-mouth topical
uoride varnish (FV) application
every three months.35 Children
with a moderate caries risk should
receive FV every six months, even
if the child lives in a community
with uoridated water. e provider
should reiterate the cumulative
benet of FV, even if it has been
mentioned earlier in the visit. After
application, the child should be
limited to a soft diet (that is, no
crunchy or chewy foods) for the
remainder of the day; in addition,
for the varnish to be eective, the
parent/caregiver should not brush
the child’s teeth until the next day.
Assignment of risk, anticipatory
guidance, and counseling
Once all of the data have been
gathered and recorded in the caries
risk assessment form, the practitio-
ner can evaluate and determine the
child’s risk for developing carious
lesions. e practitioner should
record all “Yes” answers to each
question within the three areas
of risk assessment and record any
“No” answers to a protective factor
under the High Risk column.
A “No” response to a protective
factor is equal to a high risk factor.
High risk factors can be mitigated
by armative protective factors,
which help to determine if a child
is at moderate or even low risk for
caries development.
www.agd.org General Dentistry November/December 2010 511
Table 2. CAMBRA dental caries treatment protocol for children from ages 3– 6.
Risk
categor y
Diagnostic Preventive intervention Restoration
Periodic
oral
examinations Radiographs
Saliva
test Fluoride Xylitol Sealants Antibacterials
Anticipatory
guidance/
counseling
Self-
management
goals
White spot/
precavitated
lesions Existing Lesions
Low Annual Posterior bitewings at 12–24 month intervals if
proximal surfaces cannot be examined visually
or with a probe
Optional
baseline
In office : no; Home: brush twice a day with a
pea-sized amount of fluoride toothpaste
Not required No No Yes No n/a n/a
Moderate Every six
months
Posterior bitewings at 6–12 month inter vals if
proximal surfaces cannot be examined visually
or with a probe
Recom-
mended
In office : FV at initial visit and recalls; Home:
brush twice a day with a pea-sized amount of
fluoride toothpaste; Caregiver: OTC sodium fluoride
treatment rinses
Child: xylitol wipes/ products
to substitute for sweet treats
or when unable to brush;
Caregiver: two sticks of gum
or two mints four times a day
Fluoride-releas-
ing sealants
recommended
on deep pits and
fissures
No Yes No Treat with fluoride
products as indi-
cated to promote
remineralization
n/a
Moderate;
non-
compliant
Every three
to six months
Posterior bitewings at 6–12 month inter vals if
proximal surfaces cannot be examined visually
or with a probe
Required In office: FV at initial visit and recalls ; Home: brush
twice a day with a pea-size of fluoride toothpaste
combined with a pea-size of 900 ppm calcium
phosphate paste, leave on at bedtime ; Caregiver:
