**Oral Health Care in Children – A Preventive Perspective**

Agim Begzati1, Kastriot Meqa2, Mehmedali Azemi3, Ajtene Begzati1, Teuta Kutllovci1, Blerta Xhemajli1 and Merita Berisha4 *1Department of Pedodontics and Preventive Dentistry, School of Dentistry, Medical Faculty, University of Prishtna, Prishtina, 2Department of Periodontology and Oral Medicine, School of Dentistry, Medical Faculty,University of Prishtina, Prishtina, 3Department of Paediatric, Medical Faculty, University of Prishtina, Prishtina, 4National Institute of Public Health of Kosovo, Department of Social Medicine, Medical Faculty, University of Prishtina, Prishtina Republic of Kosovo* 

#### **1. Introduction**

18 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

Williams, N. J., Whittle, J. G., & Gatrell, A. C. (2002). The Relationship between Socio-

Yin, H. S., Johnson, M., Mendelsohn, A. L., Abrams, M. A., Sanders, L. M., & Dreyer, B. P.

Zeedyk, M. S., Longbottom, C., & Pitts, N. B. (2005). Tooth-Brushing Practices of Parents and

ISSN 0007-0610

(Jan-Feb 2005), pp. 27-33, ISSN 0008-6568

1098-4275

Demographic Characteristics and Dental Health Knowledge and Attitudes of Parents with Young Children. *Br Dent J*, Vol.193, No.11, (Dec 7 2002), pp. 651-4,

(2009). The Health Literacy of Parents in the United States: A Nationally Representative Study. *Pediatrics*, Vol.124 Suppl 3(Nov 2009), pp. S289-98, ISSN

Toddlers: A Study of Home-Based Videotaped Sessions. *Caries Res*, Vol.39, No.1,

Health has been described by the World Health Organization (WHO) as follows:"health comprise complete physical and social well-being and is not merely the absence of disease" (World Health Organization 1946).

According to World Health Organization, oral health is the overall health of teeth and toothsupporting tissues, and oral soft tissues, with the aim of fulfilling physiological functioning of the masticatory organ for chewing, phonation and esthetics. The US the Department of Health defined the health as oral "standard of health of the oral and related tissues which enables an individual to eat, speak and socialize without active disease, discomfort or embarrassment and which contributes to general well-being" (US Department of Health, 2000). Oral health is integral to general health and should not be considered in isolation. Oral disease has detrimental effects on an individual's physical and psychological wellbeing and it reduces quality of life.

Oral health is not only important to person's appearance and sense of well-being, but also to person's overall health. Dental caries is the most common cause of the disturbances of normal functions in the oral cavity, respectively it is a lack of preventive and curative measures.

Gingivitis represents another serious problem for oral health. Data have shown a high prevalence of gingivitis among children. Gum disease is an inflammation of the gums, which may also affect the bone supporting the teeth, and may be followed with periodontitis. The role of dental plaque, respectively of the periopathogenic bacteria, has been considered as the most important factor in occurrence of caries and gum diseases. Plaque is a sticky colorless film of bacteria (biofilm) that constantly builds up, thickens and hardens on the teeth. If it is not removed by daily brushing and flossing, this plaque may harden into tartar and may contribute to inflammation and infections in the gums. Plaque is

Oral Health Care in Children – A Preventive Perspective 21

multifactorial etiology. Dietary factors, oral microorganisms that can produce acids from sugars, and host susceptibility all need to coexist for caries to develop (Konig & Navia

Analyzing the etiology, prevalence, clinical specifics, consequences and complications, dental caries is estimated as a serious disease, which represents not only as a health problem, but also a great serious social and economic problem. Many studies, clinical, but mostly longitudinal epidemiological studies, have offered convincing facts on the multifactorial nature of this disease. The multitude of factors that influence in the dental caries occurrence, having in mind that they act together, not separately, contribute in the complexity of the pathogenesis of caries, making it more difficult to undertake efficient

There are some important factors that comprise the etiological circles of the dental caries: host or the tooth, dental or bacterial plaque, substrate – carbohydrates and saliva, and altogether co-react with the time factor. These circles are the *circulus viciosus* of the dental caries development. The hard dental structures, initially the enamel, undergo the demineralization process, respectively the caries. The caries development in the enamel surface is equally dependent from the inner hard dental structure and from the intensity of

Newest concept in the field of dentistry gives an explanation how dental caries is caused as a result of the disturbance of the "Caries Balance" (Featherstone 2004). This misbalance may be manifested in the beginning of demineralization or during the process of remineralization. The theory of "Caries Balance" defines dental caries as a disease of hard dental tissues, and the destruction of the enamel surface as a result of the disruption of the balance of demineralization and remineralization. The defect in the enamel surface is a result of the domination of the demineralization process and such process has progressive course directed towards pulpar space. Which process will dominate depends on the proportions of the factors that constitute "Caries Balance", i.e. protetctive and pathological

1995).

factors.

preventive measures.

the extrinsic factors' action.

