ABCD Pedodontia

A MANUAL FOR DENTAL PROVIDERS
By:
Department of Pediatric Dentistry

Department of Dental Public Health Sciences
University of Washington
Division of Client Services

Medical Assistance Administration
Department of Social and Health Services
State of Washington
To Download a copy of this manual visit:

http://www.dental.washington.edu/pedo
Visit the ABCD Web Site at:
http://www.abcd-dental.org
February, 2001
A MANUAL FOR DENTAL PROVIDERS
By:
Department of Pediatric Dentistry

Department of Dental Public Health Sciences
Division of Client Services

Medical Assistance Administration
Department of Social and Health Services
State of Washington
To Download a copy of this manual visit:

http://www.dental.washington.edu/pedo
Visit the ABCD Web Site at:
http://www.abcd-dental.org
February, 2001
ABCD
A Manual for Dental Providers
Table of Contents
Section 1 Introduction
Section 2 Bright Futures in Practice: Oral Health
Oral Health Supervision Guidelines…………….…………………… 2

Prenatal………………………………………………………………… 6
Infancy…………………………………………………………………. 8
Early Childhood……………………………………………………….. 13
Middle Childhood………………………………...…………………… 18
Section 3 Examination of Infants and Toddlers
Examination of Infants and Toddlers……………………………….. 24

Management of the Very Young Child……………………………… 26
Coping with the Crying Child………………………………………… 27
Section 4 Family Oral Health Education
Family Oral Health Education……………………………………….. 29

Pacifiers and Sucking………………………………………………… 35
Eruption Chart………………………………………………………… 36
Diets of Infants and Toddlers………………….…………………….. 37
Section 5 Prevention of Dental Disease
Topical Fluoride Varnishes…………………………………………... 41

Fluoride Varnish Application………………………………………… 49
Fluorides in Dentistry…………………………………………………. 50
Common Questions about Fluoride………………………………… 56
Glass Ionomers as Sealants………………………………………… 57
Section 6 Glass Ionomer Restoration to Control Carious Lesions in

Pre-cooperative Children
Glass Ionomer Restoration to Control Carious Lesions in

Pre-cooperative Children………………………………………… 62
Section 7 Treatment of Pregnant Women

Managing the Pregnant Dental Patient 66
i
Section 8 Restorative Dentistry
Current Methods of Pulpal Therapy in Primary Dentition………… 80

Space Maintainers……………………………………………………. 83
Section 9 Initial Assessment and Management of Infection and

Trauma
Initial Assessment and Management of Infection and Trauma 85

Recommended Treatment for Common Oral Lesions……………. 87
Topical Anesthetics and Coating Agents for Primary Herpes
Gingivostomatitis……………………………………………………… 93
Section 10 How to Make a Referral
How to Make a Referral 95
Section 11 Appendix
ABCD Dental Program Benefits

ABCD Dental Program Tips
Handouts for Parents
Your Baby's Teeth

Fluoride Varnish
Suggested Milgrom P and Weinstein P. Early Childhood Caries. A Team

Reading Approach to Prevention and Treatment. Seattle: University
of Washington School of Dentistry, 1999
ii
INTRODUCTION
The aim of this manual is to provide a chair side guide for clinicians who intend
to implement effective preventive and early intervention oral health therapies for
infants and toddlers.
Clearly, the interval from conception to three years is the most dramatic period of
growth and development for the child. In nine months, a single cell, the fertilized egg,
develops into a complex fully developed individual in utero. In subsequent months after
birth the infant displays emotion, initiates language development, and rapidly develops
gross and fine motor skills. By age three, the toddler is a walking, talking, bundle of
curiosity and energy. By age three, the child usually has all 20 primary teeth
erupted and has begun to develop enamel on 28 permanent teeth. Actually,
enamel development on the four first permanent molars is usually completed by age two
and one half to three years.
For the majority of infants and toddlers in the U.S., dental development proceeds
normally and the caries rate is very low. All toddlers are at risk for dental trauma as
soon as they acquire their first tooth and a significant minority is also at risk for infant
dental caries. A recent survey of 3rd grade children in Washington revealed that 20
percent of the children surveyed had experienced 84 percent of the caries.
Clearly, there is a group of high risk for dental caries children in Washington State. We
believe that this high risk group exists throughout all age groups and is manifested by
the hundreds of children under four years of age who are treated for infant caries under
general anesthesia in Washington's hospitals every year.
With the successful implementation of comprehensive primary prevention programs for

infants and toddlers, we anticipate a dramatic decrease in the prevalence and severity
of caries in the primary dentition. We want to enlist your support and assistance in
expanding access to preventive dental measures for all children under three years.
Additional References
Casamassimo P. Bright Futures in Practice: Oral Health. Arlington, VA: National
Center for Education in Maternal and Child Health, 1996
Pinkham JR, senior editor: Pediatric Dentistry: Infancy through Adolescence. 2nd
ed. Philadelphia, WB Saunders, 1994.
Peterson DS and Davis JM: Pediatric Restorative Dentistry: A Computerized

Instructional and Reference Program. University of Washington, 1995.
Peterson DS and Davis JM: Pediatric Pulp Therapy: A Computerized Instructional

and Reference Program. University of Washington, 1998
iii
Bright Futures in Practice:
Oral Health
1
BRIGHT FUTURES IN PRACTICE: ORAL HEALTH
Adapted from Paul Casamassimo, 1996
Oral Heath Supervision Guidelines

Oral health supervision involves regular, periodic health intervention by a dental
professional. The dental professional performs a risk assessment, diagnoses existing
conditions, and provides anticipatory guidance in order to promote oral health.
Optimal oral health supervision occurs when there is a therapeutic alliance between the
dental professional and the family—beginning between the dental professional and the
parents during the prenatal period or early in the child's life, progressing between the
dental professional and the growing child, and continuing to grow between the dental
professional and the adolescent. Early in the alliance, parents assume responsibility for
preventive and oral health procedures, but the child gradually assumes greater
responsibility. This alliance creates a relationship based on familiarity, trust, and a
shared history that supports health.
Oral health supervision occurs over time. The frequency of intervention should be keyed
to the individual's needs and developmental milestones. The interval between health
supervision visits must be short enough to take advantage of change, because it is
important to intercept incipient disease and to maximize opportunities for anticipatory
guidance. Traditionally, a period of six months has been the interval for oral health
supervision, but this guide strongly encourages assessing each child's individual risk, in
order to address normal growth and development issues (such as nonnutritive sucking
and the need for dental sealants) and to provide care more efficiently. Some children
will need more frequent dental visits if they are at higher risk; children with low risk,
stable environments, and demonstrated wellness habits may need less oral health
supervision. Past experience and current oral health status may be a key to determining
appropriate intervals for a child.
The success of oral health supervision depends to a large degree on the relationship or
alliance between the family, dental professional, and other health professionals.
Successful oral health supervision also depends on the systematic assessment of risk;
the prevalence of protective factors; the consideration of community, familial, economic,
cultural, and social factors; and the integration of oral health with general health
initiatives for the child.
Components of Oral Health Supervision

Family Preparation
Just as the dental health professional prepares for oral health supervision, families need
to prepare, too. Families can gather health information, prepare questions, and
complete forms in anticipation of the health supervision visit. This step is an essential
component of oral health supervision, and the dental professional should guide the
family in how to prepare. Between health supervision visits, the child and the family
might assess how well the child is complying with recommendations, and then
determine how the self-assessment compares to the dental professional's assessment
of the child's performance.
2
Periodicity and Services
The periodicity of services included in these guidelines is based on what most infants,
children, and adolescents need. The periodicity listed under the term ‘‘health
professional" refers to the general preventive care the child or adolescent receives,
usually from a nurse or physician. (The recommended periodicity listed in this guide is
the same as that listed in Bright Futures: Guidelines for Health Supervision of Infants,
Children, and Adolescents.) This periodicity is not meant to suggest supplemental
visits to health professionals specifically for oral health; rather, within the context of
health supervision visits with children and adolescents, health professionals can
reinforce the oral health messages provided by a dental professional. All health
professionals have an important role in educating and screening children to ensure that
they are receiving the oral health care they need.
The periodicity listed under "dental professional" refers to preventive and health
promoting services provided by an appropriately trained dental professional. In addition
to educating children and families, the dental professional examines the child or
adolescent and uses oral health risk assessment to decide on appropriate interventions
and guidance. The first dental visit is recommended by age one, with the aim of
intervening early and providing appropriate counseling before the caries process
develops.
Health Supervision Interview

The goal of the interview is to ascertain key issues that should be addressed in the
health supervision visit. The interview needs to address information gleaned from
previous health supervision visits, as well as issues specific to the age and development
of the child. The dental professional needs to assess whether the child or family has
assumed personal responsibility for oral health and demonstrates a sense of mastery
and consistent use of preventive oral health care. As the child matures and becomes
more responsible, the dental professional should discuss these issues directly with the
child or adolescent.
During the interview, it is important to listen to the family members in order to learn what
they want and expect and how they view oral health. Do the parents believe it is
realistic for their child to have a healthy mouth, free from dental caries? Do the parents
feel empowered to teach their child good oral health practices? Does the child think it is
possible to have healthy teeth with no decay? How does the adolescent feel about
dental visits? About the appearance of her teeth and smile? Trigger questions, which
address age-specific oral health issues and risk factors that are relevant to the child and
family, can help guide the interview. Cultural, economic, social, and environmental
factors influencing the family and child should be considered.
Observation of Parent-Child Interaction

Since parents are the child's primary teachers of healthy habits, interactions within the
family can have a major impact on oral health. Watching parents with their children in
the dental setting provides clues to learning strategies, potential behaviors, and
3
difficulties (and, in the extreme, parental child abuse and neglect situations). If children
are clinging to the parents, especially at three to six years of age, their parents may
need extra support to encourage independence. Detached and depressed children who
are afraid of parental and other adult reactions may signal an abusive home situation.
Observing how parents communicate with and motivate their child at early ages can
indicate the strengths and difficulties parents may have in guiding oral hygiene efforts.
Later, in middle childhood and adolescence, the dynamics between parent and
adolescent when discussing habits and behaviors is also revealing. It can indicate
difficulties or strengths in the relationship that will affect the adolescent's compliance
with anticipatory guidance suggestions.
Oral Exam and Diagnostic Procedures

While physical risk factors can be noted during general screenings by other health
professionals, an oral exam by a dentist is a vital part of health supervision because it
provides evidence about the condition of the gums, teeth, and occlusion. It is an
empirical way to measure oral health, the success of preventive interventions and
treatments, and attainment of good oral health outcomes.
Traditionally, the goal of the oral exam has been to identify disease. In the context of
developmentally based health supervision, another critical goal is to identify risk factors.
In addition to gaining information about the progress of disease, dentists should use the
oral exam to thoroughly evaluate the child's or adolescent's physical risk factors and
perform a risk assessment. Particularly with children under age three who may have no
obvious disease, assessment of physical risk factors such as plaque can be done only
with information gained through a thorough exam. In the adolescent, visual signs of
tobacco use discovered in the oral exam can predict more serious problems later.
Dentists may also need radiographs, if indicated, to assist in diagnosis, though

radiographs are not used as a routine part of the exam. Other less common diagnostic
procedures can include saliva tests or cultures of caries-causing bacteria, such as
mutans streptococci.
Risk Assessment
Risk assessment provides the dental professional with the opportunity to tailor
periodicity and oral health supervision to the individual's level of risk for specific
diseases, conditions, and injuries. This assessment involves identifying risk factors that
may negatively impact a child's oral health, and protective factors that promote oral
health. Risk assessment allows health professionals to individualize intervention by
focusing resources and education on specific components of oral health according to a
child's risk and protective factors. The risk and protective factors are organized
according to four major dental problems: dental caries, periodontal disease,
malocclusion, and injury. The guidelines indicate which factors can be an issue for all
ages of children, and which are most common at a particular developmental period.
4
Anticipatory Guidance
Anticipatory guidance refers to the information provided to the child and family about the
child's current oral health and what to expect as the child enters the next developmental
phase. The guidance should be modified based on the risk assessment. The dental
professional, for example, can not only remind an 11 year old and his family about the
importance of wearing a mouth guard while playing soccer, but can also discuss how
dental sealants will protect the second permanent molars, which should erupt in a year
or two. Through advance discussion of dental sealants, the family learns about the
procedure before the next dental visit, considers its benefits, and is better prepared to
ask more informed questions of the dental professional. When providing anticipatory
guidance, the dental professional is encouraged to discuss age-related risk and
protective factors. The health professional can explain to families, for example, that
inappropriate use of the baby bottle can produce baby bottle tooth decay (BBTD) in
infancy and early childhood, increasing the risk of caries later in childhood. Discussing
tobacco use as a risk factor for oral soft tissue problems becomes important to the
middle-school child and the adolescent. It is also important for the dental professional to
reinforce the key messages of anticipatory guidance in subsequent oral health
supervision visits.
Review
As the need for accountability in health care increases, utilization review, outcomes
assessment, and continuous quality improvement—new terms for many dental
professionals—become more important. Additionally, individualized risk assessment,
which requires more sophisticated tracking of individual progress and community risk
profiles, needs automated and organized data. The review section suggests several
sources of information that could indicate whether oral health supervision has been
provided appropriately. This section, rather than being all-inclusive, describes the range
of sources of information that can be adapted and used for utilization review, outcomes
assessment, and continuous quality improvement.
Outcome
The success of oral health supervision can be measured by whether the child or
adolescent has achieved certain outcomes. Measured outcomes will also help guide the
dental professional in determining the necessary periodicity for subsequent visits, and in
providing the appropriate anticipatory guidance.
The guidelines include a list of general outcomes that are comprehensive, behavioral,
and physical outcomes, since sustainable health promotion requires knowledge and
effort as well as the ability to achieve a certain health status. The outcomes are keyed
to developmental stages and thus represent clear and useful tools to determine
intervals for oral health supervision, particularly when risk is low. These general
outcomes can be refined for each child.
5
PRENATAL
Family Preparation for Health Supervision

Be prepared to discuss at your first visit:
• Your dental history
• Dental history of baby's family
• Questions about oral health aspects of pregnancy
• Any other questions about oral health

Health or Dental Professional
• Oral health supervision can be reinforced at the prenatal visit (usually with the
health professional):
• Education of the parents concerning fluoride supplementation, first-year oral
development, nonnutritive sucking habits (sucking on thumb finger, or pacifier),
breast feeding, bottle use, teething/tooth eruption, oral hygiene after tooth
eruption
• Scheduling and provision of dental education and treatment for parents before
infants birth
Interview: Trigger Questions

To be used selectively by the health or dental professional. Discuss any issues
or concerns of the family.
• What questions do you have for me today?
• Do you have any problems with your teeth?
• Does you family have any inherited problems/diseases affecting the teeth?
• Do you know the fluoride status of your drinking water?
• Are you brushing and flossing regularly?
• When is the last time you saw a dentist?
• Are you taking prenatal vitamins?
• How do you plan to feed your baby? Breast feeding? Formula? Why?
• As your child grows up, do you think you can help your child prevent dental
caries (the disease process that leads to "cavities")? What kinds of things do you
want to do to protect your child's teeth?
• Obtain a dental checkup and treatment for yourself before the birth of the baby.
• Do not use baby walkers at any age. Tell family member not to give you one as a
gift.
• If you plan to bottle feed: To avoid developing a habit that will harm the child's
teeth, do not put the baby to bed with a bottle, prop it in the baby's mouth, or
allow the baby to feed "at will."
6
Review
• Mother's prenatal record
• Attendance
• Appropriate screening/referral
• Follow-up
• Utilization review (appropriateness/quality of care)
• Policies of health professional and dental professional regarding quality of care
Outcomes
• Parents are informed of issues relating to preventive dentistry and oral
development
• Parents understand they should not put infant to bed with a bottle
• Parents obtain dental information and individual treatment at appropriate
intervals before the baby's birth
7
INFANCY

Be prepared to give updates on the following at visits to a health or dental
professional during infancy:
• Supplemental fluoride and vitamins
• Changes in the source of the water used for drinking, cooking, or formula
preparation (bottled water, etc.)
• Use of bottle, cup
• Injuries to the mouth or teeth
• Infections in the mouth
• Medications, illnesses
• Oral hygiene procedures (frequency, problems)
• Changes in teeth present in the mouth
• Thumb sucking or pacifier use

Dental Professional
• If indicated by the infant's needs and/or susceptibility to disease, at health
professional's referral:
• Treatment for injury/dental disease
• Recognition and reporting of suspected child abuse/neglect
• Education and anticipatory guidance for parents concerning fluoride
supplementation, oral development, nonnutritive sucking habits (thumb or
pacifier), bottle use, teething/tooth eruption, tooth cleaning, injury prevention,
dietary habits
• Referral, as needed, to other health professionals
Health Professional
• Health professionals can provide oral health supervision within the context of the
health supervision visits during the first year— suggested at birth, 1 week, and 1,
2, 4, 6, and 9 months:
• Screening
• Oral health risk assessment
supplementation, oral development, nonnutritive sucking habits (thumb or
pacifier), bottle use, teething/tooth eruption, tooth cleaning, injury prevention,
dietary habits
• Referral as needed to other health professionals

• To be used selectively by the health or dental professional. Discuss any issues or
concerns of the family.
• How is feeding going?
8
• How well does Julia fall asleep? Do you give her a bottle in bed?
• Is Hannah easy or difficult to console?
• What drinking water do you give to Ana?
• Does Nikita use a pacifier? Does she suck her thumb or finger?
• Do you put Celeste in a safety seat when she rides in a car?
• Are you brushing Alexander's teeth? How has this been going?
• How much toothpaste do you use on baby's brush?
• Do you have a family dentist?
• Have you made an appointment for Carlos' one-year dental visit?

• Are the parent and infant interested in and responsive to each other (i.e., sharing
vocalizations, smiles, and facial expressions)?
• Is the parent aware of environmental risks, yet supportive of the infant's emerging
autonomy and independence?

As part of the complete oral exam, the following should be noted:
• Pathologic conditions
• Developing dental anomalies
• Risk factors
9
Risk Assessment: Dental Caries
RISK FACTORS PROTECTIVE FACTORS
All Ages: Examples All Ages: Examples

Inadequate fluoride Optimal systemic and/or topical fluoride
Inadequate oral hygiene Good oral hygiene
Poor family oral health Access to care and good oral hygiene
Poverty Access to care
Frequent snacking Reduction in snacking frequency
Special carbohydrate diet Preventive intervention to minimize effects
Frequent intake of sugared medications Alternative to minimize effects
Reduced saliva flow from medication or Saliva substitutes

irradiation
Variations in tooth enamel; deep pits and Sealants (if possible) or observation
fissures; anatomically susceptible areas
Special health needs Preventive intervention to minimize effects
Previous caries experience Increased frequency of supervision visits
Gastric reflux Management of condition
High mutans streptococci count Reduction of mutans streptococci
Infancy: Examples Infancy: Examples

Bottle used at night for sleep or "at will" Prevention of bottle habit and weaning
while awake from bottle by 12 months
High parental levels of bacteria (mutans Good parental oral health and hygiene
streptococci)
History of baby bottle tooth decay Increased frequency of supervision
10
Throughout Infancy:
• Use an infant safety seat that is properly secured at all times.
• To avoid developing a habit that will harm the child's teeth, do not put the baby to
bed with a bottle, prop it in the baby's mouth, or allow the baby to feed "at will."
• Most infants do not get their first teeth until after six months, and some will not do
so until after one year. Teethers may be irritable.
• Familiarize yourself with the normal appearance of your baby's gums and teeth
so that you can identify problems if they occur.
• Many babies need extra sucking. If the infant is receiving enough milk and
growing well, sucking a thumb or pacifier may help calm the infant and will not
harm the teeth during infancy.
• Try to console the infant, but recognize that the infant may not always be
consolable, regardless of your efforts. Accept support from your partner, family
members, and friends. If you feel overwhelmed, discuss it with your health
professional.
• Always keep one hand on the baby on high places such as changing tables,
beds, sofas, or chairs.
• Keep all poisonous substances, medicines, cleaning agents, health and beauty
aids, and paints and paint solvents locked in a safe place out of the baby's sight
and reach.
• Use safety locks on cabinets.
• Install gates at the top and bottom of stairs, and place safety devices on
windows.
• Lower the crib mattress.
• Avoid dangling electrical and drapery cords. Ensure that appliances are out of
reach.
• Keep pet food and dishes out of reach. Do not permit the baby to approach the
pet while it is eating.
• Do not use an infant walker at any age.
• Always use a safety belt or infant seat when placing the infant in a shopping cart.
At six months:
• Begin to offer a cup for water or juice.
• Clean the infant's teeth with a soft brush, beginning with the eruption of the first
tooth.
• Give the infant fluoride supplements only as recommended by the health
professional, based on the level of fluoride in the infant's drinking water.
At nine months:
• Encourage the infant to drink from a cup. If bottle-feeding, begin weaning from
the bottle.
11
Review
• Chart with assessment of child's oral health.
• Appropriate screening/referral.
• Follow-up.
• Utilization review (appropriateness/quality of care).
• Policies of health professional and dental professional regarding quality of care.
Outcomes
• Parents are informed of oral development and teething issues.
• Parents are informed of and practice preventive oral health care, including
brushing infant's teeth with pea-size amount of fluoridated toothpaste.
• Infant rides in car safety seat.
• Infant's environment is safeguarded to protect against oral facial injuries.
• Infant receives appropriate fluoride supplementation.
• Infant has no active carious lesions.
• Infant has healthy oral soft tissues
12
EARLY CHILDHOOD

Be prepared to give updates on the following at the visits during early childhood:
• Changes in the source of the water used for drinking or cooking (bottled water,
etc.)
• Use of bottle, cup
• Eating habits
• Thumb sucking or pacifier use

Dental Professional
• Every 6 months, or as indicated by the child's needs or susceptibility to disease,
as determined by a primary care dentist:
• Examination
supplementation, appropriate use of dental sealants, oral development,
nonnutritive sucking habits (thumb or pacifier), bottle use, tooth eruption, tooth
cleaning, injury prevention, dietary habits
• Preventive dental procedures
• Guidance of developing occlusion
• Treatment of injury/dental disease
Health Professional
• Health professionals can reinforce oral health supervision within the context of
other health supervision visits— suggested at 12, 15, and 18 months, and 2, 3,
and 4 years:
• Screening
• Referral, as needed, to dental professional
13
• To be used selectively by the dental or health professional. Discuss any issues or
concerns of the family.
• Do you help Lynne with brushing her teeth? How has this been going?
• Does Brittany's brother have fillings? Have you had any problems with your own
teeth?
• Are you using fluoridated toothpaste on Bassam's teeth?
• Do you know about dental sealants?
• What would you do if JoAnne knocked out one of her teeth?
• Does Benita drink from a cup? Does she take a bottle?
• How often does Marie snack? What does she usually eat?
• Does Marcos use a pacifier? Does he suck his thumb or finger?
• Have you taken Michael for regular dental checkups?
• When did Lee have his last checkup with a nurse or doctor?
• When did he last get immunizations?

