ray wagner, md, and rama oskouian, dmd, mph...ing (due to decay), or filled tooth surface in any...

60 www.contemporarypediatrics.com Vol. 25, No. 9

RAY WAGNER, MD, AND RAMA OSKOUIAN, DMD, MPH

DR. WAGNER is currently in general pediatric practice at the El Rio Community Health Center, Tucson, Ariz.

DR. OSKOUIAN is currently in private practice in Woodinville, Wash., and is also affiliate faculty at the University of Washington, Seattle.

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SEPTEMBER 2008 CONTEMPORARY PEDIATRICS 61

Several years ago, I had one of those pediatricwake-up calls that scared me. I was attend-ing to the care of a 2 1/2-year-old child with

Beckwith-Wiedemann syndrome. He lived in a low-income family, and temporarily had fallen through thehealth insurance safety net. For some reason, his Med-icaid insurance had lapsed, and here he was in my officeappearing very ill with a temperature of 40° C (104° F).His left maxillary area was quite swollen and dusky red.I looked in his mouth, and not surprisingly, found aninfected first left upper molar surrounded by a very ery-thematous gingiva. His teeth were riddled with cavities.

Fortunately, I was able to urgently admit him to thecounty hospital through a colleague in the emergencyroom. He did well with IV antibiotics, and was dis-charged four days later on oral clindamycin, andreferred for outpatient extraction of the tooth by theoral surgery department through the county healthdepartment. This case, including EMS transport, hospi-tal services, and outpatient dental surgical intervention,resulted in an $8,000 cost to the health care system. Theparents had to absorb some of this cost, and are stillmaking monthly payments to the hospital.

After this experience, I began to look at the teeth ofyoung children a little more carefully. It soon becameapparent to me that more than half of my patients had

dental caries! During this time, I supervised a teachingclinic and had medical students rotating through daily.As a teacher and clinician, I knew that I needed toimprove my knowledge on the diagnosis and manage-ment of dental disease in children, to better inform andeducate my students, and my patients’ parents.

This personal wake-up call has become a call to actionin my professional life. It is my goal to convince you, thereader, to take ownership and assume some responsibili-ty for the prevention and early diagnosis of this chronicdisease affecting millions of our children.

At the top of its classThe American Academy of Pediatric Dentistry’s

(AAPD) most recent definition of early childhood caries(ECC) is paraphrased as follows: ECC is the presence ofone or more decayed (noncavitated or cavitated), miss-ing (due to decay), or filled tooth surface in any primarytooth in a child younger than six years (71 months oryounger).1 More serious cases are classified as severeearly childhood caries, or S-ECC, previously known as“bottle rot” or “nursing caries.” Characteristics of S-ECC include any sign of smooth-surface caries in chil-dren younger than 3; or, in the 3- to 5-year-old agegroup, any cavitated, missing, or filled smooth surfacesin the primary maxillary anterior teeth. Additionally, S-

Are you missing the diagnosisof the most common chronicdisease of childhood ?

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ECC may be defined as an overall decayed, missing, orfilled (DMF) score as follows: age 3 with DMF ≥ 4, age4 ≥ 5, or age 5 ≥ 6.1

In terms of incidence, the numbers are staggering.ECC is the most common chronic disease among Amer-ican children, affecting more than half of all 7-year-olds.It is three times more prevalent than obesity, and fivetimes more prevalent than asthma (Figure 1).2

Children in poverty are particularly at risk, with den-tal caries rates as high as 80%. Yet less than a third ofthese children receive any dental care.3 ECC/S-ECC notonly have the potential to affect a child’s nutritionalintake, but also their ability to pay attention in school,and to sleep at night.4 Most importantly, the decay on achild’s primary teeth can spread to their permanentteeth, inevitably setting up the child for persistent andprogressive tooth decay during their lifetime. Burt Edel-

stein, DDS, of the Children’s Dental Health Project(www.CDHP.org) believes that ECC may have broaderimplications for health, describing caries as, “often thefirst significant acquired pathology in children…and asentinel for other health-behavior related risks for dis-ease” later in life.5