Pathological factors that include:

Protective factors that include: 1. salivary components,

2. fluoride and remineralization, and

2. frequent ingestion of fermentable carbohydrates, and

Effective caries managment revolves around these principles.

factors tend to be influenced specifically by the culture in place.

3. salivary dysfunction drive the caries process towards demineralization.

3. antibacterial therapy drive the caries process towards remineralization.

In order to control dental caries, i.e. to prevent its occurrence or to start the remineralization process during initial stage, it is necessary that the proportions of these factors be kept in the direction of the protective factors. The level of risk for dental caries depends on the domination of the certain group of factors that participate in the "Caries Balance". If there is a domination of the pathological factors, the risk for dental caries will be higher and the treatment needs will require larger restorative interventions, as well as other consequences. If there is a domination of protective factors, then the invasive restorative dentistry will have fewer burdens, and concentrate in minimal restorations of superficial caries. Biological factors tend to be similar within all cultures and populations, although habit/environmental

1. cariogenic bacteria,

an important prerequisite in aethiology of caries because acid is generated within its substance to such an extent that enamel may be demineralised. Dietary sugars diffuse rapidly through plaque where they are converted to acids by bacterial metabolism. Mutans streptococci are now considered to be the major cariogenic bacteria species involved in the caries process. (Soames & Southam 1999; Norman & Franklin 1999).

Oral diseases may contribute in many serious conditions, such as heart disease and stroke, pneumonia and other respiratory diseases, diabetes. Untreated cavities can also be painful and lead to serious infections. Currently, studies have been examining whether there is a link between poor oral health and heart disease and between poor oral health and women delivering pre-term, low birth rate babies.

Caries and tooth supporting structures' diseases (gingivitis and periodontitis), as the most spreading diseases worldwide, do not disturb only the dental and oral functions, but due to the complications and consequences of non-prevention or lack of treatment they may seriously endanger the systemic health and influence directly the living quality. Thus these diseases should be characterized not only as medical, but also as social problem. These diseases have been studied and discussed also by the public health fields, such as: Dental public health, Oral public health, Community public health, etc.

Dental public health has been described by the American Board of Dental Health as the science and art of preventing and controlling dental disease and promoting dental health through organized community efforts (Winslow 1920).

The terms public health and community health are used synonymously, and both refer to the "effort that is organized by society to protect, promote and restore the health and quality of life of people" (Block 2003).

Since dental caries, as well as gingivitis and periodontitis, both have a high prevalence and etiological factor – the bacterial plaque, this chapter will be based on the explanation of the prevalence, ethiopathogenesis of the bacterial plaque and the role of the bacteria, favorizing factors for plaque accumulation (oral hygiene and feeding habits), and finally the role of the preventive measures from the educational perspective.

The explanation of these objectives will be done through scientific examinations conducted from the subjects regarding the dental caries in general and early childhood caries in particular, as well as through oral health promotion in children and mothers.

#### **2. Dental caries**

#### **2.1 Definition, etiology and risk factors**

Dental caries may be defined as a bacterial disease of the hard tissues of the teeth characterized by demineralization of the inorganic and destruction of the organic substance of tooth (Soames & Southam 1999).

Dental caries is one of the most prevalent diseases in children worldwide. The Centers for Disease Control and Prevention reports that dental caries is perhaps the most prevalent infectious diseases in children. Dental caries is five times more common than asthma and seven times more common than hay fever in children (US Department of Health and Human Services 2000).

Dental caries is a disease that affects all age groups, most commonly children.