OTC sodium fluoride treatment rinses
Child: xylitol wipes/ products
to substitute for sweet treats
or when unable to brush;
Caregiver: two sticks of gum
or two mints four times a day
Fluoride-releas-
ing sealants
recommended
on deep pits and
fissures
Recommend
for caregiver
Yes Yes Treat with fluoride
products as indi-
cated to promote
remineralization
n/a
High Every three
months
Anterior ( No. 2 occlusal film) and posterior
bitewings at 6–12 month intervals if proximal
surfaces cannot be examined visually or with
a probe
Required In office: FV at initial visit and recalls ; Home: brush
twice a day with a pea-size of fluoride toothpaste
combined with a pea-size of 900 ppm calcium
phosphate paste, leave on at bedtime ; Caregiver:
OTC sodium fluoride treatment rinses
Child: xylitol wipes/ products
to substitute for sweet treats
or when unable to brush;
Caregiver: two sticks of gum
or two mints four times a day
Fluoride-releas-
ing sealants
recommended
on deep pits and
fissures
Recommend
for caregiver
Yes Yes Treat with fluoride
products as indi-
cated to promote
remineralization
ITR or conventional
restorative treatment
as patient coop-
eration and family
circumstances allow
High; non-
compliant
Every one to
three months
Anterior ( No. 2 occlusal film) and posterior
bitewings at 6–12 month intervals if proximal
surfaces cannot be examined visually or with
a probe
Required In office: FV at initial visit and recalls ; Home: brush
twice a day with a pea-size of fluoride toothpaste
combined with a pea-size of 900 ppm calcium
phosphate paste, leave on at bedtime ; Caregiver:
OTC sodium fluoride treatment rinses
Child: xylitol wipes/ products
to substitute for sweet treats
or when unable to brush;
Caregiver: two sticks of gum
or two mints four times a day
Fluoride-releas-
ing sealants
recommended
on deep pits and
fissures
Recommend
for caregiver
Yes Yes Treat with fluoride
products as indi-
cated to promote
remineralization
ITR or conventional
restorative treatment
as patient coop-
eration and family
circumstances allow
Extreme Every one
to three
months
Anterior ( No. 2 occlusal film) and posterior
bitewings at 6–12 month intervals if proximal
surfaces cannot be examined visually or with
a probe
Required In office: FV at initial visit and recalls ; Home: brush
twice a day with a pea-size of fluoride toothpaste
combined with a pea-size of 900 ppm calcium
phosphate paste, leave on at bedtime ; Caregiver:
OTC sodium fluoride treatment rinses
Child: xylitol wipes/ products
to substitute for sweet treats
or when unable to brush;
Caregiver: two sticks of gum
or two mints four times a day
Fluoride-releas-
ing sealants
recommended
on deep pits and
fissures
Recommend
for caregiver
Yes Yes Treat with fluoride
products as indi-
cated to promote
remineralization
ITR or conventional
restorative treatment
as patient coop-
eration and family
circumstances allow

