Preventive dental care and counseling for infants and young children

INTRODUCTION — Many oral health problems, including dental caries, malocclusion, and fluorosis, begin in childhood and can be prevented through early and periodic preventive dental care and counseling.

The provision of preventive dental care and counseling at regularly scheduled health maintenance visits is essential to the achievement of these goals and will be discussed below. Oral health habits are discussed separately. (See "Oral habits and orofacial development in children".)

EPIDEMIOLOGY — Although the prevalence of dental caries has decreased since the 1970s [1-5], it remains one of the most common chronic diseases in children of all age groups [6]. Among adults and children worldwide, the age-standardized prevalence of untreated caries was approximately 8 percent in deciduous teeth and 29 percent in permanent teeth in 2017 [5]. Among children 2 to 19 years in the United States, the total prevalence of dental caries (treated and untreated) was 45.8 percent during 2015 to 2016; the prevalence of untreated dental caries was 13 percent [4]. The prevalence was lower in children age 2 to 5 years (21.4 total, 8.8 percent untreated) than among older children (51 to 54 percent total, 13 to 15 percent untreated). The prevalence of dental caries in children age 2 to 5 years has fluctuated since the 1980s but has not declined overall, ranging between approximately 21 and 28 percent [2,4,7,8].

PATHOGENESIS OF DENTAL CARIES — Ingestion of sugars is necessary for caries to develop; sugars and acidogenic oral bacteria are the root cause of caries [9]. The acid that is produced when the bacteria in plaque metabolize carbohydrates decreases the pH of the oral cavity. Saliva is able to buffer the acid until the oral pH is less than 5.5; at pH <5.5, the dental enamel is demineralized. With continued exposure to pH <5.5 (eg, from constant snacking or grazing), the surface enamel develops a chalky texture, known as the white spot lesion (picture 1). At this stage, teeth cleaning, plaque removal, and the use of topical fluoride promote remineralization; without intervention, cavitation will result.

Foods and beverages that contain carbohydrates are cariogenic. The cariogenic potential is determined by the macronutrient composition, oral clearance, and consumption patterns (table 1):

●Simple sugars (ie, monosaccharides and disaccharides, such as glucose, fructose, and sucrose) generally are considered more cariogenic than modified starches (oligosaccharides [short chains of monosaccharides]) and starches (polysaccharides) because simple sugars are more readily metabolized by bacteria than modified starches. However, foods and beverages containing only sugars that are readily cleared from the mouth (eg, sugar-sweetened beverages) may be less cariogenic than foods containing a combination of sugars and starches that are retained in the mouth (eg, baked sweets, salty snacks).

●The presence of protein and/or fat within the food item (eg, milk) or in foods consumed with the carbohydrate-containing food (eg, meat, cheese) lessen the cariogenic potential of the carbohydrate.

●Frequent and/or prolonged consumption of the carbohydrate-containing foods or beverages increase cariogenic potential [10].

Molar incisor hypomineralization (MIH) is a condition in which the tooth enamel of erupting permanent teeth is incompletely formed (picture 2), increases the risk of dental caries in affected teeth. Children with MIH should be immediately referred for dental evaluation and treatment. MIH is discussed separately. (See "Developmental defects of the teeth", section on 'Molar incisor hypomineralization'.)

RISK ASSESSMENT — Dental risk assessment in children younger than three years can help to identify children who are at risk for development of dental disease (table 2) [11,12]. Risk factors for the development of dental disease have been identified in several prospective studies and include findings from both the history and examination [13-18]. Environmental exposures (eg, nonfluoridated water, sugar intake) appear to be more important in the development of dental caries than genetic factors [19]. In an observational study, risk factors documented in the medical record before 18 months of age predicted the risk of early childhood caries at the time of the initial dental visit [20].

Children with the following risk factors should be referred for early dental evaluation, preventive care, and counseling:

●Mother/primary caregiver with active caries

●Parent/caregiver with low socioeconomic status

●Breastfeeding or bottle-feeding beyond 12 months of age

●Frequent consumption of sugary beverages and snacks

●Prolonged use of a training cup (sippy cup) throughout the day

●Use of a bottle at bedtime, especially with sweetened beverages

●Use of liquid medication for longer than three weeks

●Exposure to environmental tobacco smoke (eg, a smoker in the household)

●Children with special health care needs

●Insufficient fluoride exposure (see 'Fluoride' below)

●Visible plaque on upper front teeth

●Enamel pits or defects

SCREENING EXAMINATION — Pediatric primary care providers should begin performing a dental screening examination as soon as the first teeth erupt, usually when the child is between five and eight months of age (figure 1) [21]. With adequate training, primary care clinicians can appropriately identify children who require dental referral (eg, those with cavities, soft tissue pathology, tooth or mouth trauma) [22].