• Is the parent positive and supportive during the dental visit, helping to reduce
anxiety?
• How does the parent help to relieve the child's anxiety?
• Does the parent seem concerned about the oral health of the child?

As a part of the complete oral exam, the following should be noted:
Tooth eruption
Caries
Plaque accumulation
Baby bottle tooth decay
Dental injuries
Pathologic conditions
Developmental dental
Risk factors
At two-year exam, the professional should also check for:
Malocclusion
14

Inadequate fluoride Optimal systemic and/or topical fluoride
Frequent snacking Reduction in snacking frequency
Special carbohydrate diet Preventive intervention to minimize

effects
Frequent intake of sugared medications Alternative to minimize effects
Reduced saliva flow from medication or Saliva substitutes

irradiation
Variations in tooth enamel; deep pits Sealants (if possible) or observation

and fissures; anatomically susceptible
areas
Special health needs Preventive intervention to minimize

effects
Previous caries experience Increased frequency of supervision visits
Gastric reflux Management of condition
High mutans streptococci count Reduction of mutans streptococci
Early Childhood: Examples Early Childhood: Examples

Bottle used at night for sleep or "at will" Prevention of bottle habit and weaning
while awake from bottle by 12 months
High parental levels of bacteria (mutans Good parental oral health and hygiene
streptococci)
History of baby bottle tooth decay Increased frequency of supervision visits
15
Throughout early childhood:
• Use a car safety seat that is properly secured at all times.
• Give the child fluoride supplements only as recommended by the health
professional, based on the level of fluoride in the child's drinking water.
• After the one-year visit, schedule the next dental appointment for the child
according to the schedule recommended by the dental professional, based on
the child's individual needs and/or susceptibility to disease.
• Familiarize yourself with the normal appearance of your child's gums and teeth
• Keep all poisonous substances, medicines, cleaning agents, health and beauty
aids, and paints and paint solvents locked in a safe place out of the child's sight
and reach.
• Use safety locks on cabinets.
• Always use a safety belt or child safety seat when the child rides in a shopping
cart.
• Continue to use gates at the top and bottom of stairs and safety devices on
windows.
• Supervise closely when the child is on stairs.
• Ensure that the child wears a bicycle helmet when riding in a seat on an adult's
bicycle, on a tricycle, or on a bicycle with training wheels. Wear a helmet
yourself.
• Teach the child to use caution when approaching dogs, especially if the dogs are
unknown or are eating.
• Ask any questions you have about how to prevent dental injuries and how to
handle dental emergencies, especially the loss or fracture of a tooth.
• Provide the child's caregivers with the dentist's emergency phone contacts and
ensure that the caregivers are familiar with how to handle oral health
emergencies.
At 12 months:
• Begin brushing the toddler's teeth with a pea-size amount of fluoridated
toothpaste.
• Make an appointment for the toddler's first dental examination and risk
assessment.
• To protect the child's teeth, do not put the child to bed with a bottle, prop it in the
child's mouth, or allow the child to feed "at will."
• Continue to encourage the toddler to drink from a cup. Wean the toddler from the
bottle.
At 15 and 18 months:
• Continue to brush the toddler's teeth with a pea-size amount of fluoridated
toothpaste.
• Children under four to five years of age will continue to need help since they do
not have the manual dexterity to clean their own teeth adequately.
• Schedule the toddler's first dental visit if it has not already taken place.
16
At three years:
• Begin teaching the child to brush teeth with a small amount (just a smear) of
fluoridated toothpaste.
• At four years:
• Ensure that the child brushes her teeth twice a day with a pea-size amount of
fluoridated toothpaste. Regularly supervise the tooth brushing.
• If the child regularly sucks a pacifier or fingers or thumb, begin to intervene to
help the child discontinue the habit.
• Review:
• Chart with assessment of child's oral health
• Follow-up
• Policies of dental professional and health professional regarding quality of care
• Outcomes:
• Parents are informed of oral development issues
• Parents and child are informed of and practice preventive oral health care
• Child receives appropriate fluoride supplementation
• Child uses car safety seat or safety belt
• Child wears appropriate play and athletic protective gear
• Child is under the care of a dentist
• Child has no active carious lesions
• Child has healthy oral soft tissues
• Child has functional occlusion
Review:
• Follow-up
• Policies of dental professional and health professional regarding quality of
care
Outcomes:
• Child uses car safety seat or safety belt
17
MIDDLE CHILDHOOD
Be prepared to ask for updates on the following at the visits during middle
childhood:
• Changes in the source of the water used for drinking or cooking (bottled water,
etc.)
• Current sports and activities
• Eating habits
• Thumb sucking
• Use of substances (tobacco, other drugs)

Dental Professional
Every 6 months, or as indicated by the child's needs or susceptibility to disease,
as determined by a primary care dentist:
• Examination
nonnutritive sucking habits (thumb), tooth eruption, tooth cleaning, injury
prevention, dietary habits, use of tobacco and other drugs
• Preventive dental procedures
• Guidance of developing occlusion
• Treatment of injury/dental disease
Health Professional
Health professionals can reinforce oral health supervision within the context of
other health supervision visits— suggested at 5, 6, 8, and 10 years:
• Screening
• Oral risk assessment
• Referral, as needed, to dental professional
18
To be used selectively by the dental or health professional. Discuss any issues or
concerns of the family. As the child grows, ask the child questions directly.
To parent:
• Are you familiar with dental sealants? Do you have any questions about them?
• Do you understand what to do if Elisa knocks out one of her teeth?
• Is Jee brushing and flossing his teeth without being reminded?
• Do you have any special problems with brushing because of Perry's other
medical issues?
• Do you and your family members wear safety belts in the car?
• Does Selena ever comment about her teeth and how they look?
To child:
• How often do you brush your teeth? Floss? Do you think it helps?
• Do you always wear a safety belt in the car?
• What sports do you play? Do you wear a mouth guard? Other protective gear?
• Are you familiar with dental sealants?
• Do you have any questions about them?
• Do you think your teeth look okay?
• Do you snack at school? After school? What do you eat?

• Is the child comfortable separating from the parent during the dental visit?
• Does the child ask questions?
• Does the parent support the professional's recommendations to the child?
• Does the parent seem interested in oral health?

• As a part of the complete oral exam, the following should be noted:
• Caries
• Developmental dental anomalies
• Malocclusion
• Pathologic conditions
• Dental injuries
• Risk factors
19

Unrestored caries Restoration of carious lesions
Special health needs Prevention intervention to minimize effects
Nutritional deficiency (e.g., vitamin C) Healthy eating habits
Infectious disease (e.g., HIV/AIDS) Treatment of disease or preventive intervention

to minimize effects
Medications (e.g., Dilantin) Prevention intervention to minimize effects
Metabolic disease (e.g., diabetes, Treatment of disease

hypophosphatasia)
Neoplastic disease (e.g., leukemia and its Treatment of disease and preventive intervention to
treatment) minimize effects
Genetic predisposition (e.g., Down or Papillon Prevention intervention to minimize effects

Lefevre syndrome)
Poor-quality restorations Properly contoured and finished restorations
Mouthbreathing Management of mouthbreathing
Injury Use of age-appropriate safety measures and treatment

of injury
Middle Childhood: Examples Middle Childhood: Examples

Malpositioned and crowed teeth Orthodontic care
Puberty Preventive measures to address oral effects
Tobacco use Tobacco cessation
Anatomical variations (e.g., frenum) Surgical correction
20
Throughout middle childhood:
• Ensure that the child wears a safety belt in the car at all times
• Ensure that the child brushes her teeth twice a day with a pea-size amount of
fluoridated toothpaste. Regularly supervise the tooth brushing.
• Give the child fluoride in the child's drinking water
• Ensure that the child wears a helmet when riding a bicycle
• Ask questions you have about how to prevent dental injuries and handle dental
emergencies, especially in the loss or fracture of a tooth
• Provide the child's caregivers with the dentist's emergency phone contacts and
ensure that the caregivers know how to handle oral health emergencies
• Familiarize yourself with the normal appearance of your child's gums and teeth
so that you can identify problems if they occur
• Schedule the next dental appointment for the child according to the schedule
recommended by the dental professional, based on the child's individual needs
and/or susceptibility to disease
At 6 years:
Teach the child about sports safety, including the need to wear protective sports gear
such as a mouth guard and a face protector
If the child regularly sucks fingers or thumb, begin to intervene gently to help the child
stop
At 8 years:
Teach the child how to floss.
Teach the child how to handle dental emergencies, especially the loss or fracture of a
tooth.
Teach the child not to smoke or use spit tobacco
At 10 years:
Help the child understand the dangers of smoking, spit tobacco, and other drugs
Review
• Follow-up
• Policies of dental professional and health professional regarding quality of care
Outcomes
• Child wears safety belt
• Child does not suck fingers or thumb
21
• Child does not use tobacco or other drugs
• Child has been assessed for dental sealants
22
Examination of
Infants and Toddlers
23
Examination of Infants and Toddlers
Peter K. Domoto, DDS, Department of Pediatric Dentistry and Donna Oberg, RD, MPH,
Public Health Nutritionist Seattle-King Department of Public Health
Objectives
• Introduction to dentistry. The infant and toddler's introduction to dentistry
should occur in an environment, which is perceived by the child and caretaker as
a safe and pleasant one. The dental team should exude caring and confidence
as it introduces the family to pediatric dentistry. The "golden rule" and the
principle of "do no harm" should prevail. Both the child and the caretaker(s)
should be treated with kindness and respect. This introduction will serve as the
foundation for the development of positive attitudes and responsible relationships
with members of the dental health profession in the future.
• Prevention. The value and effectiveness of preventive dentistry is a major

emphasis of the infant and toddler dental examination. Preventive dialogue
should include discussions of diet and feeding practices, tooth cleaning
procedures, and optimal fluoride use - both systemic and topical.
• Assessment. This objective is achieved through the process of evaluation and

synthesis of information from a variety of sources. Demographic data from the
patients' record, including information from other agencies and providers provide
important descriptions of the child and family's status. Observations of the child
and caretaker(s) as they interact, both in the dental setting and elsewhere
provide useful information regarding the child's developmental status and
"readiness" for a dental examination. Finally, an evaluation of the child's head
and neck region and oral cavity will be used to detect the presence of trauma,
infection, and/or signs of infant caries, including white spot lesions.
• Pre-appointment Assessment in WIC:

WIC certifiers conduct a health history, current health status and dietary
assessment to determine client eligibility for the program. In order to qualify for
WIC, infants and children up to age five (and pregnant and breastfeeding
women) must meet income requirements and have a medical or nutritional risk.
One of the qualifying risk criteria is a severe dental problem which is defined as:
"A child with a diagnosis of baby bottle tooth decay, rampant caries or needing
dental treatment for 3 or more caries in the last six months." (WA State WIC
Manual page 76). Certifiers across Washington State have been offered oral
screening training at statewide WIC conferences for the past three years to assist
them in determining eligibility for WIC. In 1994 disposable mouth mirrors (funded
by the Washington Dental Service Foundation) were distributed to all WIC
agencies in Washington to improve the ability to conduct the visual oral
screening.
Monthly WIC computer reports are available, which describe the total number of
children in each clinic on WIC with severe dental problems (#14). When
24
interpreting this data and comparing different months, remember that each month
some children are added to WIC and some move or are no longer eligible due to
a variety of reasons. Therefore, the data for #14 reflects all children currently on
WIC at a clinic who have been identified with "severe dental problems" according
to the above definition.
Interview
The interview occurs prior to the dental examination. The following issues are
addressed during the interview:
• Build rapport with the family. Focus on the comfort of the client. Demonstrate
effective nonverbal skills and position yourself appropriately during the interview.
Use open-ended questions and address the client's concerns in an empathic and
courteous manner. Attend to the clients' need for appropriate words and in the
case where English is not the primary language, speak slowly and clearly.
Where an interpreter is required, allow adequate time for translation and
clarification with both the interpreter and the clients.
• Specific concerns of the parents are elicited. "Why are you here today?"
• Confirm pre appointment information.
• Assess the family's current dental prevention practices:
1. Family history of dental disease
2. Fluoride inventory
3. Tooth cleaning procedures
4. Diet history and feeding pattern
The examination procedure

The dental exam should not proceed until the clinician has had a chance to establish
some contact and rapport with the child. An effective way to achieve this is to give a
toothbrush to the child and briefly observe. Often the child will place the brush in his/her
mouth and the examiner can effectively catch a glimpse of the teeth as well as observe
the child's behavior with the toothbrush and the interaction with the caretaker.
Armamentarium
Mouth mirror
Infant size toothbrush
Procedure
Give the child a toothbrush.
Position the child on the examining table or assume the "knee to knee" posture and
have the caretaker lower the child's head onto your lap.
Use the child's toothbrush and quickly assess the child's oral condition.
Use a dental mirror and continue to assess the child's oral condition.
Record findings.
Advise caretaker of oral findings and recommendations for follow-up
25
MANAGEMENT OF THE VERY YOUNG CHILD
Philip Weinstein, PhD, Professor, Department of Dental Public Health Sciences, Adjunct
Departments of Pediatric Dentistry and Psychology
Goal
The aim of this early intervention program for infants and toddlers is that the children
return for subsequent care and monitoring. What is accomplished at a given
appointment is secondary to continuity of care and maintaining an effective relationship
with the child and caretaker(s).
Essentials of successful management

Rapport and trust with the caretaker and child are essential to the success of the
program and the health of the child. Learning about the caretaker and child and
showing genuine interest in their welfare is necessary. The environment in the waiting
room and even the operatory should reflect concern for the comfort of the caretaker and
child. It is very helpful to play with the child when you first meet him or her. It can be
fun. While few toys are really needed, they help structure the initial interaction. A range
of age-appropriate toys and games are suggested.
Role of the caretaker

Competent caretakers tend to be very useful during the dental team's interaction with
the infant or toddler. Give caretakers detailed instructions on how to hold the child
during the exam or treatment. Practice a few times. Moreover, parents can be taught
to coach or distract the child. Caretaker tolerance of crying should be discussed.
Teaching coping
Even very young children can do a breathing exercise (blow) with a pinwheel, party
noisemaker (blower), or make sounds like a leaky balloon or tire. Imagery you provide
(birthday parties, rides, etc.) can be hypnotic. Distraction, especially when expecting
danger, is another useful strategy. Toys, coloring, reading books, especially those that
are interactive, and games are all possible adjuncts to building rapport and comfort.
Gifts
Gifts are a common way to reward the child. It may be best to provide the gift to the
child at the beginning of the appointment. A gift for the caretaker is also a good idea.
26
COPING WITH THE CRYING CHILD
Background
This section presents information about crying in young children. Crying is believed to
have a purpose; it has a social/communicative function and facilitates parental
recognition. Research has identified and differentiated among a variety of cries.
Tempo, pitch and melody are the important variables. Most studies have been
conducted with neonates and infants less than six months. Crying itself has positive
and negative physiological consequences for the child
Tolerance to crying
Crying is an aversive stimulus that leads the listener to react. The desired response is
to reduce discomfort; unintended responses by the listener include avoidance and
abuse. Perceived averseness of crying is influenced by cry characteristics and the
characteristics and experiences of the listener. Parents and caregivers have increased
tolerance. Information i.e., knowledge that the baby is sick, alters tolerance. Research
also shows that focus on discriminating different types of cries makes them more
tolerable.
Coping with crying

Emotional upset and stress decrease tolerance to many aversive stimuli. Therefore
strategies that decrease upset or stress will increase tolerance. It may be best to use
multiple strategies. Medical personnel have learned not to allow themselves to engage
their emotions when working on a cadaver. They focus on the technical aspects of the
task at hand. This ability to "dissociate" is helpful in tolerating crying. Self-talk can be
useful in controlling negative cognitions that reduce tolerance. Breathing exercises and
practice are also recommended. If you are "losing it", it is important to take a rest break
(a breather) and to begin again when you are no longer upset.
27
Family Oral Health
Education
28
Family Oral Health Education
Prenatal Counseling
The participants in the ABCD Program have an exciting and important opportunity to
provide an essential resource for existing programs in the community which serve
clients who access prenatal counseling and care, e.g. WIC, Maternal and Child Health
Programs like First Steps. Regardless of where the program is conducted, close
collaboration among members of the various health professionals and community
support groups is essential. Research in both education and health promotion supports
the emphasis of specific information introduced prenatally and reinforced often both
prenatally and postnatally.
Family Oral Health Education is a benefit in this program. It is allowed twice per year
for a family. It needs to be documented in the chart.
Objectives:
1. Establish/maintain trust so that caretaker will return
2. Choose more than one strategy that will help prevent the disease from
getting started
3. Choose more than one strategy that will help stop the disease process,
once started
4. Establish / maintain rapport and trust with caretaker(s) so that
caretaker(s) and child return.
• Demonstrate concern for child and caretaker
• Play with the child
• Affectionate, culturally-appropriate touch
• Discuss caretaker’s experience in obtaining dental care for child and self
• Access / barriers
• Quality / satisfaction
• Fear / avoidance and distrust
• Do not talk of the benefits of dental health, especially at initial appointment
• Do not criticize caretaker in any manner
• Be empathic with the difficulties and stresses in low income families
• Discuss developmental issues that are relevant
• Assess and discuss risk for infant/toddler caries
• Debrief at end of appointment
Risk for Infant/Toddler Caries (Nowak & Crall, 1988)

• Family history moderate-to-severe dental disease
• Hereditary / congenital defects / anomalies
• High-risk pregnancy or complicated delivery
• No systemic fluoride received
29
Assessing Family History
Do siblings have dental disease?
Do caretaker(s) have dental disease?
Strategies That Will Help Prevent Disease from Getting Started

Teach caretakers how to “lift the lip”
Caretaker cleaning
Enhanced access to fluoride
Nutritional / diet counseling
Strategies that will help stop the disease process, once started
Teach caregivers to 'Lift the Lip"
Flip chart or video and practice with feedback
Use of mirror
Handout
Frequency of exam
Caries control measures: frequent application of fluoride varnish; glass ionomer
restorations
Caretaker Cleaning
• While encouraging toddler use of brush, caretaker must clean; usually until age 5
or so
• No access to toothpaste for infants / toddlers without caretaker present
• Clean high-risk surfaces
- Maxillary incisors
- Any decalcified / hypoplastic or cavitated toot
- Special attention to places where no spaces between teeth
• Developmental differences
0 - 9 months
- Stimulate gingiva around where teeth will be coming in. Cold
teething ring afterwards
- Clean erupting tooth, especially in maxilla with cold, wet
washcloth
- Cleaning 1 x a day
10 - 48 months
- Continue cleaning erupting teeth and other high-risk surfaces
• Brushes
- Massage brush, washcloth / gauze
- Triple-headed toothbrush
- Very small-headed brush
• Make it a habit
- Same time every day - Before bath, before bedtime story
30
• Technique
- Position so can see
- Smear layer of toothpaste only
Enhanced Access to Fluoride

• Limited transfer of fluoride from human milk (only 2% of a high dose of fluoride—
11.25 mg) given to lactating mother was transferred to infant (Ekstrand, 1984)
• H2O fluoridated? Critical question
• The use of fluoride-containing toothpaste
• A pea-size amount (Pang & Vann, 1992)
• Only provided by caretaker, no unsupervised access to toothpaste
• The use of fluoride supplements
• “In areas with inadequate water fluoridation (< 0.3 ppm), all infants, breast-fed
and formula-fed, should be given fluoride supplements (0.25 mg/d) beginning at
6 months of life” (ADA Council on Dental Therapeutics 1994).
Topical and systemic effects:
Problems
Solution: let caretaker and child try it out right now
Cues, Premack Principle
Continued contact with enthusiastic and dedicated staff makes a big
difference (Newbrun, 1978)
An infant’s daily fluoride intake is determined by the amount of fluoride in the

breast milk, formula, and water source (Clarkson, 1991)
• At relatively high concentrations (71 ppm) fluoride reduces the acidogenic
potential of pathogenic bacteria
• At lower concentration effects remineralization/demineralization of hard tissue
Feeding Practices to Avoid

• No juice or other sugar product in bottle
• No bottle while sleeping
• Control snacking for toddlers
• Set time
• Reduce number of snacks
31
Feeding Practices to Follow
• Sugary liquids from cup only -- begin cup as young as 6 - 7 months
• Begin cup as soon as possible- introduce juice
• Begin adding solids 4 - 6 months -- see WIC personnel
• Counseling concerning given strategy
• Counseling - giving information
• Listen
• Ask questions
• Mention possibilities
• List
• Summarize verbally
• Write down the plan
• Review progress - by phone and at next appointment
What are some bottle elimination options?