Pediatric Dentistry
Caries risk assessment, prevention, and management in pediatric dental care
512 November/December 2010 General Dentistry ww w.agd.org
Table 3. Age-specific anticipatory guidance.
Prenatal Birth to age 1 Ages 2–3 Ages 3– 6
Take -hom e
message for
caregivers
Baby teeth are important!
Parents’/caregivers’oralhealth
affectsthebaby’soralhealth.
Parents/caregivers should
obtain regular dental
check-ups and get treatment if
necessary.
Schedulechild’srstdental
appointment by age 1.
Useofuorides,including
brushing the teeth with a
uoridetoothpaste,isthemost
effective way to prevent tooth
decay
Baby teeth are important!
Parents’/caregivers’oralhealth
affectsthebaby’soralhealth.
Parents/caregivers should obtain
regular dental check-ups and get
treatment if necessary.
Parents/caregivers should avoid
sharing with their child things that
have been in their mouths.
Schedulechild’srstdental
appointment by age 1.
Prevention is less costly than
treatment.
Useofuorides,includingbrushing
theteethwithauoridetoothpaste,
is the most ef fective way to prevent
tooth decay.
Baby teeth are important!
Parents’/caregivers’oral
healthaffectsthebaby’s
oral health.
Parents/caregivers should
obtain regular dental check-
ups and get treatment if
necessary.
Parents/caregivers should
avoid sharing with their
child things that have been
in their mouths.
Prevention is less costly
than treatment.
Useofuorides,including
brushing the teeth with
auoridetoothpaste,is
the most effective way to
prevent tooth decay.
Baby teeth are important!
Parents’/caregivers’oral
healthaffectsthechild’s
oral health.
Parents/caregivers should
obtain regular dental check-
ups and get treatment if
necessary.
Parents/caregivers should
avoid sharing with their
child things that have been
in their mouths.
Prevention is less costly
than treatment.
Useofuorides,including
brushing the teeth with
auoridetoothpaste,is
the most effective way to
prevent tooth decay.
Oral health
and hygiene
Encourage parents/caregivers
to obtain dental check-ups
and, if necessary, treatment
before birth of the baby to
reduce cavity-causing bacteria
that can be passed to the baby.
Encourage parents/caregivers
tobrushteethwithuoride
toothpaste.
Encourage parents/caregivers to
maintain good oral health and get
treatment, if necessary, to reduce
the spread of bacteria that can cause
tooth decay.
Encourage parents/caregivers to
avoid sharing with their child things
that have been in their mouths.
Encourage parents/caregivers to
become familiar with the normal
appearanceofthechild’sgums.
Emphasizeusingawashclothor
toothbrush to clean teeth and gums
after the eruption of the first tooth.
Encourage parents/caregivers to
check front and back teeth for white,
brown, or black spots (signs of
cavities).
Encourage parents/caregiv-
ers to maintain good oral
health and get treatment,
if necessary, to reduce the
spread of bacteria that can
cause tooth decay.
Encourage parents/caregiv-
ers to avoid sharing with
their child things that have
been in their mouths.
Reviewparent’s/caregiver’s
roleinbrushingtoddler’s
teeth.
Discuss brush and
toothpaste selection.
Problem-solve oral hygiene
issues.
Encourage parents/caregiv-
ers to maintain good oral
health and get treatment,
if necessary, to reduce the
spread of bacteria that can
cause tooth decay.
Encourage parents/caregiv-
ers to avoid sharing with
their child things that have
been in their mouths.
Discuss the continued
responsibility of parents/
caregivers to help children
under8tobrushtheirteeth.
Encourage parents/caregiv-
ers to consider dental
sealants for primary and
permanent first molars
Oral
development
Describe primary tooth
eruption patterns (first tooth
usuallyeruptsbetween6and
10monthsofage).
Emphasizeimportanceofbaby
teeth for chewing, speaking,
jaw development, and
self-esteem.
Discuss primary tooth eruption
patterns.
Emphasizeimportanceofbaby
teeth for chewing, speaking, jaw
development, and self-esteem.
Discuss teething and ways to soothe
sore gums, such as chewing on
teething rings and washcloths.
Emphasizeimportanceof
baby teeth for chewing,
speaking, jaw development,
and self-esteem.
Discuss teething and ways
to soothe sore gums, such
as chewing on teething
rings and washcloths.
Emphasizeimportanceof
baby teeth for chewing,
speaking, jaw development,
and self-esteem.