Recommended equipment for this examination includes a light source, disposable mouth mirror, and a soft-bristled toothbrush. The examination may be conducted on the examination table or in the "knee-to-knee" position (picture 3). In the "knee-to-knee" position, the child is well supported and stable, the child's mouth is visible and accessible to the examiner, and the caregiver can support and distract the child.

The goals of the screening dental examination include:

●Evaluation for abnormalities of teeth and oral mucosa (see "Soft tissue lesions of the oral cavity in children")

●Assessment for dental plaque

●Assessment for white spots and/or cavities

With gloved hands and a good light source, the examiner should lift the child's upper lip to inspect the teeth for plaque. The teeth should be cleaned with a gauze square or a wet toothbrush, using a gentle scrubbing motion to remove plaque if it is present. After cleaning, the front and back surfaces of the teeth should be inspected for white spots, pitted enamel, stains, and cavities (picture 1).

If obvious decay, abscess, or other significant disease is noted during screening, the child should have an immediate referral to a dentist experienced in caring for children. Collaboration between pediatric primary care providers and dentists and/or provision of dental services in medical settings may be necessary to ensure follow-up with dental care [23].

Oral health assessment by six months of age is recommended by the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry [11,21,24]. The AAP recommends repeat oral health assessment at 12, 18, 24, and 30 months, and 3, 4, 5, and 6 years of age if the child has not yet established a dental home [21]. Relatively few studies have evaluated the effectiveness of these recommendations in preventing caries [25], and existing studies have inconsistent findings and methodologic limitations [23,26-34]. However, on balance, the limited available evidence suggests early visits help to prevent caries and reduce costs, and there is little risk of harm [35-38].

DENTAL REFERRAL — All children should receive a dental referral to establish a dental home at or near their first birthday [39]. However, if dental providers in the area are unwilling to see children who are younger than three years of age, the pediatric health care provider may continue to provide preventive dental care and counseling for infants and children who are at low risk of developing dental disease and have no abnormalities on screening examination. Children with risk factors for caries and/or abnormalities on screening examination should be referred preferably to a pediatric dentist who accepts infants and toddlers. The American Academy of Pediatric Dentistry provides a website to help find a pediatric dentist.

Making a dental referral provides the pediatric care provider with an opportunity to explain the concept of the dental home and encourage the caregivers to establish one as soon as possible after the first birthday, and certainly by the time the child is three years of age. Once the referral is made, pediatric and dental care providers should communicate regarding the child's diagnosis and treatment plans. The pediatric care provider should verify that the child kept the initial appointment and continues to be seen by the dentist at least annually. The pediatric care provider should continue to provide oral health anticipatory guidance at regularly scheduled health maintenance visits. (See 'Dental home' below and 'Anticipatory guidance' below.)

FIRST DENTAL VISIT — The American Academy of Pediatric Dentistry and the American Academy of Pediatrics (AAP) recommend that the first dental visit occur at or near one year of age [39,40]. We support this recommendation , particularly for children who are at risk for developing oral health problems.

The rationale for the early dental visit center on the early initiation of preventive care and counseling, including evaluation of dental risks (ie, caries, malocclusion) and anticipatory guidance regarding dental hygiene, fluoride, diet, dietary habits, and oral habits [41-43]. In addition, early dental referral can provide a pleasant, nonthreatening introduction to the dentist [44]. (See "Oral habits and orofacial development in children".)

Early initiation of dental care is associated with improved outcomes. In a randomized trial in 448 pregnant Aboriginal Australian women, preventive dental care (dental treatment of mothers, fluoride varnish application, and anticipatory guidance) initiated during pregnancy was more effective in preventing dental decay at age 3 years and age 5 years than preventive dental care initiated at 24 months of age (mean number of decayed teeth at age 3 years 1.44 versus 1.86; mean number of decayed, missing, or filled teeth at age 5 years 2.10 versus 2.91) [35,36].

Similarly, in a retrospective study of 42,532 children (zero to seven years of age) who had a first dental visit during 2004 and eight years of dental follow-up, having had the first dental visit before four years of age (40 percent of subjects) was associated with fewer dental procedures (eg, restorations, crowns, pulpotomies, extractions) during the follow-up period (7.69 versus 11.27) and lower cost of dental care [37].