“Cold turkey” vs. gradual elimination
Water down; reduce volume
Change one feeding at a time
Sleep-related problem?
Introduce the Cup as Early as Possible

Recommend that the bottle not be used as a pacifier
Pacifiers are readily available
No sweets on pacifiers
If bottle used as pacifier, put water in it
Relevant Developmental Issues

Teething and how to help the child
Use and selection of a pacifier
What to do if there is a dental emergency
Prevention of oral injuries
What Caretaker Can Do for Teething

Rubbing pressure
Clean the area
Teething toy, ring
Home Care
The prevention of dental diseases is a personal responsibility, which initially falls to the
parents or caretaker and must be eventually adopted by the child. As has been
previously mentioned, learning preventive behaviors should begin prenatally. Attention
to a balanced diet and reasonable feeding practices, optimal use of systemic and topical
fluorides, and effective home care are the foundation for building life long personal
preventive practices to ensure oral health. Plaque removal is often a neglected part of
the preventive regimen suggested by health care professionals for infants. It should be
understood that plaque begins to form as soon as baby's first tooth has begun to erupt.
32
The plaque harbors bacteria, many of which cause carious infections. Some plaque
bacteria cause gingival infections. Daily disruption and removal of plaque will reduce
the numbers and the virulence of the bacteria in the infant’s mouth thus leading to a
reduced risk for caries and gingivitis.
Recently, Caulfield has demonstrated that children of mothers with high levels of S.
mutans tend to become infected with these bacteria between 19 and 28 months of age.
While transmission does not occur from mother to child in all cases, it is clear that there
is a period of time when the baby is highly susceptible to being infected with caries
producing bacteria. This period of time, probably between 12 to 30 months, is an
interval when the child is actively erupting teeth. These newly erupted teeth are
vulnerable to rapid demineralization because the enamel has not had an opportunity to
mature. If the plaque is allowed to accumulate and the infant's diet and feeding pattern
provide exposure to fermentable carbohydrates frequently or for a long duration, the
acid produced in the plaque will be sufficient to produce demineralization and eventual
cavitation of the tooth surface.
Daily removal of plaque with a wet, soft bristled brush will enhance both caries
prevention and will prevent gingivitis. The parent or caretaker must, of course, take
responsibility for this activity. A goal is to have the child take more and more
responsibility over the years but initially plaque removal is an adult caregiver’s
responsibility. Initially, the baby only has a few anterior teeth that are erupted and
naturally likes to put anything and everything into her/his mouth. A perfect time to
introduce a small toothbrush!
Positioning of the baby is the first step in efficient and effective plaque removal for the
youngster. The two people, knee-to-knee technique that was demonstrated during the
section on the infant dental examination is an ideal method of performing tooth brushing
for the baby. If it is not possible to have another person assist, the baby should be
reclining when the brushing is performed. Perhaps an appropriate setting is one that is
similar or identical to the area that is used for changing diapers. The main difference
would be that the brushing should be done from behind the baby or to the side.
Regular, effective plaque removal takes skill and persistence on the part of the
caretaker. The caretaker's enthusiasm and willingness to tolerate some resistance on
the part of the child will go far in establishing lifetime habits for the child.
Teething
There is a general pattern in the eruption of teeth, with wide variation. The first teeth to
come in are lower central incisors, followed by upper central incisors. Babies may vary
by several months.
Once the central incisors begin to erupt at about 8 months, the child will be teething for
the next 2 years or so. Around 10 months, the upper incisors begin to erupt. At about
16 months, the upper first molars begin to come in, leaving a gap filled at about 20
months by the canines. See the eruption chart on page 36.
33
Teething frequently is believed to result in feverish, fussy, cranky babies who whine,
drool, and put objects into their mouths. Clearly, there are other causes of such
behavior. Teething is a normal physiologic process. If a child has fever, nausea, or
congestion, it is important not to assume the cause is teething. Have the caretaker
check with a pediatrician. Do not cut gingival tissues to help the primary teeth erupt.
A wide variety of remedies for teething are available; some folk remedies caretakers
use actually work. We recommend rubbing and cleaning the area where the teeth are
erupting and giving the baby something safe to bite on—for example, a teething ring;
cool spoon; or a cold, wet washcloth.
34
Pacifiers and Sucking
Nature provides great pacifiers - the thumb and fingers. Artificial pacifiers are
purchased in stores.
Babies have the inborn desire to suck on anything near their mouth. This reflex should
not be discouraged. Some babies get enough sucking actually by nursing or using a
bottle with a proper nipple (non-free-flow-up type). Others seem to want more sucking.
Sucking habits by children prior to eruption of permanent incisors (about age 6 or 7) is

not a serious problem. The only advantage to the pacifier is that it is likely to be “lost”
and at some future date the habit will be more easily terminated.
Pacifiers may be useful when the child wants to suck, but is adequately fed; it may
replace reliance on the bottle in some circumstances and, thereby, reduce risk of dental
disease. As the child grows older and the risk of dental disease decreases, reliance on
the use of a pacifier can be decreased to reduce risk of misalignment of permanent
teeth. Moss (1993) recommends stopping the use of artificial / natural pacifiers by 4
years (if it can be easily accomplished). Most children give up pacifiers by themselves
by ages 3 to 4.
Safe Use of Pacifiers

Recommend that the caretaker:
• NOT hang the pacifier around the baby’s neck; this has resulted in a number of
deaths!
• Find a sturdy pacifier with one-piece construction, made of non-toxic, flexible
material with an easily grasped handle.
• Find a pacifier with a shield or mouth guard that can separate from nipple, two
ventilating holes, and that is too large to be swallowed.
• Find a pacifier where the nipple is intact. Caretaker should pull on nipple and
replace when it shows signs of wear.
35
Eruption Chart
Tooth Eruption Age in months (+ Range)

Mandible
Central 8 (6-10)
Lateral 13 (10-16)
Canine 20 (17-23)
First Molar 16 (14-18)
Second Molar 27 (23-31)
Maxilla
Central 10 (8-12)
Lateral 11 (9-13)
Canine 19 (16-22)
First Molar 16 (13-19)
Second Molar 29 (25-33)
Teeth that erupt earlier are at greater risk!
36
DIETS OF INFANTS AND TODDLERS
Donna Oberg RD, MPH , Public Health Nutritionist, Seattle-King County, Department of
Public Health
Infant Feeding
Normal infants triple their birth weight by one year of age and require adequate nutrition
to obtain optimal growth and development. Breast feeding or infant formula is
recommended for the entire first year of life, especially for low-income infants. During
the first four to six months solely breast-feeding or iron-fortified infant formula is
recommended.
Introduction of solid foods begins with infant cereal offered by spoon (adding infant
cereal to the baby bottle is not normally recommended with the exception of esophageal
reflex) between four and six months, depending upon the infant's developmental
readiness. At six months of age infants can begin drinking juice from a cup with
assistance from a caregiver. Breast or bottle-feeding often occurs at bedtime. However,
it is recommended to hold the infant while feeding and then lay them down with the a
favorite stuffed animal, blanket or something comforting rather than a baby bottle
containing any sweetened liquid (milk, formula, juice, Kool-aid, etc.) which can
contribute to dental disease. Water is the only dentally safe liquid. Offering pureed
fruits or vegetables is recommended next and by about eight months some easily
chewable protein foods should be introduced. Gradually more and more bite-size table
foods are added to an infant's diet depending upon their readiness.
Feeding Toddlers
At one year of age, toddlers can easily get a balanced diet if offered a variety of foods.
From 1 -2 years of age a child's daily intake should be: 1 ounce of protein; 2 cups of
whole milk; approximately 3/4 cup of fruits and vegetables; and 6-11 servings of grain
products (servings = 1/4 slice of bread; 1/8 cup hot cereal, rice, or pasta).
Toddlers who continue using baby bottles may over consume milk and/or juice
and may not eat a balanced diet required for optimal growth. By introducing the
baby cup early and providing adequate practice toddlers can easily use a cup to obtain
the recommended 2 cups of milk/ day (1/2 cup of milk with each meal and with one
snack).
Eating habits begin developing early and can be greatly influenced by caregivers.
Changing bad habits is much more difficult than learning good eating habits. For
example, when a caregiver uses food to control a child's behavior like providing a
favorite treat for good behavior and the child learns that foods are rewards. When a
child goes to sleep each night sucking on a beverage from their bottle, they are learning
how to comfort themselves with food. Instead of eating to satisfy a hunger cue, eating
satisfies emotional needs like fussiness or boredom and this feeding pattern can
establish life-long eating patterns that may contribute to overweight and possibly poor
eating habits.
37
Picky eating is a common trait of two-year-old children. Food is one of the few
things they can control in their life and they often will show their independence by
refusing to eat certain foods. It is the caregiver's responsibility to offer healthy foods,
but it is the child's responsibility to choose what and how much to eat. It is not
recommended to force anyone to eat, especially a toddler. The caregiver may win the
battle but will most likely lose the war. Treating children's food preference respectfully is
highly recommended.
Snacking habits are especially important to toddler-aged children because they

have small appetites at mealtime due to their stomach's limited capacity.
Therefore, three small snacks are recommended between meals, but not too close to
mealtime. Ideally snacks should contribute to getting a balanced diet, such as a
vegetable or fruit. (See handout: Snacks for Tots) Frequent snacking on sweet, sticky
or starchy foods (containing fermentable carbohydrates) can contribute to dental caries.
Many caregivers use crackers or baby bottles of sweetened beverages as a continuous
snack/pacifier for their toddler that will reduce their appetite at mealtime and may
contribute to caries. Snacking habits have been implicated by recent research as
contributing to baby bottle tooth decay. Good snacking choices will benefit toddler's oral
health and total health and will contribute to establishing better eating habits.
BBTD Prevention Project in WIC

For the past three years the Washington state WIC Program (Special Supplemental
Nutrition Program for Women, Infants, and Children) has conducted a BBTD Prevention
Project. The Washington Association of Local WIC Agencies (WALWICA) and the
Seattle-King County Department of Public Health have coordinated this successful
project. The project has been funded by the Washington Dental Service Foundation to
provide baby cups when infants are six months of age and a disposable mouth mirror
for oral screening and early identification of infant caries. For more details see
appendix.
WIC is a federally funded nutrition program serving 95,000 low-income children under
age five and pregnant or breastfeeding women in Washington at approximately 250
clinics throughout Washington. A nutritional or medical risk must be diagnosed in
addition to meeting low-income requirements. This unique program combines free
nutritious foods (eggs, milk/cheese, juice, cereal, peanut butter/dried beans, infant
formula and infant cereal) with nutrition education and healthcare referrals. Studies
indicate WIC is effective in improving pregnancy outcomes by reducing the number of
low birth weight infants and producing a significant savings in health care dollars.
Additional Reading:
R.C. Burgess: Diet and Dental Caries, National Institute of Nutrition, Vol. 4:No2; 1989,
Supplement, pages 1-4.
W.J. Loesche: Nutrition and dental decay in infants, American Journal of Clinical
Nutrition, Vol. 41: 1985, pages 423-435.
38
G. Acs: Effect of nursing caries on body weight in pediatric population, Pediatric
Dentistry, Vol. 14:No5, 1992, pages 302-305.
J.M. Navia, Caries Prevention in Infants and Young Children: Which Etiologic Factors
Should We Address?, Journal of Public Health Dentistry, Vol. 54:No 4, 1994, pages
195-196.
E. Satter, How to Get Your Kids to Eat...But Not Too Much, Bull Publishing Co. 1987.
P.L. Pipes, Nutrition in Infancy and Childhood, Times Mirror/Mosby, 1989.
39
Prevention of Dental
Disease
40
TOPICAL FLUORIDE VARNISHES
Introduction
The last half-century in the US has demonstrated dramatic reductions in decay rates.
While the causes of this reduction are multifactorial, it is clear that enormous benefits in
caries reductions must be attributed to both systemic and topical mechanisms of
fluoride ion. The efficacy of topical fluoride, both home and professional applications, is
well established.1 In recent years as caries rates have gone down there has been a
rise of mild to moderate dental fluorosis in permanent teeth.1,2 Thus there are
concerns regarding excessive ingestion of fluoride especially in children under the age
of 3 years.3-7.
At the same time, both national data and small area data indicate that some 20% of the
population experiences 80% of the decay.8,9 Clearly, the benefits of fluoride are
essential for this high risk for caries group. The challenge for further reductions in
caries lies in reducing the rates in these high-risk groups.
Fluoride varnishes are a type of topical fluoride and have extensive evidence of efficacy
as a caries preventive agent in Europe over the past three decades.10-17 Fluoride
varnishes appear to be comparable in efficacy to traditional fluoride gels currently used
in dental practice. In spite of approval by the FDA as a device, fluoride varnishes are
not used extensively in this country. The purpose of this paper is to suggest a rationale
for the "off-label" use of fluoride varnish as a professionally applied topical for caries
prevention.
The FDA and Federal Law

The US Food and Drug Administration (FDA) administers the Federal Food, Drug and
Cosmetic Act which requires manufacturers to demonstrate safety and effectiveness of
all new drugs for their indications i.e., (the new drug) "will have the effect it purports or is
represented to have under the conditions or use prescribed, recommended or
suggested in the proposed labeling".18 The FDA requires substantial evidence from
adequate and well-controlled investigations in order to approve a new drug for
marketing.18,19
Fluoride varnishes became available in the United States in 1991 when the FDA
approved Duraflor. FluorProtector and Duraphat are also currently approved. Duraflor,
Duraphat and FluorProtector have FDA approval as root desensitizers or cavity
varnishes, but not as a therapeutic topical fluoride. These three varnishes are
considered by the FDA to fall into a category of drugs and devices that "present minimal
risk and is (are) subject to the lowest level of regulation".20 The FDA will not accept the
extensive findings from European investigations as adequate evidence for approval for
labeling as a caries preventive agent, primarily because European research compares
the active drug to no treatment and not to a placebo.
41
Off-label Use of Approved Drugs in Medicine
Use of approved fluoride varnishes for caries prevention therefore is an unapproved use
or more commonly, "off-label" use, of an approved drug. Such use is not considered
unlawful; indeed, the use of drugs off-label is common practice in medicine. Three
fourths of the prescription drugs currently marketed in the US lack full pediatric
approval.18 Quoting from the recommendations of the Committee on Drugs of the
American Academy of Pediatrics:
"Unapproved use does not imply an illegal use. The word unapproved is used
merely to indicate lack of approval, not to imply disapproval or contraindication
based on positive evidence of a lack of safety or efficacy." (Committee on Drugs,
American Academy of Pediatrics 1996)18
The labeling of many drugs, "old and new", contain pediatric disclaimers and are being
used extensively "off-label". The following are a few examples of commonly used "off-
label" drugs with pediatric disclaimers:19
• Albuterol (Ventolin)
• Meperidine hydrochloride (Demerol) injection (PCA)
• Ketorolac tromethamine (Toradol)
• Morphine (PCA)
• Midazolam hydrochloride (Versed)
In addition, some drugs are used off-label when the drugs labeling do not cover their
use. Some examples are as follows:22
• Finasteride for benign prostatic hyperplasia. Off-label: male pattern baldness
• Fluoxethine (Prozac) for depression. Off-label uses: Anorexia nervosa,
alcoholism, ADHD
• Mexiletine for refractory ventricular arrhythmias. Off-label: Paresthesia
associated with diabetic neuropathy
• Triprolidine and Pseudoephedrine (Actifed) for bronchodilation. Off-label: Otitis
Media
Both physicians and dentists assume the responsibility for justifying off-label use of
approved drugs. If one considers that the application of topical fluoride for a patient
who is at risk for caries is the standard of dental practice for his/her community then the
selection of an approved fluoride varnish is a reasonable choice.
Purpose of Topical Fluorides

The purpose of applying topical fluoride to the exterior of teeth is to retard, arrest,
and reverse the caries process. As was noted earlier topical benefits of fluoride are
derived from water, dentifrices, over the counter rinses, prescription rinses and gels,
and professionally applied products.
42
Topical Fluoride Enhanced Benefit
The fluoride benefit in the ABCD Program is the application of fluoride varnish
three times in a year for each eligible child. There is no set time interval between
fluoride varnish treatments in the program.
Safety of Fluoride Varnish

Despite Duraphat's high fluoride concentration, Ekstrand et al.23 found no toxic effect
on fluoride plasma levels or renal function in pre-school children and school
children treated with Duraphat. This is as would be expected considering the
material's fast setting, its slow release of the fluoride and the small amount of varnish
required for an application. In Ekstrand's investigation all teeth of the children were
coated with varnish. An average of 0.3 to 0.5 ml of varnish was used which would
contain a maximum of 12 mg fluoride. In applying varnish to the infant or toddlers
four maxillary incisors, no more than two drops of Duraflor are dispensed and
thus less than 0.3 ml of the varnish would be applied which would result in a
maximum of a little over 7 mg of fluoride.
Rationale and Efficacy