www.agd.org General Dentistry November/December 2010 513
Table 3. Age-specific anticipatory guidance.
Prenatal Birth to age 1 Ages 2–3 Ages 3– 6
Take -hom e
message for
caregivers
Baby teeth are important!
Parents’/caregivers’oralhealth
affectsthebaby’soralhealth.
Parents/caregivers should
obtain regular dental
check-ups and get treatment if
necessary.
Schedulechild’srstdental
appointment by age 1.
Useofuorides,including
brushing the teeth with a
uoridetoothpaste,isthemost
effective way to prevent tooth
decay
Baby teeth are important!
Parents’/caregivers’oralhealth
affectsthebaby’soralhealth.
Parents/caregivers should obtain
regular dental check-ups and get
treatment if necessary.
Parents/caregivers should avoid
sharing with their child things that
have been in their mouths.
Schedulechild’srstdental
appointment by age 1.
Prevention is less costly than
treatment.
Useofuorides,includingbrushing
theteethwithauoridetoothpaste,
is the most ef fective way to prevent
tooth decay.
Baby teeth are important!
Parents’/caregivers’oral
healthaffectsthebaby’s
oral health.
Parents/caregivers should
obtain regular dental check-
ups and get treatment if
necessary.
Parents/caregivers should
avoid sharing with their
child things that have been
in their mouths.
Prevention is less costly
than treatment.
Useofuorides,including
brushing the teeth with
auoridetoothpaste,is
the most effective way to
prevent tooth decay.
Baby teeth are important!
Parents’/caregivers’oral
healthaffectsthechild’s
oral health.
Parents/caregivers should
obtain regular dental check-
ups and get treatment if
necessary.
Parents/caregivers should
avoid sharing with their
child things that have been
in their mouths.
Prevention is less costly
than treatment.
Useofuorides,including
brushing the teeth with
auoridetoothpaste,is
the most effective way to
prevent tooth decay.
Oral health
and hygiene
Encourage parents/caregivers
to obtain dental check-ups
and, if necessary, treatment
before birth of the baby to
reduce cavity-causing bacteria
that can be passed to the baby.
Encourage parents/caregivers
tobrushteethwithuoride
toothpaste.
Encourage parents/caregivers to
maintain good oral health and get
treatment, if necessary, to reduce
the spread of bacteria that can cause
tooth decay.
Encourage parents/caregivers to
avoid sharing with their child things
that have been in their mouths.
Encourage parents/caregivers to
become familiar with the normal
appearanceofthechild’sgums.
Emphasizeusingawashclothor
toothbrush to clean teeth and gums
after the eruption of the first tooth.
Encourage parents/caregivers to
check front and back teeth for white,
brown, or black spots (signs of
cavities).
Encourage parents/caregiv-
ers to maintain good oral
health and get treatment,
if necessary, to reduce the
spread of bacteria that can
cause tooth decay.
Encourage parents/caregiv-
ers to avoid sharing with
their child things that have
been in their mouths.
Reviewparent’s/caregiver’s
roleinbrushingtoddler’s
teeth.
Discuss brush and
toothpaste selection.
Problem-solve oral hygiene
issues.
Encourage parents/caregiv-
ers to maintain good oral
health and get treatment,
if necessary, to reduce the
spread of bacteria that can
cause tooth decay.
Encourage parents/caregiv-
ers to avoid sharing with
their child things that have
been in their mouths.
Discuss the continued
responsibility of parents/
caregivers to help children
under8tobrushtheirteeth.
Encourage parents/caregiv-
ers to consider dental
sealants for primary and
permanent first molars
Oral
development
Describe primary tooth
eruption patterns (first tooth
usuallyeruptsbetween6and
10monthsofage).
Emphasizeimportanceofbaby
teeth for chewing, speaking,
jaw development, and
self-esteem.
Discuss primary tooth eruption
patterns.
Emphasizeimportanceofbaby