In a cost-benefit analysis of dental claims for 94,574 privately insured children from four states, initial dental visit at one year of age was associated with decreased costs and number of complex procedures; it was estimated that a preventive dental visit at or before one year of age could reduce complex procedures over five years by as much as 22 percent [38].

The number of children with a first dental visit at 12 months of age has improved since 2003 (when the AAP lowered the recommended age for the first visit from 3 years to 12 months [11]) but continues to be suboptimal. Although surveys indicate that dentists are increasingly willing to see children at or before 12 months of age [45-47], persistent barriers include lack of reimbursement, busy schedules, and inexperience in providing dental care to young children.

Telehealth services ("teledentistry") are relatively new to dental care and improve access to dental care [48,49]. Teledentistry holds promise for improving access to dental care for children with multiple applications, including treatment planning, emergency trauma management, and provision of anticipatory guidance [50].

DENTAL HOME — The dental home, similar to the medical home that is recommended by the AAP, should be established at the initial dental examination [51-55]. (See "Children and youth with special health care needs", section on 'Framework of care'.)

The dental home should provide the following services:

●Initial dental visit at 12 to 18 months of age

●Risk assessment for dental disease

●Evaluation of fluoride needs

●Demonstration of appropriate teeth-cleaning method

●Discussion of the benefits and risks of nonnutritive sucking

●Monitoring of the child's oral health care on a schedule that is individualized to the child's risk for dental disease

●Treatment (or referral for treatment) of dental caries

●Twenty-four-hour availability for acute dental problems

●Recognition of the need for specialty consultation and referrals

●Provision of continuing, comprehensive dental care for all children, including those with special health care needs

ANTICIPATORY GUIDANCE — The pediatric care provider should provide and reinforce dental anticipatory guidance at regularly scheduled health maintenance visits [39].

●Before the eruption of primary dentition – Nonnutritive sucking and the teething process

●Before the six-month check-up – Fluoride supplementation (so that it can be initiated at age six months if it is necessary) (table 3)

●As the primary dentition erupts – Feeding habits, the use of bottles and cups, and cleaning of the teeth

High-quality studies evaluating the effectiveness of specific educational or counseling interventions are lacking [56]. However, there is some evidence that education combined with other interventions (eg, provision of toothbrushes and toothpaste, additional training of primary care providers) is associated with decreased caries in high-risk children younger than five years [57-59].

Nonnutritive sucking — Nonnutritive sucking (eg, sucking on a pacifier, thumb, or fingers) is a self-soothing behavior that is normal in early development but may become a learned habit if it persists beyond 12 to 18 months of age and should be discontinued at approximately 24 months.

Nonnutritive sucking occurs in 70 to 90 percent of infants in various populations [54,60-62]. The frequency of sucking on digits or pacifiers decreases with increasing age; by the age of four to five years, nonnutritive sucking is usually replaced by other coping mechanisms [60]. Compared with pacifier sucking, digit sucking is more likely to persist into the fourth or fifth year of life [63,64]. If it persists into the period of permanent tooth eruption, nonnutritive sucking, especially pacifier use, may contribute to the development of malocclusion [65]. The dental effects and recommendations for the discontinuation of sucking habits are discussed separately. (See "Oral habits and orofacial development in children", section on 'Nonnutritive sucking'.)

Teething — It is normal for infants whose primary teeth are erupting to be cranky, chew on objects, and have excessive drooling. Caregivers frequently report that their teething infants have fever, diarrhea, or other systemic symptoms; however, no proven association exists between these symptoms and teething [66-71]. In an observational study, caregiver-reported teething symptoms were more common in infants with birth weight <2500 g than in infants with higher birth weights [71]. The management of teething symptoms is palliative (eg, chewing on a chilled [not frozen] teething ring or other teething device, systemic analgesia). (See "Anatomy and development of the teeth", section on 'Teething symptoms'.)

Ankyloglossia — Ankyloglossia ("tongue-tie") is discussed separately. (See "Ankyloglossia (tongue-tie) in infants and children".)

Dietary habits — Anticipatory guidance regarding diet and dietary habits can play a major role in the prevention of caries [39]. In vitro, human breast milk, formula, and other beverages differ in their ability to support bacterial growth, dissolve enamel mineral, reduce plaque pH, buffer acid, and decalcify enamel and dentin [72,73].