The general opinion regarding the etiology of dental caries nowadays is that it is a very complex multifactorial disease, presented with high prevalence in all age groups. It has already been established that dental caries is a chronic infectious process with a

an important prerequisite in aethiology of caries because acid is generated within its substance to such an extent that enamel may be demineralised. Dietary sugars diffuse rapidly through plaque where they are converted to acids by bacterial metabolism. Mutans streptococci are now considered to be the major cariogenic bacteria species involved in the

Oral diseases may contribute in many serious conditions, such as heart disease and stroke, pneumonia and other respiratory diseases, diabetes. Untreated cavities can also be painful and lead to serious infections. Currently, studies have been examining whether there is a link between poor oral health and heart disease and between poor oral health and women

Caries and tooth supporting structures' diseases (gingivitis and periodontitis), as the most spreading diseases worldwide, do not disturb only the dental and oral functions, but due to the complications and consequences of non-prevention or lack of treatment they may seriously endanger the systemic health and influence directly the living quality. Thus these diseases should be characterized not only as medical, but also as social problem. These diseases have been studied and discussed also by the public health fields, such as: Dental

Dental public health has been described by the American Board of Dental Health as the science and art of preventing and controlling dental disease and promoting dental health

The terms public health and community health are used synonymously, and both refer to the "effort that is organized by society to protect, promote and restore the health and quality

Since dental caries, as well as gingivitis and periodontitis, both have a high prevalence and etiological factor – the bacterial plaque, this chapter will be based on the explanation of the prevalence, ethiopathogenesis of the bacterial plaque and the role of the bacteria, favorizing factors for plaque accumulation (oral hygiene and feeding habits), and finally the role of the

The explanation of these objectives will be done through scientific examinations conducted from the subjects regarding the dental caries in general and early childhood caries in

Dental caries may be defined as a bacterial disease of the hard tissues of the teeth characterized by demineralization of the inorganic and destruction of the organic substance

Dental caries is one of the most prevalent diseases in children worldwide. The Centers for Disease Control and Prevention reports that dental caries is perhaps the most prevalent infectious diseases in children. Dental caries is five times more common than asthma and seven times more common than hay fever in children (US Department of Health and

The general opinion regarding the etiology of dental caries nowadays is that it is a very complex multifactorial disease, presented with high prevalence in all age groups. It has already been established that dental caries is a chronic infectious process with a

particular, as well as through oral health promotion in children and mothers.

Dental caries is a disease that affects all age groups, most commonly children.

caries process. (Soames & Southam 1999; Norman & Franklin 1999).

public health, Oral public health, Community public health, etc.

through organized community efforts (Winslow 1920).

preventive measures from the educational perspective.

**2.1 Definition, etiology and risk factors** 

of tooth (Soames & Southam 1999).

delivering pre-term, low birth rate babies.

of life of people" (Block 2003).

**2. Dental caries** 

Human Services 2000).

multifactorial etiology. Dietary factors, oral microorganisms that can produce acids from sugars, and host susceptibility all need to coexist for caries to develop (Konig & Navia 1995).

Analyzing the etiology, prevalence, clinical specifics, consequences and complications, dental caries is estimated as a serious disease, which represents not only as a health problem, but also a great serious social and economic problem. Many studies, clinical, but mostly longitudinal epidemiological studies, have offered convincing facts on the multifactorial nature of this disease. The multitude of factors that influence in the dental caries occurrence, having in mind that they act together, not separately, contribute in the complexity of the pathogenesis of caries, making it more difficult to undertake efficient preventive measures.

There are some important factors that comprise the etiological circles of the dental caries: host or the tooth, dental or bacterial plaque, substrate – carbohydrates and saliva, and altogether co-react with the time factor. These circles are the *circulus viciosus* of the dental caries development. The hard dental structures, initially the enamel, undergo the demineralization process, respectively the caries. The caries development in the enamel surface is equally dependent from the inner hard dental structure and from the intensity of the extrinsic factors' action.

Newest concept in the field of dentistry gives an explanation how dental caries is caused as a result of the disturbance of the "Caries Balance" (Featherstone 2004). This misbalance may be manifested in the beginning of demineralization or during the process of remineralization. The theory of "Caries Balance" defines dental caries as a disease of hard dental tissues, and the destruction of the enamel surface as a result of the disruption of the balance of demineralization and remineralization. The defect in the enamel surface is a result of the domination of the demineralization process and such process has progressive course directed towards pulpar space. Which process will dominate depends on the proportions of the factors that constitute "Caries Balance", i.e. protetctive and pathological factors.

Pathological factors that include:


3. salivary dysfunction drive the caries process towards demineralization.