teeth for chewing, speaking, jaw
development, and self-esteem.
Discuss teething and ways to soothe
sore gums, such as chewing on
teething rings and washcloths.
Emphasizeimportanceof
baby teeth for chewing,
speaking, jaw development,
and self-esteem.
Discuss teething and ways
to soothe sore gums, such
as chewing on teething
rings and washcloths.
Emphasizeimportanceof
baby teeth for chewing,
speaking, jaw development,
and self-esteem.
Prenatal Birth to age 1 Ages 2–3 Ages 3– 6
Fluoride
adequacy
Evaluateuoridestatusof
residential water supply
Review topical and systemic
sourcesofuoride.
Encourage mother to drink
uoridatedtapwater.
Evaluateuoridestatusofresidential
water supply.
Review topical and systemic sources
ofuoride.
Encouragedrinkinguoridatedtap
wat er.
Considertopicalneeds(e.g.,
toothpaste,uoridevarnish).
Re-evaluateuoridestatus
of residential water supply.
Review topical and systemic
sourcesofuoride.
Encourage drinking
uoridatedtapwater.
Review need for topical
uorides.
Re-evaluateuoridestatus
of residential water supply.
Review topical and systemic
sourcesofuoride.
Review need for topical or
otheruorides.
Oral habits Encourage mother to stop
smoking
Encourage breastfeeding.
Advise mother that removing child
from breast after feeding and wiping
baby’sgums/teethwithadamp
washclothreducestheriskofECC.
Review pacifier safety.
Remind mother that
removing child from breast
after feeding and wiping
baby’sgums/teethwitha
damp washcloth reduces
theriskofECC.
Begin weaning of
non-nutritive sucking habits
at age 2.
Discussconsequencesof
digit sucking and prolonged
non-nutritive sucking
(e.g.,pacier)andbegin
professional intervention if
necessary.
Diet and
nutrition
Emphasizeeatingahealthy
diet and limiting the number
of exposures to sugar snacks
and drinks.
Emphasizethatitisthe
frequencyofexposures,not
the amount of sugar, that
affects susceptibility to caries.
Encourage breastfeeding.
Remind parents/caregivers
never to put the baby to
bed with a bottle containing
anything other than water or
to allow feeding “at will.”
Remind parents/caregivers never to
put the baby to bed with a bottle
containing anything other than water
or to allow feeding “at will.”
Emphasizethatitisthefrequencyof
exposures, not the amount of sugar,
that affects susceptibilit y to caries.
Encourage weaning from bottle to
cup by age 1.
Encourage diluting juices with water.
Remind parents/caregivers
never to put the baby to
bed with a bottle or to
allow feeding “at will.”
Discuss a healthy diet and
oral health.
Emphasizethatitisthe
frequencyofexposures,
not the amount of sugar,
that affects susceptibility
to caries.
Review snack choices and
encourage healthy snacks.
Review and encourage a
healthy diet.
Remind parents/caregivers
aboutlimitingthefrequency
of exposures to sugar.
Review snacking choices.
Emphasizethatthechild
should be completely
weaned from the bottle
and should be drinking
exclusively from a cup.
Injury
prevention
Encourage childproofing of
home, including electrical cord
safety and poison control.
Emphasizetheuseofa
properly secured car seat.
Encourage caregivers to keep
emergency numbers handy.
Review childproofing of home,
including electrical cord safety and
poison control.
Emphasizetheuseofaproperly
secured car seat.
Encourage caregivers to keep
emergency numbers handy.
Review childproofing of
home, including electrical
cord safet y and poison
control.
Emphasizetheuseofa
properly secured car seat.
Emphasizetheuseofa
helmet when child is riding
a tricycle/bicycle or is in the
seat of an adult bike.
Remind caregivers to keep
emergency numbers handy.
Emphasizetheuseofa
properly secured car seat.
Encourage safety in play
activities, including helmets
when riding bikes and
mouthguards when playing
sports.
Remind caregivers to keep
emergency numbers handy.

