Anticipatory guidance included

1. Preventive Pedodontics
Dr. Sucheta Prabhu
Second year MDS

2. Contents
• Levels of prevention
• Infant oral health care
• Anticipatory guidance
• Dental home

3. Questions asked previously
Short essay
1.Anticipatory guidance for infant oral health care.
2.Anticipatory guidance
3.Infant oral health care
4.Risks & benefits of pacifiers AAP and AAPD guidelines.
5. Dental home
Long essay
Describe the comprehensive programme for infant oral health care in
India. (20 marks)
Infant oral health and dental home

4. What is prevention?
• The art and science of utilization of
knowledge,skill and available measures to
prevent occurrence of a disease, control
already existing diseases so that it
prevents spread and complications.

6. Levels of prevention

7. Primary prevention
Health promotion
Specific protection

8. Primary Prevention

9. Secondary Prevention

10. Disability limitation
Disease
Impairement
Disability
Handicap

11. Tertiary Prevention
Preventive
Services
Disability
Limitation
Rehabilitation
Services provided
by the individual
Use of dental
services
Use of dental
services
Services provided
by the community
Provision of
dental services
Provision of
dental services
Services provided
by the dental
professional
Complex
restorative
dentistry
Pulpotomy
RCT
Extractions
Removable &
fixed
prosthodontics
Implants

12. Infant oral health
care

13. Definition
Professional intervention
within 6 months after the
eruption of the first
primary tooth or no later
than 12 months of age
directed at factors
affecting the oral cavity,
counselling on oral
disease risks and delivery
of anticipatory guidance.

14. Historical
background
G V Black proposed
oral care beginning
“as soon as a baby
has a tooth”.
1948: American
Academy of
Pedodontics was
founded.
1967: AAP began
promoting children’s
healthcare that
includes oral health.
1986: AAPD’s first
infant oral health
care policy
statement approved
• 1994: The term
Early childhood
caries was
adopted at CDC
meeting
2002: ‘Dental
home concept’
was established
– JADA
publication

15. GOALS OF INFANT ORAL
HEALTH PROGRAM
• To identify, intercept and modify the
potentially harmful parenting practices that
may adversely affect the infant’s oral health.
• Parent education right from the prenatal
period highlighting the importance of their role
in the prevention of dental disease for their
child.
• Parent/ caregiver orientation to perceive
dental services as an integral part of infant’s
overall health program.
• Periodic evaluation of the oro-facial
development and oral health by the clinician.

16. PREVENTION AND
MANAGEMENT PROTOCOLS
FOR INFANTS
Since family physicians and pediatricians often see the child up to six times
before age 2, it is crucial to take these appointments as opportunities to
increase awareness of oral health evaluations and screen young children for
caries risk and refer for dental care.
– Tooth eruption
– Preventive oral hygiene
– Orofacial development
– Fluoridation
– Diet

17. PRENATAL COUNSELLING
• Objectives:
– Establishing a positive Pediatric dentist-
family relationship.
– Information gathering from the family
– Anticipatory guidance
– Establishing sequence of subsequent
visits

18. PERINATAL ORAL
HEALTH
•A direct relationship exists between MS
levels in adult caregivers and that of caries
prevalence in their children. (Douglas JM
et al)
• Improving expectant mother’s oral health
by reducing pathogenic bacteria levels in
their own mouths, will delay the acquisition
of oral bacteria and the development of
ECC in their children. (Ramos-Gomes F)
• Therapeutic intervention and lifestyle
modification counseling both during pre-
and post-partum should be practiced, to
reduce maternal MS and lactobacilli
levels

19. Colonization of infant’s oral
cavity
Vertical transmission
• From mother to infant. (Davey AL
et al, Berkowitz RJ, Douglass JM et
al)
• The genotypes of streptococcus
mutans in infants appear to be
identical to that present in mother.

