Oral Health (Dental) Screening & Prevention

Oral Health

Oral health screening by the primary care clinician is an important part of comprehensive well-child care. Oral health affects eating habits, sleep, smiling, social interactions, and the overall health of the child. 
Smiling Boy with Healthy Teeth and a Confidant Smile.jpg
In addition, poor oral health increases the risks of developing problems with drinking, eating, and speaking for children with special health care needs. [Weckwerth: 2016] Because infants and young children usually have several visits with their medical home before ever seeing a dentist, the primary care clinician is often the first person to recognize and address their oral health needs; >20% of children ages 2-11 have untreated dental caries that could be identified in the medical home. [National: 1999] Caries can cause pain and increase the risk of systemic infections.

Screening and Assessment

The American Academy of Pediatrics recommends that an oral health risk assessment should be performed in the medical home starting at the 6- and 9-month well-child checks. [Bright: 2010] If the child’s family has not yet established a dental home, repeat the assessment at the 12-, 18-, 24-, and 30-month well-child checks and the 3- and 6-year checks. [Centers: 1999] See Oral Health Risk Assessment Tool (AAP) (PDF Document 302 KB) for photos and a brief questionnaire about risk factors, protective factors, and clinical findings.
For children who receive oral health screening from programs like Early Intervention, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), or Early Head Start, medical homes may choose to limit screening to questions about feeding problems and continue with anticipatory guidance. 

Physical Examination

Physical examination should include visual inspection of the mouth for:
  • Thrush
  • Tooth decay
  • Gingivitis/gum disease
  • Abscesses
  • Tongue-tie or ankyloglossia
  • Tooth discoloration
  • Tongue plaques
  • Canker sores
  • Cold sores
  • Chipped teeth
  • Jaw pain
  • Halitosis
  • Tumors
  • Plaque build-up
  • Presence of prior fillings
  • Abnormal tooth eruption
Signs of normal and abnormal tooth eruption
  • Permanent teeth erupt in a pattern similar to that of the primary teeth.
  • The permanent teeth typically begin erupting between ages 5 and 7 years and finish by ages 13 to 14 years.
  • Although some infants develop natal or neonatal teeth, this type of eruption is uncommon.
  • Delayed tooth eruption in children >12 months old may be the result of a medical condition and should be evaluated. Referral is warranted if a child has no teeth by 18 months of age. [American: 2017]
Monitor for regular dental visits for patients as well as their parents. Children are at higher risk for dental caries if the primary caregiver has had cavities in the past year. All family members should have routine dental visits with teeth cleanings twice a year. [Hale: 2003]
Bright Futures Oral Health Pocket Guide
For anticipatory guidance information, a risk assessment guide, a fluoride supplement chart, and tools for improving the oral health of children from before birth to young adulthood, see the Oral Health Pocket Guide (Bright Futures) (image, left, links to pdf).

Children with Special Health Care Needs

Children with special health care needs may face additional oral health challenges related to: [Hale: 2003]
  • Inability to perform self-care
  • Medical devices that impact oral health
  • Medications that have adverse effects on oral health
  • Oral aversions from previous medical procedures or sensory defensiveness
  • Xerostomia (dry mouth)
  • Dietary factors
  • Gastroesophageal reflux disease or vomiting
  • Seizures
  • Attention deficit hyperactivity disorder
  • Gingival hyperplasia
  • Overcrowding of teeth or malocclusion
  • Enamel hypoplasia (particularly in premature infants)
  • Bruxism
  • Lack of access to dentists with appropriate skills

