Assessing risk and reducing dental disease in the young child

Introduction

Early childhood caries (ECC) is currently the major public health epidemic facing dentistry in both underdeveloped and developed countries. (1) A 2007 Centers for Disease Control report noted that while Americans of all ages demonstrated improvement in oral health in the past decade, the two- to five-year old age group distinguished itself as the only cohort to experience an increase in untreated tooth decay--from 24 percent to 28 percent. (2)

The American Academy of Pediatric Dentistry (AAPD) defines ECC as 'the presence of one or more decayed, missing or filled tooth surfaces in any primary tooth in a child 71 months or younger. (3) Although often under-reported, there are numerous morbidities associated with the diagnosis and treatment of ECC, including parental days lost from work, transportation costs, acute pain, loss of function and utilization of emergency services. (4)

With nearly one-third of all children in early childhood affected by ECC, determining potential risk factors and preventive clinical strategies is essential and extremely important. The challenge for the clinician is identifying potential risk in order to predict dental disease in young children before it occurs. The scope of risk factors is wide and far reaching; however, we will focus on two critical ones: dietary and developmental factors.

The dental hygienist, as health promoter, is in a critical position to intervene and advocate healthy habits to families. Diet counseling and anticipatory guidance based on development are two valuable tools in that armamentarium that can help ensure a child's physical, social, emotional and behavioral health. To fully appreciate the magnitude of dietary and developmental issues, an understanding of the caries paradigm and shifts in risk assessment are required. (5)

[FIGURE 1 OMITTED]

Etiology

The traditional Venn diagram-based caries risk paradigm (Figure 1) at its most elemental was based on a substrate (plaque with fermentable carbohydrates), host (tooth) and oral microflora. The intersection of these three factors resulted in dental caries. Subsequent modifications recognized that the entire system progressed along time. Studies in the 1990s further refined the notion of a host by determining that bacterial colonization with mutans streptococci occurred in pre-dentate infants as young as three months of age. (6) The original Venn diagram came to be acutely recognized as a simplified representation of a chronic and infectious disease with a myriad of external and internal factors. It is now recognized that within each component of the traditional Venn diagram there are numerous subsections. As an example, within the 'host' category, oral clearance of sugars, dental age, local host factors and presence of mineralized structures such as Bohn's nodules have all been suggested as modifying the disease process in the young child. (6) The varying presence and strength of expression of these subsections may influence dental disease.

Risk Assessment

The science of determining risk factors for ECC presents a challenge in and of itself, primarily because, as suggested above, true causation is multifactorial and many limitations are inherent in the research. Studies that focused on socioeconomic status (SES) concluded a higher overall prevalence, possibly due to inclusion of a largely low SES patient pool, a population traditionally most vulnerable to the ravages of ECC. (7) Studies with younger children in samples had a lower overall prevalence possibly because in general children tended to get more caries as they got older. (8) Studies that focused on purely biological factors (i.e. the salivary concentration of cariogenic bacteria) sometimes neglected external variants such as maternal education affecting bacterial colonization. (9-11) Likewise, pure prevention-based studies that have focused on societal variants and therapeutic interventions sometimes sidestepped the significance of varying bacterial virulence and epi-genetic biomarkers as indicators of disease intensity. (12)

Figure 2. Dental nutrition risk assessment

Questions for a child's parent/caregiver:

Has your child ever had any cavities or fillings?

Enter 1 for yes
Enter 0 for no

Have any of the child's brothers or sisters ever had cavities
or fillings?

Enter 1 for yes
Enter 0 for no

How often does your child brush his/her teeth?

Enter 0 for at least twice a day
Enter 1 for once a day
Enter 2 for never or less than once a day

Does your child use fluoride toothpaste?

Enter 0 for yes
Enter 1 for no

How often does your child floss?

Enter 0 for every day or most days
Enter 1 for at least once a week, but not daily
Enter 2 for never/rarely (less than once a week)

Does your child take any sugar-containing medications or
vitamins on a regular basis?

Enter 0 for yes
Enter 1 for no

How many snacks does your child eat per day?

Enter 0 for 0, 1, or 2 snacks
Enter 1 for 3 snacks
Enter 2 for more than 3 snacks
Enter 3 for constant snacking

Which best describes when your child eats sweets?

Enter 0 for with meals
Enter 1 for at the end of meals
Enter 2 for with or as snacks
Enter 3 for never

How often does your child snack before bedtime?

Enter 0 for never
Enter 1 for occasionally
Enter 2 for often

How often does your child eat slowly dissolving candies
and/or lozenges?

Enter 0 for never/rarely
Enter 1 for often
Enter 2 for once a day
Enter 3 for more than once a day

Does your child chew sugar-free gum?

Enter 0 for yes
Enter 1 for no

How often does your child drink fruit juice, soda, or other
carbonated beverages?

Enter 0 for never/rarely
Enter 1 for often, but not every day
Enter 2 for daily, one or more consumed fast
Enter 3 for daily, one or more sipped slowly

If end score was:

9 or higher: Very high risk and needs nutrition counseling

4-8: Moderate risk. Will probably benefit from instructions
and handout.

0-3: Low risk. Will probably benefit from review of basic
instructions and handout.

Source: Harper LF, Faine NP: Nutrition in pregnancy, infancy, and
childhood. In M Cohen & N Kerian (Eds.), Diet and nutrition in oral
health (p. 360). Upper Saddle River, NJ: Pearson Education, Inc.
Used by permission from Pearson Education, Inc.