Oral hygiene practices should be implemented once a child’s permanent teeth have erupted.

Health professionals should select the information in this section that is most appropriate, using clinical judgment to decide what is timely and relevant for each individual child and family.

Family Preparation

To help prepare families for oral health supervision visits, health professionals can provide parents with a list of topics to discuss at the next visit. Topics may include the following:

• Changes in the teeth and the mouth
• Oral hygiene practices (frequency, problems)
• Use of fluoridated water for drinking, cooking, or formula preparation
• Fluoride use (fluoridated toothpaste, fluoridated mouthrinse, fluoride supplements)
• Use of bottle or cup by child
• Feeding and eating practices
• Nonnutritive sucking (pacifier, thumb, finger)
• Illnesses or infections
• Medications
• Injuries to the teeth or mouth
• Parents' tobacco use

Interview Questions

Following are examples of questions that health professionals may use. In addition to asking these or other interview questions, discuss any issues or concerns the family has.

• Do you help Lynne brush her teeth? How has this been going? Are you using fluoridated toothpaste? How much toothpaste do you use to brush her teeth?
• Does Thomas drink from a cup? Does he take a bottle?
• How often does Benita snack? What does she usually eat?
• Does Kevin use a pacifier? Does he suck his thumb or finger?
• Do you and your family members wear seat belts in a car?
• What would you do if Jane knocked out one of her teeth?
• Has Carlos been to the dentist? If not, have you made an appointment for his first dental visit?
• When was Tracy's last visit to a health professional? Is it time for her next health supervision visit?

Risk Assessment

Use the risk assessment tables and caries risk assessment tools to assess the child's risk factors for oral health issues.

Screening

Visually inspect the lips, tongue, teeth, gums, inside of the cheeks, and roof of the mouth.

Examination

The first oral examination should occur within 6 months of the eruption of the first primary tooth, and no later than age 12 months. Thereafter the child should be seen according to a schedule recommended by the dentist, based on the child's individual needs and risk for developing oral diseases.

Anticipatory Guidance

Discuss with Parents:

Oral Health Care

• If the child has not yet been to a dentist, making an appointment for the child's first dental visit, thereby establishing a dental home.
• After the initial dental visit, making the next appointment for the child according to the schedule recommended by the dentist, based on the child's individual needs or risk for developing tooth decay.
• For children with special health care needs, making appointments for more frequent dental visits based on the child's individual needs or susceptibility to disease.
• Discussing with a dentist or other qualified health professional the need to apply fluoride varnish. Topical fluoride may be especially effective for children at high risk for tooth decay, particularly those who have a history of decay, do not have access to fluoridated water, snack frequently on foods or beverages containing sugar, or have a medical problem that decreases their resistance to tooth decay.
• Giving the child at high risk for developing tooth decay dietary fluoride supplements only as prescribed by a dentist or physician (see Dietary Fluoride Supplementation Schedule for Children and Adolescents at High Risk for Developing Caries).
• Discussing with a dentist or other qualified health professional the need to apply dental sealants to prevent tooth decay, shortly after the teeth erupt.

Oral Hygiene

• For children under age 3, brushing the teeth with a small smear of fluoridated toothpaste twice a day (after breakfast and before bed). Do not have the child rinse with water. The small amount of fluoridated toothpaste that remains in the mouth helps prevent tooth decay.
• For children ages 3 to 6, brushing the teeth with a pea-sized amount of fluoridated toothpaste twice a day (after breakfast and before bed). Make sure the child spits out the toothpaste after brushing but does not rinse with water. The small amount of fluoridated toothpaste that remains in the mouth helps prevent tooth decay.
• For effective plaque removal, making sure that a parent brushes the child's teeth at least once a day. Because brushing requires good fine motor control, young children cannot clean their teeth without parental help. After children acquire fine motor skills (e.g., the ability to tie their shoelaces), typically by age 7 or 8, they can clean their teeth effectively but should be supervised by a parent.
• For children with special health care needs, adapting or obtaining special oral health equipment (e.g., adapting a toothbrush) to brush the child's teeth, if needed.
• Becoming familiar with the normal appearance of the child's gums and teeth so that problems can be identified if they occur (see Tooth Eruption Chart). Checking the child's gums and teeth about once a month.
• Not allowing a child to use fluoridated mouthrinse, unless the child is able to spit the mouthrinse out.
• If the child has sore gums caused by tooth eruption, rubbing the child's gums with a clean finger or a moistened gauze pad or cool damp washcloth to try to ease the discomfort. Other options include giving the child a chilled teething ring (made of firm rubber) or cool spoon. If the child is especially cranky, give acetaminophen or ibuprofen following the dosage directions for children on the container.