Duraflor (Pharmascience Inc., New Jersey) Duraphat (Colgate-Hoyt) appear to be
particularly suitable topical fluorides for infants and toddlers when professionally
applied. This fluoride containing varnish was first introduced in Germany in 1964 under
the trade name Duraphat.24 Duraflor contains 5% by weight NaF or 2.26% by weight
fluoride in a neutral colophonium base. Duraflor is usually applied with a brush. Upon
contact with saliva or water the material sets quickly as a yellow-brown coating.
During the last 25 years a number of laboratory investigations and clinical investigations
have shown that varnishes supply fluoride more efficiently than other topical agents.
Caries reductions have been shown to be in the range of 40% to 70% which is
comparable to APF.10-17 A recent clinical investigation conducted by the University
of Washington among high risk toddlers it appeared that an every 6 months application
of Duraflor was particularly useful in enhancing remineralization of affected teeth15. In
high risk groups it is generally recommended that Duraflor be applied at intervals of
3-6 months. (Petersson et al. reported that three consecutive applications of Duraphat
within a 10 day period, once a year for three years obtained better results than with two
applications per year.13) The principle of the varnish delivery system is based on
contact of topical fluoride with the teeth over a sustained period of time. By the mid
'70's the benefits of fluoride varnishes were accepted by the European dental
community and were being used extensively.
Fluoride varnish does not appear to be inactivated by dental plaque25 and this may be
applied without any previous prophylaxis. However, de Bruyn and Arends12
recommended normal tooth brushing followed by drying prior to the varnish application.
Koch et al.26 found that dry tooth surface facilitates fluoride uptake in enamel.
Helfenstein and Steiner14 recently reviewed the methodology and findings of
investigations of Duraphat over the last 20 years.
43
No serious side effects have been reported from the use of Duraphat or Duraflor.
However, it should not be applied to bleeding gingival tissue in order to avoid risk of
developing a contact allergy to the colophonium base.
Duraflor does not have a strong flavor and appears to be reasonably well tolerated by
young taste buds. It is recommended that all providers perform a "taste test" prior
to initiating the use of Duraflor with patients as experience has taught us that
providers who are uninformed may unnecessarily bias children and/or caretakers
against the flavor.
Justification for Off-label Use of Fluoride Varnish:

Application of varnish is safe, effective, quick and easy. Fluoride varnish is safe.
FluorProtector is 0.9% fluor silane that yields a fluoride concentration approximately one
half of conventional acidulated phosphate fluoride (APF). The fluoride concentration of
Duraphat and Duraflor varnishes is twice that of APF gels, at 5% NaF, but the amount
used per treatment is ten times less. For applications in the primary dentition 0.1 ml to
0.3 ml are utilized (2.3 to 6.8 mg of fluoride ion).23 The toxic dose of fluoride varnish is
reached with 10 times the normal dose. The toxic dose of APF gel is reached with
about double the normal dose. In essence, we do not have any alternatives for use of a
topical fluoride on very young children. Fluoride varnishes offer the safest topical
fluoride available for the young, at risk child. An additional advantage of fluoride varnish
is its slow release over time. APF gel is swallowed as a bolus, but varnish sets on the
teeth and is swallowed over many hours.
Professionally applied topical fluorides actually present little risk for fluorosis. Burt
found that dietary supplements, inadvertent swallowing of fluoride toothpaste, and
increased fluoride in food and beverages are the most likely sources of increased
fluoride ingestion.27 In addition, Burt states that "...there is no evidence that swallowing
of fluoride gels has been a factor in the increase in fluorosis among North American
children". Since the amount of fluoride that is applied in the application of fluoride
varnish is small and the varnish sticks to the tooth surface the risk for fluorosis is almost
negligible.23 Clark and Berkowitz in a longitudinal study of dental fluorosis in three
Canadian communities concluded that while the prevalence of esthetic problems
resulting from fluorosis is low in these communities, children's risk for esthetic problems
increases when fluoride dentifrices, fluoride supplements, and fluoridated water are
used in the third year of life.28
Fluoride varnish is effective. Caries reductions have been shown to be in the range of
40% that is comparable to APF.10-17 The principle of the varnish delivery system is
based on contact of topical fluoride with the teeth over a sustained period of time. By
the mid '70's the benefits of fluoride varnishes were accepted by the European dental
community and were being used extensively. By the early '90's almost 93% of all
professionally applied topical fluorides in Scandinavia were varnishes.29 In
addition, there is some evidence that varnishes are more effective than other topical
fluorides in reducing caries on fissured surfaces.30
44
Fluoride varnishes offer several advantages over traditional topical fluoride such as
speed and ease of application and a greater range of applications. Varnish can be
safely and effectively applied to infants and toddlers, developmentally disabled patients,
and patients with active gag reflexes. Varnish can be applied to at risk surfaces in a
matter of seconds. An effective application is quick and easy. In addition, high risk for
caries patients including adults with root caries and/or xerostomia benefit greatly from
regular application of fluoride varnish.
Conclusions
Fluoride varnish provides a useful and effective means of delivering topical fluoride to
the teeth of patients. As with any topical fluoride, the at-risk-for-caries patient will
benefit the most from periodic applications of this material. The fact that fluoride varnish
as a caries preventive measure currently must be used "off-label" should not be a
barrier to its use in clinical practice. The benefits of fluoride application far outweigh the
risk for fluorosis in the at-risk-for-caries patient. If a patient requires a professionally
applied topical fluoride and is too young, too uncooperative or too medically
compromised for a four minute (or even one minute) APF treatment, fluoride varnish
offers an efficacious and safe alternative.
Fluoride supplementation is not a substitute for topical fluorides in the child less than
three years of age. Supplementation is prescribed for the infant and toddler in the form
of drops or other liquid medium. Since the caries preventive effect of supplements is
primarily posteruptive it is reasonable to encourage a chewable tablet as soon as
possible in order to exploit these topical benefits.31 There is no evidence that the high
risk for caries child would receive any meaningful topical effect from this systemic
method of fluoride supplementation.
The "off-label" use of drugs is a practice that is common in medicine with a number
drugs that have multiple efficacious therapeutic uses. The literature is clear that the
major benefit of the fluoride varnishes is their caries preventive properties.10-17,30 The
FDA requirements for substantial evidence from well-controlled investigations should be
met as soon as possible. Colleagues at the University of Washington are currently
conducting controlled investigations designed to provide efficacy data on the use of a
fluoride varnish in children less than five years of age. An approved status from the
FDA for one or more fluoride varnish products will greatly facilitate the use of effective
caries preventive measures in both public and private programs.
Varnish is currently classified as a "device" but the FDA has ruled that it is a drug if it is
used for caries prevention. There are, unfortunately, significant cost barriers for
companies to support the investigations for full approval as a therapeutic agent. Full
approval for new FDA labeling is a costly endeavor. It has been estimated that it would
require at least half a million dollars for a company to fund the investigations necessary
to meet the FDA requirements for new labeling. Dentistry is a small industry and an
analysis of potential markets may not justify funded investigations in the minds of the
45
fluoride varnish manufacturers. The reality is that dentistry may have to choose to use
fluoride varnishes "off-label" for an extended time.
The Early Childhood Caries (ECC) Conference held on the NIH Campus in October
1997 addressed the etiology, implications and prevention of ECC.32 It is clear that
ECC is of epidemic proportions in many US minority populations. Unfortunately, an
effective preventive regimen for high risk for ECC patients has not been developed.
Much work remains to develop successful office and community based approaches to
the prevention of ECC. In spite of the dearth of well-controlled trials in the prevention of
ECC, current knowledge of caries and its prevention yields some obvious guidance.
The key to an effective primary prevention program with infants and toddlers is to
deliver topical fluoride early and often to children at risk. At risk children include those
with existing caries (including white spot lesions), family histories of moderate to severe
dental disease, and congenital enamel defects. Other risk factors include high-risk
pregnancy or complicated delivery and no systemic fluoride received.
Dental care providers and policy makers are encouraged to carefully review the existing
data and practices involving the use of fluoride varnishes. A thorough assessment of
the caries status of their patients and the potential risks and benefits of fluoride varnish
application should result in the adoption of varnishes as a valid means of delivering
fluoride to their patients' teeth. Fluoride varnishes are safe, effective, and easily
incorporated into both public and private programs of caries prevention.
REFERENCES
1. Ripa LW: A critique of topical fluoride methods in an era of decreased caries

and increased fluorosis prevalence. J Public Health Dent 51:23-41, 1991.
2. Pendrys DG and Stamm JW: Relationship of total fluoride intake to beneficial
effects and enamel fluorosis. J Dent Res 69 (Spec Iss):529-538, 1990.
3. Pang DT and Vann WF, Jr.: The use of fluoride-containing toothpastes in
young children: The scientific evidence for recommending a small quantity.
Pediatr Dent 14:384-387, 1992.
4. Levy SM, Maurice TJ and Jakobsen JR: A pilot study of preschoolers' use of
regular-flavored dentifrices and those flavored for children. Pediatr Dent
14:388-391, 1992.
5. Levy SM, Maurice TJ and Jakobsen JR: Dentifrice use among preschool
children. J Am Dent Assoc 124:57-60, 1993.
6. Stookey GK: Review of fluorosis risk of self-applied topical fluorides:
dentifrices, mouthrinses and gels. Community Dent oral Epidemiol 22:282-
286, 1994
7. Skotowski MC, Hunt RJ and Levy SM: Risk factors for dental fluorosis in
pediatric dental patients. J Public Health Dent 55:154-159, 1995.
8. NIDR National survey of oral health in US school children 1986-87.
Bethesda, MD: National Institute of Dental Research, 1992.
9. Leroux B, Maynard R, Domoto P, Zhu C, Milgrom P: The estimation of caries
prevalence in small areas. J Dent Res 75:1947-1956, 1996.
46
10. Petersson LG: On topical application of fluorides and its inhibiting effect on
caries; thesis University of Lund. Odont Rev 26(suppl 34) 1975.
11. Seppa L: Fluoride varnishes and enamel caries; thesis University of
Groningen, 1987.
12. de Bruyn H and Arends J: Fluoride varnishes. J Biol Buccale 15:71-82, 1987.
13. Petersson LG, Arthursson L, ÷sterberg C, Jonsson G and Gleerup A: Caries-
inhibiting effects of different modes of Duraphat varnish reapplication: A 3
year radiographic study. Caries 25:70-73, 1991.
14. Helfenstein U, Steiner M: Fluoride varnishes (Duraphat): A meta-analysis.
Community Dent Oral Epidemiol 22:1-5, 1994.
15. Weinstein P, Domoto P, Koday M, and Leroux B: Results of a promising
open trial to prevent baby bottle tooth decay: a fluoride varnish study. J Dent
Child 61:338-341, 1994.
16. Twetman S, Petersson LG and Pakhomov GN: Caries incidence in relation to
salivary mutans streptococci and fluoride varnish applications in preschool
children from low- and optimal-fluoride areas. Caries Res30:347-353, 1996.
17. Twetman S and Petersson LG: Prediction of caries in pre-school children in
relation to fluoride exposure. Eur J Oral Sci 104:523-528, 1996.
18. Committee on Drugs (Berlin CM, Jr., Chair) American Academy of Pediatrics.
Unapproved uses of approved drugs: The physician, the package insert, and
the Food and Drug Administration: Subject review. Pediatrics 98:143-145,
1996.
19. Coté CJ, Kauffman RE, Troendale GJ and Lambert GH: Is the "Therapeutic
Orphan" about to be adopted? Pediatrics 98:118-123, 1996.
20. Code of the Federal Registry Part 130. Legal status of approved labeling for
prescription drugs; prescribing for uses unproved by the Food and Drug
Administration. Aug. 15, 1972.
21. Hom L: Off-label use of approved drugs. Pharmacy Newsletter 15:17-18,
1997.
22. Ekstrand J, Koch G, Petersson LG: Plasma fluoride concentration and
urinary fluoride excretion in children following application of the fluoride
containing varnish Duraphat. Caries Res 1980;14:185-189.
23. Schmidt HIM: Ein neus Touchierungsmittle mit besonders lang anhaltendem
intesivem Fluoridierungseffect. Stoma 17:14-20,1964.Sepp‰ L and
Hanhijarvi H: Fluoride concentrations in whole and parotid saliva after
application of fluoride varnishes. Caries Res 17:476-480, 1983.
24. Seppa L: Effect of dental plaque in fluoride uptake by enamel from a sodium
fluoride vanish in vivo. Caries Res17:71-75, 1983.
25. Koch G, Hakeberg M, Petersson LG: Fluoride uptake on dry versus water-
saliva wetted human enamel surfaces in vitro after topical application of a
varnish (Duraphat) containing fluoride. Swed Dent J 12:221-225, 1988.
26. Burt BA: The changing patterns of systemic fluoride intake: J Dent Res
71(Spec Iss):1228-1237, 1992.
27. Clark CD and Berkowitz J: The influence of various fluoride exposures on the
prevalence of esthetic problems resulting from dental fluorosis. J Pub Health
Dent 57:0144-149, 1997.
47
28. Moran R. and Saemundsson, S: Fluoride Varnish: An alternative to
traditional topical fluoride therapy. Department of Pediatric Dentistry,
University of North Carolina 1996.
29. Bravo M, Baca P, Llodra JC and Osorio E: A 24-month study comparing
sealant and fluoride varnish in caries reduction on different permanent first
molar surfaces. J Public Health Dent 57:184-186, 1997.
30. Clark CD: Appropriate use of fluorides in the 1990s. J Canad Dent Assoc
59:272-279, 1993.
31. Tinanoff N and O'Sullivan DM: Early childhood caries: Overview and recent
findings. Pediatric Dent 19:12-15, 1997.
48
FLUORIDE VARNISH APPLICATION
Armamentarium
• Mouth mirror
• 2x2 gauze sponges
• Infant size toothbrush
• Disposable brush
• Disposable dampen dish
• Two (2) drops fluoride varnish
Procedure
1. Give the child a toothbrush.
2. Position the child in the "knee to knee" posture and have the caretaker lower the
child's head onto your lap.
3. Use the child's toothbrush and quickly brush the child's teeth.
4. Dry the teeth with 2x2 gauze sponges and apply fluoride varnish with the
disposable brush to all surfaces of the teeth.
5. Continue to “wipe and paint” until all the teeth have been treated. The varnish will
set upon contact with saliva.
6. Advise caretaker that the varnish is slightly yellow and that it may be visible for a
few hours. Request that the caretaker not resume brushing until tomorrow in
order to preserve the varnish coating as long as possible.
7. Fluoride varnish should be applied every two or three months on the at-risk-for-
caries child.
49
FLUORIDES IN DENTISTRY
Rationale
The rationale for the use of fluoride to prevent caries is based on both systemic and
topical effects of fluoride. Both pre-eruptive (systemic) and post-eruptive (topical)
benefits are apparent in extensive research findings and clinical practice. The following
mechanisms are considered to be the primary methods for caries prevention and are
assumed to operate simultaneously
• Reduction in enamel solubility
• Remineralization
• Interference with plaque microorganism metabolism
• Modification of tooth morphology i.e. enhancing the completion of
development in pits and fissures
• Increased rate of post-eruptive maturation
Community water fluoridation is the method of choice to provide reliable and effective
caries for the children of a community. Water fluoridation has been long recognized as
the classical public health measure. Water fluoridation is safe, effective, low cost, and
non-discriminatory and should be the cornerstone of all caries preventive programs.
Metabolism of Fluoride
t is essential that dentists, dental hygienists, other dental team members, as well as
other health care workers understand the process of fluoride metabolism. All forms of
fluoride intended for human use, whether designed for systemic or topical use, should
be evaluated for efficacy and safety. It is well known that substances that are designed
as topical agents, including dentifrices, mouthwashes, and professionally applied
topicals, are usually swallowed in varying amounts by individuals.
Water is the most efficient source of systemic fluoride since 82 to 97% of the fluoride is
absorbed from ingested water. Milk can be used as a vehicle for fluoride but there is
much less absorption of fluoride in the first hour after ingestion since calcium fluoride, a
relatively insoluble compound, is formed. After the first hour fluoride ion continues to be
absorbed and eventually the level of absorption is comparable to the levels absorbed
from water.
Excretion of fluoride is accomplished through the gut, kidney, and skin. The kidney is
the chief organ of excretion for fluoride; approximately half of all ingested fluoride is
excreted in the urine.
Fluoride has a great affinity for bone and teeth. Ninety-seven percent of the fluoride
that is stored in the body is stored in bone and teeth.
Osteoporosis and Fluorides

Osteoporosis is a condition characterized by a reduced bone mass and a high
frequency of bone fractures. Claims have been made that water fluoridation is
associated with osteoporosis. Experts in the field of epidemiology have clearly
50
demonstrated that there is no relationship between water fluoridation and increased risk
for osteoporosis.
Fluoride Transfer by Placenta

Fluoride readily crosses the mother's placenta to the fetus. Developing primary teeth
receive maternal levels of fluoride. However, prenatal supplementation of fluoride for
expectant mothers cannot be recommended at this time because conclusive clinical
evidence of its efficacy is lacking. Fluoride acquired in utero has little effect on caries in
primary teeth since the major part of enamel is formed postnatally.
Safety and Toxicity of Fluoride

When used appropriately, the various forms of fluoride are safe and effective. However,
as with any other therapeutic agent fluoride has a potential to produce undesirable side
effects if used improperly. The dental professional must be knowledgeable and vigilant
in order to ensure safe and effective utilization of fluoride by children and their families.
Acute toxicity can occur from ingestion of excessive amounts of fluoride. Nausea and
vomiting are the usual result of acute toxicity, however more serious problems are
possible and on at least one occasion toxic levels of fluoride ingestion have resulted in
the death of a child. The greatest risk to the child occurs when she/he is left unattended
and has access to excessive amounts of fluoride. Therefore, care should be taken to
limit the amount of fluoride stored in the home to a safe level for a toddler. In
prescribing fluoride supplements the provider must limit the total amount to that amount
which would be within safe limits for an infant or toddler. Thus, there is a limit of 120
tablets of 2.2 mg NaF that can be prescribed to a family at any given time. A 2.2
mg tablet yields one (1) mg of fluoride ion therefore ingestion of the entire prescription
would result in the intake of 120 mg of fluoride. In the dental office great care should be
exercised to prevent children from having access to excessive amounts of fluoride.
Never allow children access to large containers of APF and use no more than half a
teaspoon (2.5 ml) of topical fluoride per tray. Note that "Duraflor" is packaged in 10 ml
tubes which, in the unlikely event that the contents of the tube were swallowed, would
result in a maximum ingestion of 226 mg of fluoride. The lethal dosages for a three year
old, a 6 year old, and a 9 year old are about 500 mg, 750 mg, and 1000 mg
respectively.
Fluoride products in homes, schools, institutions, and dental facilities must be secure
and carefully monitored. The "worst case scenario" would invariably involve a young
child who had access to massive amounts of fluoride. The tendency to use products
that are pleasantly scented and flavored to enhance acceptance by children can be
dangerous. Children who like the flavor of a product may swallow excessive amounts of
the agent or, worse yet, may seek out the product to ingest it simply because it "tastes
good".
Should excessive amounts of fluoride be swallowed vomiting should be induced

immediately. This can be accomplished by administering Syrup of Ipecac (Eli Lilly and
51
Co.) with a few ounces of water. A tablespoon of syrup is suitable for children over the
age of one and 2 teaspoons are indicated for babies less than one year of age.
FIRST AID FOR INGESTION OF FLUORIDE

•Induce vomiting
•Give milk or milk of magnesia (will bind fluoride temporarily)
•If possible, calculate dosage and call the Poison Control Center
FIRST AID FOR INGESTION OF FLUORIDE