For example, children who
frequently eat snacks or drink juice
may be at only moderate risk if they
live in a community that has uori-
dated water and if they brush twice
a day with a uoride toothpaste.
However, some factors are prepon-
derant, and a “Yes” response to the
biological factor “Mother/primary
caregiver has active caries” or to the
clinical ndings “Child has more
than one decayed, missing, or lled
tooth surface (dmfs)” or “Child has
active white spot lesions or enamel
defects” immediately places the
child at high or extreme high risk.
When the risk factors outweigh
the protective factors, there is an
increased likelihood for the devel-
opment of caries, which places the
child in a high risk category. When
protective factors prevail and risk
factors are controlled, the child
can be considered low risk. Most
importantly, though, the clinician’s
experience and expertise is a vital
component for determining a
child’s ultimate risk, which serves
as the basis for an individualized
treatment plan for each infant
and caregiver. An approach that
considers expected parental compli-
ance to recommended treatment
protocols is essential for children at
moderate or high caries risk.
e treatment protocol guide-
lines presented in this article
outline care paths for children
with moderate or high risk as well
as guidelines for a child who has
non-compliant parents and who
is at moderate or high risk. Table
1 lists caries management by risk
assessment (CAMBR A) treatment
protocol guidelines and recom-
mendations for children up to
age 2; Table 2 lists guidelines and
recommendations for children from
ages 3–6. Chlorhexidine rinses, FV,
and xylitol-based products may be
employed to modify the maternal
Toothdecayiscausedbycertaintypesofbacteria(bugs)thatliveinyourmouth.Whentheystick
tothelmonyourteeth(alsocalleddentalplaque) ,theycancausedamage.Thebacteriafeed
onwhatyoueat,especiallysugars(includingfruitsugars)andcookedstarches(bread,potatoes,
rice,pasta,etc.).Withinapproximatelyveminutesafteryoueatordrink,thebacteriabegin
making acids as they digest your food. These acids can break into the outer surface of the tooth
and melt away some of the minerals. Your saliva can balance the acid attacks as long as they
don’thappenver yoften.However,if:1)yourmouthisdr y,2)youhavealotofthesebacteria,or
3)yousnackfrequently,thentheacidcausesthelossoftoothminerals.Thisisthestartoftooth
decay and leads to cavities.
Methods of controlling tooth decay
Diet
Reducing the amount of sugar y and starchy
foods, snacks, and drinks you consume can
helptoreducetoothdecay.Thisdoesn’t
mean that you can never eat these types of
foods, just that you should limit the number
of times you eat them between main meals.
A good rule is three meals per day and no
more than three snacks per day.
Fluorides
Fluorides help to make teeth stronger, to protec t against tooth decay, and to heal tooth decay if it
has not gone too far. Fluorides are available from a variety of sources, such as drinking water and
toothpastes and rinses you can buy at the supermarket or drug store. They may also be prescribed
byyourdentistorappliedinthedentalof ce.Thedailyuseofuorideisveryimportanttohelp
protect against the acid attack s.
Plaque removal
Plaqueisayellowishlmthatstickstothesurfaceofteeth.Brushingyourteethremovesplaque
andshouldbedonetwiceeveryday.Bac terialiveinplaque,soremovingtheplaquefromyour
teethonadailybasishelpstocontroltoothdecay.Plaqueisverystick yandmaybehardto
remove from between your teeth and from the grooves on the biting surfaces of your back teeth.
Ifyourchildhasanorthodonticretainer,besuretoremoveitbeforebrushingyourchild’steeth.
Brush all surfaces of the retainer as well.
Saliva
Salivaisimportantforhealthyteeth.Itbalancesacidsandprovidesotheringredientsthatprotec t
the teeth. If you cannot brush after a meal or snack, you can chew sugar-free gum. This will
stimulatetheowofsalivatohelpreducetheeffectofacids.Sugar-freecandyormintscanalso
be used, but some of them contain acids themselves. Acids in sugar-free candy will not cause
tooth decay, but they can slowly dissolve the tooth surface over time (a process called
erosion
).
Somesugar-freegumsaremadetohelpghttoothdecay,whilesomegumscontainbakingsoda,
whichneutralizestheacidsproducedbythebacteriainplaque.Gum that contains xylitol as
its first listed ingredient is the gum of choice. This type of gum has been shown to protect
against tooth decay and to reduce the number of bacteria that cause decay.
Antibacterial mouthrinses
Rinses that your dentist can prescribe are able to reduce the number of bacteria that cause tooth
decay and can be useful in patients at high risk for tooth decay. These rinses are recommended
only for children who can rinse and spit.
Sealants
Sealantsareplasticcoatingsbrushedontothebitingsurfacesofbackteethtoprotectthedeep
grooves from decay. In some people, the grooves on the surfaces of the teeth are too narrow
and deep to clean with a toothbrush. These grooves may decay even if you brush them regularly.
Sealantsareanexcellentpreventivemeasureforchildrenandyoungadultsatriskforthistype
of decay.
Sugar
Bacteria
Acid
Pediatric Dentistry
Caries risk assessment, prevention, and management in pediatric dental care
514 November/December 2010 General Dentistry www.agd.org
Fig.4.Aparent /caregiverhandout:Howtoothdecayhappens.
From:
Patient information on tooth
decay. Available at: http://www.cdafoundation.org/library/docs/jour0303/consensus_forms.pdf.
(©Copyright2003bytheCaliforniaDentalAssociation.Reprintedwithpermission.)