Protective factors that include:


In order to control dental caries, i.e. to prevent its occurrence or to start the remineralization process during initial stage, it is necessary that the proportions of these factors be kept in the direction of the protective factors. The level of risk for dental caries depends on the domination of the certain group of factors that participate in the "Caries Balance". If there is a domination of the pathological factors, the risk for dental caries will be higher and the treatment needs will require larger restorative interventions, as well as other consequences. If there is a domination of protective factors, then the invasive restorative dentistry will have fewer burdens, and concentrate in minimal restorations of superficial caries. Biological factors tend to be similar within all cultures and populations, although habit/environmental factors tend to be influenced specifically by the culture in place.

Oral Health Care in Children – A Preventive Perspective 23

lesion. Decayed, filled and extracted/missing (due to caries) teeth were recorded in a

DMFT (for permanent dentition) and dmft (for primary dentition) describe the number, or the prevalence, of caries in an individual. DMFT and dmft are methods to numerically express the caries experience and are obtained by calculating the number of decayed (D),

In the sample, 28.6% of the children were with no observable clinical signs of caries (dmft =0) at the age of two. As expected, this percentage decreased with increasing age. Only 2.1% of six-year-old children were caries-free. The mean dmft in preschool children was 5.6. The lowest mean dmft was seen in two-year-old children (2.1), while the highest

As expected, the mean dmft among preschool children increased with age, with significant statistical differences between adjacent age groups (two-year-olds vs. three-year-olds, threeyear-olds vs. four-year-olds, and four-year-olds vs. – p<0.001), except between five-yearolds and six-year-olds (p>0.5). An ANOVA test showed statistical differences between all of

**≤2 y 3 y 4 y 5 y 6 y age groups**

The greatest contribution to the dmft index was untreated caries, which varied from 2.04 for two-year-olds to 6.37 for five-year-olds. A slight decrease was showed among six-year-old

children. Six-year-old children showed a slight decrease (6.09) (Fig. 1).

modified WHO Oral Health Assessment Form.

**2.3.1 The prevalence of caries of preschool children** 

Fig. 1. Mean dmft of preschool children by age groups

the age groups (F=204.59, p<0.001).

**0**

**2 4**

**6 8**

**10**

**12 14**

**16 18**

**20**

were in five- and six-year-olds (8.1 and 7.9, respectively). (Fig. 1)

missing (M), and filled (F) teeth (T).

#### **2.2 The epidemiology of dental caries**

It has already been mentioned that dental caries is the mostly spread disease in the world. In a study carried out in Kosovo we have assessed the prevalence of dental caries in comparison with other countries. The data from this oral health assessment of children of Kosovo showed a very high caries experience in both the primary and permanent dentitions. Caries prevalence expressed via the DMFT index was very high. Epidemiological data (years 2002-2005) derived from our study showed a high prevalence of dental caries among children in Kosovo (89.2% among preschool children and 94.4% among school children). The mean dmft/DMFT index was 5.86 for preschool children (ages 2 to 6) and 4.86 for all school children (ages 7 to 14) (Begzati et al. 2011).

The results from the same previous study show that dental health of these children in Kosovo is worse than that of children in other European countries. Specifically, the mean dmft of five-year-olds at preschools in Kosovo (8.1) was found to be higher than the same value of preschool children in USA (1.7) and in many other European countries (1991-1995), including Ireland (0.9), Spain (1.0), Denmark (1.3), Norway (1.4), Finland (1.4), Netherlands (1.7), United Kingdom (2.0), France (2.5), and Germany (2.5). Our results are only comparable to the rates in Belarus (7.4), Sarajevo, Bosnia (7.53) (ages 5-7) and Albania (8.5), (Marthaler 1995; Kobaslia 2000). The low treatment rate of children in Kosovo (<2%) indicates a high treatment need. Also, the mean DMFT (5.8) of school children in Kosovo (age 12) was higher in comparison with school children (age 12) of the following developed countries: Netherlands (1.1), Finland (1.2), Denmark (1.3), USA (1.4), United Kingdom (1.4), Sweden (1.5), Norway (2.1), Ireland (2.1), Germany (2.6) and Croatia (2.6) (16). The mean DMFT of Kosovo's children (age 12) was similar to the mean values in Latvia (7.7), Poland (5.1) and a group of 12- to 14-year-olds in Sarajevo, Bosnia (7.18) (Marthaler 1995; Kobaslia 2000). As it was previously mentioned, the low treatment rate of the children in Kosovo is unfavorable and indicates a high treatment need.