20. Maternal factors associated with
infant colonization
Salivary levels
of mutans
streptococci
Mother’s oral
hygiene
Periodontal
status
Socioeconomic
status
Snack
frequency
Wan AK et al 2010

21. Horizontal transmission
• Between members of a group.
• Siblings of similar age.
• Children in a day care centre.

22. Effect of mode of delivery on
oral microflora
• In the oral cavity, mutans streptococci were
detected more frequently and at a younger age
in children delivered by C-section than in those
delivered vaginally.

23. Predentate infants
• Berkowitz RJ (2006), Law V (2007) and Tanner ACR (2002): furrows
of tongue can also harbour mutans streptococci in predentate
infants.

24. Oral flora of pre-dentate
mouth
• Since the oral cavity of the
neonate lacks teeth and only
mucosal surfaces are available
during the first months of life,
organisms with ligands for the
tooth are absent.
• Epithelial binding sites for group
A streptococci and their
lipoteichoic acid in the oral cavity
of newborn infants are absent or
minimal at birth, but reach adult
levels between 48 and 72 hours
after birth.

25. WINDOW OF
INFECTIVITY
• The “window of infectivity,”
defined as the time of initial
colonization of the infant’s
oral environment with the
cariogenic bacteria mutans
streptococci (MS)
• Early studies reported that the
“window of infectivity” for MS
occurs at a mean age of 27
months.

26. Few Studies
Mohan
(1998)
4 months
Karn (1998)
10 months
Milgrom
(2000)
6 months

27. Second window of infectivity
• Speculated at 6 years of
age
• First molars erupt
Straetemans(1998)
• 75% of children uninfected
by age 5 become infected
by age 11

28. Diet counselling during the infant oral health
visit
• Breastfeeding:
• Exclusive breastfeeding till 6 months
followed by addition of iron-enriched
solid foods between 6-12 months of
age.
• Ad libitum nocturnal breast-feeding
should be avoided after the first
primary tooth begins to erupt.
Weaning:
• It has been observed that breast-feeding
for over 1 year and at night beyond
eruption of teeth may be associated with
Early Childhood Caries.
• AAPD recommends that infants should
drink from a cup as they approach their
first birthday and be weaned from the
bottle at 12-14 months of age.

29. Diet counselling during the
infant oral health visit
• Dietary fluoride supplements:
• Infants > 6 months of age exposed to water with
less than 0.3 ppm fluoride, dietary fluoride
supplements of 0.25 mg fluoride per day
should be prescribed.
• Irrespective of fluoride exposure in water dietary
supplements should not be prescribed for
infants under the age of 6 months.
Bottle feeding:
Infant formulas are acidogenic and
possess cariogenic potential.
Parents need to be aware of deleterious
effects of inappropriate bottle usage and
the need for good oral hygiene practices
upon the first primary tooth’s eruption.

30. ADVANTAGES OF
BREASTFEEDING
• Essential nutrients.
• Contains anti-infective factors
• psychological advantage
• Easily digestible.
• Breast milk has low osmotic load.
• Confers passive immunity to the
baby.

31. Composition of breast milk
• Its energy content is 60-75 kcal/100 ml.
• Contains over 200 nutritional, as well as
functional components.
Colostrum
• Secreted first 3- 7 days postpartum.
• Slightly yellow, more viscous, and
thicker.
• Lower in calories, contains less sugar.
• Contains more protein and electrolytes.
• Immunoglobulin A is the principal
protein found in colostrum. IgA helps
protect the infant from gastrointestinal
tract infections.

32. Breast milk
Transitional Milk
•One week postpartum colostrum changes into
transitional milk.
• Transitional milk is between colostrum and mature
milk, it is composed of more protein and less fat
and less lactose than mature milk.
• Fully mature milk is produced at about three
weeks postpartum, but this rate may vary from
mother to mother.

33. Breast milk vs Formula

34. BREAST FEEDING vs BOTTLE
FEEDING
Breastfeeding
• Stimulates muscles
around the mouth and
tongue activity for
normal growth of teeth
and jaws
• Allows milk flow on
demand ie by action of
infant’s lips.
• Allows gravity working
correctly on the muscles
involved in swallowing
• Reduced possibility of
overfeeding.
Bottle feeding
• Muscles don’t have to
work hard for bottle-
feeding.
• Milk flows from the
bottle in a continuous
flow.
• Lying on the back for
bottle-feeding keeps the
tongue in an unnatural
forward position to keep
from choking.