Nutrition

• Serving a variety of healthy foods such as fruits, vegetables, whole-grain products (cereals, bread, or crackers), and dairy products (milk, cheese, cottage cheese, and unsweetened yogurt). Meats, fish, chicken, eggs, beans, and nuts are also good choices for meals and snacks.
• Serving healthy foods during planned meals and snacks, and limiting eating (grazing) in between.
• Serving fewer foods with added sugar, such as candy, cookies, cake, fruit-flavored drinks, and pop (soda). Frequent consumption of foods containing sugar increases the risk for tooth decay. Many foods contain one or more types of sugar, and all types of sugar can promote tooth decay. To help choose foods low in sugar, read food labels.
• Offering fruits rather than fruit juice. If juice is offered, serve only 100-percent fruit juice or reconstituted juice, and limit juice consumption to 4 oz per day for children ages 1–3 and 4–6 oz per day for children ages 4–6.
• To prevent sugary fluids from pooling around the teeth, which can increase the child's risk for tooth decay, not putting the child to sleep with a bottle or sippy cup. Also, do not allow prolonged bottle feedings or use of sippy cups with beverages containing sugar (e.g., fruit drinks, pop (soda), fruit juice), milk, or formula during the day or at night.
• Weaning the child from a bottle to a cup by age 12 to 14 months. Serve beverages in a cup.
• If the child drinks beverages between meals, serving water or milk rather than fruit juice, fruit-flavored drinks, or pop (soda).
• Serving water throughout the day, especially between meals and snacks. Drink fluoridated water (via a community fluoridated water source) or bottled water that contains fluoride.
• Avoiding sharing utensils (e.g., spoons) or orally cleaning a pacifier or a bottle nipple. This practice helps prevent transmission of bacteria that cause tooth decay from the parent to the child via saliva.

Nonnutritive Sucking

• If parents choose to have their child suck a pacifier, advising them to take certain safety precautions. The following precautions are recommended:
  • Never attaching a pacifier to a ribbon or string around the child's neck.
  • Making sure the pacifier is of sturdy, one-piece construction and that the material is flexible, firm, and not brittle.
  • Keeping the pacifier clean.
  • Not dipping a pacifier in sweetened foods (e.g., sugar, honey, syrup) to encourage sucking.
  • Never orally cleaning a pacifier, then giving it to a child.

Injury Prevention

• Being aware that injuries to the head, face, and mouth are common among children.
• Learning how to prevent oral injuries and how to handle oral emergencies. Because of the danger of damaging the underlying permanent teeth, never attempt to reinsert an avulsed (lost) primary tooth. It is impossible to relocate the tooth accurately, and there is danger of pushing it too far into the soft alveolar bone and damaging the permanent tooth developing below the primary tooth.
• Using an appropriate car seat in the back seat of the vehicle at all times.
  • For children ages 12 to 36 months, buckle children into rear-facing car seats until they reach the upper weight or height limits of their seats. Once they reach the upper weight or height limit of the rear-facing car seat, buckle children into forward-facing car seats. Check the owner's manual and/ or labels on the seat for weight and height limits.
  • For children ages 3 to 7, when they reach the upper weight or height limit of the rear-facing car seat, buckle the child into a forward-facing car seat with a harness and tether. Check the owner's manual and/ or labels on the seat for weight and height limits.
• Not placing a child in a carrier on top of a shopping cart. Instead, consider using a stroller, a wagon, or a frontpack while shopping with a child. If placing the child in a shopping cart, use a safety belt or harness at all times. If the child is placed in a shopping cart, follow these safety rules:
  • Place the child in a safety belt or harness at all times while in the cart.
  • Never leave the child alone in the shopping cart.
  • Do not let the child stand up in the shopping cart.
  • Do not let the child ride in the shopping cart basket.
  • Never let the child ride on the outside of the shopping cart.
• Using safety locks or latches on cabinets and drawers. Keep all sharp knives or other sharp utensils, poisonous substances, medicines, cleaning agents, health and beauty aids, and paints and paint solvents in a safe place.
• Keeping pet food and dishes out of reach. Do not permit the child to approach the pet while it is eating.
• Keeping electric appliance cables and dangling telephone, electric, blind, and drapery cords out of reach of children (e.g., wrap blind and drapery cords onto cleats so children cannot access them).
• Locking doors or using safety gates at the tops and bottoms of stairs, and using safety locks and safety devices on windows above the ground floor.
• Supervising the child on stairs and when climbing on and off furniture.
• Making sure that playgrounds are carefully maintained and that equipment is in good condition. All playground equipment should be surrounded by a soft surface (e.g., fine, loose sand; wood chips; wood or rubber mulch) or by rubber mats manufactured for this use.
• Supervising the child on playground equipment. Make sure children play only on developmentally appropriate equipment.
• Not giving toys small enough to be placed in the mouth. Make sure that toys do not have parts that can become detached. Keep toys with small parts or sharp edges out of reach.
• Making sure that toys are soft (e.g., balls not made with leather or hard materials).
• Ensuring that the child wears a bicycle helmet on all wheeled toys, even on a tricycle.
• Providing the child's caregivers with the dentist's emergency phone contacts, and ensuring that the caregivers know how to handle all emergencies.

Substance Use

• Avoiding exposing the child to secondhand smoke.

Outcomes

• Parents and child are under the care of an oral health professional.
• Parents are informed of oral development issues.
• Parents understand and practice good oral hygiene, feeding, and eating behaviors.
• Parents establish a safe environment and practice safety behaviors.
• Child has no oral disease or injury.