4. First dental visit.pptx

First dental visit  Introduction The oral health of children in industrialized countries has improved considerably during the past four decades. Yet, a significant number of children still present with oral disease at the first dental visit. Oral disease, especially...

First dental visit  Introduction The oral health of children in industrialized countries has improved considerably during the past four decades. Yet, a significant number of children still present with oral disease at the first dental visit. Oral disease, especially dental caries, is complicated and multifactorial, and it often begins to develop during infancy. Although certain risk factors are associated with the development of oral disease in children, it has been difficult to consistently identify infants at greatest risk for oral disease later in life. For this reason, contemporary guidelines on the management of oral disease recommend that more emphasis be placed on primary prevention.  For many years, the approach to oral disease (dental caries, periodontal disease and acquired or hereditary oral conditions) has been to treat destructive effects and then initiate a preventive program. Contemporary guidelines recommend more emphasis on early professional intervention consisting of an oral examination, risk assessment of infants and anticipatory guidance for parents. The goal of primary prevention is to stop the onset of disease or to interfere with its progression before treatment becomes necessary. With early professional intervention, it may be  American Academy of Pediatric Dentistry Recommendations on Infant Oral Health Care Ideally, infant oral health begins with prenatal oral health counselling for parents; a postnatal initial oral evaluation should be performed within six months of the eruption of the first primary tooth in an infant but by no later than 12 months of age.  At the infant oral evaluation visit, the dentist should do the following:  Obtain a thorough medical and dental history, covering the prenatal, perinatal and postnatal periods. Perform a thorough oral examination.  Assess the infant's risk of developing oral and dental disease, and determine the appropriate interval for periodic re-evaluation based on the assessment.  Provide anticipatory guidance for the parent or other caregiver regarding dental and oral development, fluoride status, non-nutritive oral habits, injury prevention, oral hygiene and effects of diet on dentition.  Onset of dental caries By the age of 12 months, infants begin to establish an oral environment that places them at risk for dental caries. The mutans streptococci (i.e., Streptococcus mutans and Streptococcus sobrinus) have been implicated as the principal bacteria responsible for the initiation of dental caries in humans. Because colonization requires the presence of a hard, non-desquamating surface, infants do not harbor these organisms until sometime after teeth emerge.  Infants acquire mutans streptococci primarily from their mothers. The initial acquisition of these bacteria appears to occur during a well-delineated age range (window of infectivity), estimated to be 19 to 31 months of age. Earlier acquisition of the bacteria has been associated with certain risk factors, including sibling caries, maternal caries, feeding habits, dietary habits, fluoride exposure and oral hygiene practices. Therefore, infants should receive early intervention before the established window of infectivity, and parents should be given appropriate recommendations concerning oral health care for their infants.  Feeding Practices To cause dental caries, oral bacteria require the presence of a particular environment. Prolonged bottle or breast feeding provides the substrate (i.e., the presence of fermentable carbohydrates) that produces an oral environment favourable to bacterial proliferation and the formation of acidogenic plaque. This plaque environment lowers oral pH, promoting demineralization of dental enamel, and can eventually lead to caries formation.  ECC Early childhood caries, also termed “nursing caries,” “baby-bottle tooth decay” and “bottle caries,” is a specific dental disease occurring in very young children. This disease affects primary dentition, is characterized by rapid and extensive dental caries and is often associated with prolonged bottle or breast feeding. Early childhood caries affects an estimated 1 to 11% of infants in the urban population.  To reduce the incidence of dental caries, parents and other caregivers should be counselled about proper feeding practices during infancy & preschool years. One such measure is limiting the intake frequency of foods and liquids that promote acid production AAPD Recommendations on the Prevention of ECC Infants should not be put to sleep with a bottle. Ad libitum nocturnal breast feeding should be avoided after the first primary tooth begins to erupt. Parents should be encouraged to have infants drink from a cup as they approach their first birthday; infants should be weaned from the bottle at 12 to 14 months of age. Consumption of juice from a bottle should be avoided; when juice is offered, a cup should be used. Oral hygiene measures should be implemented by the time the first primary tooth erupts. An oral health consultation visit within six months of the eruption of the first tooth is recommended as an opportunity to educate parents and provide anticipatory guidance for the prevention of oral disease.  Education on Oral Hygiene & Dietary Habits Poor oral hygiene and poor dietary habits are associated with the development of caries in infants and young children. Because children are not able to control these factors, their dental health is greatly influenced by the amount of education and subsequent practices of parents and other caregivers.  Mothers appear to be the primary source of a child's dental knowledge. Therefore, failure to adequately educate mothers at an early stage can lead to subsequent dental problems in children. Nutritional and lifestyle counselling (i.e., alcohol and tobacco use), medication warnings and advice concerning breast feeding and postnatal care can also have a positive influence on oral health in children.  