●Breast milk and infant formula – If possible, infants should be breastfed exclusively for approximately the first six months of life and breastfeeding should continue until the child is one year of age, as recommended by expert groups [74]. Whether infants are fed human milk or infant formula, solid foods should be introduced at approximately six months of age. (See "Introducing solid foods and vitamin and mineral supplementation during infancy".)

Compared with water, breast milk and most infant formulas reduce plaque pH, have variable buffering capacity, and may support bacterial growth and dissolve enamel mineral when exposure is prolonged [72,73]. To decrease the duration of exposure of newly erupted teeth to breast milk or infant formula, the use of a training cup can begin as soon as the child is able to drink from one (at approximately six months of age), and bottles should be discontinued as soon as possible after the first birthday [75].

Studies evaluating the risk of caries in breastfed versus formula-fed children are heterogeneous, which limits generalizability [76,77]. A 2015 systematic review and meta-analysis of heterogeneous observational studies suggests that breastfeeding before 12 months of age is associated with decreased risk of dental caries and breastfeeding after 12 months is associated with increased risk of caries, particularly in infants who fed at night or "on-demand" [76]. The increased risk of caries in children breastfed >12 months may be due to the eruption of additional primary teeth after 12 months, the introduction of cariogenic foods and beverages, and inadequate oral hygiene [78,79], but studies specifically evaluating these issues were lacking.

Breastfeeding has been suggested to reduce the risk of malocclusion. In a meta-analysis of seven observational studies, breastfeeding for <12 months was associated with increased risk malocclusion in the primary dentition [80]. However the evidence for this relationship is weak, as there are relatively few studies and they have largely relied on caregiver report or cursory assessment of malocclusion rather than actual measurements [81-84]. Moreover, many studies did not account for the effects of nonnutritive sucking habits, and most were limited to the primary dentition [80].

●Juice and sweetened beverages – Juices and other sugar-sweetened beverages that are commonly given to toddlers in bottles or training cups have high cariogenic potential. Pure juices (100 percent juice) should not be offered to infants younger than 12 months and limited to no more than 4 ounces per day for toddlers 12 to 36 months of age. Other sweetened beverages, such as soda pop, fruit drinks (with added sugar), or flavored milks, should not be given to children younger than five years [85]. (See "Introducing solid foods and vitamin and mineral supplementation during infancy", section on 'Beverages to avoid' and "Dietary recommendations for toddlers and preschool and school-age children", section on 'Beverages'.)

●Other considerations – Other dietary habits that may decrease the cariogenicity of sugar-containing foods and beverages include:

•Avoiding added-sugar beverages as much as possible throughout childhood

•Consuming 100 percent fruit juice or added-sugar beverages (if consumed) from an open cup rather than a bottle or training cup, avoiding sipping these beverages throughout the day or in bed

•Including sweetened items as part of meals rather than as separate snacks or "grazing" throughout the day

•Consuming sweetened items with other foods that contain protein and/or fat

•Rinsing the mouth with water immediately after consumption of sweetened items; for children in whom chewing gum is not a choking hazard, chewing sugar-free gum immediately after consumption

Oral hygiene — Although oral hygiene measures in the absence of fluoride have not been proven to reduce caries [86], they provide a vehicle for fluoride delivery and are important for gingival health. Caregivers should be encouraged to clean the child's teeth twice daily for two minutes [24,39] with fluoride-containing toothpaste. The teeth should be cleaned with an age-appropriate toothbrush. Flossing may be initiated when the space between teeth becomes too small to clean adequately with a toothbrush, although available evidence shows no benefit of self-flossing in caries reduction [87]. (See 'Fluoride toothpaste' below.)

Caregivers should supervise brushing and flossing until the child is approximately 8 to 10 years of age and can tie shoelaces (a marker of the manual dexterity necessary for effective brushing, including spreading fluoride-containing toothpaste on all surfaces of the teeth) [12,39]. Supervision may be necessary beyond attainment of this skill to ensure that the proper amount of toothpaste is used and that the child does not swallow the toothpaste. Evidence to support the use of mechanical (power, electric) brushes over manual brushing in preschool children is lacking. Toothpaste containing fluoride is recommended, but to avoid fluorosis, fluoride-containing toothpaste should be used in very small amounts. (See 'Fluoride toothpaste' below.)