36. WEANING
• Process of expanding the diet
to include foods and drinks other
than breast milk and infant
formulae.
• It is a gradual process
Babies should not be weaned
at an earlier age,
• Lack neuromuscular
coordination needed to move
food from tip of tongue to the
back of the mouth.
• Gastrointestinal tract is too
immature to digest

37. Stages of Weaning
4-6 months
6-9 months
9-12 months

38. Recommend that parents start
weaning at approximately 9
months of age and accomplish
soon after the first birthday
(AAP1985)
• Bed time bottle feedings to be
discouraged especially after
tooth eruption.
• If bed time bottles are given,
water is considered the only
acceptable feeding substance
(Feigal 1985)

39. 4-6 months
Teething
• Symptoms:
– Fussiness, irritability
– Increased sucking
– Loose stools
– Increased drooling of saliva
– High temperature
– Swollen gums
• Symptomatic treatment of
teething:
– Sucking on teething rings
– Numbing gels
– Frozen pacifier
– Teething tablets

40. ANTICIPATORY GUIDANCE
“The process to provide practical,
developmentally appropriate information
about the children’s health to prepare
parents for the significant physical,
emotional and psychological milestones.”

41. AAPD’s Age Ranges
6-12
months
12-24
months
2-6
years

42. Content areas
Oral development
Fluoride adequacy
Oral hygiene
Diet and nutrition
Habits
Injury prevention

43. Guidelines for 6 to 12 months of
age
Milestones: the
eruption of the first
primary tooth
Oral development
 Review pattern of eruption
 Review teething fact
 Fluoride
 Assess fluoride status- no more than smear
sized fluoridated toothpaste used twice daily
 Determine supplements if needed such as
fluoride varnishes
Oral hygiene/health
 Review oral hygiene techniques with parents
 Plan for next visit based on risk assessment
Habits
 Review pacifier use
 Discuss thumb sucking effects on mouth

44. Guidance for 12 to 24 months of
age
• Milestones :
completion primary
dentition, occlusal
relationships
establishment, arch
length determined.
Oral development
 Discuss importance of space maintaining
 Discuss bruxing
Fluoride
 Reassess fluoride status
 Discuss toxicity and how to manage
accidental ingestion
Oral hygiene/health
 Review home oral care procedure and
compliance

45. Guidance for 12 to 24 months of
age
Habits
 Review non nutritive sucking
 Thumb sucking and pacifiers use will lead
to Anterior open bite, maxillary constriction
etc..
Nutrition and diet
 Discuss carbohydrate and their role in
plaque development
 Discuss the frequency of carbohydrate
intake as caries factor
Injury prevention
 Discuss electric cord safety, child proofing
the house
 Develop plans for oral trauma
management for preschool and child
care

46. Guidance for 2 to 6 years of age
Milestones : loss of first primary
tooth, eruption of first
permanent molar or incisor
Oral development
 Review patterns of eruption, point out
permanent incisor
 Describe healthy periodontal tissue
Fluoride
 Fluoridated toothpastes not more than a pea
size
 Child should brush under the supervision of
parents to ensure expectoration
Oral hygiene/health
 Review home oral care procedures and
compliance
 Discuss dental sealants and describe dental
radiographs
 Plan for next visit based on risk assessment

47. Guidance for 2 to 6 years of age
Habits
 If child is still sucking the thumb, discuss to
help him stop the habit
Nutrition and diet
 Review diet outside the home and its caries
potential
 Discourage the use of food as a behavioral
tool
Injury prevention
 Encourage the use of helmets, mouth guards,
and car seats
 Develop plans for oral trauma management
 Review difference between primary and
permanent teeth with parents during examination

48. Guidance for 6 to 12 years of
age
Milestones: eruption of first
permanent molar
Oral development
 Discuss about the importance first
permanent molar
 Discuss the various preventive
measures taken at this stage to prevent
progression of caries
Nutrition and diet
 Review diet outside the home and its
caries potential
Fluorides
 Application topical fluorides if needed
 Regular use of tooth paste is
recommended