Recently, the Centers for Disease Control and Pre-vention reported that the prevalence rate of toothdecay is actually rising among 2- to 5-year olds, from24% in a 1990-1994 survey, to 28% in the most recent2000-2004 NHANES III survey.6 This 15% increaserepresents 600,000 additional preschoolers with thedisease as compared to caries levels in the 1990s. Thisrecent and rapid rise in ECC incidence is the basis forthe claim that we are now facing an early childhoodcaries disease epidemic. This is despite steady expan-sion of the use of fluoridated waters and dentifricesover the past 30 years, the increased use of dentalsealants in primary teeth, as well as many other den-tal public health initiatives. Given the significance ofthis epidemic, all medical and dental organizationsnow recommend that children have their first dentalvisit by age 1. However, financial and health careworkforce constraints continue to make this an unre-alized goal.

The roots of ECC/S-ECCECC is a multifactorial infectious disease that starts assoon as the baby teeth begin to emerge. Additionally,mothers often pass the cariogenic bacteria, includingS mutans, to their infants in the first year of life (moreon this later). The ecology of these bacteria dependsupon the presence of hard tooth enamel surfaces,upon which plaque-forming bacterial biofilms cangrow. Fueling the plaque biofilm are fermentable car-bohydrates, which are found in fruit juices (fructose),milk (lactose), and foods (sucrose, simple starches).The bacterial fermentation of these carbohydratesprovides energy for bacterial growth as well as the

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Figure 1

Chronic disease prevalencerates in school age children

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60Prevalence rate (% of children) 59% Caries 19% Obesity 11% Asthma


production and excretion of sticky polysaccharides,which promote adherence of the plaque biofilms tothe teeth.

The cariogenic species are acidophilic, thriving inacidic environments. They all produce organic acids(lactic and pyruvic acid) as waste products. When achild with caries infection ingests a sugary beverageor food, their mouth pH will quickly drop from theneutral range to a pH of 3.0 to 4.0. It then takesabout 20 minutes for saliva to buffer and neutralizethe acid attack.

In the meantime, significant demineralization canoccur. These acid attacks eventually produce chalkywhite erosions (“white spots”) on the enamel, usual-ly near the gum lines of the maxillary primary inci-sors where plaque is most difficult to remove,because of the overriding upper lip and low salivaryflow. This zone of demineralization further facilitatesincreased plaque adherence and progression of thedental biofilm. Brownish discoloration of the dem-ineralized enamel signals a more advanced process(Figures 2, 3A, and 3B).

Unless the plaque in and around these white spots isactively removed by brushing, allowing for salivary cal-cium and phosphorus to diffuse back into the damagedtissue, the erosions will often progress to cavities thatmay need restorative treatment by the dentist. It is cru-cial that providers (and parents) understand that white-spot lesions represent early and potentially reversibleareas of dental decay, and that missing or downplayingthe existence of these spots can prove to be costly—both medically and financially.

The costs of doing nothingECC can turn into S-ECC in a matter of months, andhas the potential to progress to severe local or systemicinfection, or in some cases, life-threatening illness.Recently, national media outlets reported the heart-breaking story of a 12-year-old boy from Maryland,

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Figure 2Lifting the lip to reveal a healthy set of teeth and gums.

Figure 3BWhite spots typically appear first on the upper frontincisors where salivary flow is minimal; the dentalcaries disease process can potentially be arrested oreven reversed at this stage.

Figure 3AWhite spot and early brown spot demineralizations.

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Deamonte Driver, who died from complications of anuntreated dental abscess that resulted in a disseminatedbrain infection.7

The emotional aspects of dental caries can also betraumatic for a young child and their parents. Manychildren with extensive decay or abscess, for example,will have space loss or shiny steel caps inserted as partof an orthodontic treatment plan (Figures 4, 5).This,in turn, may cause the child to feel self-conscious orembarrassed about their appearance in the company

of their peers, with school attendance being adverse-ly affected.