Children with developmental and intellectual disabilities may require partial or total assistance in tooth brushing from a parent or caregiver. In children with severe disabilities, more than one person may be necessary to stabilize the head and/or prop open the mouth to increase visibility. Caregivers may have to try several brush types to determine which works best. Minimal toothpaste should be used to reduce the potential for gagging.

Trauma — Nearly one-half of children sustain some type of dental injury during childhood. Many of these injuries are preventable through anticipatory guidance regarding prevention of falls, particularly when the child is learning to walk. As the child begins to participate in sports and recreation activities that are associated with a risk of dental trauma, caregivers and children should be counseled about the use of protective gear (eg, facemasks and mouth guards) [39,88]. In addition, caregivers should be instructed regarding the proper management of avulsed primary and permanent teeth, as well as the importance of regular dental care and maintenance. (See "Evaluation and management of dental injuries in children".)

Tooth whitening and bleaching — Although products that whiten/bleach teeth are popular, we generally avoid them in children younger than 18 years.

Products that whiten the teeth generally fall into two categories – those that whiten teeth through cleaning agents and those that bleach the tooth enamel.

Whitening products include over-the-counter toothpastes that often contain silica-based compounds that help to remove stains and thereby "whiten" teeth. These toothpastes usually also contain fluoride and can be recommended for children age 12 or older. (See 'Fluoride toothpaste' below.)

Whitening mouth rinses often contain hydrogen peroxide, which is unlikely to provide significant whitening of the teeth and, as with any mouth wash, is contraindicated in young children.

Bleaching products whiten teeth through prolonged contact of the tooth enamel to peroxides – usually carbamide peroxide. Bleaching products include professional-use products that range in concentration from 10 to 38 percent carbamide peroxide and over-the-counter products that contain from 5 to 14 percent carbamide peroxide. Both professional-use and over-the-counter bleaching agents have common side-effects of increased tooth sensitivity and gingival irritation. These side-effects typically subside within a few days when use of the product is stopped.

There has been little study of the effects of bleaching products on children, but primary tooth enamel is thinner and may respond differently than permanent tooth enamel. Given these considerations, and the need to closely adhere to bleaching protocols to avoid overuse and side-effects, we restrict the use of bleaching agents to individuals who are ≥12 years of age, and in most cases do not recommend their use until age 18. The American Academy of Pediatric Dentistry recommends judicious use of bleaching agents in children and discourages full-arch cosmetic bleaching in the primary or mixed dentition (ie, children age 12 years or younger) [89].

FLUORIDE — Use of fluorides is the primary means of preventing dental caries across all age groups. However, excessive fluoride exposure in children can cause dental fluorosis, which typically presents as white streaks in the enamel of permanent teeth. Thus, fluoride should be used judiciously in children, particularly during the critical months of enamel maturation (up to 48 months), when the developing anterior permanent teeth are most vulnerable to excessive fluoride that can cause fluorosis [90]. This is especially true for daily-use fluoride products, such as fluoride toothpaste.

Fluoride toothpaste — We suggest that all children with teeth have their teeth brushed twice daily for two minutes with small amounts of fluoride-containing toothpaste. The appropriate amount of toothpaste for infants and toddlers (younger than three years) is a "smear" (a very thin layer of toothpaste that covers less than half of the bristle surface of a child-size toothbrush (picture 4)) or the size of a grain of rice [12,39,91]. The amount of toothpaste should be increased to no more than a "pea-sized" (picture 5) amount at age three years; older preschoolers can use slightly more than a "pea-sized" amount. It is important to provide counseling to caregivers to ensure that the appropriate amount of toothpaste is used; in a national survey (2013 to 2016), nearly 40 percent of children age three to six years used more toothpaste than recommended [92]. To avoid swallowing fluoride toothpaste, young children should not be given water to rinse after brushing [12]. A systematic review of observational studies found limited evidence that although ingesting more than a pea-sized amount of fluoride-containing toothpaste is associated with increased risk of fluorosis [93], most cases of fluorosis associated with fluoride toothpaste are mild, and not considered unattractive [94-96].

