During our Let’s talk Oral Health webinar series for oral care professionals, we have monthly conversations about home-based oral care, each time from the viewpoint of a different dental specialty. After hosting conversations about periodontology, orthodontics, cancer therapy, and special needs dentistry earlier this year, we talked about pediatric dentistry in September. Find out what the highlights of the discussion were between Dr. Silvia Sabatini, a dental hygienist from Italy, and Dr. Luis Karakowsky, a pediatric dentist from Mexico.
As its name already gives away, pediatric dentistry is the specialty that treats children from birth through adolescence. Considering the huge changes children undergo during this time, the conversation was structured by distinguishing three life stages during childhood, starting with the first tooth eruption until 6 years old.
First tooth eruption until 6 years old
Most oral care professionals will acknowledge the main challenge in this age group: Early Childhood Caries (ECC). Dr. Karakowsky starts by taking us through the basics of this condition. For many years, there was confusion about the definition, so after meetings by the WHO in 2016 and the IAPD in Bangkok in 2019, a simple definition was drafted: “Presence of one or more decayed (non-cavitated or cavitated lesions), missing or filled tooth (due to caries) surfaces in any primary tooth in a child under six years of age”. The IAPD also developed a classification, distinguishing four stages. The first one is ECC-0, which means that there are no signs of lesions, followed by ECC-1, which includes white spot lesion(s). Dr. Karakowsky: “Here you can already start the remineralization process, as it’s a sign that something is wrong”. The next step, ECC-2, includes enamel breakdown, but the cavity has a hard bottom, ensuring that the lesion is confined to the enamel. Dr. Karakowsky: “This is already a cavity, so we have to restore it in a very conservative way, and then we can protect the rest of the surface”. Finally, we have ECC-3, which obviously is a more serious form of disease: “Here, we have the problem already inside the dentin, and sometimes it even involves the pulp, so the situation changes completely, even from the treatment point of view”.
On the question about what makes ECC such a unique disease, Dr. Karakowsky mentions a four-fold explanation: “It’s the most common childhood disease; its speed of progression is impressive; there’s a high impact on quality of life of the children and their families, which is directly related to the severity of the disease and its treatment; and finally, it’s completely preventable”.
Talking about primary prevention, Dr. Sabatini shares her perspective, talking us through the three main pillars:
- Improving oral health literacy of parents/caregivers and healthcare workers, including pediatricians, gynecologists, speech therapists, nurses, midwives, etc., who have a key role in supporting children.
- Limiting children’s consumption of free sugar in drinks and foods and paying attention to the frequency of intakes. Many drinks that seem safe still contain a lot of sugar, such as iced tea or fruit juices.
- Daily exposure to fluoride, recommending a pea-sized amount of toothpaste at least 1000ppm.
While primary prevention focuses on completely avoiding a disease from developing, secondary prevention aims to reduce the impact of the disease once it has already developed. In the case of ECC, secondary prevention means to prevent progression or stimulate regression (remineralization) of the carious lesion before the cavitated lesion period. Dr. Karakowsky lists a few strategies and tactics that can support secondary prevention of ECC:
- Early detection of incipient caries, and for this, it is crucial for the child to visit an oral care professional frequently.
- Addition to primary prevention approaches (improving oral health literacy of parents/caregivers, limiting free sugar consumption and daily exposure to fluoride)
- More frequent fluoride varnish applications (4x per year), which is the best way to remineralize the enamel and the dentin
Finally, there’s tertiary prevention, where you deal with a problem that is no longer reversible. Basically, this includes arrest of the cavitated lesions and tooth‐preserving invasive or non-invasive operative care. Dr. Karakowsky explains: “The best non-operative mean that we have for cavitated lesions is silver diamine fluoride. For the invasive way of treating, this has to be a very conservative caries removal and restoration approach. The treatment decision for this tertiary prevention must be made in conjunction with the caries risk assessment”.
