Other Names & Coding

Krol DM, Whelan K.
Maintaining and Improving the Oral Health of Young Children.
Pediatrics. 2023;151(1). PubMed abstract

Clark MB, Keels MA, Slayton RL.
Fluoride use in caries prevention in the primary care setting.
Pediatrics. 2020;146(6). PubMed abstract / Full Text

Children and youth with special health care needs may face oral health challenges related to:

• Inability to perform self-care
• Medical devices that impact oral health
• Medications that have adverse effects on oral health
• Seizures
• ADHD/autism/ developmental delays
• Gingival hyperplasia
• Overcrowding of teeth or malocclusion
• Oral aversions from previous medical procedures or sensory defensiveness
• Xerostomia (dry mouth)
• Dietary factors
• Gastroesophageal reflux disease or vomiting
• Enamel hypoplasia (particularly in premature infants)
• Bruxism
• Lack of access to dentists with appropriate training in treating children and adolescents with complex health care needs [American: 2018]

Physical examination should include visual inspection of the mouth for:

• Candidiasis (thrush)
• Dental caries (tooth decay)/white spot lesions
• Gingivitis/gum disease (inflamed, red, or bleeding gums)
• Abscesses
• Tongue-tie or ankyloglossia
• Tooth discoloration
• Tongue plaques
• Intraoral ulcerations (canker sores)
• Herpes simplex virus lesions (intra and extraoral cold sores)
• Chipped teeth
• Jaw pain
• Halitosis
• Tumors
• Plaque or calculus build-up
• Presence of prior fillings
• Abnormal tooth eruption
• Oral habits (pacifier or digit sucking)

Signs of normal and abnormal tooth eruption

• Primary teeth usually erupt between 6-12 months of age, typically beginning with the lower anterior incisors and complete eruption between 25-33 months of age.
• Although some infants develop natal or neonatal teeth, this type of eruption is uncommon.
• Delayed tooth eruption in children >12 months old may result from a medical condition and should be evaluated. Referral is warranted if a child has no teeth by 18 months of age. [American: 2017]
• Permanent teeth typically erupt between ages 5 and 7 years with the 1st molars or lower central incisors and finish eruption, except the third molar, by age 13 years old.

For more detail, see Dental Growth and Development (American Dental Association).

The primary care clinician regularly evaluates and treats common conditions affecting the oral cavity, including the tongue, cheeks, and lips. Primary care clinicians should also provide anticipatory guidance for oral health, including establishing a dental home, diet, home care routines, and the use of fluoride toothpaste. Guidance can be found at Dental and Oral Health Screening.

Pediatric and general dentists provide care for most conditions affecting dentition (teeth) and gums. Encourage families to establish a dental home by 12 months of age (and as early as 6 months of age) and monitor for regular dental visits. [American: 2005] A dental home is an ongoing relationship between the dentist and patient that addresses anticipatory guidance and preventative, acute, and comprehensive oral health. [American: 2023]

A pediatric dentist has special training in meeting the needs of infants, children, and adolescents, particularly children with special health care needs who may have complex oral health challenges or have difficulty cooperating with an oral exam or procedures. Children and youth with special health care needs will likely need a pediatric dentist who can perform moderate to full sedation for evaluations and procedures, and the primary care provider should provide an appropriate referral. The primary care clinician can assist parents with identifying a dentist covered through their insurance plan. (See Services below.)

Children with complex medical conditions or special health care needs may have trouble with regular toothbrushing at home. Modifications can help them maintain good oral hygiene (e.g., electric toothbrushes, modified toothbrushes, chlorhexidine mouth rinses, or sprays). [Levy: 2018] In some cases where caregivers do not seek care or assistance, dental neglect may be present. Primary care providers need to assess these situations and determine if a report to child protective services is needed when true neglect is diagnosed. [Fisher-Owens: 2017]

Condition-Specific Guidance

Fluoride acts in 3 important ways to prevent caries: 1) by strengthening enamel, 2) by remineralizing enamel, and 3) by affecting microbial metabolism and reducing acid production by cariogenic bacteria. Systemic, fluoride in water or by supplement, and topical fluoride applications are the primary sources of fluoride. [American: 2021]

Patients usually do not need prophylactic antibiotics for minor dental procedures, such as routine anesthetic injections through non-infected tissue, dental radiographs, placement of removable prosthodontic or orthodontic appliances or brackets, shedding of primary teeth, and bleeding from trauma to the lips or oral mucosa. [Otto: 2021] [Wilson: 2021] Remember that most systemic infections in these patients are NOT due to dental procedures. Good oral hygiene is the primary prevention tool.

Consider prescribing prophylactic antibiotics for certain invasive dental procedures (manipulation of the gingival tissue or the peri-apical tooth area or perforation of the oral mucosa) to patients at the highest risk of a distant site infection in the body. [Otto: 2021] [Wilson: 2021] The primary care clinician should discuss with the family the potential benefits and risks (including developing resistant bacteria) of prophylactic antibiotics for patients with any of the conditions described in the section above.

The 2021 Endocarditis Prophylaxis Wallet Card (AHA) provides a table of antibiotic prophylactic regimens for dental procedures by situation, agent, and dose. Recommendations and further information about population, procedures, specific antibiotics, dosing, and timing are detailed in the 2007 American Heart Association guidelines. [Wilson: 2021]

Medicaid (see NM providers [8]) and CHIP, State Children's Health Insur Prog (see NM providers [0])
Medicaid and the Children’s Health Insurance Program (CHIP) are major sources of coverage for pediatric dental care. States define what constitutes “medically necessary” oral health services for Medicaid recipients. [U.S.: 2017] Some state Medicaid programs provide enhanced payments when a modifier (EP) is applied to the claim for specific oral health services during well-child visits. For those families without dental insurance, the primary care clinician should provide information for a local, publicly funded, or charity-care dental office.

The Affordable Care Act expanded insurance coverage of pediatric oral health services; however, there are still children who cannot access oral health care. Other services include:

• Pediatric Dentistry (see NM providers [6])
• Oral/Maxillofacial Surgery (see NM providers [1])
• General Dentistry (see NM providers [12])
• Healthcare, Dental > … (see NM providers [16])

99188, application of topical fluoride varnish by a physician or other qualified health care professional