Anticipatory Guidance

Primary care clinicians can help all children by providing anticipatory guidance that includes: [Clinical: 2016]
  • Wipe the infant's gums and tongue with a wet cloth after feeding.
  • Brush twice daily using fluoride toothpaste. Once teeth erupt, all children <3 years old should use a smear of fluoride toothpaste (about the size of a grain of rice) and older children should use a pea-size amount.
  • Floss daily
  • All family members should see a dentist twice a year for preventive care and cleaning.
  • Bottles and sippy cups should not be propped or left with infants when caregivers are not actively feeding the child.
  • Once teeth erupt, avoid nursing or feeding at night because the milk remaining in the mouth can lead to caries. The caregiver can offer water if the older infant or child is thirsty at night.
  • Wean from bottle feeding by age 12 months.
  • Discourage thumb sucking after age 4 or 5 years.
  • Provide healthy snacks (e.g., cheese, fruit, and vegetables).
  • Prevent frequent snacking on sugar- and carbohydrate-containing foods; these increase durations of acidity in the mouth.
  • Minimize juice consumption to 0-6 ounces per day of 100% fruit juice; avoid soda, energy drinks, and other sweetened beverages.
  • Drink and cook with fluoridated tap water, if it is available.
  • Consider daily xylitol use.
  • Consider fluoride mouthwash for children ≥6 years old. [Council: 2013]
For older children, also discuss the adverse effects of:

Supplemental Fluoride

The recommended level for community fluoride in water supply is 0.7 mg fluoride per liter (0.7 parts per million). Fluoride occurs naturally in water supplies, so if the level is unknown (such as in well water) it should be tested to determine if supplementation is needed. [American: 2017] Fluoride content of water supplies in the United States can be found at My Water's Fluoride (CDC).
Fluoride Supplement Dosage Schedule
Fluoride Supplement Dosage Schedule
American Dental Association (Oral Health Topics)
Oral fluoride supplements for children ages 6 months to 16 years are recommended for children with suboptimal fluoridated water intake (consider drinking water, cooking water, water at school, etc.). [American: 2017] Supplementation of fluoride and Vitamin D during the first year of life is associated with fewer cavities in the primary teeth. [Kühnisch: 2016] Although recommendations are from 2010, the table, left, still provides current supplementation information.

Fluoride dental varnish should be placed approximately every 6 months, either in the medical or dental home. If in the medical home, administration of the varnish may be performed by trained staff, such as a medical assistant or nurse. A 1-hour, online course, with continuing medical education credits available, can be found at Online Fluoride Varnish Training (SFL). For more information about fluoride, see The Debate Over Fluoridated Water (AAP).

Prophylactic Antibiotics

Patients generally 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. [Wilson: 2007] Keep in mind 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 (table, left) 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 highest risk from a distant site infection in the body. [Wilson: 2007]
Antibiotic Prophylactic Regimens for Dental Procedures
Antibiotic Prophylaxis Regimens for Dental Procedures
American Heart Association from [Wilson: 2007]
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 below.

Compromised immunity
[Clinical: 2016]
  • Immune suppression (e.g., HIV/AIDS, SCIDS, neutropenia, undergoing chemotherapy or chronic use of steroids, or stem cell or solid organ transplant)
  • Autoimmune conditions (e.g., juvenile arthritis or lupus)
  • Sickle cell anemia or diabetes
  • Asplenia
  • Head and neck radiation
  • Bisphosphonate use
Cardiac conditions
  • Prosthetic cardiac valve
  • Previous infective endocarditis
  • Congenital heart disease (CHD) with one of the following:
    • Unrepaired cyanotic CHD, including palliative shunts and conduits
    • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
    • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device
  • Cardiac transplantation recipients who develop cardiac valvulopathy
These recommendations, and further information about population, procedures, specific antibiotics, dosing, and timing are detailed in the 2007 American Heart Association guidelines [Wilson: 2007] . Primary care clinicians should follow advice from the child’s pediatric cardiologists regarding prophylaxis.