transmission of cariogenic bacteria
to infants.16 e risk analysis should
allow the caregiver to determine
any changes that must be made
concerning the child’s diet, tooth-
brushing habits, and uoride
application.
Parents should be given addi-
tional information and anticipatory
guidance on oral health prevention
that is specic to the needs of their
child. is information should
include oral hygiene recommenda-
tions, growth and development
issues (that is, teething, digit, or
pacier habits), oral habits, diet and
nutrition guidelines, and injury
prevention tips (see Table 3). e
anticipatory guidance approach is
designed to take advantage of time-
critical opportunities for imple-
menting preventive health practices
and thus reduce the child’s risk of
preventable oral disease.18
During the child’s initial visit,
the dentist must counsel the
parent(s) to change specic factors
that may be contributing to active
caries or increasing their child’s
caries risk. Figure 4 presents a form
that is useful in communicating
the mechanisms of dental caries
to parents. eir understanding
of this process is crucial to the
successful implementation of pre-
ventive and therapeutic measures.36
A family-centered approach and
customized recommendations have
been shown to be more successful
in engaging parents to change spe-
cic parenting practices than such
generic recommendations such as
“brush your teeth twice a day” and
“don’t eat candy.”37
Motivational interviewing (MI)
is a counseling technique that
relies on two-way communication
between the clinician and the
patient or parent. MI is meant to
establish a therapeutic alliance
that is based on rapport and trust.
In this process, the clinician asks
questions to help parents identify
problems, listens to their concerns,
encourages self-motivational
statements, prepares them for
change (discussing the hurdles that
interfere with action), responds
to resistance, schedules follow-up
appointments, and prepares the
parent(s) for the family’s specic
and unique diculties, which
inevitably arise when instituting
a consistent, lifetime dental care
program for a child.
Following the brief motivational
interview, the parent/caregiver
is asked to commit to two self-
management goals or recommenda-
tions (Fig. 5) and informed that the
dentist will discuss these goals at
the child’s next appointment.38 e
form in Figure 6 can be given to
parents as a reminder of their com-
mitment to their child’s well-being
and can be led in the child’s dental
record, so that the dentist can follow
up on the family’s compliance at
subsequent visits.
Recall visits and periods
Clinicians must consider each child’s
individual needs to determine the
appropriate interval between and
frequency of oral examinations,
based on age-specic risk assess-
ment and planned treatment. Some
Checkthegoalsyouwillfocusonbetweentodayandyournextvisit.
On a scale of 1–10, how confident are you that you can accomplish your goals? ➀ ➁ ➂ ➃ ➄ ➅ ➆ ➇ ➈ ➉
Not likely Definitely
My promise: I agree to the goals checked and understand that staff may ask me how I am doing with my goals.
Date: ______________________Signedby: _____________________________________________
Review date: _________________Comments: _____________________________ Staf finitials: ______
Review date: _________________Comments: _____________________________ Staf finitials: ______