49. Oral hygiene/health
 Parents should continues to monitor
brushing and flossing frequency
and adequacy
 Application of pit and fissure sealants if
necessary
Habits
 Educate about any oral habits if it is
present
 Educate the parents about transitional
changes in the developing
dentition and the importance of primary
and permanent dentition

50. Guidance for adolescent
Prevention of periodontal disease becomes a special concern
At this age group the main process utilized are
a) Rejection of many parental values
b) The beginning of independent struggle
c) The testing out types of behavioural experimentaion
Parents are educated that they should treat the child at this stage
very diplomatically,friendly approach
The child should be given enough emotional support from parents

51. Oral hygiene/health
 The adolescent patient posses the fine motor
skills necessary for adequate
tooth brushing and flossing
 Problems in compliance are likely to be
encountered
 Diet
 High frequency of sugar consumption
 Progression of lession halted with an
appropriate diet and aggressive topical
fluoride therapy
 Fluorides
 Systemic fluorides are no longer benefit after
the last permanent tooth erupt at
about age of 13 yrs
 Topical fluorides are the most effective
preventive measure.

52.  Orthodontics
 Many Patients undergo orthodontic treatment
at this stage
 High risk for both gingivitis and gingival
hyperplasia and for dental caries
Smokeless tobacco
 Peer pressure and advertising exert pressure
on adolescent to establish a
habit that may result in addiction.
 Parents should be instructed not to punish the
adolescent as it may further worsen the habit
 Discuss the health risk in smoking
 Instruct parents to avoid smoking infront of the
children
 Discuss nicotine replacement and medication

53. “ the goal of the first oral supervision
visit is to assess the risk for dental
disease, initiate a preventive program,
provide anticipatory guidance and decide
in the periodicity of subsequent visits”.
Nowak (1997)
as early as six months of age and no
later than 12 months of age.

54. DENTAL HOME CONCEPT
Who
• AAPD
How
• Medical
home
When
• One year
age
• First tooth
erupts

55. Definition
• The Dental Home is the ongoing relationship between the dentist and the
patient, inclusive of all aspects of oral health care delivered in a
comprehensive, continuously accessible, coordinated, and family-
centered way. The Dental Home should be established no later than 12
months of age and includes referral to dental specialists when appropriate..

56. STEPS AT DENTAL HOME
History
• Prenatal
• Natal
• Postnatal
Orofacial &
Dental
examination
RISK
ASSESSMENT:
• Dietary factors
• Feeding practices

57. Ideal characteristics
5 C • Comprehensive
• Continuous
• Coordinated
• Compassionate
• Culturally competent

58. INITIAL INFANT ORAL CARE
VISIT
Should include caries risk assessment,
individualized preventive strategies
and anticipatory guidance.

59. Consists of a 6 step protocol:
.
• Periodic supervision of care (knows as periodicity) should be determined
based on the disease risk for each individual patient.

61. References
• Croll TP. A child's first dental visit: a protocol. Quint int 1984; 6:625-37.
• Nikiforuk g. Understanding dental caries. In: prevention: basic and clinical aspects. Ii.
Basel: karger, 1985; 37-8, 133-4.
• Chiodo gt, rosenstein di. Dental treatment during pregnancy: a preventive approach.
J am dent assoc 1985; 110:365-8.
• Peter s. Essentials of preventive and community dentistry.3rd ed.Arya publishing
house
• Marwah N.Textbook of pediatric dentistry .3rd ed.Jaypee medical publishers.
• AAPD Guideline on infant oral care.2015 revision Reference manual v 37 / no 6 15 /
16
• AAPD.Guideline on periodicity of examination,preventive services,anticipatory
guidance and oral treatment for infants,children and adolescents.Revision 2013.
Reference manual v 39 / no 5 178 / 82
• Sigal M Levine N. Infant oral health care.Can. Fam. Physician vol. 34: june 1988