1-800-572-0638 Emergent Information
To be used by Health Care Professionals
1-800-732-6985 Parent Access Line
Enamel fluorosis is a result of ingesting excessive amounts of fluoride during tooth

development. Fluorosis is a hypomineralization of tooth enamel and dentin. The
degree of fluorosis can range from barely noticeable whitish opacities to confluent
pitting of the enamel surface and unsightly brown staining, depending on the amount of
fluoride and duration of exposure during tooth development. In a recent survey of 3rd
grade children in Washington State 7.6% of the children surveyed had fluorosis
affecting their maxillary permanent incisors.
Fluorosis can only be produced during the relatively short period of pre eruptive enamel
development. Since the degree of fluorosis that is seen on US children is primarily of
the "very mild" to "mild" category this problem is primarily one of esthetics. The
maxillary permanent incisors are the teeth that are most important in protecting
from fluorosis. The critical "window of vulnerability" for fluorosis in these teeth
is 18 to 24 months of age. Enamel development is usually completed in the maxillary
incisors by age four.
The concentration of fluoride in the water being ingested by a given child must be
known. Seattle water supplies have been adjusted to deliver the optimum concentration
of 1 part fluoride per million (ppm) parts of water. One ppm is equal to 1 mg of fluoride
ion to a quart of Seattle water. When the level of fluoride is unknown in a particular
water supply steps must be taken to determine the concentration of fluoride that
children and others are ingesting. Local water districts and the county and state
Departments of Health may be able to provide that data from existing records. If it is not
possible to obtain the fluoride levels in this manner one must have the water tested for
fluoride. Well water has been the most common source requiring testing. However,
with the increase in the use of bottled water and water filters of various types it is
essential for testing of water to occur at the point where the child would be ingesting the
water. Fluoride analysis can be obtained from the Washington State Public Health
Laboratory (see the box on the following page for the address and phone number).
Information and a container for a water sample can be obtained by contacting the
laboratory below. The cost of the analysis is $22.
52
Washington State Public Health Laboratory
Environmental Chemistry
1610 N.E. 150th St.
Seattle, WA 98155-9701
Telephone: (206) 361-2898
In order to prevent mild to moderate fluorosis in the maxillary incisor teeth it is also
necessary to carefully supervise the tooth brushing of the infant and the toddler.
Fluoride dentifrices have been implicated in increasing the risk for fluorosis when their
use is started before age three. Children swallow a large percentage of any dentifrice
that may be used. The use of fluoridated toothpaste is recommended when primary
teeth have erupted, but only a small amount - just a thin smear. ONLY A “SMEAR”
OF DENTRIFICE IS NECESSARY! Also encourage the parents to teach the child to
spit in order to prevent swallowing of the dentifrice.
Fluoride Supplements: When fluoride concentrations in the water supply fall below
0.6 ppm dietary fluoride supplementation is necessary for children, 6 months to 16
years of age. The following table delineates the dosage schedule that was approved by
the Council on Dental Therapeutics of the American Dental Association and the
American Academy of Pediatric Dentistry in 1994. Continuous compliance with fluoride
supplementation has been shown to produce caries reductions of around 30-50%.
*Council on Dental Therapeutics, 1994
C.D.T. *Dosage Schedule (mg/day) for fluoride supplements
Concentration of Home Water Supply**

or Primary Source of Drinking Water
Age (yrs) <0.3 ppm 0.3 - 0.6 >0.6 ppm

Birth to 6 mos. 0 0 0
6 mos. to 3 0.25 mg 0 0
3 to 6 0.5 mg 0.5 mg 0.25 mg 0
6 to at least 16 1 mg 0.5 mg 0
**The fluoride content of the home water supply should be known to be fluoride
deficient before a daily fluoride supplement is prescribed.
Dietary fluoride supplements are available in liquid, lozenges, tablets, chewable tablets
and preparations combined with vitamins. When the appropriate dosage for an infant is
determined a liquid fluoride supplement with a calibrated dropper should be used. A
calibrated dropper as opposed to a dropper which delivers, for example, 0.125 mg of
fluoride per drop is preferred since measuring the proper amount on a calibrated
delivery system is more reliable than a "drop". Ross Laboratories provides 50 mL
bottles of 0.5 mg F/mL with a calibrated dropper. Half a dropper delivers 0.25 mg of
fluoride ion. Infants and toddlers will receive liquid fluoride supplements when it is
indicated based on fluoride testing. As soon as the child is able to chew and swallow a
53
tablet she/he should be switched to a chewable tablet. This chewable form of fluoride is
most advantageously given at bedtime after brushing. The tablet should be chewed or
sucked and "swished" around the mouth prior to swallowing. "Chew, swish, and
swallow" will produce both systemic and topical benefits of fluoride. Both the form and
dosage of the fluoride must be tailored to the needs of the individual children in the
family. Note the dosage of fluoride on a body weight is 0.05 mg F/kg body weight. The
1994 dosage schedule does not recommend initiation of supplementation until, at the
earliest, 6 months of age.
The following are sample prescriptions for a fluoride deficient water supply.
Rx for 7-month-old Arthur receiving water that has less than 0.3 ppm F.
NaF drops 1.1 mg/dropper
Sig: One half dropper once per day, directly in mouth or in water, juice or milk.
Dispense 50 ml
Refill as needed
Rx for 26-month-old Beth receiving water that has less than 0.3 ppm F
NaF1.1 mg/dropper
Sig: One half a dropper once per day, directly in mouth or in water, juice or milk.
Dispense 50 mL
Refill as needed
Rx for 3-year 8-month-old Charlie receiving water that has less than 0.3 ppm F.
NaF1 mg chewable
Sig: Chew, swish, and swallow one tab per day before bed.
Dispense 120
Refill as needed
Rx for 3-year 8-month-old Darlene receiving water that has 0.5 ppm F.
NaF0.55 mg chewable
Dispense 120
Refill as needed
Rx for 8-year-old Eddie receiving well water with no fluoride present.

NaF2.2 mg chewable
Dispense 120
Refill as needed
NOTE: No more than 120 tablets of NaF, 2.2 mg, should be dispensed at a time.
54
COMMON QUESTIONS ASKED ABOUT FLUORIDE
Q. Should pregnant women take fluoride supplements to benefit the

developing teeth of their babies?
A. Prenatal administration of dietary fluoride supplements cannot be recommended

at this time. Conclusive evidence is lacking to support the benefit to the fetus.
Q. Should breast fed infants receive fluoride supplementation?
A. The fluoride concentration in breast milk is low. Since the earliest age that an
infant might receive supplementation is 6 months, there is initially no need for
supplementation whether the baby is exclusively breast fed or not. If the infant is
exclusively breast fed after 6 months of age supplementation of 0.25 mg of
fluoride should be prescribed even in a fluoridated community. When the baby
begins to ingest fluoridated water, whether it is in foods or beverages, the
supplementation should be discontinued.
Q. Should I prescribe vitamin-fluoride combinations for children?
A. Since vitamins do not enhance or potentate the effect of fluoride, the Council on
Dental Therapeutics of the ADA does not endorse any vitamin -fluoride
preparation. However, if vitamins were needed, a vitamin-fluoride combination
would be more convenient and less expensive than two separate preparations. A
combination prescription should be coordinated with the child's health care
provider when vitamins are being taken. As with any prescription, the content
and dosage should be reviewed periodically for efficacy and appropriateness.
55
GLASS IONOMERS AS SEALANTS
Purpose
We have rather limited experience in the United States with the use of glass ionomer
sealants as a preventive approach. And, obviously, conventional resin sealants are a
superior strategy when satisfactory isolation can be achieved.
Nevertheless, experience in other countries and research data demonstrate that

ionomer sealants do confer some protection against carious activity, especially when
periodic reapplication can be obtained. The general findings have been that some
degree of prevention has been achieved even when the glass ionomer sealants fracture
off, either in part or totally.
Rationale
Of course, glass ionomers as sealants need to be used where there is some reasonable
expectation of adhesion, even if the procedure were still viewed as a “temporary” or
“interim” sealant.
The most common example of the justifiable use of glass ionomer sealants occurs
where conventional sealants cannot be used successfully on first permanent molars due
to behavior and/or lack of sufficient eruption preventing acceptable isolation. In such
cases, glass ionomer sealants can be used to seal erupting first permanent molars very
early in their stages of eruption (e.g., glass ionomer can be used for any exposed
occlusal surface of these molars).
When glass ionomer sealants are used, partial or total loss of coverage can be
expected at subsequent recall examinations. One major goal of ionomer sealant
therapy needs to be periodic reassessment and possible reapplication. Another
important objective is to obtain conventional sealant coverage as soon as behavior and
development make that possible.
Procedure
1. Mix the ionomer material before isolating the tooth, so the material is ready for
application when the tooth is isolated. The material can be mixed to a
“conventional sealant consistency.” This usually will mean an approximately two
drop to one scoop mix. Vitrebond is a good choice for an ionomer sealant since
no priming step is necessary with that material.
2. Isolate the tooth as much as possible with cotton rolls or gauze and apply air to
dry the tooth.
3. Apply the ionomer as you would any other sealant (i.e., with a burnisher-type
instrument, a brush, or an excavator).
4. Complete the operation by light activating the material.
57
5. Checking occlusion usually is impractical (and of course unnecessary in the case
of partially erupted first permanent molars). Also it will aggravate any behavior
problems that might be occurring. However, placement of the ionomer so that it
is out-of-occlusion will increase its longevity significantly.
RESOURCES/REFERENCES OF POTENTIAL INTEREST
1. Berg, JH. The continuum of restorative materials in pediatric dentistry-a review

for the clinician. Ped Dent. 20: 93-100, 1998.
2. Christensen, GJ. Restoration of pediatric posterior teeth. JADA. 127: 106-108,

1996.
3. Christensen, GJ. Compomers vs. resin-reinforced glass ionomers. JADA. 128:

479-480, 1997.
4. Damen, JJ, et al. Uptake and release of fluoride by saliva-coated glass ionomer
cement. Caries Research. 30: 454-457, 1996.
5. Dogon IL, et al. Biological investigation of a new light cured glass ionomer
restorative material. IADR abstract #68, 1992. Harvard School of Dental
Medicine/Forsyth Dental Center.
6. Hse, K. Clinical evaluation of compomer in primary teeth: 1-year results. JADA.

128: 1088-1096, 1997.
7. Kanellis, MJ. Atraumatic restorative treatment (A.R.T). JSSPD. 4:22-23, 1998.
8. Komatsu H, et al. Caries-preventive effect of glass ionomer sealant

reapplication: study presents three-year results. JADA. 1994; 125:543-549.
9. Kupietzky A, et al. Fluoride exchange from glass ionomer preventive

restorations. Ped Dent. 1994; 16:340-345.
10. Lacy, AM, Young, DA. Modern concepts and materials for the pediatric dentist.
18: 469-475, 1996.
11. Leinfelder KF. Glass ionomers: current developments. JADA 1993; 124:62-64.
12. Papathanasiou AG, et al. The influence of restorative material on the survival
rate of restorations in primary molars. Ped Dent. 1994;16:282-288.
13. Peterson, DS and Davis, JM. Atlas of pediatric dentistry pulp therapy chapter.
CD-ROM. University of Washington HSCER, 1998. Also released as Atlas of
pediatric dentistry pulp therapy chapter. Online. University of Washington
HSCER. Available with password:
http://eduserv.hscer.washington.edu/pulp/index.htm, 1998.
58
14. Peterson, DS and Davis, JM. Pediatric restorative dentistry. Microdiscs.
University of Washington School of Dentistry, 1995.
15. Wandera, A, et al. In vitro comparative fluoride release, and weight and volume
change in light-curing and self-curing glass ionomer materials. Pediatric
Dentistry. 18: 210-214, 1996.
16. Winkler, MM, et al. Using a resin-modified glass ionomer as an occlusal sealant:
a one-year clinical study. 127: 1508-1514, 1996.
59
Glass Ionomer
Restorations
61
GLASS IONOMER RESTORATIONS TO CONTROL CARIOUS LESIONS IN
PRECOOPERATIVE CHILDREN
Devereaux Peterson DMD, MSD, PhD, MBA, Associate Professor, Department of
Pediatric Dentistry
Purpose
The purpose of this section is to present a method of controlling caries in
precooperative children using glass ionomer restorative material with Atraumatic
Restorative Therapy.
The term Atraumatic Restorative Therapy, as we will use it in this section, refers to
providing restorative therapy to children in a way that no pain is involved. Atraumatic
Restorative Therapy usually is known by its acronym ART at the University of
Washington. Treatment using ART encompasses a range of restorative therapies where
no pain is caused. In particular, as it is used here, this means that local anesthetic is
not used and the specific restorative therapy provided is still accomplished without
eliciting pain. These are important distinctions since clinicians in different institutions
and from various parts of the United States may use the term ART somewhat
differently. For example, some clinicians may administer local anesthetic and still call it
ART.
For our purposes, we are going to limit our discussion to the use of ART and glass
ionomer restorative material to restoring carious lesions in precooperative children. We
are referring to treatment of carious lesions, usually in infants and toddlers, in a way that
is painless, requires no local anesthesia, and the lesions are restored using a resin-
modified glass ionomer (henceforth referred to as RMGI). The caries excavation is
accomplished very carefully and painlessly, using hand instruments or a slow speed
handpiece. The excavated lesions are restored with RMGI and light-cured, which is
also done without causing pain.
Because of the clinical approach, the restorations often are referred to as scoop-and-fill
restorations or band-aid restorations. We will use the term band-aid restorations since it
is consistent with terminology used in our department’s Electronic Atlas Of Pediatric
Dentistry (please see the resource/reference segment at the end of this article).
For wider coverage of the range of restorative care for children using glass ionomer-
type materials or related materials, such as compomers, we refer you to our chapter on
restorative dentistry for children in the Electronic Atlas of Pediatric Dentistry.
Our purpose in using Resin-Modified Glass Ionomers (RMGI’s) with ART is to stabilize
the child and the lesion(s). Indeed, sometimes the lesions can be quite large, but they
still can usually be stabilized. The RMGI restorations often may be interim in nature,
lasting until more durable restorations can be placed at a time when the child’s behavior
can be better managed. In fact, the basic idea is to provide a therapy that may last only
several months, but still last long enough so that the child gains the maturity to be
62
treated conventionally at a later time. In fact, sometimes retreatment is needed. On the
other hand, some of the RMGI restorations last for the life of the primary teeth involved.
Rationale
RMGI materials are excellent choices for controlling carious lesions in infants and
toddlers by using them in band-aid restorations. They have the following advantages:
1. Good handling characteristics for the practitioner
2. Good adhesion and clinical retention
3. Fluoride release
4. Biocompatibility
The resin-modified glass ionomer systems are relatively easy to handle for the dentist.
They are easily mixed and can be placed in cavity preparations with minimal excavation
if necessary, or in very difficult cases with no excavation at all. Placement can be
accomplished using a very limited number of steps, with minimal conditioning of the
tooth. Once again, in extreme cases, ionomers can be placed with no conditioning of
the tooth at all. Of course, better conditions during placement will result in improved
adhesion and durability of the restorations.
We generally use Vitrebond (3M Dental Products) as the RMGI band-aid restorative
material in our clinic. Other materials can be used also according to the preferences of
the clinician. The RMGI systems can be light cured, which of course expedites the
speed of placement and helps with managing infants and toddlers. Most RMGI
systems, including Vitrebond, also have the benefit of being self-cure systems, so
layering the material during placement is not necessary. However, the light cure
reaction results in improved physical properties in the case of Vitrebond.
The RMGI systems also adhere well clinically to dentin and enamel, giving them
advantages over many other materials that also might be used for interim band-aid
restorations. The RMGI’s also provide fluoride release.
Studies also show that ionomers result in no adverse pulpal reactions. There is even
some evidence that pulpal reactions are favorable with glass ionomer in deep
preparations (i.e., less that 1.0 mm). Nevertheless, the general advice remains to place
a calcium hydroxide base in areas of preparations which are in very close proximity to
the pulp (less than 1.0 mm).
RESIN-MODIFIED GLASS IONOMER APPLICATION

Armamentarium
Resin-modified glass ionomer restorative material (in this case, Vitrebond Liner/Base is
used as the example)
Air/water syringe, evacuation, or alternatively 2x2 gauze sponges
Slow speed handpiece with a #330, #6, or #8 bur (or another bur of your choice)
Brush applicator
Beaver tail, excavator, composite syringe, plastic instruments as preferred
Light cure unit
Mouth props/other restraints as necessary
63
Procedure
1. Stabilize the child and restrain as necessary. Isolate the tooth or teeth to be
restored. 2 x 2 gauze can be helpful here to “grip” the mucosa.
2. Remove “soft” or superficial decay with the low speed handpiece using a #330,
#6, or #8 bur or an excavator.
3. In cases where the behavior is very difficult and the decay not too deep, ionomer
application can be attempted without excavation. Obviously this approach
involves some compromises; but sometimes it is the most practical alternative.
4. Isolate the area and dry the tooth with air or gauze until it is moist (i.e., not really
wet; do not desiccate the tooth). The RMGI actually should be mixed
immediately prior to isolating and drying the tooth so that the material is ready for
placement. In this way, the amount of time “managing” or “restraining” the child
is kept to a minimum.
5. Vitrebond Light Cure Glass Ionomer Liner/Base is mixed just prior to drying the
tooth. One level scoop of powder is used for each drop of liquid. The powder to
liquid ratio may be altered to change the viscosity of the mix. Ratios ranging
from 1 scoop powder/2 drops liquid to 2 scoops powder/1 drop liquid are
acceptable. Mix rations beyond this range are not recommended. Using a
cement spatula, mix for 10 to 15 seconds until the Vitrebond is a smooth and
glossy consistency. Apply a thin layer to the tooth with a Dycal applicator,
excavator, beaver tail, or a plastic instrument and light cure for at least 30
seconds. Repeat this process as needed. The delayed auto-setting mechanism
of the Vitrebond liner/base will ensure the eventual cure of the material.
64
Treatment of Pregnant
Women
65
Managing the Pregnant Dental Patient
Susan D. Reed, MD
Assistant Professor
Department of Obstetrics and Gynecology
Box 359865
Telephone (206) 731-4292
Fax (206) 731-5249
Email: sreeds@u.washington.edu
66
I. Introduction
When treating a pregnant dental patient, a practitioner must always take in to

consideration the developing fetus. The gestational age of the fetus and the health of
the mother are very important in deciding the safety of dental care and procedures in a
pregnant woman. Each trimester should be considered separately, as the risks may
vary depending on the physiology at various times in pregnancy. It is important to be
familiar with conditions in pregnancy and their possible associated risks: including
syncope, hypoglycemia, aspiration, and seizures. Table I outlines general standards of
care in treating the pregnant dental patient.
Table I. Standards of Care

1. Follow OSHA, WISHA guidelines
2. Wear gloves, mask and eyewear.
3. Consider conditions specific to the trimester.
4. Take x-rays when necessary using proper precautions and shielding.
5. Property position your patient (See section 11).
6. Follow medication guidelines (See section 111).
7. Know how to treat potential complications with pregnant patients (See section VI).
II. Physiology of Pregnancy
The physiologic changes that occur with pregnancy determine the special
considerations in caring for the pregnant dental patients. Some general changes that
occur are applicable for all trimesters. Vital signs differ from the non-pregnant patient in
that the heart rate usually increases 10 to 15 beats per minute, the diastolic and systolic
blood pressure falls by 5-15 mm Hg. Respiratory rate may increase slightly with a
30-40% increase in tidal volume (or the amount of air inspired and expired with each
breath). Average weight gain in pregnancy is 25 to 35 pounds. Because of increased
metabolic rate, pregnant women are prone to hypoglycemia and should eat small
amounts frequently. Caloric intake increases by 200-300 kcal/d (Catalano, 1992).
Mechanical changes and progestin hormone result in bladder pressure and the urge to
empty the bladder frequently. Because of urinary frequency and possible discomfort in
the dental chair for prolonged procedures, consideration to breaking up procedures into
several appointments should, be given. Cardiac output and blood volume increases by
approximately 50% in pregnancy. Peripheral vascular resistance falls. In addition the
reinioangoiension system recalibrates, such that moving from a lying to a standing
position, vasoconstricion is somewhat retarded and patients should move slowly to
alleviate risk of syncope. Warm environments can put a patient at risk for a syncopal
episode. Physiologic changes relevant to the different trimesters are outlined below.
The first trimester is associated with nausea and vomiting, and a hypersensitive gag
reflex. Typical onset of nausea in pregnancy is 4-8 weeks with resolution by 14-16
weeks; and is probably related to increased progesterone resulting in smooth muscle
relaxation and relaxation of the gastric sphincter. This could potentially put a patient at
67
risk for aspiration. Careful history of pregnancy symptoms prior to a procedure is
important. Discussion with the patient prior to positioning that would allow her to signal
the care provider if she were to feel nauseated is of importance. If the patient is at risk
for emesis, proper suctioning device should be available and proper positioning of the
patient in a lateral and upright position so that she might protect her airway is
imperative. Because of decreased gastrointestinal motility the patient is more apt to
have a full stomach for extended periods of time. "Blow by" oxygen can sometimes
alleviate symptoms of nausea.
The late second trimester and third trimester require care in positioning the pregnant
patient. Because of the weight of the gravid uterus on the vena cava, blood return to the
heart is diminished in a supine position. There is probable complete occlusion of the
inferior vena cava in the supine position in late pregnancy (Ueland, 1969). Therefore,
the pregnant patient in the late second and throughout the third trimester should always
be positioned with a pillow under the left or right hip to displace the gravid uterus off of
the vena cava. The shoulders can be square on the dental chair, but the hips should be
laterally rotated.
Total lung volume decreases by 5% and 60-70% of pregnant women experience a