There is no clear consensus among pediatric and dental groups as to when use of fluoride toothpaste should be initiated [97]. The American Academy of Pediatrics (AAP) and the American Dental Association (ADA) recommend fluoride toothpaste "for all children with teeth" [12,91], whereas the American Academy of Pediatric Dentistry (AAPD) recommends fluoride toothpaste "for children less than two years of age at risk for dental caries" [98]. The ADA provides a list of toothpastes that meet ADA criteria for safety and effectiveness. All three organizations agree that use of fluoride toothpaste should be closely supervised by caregivers and that very small amounts should be used for infants and toddlers to reduce the risk of fluorosis in the permanent teeth. Given the cost and complexity of treating caries in young children and the lack of caries risk assessment tools that have been validated in this population, we suggest that all children with teeth should have their teeth brushed daily with small amounts of fluoride toothpaste dispensed by the parent or caregiver.

Use of fluoride toothpaste reduces the risk of dental caries in children. A systematic review included one randomized trial (998 participants) that compared toothbrushing with fluoride-containing toothpaste and toothpaste without fluoride in reducing the caries increment (ie, the change from baseline in decayed and filled surfaces of the primary dentition) [99]. Fluoride-containing toothpaste reduced the caries increment from 4.73 to 2.87 (mean difference of -1.86, 95% CI -2.5 to -1.2). In another systematic review, pooled analysis of eight observational and randomized studies (4187 patients), brushing with fluoride-containing toothpaste was associated with a small reduction in caries risk in children younger than six years who were at high risk of developing caries (standardized mean difference -0.25, 95% CI -0.36 to -0.14) [97].

The optimal concentration of fluoride is uncertain, but nearly all fluoride toothpaste in the United States has concentrations of approximately 1000 parts per million. In a network meta-analysis of 81 studies, concentrations of 1000 to 1500 parts per million (ppm) were associated with better outcomes than nonfluoride toothpaste; in indirect comparisons, outcomes were similar for concentrations of 1450 to 1500 ppm and concentrations of 1700 to 2000 ppm [99]. None of the included trials reported on fluorosis. To maximize the benefits and minimize the risks of fluoride toothpaste, we suggest that children younger than three years begin brushing with fluoride toothpaste as soon as they develop teeth but that they use only a "smear" of toothpaste.

Topical fluoride application — We suggest that prescription-strength topical fluoride be provided based on the results of a caries risk assessment (table 2) rather than universal application of topical fluoride beginning at primary tooth eruption. Prescription-strength home-use topical fluoride agents (up to 5000 parts per million) are indicated only for patients ≥6 years old who are at increased risk of developing dental caries [100]. Patients at low risk of developing caries can receive sufficient fluoride through fluoridated water and over-the-counter fluoridated toothpaste.

For children at increased risk of dental caries, topical application of fluoride can be achieved in a number of ways [100]:

●Professionally applied by health care practitioners (eg, dentist, dental hygienist, physician, nurse, or medical assistant depending on state practice acts) [12]:

•For children <6 years – 2.26 percent fluoride varnish applied at least every three to six months

•For children 6 to 18 years old – 1.23 percent acidulated phosphate fluoride foam or gel for four minutes at least every three to six months; or 2.26 percent fluoride varnish at least every three to six months

Information and resources related to fluoride varnish application in primary care practice are available through the AAP.

●Self-applied at home (by prescription)

•For children 6 to 18 years old – 0.09 percent fluoride mouth rinse at least weekly; or 0.5 percent fluoride gel or paste twice daily until the risk level is reduced (table 2)

Systematic reviews and meta-analyses have found that over-the-counter fluoride mouth rinse (0.05 percent fluoride [230 parts per million]) may be beneficial in preventing caries in children (>6 years) at high risk but does not provide any benefit beyond that of fluoride toothpaste for children at low risk of caries [101,102].

There is a lack of consensus among professional groups regarding universal or risk-based topical fluoride application. The ADA and the AAPD recommend risk-based application to avoid unnecessary use of resources in children who are at low risk of dental caries [100,103]. The United States Preventive Services Task Force (USPSTF) and the AAP recommend universal application of fluoride varnish beginning at primary tooth eruption and continuing through age five years (USPSTF) or establishment of a dental home (AAP) to avoid missed opportunities for caries prevention [12,104]. Although, we suggest a risk-based approach, we recognize that it is not always practical to perform individualized caries risk assessments.

In a 2021 meta-analysis of randomized trials comparing fluoride with placebo or no treatment, the use of topical fluoride (mainly fluoride varnish) resulted in approximately one less surface tooth decay over a two-year period (mean difference in the increment of decayed, missing, or filled primary tooth surfaces of -0.94, 95% CI -1.74 to -0.34; 13 trials, 5733 participants) [105]. In addition, in higher-risk populations or settings, topical fluoride reduced the likelihood of incident caries (absolute risk difference -7 percent, relative risk 0.80, 95% CI 0.66-0.95), predominantly in children ≤2 years of age. Evidence suggesting that a particular frequency (eg, every three versus every six months) or regimen (eg, single application versus multiple applications over a two-week period) is superior to another is limited [25,106-108].

