Infant oral health care

Anticipatory guidance included

1. Preventive Pedodontics Dr. Sucheta Prabhu Second year MDS

2. Contents Levels of prevention Infant oral health care Anticipatory guidance Dental home

3. Questions asked previously Short essay 1.Anticipatory guidance for infant oral health care. 2.Anticipatory guidance 3.Infant oral health care 4.Risks & benefits of pacifiers AAP and AAPD guidelines. 5. Dental home Long essay Describe the comprehensive programme for infant oral health care in India. (20 marks) Infant oral health and dental home

4. What is prevention? The art and science of utilization of knowledge,skill and available measures to prevent occurrence of a disease, control already existing diseases so that it prevents spread and complications.

5. Levels of prevention

6. Primary prevention Health promotion Specific protection

7. Primary Prevention

8. Secondary Prevention

9. Disability limitation

10. Tertiary Prevention Preventive Services Disability Limitation Rehabilitation Services provided by the individual Use of dental services Use of dental services Services provided by the community Provision of dental services Provision of dental services Services provided by the dental professional Complex restorative dentistry Pulpotomy RCT Extractions Removable & fixed prosthodontics Implants

11. Infant oral health care

12. Definition

13. Historical background

14. GOALS OF INFANT ORAL HEALTH PROGRAM • To identify , intercept and modify the potentially harmful parenting practices that may adversely affect the infant’s oral health. • Parent education right from the prenatal period highlighting the importance of their role in the prevention of dental disease for their child. • Parent/ caregiver orientation to perceive dental services as an integral part of infant’s overall health program. • Periodic evaluation of the oro -facial development and oral health by the clinician .

15. PREVENTION AND MANAGEMENT PROTOCOLS FOR INFANTS Since family physicians and pediatricians often see the child up to six times before age 2 , it is crucial to take these appointments as opportunities to increase awareness of oral health evaluations and screen young children for caries risk and refer for dental care. – Tooth eruption – Preventive oral hygiene – Orofacial development – Fluoridation – Diet

16. PRENATAL COUNSELLING • Objectives: – Establishing a positive Pediatric dentist-family relationship. – Information gathering from the family – Anticipatory guidance – Establishing sequence of subsequent visits

17. PERINATAL ORAL HEALTH • A direct relationship exists between MS levels in adult caregivers and that of caries prevalence in their children. (Douglas JM et al ) • Improving expectant mother’s oral health by reducing pathogenic bacteria levels in their own mouths, will delay the acquisition of oral bacteria and the development of ECC in their children. (Ramos-Gomes F) Therapeutic intervention and lifestyle modification counseling both during pre- and post-partum should be practiced, to reduce maternal MS and lactobacilli levels

18. Colonization of infant’s oral cavity Vertical transmission From mother to infant. (Davey AL et al, Berkowitz RJ, Douglass JM et al) • The genotypes of streptococcus mutans in infants appear to be identical to that present in mother.

19. Maternal factors associated with infant colonization •– –––– Wan AK et al 2010

20. Horizontal transmission • Between members of a group. • Siblings of similar age. • Children in a day care centre .

21. Effect of mode of delivery on oral microflora • In the oral cavity, mutans streptococci were detected more frequently and at a younger age in children delivered by C-section than in those delivered vaginally.

22. Predentate infants Berkowitz RJ (2006), Law V (2007) and Tanner ACR (2002): furrows of tongue can also harbour mutans streptococci in predentate infants.

23. Oral flora of pre-dentate mouth • Since the oral cavity of the neonate lacks teeth and only mucosal surfaces are available during the first months of life, organisms with ligands for the tooth are absent . • Epithelial binding sites for group A streptococci and their lipoteichoic acid in the oral cavity of newborn infants are absent or minimal at birth, but reach adult levels between 48 and 72 hours after birth.

24. WINDOW OF INFECTIVITY The “window of infectivity,” defined as the time of initial colonization of the infant’s oral environment with the cariogenic bacteria mutans streptococci (MS ) • Early studies reported that the “window of infectivity” for MS occurs at a mean age of 27 months .