sense of dyspnea. Increased progesterone levels may act as a direct respiratory center
stimulant (Skatrud, 1978). Therefore, the dental patient may require more frequent
breaks because of this increased sense of "air hunger" or shortness of breath,
Gingival hypertrophy and epulis gravidarum (pedunculated lesions at the gum line) is
most commonly seen in the third trimester and will disappear postpartum. This can
result in increased bleeding when brushing and if excessive, the epulis gravidarum
should be removed. In addition, tooth mobility increases in pregnancy quite possibly
secondary to increasing levels of the hormone, inhibin, and resolves postpartum.
III. Special Preventative Dental Care in the Pregnant Patient
Special recommendations for the patient with frequent emesis would include careful
rinsing and application of fluoride gels or baking soda rinse following each emesis;
thereby reducing the risk for enamel demineralization. Increased risk for caries and
bacterial overgrowth in pregnancy, due to immunosuppression and an estrogen rich
environment, require increased preventive care and daily oral care maintenance.
Increased tooth mobility and gingival hypertrophy can be anticipated to cease
postpartum. Careful brushing with a soft bristle and flossing will diminish risk of
excessive bleeding.
The incidence and magnitude of bacteremias of oral origin are directly proportional to
the degree of oral inflammation and infection (Pallasch, 1996). Any systemic infection
resulting in bacteremias can be associated with chorioamnionitis which can lead to low
birth weight and premature deliveries. A single study suggests untreated periodontal
disease is a risk factor for preterm low birth weight (Offenbacher, 1996). It follows that
conscientious preventative care is very important in the pregnant patient.
68
Vitamin and mineral supplementation can be reinforced by the dental practitioner.
Fluoride supplementation is not currently recommended. All pregnant women should be
taking a prenatal vitamin with 0.4 milligrams of folic acid and dietary or vitamin
supplementation of calcium for a total intake of 1500 milligrams per day. The dental
practitioner can encourage the need for proper nutrition in pregnancy.
IV. Medications
All medications have been classified by the Federal Drug Administration (FDA) for
teratogenic risk in pregnancy. This ABCD and X classification system has historically
been cumbersome and too often misinterpreted. It is being reevaluated by the FDA and
a new system should be in place within the next two years. Precautions when
administering local anesthesia, analgesia, sedation and antibiotics are outlined here
with designation of risk under the existing FDA guidelines.
Lidocaine is safely used throughout pregnancy as a local anesthetic quite commonly

given with a vasoconstrictor, epinephrine, for dental procedures. Significant
intravascular infiltration results in syncope, seizure and cardiac arrest. The
hypervascularity of the pregnant state might slightly increase this risk, but doses of less
than 3cc make this ram complication exceedingly uncommon. The precautions as with a
non-pregnant patient should be taken. Other "caine" anesthetics should be avoided as
experience in dental procedures in pregnancy is limited.
Intravenous or mask sedation should be avoided in the absence of a controlled

operative setting. Controversy as to the possible teratogenic effects of nitrous oxide in
the first trimester continues (Aldridge, 1986). Data to date suggests that these risks are
exceedingly low if not negligible. However, the greater risk of oversedation, and
subsequent untoward consequences to both the mother and the fetus should be taken
into consideration.
The mainstay of analgesia in the pregnant patient is acetaminophen. Aspirin is avoided

because of its prolonged action as a cyclooxygenase inhibitor, which can result in
decreased platelet aggregation and prolonged bleeding times. This has been
associated with risk for placental abruption. Non-steroidal anti-inflammatory agents such
as ibuprofen and indocin are used by obstetricians to inhibit pre-term labor. These
agents are used safely at gestations less than 32 weeks with normal amniotic fluid
volumes for brief periods of time, less than 48 hours. They can result in decreased
amniotic fluid volumes and reversible closure of the fetal ductus arteriosus when used
for periods of greater than 48 hours (lams, 1996). Lastly, narcotics are used safely in
every trimester and are not associated with any teratogenic effects. Just as with a
non-pregnant patient, consideration for promotion of addictive behaviors should be
considered.
Use of antibiotics in the dental patient are important to decrease the risk of bacteremia,
in the treatment of tooth abscess, and in prophylaxis against bacterial endocarditis in
69
the at risk patient. The American Heart Association published guidelines in 1997 which
are included in Table 2A and 2B (Dajani, 1997). Antibiotics of choice for prophylaxis in
the pregnant dental patient include amoxicillin, ampicillin, clindamycin, azithromycin and
cephalosporins (See Table 3). A cephalosporin is the broad-spectrum coverage of
choice for the patient with an oral infection. Table 4 summarizes FDA classification of
antibiotics for pregnancy and lactation.
Table II A. Cardiac Conditions Associated with Endocarditis

Endocarditis Prophylaxis Recommended
High-risk category
Prosthetic cardiac valves, including bioprosthetic and homograft valves
Previous bacterial endocarditis
Complex cyanotic congenital heart disease (e.g. single ventricle states,
transposititian of the great arteries tetralogy of Fallot)
Surgical constructed systemic pulmonary shunts or conduits
Moderate-risk category
Most other congenital cardiac malformation (other than above and below)
Acquired valvar dysfunction (e.g. rheumatic heart disease)
Hypertrophic cardiomyopathy
Mitral valve prolapse with valvar regurgitation and/or thickened leaflets*
Endocarditis Prophylaxis Not Recommended
Negligible-risk category (no greater risk than the general population)
Isolated secundum atrial septal defect
Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus
arteriosus (without residua beyond 6 mo)
Previous coronary artery bypass graft surgery
Mitral valve prolapse without valvar regurgitation
Physiologic functional, or innocent heart murmurs
Previous Kawasaki disease without valvar dysfunction
Previous rheumatic fever without valvar dysfunction
Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators
* Prophylaxis is recommended for patients with high- and moderate-risk cardiac conditions.
70
Table II B. Dental Procedures and Endocarditis Prophylaxis
Endocarditis Prophylaxis Recommended*
Dental extractions
Periodontal procedures including surgery, scaling and root planing, probing, and recall
maintenance
Dental implant placement and reimplantation of avulsed teeth
Endodontic (root canal) instrumentation or surgery only beyond the apex
Subgingival placement of antibiotic fibers or strips
Initial placement of orthodontic bands but not brackets
Intraligamentary local anesthetic injections
Prophylactic cleaning of teeth or implants where bleeding is anticipated
Endocarditls Prophylaxis Not Recommended
Restorative dentistry† (operative and prosthodontic) with or without retraction cord‡
Local anesthetic injections (nonintraligamentary)
Intracanal endodontic treatment; post placement and buildup
Placement of rubber dams
Postoperative suture removal
Placement of removable prosthodonlic or orthodontic appliances
Taking of oral impressions
Fluoride treatments
Taking of oral radiographs
Orthodontic appliance adjustment
Shedding of primary teeth
* Prophylaxis is recommended for patients with high- and moderate-risk cardiac conditions.
† This includes restoration of decoyed teeth (filling cavities) and replacement of missing teeth:
‡ Clinical judgment may indicate antibiotic use in selected circumstances that may create
significant bleeding.
Source: Dajani, 1997
71
Table III. Prophylactic Regimens for Dental, Oral,
Respiratory Tract, or Esophageal Procedures
Situation Agent Regimen
Standard general Amoxicillin 2.0 g po 1 h before procedure
prophylaxis
Unable to take oral Ampicillin 2.0 g intramuscularly (IM) or
medications intravenously (IV) within 30 min
before procedure
Allergic to penicillin Clindamycin 60D mg po 1 h before procedure
Or
Cephalexin or 2.0 g po 1 h before procedure
Cefedroxil*
Azithromycin or 50 mg po 1h before procedure
Clarithromycin
Allergic to penicillin and Clindamycin 600 mg within 30 min before
unable to procedure
take oral medications or
Cefazolin* 1.0 g within 30 min before
procedure
* Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction
(urticaria, angioedema, or anaphylaxis) to penicillin.
Source: Dajani, 1997
72
Table IV. Medications Commonly Used in Dentistry
Type of medication FDA pregnancy risk factor
Analgesics:
Acetaminophen (Tylenol) B
Aspirin C3
Codeine C*
Dihydrocodeine (Synalogos-DC) B*
Ibuprofen (Motrin) B3
Meperidine (Demerol) B*
Morphine B*
Oxycodone (Tylox, Percocet) C*
Pentazocine (Talwin) B*
Phenacetin B
Phenylbutazone (Azolid, Butazolidin) D
Propoxyphene (Darvon) C*
Antibiotic
Amikacin C
Amoxicillin B
Amphotericin B B
Ampicillin B
Caphalosporins B
Chloramphericol C
Clindamycin B
Clotrimazole B
Dicloxacillin B
Erythromycin B
Gentamicin C
Kanamycin D
Methicillin B
Metronidazole (Flagyl) B
Miconazole B
Nafcillin B
Nitrofurantoin B
Oxacillin B
Penicillin G B
Penicillin G procaine B
Penicillin G benzathine B
Penicillin V B
Streptomycin D
Sulfonamides B2
Tetracycline D
Vancomycin C
Antiemetics
Hydroxyzine (Atarax Vistaril) C
Prochlorperazine (Compazine) C
Promethazine (Phenergan) C
Trimethobenzamide (Tigan) C
Bronchodilators
Aminophylline C
Terbutaline B
Local anesthetics
Etidocaine B
Lidocaine B
Marcaine C
Mepivacaine C
Miscellaneous
Atropine C
Cyclamate (sweetener) C
Dexamethasone C
Diphenhydramine (Benadryl) C
Epinephrine C
Prednisolone B
Prednisone B
Sedatives
Diazepam Valium D
Chlordiazepoxide (Librium) D
Phenobarbital D
* Risk factor changes to Category D it used for prolonged periods or in high doses at the end of the term
2
Risk factor changes to Category D if administered near the end of the term
3
Risk factor changes to Category D if used in the third trimester
Source: Briggs, 19%
73
V. Documented Human Teratogens
The list of documented human teratogens is actually quite limited. Teratogenic agents
listed that could potentially be associated with dental procedures include: kanamycin,
lead, mercury, streptomycin, tetracycline, doxycycline, and radiation exposure. Of note
is doxycycline which is a tetracycline derivative. The amount of mercury used in
amalgams is minimal. Teratogenic effects at the amounts used for routine amalgams
have never been demonstrated. Radiation exposure significant enough to result in
teratogenic effect has never been seen at less than 10 rads (Briggs, 1983). In contrast
to these large doses, the amount of exposure to the fetus from a full mouth dental series
(18 intraoral, D film, with a lead apron) is 0.00001 rads. A panoramic series results in
0.00015 rads (Manson-Hing, 1976). In contrast, a daily dose from the background
radiation is considered to be 0.004 rads and the radiation dosage to the fetus from a
shielded chest x- is 0.008 rads. Therefore, the risk of radiation exposure from dental
films is minute. Use of dental x-rays should not be withheld in the pregnant patient
Table V. Documented Teratogenic Agents

Alcohol Mercury
Androgens Methotrexate
ACE inhibitors Paramethadione
Carbamazepine Phenytoin
Cocaine Radiation
exposure
Diethylslilbestrol Streptomycin
(DES)
Doxycycline Tetracycline
Etretinate Thalidomide
lsotretinoin Trimethadione
Kanamiycin Valproate
Lead Vitamin A
Lithium Warfarin
Source: Ronald J. Ruggiero Pharm. P. in M. Gyn News 8/15/98
VI. Handling Emergencies in the Pregnant Dental Patient
Prior to caring for any pregnant patient, the practitioner should assess his/her dental
suite for basic emergency equipment. The ability to assess vital signs in a timely
fashion with blood pressure cuff and stethoscope in the room are essential. In addition,
equipment for delivery of oxygen by mask, up to 10 liters per minute should be
accessible. Treatment of anaphylaxis with diphenhydramine (Benadryl®) at dosages of
25 milligrams IV or 50 milligrams IM should be readily available. Awareness of
potentially emergency situations and treatment are outlined below.
Syncope can result from dehydration, hypoglycemia, supine hypotension or pulmonary

embolus. The patient should be positioned in Trendelenburg position with hips
displaced to either the left or right side. Suction should be administered because of
74
aspiration risk in this position. Oxygen should be administered and immediate vital signs
obtained. If the patient isn't immediately arousable, call 911.
Aspiration can occur when a patient is poorly positioned, i.e. tilted with her bead below
her stomach. In this position, she is unable to clear her mouth of secretions in the event
of massive emesis. In the absence of a syncopal episode, the pregnant patient should
never be positioned with the stomach higher than the mouth. With loss of
consciousness, a suction device should always be available in order to help suction and
clew secretions in the patient with an unprotected airway. The Heimlich maneuver
should not be administered in the pregnant patient during the second or third trimester,
because of possible fetal injury.
Seizures can occur in the event of an intravascular injection of lidocaine, a significant

bypotensive episode, or in the event of a seizure associated with preeclampsia. Dental
procedures should be avoided on all patients with a diagnosis of preeclampsia.
Preeclampsia is diagnosed by the obstetrician in the patient with elevated blood
pressure, edema and proteinuria. Preeclampsia is most commonly seen in the last
month of pregnancy, however in high-risk individuals it can be seen as early as twenty
weeks gestation. Careful triage of these patients with an office questionnaire prevents
untoward complications in your office.
Vaginal bleeding would not be expected to be associated with any dental procedures.
However, vaginal bleeding could coincidentally occur in the dentist's office. Careful
screening for risk of bleeding with dental history prior to procedure will assist the dentist
in triaging this problem.
Uterine contractions occur in association with severe pain or high stress levels.
Contractions association with pain and emotional stress would rarely result in a pre-term
birth. However, these are disconcerting for the patient and the care provider and if
significant contractions occur in the dental office, the procedure should be curtailed and
the patient rescheduled after consultation with the obstetrician_
Cardiopulmonary arrest in the pregnant patient most commonly occurs in association

with pulmonary embolus or amniotic fluid embolus. Other etiology of cardiopulmonary
arrest in the pregnant patient would include a severe hypotensive episode or an
intravascular injection of lidocaine. This medical emergency in the pregnant patient is
handled in identical fashion to a non-pregnant patient with the exception that the uterus
should be displaced to the left or right lateral position by wedge or pillow under the hip
of the patient- The thorax should be positioned on a flat surface such that proper
cardiac and respiratory resuscitation can be administered. Office staff should all be
trained in Basic Cardiac Life Support (BCLS).
VII. Care of the Lactating Patient
Care for the post partum lactating patient is quite similar to the non-pregnant patient.
The dental practitioner should be aware that all narcotics are secreted into the breast
75
milk and will result in some mild sedation of the infant. In addition, antibiotics are also
secreted in the breast milk and can result in diarrhea for the newborn infant. After
discussion with the patient, if these medications are indicated for the dental procedure,
they are usually prescribed. These essential medications are not withheld for any
necessary surgical procedures.
VIII. Summary/Goals in Managing the Pregnant Dental Patient
Apprehension of providing dental care for the pregnant patient can be alleviated by
careful screening for at risk situations through the use of the dental history
questionnaire and by taking proper precautions appropriate to the gestation of the
patient. Careful maintenance and provision of emergency equipment in the dental suite
is imperative for all dental procedures in pregnant and non-pregnant patients. Dental
care in the gravid patient should emphasize maintenance of hygiene, provision of all
required procedures, and common sense in the provision of routine care. Preventive
care, emergency care, orthodontics, scaling and curettage can be provided in all
trimesters.
Consultation with the obstetrician is encouraged if uncertainty regarding medications or

procedures arise; however, adherence to the guidelines outlined in this review article
will make consultation with the obstetrician a rare event Certainly for any procedure
requiring a general anesthetic, obstetrical consultation should be obtained.
IX. Health History and Dental Interview
Dental Interview
How many weeks are you?

Rationale - This will help you know what trimester the patient is in. Second trimester is
the best time to treat.
Do you have children?

Rationale - If a patient has had children, she will know more about conditions associated
with pregnancy.
Have you bad any complications with this pregnancy?

Rationale - This will alert you to changes in procedure or a consult with the doctor.
Has your blood pressure been normal?

Rationale - If the blood pressure is high, you may not want to treat this patient today. If
the blood pressure id borderline high, you may want to use an anesthetic without
Epinephrine.
Have you had morning sickness or nausea? If so, how recent?

Rationale - If the patient is not felling well, you may elect to do a shorter procedure or
reappoint
76
Are you using any drugs, alcohol or are you smoking?
Rationale - Many pregnant teens do not know the risks of drugs, alcohol, or smoking
during pregnancy
Do you have a safe place to live?

Rationale - Many pregnant teens may be living with friends, on the street, or with a
boyfriend. There is the possibility of domestic violence.
Do you have transportation?

Rationale - If the patient has difficulty coming to the appointment, it is likely she will miss
other appointments.
Are you eating or sleeping well?

Rationale - It is a good way to assess the overall health and attitude of self.
When was your last dental visit?

Rationale - This a way to assess if the patient has had access to dental care.
Was it a routine visit?

Rationale - This is a way to see if the patient has had a lot of emergencies or just had
routine care.
Do you feel your teeth and mouth are healthy?

Rationale - This will assess their own feeling about their teeth and their attitudes about
Dentistry
What are your expectations for your baby's teeth?

Rationale - This will assess if the patient feels she can stop dental caries through early
intervention and education about dentistry.
It is also recommended to do an updated health history at each visit in a modified form.

This can alert you to any changes in health and help you to decide if you need to modify
the treatment plan.
Updated Health History at each visit:

How are you feeling today?
Have you had morning sickness in the past 24 hours?
Was your blood pressure normal at your last OB visit?
Have you been sleeping/eating well?
Did you have difficulty coming to this appointment?
Any changes in your health?
Do you have any pain in your mouth or teeth?
What can I do to make your visit easier?
77
X. References
Aldridge LM, Tunstall ME. Nitrous oxide and the fetus: A review and the results of
a retrospective study of 175 cases of anaesthesia for insertion of shirodkar
suture. Br J Anaesth 1986;58:1348-1356.
Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation: A
reference guide to fetal and neonatal risk. 5th ed. Baltimore, Maryland: Williams
& Wilkins,1998.
Catalono, PM, Hollenbeck C. Energy requirements in pregnancy: A review.

Obstet Gynecol Surv 47:368, 1992.
Dajani, AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, et al.
Prevention of bacterial endocarditis: Recommendations by the american heart
association 1997;277(22):1794-1801.
lams JD. Preterm birth. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics:
Normal and Problem Pregnancies. New York- Churchill Livingstone, 1996.
Manson-Hing L.R. Panoramic dental radiography. Springfield, Illinois: Charles C.