Regular dental
visits for child

Family receives
dental treatment

Weanoffbottle(atleast
nobottleduringsleep)

Brushwithuoridetoothpaste
at least twice a day

Only water or
milk in sippy cup

Less or
no juice

Healthy
snacks

No soda

Chew
xylitol gum

Drink
tap water

Less or no candy
or junk food
IMP OR TAN T: The last
thing that touches your
child’s teeth before
bedtime is a toothbrush
with fluoride toothpaste.
Fig.5.Self-managementgoalsforparents/caregivers.
www.agd.org General Dentistry November/December 2010 515

infants and toddlers at a high risk
for caries should be re-evaluated on
a monthly basis. Most older children
at high risk should be seen at three-
month intervals for re-evaluation.
Children in the moderate risk cat-
egory should return every six months
for re-evaluation; low-risk children
should return every 6–12 months.
After the parents have followed
the recommended protocol for three
to six months, they should bring the
child back for reassessment. Parents
need periodic encouragement
and support whenever behavioral
changes are required; they should
be questioned about any problems
they might have had following the
recommendations. It is essential to
re-assess the risk status and monitor
improvement on the previously
set self-management goals. At
every visit, the clinician should
re-evaluate whether it is necessary
to change the recommendations or
to continue reinforcing the exist-
ing prevention protocol. Parents
should know that changing dietary
and home care practices does not
happen overnight.
Summary
General dentists have an important
role in preventing and reducing the
severity of ECC in young children.
By embracing the concepts of
the dental home and perinatal
and infant oral health, general
dentists can implement preventive
and treatment protocols in their
practice by using an appropriate,
age-specic caries risk assessment
instrument to determine the caries
risk of their pediatric patients.
Acknowledgements
e authors thank Ms. Debra L.
Tom for her editorial assistance.
Author information
Dr. Ramos-Gomez is a professor,
School of Dentistry, University
of California, Los Angeles.
Dr. Crystal is in private practice in
Bound Brook, New Jersey. Dr. Ng
is dentist-in-chief and an assistant
professor, Oral and Developmental
Biology, Harvard School of Dental
Medicine, Boston, Massachusetts.
Dr. Tinano is chair, Health
Promotion and Policy, Univer-
sity of Maryland in Baltimore.
Dr. Featherstone is a professor and
dean, School of Dentistry, Univer-
sity of California, San Francisco.
Pediatric Dentistry
Caries risk assessment, prevention, and management in pediatric dental care
516 November/December 2010 General Dentistry www.agd.org
Fig.6.Parent /caregiverrecommendationsform.
Parent/caregiver recommendations for control of dental decay
Daily oral hygiene/fluoride toothpaste treatment
These procedures reduce the number of bacteria in the mouth and provide a small amount of
uoridetoguardagainstfur thertoothdecayandtorepairteeththatdisplayearlydecay.
_____ Brushchild’steethwithauoride-containingtoothpaste(smallsmearorpea-sized
amountonasof tsmallinfant-sizedtoothbrush)twicedaily(gentlybrushedbyparent
orcaregiver)
_____ Selectivedailyossingofteethwithearlycaries(whitespots)
_____ Other: ___________________________________________________________
Diet
The aim is to reduce the number of between-meal sweet snacks that contain carbohydrates,
especiallysugars.Substitutingsnacksrichinprotein,suchascheese,willalsohelp.
_____ OK as is
_____ Limitbottle/nursing(toavoidprolongedcontactofmilkwithteeth)
_____ Replacejuiceorsweetliquidsinthebottlewithwater
_____ Limitsnacking(particularlysweets)
_____ Replace high carbohydrate snacks with cheese and protein snacks
_____ Other: ___________________________________________________________
Xylitol (parents/caregivers)
Xylitol is a sweetener that bacteria cannot digest. Using xylitol-containing chewing gum or
mints/lozengesisawayforparents/caregiversofchildrenathighriskforcariestoreducethe
transfer of decay-causing bacteria to their baby/toddler. This is most effective when used by
the parent /caregiver starting shortly after the child is born. Parents/caregivers with dental
decay place their children at high risk for early childhood caries.
_____ Parents /caregivers of children up to the age of 3 who have high bacterial levels should
usexylitolmints/lozengesorxylitolgumtwotofourtimesdaily.
Antibacterial rinse (parents/caregivers)
Parents/caregiversofchildrenathighriskforcariesmayrequireantibacterialtreatmentto
decreasethetransmissionofcariogenicbacteriaandtoreducetheinfant /child’sriskofearly
childhood caries.
_____ Parents /caregivers of children up to the age of 3 who have high bacterial levels should
rinsewith10mLofchlorhexidinegluconate0.12%(byprescriptiononly).Rinseat
bedtime for one minute once a day for one week. Repeat each month for one week
untiltheinfectioniscontrolled.Separatefromuorideusebyonehour.Continueforsix
months or until bacterial levels remain controlled.
Practitioner signature: ___________________________________ Date: _____________
Parent/caregiver signature: _______________________________ Date: _____________

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