The chronic pain that can be associated with S-ECCcan be equally traumatic. I will never forget the newfamily I saw in my general pediatric clinic one day.Mom, Dad, and all three brothers were together in anexam room waiting for me to do routine physicals onthe boys. When I walked into the room, I noticed twothings right away. First, both parents and the twoolder boys were heavyset, while the youngest child,age 5, was thin. Then the youngest child smiled, and Iimmediately noticed that he had nubs for front teeth.Further exam of his mouth revealed that almost all histeeth were decayed. He was skinny because it hurt toomuch to eat!

Sadly, many children often present to dental clin-ics or their primary care providers for the first timewith what we now consider to be late-stage disease.Contributing factors to this phenomenon includeparents’ lack of understanding of the disease process,physicians and nurse practitioners failing to diag-nose and refer children with early and reversiblesigns of ECC to dental services, and, in some cases,general dentists being uncomfortable seeing pre-school-age children.

Other factors include parents’ concerns with theneed for child restraints in order to perform dentalprocedures on non-cooperative children, and the cir-cumstance that these procedures must often be per-formed with the parent outside of the dental operatory.Of course, many parents and providers are rightly con-cerned over the potential risks of sedation or generalanesthesia, which is often required to treat and restorethe decayed teeth.

Finally, we encounter the problem of payment forservices. Many dental plans do not cover routine dentalprophylaxis under age 3, and have monetary caps oncoverage for the extensive restorative treatments need-ed for S-ECC. A child with advanced S-ECC needing

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Figure 4This child with S-ECC will require dental surgery(pulpotomies and placement of crowns) to restorefunction and maintain space for the eruption of thepermanent teeth.

Figure 5Advanced S-ECC; “These are flesh-eatingbacteria,” notes Joel Berg, DDS.


multiple fillings, crowns, pulpotomies, and/or extrac-tions with placement of spacers can easily expend thou-sands of dollars in services.

Fortunately, the current ECC disease model nowrecognizes that early caries disease can and should bemanaged medically,8 providing a window for earlyintervention. How then, should providers and par-ents proceed?

Diagnosis, treatment, and preventionAll parents and medical providers must learn to close-ly inspect the child’s teeth. The caries disease almostinvariably starts on the upper incisors, where protec-tive salivary flow is minimal. Persistent, heavy dentalplaque, which is easy to see with close visual inspec-

tion, is the first warning sign. As previously men-tioned, clinical findings of a few white-spot lesions arethe hallmark of early (medical) disease, which is oftenreversible. In most cases, these lesions can be identifiedby lifting the baby’s upper lip, and carefully looking forchalky white spots on the upper tooth enamel surfacesadjacent to the gum line (Figure 3A). These lesions areareas of demineralization, and can progress into deep,often painful, brown cavitations (Figure 6). Childrenwith brown cavitations require urgent referral to apediatric dentist.

In addition to visual inspections, medical providersshould conduct a risk assessment for early dental caries.In 2003, the American Academy of Pediatrics (AAP) man-dated that the cornerstone of ECC prevention efforts mustbe the routine application of a caries risk assessment eval-uation by the primary care clinician for all young children,optimally at the six month well-child visit, and the estab-lishment of a dental home by age one or earlier if oralpathology is identified (see “A call for collaboration”).9

This recommendation is based upon the published oralhealth guidelines of both the AAP and the AAPD.

Working together, these two organizations haverecently updated a consensus guideline for promotingoral health in all children and adolescents, which has

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• Caregivers or siblings who have caries

• Visible plaque or white spots on the teeth

• Suboptimal exposure to fluoridated water

• Lower socioeconomic groups

• Drinking juice from bottles, and nighttime milk bottles

• Frequent intake of sugar or cooked starch (eg, sportdrinks, juice, crackers, cereals) between meals

• Special-needs patients (preemies, developmentallydelayed, immunosuppressed)

If high-risk (multiple risk factors or suspected enamellesions), then early dental referral is strongly advisedbefore age 1; otherwise, the goal is a routine dental home for all children at age 1.