Topical fluoride application appears to be safe. In a meta-analysis of four randomized trials (414 participants) comparing fluoride varnish with placebo or no treatment, the rates of fluorosis and other adverse events were similar [105]. In addition, in a pharmacokinetic study in six toddlers (12 to 15 months of age) in whom urinary fluoride was measured for five hours after application of 5 percent sodium fluoride (2.26 percent fluoride) varnish, the average estimated retained fluoride was 20 mcg/kg, well below the "probable toxic dose" of 5 mg/kg [109,110].

Despite strong evidence of fluoride's safety and effectiveness, small groups of people in the United States have opposed fluoride use – particularly water fluoridation – for decades [111]. In addition, patient reluctance to accept in-office topical fluoride applications appears to be a growing problem [112]. Although the reasons for "fluoride hesitancy" are unclear, reasons provided by parents of young children for refusing topical fluoride application include that their children are not at risk for caries, that fluoride is not effective, that other means of caries prevention (eg, reduced sugar consumption) are preferable, and that fluoride is harmful [113].

Fluoride supplementation — Fluoride supplementation, if indicated based upon fluoride intake and caries risk (table 2), should begin at six months of age (table 3) [104,114]. Fluoride supplementation is only necessary if the child is at high risk for caries, other fluoride vehicles (eg, fluoride toothpaste, mouth rinse, varnish, gel) have proved to be inadequate, and the family is using nonfluoridated water, bottled or processed waters, or well water that does not contain fluoride [12,115,116]. In the United States, the Centers for Disease Control and Prevention provide information about community water fluoridation [117]. The United States Public Health Service recommends an optimal community drinking water concentration of 0.7 mg/L to prevent dental caries [118].

Most bottled water products contain negligible levels of fluoride, although the content varies [119]. The fluoride content is not included on the label unless fluoride has been added by the manufacturer [12].

The treatment of water before drinking may affect the fluoride concentration. Faucet water filters that use reverse osmosis systems and distillation units substantially reduce the fluoride content [120-122]. Most "pour through" devices using activated carbon filters do not reduce fluoride [12,120,122,123]. Water softener systems do not alter fluoride content [122,124,125].

Fluorosis — Excess fluoride consumption (generally greater than 0.05 mg/kg per day) can cause fluorosis or hypomineralization of the dental enamel [126]. Dental fluorosis occurs only when there is excessive fluoride concentration during tooth development – generally up to 48 months of age [90]. (See "Developmental defects of the teeth", section on 'Fluorosis'.)

Tap water may be used to reconstitute powdered or concentrated infant formula [12,127]. Although use of optimally fluoridated water to reconstitute powdered infant formula was associated with an increased risk of dental fluorosis in a prospective study [128], children may be exposed to multiple sources of fluoride during infancy (eg, reconstituted fruit juice, fluoride-containing toothpaste) and it is difficult to determine the contribution of one particular source [127].

DENTAL SEALANTS — Dental sealants are plastic coatings that are bonded to the chewing surfaces of the teeth. They prevent cariogenic bacteria from colonizing the pits and fissures of the teeth and/or having access to ingested sugars, which the bacteria metabolize into acids [129]. Sealants typically are applied by dentists or dental hygienists in dental offices or clinics. However, school-based sealant programs are common and generally target schools in lower-income neighborhoods.

Dental sealants generally are recommended for preventing and arresting carious lesions in primary and permanent molars of children and adolescents [130]. Sealants often are used combination with topical fluoride for comprehensive caries prevention. Sealants prevent caries on chewing surfaces and surfaces with anatomic pits and fissures, whereas topical fluorides are most effective on smooth tooth surfaces.

Sealants usually are applied soon after eruption of the molars (eg, approximately six years of age for the first permanent molar). They are effective as long as they remain on the tooth surfaces. Sealant retention is variable, typically ranging from two to four years, but may last for 10 years or longer [131].