25. Few Studies

26. Second window of infectivity

27. Diet counselling during the infant oral health visit Breastfeeding : Exclusive breastfeeding till 6 months followed by addition of iron-enriched solid foods between 6-12 months of age. Ad libitum nocturnal breast-feeding should be avoided after the first primary tooth begins to erupt . Weaning : It has been observed that breast-feeding for over 1 year and at night beyond eruption of teeth may be associated with Early Childhood Caries. AAPD recommends that infants should drink from a cup as they approach their first birthday and be weaned from the bottle at 12-14 months of age.

28. Diet counselling during the infant oral health visit Dietary fluoride supplements: Infants > 6 months of age exposed to water with less than 0.3 ppm fluoride, dietary fluoride supplements of 0.25 mg fluoride per day should be prescribed. Irrespective of fluoride exposure in water dietary supplements should not be prescribed for infants under the age of 6 months. Bottle feeding: Infant formulas are acidogenic and possess cariogenic potential. Parents need to be aware of deleterious effects of inappropriate bottle usage and the need for good oral hygiene practices upon the first primary tooth’s eruption.

29. ADVANTAGES OF BREASTFEEDING

30. Composition of breast milk • Its energy content is 60-75 kcal/100 ml. • Contains over 200 nutritional, as well as functional components . Colostrum Secreted first 3- 7 days postpartum. Slightly yellow, more viscous, and thicker. Lower in calories, contains less sugar. Contains more protein and electrolytes. Immunoglobulin A is the principal protein found in colostrum. IgA helps protect the infant from gastrointestinal tract infections.

31. Breast milk Transitional Milk •One week postpartum colostrum changes into transitional milk. • Transitional milk is between colostrum and mature milk, it is composed of more protein and less fat and less lactose than mature milk . • Fully mature milk is produced at about three weeks postpartum, but this rate may vary from mother to mother.

32. Breast milk vs Formula

33. BREAST FEEDING vs BOTTLE FEEDING •

34. WEANING • Process of expanding the diet to include foods and drinks other than breast milk and infant formulae. • It is a gradual process Babies should not be weaned at an earlier age, • Lack neuromuscular coordination needed to move food from tip of tongue to the back of the mouth. • G astrointestinal tract is too immature to digest

35. Stages of Weaning

36. R ecommend that parents start weaning at approximately 9 months of age and accomplish soon after the first birthday (AAP1985) • Bed time bottle feedings to be discouraged especially after tooth eruption. • If bed time bottles are given, water is considered the only acceptable feeding substance ( Feigal 1985)

37. 4-6 months Teething • Symptoms: – Fussiness, irritability – Increased sucking – Loose stools – Increased drooling of saliva – High temperature – Swollen gums • Symptomatic treatment of teething: – Sucking on teething rings – Numbing gels – Frozen pacifier – Teething tablets

38. ANTICIPATORY GUIDANCE “The process to provide practical, developmentally appropriate information about the children’s health to prepare parents for the significant physical, emotional and psychological milestones .”

39. AAPD’s Age Ranges

40. Content areas

41. Guidelines for 6 to 12 months of age Milestones: the eruption of the first primary tooth  Oral development  Review pattern of eruption Review teething fact  Fluoride  Assess fluoride status- no more than smear sized fluoridated toothpaste used twice daily  Determine supplements if needed such as fluoride varnishes  Oral hygiene/health  Review oral hygiene techniques with parents  Plan for next visit based on risk assessment  Habits  Review pacifier use  Discuss thumb sucking effects on mouth

42. Guidance for 12 to 24 months of age Milestones : completion primary dentition, occlusal relationships establishment, arch length determined.  Oral development  Discuss importance of space maintaining  Discuss bruxing  Fluoride  Reassess fluoride status  Discuss toxicity and how to manage accidental ingestion  Oral hygiene/health  Review home oral care procedure and compliance

43. Guidance for 12 to 24 months of age  Habits  Review non nutritive sucking  Thumb sucking and pacifiers use will lead to Anterior open bite, maxillary constriction etc..  Nutrition and diet  Discuss carbohydrate and their role in plaque development  Discuss the frequency of carbohydrate intake as caries factor  Injury prevention Discuss electric cord safety, child proofing the house  Develop plans for oral trauma management for preschool and child care