Table 1

Screening tool for assessingdental caries risk in infancy

Figure 6A 2 1/2-yr-old child with S-ECC that was put tobed with a sippy cup containing apple juice.


been published in the third edition of Bright Futures.10

A detailed Caries-Risk Assessment Tool (CAT) isincluded, but a rapid caries-risk screening tool is alsodescribed in Table 1, for busy practices.

One of the most important and least appreciated riskfactors associated with dental caries is the presence ofactive tooth decay in the mother. Transmission of the Smutans bacteria from mother to baby has been shown tooccur as early as 2 months of age when DNA-identicalbacteria may be detected in mothers, and in tonguescrapings from their infants.11 Thus good maternal oralhygiene, and daily use of caries-inhibitive xylitol chew-ing gums beginning shortly after birth, has become animportant disease prevention tool.

Xylitol is a naturally occurring 5-carbon sugaralcohol that is found in most plant materials, as wellas normal human metabolism, involving the pen-tose-phosphate shunt pathways. Due to xylitol’spentose sugar structure, it tends to interfere with thenormal bacterial fermentation of hexose sugars suchas glucose, which the cariogenic bacteria are depen-dant upon for their growth and proliferation. Therecommended dose is two grams of xylitol, or twopieces of gum chewed regularly by a new motherthree times per day for six months.12 In a similargum-chewing regimen, regular use of xylitol chew-ing gum was also shown to decrease caries rates inschool-age children.13

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There is no debate that early referral by the

primary care provider to a dental disease

specialist (aka the pediatric dentist) routinely at

age one, and earlier if there are signs of

pathology, remains the foundation of successful

long-term caries disease management. Dr. Joel

Berg, Professor and Chairman of Pediatric

Dentistry at the University of Washington recently

stated unequivocally that the concept of the

universal Age One Dental Home is the most

important development to occur within the field

of pediatric dentistry in the past decade.14

The fact that most American children with

early childhood caries present for their first

dental visit well after age 1, and often with late-

stage disease, suggests that there is an

inadequate community standard of care for

ECC in most parts of our country. In otherwords, children’s primary health care

providers are failing to recognize cariesdisease in its earliest stages, during whichtime urgent dental intervention can effectivelyprevent disease progression, and in somecases even reverse the disease process.

The epidemic of early childhood caries in our

country and around the world requires a new

paradigm for prevention and care. There are

approximately 6,000 practicing pediatric

dentists in America, and obviously they are not

able to see all of our nation’s pre-school aged

children. Fortunately, unlike in years past, many

general dentists are now willing to see younger

children for their initial dental evaluations. The

bottom line is that the dental community

desperately needs our teamwork and support.

By focusing more attention on high-caries-risk

populations, limited dental services can be

more efficiently utilized.

A c a l l f o r c o l l a b o r a t i o n

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Nutritional counseling should include not only adiscussion of patterns of bottle and sippy cup use, butalso recognition of the hidden sugars in “cookedstarch,” such as breads, French fries, snack crackers,cereals, and chips. Cooked starches can get trappedbetween teeth, and promote tooth decay as readily aspure sugar. Limiting sugar-containing cough and coldsyrups and medications that can cause dry mouth, suchas antihistamines, is another important strategy that isoften overlooked.

Additionally, nighttime bottles and delayed bottleweaning, nighttime breastfeeding beyond age 1, and theuse of juice sippy cups (Figure 6) all contribute to earlyand persistent over growth of the enamel surfaces bycariogenic plaque. Further exacerbating the problem isinadequate infant oral hygiene practices by the child’scaregiver. Therefore, a daily routine of wiping thebaby’s gums should be established in the first fewmonths of life, and daily brushing should begin as soonas the first teeth appear.