Sealants are effective in preventing dental caries in permanent teeth; evidence of effectiveness in primary teeth is limited [132]. In a systematic review of 15 studies comparing resin-based sealants with no sealant in 3620 children, the incidence of caries in the permanent teeth of control groups ranged from 16 to 70 percent at 24 months of follow-up compared with 5 to 19 percent in the sealant groups [133]. In a meta-analysis of seven randomized trials in >1300 children age 5 to 10 years, resin-based sealants reduced the risk of caries in first permanent molars over 24 months of follow-up (odds ratio 0.12, 95% CI 0.08-0.12) [133]. Sealants were estimated to decrease the absolute risk of caries by 11 to 51 percent (from 16 to 5 percent using the lower range of incidence in the control group and from 70 to 19 percent using the upper range of incidence in the control group).

In another systematic review of randomized trials, dental sealants (resin- or glass ionomer-based) and fluoride varnish were similarly effective in preventing caries on the occlusal surfaces of permanent molars [134]. The combination of resin-based sealant and application of fluoride varnish appeared to be more effective than fluoride varnish alone. Among the trials that reported on adverse effects, none were reported.    

SILVER COMPOUNDS — Silver compounds, particularly silver nitrate, were widely used in dentistry during the 19^th and early 20^th centuries and have received renewed attention for the treatment and prevention of caries in children. While these agents may halt progression of established caries lesions [135-140], they permanently stain the caries lesions a dark black color and temporarily stain any soft tissue they contact [12,141]. Thus, their use is generally limited to severe caries in young children in whom traditional surgical management is not feasible [142,143].

●Silver diamine fluoride – Silver diamine fluoride (SDF) became available in the United States in 2015 to treat tooth sensitivity. Although it is not approved for treatment and prevention of caries in the United States [143], it has been used for these indications in other countries, and off-label use is permitted in the United States. In a meta-analysis of five trials, application of SDF "arrested" 65.9 percent (95% CI 41.2-90.7 percent) of caries lesions [137]. The American Academy of Pediatric Dentistry supports the use of SDF to prevent progression of caries that does not involve the pulp in primary teeth as part of a comprehensive management program, particularly for children with severe caries that cannot be managed with traditional surgical techniques [144]. Allergy to silver is a contraindication to SDF.

●Silver nitrate – Silver nitrate is also used by some dentists – often with fluoride varnish – to treat and prevent dental caries in children, although published studies regarding its efficacy are lacking [145].

DENTAL RESOURCES — The following resources may provide useful oral health information:

●The American Academy of Pediatric Dentistry provides information and resources including help finding a pediatric dentist

●The American Academy of Pediatrics

●American Dental Association

●National Institute of Dental and Craniofacial Research

●National Maternal and Child Oral Health Resource Center

SUMMARY AND RECOMMENDATIONS

●Dental risk assessment – Dental risk assessment (table 2) in children younger than three years of age can help to identify children who are at risk for development of dental disease. Children with the following risk factors should be referred for early dental evaluation, preventive care, and counseling (see 'Risk assessment' above):

•Mother/primary caregiver with active caries

•Parent/caregiver with low socioeconomic status

•Breastfeeding or bottle-feeding beyond 12 months of age

•Frequent consumption of sugary beverages and snacks

•Prolonged use of a training cup (sippy cup) throughout the day

•Use of a bottle at bedtime, especially with sweetened beverages

•Use of liquid medication for longer than three weeks

•Exposure to environmental tobacco smoke (eg, a smoker in the household)

•Children with special health care needs

•Insufficient fluoride exposure

•Visible plaque on upper front teeth (see 'Fluoride' above)

•Enamel pits or defects

●Screening examination – Pediatric primary care providers should begin performing a dental screening examination for abnormalities of the oral mucosa and teeth (including dental plaque, white spots, and cavities) as soon as the first teeth erupt. Obvious decay, abscess, or other significant disease are indications for immediate referral to a dentist experienced in caring for children. (See 'Screening examination' above.)

●Dental referral – All children should receive a dental referral at or near their first birthday. However, if dental providers in the area are unwilling to see young children, the pediatric clinician may continue to provide preventive dental care and counseling for infants and children who are at low risk of developing dental disease and have no abnormalities on screening examination. (See 'Dental referral' above.)

●Anticipatory guidance – The pediatric care provider should provide and reinforce dental anticipatory guidance at regularly scheduled health maintenance visits. Topics to be discussed include nonnutritive sucking, the teething process, oral hygiene, feeding habits (eg, the use of bottles and cups), avoidance of fruit juice before one year of age, limiting fruit juice consumption in older children, indications for fluoride supplementation (table 3), and dental trauma. (See 'Anticipatory guidance' above.)