Thomas Publishers, 1976.
Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. Periodontal

infection as a possible risk factor for preterm low birth weight J Periodontol
1996;67:1103-1113.
Pallasch TJ, Slots I Antibiotic prophylaxis and the medically compromised patient
Peridonlo12000. 1996; 10:107-138
Ruggerio RJ. Pharm D. Ob Gyn News, 1999.
Skatrud JB, Dempsey JA, Kaiser DG. Ventilatory response to

medioxyprogesterone acetate in normal subjects: Time course and mechanisms.
J Appl Physiol 1978;44:939.
Ueland K, Novy MJ, Peterson EN, et al. Maternal cardiovascular dynamics, IV:
The influence of gestational age on thematernal cardiovascular response to
posture and exercise. Am J Obstet Gynecol 1969;104:856.
78
Restorative Dentistry
79
CURRENT METHODS OF PULPAL THERAPY IN THE PRIMARY DENTITION
A. Direct Pulp Therapy -- A pulp dressing is placed in contact with a pulp exposure
over which a temporary or permanent restoration is inserted.
Calcium hydroxide is currently the drug of choice. The objective of this therapy is the
creation of new dentin in the area of exposure and subsequent healing of the pulp
tissue. Direct pulp capping is ordinarily contraindicated in the primary dentition because
internal resorption is frequent sequelae.
B. Indirect Pulp Therapy -- All of the superficial carious dentin is excavated, the caries
that is estimated to be approximating a potential pulp exposure is left in the tooth if it is
still sufficiently healthy (i.e., affected - not infected dentin), and a pulp dressing is placed
in the tooth for a determined period of time (1-6 months). At the second appointment,
all of the carious material is excavated, and the floor of the cavity is examined for pulp
exposures. If no exposures are seen and the tooth has been asymptomatic, the
treatment is considered successful, and a permanent restoration is place. The single
appointment procedure is also gaining popularity, where a permanent restoration is
placed at the first appointment, with periodic monitoring of the tooth. The preoperative
x-ray of the tooth to be treated by indirect pulp therapy must not indicate a carious
exposure of the pulp, the tooth should be asymptomatic, and no periapical change is
observable on the x-ray.
C. Pulpotomy -- That procedure in which the coronal pulp tissues are completely
extirpated while the radicular pulp tissues are left intact. A zinc oxide eugenol base is
placed over the amputation sites and a permanent restoration is completed. The
objective is to maintain the restored tooth so it may function as a healthy biological unit.
Because of systemic distribution and potential mutagenic and carcinogenic effects from
full strength formocresol alternative pulpotomy procedures are suggested:
1. One-fifth dilution of formocresol - acceptable procedure

1. (Note: cotton pellets are not sealed ion the tooth)
2. Glutaraldehyde - acceptable procedure
3. Electrosurgery - acceptable procedure
4. Laser - acceptable procedure
5. Ferric Sulfate - acceptable procedure
6. Ca(OH)2 - usually not acceptable
7. Zinc oxide eugenol - usually not acceptable
8. BMP (bone morphogenic protein) - futuristic procedure
80
Pulpotomy Indications
1. Radiographic
P.D.M. - normal
Lamina dura - normal
P.A. bone - normal
Bifurcation - normal
Lack of internal resorption
2. Subjective Symptoms
Lack of spontaneous pain
3. Miscellaneous
Lack of tenderness to percussion
Lack of mobility
Lack of fistulae
Lack of gingival inflammation
D. Pulpectomy -- That procedure in which the entire pulpal contents are removed
from the crown root portions of the tooth.
Children seen in your clinic will vary in age, but many dental problems fall in the 4 to 7
year age group. The primary molars have been present from 2 to 5 years and it is
possible to observe any condition from a clean caries-free mouth to infected and
necrotic teeth.
Once the pulp has become infected, you are faced with the decision to treat or remove
the tooth. There are many advantages to retaining the pulpally involved molar, but of
most importance is preserving space for erupting permanent teeth.
Endodontics for the primary dentition is a relatively quick and easy procedure for
treating teeth with necrotic tissue which cannot be treated with the pulpotomy
procedure. A high-speed bur is used to gain access into the pulp chamber and
Hedstrom files are then used for filing the canals. The canals are irrigated to wash any
remaining tissue and loose dentin. The canals and chamber are then filled, a post-
operative x-ray is taken to evaluate the condensation procedure, and the tooth is then
usually restored using a stainless steel crown.
Indications:
A tooth that is restorable with stainless steel crown.
No pathological root resorption.
Layer of overlying bone between permanent tooth bud and area of pathological bone
resorption. (On the x-ray, a layer of healthy bone should exist between the lesion and
the permanent tooth bud. This allows the lesion to fill in with normal bone once the
endodontic therapy is completed.)
Contra-Indications:
81
Pulpal floor opening into the bifurcation.
Radiographic indication of extensive internal resorption (tooth has been weakened to
the extent that it cannot support a stainless steel crown).
More than 2/3 of the roots have been resorbed.
No bone between the permanent tooth bud and the lesion.
82
SPACE MAINTAINERS
The premature loss of a primary molar may have a deleterious effect on the
development of a normal occlusion for the child. Careful considerations are necessary
to determine the need to maintain this space.
The most common types of appliances to maintain space are:
A. Fixed
1. Crown - loop space maintainer
2. Band - loop space maintainer
3. Distal shoe
4. Mandibular lingual arch
5. Maxillary lingual arch
B. Removable
1. Bilateral acrylic spacers occasionally indicated provided there is patient
compliance.
2. Unilateral acrylic spacers contraindicated.
83
Initial Assessment and
Management of Infection
and Trauma
84
INITIAL ASSESSMENT AND MANAGEMENT OF INFECTION AND TRAUMA
Injuries and Trauma

Prevention: Suggest that infants and toddlers always use safety seats in autos to avoid
injury. No running with dangerous objects; no standing while swinging.
Any injury to primary teeth can damage developing permanent teeth, especially before
age 3. Report all such injuries to dentist.
Child Toothaches—What to do at first: See a dentist as soon as possible. Don’t wait,

the pain may go away, but will surely return and be more difficult to eliminate. If all else
fails, over-the-counter-preparations that numb baby’s gums are available.
It is our belief that teething time is especially important for babies—as erupting teeth are
especially vulnerable to decay (Teeth erupt at night when saliva flow is shut off.).
Suggest increased attention to protecting them by home care activities (cleaning), and
professional application of fluorides (and in the future, the use of antimicrobials—a
research topic right now).
A note about drooling: it is not unusual for healthy children. Many things stimulate
drooling—including food, smells, tastes, or irritation around an erupting tooth that has
not been cleaned.
Initial Patient Contact

Telephone checklist for reception staff
Advantages
- Determine if true emergency
- Determine responsibility of parent
- Clinician can narrow diagnosis
Only Two Real Emergencies
- Trauma
- Infection with pain
Trauma
Primary Incisor Injuries
Coronal Fractures- Enamel only- Smooth as necessary- Enamel/Dentin- Vitrebond
bandage- Pulpal Exposure- Pulpotomy/Pulpectomy - Extract
Root Fractures
- Coronal, Middle 1/3- Extract
- Apical 1/3- Leave if Firm
Luxation
- Mild with little mobility- Leave
- Major +/- mobility- Extract
- Do not splint except to hold alveolus
85
Intrusion
-Up to 2-3mm leave if tooth firm
- >3mm or if mobile- Extract
ODONTOGENIC INFECTIONS
Unprovoked Pain
Primary Incisor- Extract- Pulpect
Primary Molar-Pulpectomy-Extract
Pulpotomy?
Not reliable if infection extended beyond pulp chamber
Therefore pulpotomy unreliable in situations with unprovoked pain
Odontogenic Infection
Antibiotic Therapy is not a substitute for correcting the problem but an adjunct to dental
treatment to treat the problem. The best antibiotics are those that are active against
staphylococcus aureus and streptococcus viridans. The usual antibiotics recommended
for cardiac prophylaxis are excellent choices.
86
RECOMMENDED TREATMENT FOR COMMON ORAL LESIONS
Angular Cheilitis:
Rx: Triamcinolone and nystatin ointment (Mycolog II

Disp: 15 g tube
Sig: Apply to affected area after each meal and at bedtime
Category: Topical corticosteroid. Antifungal

Mechanism: Nystatin alters fungal cell membrane. Triamcinolone decreases
inflammation.
Side effects: Dryness, itching, burning
Aphthous Ulcer:
Rx: Triamcinolone acetonide (Kenalog in Orabase)

Disp: 5 g tube
Sig: Dry lesion. Coat lesion with a thin film after each meal and at bedtime
Category: Topical corticosteroid

Mechanism: Decreases inflammation.
Warning: Do not use on fungal ulcerations. Do not use for diabetics
*If significant improvement has not occurred in 7 days, discontinue treatment and
reassess the diagnosis.
Candidiasis:
Rx: Nystatin suspension 100,000 units/ml

Disp: Infants :125 ml (Infant dose:200,000 units qid)
Child/adult:300 ml (Child/adult dose:500,000 units qid)
Sig:Infants: 2 ml qid. Swab oral tissues and encourage swallowing.

Child/adult:5 ml qid. Swish for two minutes and swallow.
Category: Antifungal
Mechanism: Alters fungal cell membrane
Side effects: Nausea, vomiting, diarrhea, contact dermatitis
Rx: Fluconazole suspension 40 mg/ml

or
Fluconazole tablets 100 mg (Diflucan)
Dose:6 mg/kg loading dose, then 3 mg/kg qd x 13 days
Sig: 1 dose qd x 14 days

Category: Antifungal
87
Mechanism: Inhibits fungal cell membrane formation.
Indications: Immunocompromised patients. Patients unable to comply with qid schedule
for Nystatin
Warning: Not for patients with renal or hepatic dysfunction
Recurrent herpes labialis:
Rx: Penciclovir cream (Denavir)

Disp: 5 g tube
Sig: Apply to affected area at first sign, then q 2 h until lesion is gone
Category: Antiviral
Mechanism: Inhibits viral DNA multiplication
Side effects: Mild skin irritation
Multiple oral ulcerations:
Home remedy coating agent:
Diphenhydramine (Benadryl) elixir 12.5 mg/5 ml and Kaopectate

Mix equal parts by volume
Rinse with 5 ml q 2 h and spit out
Maalox can be used in place of Kaopectat
By prescription:
Rx: Sore-away mouth rinse (equal parts Nystatin oral suspension 100,000 u/cc,
diphenhydramine elixir 12.5 mg/5 ml, and Maalox (OTC))
Disp: 12 oz
Sig: < 3 years :Swab around entire mouth qid
3-5 years :Swish and swallow 2-3 ml qid
> 5 years:Swish and swallow 5 ml qid
Halitosis:
Rx: Chlorhexidine gluconate mouthwash 0.12% (Peridex)

Disp: 16 oz
Sig: Brush on posterior part of tongue or gargle with 5 ml for 1 minute
at bedtime
Category: Topical antibacterial

Mechanism: Alters bacterial cell wall. Bacteriocidal or bacteriostatic
Side effects: Increases calculus on teeth, altered taste sensation, tooth staining
88
RUG GUIDELINES FOR COMMON
PEDIATRIC ORAL CONDITIONS
ANTIBIOTICS:
Penicillin VK
Children’s dose:25-50 mg/kg/day divided q 6 h x 7 days
Adult dose:250-500 mg q 6 h x 7 days
Maximum dose:3 g/day
Forms Suspension: 125 mg/5 ml and 250 mg/5 ml

Tablets: 250 mg and 500 mg
Category: Bacteriocidal antibiotic
Indications: First choice for orofacial infections: cellulitis, periapical abscess, periodontal
abscess, acute suppurative pulpitis, pericoronitis, osteitis,osteomyelitis, post-surgical
infection, post-traumatic infection
Mechanism: Inhibits cell wall synthesis
Side effects: Nausea, vomiting, rash, hypersensitivity
Warnings: Patients with hypersensitivity to cephalosporins
Amoxicillin Trihydrate
Children’s dose: 30-50 mg/kg/day divided q 8 h
Adult dose: 250-500 mg q 8 h
Maximum dose: 1.5 g/day
Forms: Suspension: 125 mg/5 ml and 250 mg/5 ml

Chewable tablet: 125 mg and 250 mg
Capsule: 250 mg and 500 mg
Category: Broad spectrum, bacteriocidal antibiotic
Indications: First choice for SBE regimen
Mechanism: Interferes with bacterial cell wall synthesis
Side effects: Diarrhea, rash, superinfection
Warnings: Reduces efficacy of oral contraceptives. Efficacy is reduced by tetracyclines
89
Erythromycin
Children’s dose: As ethylsuccinate - 50-80 mg/kg/day divided q 8 h
Adult dose: As base - 250 mg q 6 h
Forms: Ethylsuccinate suspension: 200 mg/5 ml and 400 mg/5 ml

As base (enteric coated tablet): 250 mg
Category: Narrow spectrum, bacteriostatic antibiotic
Indications: Alternative to Pen VK for infections. Alternative to amoxicillin for SBE
prophylaxis
Mechanism: Inhibition of RNA-dependent protein synthesis
Side effects: GI pain, cramping, nausea, vomiting
Warnings: Increases blood levels of Tegretol and theophylline
Augmentin (Amoxicillin and Clavulanic Acid)

Children’s dose:25-45 mg amoxicillin/kg/day divided q 12 h
Adult (>40 kg) dose: 400 mg bid (875 mg bid for severe infections)

Chewable tablet: 200 mg and 400 mg
Tablet: 875 mg
Category: Broad spectrum, bacteriocidal antibiotic
Indications: Treatment of orofacial infections when beta-lactamase producing
staphylococci and bacteroides are present
Mechanism: Interferes with bacterial cell wall synthesis
Side effects: Diarrhea, rash, superinfection
Warnings: Increases efficacy of anticoagulants. Decreases efficacy of oral
contraceptives.
Clindamycin
Children’s dose:8-25 mg/kg/day divided q 6-8 h
Adult dose:150-450 mg q 6-8 h
Maximum dose:4.8 g/day
Forms: Suspension: 75 mg/5 ml

Capsule: 150 mg
Category: Broad spectrum, bacteriocidal or bacteriostatic depending on dose
Indications: Second choice (to Pen VK) for orofacial infections, third choice (to
amoxicillin and erythromycin) for SBE prophylaxis
Mechanism: Inhibits bacterial protein synthesis
Side effects: Diarrhea and rash
Warning: Can cause severe colitis. Discontinue if significant diarrhea occurs.
90
Cefpodoxime Proxetil (Vantin)
Children’s dose: 10 mg/kg/day divided q 12 h maximum 400 mg /day
Adult dose: 400 mg q 12 h

Tablets: 100 mg and 200 mg
Category: Broad spectrum, bacteriocidal, second generation cephalosporin
Indications: Dirty skin wounds
Side effects: Dizziness, rash, diarrhea, nausea, vomiting, abdominal pain
Warning: Do not take with antacids (decrease absorption)
Use with caution in penicillin-allergic patients
Analgesics
Acetaminophen
Children’s dose: 15 mg/kg/dose or 80 mg/year of age/dose qid
Adult dose: 325 - 650 mg q 4 -6 h
Maximum dose: 4 g/day
Forms:Drops: 100 mg/ml

Suspension: 160 mg/5 ml
Suppository 120 mg, 325 mg, and 650 mg
Chewable tablet: 80 mg
Tablet: 325 mg and 500 mg
Category: Analgesic, Non-narcotic, Antipyretic
Indications: Mild to moderate pain
Mechanism: Inhibits prostaglandin synthesis in the CNS, peripherally blocks pain
impulse generation
Side effects: Rash, blood dyscrasias, hepatic necrosis with overdose, renal injury with
chronic use
Interactions: Barbiturates, carbamazepine, hydantoins increase hepatotoxic potential of
acetaminophen
91
Acetaminophen and Codeine Phosphate
Children’s dose: Codeine 3 mg/kg/24 h divided qid . Maximum 60 mg
codeine/dose
Adult dose: 1 - 2 tablets q 4 h
Maximum: 12 tablets / 24 h
Forms: Elixir: acetaminophen 120 mg and codeine 12 mg/5 ml (with alcohol 7%)
Tablets: # 2 - acetaminophen 300 mg and codeine 15 mg
# 3 - acetaminophen 300 mg and codeine 30 mg
Category: Analgesic, Narcotic
Indications: Moderate pain
Mechanism: Acetaminophen (as above). Codeine binds to opiate receptors in the CNS,
inhibiting ascending pain pathways and altering perception of pain
Side effects: Lightheadedness, dizziness, sedation, nausea, vomiting, constipation
Interactions: Acetaminophen (as above). Codeine increases toxicity of CNS
depressants, tricyclic antidepressants, MAO inhibitors
Ibuprofen
Children’s dose: 10 mg/kg/dose q 6 – 8 h . Maximum dose 40 mg/kg/24 h
Adult dose: 400 - 600 mg/dose q 4 - 6 h
Maximum dose: 2.4 g/day
Forms: Suspension: 100 mg/5 ml

Tablets: 200 mg, 300 mg, 400 mg
Category: Analgesic, Non-Narcotic, Non-steroidal Anti-inflammatory (NSAID)
Indications: Mild to moderate pain and inflammation
Mechanism: Inhibits prostaglandin synthesis
Side effects: Indigestion, nauseaInteractions:
Increases levels of digoxin
92
Topical Anesthetics and Coating Agents for Primary Herpes Gingivostomatitis
Catherine Flaitz, DDS, MS, The University of Texas-Houston
Alcohol-free Benadryl elixir (diphenylhydramine HCl) and Maalox. Mix in a 1:1

ratio (OTC). Dispense 200 ml
Sig: Rinse with one teaspoonful every 2 hours and expectorate.
NB: Kaopectate or other magnesium aluminum hydroxide solution can be used in place
of Maalox. Peridex or PerioGard may be beneficial for managing gingivitis once oral
ulcerations have resolved.
Rx: Benadryl/Lidocaine/Maalox mouthrinse

Instruct: Mix 1.5 ml dephenhydramine injectable (50 mg/ml), 45 ml xylocaine viscous
2%, 45 ml magnesium aluminum hydroxide solution.
Sig: Rinse with 1 teaspoonful every 3 hours. Spit out excess. Not more than 8 doses
should be given in a 24 hour period.
NB: Do not use 2% xylocaine HCl viscous in children who cannot expectorate because
of potential for aspiration. Overuse of viscous Lidocaine will result in delayed healing of
oral ulcerations.
Dyclone 0.5% or 1% (Dyclone HCl( may be substituted for viscous Lidocaine for greater
anesthetic efficacy. Safety and efficacy under the age of 12 years have not been
established. Good substitute for patients allergic to ester or amide compounds.
Rx Carafate (sucralfate) suspension 1 gm/10 ml

Dispense: 200 ml
Sig: Rinse with 1-2 teaspoonfuls 4 times a day. Spit out excess.
NB: Should not be used in children who cannot expectorate because its safety has not
been established for pediatric use.
93
How to Make a Referral
94
How to Make a Referral
Adapted from Bright Futures: Guidelines for Health Supervision of Infants, Children,
and Adolescents. Morris Green, MD, Editor
Successful interventions often require efforts that extend beyond what can be provided
in any one setting or through any one discipline. Health supervision can be provided in
many settings, often with collaboration between a variety of organizations and
disciplines. To insure our goal to provide integrated preventive and health-promoting
services we need to form a health care team. This may require specific outreach to
dental and medical providers in your community.
Finding the right provider is important, and should take some time. People who are
selected hastily or because of their visibility and accessibility are not necessarily the
best contacts for your health promotion efforts.
Telephone or Personal Contact

Communicate to the health care profession as you would another dental colleague.
Introduce your patients to the health care provider either by phone consultation or with a
written response. Provide information about the family dynamics and perceived needs.
Written Request
You will want to develop a collaborative referral form that will provide the information
needed to help involve the family in oral health supervision.
Factors to Teach the Caregiver

1. Review with the caregiver the importance of making an appointment they can keep.
If an appointment change is needed, please call at least 24 hours in advance.
2. Not to use the health care visit as a threat. Keep the words hurt, pain or brave out of
the vocabulary when talking to the child about the upcoming medical visit.
3. Go to the health care office with clean teeth and a clean body.
4. Carry a means to dispose of dirty diapers.
5. Only take the child who has an appointment (if possible).
6. How to be a good historian providing the health care provider with information
about child's needs.
7. How to ask questions of the dentist.
95
Appendix
i
ABCD DENTAL PROGRAM BENEFITS
FOR THE CHILDREN:
✰ Provided access to a dentist (previously unavailable to children on medical coupons)

✰ Allows multiple applications of topical fluoride varnish yearly
✰ Allows frequent risk assessment
✰ Early parent education - opportunity for better dental habits
✰ Home care instructions teach parents how to recognize/prevent problems
✰ Early dental visits set up a positive experience for future visits
FOR THE DENTAL OFFICE:
✰ Community service and goodwill

✰ The more local dentists address the need of dental access for kids, the less likely the
legislature will mandate services
✰ The ABCD Dental program is nationally recognized and published in national journals
✰ Enhanced fee structure - better bottom line
✰ Receive training in how to work with young children
✰ Personalized access to DSHS billing help - free, in your office
✰ Program is designed to get kids decay free and keep decay free
✰ Early care lets the child be seen before problems develop, increasing rapport and
trust
✰ Parents have received dental education prior to the child's first visit - easier patients
✰ Not all parents are on public assistance - many are paying for Basic Health and will
become regular patients
ABCD DENTAL STAFF ASSISTS YOU:
✰ Conducts parent education prior to enrollment