Unfortunately, many infants and toddlers are averseto brushing, and if parents give in too easily, the poororal hygiene behavior becomes habitual. A potentialsolution to this challenge is the use of xylitol-saturateddisposable tooth wipes. Recently introduced into theconsumer market, these wipes were shown not only tobe effective for plaque removal from the front teeth, butalso more readily acceptable as an oral hygiene regimenby maternal-infant pairs.15

But perhaps the most important preventive measuresagainst this epidemic are the serial application of topi-cal fluorides by a health care provider, and/or daily useof rice grain-sized smears of anti-cariogenic toothpastescontaining fluoride. These measures should be initiatedeither prophylactically at age 1 if risk factors are pres-ent, or at the first sign of a white spot.

While the use of fluoride varnishes in young chil-dren are still considered “off-label” by the FDA, this isnot a major concern for practicing pediatricians who

are simply following the lead of the pediatric dentalprofession. A recent report by pediatric dentists of afluoride varnish trial in infants aged 6 to 18 monthsdemonstrated significant clinical benefit, and noharm.16 Many children’s medical providers are nowlearning to apply fluoride varnishes in their offices toaugment the preventive efforts of children’s dentists,17

and to provide more aggressive medical therapeuticsat the time of early caries diagnosis, pending urgentevaluation by the dentist.

The application of fluoride varnish is most easilyaccomplished with two adults sitting knee-to-knee,child supine in their laps, with one controlling thearms and legs and the other responsible for brushing(Figure 7). Single adults can also accomplish this taskwith practice. This technique can and should beshared with parents, along with proper brushingtechniques (see Parent Guides in English and Spanishon pages xx).

Dental screening: Done in 60 secondsSurely, we can teach ourselves to routinely query theparent about caries risk factors, and look at the child’steeth on a regular basis. The whole process takes lessthan a minute, and can be done at the time of the throatexam during a well-visit:


Figure 7The “knee-to-knee” technique for examining andbrushing the baby teeth.


In fact, parents are uniformly pleased andimpressed when I exam the baby teeth with my oto-scope light prior to examining the throat. And thenutritional counseling that I do for caries preventiondovetails perfectly (almost word for word) with theobesity prevention counseling that I am already doinganyway. More caries prevention talking points arepresented in Table 2.

If I suspect ECC or identify significant ECC risk fac-tors, I include this in my patient encounter note as partof the clinical assessment ([ICDM] code for dentalcaries: 521.00) and make sure that the patient problem

list is updated to include ECC (or risk of ECC). I thendocument a patient care plan, which includes oralhygiene and nutritional counseling, a recommendationto begin early brushing of the baby teeth with a pea-sized smear of standard over-the-counter 1,000 ppmfluoride toothpaste (which normally is recommendedto be initiated at age 2 in low-risk patients), or an appli-cation of fluoride varnish to the teeth. Finally, I docu-ment in my chart a referral to a pediatric dentist fordefinitive care and management. The referral is classi-fied as urgent if I suspect ECC, in which case my stafffacilitates a referral process similar to any other formalmedical referral that I make (cardiology, gastroenterol-ogy, ear-nose-throat, etc).

After seeing the patient, the pediatric dentist willusually send me a consult note that documents the

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Pregnant and new moms should practice especially good oral hygiene. After the baby is born, moms should chew gums with xylitol (should be the first or second ingredient) three times a day for six months

Breastfeeding should be encouraged to enhance the child’s immune defenses, including oral immune defenses

Beginning at 2 to 4 months of age, start cleaning the mouth with a clean wet towel, gauze, or toothwipes

Use fluoridated water (or “nursery water”) for infant formula preparation and cooking after 6 months of age

Start brushing the baby teeth with water at least once a day (bedtime) between 6 and 9 months (nighttime feeders must be brushedin the morning too)

Fruit juices should only be given twice a day from a standard cup, and always with food

Avoid snack foods with high refined sugar or starch content

Once they learn to hold their own bottle, bottle-fed babies should only be given water in their bottle between meals or at night

See a dentist as soon as possible on or after the first birthday; take advantage of fluoride varnishes or treatments if recommended

Cleaning teeth every day is the most important message.

Table 2

Caries prevention timeline for infancy

“Mom, do you or your other kids have cavities?”

“Are you brushing your baby’s teeth every day?”