Pregnancy and infancy
The conversation continued with a discussion around our youngest patients: infants (and even before their birth). Dr. Sabatini: “I really love to start prevention as soon as possible, so the best period is the first months or even better the pregnancy”. One of the circumstances that makes prevention in infants challenging is breast- and/or artificial feeding: “We have to guide the mom in choosing the best or the suitable baby bottle, meaning that the mouthpiece needs to be soft and to perfectly fit the sides of the mouth, to allow a harmonious development of the mouth”. Furthermore, it’s important to clean the mouth after feeding, even if there are no teeth present yet. Dr. Sabatini has some tips and tricks: “You can use a soft silicone thimble or a very soft microfiber glove, and if none of these tools are available, you can also use a moistened gauze. When there are teeth present, we can introduce a soft and small toothbrush with a lentil-sized amount of toothpaste, starting from six months. If the baby is breastfed, we have to consider that mother’s milk contains colostrum, which is a great source of antibodies. This means we don’t need to clean the mouth of the baby immediately after feeding”. About providing this information to the mother, Dr. Sabatini says: “it would be best to inform the mother already during her pregnancy, so that she’s ready once the baby is born. Parents have many other things to take care of, so the information needs to be really easy”.
She continues: “These tips are important to prevent ECC, but we have to keep in mind that other conditions can occur in this life stage as well. For example, candidiasis. Candida is commonly present in our mouth, but it can create a pathological condition that causes redness but above all a painful burning sensation. The baby can become nervous and can’t eat well, so parents need to be aware about this possibility”. Again, cleaning the mouth is crucial: “Candidiasis can be prevented by regularly cleaning the mouth, again using a silicon thimble, a microfiber glove, or a gauze”. But there’s more parents can do: “Artificial nutrition can be higher in sugar content, and we have to remember that sugar can favor the taking over by the fungus”.
Dr. Karakowsky circles back to ECC and lists four feeding practices that are risk factors: “First, early introduction of sucrose, as tasting sugar early strongly influences future behavior and food preference for children. The second risky feeding practice for ECC is the high frequency of food intake, and the third one is improper use of the bottle, or better, what is inside of the bottle (containing natural or added sugar). Finally, there is prolonged and high-frequency breastfeeding practices”.
6 years and older
A condition oral care professionals have to deal with in this age range is Molar Incisor Hypomineralization (MIH). Dr. Karakowsky takes us through the basics again: “Unlike caries, it’s not a lifestyle condition, but something that happens during the development of permanent teeth. It has a multifactorial origin, with a possible genetic component, which makes it much more difficult to prevent. It mainly affects permanent molars, and frequently also permanent incisors, but it can also affect second primary molars and other permanent teeth, like second permanent molar”. It is important to deal with the condition at an early stage: “A very interesting treatment plan for MIH is what we call a protective restoration, which is a temporary treatment that prevents post-eruptive breakdown. It also prevents caries lesions in the future, but we have to be there for the eruption”. The prevalence is also high, just under 20% worldwide. Dr. Sabatini continues with a clinical example from her own practice: “This patient has MIH of the four molars, and before the COVID-19 lockdown, I used to see her every three or four months to perform professional oral hygiene, and once per month to apply topical fluoride varnish. However, during lockdown, I didn’t see her for three months, and the destruction of her teeth clearly worsened”. Now she’s back to a professional oral hygiene plan, with monthly topical fluoride varnish application, and applying a remineralizing paste at home every day. But as an oral care professional, it is important that you are there to prevent the condition from worsening. Besides taking their children to the dental office frequently, parents can at home pay attention to rapidly changing colors or dimension of teeth, as an early indicator of MIH. Dr. Karakowsky again emphasizes to be conservative in the restoration of teeth with MIH, because all the tissue that you destroy during restoration is lost for life.
Finally, another condition observed in adolescents, are white spot lesions, that often occur during orthodontic treatment. Dr. Sabatini emphasizes again the importance of oral hygiene: “It’s important to stress the concept of a proper, tailor-made approach when talking about home care oral hygiene, taking in consideration the specific condition of each patient. Cleaning includes brushing and also interdental brushing, because we know that caries – and gingivitis too, we shouldn’t forget this condition – often start from interproximal areas. So, it is crucial to keep these areas well cleaned. The choice of toothpaste must be done with the specific condition in mind. As we said in case of demineralization, fluoride, or in general remineralizing toothpaste, is mandatory. In the case of gingivitis, chlorhexidine mouthwash can help. We should also not forget to clean the tongue properly”.
You can re-watch the full webinar here.