✰ Addresses your no-shows with parents
✰ Helps find addresses and phone numbers for patients who have moved
✰ Provides interpreter information
✰ When CPS-DD referrals are appropriate, can act as the referral facilitator
✰ Billing problems? Can put you in touch with the right people in Olympia
✰ Supports offices in every way possible - appreciates your care for our children
ii
ABCD DENTAL PROGRAM TIPS
✰ The ABCD program is designed to begin seeing children as soon as the first teeth
emerge. Parents are encouraged to get their children to the dentist by the child's first
birthday. Dental offices examine the child, provide fluoride varnish and other services
as needed, then remind the parent to continue to bring the child in at appropriate
intervals.
**********************************************
✰ Three topical fluoride varnish treatments are allowed yearly. Currently two
applications may be billed under 0122D and the third one under 0123D. As of April's
new billing instructions, up to three fluoride applications can be applied using the same
code.
(All children enrolled in the ABCD Dental Program are considered high risk - no further
justification is required.)
***********************************************
✰ Using code 4475D, your office may bill $25 for a "family oral health education"
component, twice per year per family. This education piece may be conducted by
auxiliary staff.
For audit purposes, ensure that all component of the family oral health education (as
described on p. 8 - 9 in the ABCD Billing Instructions Manual) are given and
documented in the patient file.
For your ease, ABCD Dental staff has developed a charting tool for documenting
family oral health education.
**********************************************
✰ There is no cost assistance available to you in your office for help in solving DSHS
billing problems, coding problems, answering questions and proper reimbursement
techniques. To sign up for free in-office billing training, contact:
iii
Q. When should I start cleaning
my baby's teeth?
A. This is a good habit to start

early! The teeth must be cleaned as
they erupt. Use a damp washcloth
or a toothbrush. If your dentist YOUR
agrees, use a tiny dab of fluoride BABY’S
toothpaste. Tooth brushing is
TEETH
definitely a parent job in the
preschool years and beyond.
Children are usually able to brush
their teeth well when they are 9-11
years old. Be sure to check your
child's teeth regularly for any chalky
white or brown spots that could be
beginning decay.
Q. Any advice on teething?
A. Sore gums from teething often

occur for a few days at a time
between six months to age three.
Babies often get relief from a clean
teething ring, cool spoon, cold wet
washcloth or toothbrush. Chilled
teething rings or rubbing a clean
finger on the sore gum area often
helps too.
4
Q. When should my child first see visit, the better chance of preventing Q. When should I start
a dentist? dental problems. Children with cleaning my baby's teeth?
healthy teeth can chew food well,
A. "First visit by first birthday" speak clearly and share precious A. This is a good habit to start
sums it up. Your child should visit smiles. Start your child on a lifetime early! The teeth must be cleaned as
a dentist when the first tooth comes of good dental habits now! they erupt. Use a damp washcloth
in, usually between six and twelve or a toothbrush. If your dentist
months of age. Early examination Q. When should bottle-feeding be agrees, use a tiny dab of fluoride
and preventive care will protect stopped? toothpaste. Tooth brushing is
your child's smile now and in the definitely a parent job in the
future. A. Begin teaching your baby to use a preschool years and beyond.
cup by six months. It's a good idea Children are usually able to brush
Q. Why so early? What dental to introduce juice in a cup. Your their teeth well when they are 9-11
problems could a baby have? baby can be off the bottle by 12 years old. Be sure to check your
months. child's teeth regularly for any
A. Dental problems can begin chalky white or brown spots that
early. A big concern is Baby Bottle Q. Should I worry about thumb or could be beginning decay.
Tooth Decay (BBTD) that is finger sucking?
preventable. BBTD can result from
A. Thumb sucking is perfectly
long periods of exposing baby teeth
normal for infants; most stop by
to liquids that contain sugar
age two. Prolonged (beyond age 5
including formula and juice. A baby
or 6 years) thumb sucking can
who has a habit of sleeping with a
create crowded crooked teeth or
baby bottle filled with any sugary
bite problems. Your dentist will be
liquid in their mouth is at risk of
glad to suggest ways to address a
getting BBTD. Frequent snacking on
prolonged thumb-sucking habit.
sweet or sticky foods can also cause
decay. The earlier the first dental
5
INTRODUCTION
Topical fluoride application on a

child’s teeth is proven to be one of
the most effective ways to retard,
arrest, and reverse early cavities. It
is also highly effective in
preventing initial decay. Once
applied, it helps the tooth
“remineralize” or restore surface An Alternative to
enamel. Fluoride varnishes are Traditional Topical
applied directly to the tooth Fluoride Therapy
surface, providing for both
immediate “remineralization” as
well as on-going “time-released”
fluoride protection.
6
ANSWERS TO COMMONLY Q. How is the varnish applied?
ASKED QUESTIONS ABOUT
FLUORIDE VARNISH A. Application is quick and easy;
small droplets of varnish are
Q. Is this a new method? applied directly to the tooth
surface.
A. No. Fluoride varnish was
developed in the early 60’s in Q. What about application
Europe. precautions?
Q. Is it effective in reducing
decay? A. After application, the teeth will
have a “yellow film” – that is the
A. Yes. Fluoride varnish has been fluoride varnish. It’s O.K. for your
found to reduce decay on tooth child to drink or eat after the
surfaces between 50 and 70%. application of fluoride varnish.
The child should not brush the
evening following the application,
Q. Is it more costly than but should resume normal
conventional topical fluoride? hygiene practices the following
morning.
A. No. Fluoride varnish applications
cost the same as those for Q. Is it safe?
conventional topical fluoride.
A. Yes. Fluoride varnishes are very
Q. Why would you use fluoride safe. They have been used in
varnish instead of traditional Scandinavia and Canada for a long
fluoride? time. A toxic dose of fluoride is not
reached until ten times the normal
A. Varnishes provide a more dose.
efficient way for the tooth to
absorb fluoride; its slow release
time further enhances its
effectiveness.
7
DENTIST PARTICIPATION IN A PUBLIC-PRIVATE
PARTNERSHIP TO INCREASE MEDICAID PARTICIPATION AND
ACCESS FOR CHILDREN FROM LOW INCOME FAMILIES
Ken McNabb, DDS1

Peter Milgrom, DDS1
David Grembowski, PhD1, 2
1
Department of Dental Public Health Sciences, University of Washington
2
Department of Health Services, University of Washington
Correspondence to Dr. Peter Milgrom, Professor of Dental Public Health Sciences,

Department of Dental Public Health Sciences, Box 357475, University of Washington,
Seattle, Washington 98195-7475. Telephone number 206-543-2034; Fax number 206
685-4258; E-mail: dfrc@u.washington.edu.
Reprint requests should be addressed to Dr. Peter Milgrom, Professor of Dental Public
Health Sciences, Department of Dental Public Health Sciences, Box 357475, University
of Washington, Seattle, Washington 98195-7475.
1
Abstract
The purpose of this research to solicit feedback from dental society members involved
in a program (Access to Baby and Child Dentistry, ABCD) to provide care for children
receiving Medicaid benefits, and to gain an understanding of dentist participation. We
investigated whether general dentists who were participants in ABCD were more fully
integrated into the dental society, profession and community, and whether they
demonstrated greater interest in children. Dentists were stratified regarding ABCD
participation and randomly selected to be interviewed (N=40). The majority thought it
appropriate for general dentists to care for very young children. Participants found fewer
problems in fee levels in Medicaid but there was no difference in an index of fees
between the groups. Participants were no more active in the dental society, and few
differences existed between the groups regarding other aspects of personal or
professional life. Dentists participating in ABCD to improve access had a good
experience and have positive views of the program. This may encourage other non-
specialist colleagues to participate in programs for children.
2
INTRODUCTION
Access to dental cam for children receiving Medicaid benefits is problematic1, 2.
Although this is not a new problem, there is renewed interest in finding solutions3. As a
result, there have been a number of recent state-based surveys of dentists 4-6. These
studies tend to reinforce the impression that the reasons dentists fail to see Medicaid
child clients is primarily because of low allowable fees, poor payment speed and
bureaucracy, lack of specific benefits, and client behavior.
We previously reported on a community partnership -- Access to Baby and Child
Dentistry (ABCD) -- demonstrated to improve access to dental care for Medicaid
recipients from birth to 5 years old7. The high rates of utilization in the program are in
marked contrast to those in other areas. The program has continued for more than 5
years and was awarded the 1999 Maternal and Child Health Award of the National
Association of County and City Health Officers.
Because this program is unique, we solicited feedback from the dental society regarding
the strengths and weaknesses of the program, and a better understanding of
participation by non-specialists. With respect to the latter, we investigated whether
general dentists who were participants in ABCD were more fully integrated into the
dental society, profession and community, and whether they demonstrated a greater
interest in children than non-participants did.
3
METHODS
General dentist participants (P) in the ABCD program were identified from Medicaid
claims. Non-participants (NP) were defined as general dentists who were members of
the local society, but had no paid claims for the program. These lists were sampled
randomly and dentists approached by telephone. The response rate was 76.7 percent
(23/30) for Ps and 60.7 percent (17/28) for NPs. The constraints of a student summer
research project limited the sample size. The informed consent of all participants was
obtained.
A 35-item questionnaire was constructed8 for use by a single interviewer. Some items
were taken from a previous statewide survey of general dentists and specialists6; others
were written for this survey. Items were pretested and revised as necessary. The items
were in four conceptual areas: knowledge and skills in the care of children; participation
in continuing dental education and dental society activities; integration in the
community; and views about ABCD. Summary measures were created for skill in
treating preschool children and for enjoyment of children in general by summing the
items in each scale. Summing the typical fee for intraoral exam, bitewings, 1 surface
amalgam and simple extraction also created a fee index. The interview lasted, on
average, 20 minutes and was conducted in the dentist's office.
The data were entered, verified, and analyzed using SAS version 6.12 for Power
Macintosh. Descriptive statistics are used to characterize the subjects in the study and
to compare the Ps and NPs in the areas of knowledge and skills, participation in
4
continuing education and dental society, integration into the community, and views
about the ABCD program
RESULTS
The typical (median) general dentist respondent graduated from dental school in 1980
(range 1947-1997) and had been in the current practice arrangement 10 years. Twenty-
five of the 40 dentists (62.5%) had no post-DDS training either in a residency or in a
military service. The remaining dentists had one year (8 dentists) or more (7 dentists) of
training. Dentists reported seeing patients an average of 32 hours per week (SD 5
hours) over an average of 47 weeks (SD 3 hours). The typical (mean) practice size was
five fully equipped operatories (SD 2.5 operatories). Sixty percent (24/40) were in solo
practice.
The typical (median) dentist described the practice as providing care to all that
requested appointments and not overworked. Fifteen practices (37.5%) reported being
overworked (9) or too busy to treat all people requesting appointments (6). The typical
patient pool was 60 percent private insurance (range 0-90%), 15 percent public
assistance (range 0- and 20 percent self-pay (range 0-50%). For child patients seen
during the last year, typical practice profile was 15 percent preschoolers (range 0-45),
and 25 percent elementary school children (range 0-75).
5
Questions about the ABCD Program
Both groups felt strongly that it was appropriate to care for infants and toddlers (1=
strongly agree, mean P 1. 1 v. NP 1.4, t= 1.8, p=0.07). Ps were no more likely to
support the use of fluoride varnish to remineralize white spots in primary teeth than NPs
(1= strongly agree, mean P 2.3 v. NP 2.7, t=1,0, p=0.3) and the use of glass ionomer
fillings for young children versus other materials (mean P 3.4 v. NP 2.9, t= 1.2, p=0.2).
Table 1 gives the responses of the dentists to questions about the ABCD program. PS
were more positive than NPs in their assessments of the adequacy of Medicaid benefit
levels in relation to commercial insurance (mean 2.8, v. 3.7, t=2.3. p=0.02), but held
similar views regarding payment speed (mean 2.9 v. 3.6, t-=1.5, p=0.15). Ps were more
positive on compensation for oral hygiene instruction (mean 4.2 v. 28, t=2.7. p=0.01).
The later is a covered benefit under this special program. Otherwise, there were no
significant differences between the groups. Ps rated the demands made by the ABCD
program as less than NPs (mean 1.4 v. 2.4, t=3.0, p=0.008). Ps were also twice as
likely to know that fluoride varnish was a covered benefit under insurance programs
(20/23 v. 10/17, chisquare=6. 1, p=0.05).
6
Differences between ABCD Participants and Nonparticipants
Ps attended about the same number of dental society meetings per year (mean 3.8 v.
2.8 meetings, p=0.3) and were no more likely than NPs to have been an officer or
delegate (59 v. 4 1 %, p=0.26). More Ps were approached by another dentist to
participate in ABCD (57 v. 41 %; chisquare = 0.9, p=0.3) but the differences are only
suggestive.
Ps took about the same number of CDE hours in the past two years (mean 96 v. 80,
t=.9, p=0.3). There were no differences in their participation in a study club (74% of Ps
and 71% participated in at least one study club). Similarly there was no difference
regarding membership in organization s such as the Academy of General Dentistry.
There were also no differences in the number of dentist close friends or the number of
dentists who consult the subject dentist for advice.
A series of four questions asked about the extent of involvement with youth serving
organizations (e.g. Boy Scouts); fraternal service groups (e.g. Rotary); adult volunteer
organizations (e.g. Sierra Club); or religious organization. Levels in all of these areas
were typically low (means 1-2 on a scale where 5 is maximally involved) and there were
no differences between Ps and NPs. Similarly there was no difference in the proportions
that had been leaders in one of these organizations.
The general dentists were asked to rate their skill (1 =inadequate, 10=adequate) in
response to a series of four patient management scenarios involving preschool children.
7
The typical (median) response was about 7; there were no differences between Ps and
NPs. Similarly, the subjects were asked to respond to a series of four scenarios
regarding interaction with preschoolers in general, outside of the dental office (1=no
enjoyment, 10=a lot of enjoyment). As with the patient management skills, the typical
response was about 7. There were no differences between Ps and NPs.
More Ps than NPs to schedule at least 10 minutes for a preschool child exam (87 v.
69%) but the difference was not significant. Neither group selected chairside staff
especially for its skill or interest in treating children. There was no significant difference
in ABCD participation by practice busyness. The proportion of 'less busy" practices was
nearly the same between the ABCD groups. Similarly there was no difference in the
proportion of patients who had commercial insurance or Medicaid between the groups.
Ps were, however, less likely to see patients on a strictly self-pay basis than NPs (15%
of patients v. 24% of patients, t=2.2, p=0.03). On the other hand, there was no
difference in the fee index between participants and non-participants. The overall fee
index mean was $209 (SD $22).
8
DISCUSSION
In contrast with dentists in the state overall6, most general dentists interviewed rated the
care of infants and preschoolers as either "appropriate" or "very appropriate." In the
state as a whole, only about one-half gave this rating. Thus the creation of a dental
society partnership with other community agencies has created greater awareness of
dental access issues among non-specialists.
Participants were less concerned about fee levels than non-participants. This reflects
their experience with the fee enhancements in the program and steps taken to be sure
that the program functions well. Otherwise, there were few differences between the
groups, perhaps reflecting the publicity about the program and discussion within the
dental society. Nevertheless, there were concerns about patient behaviors such as
parental knowledge and appointment keeping.
The notion that there are unique, readily identifiable predictors of dentist participation
was not supported. Participants were not more active in the dental society or in CDE
than non-participants. Similarly, other measures of integration into dentistry as a
profession failed to identify any meaningful differences. Neither group was particularly
active in community organizations.
Similarly there were few differences regarding their interest and skills with children. This
lack of difference may reflect the limited training provided to be certified in the ABCD
program and suggests an area for improvement. There were no differences between
9
the practices in terms of fees or busyness. AD types of practices have participated in
the program.
These data suggest that non-specialist volunteers for this unique program to increase
Medicaid participation and services for children were quite typical of members of this
local dental society and that the positive results of the ABCD program may be
generalizable to other communities. The results suggest that the problem of access for
children from low income families can be solved if non-specialists become more aware
of the problems faced by children and if they are offered opportunities to participate in
solutions to these vexing problems.
10
ACKNOWLEDGMENTS
This research was supported, in part, by Grants No. IR01 DE0982 and T35 DE07150
from NICDR/NIH and by the Medical Assistance Administration, DSHS, State of
Washington. The authors acknowledge the assistance of Connie Robohn and Robert
Shaw of the Spokane District Dental Society and Professor Linda LeResche of the
University of Washington.
REFERENCES
1. Brown, J.G.: Children's dental services under Medicaid Access and utilization.
Department of Health and Human Services, Office of the Inspector General April 1996;
Report No. OEI-09-93-00240.
2. Brown, J.G.: Performance report on EPSDT Department of Health and Human
Services, Office of the Inspector General April 1996; Report No. HCFA-416.
3. Federal agencies convene conference on Children's Access to Medicaid Oral
Health Services. N. Y., State Dent J, 64(6):56, June-July, 1998.
4. Capilouto, E.: The dentist's role in access to dental cam by Medicaid recipients. J
Dent Educ, 52:647-652, 1988.
5. Damiano, P.C.; Brown, E.R.; Johnson, J.D., et.al.: Factors affecting dentist
participation in a state Medicaid program. J Dent Educ, 54(11):638-43, November,
1990.
6. Milgrom, P.; Riedy, C.: Survey of Medicaid child dental services in Washington
state: preparation for a marketing program. J Am Dent Assoc, 129:753-763, 1998.
7. Milgrom, P.; Hujoel, P.; Grembowski, D.: Making Medicaid child dental services
11
work: A partnership in Washington state. J Am Dent Assoc, 128:1440-1446, 1997.
8. Salant, P.; Dillman, D.: How to conduct your own survey. New York: John Wiley and
Sons, Inc., 1994.
Dr. McNabb completed his Doctor of Dental Studies degree at the University of
Washington in 2001.
Dr. Milgrom is professor, Department of Dental Public Health Sciences and Director,
Dental Fears Research Clinic, University of Washington, Seattle.
Dr. Grembowski is professor, Departments of Dental Public Health Sciences and Health
Services, University of Washington.
12
Table 1. Questions about the ABCD program (N=40 dentists).
ABCD reimburses at a much lower 3.1 5 8 8 7 8
rate than insurance companies, in
general.
There are often long delays in gaining 3.2 4 7 4 8 6
payment from ABCD
ABCD compensates dentists 3.7 5 2 5 9 14
adequately for time spent on oral
hygiene instruction
ABCD does not compensate for time 3.6 3 2 5 9 7
spent with preschoolers who are
behavior management problems.
ABCD benefits exclude procedures 2.8 9 10 1 3 9
that I think are important to children’s
health.
ABCD children are better behaved 2.5 9 7 8 4 3
than most welfare patients.
Parents of ABCD children are not 3.3 1 10 8 8 8
well informed about their children's
teeth.
ABCD families tend to miss 3.1 3 10 7 7 7
appointments or be late.
The ABCD program makes too many 1.7 18 7 7 1 0
demands on me.
If I took care of ABCD children then 3.3 7 4 7 8 11
I would feel obligated to take care of
their brothers and sisters not in the
program
*Scale ranges from 1 to 5 where 1 =strongly disagree and 5=strongly agree. Number of
responses to each item varies.
13

ABCD Pedodontia

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A MANUAL FOR DENTAL PROVIDERS

Department of Pediatric Dentistry

Division of Client Services

To Download a copy of this manual visit:

Department of Pediatric Dentistry

Division of Client Services

To Download a copy of this manual visit:

Section 2 Bright Futures in Practice: Oral Health

Oral Health Supervision Guidelines…………….…………………… 2

Section 3 Examination of Infants and Toddlers

Examination of Infants and Toddlers……………………………….. 24

Section 4 Family Oral Health Education

Family Oral Health Education……………………………………….. 29

Section 5 Prevention of Dental Disease

Topical Fluoride Varnishes…………………………………………... 41

Section 6 Glass Ionomer Restoration to Control Carious Lesions in

Glass Ionomer Restoration to Control Carious Lesions in

Section 7 Treatment of Pregnant Women

Current Methods of Pulpal Therapy in Primary Dentition………… 80

Section 9 Initial Assessment and Management of Infection and

Initial Assessment and Management of Infection and Trauma 85

Section 10 How to Make a Referral

How to Make a Referral 95

 ABCD Dental Program Benefits

Handouts for Parents

 Your Baby's Teeth

Suggested Milgrom P and Weinstein P. Early Childhood Caries. A Team

With the successful implementation of comprehensive primary prevention programs for

Peterson DS and Davis JM: Pediatric Restorative Dentistry: A Computerized

Peterson DS and Davis JM: Pediatric Pulp Therapy: A Computerized Instructional

Oral Heath Supervision Guidelines

Components of Oral Health Supervision

Health Supervision Interview

Observation of Parent-Child Interaction

Oral Exam and Diagnostic Procedures

Dentists may also need radiographs, if indicated, to assist in diagnosis, though

Family Preparation for Health Supervision

Periodicity and Services

Interview: Trigger Questions

Family Preparation for Health Supervision

Periodicity and Services

Interview: Trigger Questions

Observation of Parent-Child Interaction

Oral Exam and Diagnostic Procedures

RISK FACTORS PROTECTIVE FACTORS

All Ages: Examples All Ages: Examples

Inadequate oral hygiene Good oral hygiene

Poverty Access to care

Frequent snacking Reduction in snacking frequency

Special carbohydrate diet Preventive intervention to minimize effects

Frequent intake of sugared medications Alternative to minimize effects

Reduced saliva flow from medication or Saliva substitutes

Special health needs Preventive intervention to minimize effects

Previous caries experience Increased frequency of supervision visits

Gastric reflux Management of condition

High mutans streptococci count Reduction of mutans streptococci

Infancy: Examples Infancy: Examples

History of baby bottle tooth decay Increased frequency of supervision

Family Preparation for Health Supervision

Periodicity and Services

ABCD Dental Program Benefits

Your Baby's Teeth