“Look how pretty these front baby teeth are…but wehave to clean that plaque off a little better.”

“I know a dentist that will see your child at age 1;please give them a call, or I will refer you if you like.”Or, in one out of four children, “I see a white spot. This needs immediate attention.”


presence and severity of caries disease, treatment plan,and timing of follow-up, which is then filed in themedical chart. This helps me in two ways: 1) I receivefeedback on the accuracy of my diagnosis—ie, maybewhat I thought were brown-spot caries lesions wereactually enamel stains not requiring treatment—and 2)by filing the note in the chart I have a reference fordetermining the timing of future dental follow-up,which helps me in my “gatekeeper” role as the patient’sprimary care provider.18

It’s time to assume more responsibilityWe know the feeling of satisfaction we experience whenwe give good medical advice, and make an early andaccurate diagnosis on behalf of our patient. In particular,most pediatricians take personal pride in their ability todiagnose and manage the numerous infectious diseasesof childhood. See how good you will feel when you makethis important diagnosis, and begin to provide an effec-tive caries prevention or treatment plan for your patients.

References1. American Academy of Pediatric Dentistry, Council on Clinical Affairs:Definition of Early Childhood Caries (ECC). 2003 (rev 2007)2. US Department of Health and Human Services: Oral Health in America:A Report of the Surgeon General. Rockville: National Institute of Dental andCraniofacial Research, National Institutes of Health 2000; 3083. Crall JJ: Access to oral health care: professional and societal consider-ations. J Dent Edu 2006;70:11334. National Maternal and Oral Health Resource Center: Promoting Aware-ness, Preventing Pain: Facts on Early Childhood Caries (ECC). NationalMaternal and Oral Health Resource Center, Georgetown University, 20045. Edelstein B, Foley M: “Children’s Oral Health: Closing the Gaps”,National Conference of State Legislators: Health Web Cast, 2006. Avail-able at: www.ncsl.org/programs/health/webcastmar06.htm. Accessed onJuly 14, 2008 6. Dye BA, Tan S, Smith V, et al: Trends in oral health status: UnitedStates, 1988-1994 and 1999-2004. National Center for Health Statistics.Vital Health Stat 2007;248:17. Otto M: For Want of a Dentist; Pr. George’s boy dies after bacteria fromtooth spread to brain. Washington Post, Feb. 28, 2007; B1 8. Stewart RE, Hale KJ: The paradigm shift in the etiology, prevention, andmanagement of dental caries; its effect on the practice of clinical dentistry.J Calif Dent Assoc 2003;31:2479. Hale, KJ: Policy Statement: Oral Health Risk Assessment Timing andEstablishment of the Dental Home. American Academy of Pediatrics, Sec-tion on Pediatric Dentistry, Pediatrics 2003;111:111310. Hagan JS, Shaw JS, Duncan PM (eds): Bright Futures: Guidelines forHealth Supervision of Infants Children, and Adolescents (Promoting OralHealth), ed 3. American Academy of Pediatrics, 200811. Li Y, Caufield PW: The fidelity of initial acquisition of mutans strepto-cocci by infants from their mothers. J Dent Res 1995;74:68112. Söderling E, Isokangas P, Pienihäkkinen, K, et al: Influence of mater-nal xylitol consumption on acquisition of mutans streptococci by infants. JDent Res 2000;79:88213. Mäkinen KK, Bennett CA, Hujoel PP, et al: Xylitol chewing gums andcaries rates: a 40-month cohort study. J Dent Res 1995;74:190414. Berg J: Caries diagnosis and treatment in children (lecture). YankeeDental Congress 33, Boston Mass., 200815. Galganny-Almeida A, Queiroz MC, Leite AJM: The effectiveness of anovel infant tooth wipe in high caries-risk babies 8 to 15 months old. Pedi-atr Dent 2007;29:33716. Weintraub JA, Ramos-Gomez F, Jue B, et al: Fluoride varnish efficacyin preventing early childhood caries. J Dent Res 2006;85:172 17. Lewis C, Lynch H, Richardson L: Fluoride varnish use in primary care:what do providers think? Pediatrics 2005;115:e6918. Wagner R: Early childhood caries (letter). J Am Dent Assoc2006;137:150

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Dr. Wagner would like to thank Dr. Oskouian for providing a careful reviewand editing of the technical aspects of thisarticle, the photos of children with ECCfrom her dental practice, and advice on theneed for collaboration between the fields ofchildren’s medicine and dentistry.