44. Guidance for 2 to 6 years of age Milestones : loss of first primary tooth, eruption of first permanent molar or incisor  Oral development  Review patterns of eruption, point out permanent incisor  Describe healthy periodontal tissue  Fluoride  Fluoridated toothpastes not more than a pea size  Child should brush under the supervision of parents to ensure expectoration  Oral hygiene/health  Review home oral care procedures and compliance  Discuss dental sealants and describe dental radiographs  Plan for next visit based on risk assessment

45. Guidance for 2 to 6 years of age  Habits  If child is still sucking the thumb, discuss to help him stop the habit  Nutrition and diet  Review diet outside the home and its caries potential  Discourage the use of food as a behavioral tool  Injury prevention  Encourage the use of helmets, mouth guards, and car seats  Develop plans for oral trauma management  Review difference between primary and permanent teeth with parents during examination

46. Guidance for 6 to 12 years of age Milestones: eruption of first permanent molar  Oral development  Discuss about the importance first permanent molar  Discuss the various preventive measures taken at this stage to prevent progression of caries  Nutrition and diet  Review diet outside the home and its caries potential  Fluorides  Application topical fluorides if needed  Regular use of tooth paste is recommended

47.  Oral hygiene/health  Parents should continues to monitor brushing and flossing frequency and adequacy  Application of pit and fissure sealants if necessary  Habits  Educate about any oral habits if it is present  Educate the parents about transitional changes in the developing dentition and the importance of primary and permanent dentition

48. Guidance for adolescent  Prevention of periodontal disease becomes a special concern  At this age group the main process utilized are a) Rejection of many parental values b) The beginning of independent struggle c) The testing out types of behavioural experimentaion  Parents are educated that they should treat the child at this stage very diplomatically,friendly approach  The child should be given enough emotional support from parents

49.  Oral hygiene/health  The adolescent patient posses the fine motor skills necessary for adequate tooth brushing and flossing  Problems in compliance are likely to be encountered  Diet  High frequency of sugar consumption  Progression of lession halted with an appropriate diet and aggressive topical fluoride therapy  Fluorides  Systemic fluorides are no longer benefit after the last permanent tooth erupt at about age of 13 yrs  Topical fluorides are the most effective preventive measure.

50.  Orthodontics  Many Patients undergo orthodontic treatment at this stage  High risk for both gingivitis and gingival hyperplasia and for dental caries  Smokeless tobacco  Peer pressure and advertising exert pressure on adolescent to establish a habit that may result in addiction.  Parents should be instructed not to punish the adolescent as it may further worsen the habit  Discuss the health risk in smoking  Instruct parents to avoid smoking infront of the children  Discuss nicotine replacement and medication

51. “ the goal of the first oral supervision visit is to assess the risk for dental disease, initiate a preventive program , provide anticipatory guidance and decide in the periodicity of subsequent visits ”. Nowak (1997) as early as six months of age and no later than 12 months of age.

52. DENTAL HOME CONCEPT

53. Definition The Dental Home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive , continuously accessible , coordinated , and family-centered way . The Dental Home should be established no later than 12 months of age and includes referral to dental specialists when appropriate. .

54. STEPS AT DENTAL HOME

55. Ideal characteristics Comprehensive Continuous Coordinated Compassionate Culturally competent

56. INITIAL INFANT ORAL CARE VISIT Should include caries risk assessment, individualized preventive strategies and anticipatory guidance.

57. Consists of a 6 step protocol: . • Periodic supervision of care (knows as periodicity) should be determined based on the disease risk for each individual patient.

58. References Croll TP. A child's first dental visit: a protocol. Quint int 1984; 6:625-37. Nikiforuk g. Understanding dental caries. In: prevention: basic and clinical aspects. Ii. Basel: karger , 1985; 37-8, 133-4. Chiodo gt , rosenstein di. Dental treatment during pregnancy: a preventive approach. J am dent assoc 1985; 110:365-8. Peter s. Essentials of preventive and community dentistry.3 rd ed.Arya publishing house Marwah N.Textbook of pediatric dentistry .3 rd ed.Jaypee medical publishers. AAPD Guideline on infant oral care.2015 revision Reference manual v 37 / no 6 15 / 16 AAPD.Guideline on periodicity of examination,preventive services,anticipatory guidance and oral treatment for infants,children and adolescents.Revision 2013. Reference manual v 39 / no 5 178 / 82 Sigal M Levine N. Infant oral health care.Can . Fam. Physician vol. 34: june 1988