Vascular shunts for hydrocephalus
  • Vascular shunts including ventriculo-atrial, -cardiac, or –venous, but not ventriculoperitoneal

Prosthetic joints and rods
  • While most patients with a history of orthopedic implants or joint surgery with indwelling components like pins, plates, or screws will not need antibiotic prophylaxis, consider prophylaxis for those with a prosthetic joint or history of full joint replacement, Harrington rods (in the spine), or external fixation devices.
  • Although there is no consensus about recommendations for prophylatic antibiotics in this population, highest risk patients for a hematogenous total joint infection include those with prosthetic joint replacement, previous prosthetic joint infection, inflammatory arthropathies (e.g., rheumatoid arthritis, systemic lupus erythematosus), megaprosthesis, hemophilia, malnourishment, and compromised immunity. [Clinical: 2016]

Referral Information

The primary care clinician will usually treat common conditions affecting the tongue, cheeks, and lips. For most children, a general dentist provides care for most conditions affecting the teeth and gums. 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. Rarely, an oral surgeon is required to provide care for severe conditions. Children with bleeding disorders should be evaluated by a hematologist prior to dental procedures at risk for bleeding, such as tooth extraction.

Access to Dental Care

Help families establish a dental home
The medical home should talk with families about establishing a dental home by 12 months of age (and as early as 6 months of age). [American: 2005] A dental home is a primary care dental provider with a comprehensive and up-to-date approach to pediatric dental care, including preventing dental problems, providing anticipatory guidance about dental issues and nutrition and behaviors that affect dental care, assessing for adequate fluoride and prescribing supplements (see Tools and Resources for dosing) when indicated, administering topical fluoride applications, assessing and treating dental issues, placing sealants for high-risk children, and referring to dental specialists as needed. [EQIPP: 2017] The primary care clinician can assist parents in identifying a dentist who is covered through their insurance plan:
Access to Care
Medicaid and the Children’s Health Insurance Program (CHIP) are major sources of coverage for pediatric dental care. [Paradise: 2012] The Affordable Care Act expanded insurance coverage of pediatric oral health services; however, there are still children who are unable to access oral health care. (See Oral Health Care and the Affordable Care Act (PDF Document 340 KB) for more details.)
Access to Oral Care - Silly Children with a Big Tooth Brush
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, publically funded or charity-care dental office; see all Dental Care Expense Assistance services providers (17) in our database.
Children may be able to receive oral health screening from programs like Early Intervention, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), or Early Head Start, For providers of these programs:

Resources

Information & Support

Resources for Clinicians:

Online Training Modules for Clinicians

Oral Health Screening Online Module (MDH)
Learn about the primary care providers role in providing oral health screening; free of charge from the Minnesota Department of Health.

Open Wide: Oral Health Training for Health Professionals (OHRC)
Four, free modules about tooth decay, risk factors, prevention, and anticipatory guidance; National Maternal and Child Oral Health Resource Center, Georgetown University.

Protecting All Children's Teeth (PACT): A Pediatric Oral Health Training Program (AAP)
A free, comprehensive online training module for primary care providers to learn more about providing pediatric care and guidance. Continuing medical education credits available; American Academy of Pediatrics.

Online Fluoride Varnish Training (SFL)
A 1-hour, free course to train medical home providers on how and when to administer fluoride varnish and other care. This is within the Access the Caries Risk Assessment, Fluoride Varnish, and Counseling module. Continuing medical education credits available; Smiles for Life National Oral Health Curriculum.

For Professionals

Oral Health Anticipatory Guidance List (Bright Futures)
A brief list of anticipatory guidance items for children from birth to young adulthood.

The Debate Over Fluoridated Water (AAP)
Pro-fluoride and anti-fluoride facts and myths; American Academy of Pediatrics.

Children's Oral Health (SCAA) (PDF Document 2.8 MB)
Reports the impacts of poor oral health and gives recommendations to improve the situation; Schuyler Center for Analysis and Advocacy.

Community Water Fluoridation FAQs (CDC)
Information about guidelines, scientific reports, and frequently asked questions about fluoride in wells and bottled water; Centers for Disease Control and Prevention.