Looking for pediatric dental

services?Clinic services

Many of today’s pediatric dental residencyprograms operate in conjunction with a satellite

clinic where children can receive dental services.A valuable resource to keep in mind.

Local dentists

A list of local pediatric dentists is availablethrough the AAPD’s “Find a pediatric dentist”

tab on their home page (www.aapd.org).This database of providers is

updated weekly.



GUIDE for PARENTSpediatricsCONTEMPORARY

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Early childhood toothdecayDid you know that tooth decayis the most common childhooddisease? Forty percent ofAmerican children have cavi-ties by age 6. Worst of all, ifchildren get cavities in theirbaby teeth, the infection almostalways passes to their perma-nent teeth. You can help preventthis disease.

Mom, your oral healthmattersOne of the biggest risks for your baby to get earlytooth decay is the presence of dental cavities in yourmouth. That’s because tooth decay is a bacterial infec-tion that can be transmitted from you to your baby.Everyone in the family should keep their teeth clean(brush and floss) to reduce the bacteria levels.

Sugar feeds tooth decayThe tooth decay bacteria use sugar for energy, andthey produce an acid that dissolves calcium, whichcauses a hole in the tooth. Any food or drink withsugar is potentially a problem; this includes juices,sodas, sports drinks, infant formula, and sweetenedmilk. Remember, after age 1 cups are always betterthan bottles. Another common form of sugar that isoften overlooked is cooked starch—the white flourthat’s in crackers, cereal, chips, and junk foods in gen-eral. Give your child whatever you feel is right andhealthful, but be sure to clean their gums and teethafterward.

Clean your baby’s gums and teethearly (4 months)The decay process can start as soon as the child’s firsttooth pokes out from the gum, typically at 5 to 9months. To stop the attack from happening, it’simportant to begin cleaning baby’s mouth very early,starting at 4 months. Simply wipe baby’s gums and

teeth several times a day, especiallyafter feedings.

The tooth-brushing habit (6 to 9 months)Your child should be encour-aged to brush their teeth them-selves, as soon as they can holda toothbrush, but parents

should be there to supervise andcomplete the brushing. The night

brushing is critical, as the bacteriathat cause cavities have 12 hours or

more to grow as your child sleeps. Makesure this brushing is done as effectively as possible tostop those cavity-causing bacteria from moving intoyour child’s mouth as a permanent resident. A goodrule of thumb is for parents to help with brushinguntil their child can write their name in cursive let-ters, which typically occurs at age 6 or 7.

Look closely and often at your baby’steeth (9 to 12 months)The first sign of a cavity is a white spot. These spotsoften start on the upper front teeth at the gum line. Tolook for these spots, lay your baby in your lap and lifttheir upper lip using your fingers. If you don’t takecare of your baby’s first teeth, your child may wind upwith a lifelong struggle with tooth decay.

See the dentist at age 1Starting at birth, every baby needs a “medical home”for regular doctor visits to ensure they stay healthyand get their vaccinations on time. Many parentsdon’t realize that babies need a “dental home” aftertheir baby’s first birthday, or even sooner if there’s aproblem. The dentist can help you make sure yourbaby doesn’t get early childhood tooth decay. It’s awhole lot easier to prevent tooth decay than it is totreat it.

*First published by El Rio Health Center Maternal andInfant Oral Health Program

Right from the start: A maternaland infant health oral program*

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GUIDE for PARENTSpediatricsCONTEMPORARY

Caries durante la niñez temprana¿Sabía usted, que la enfermedad más común de laniñez, son las caries? El 40% de los niños americanosdesarrollan caries antes de los 6 años de edad. Lo peorde todo es que, si los niños desarrollan caries en susdientes “de leche” (los que se caen), la infección casisiempre se pasa a los dientes permanentes. Usted puedeayudar a la prevención de este padecimiento.