The AAPD age-specific home oral hygiene instructions Infants (birth to 1 year of age) Counsel parents to clean the infant's gums daily before eruption of the first primary tooth to help establish a healthy oral flora, using the following procedure: 1. Cradle the infant with one arm. 2. Wrap a moistened gauze square or washcloth around the index finger of the hand of the other arm and gently massage the teeth and gingival tissues. 3. Introduce a soft-bristled toothbrush during this age only if parents feel comfortable using the toothbrush. 4. Do not use dentifrice containing fluoride, because fluoride ingestion is possible. Toddlers (1 to 3 years of age) Introduce a toothbrush into the plaque-removal procedure (if not done earlier). Use dentifrice beginning around the age of 2 years; use only a pea-sized amount of toothpaste (apply across the narrow width of the toothbrush, rather than along its length, to decrease the chance of applying an excessive amount). Encourage the child to begin rudimentary brushing; however, parents should remain the primary caregiver in oral hygiene procedures. Preschool-age children (3 to 6 years of age) Remind parents to continue their responsibility as primary providers or supervisors of oral hygiene procedures. Continue to use only a pea-sized amount of toothpaste on the child's toothbrush. Use daily flossing if any interproximal area has tooth-to-tooth contact.  Anticipatory guidance Anticipatory guidance is the process of providing practical, developmentally- appropriate information about children’s health to prepare parents for the significant physical, emotional, and psychological milestones. Individualized discussion and counselling should be an integral part of each visit. Topics to be included are oral hygiene and dietary habits, injury prevention, non-nutritive habits, substance abuse, and speech/language development.  Oral hygiene counselling involves the parent and patient. Initially, oral hygiene is the responsibility of the parent. As the child develops, home care is performed jointly by parent and child. When a child demonstrates the understanding and ability to perform personal hygiene techniques, the health care professional should counsel the child. The effectiveness of home care should be monitored at every visit and includes a discussion on the consistency of daily preventive activities.  Caries-conducive dietary practices appear to be established early, probably by 12 months of age, and are maintained throughout early childhood. Dietary practices, including prolonged and/or frequent bottle or training cup with sugar- containing drinks and frequent between-meal consumption of sugar-containing snacks or drinks (eg, juice, formula, soda), increase the risk of caries. The role of carbohydrates in caries initiation is unequivocal. Acids in carbonated beverages and sports drinks can have a deleterious effect (ie,  Excess consumption of carbohydrates, fats, and sodium contribute to poor systemic health. Dietary analysis and the role of dietary choices on oral health, mal-nutrition, and obesity should be addressed through nutritional and preventive oral health counselling at periodic visits. Provide guidance for parents and their children and promote better understanding of the relationship between healthy diet and development.  Facial trauma that results in fractured, displaced, or lost teeth can have significant negative functional, esthetic, and psychological effects on children. Dentists should provide age-appropriate injury prevention counselling for oro-facial trauma. Initially, advice regarding play objects, pacifiers, and electrical cords. As motor coordination develops, the parent/patient should be counselled on additional safety and preventive measures, including use of athletic mouth-guards for sporting activities.  The greatest incidence of trauma to the primary dentition occurs at two to three years of age, a time of increased mobility and developing coordination. The most common injuries to permanent teeth occur secondary to falls, followed by traffic accidents, violence, and sports.  Non-nutritive oral habits (eg, digital & pacifier habits, bruxism, abnormal tongue thrusts) may apply forces to teeth and dentoalveolar structures. Although early use of pacifiers and digit sucking are considered normal, habits of sufficient frequency, intensity, and duration can contribute to deleterious changes in occlusion and facial development. It is important to discuss the need for early pacifier & digit sucking, then the need to wean from the habits before malocclusion or skeletal dysplasias occur.  Early dental visits provide an opportunity to encourage parents to help their children stop sucking habits by age three years or younger. For school-aged children and adolescent patients, counselling regarding any existing habits (eg, fingernail biting, clenching, bruxism) is appropriate.  Speech and language are integr components of a child’s early development. Deficiencies and abnormal delays in speec and language production can be recognize early and referral made to address thes concerns. Communication and coordination of applianc therapy with a speech and languag professional can assist in the time treatment of speech dis-orders.  Conclusion Early dental intervention provides an opportunity to supplement oral health education for parents in areas such as proper oral hygiene, prevention of dental injuries and prevention of nursing caries. Such intervention may also allow children to become comfortable in the dentist's office. Unfortunately, the provision of early and regular dental care among children is uncommon. Despite the current AAPD recommendations, it has been difficult to achieve uniformity among health care professionals regarding timing for the provision of preventive oral information as well as who should provide it. Thank you  Because even healthy children visit physicians frequently, beginning at an early age, physicians who provide primary care for children are in a unique position to help ensure that parents and other caregivers receive information on the prevention of oral disease in infants and young children. By working together, physicians and dentists can reinforce each others' efforts to provide excellent preventive oral care.