For Parents and Patients

Campaign for Dental Health (AAP)
Created to ensure that people of all ages have access to the most effective, affordable and equitable way to protect teeth from decay; American Academy of Pediatrics.

Dental Exam for Children (MayoClinic)
Discusses why dental exams are important for children, how they are performed, what to expect from the assessment.

Top Problems in Your Mouth Slideshow (WebMD)
Images and descriptions of common oral health problems.

Parent's Checklist for Good Dental Practices in Child Care (NRC) (PDF Document 1023 KB)
A 1-page checklist for parents with information about brushing, preventing tooth decay, safety issues, and dental emergencies; National Resource Center for Health and Safety in Child Care and Early Education.

The Debate Over Fluoridated Water (AAP)
Pro-fluoride and anti-fluoride facts and myths; American Academy of Pediatrics.

Practice Guidelines

Casamassimo P, Holt K.
Bright Futures: Oral Health—Pocket Guide, 3rd edition.
2016; 3rd. Washington, DC: National Maternal and Child Oral Health Resource Center.

Moyer VA.
Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
Pediatrics. 2014;133(6):1102-11. PubMed abstract

Patient Education

What Is Infective Endocarditis? (AHA) (PDF Document 571 KB)
A fact sheet about this condition and the importance of treatment; American Heart Association.

Tools

My Water's Fluoride (CDC)
A user-friendly, searchable database that allows consumers to learn about the fluoride levels in their drinking water; Centers for Disease Control and Prevention.

Oral Health Pocket Guide (Bright Futures)
Anticipatory guidance information, risk assessment guides, a fluoride supplement chart, and tools for improving the oral health of children from before birth to young adulthood.

Oral Health Risk Assessment Tool (AAP) (PDF Document 302 KB)
A tool to aid in the implementation of oral health risk assessment during health supervision visits. Contains photos and a brief questionnaire about risk factors, protective factors, and clinical findings; American Academy of Pediatrics.

Services

Dental Care Expense Assistance

See all Dental Care Expense Assistance services providers (17) in our database.

Early Intervention Programs

See all Early Intervention Programs services providers (153) in our database.

General Dentistry

See all General Dentistry services providers (7) in our database.

Head Start/Early Head Start

See all Head Start/Early Head Start services providers (36) in our database.

Oral Surgery

See all Oral Surgery services providers (2) in our database.

Orthodontics

See all Orthodontics services providers (3) in our database.

Pediatric Dentistry

See all Pediatric Dentistry services providers (49) in our database.

Pediatric Hematology/Oncology

See all Pediatric Hematology/Oncology services providers (3) in our database.

WIC Clinics

See all WIC Clinics services providers (22) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Content Last Updated: 5/2017

Page Bibliography

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Protecting All Children's Teeth (PACT): A Pediatric Oral Health Training Program.
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Fluoride Supplements.
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Bright Futures Medical Screening Reference Table 2 to 5 Day (First Week) Visit.
American Academy of Pediatrics; (2010) Accessed on April 2017.

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Pediatr Dent. 2016;38(6):328-333. PubMed abstract / Full Text

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Pediatr Dent. 2013;35(5):E157-64. PubMed abstract / Full Text

EQIPP.
Oral Health Online Course.
2017; American Academy of Pediatrics; https://shop.aap.org/eqipp-oral-health/

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Oral health risk assessment timing and establishment of the dental home.
Pediatrics. 2003;111(5 Pt 1):1113-6. PubMed abstract / Full Text
An American Academy of Pediatrics Policy Statement. Optimal practices of diet, oral hygiene, and fluoride exposure can significantly and positively impact a child’s predisposition to early childhood caries. Pediatricians and pediatric health care professionals should perform oral health risk assessments on all patients beginning at 6 months of age. A dental home should be established by 1 year of age for children deemed at risk.

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Does Medicaid Cover Dental Care.
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