Mamá, la salud oral de usted esimportanteUna de las causas más importantes para obtener caries

durante la edad temprana, es la presencia de cavidadesdentales en la boca de usted. Eso ocurre porque lascaries, son infecciones bacterianas que pueden ser trans-mitidas de usted a su bebé. Todos en la familia debenmantener sus dientes limpios (cepillo y uso de hilo den-tal), para reducir así, el nivel de bacterias en la boca.

El azúcar favorece la caries dentalLas bacterias de las caries dentales, utilizan azúcar paraobtener energía y al mismo tiempo producen un ácidoque erosiona el calcio del diente, produciéndose unacavidad. Cualquier bebida o alimento con azúcar es unproblema potencial; mencionaremos los jugos, losrefrescos gaseosos, las bebidas “deportivas”, las lechesinfantiles y las leches azucaradas. Recuerde que despuésdel año de edad, es preferible el uso de vaso, al uso debotella. Otra fuente de azúcar que a veces se pasa poralto, son los almidones cocidos—la harina blanca quecontienen ciertas galletas, los cereales, las papas fritas(chips), y en general, la comida “chatarra”. Déle a suniño lo que crea conveniente y saludable, pero al final,asegúrese de limpiar sus encías y dientes.

Limpie las encías y los dientes de subebé a temprana edad (4 meses)El proceso de caries puede comenzar tan pronto como

el primer diente brota de la encía, cosa que ocurre gen-eralmente entre los 5 y los 9 meses. Para evitar que estosuceda, es importante empezar a limpiar la boca delbebé, desde los 4 meses de edad. Simplemente limpie lasencías y los dientes varias veces al día, especialmentedespués de las comidas.

El hábito de cepillarselos dientes(6 a 9 meses)Su hijo debe ser motivado a

cepillarse los dientes él sólo,tan pronto como puedasostener un cepillo dental, perolos padres deben estar presentespara supervisar el cepillado. El lavado dedientes “de la noche” es de suma importancia, pues lasbacterias que producen las cavidades, tienen 12 horas omás para desarrollarse mientras su hijo duerme.Asegúrese que el cepillado sea hecho con la mayor efec-tividad posible, con el fin de impedir que la bacteria pro-ductora de cavidades se introduzca como residente per-manente en la boca de su hijo. Una buena regla empíri-ca consiste, en que los padres ayuden con el cepilladohasta que el niño sepa escribir su nombre en letra cursi-va, lo que generalmente ocurre entre los 6 y 7 años deedad.

Examine detenida y repetidamente losdientes de su hijo (8 a 12 meses)La primera seña de una cavidad es una mancha blanca.Estas manchas generalmente comienzan en los dientesfrontales superiores, al margen de la encía. Para buscarestas manchas, recueste al bebé en su regazo y con losdedos, levante el labio superior. Si usted no cuida losprimeros dientes del bebé, éste puede terminar en unalucha de por vida contra las cavidades dentales.

Vea al dentista al año de edadDesde su nacimiento, todo bebé necesita de “un hogarmédico” para visitas de rutina, que promueven su saludy la obtención de vacunas a tiempo. Muchos padres nosaben que sus hijos necesitan también de “un hogar den-tal” a partir del primer cumpleaños, o antes, si existealgún problema. El dentista puede ayudar a asegurar queel bebé no adquiera caries durante la niñez temprana. Esmucho más fácil prevenir las caries que tratarlas.

*Publicado por vez primera (en inglés), por El Rio HealthCenter Maternal and Infant Oral Health Program

TRANSLATED BY NEFTALI AVIGDOR, MD

Desde el principio: Un programamaterno-infantil de salud oral*

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ray wagner, md, and rama oskouian, dmd, mph...ing (due to decay), or filled tooth surface in any...

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