#### **2.3 Oral health assessment in school and preschool children – Epidemiological study**

In order to assess the oral health of preschool and school children, the dental examination was carried out (Begzati et al. 2011). The sample in this study consisted of two groups derived from a multi-site examination: preschool and school children. From a total of 3,793 examined children, there were 1,237 preschool children (aged 2 to 6 years old) and 2,556 school children (aged 7 to 14 years old). This was a cross-sectional study conducted in randomly selected locations in Kosovo. The sample size was calculated with a confidence level of 95% and a confidence interval of 2.

The study was specifically based on the dmft/DMFT index, following the recommendations of the World Health Organization (WHO Oral Health Surveys 1997).

Preschool children were examined at various kindergartens in different locations of Kosovo. The examinations were done under natural light, using a dental mirror and a probe. It was performed by five dentists from the Prishtina University Dental Clinics, mainly from the Preventive Dentistry Department. The Study Group for Oral Health Promotion conducted the study, and the examiners received relevant training in advance. Diagnostic criteria were calibrated (Hunt 1986), with an inter-examiner reliability of kappa = 0.92 based on the examination of 30 children of different ages. For the caries assessments, all tooth surfaces were examined. Every defect in the tooth was tested with a probe, and every visual change in the enamel transparency in the early phases of demineralization was defined as a carious

It has already been mentioned that dental caries is the mostly spread disease in the world. In a study carried out in Kosovo we have assessed the prevalence of dental caries in comparison with other countries. The data from this oral health assessment of children of Kosovo showed a very high caries experience in both the primary and permanent dentitions. Caries prevalence expressed via the DMFT index was very high. Epidemiological data (years 2002-2005) derived from our study showed a high prevalence of dental caries among children in Kosovo (89.2% among preschool children and 94.4% among school children). The mean dmft/DMFT index was 5.86 for preschool children (ages 2 to 6) and

The results from the same previous study show that dental health of these children in Kosovo is worse than that of children in other European countries. Specifically, the mean dmft of five-year-olds at preschools in Kosovo (8.1) was found to be higher than the same value of preschool children in USA (1.7) and in many other European countries (1991-1995), including Ireland (0.9), Spain (1.0), Denmark (1.3), Norway (1.4), Finland (1.4), Netherlands (1.7), United Kingdom (2.0), France (2.5), and Germany (2.5). Our results are only comparable to the rates in Belarus (7.4), Sarajevo, Bosnia (7.53) (ages 5-7) and Albania (8.5), (Marthaler 1995; Kobaslia 2000). The low treatment rate of children in Kosovo (<2%) indicates a high treatment need. Also, the mean DMFT (5.8) of school children in Kosovo (age 12) was higher in comparison with school children (age 12) of the following developed countries: Netherlands (1.1), Finland (1.2), Denmark (1.3), USA (1.4), United Kingdom (1.4), Sweden (1.5), Norway (2.1), Ireland (2.1), Germany (2.6) and Croatia (2.6) (16). The mean DMFT of Kosovo's children (age 12) was similar to the mean values in Latvia (7.7), Poland (5.1) and a group of 12- to 14-year-olds in Sarajevo, Bosnia (7.18) (Marthaler 1995; Kobaslia 2000). As it was previously mentioned, the low treatment rate of the children in Kosovo is

**2.3 Oral health assessment in school and preschool children – Epidemiological study**  In order to assess the oral health of preschool and school children, the dental examination was carried out (Begzati et al. 2011). The sample in this study consisted of two groups derived from a multi-site examination: preschool and school children. From a total of 3,793 examined children, there were 1,237 preschool children (aged 2 to 6 years old) and 2,556 school children (aged 7 to 14 years old). This was a cross-sectional study conducted in randomly selected locations in Kosovo. The sample size was calculated with a confidence

The study was specifically based on the dmft/DMFT index, following the recommendations

Preschool children were examined at various kindergartens in different locations of Kosovo. The examinations were done under natural light, using a dental mirror and a probe. It was performed by five dentists from the Prishtina University Dental Clinics, mainly from the Preventive Dentistry Department. The Study Group for Oral Health Promotion conducted the study, and the examiners received relevant training in advance. Diagnostic criteria were calibrated (Hunt 1986), with an inter-examiner reliability of kappa = 0.92 based on the examination of 30 children of different ages. For the caries assessments, all tooth surfaces were examined. Every defect in the tooth was tested with a probe, and every visual change in the enamel transparency in the early phases of demineralization was defined as a carious

of the World Health Organization (WHO Oral Health Surveys 1997).

**2.2 The epidemiology of dental caries** 

4.86 for all school children (ages 7 to 14) (Begzati et al. 2011).

unfavorable and indicates a high treatment need.

level of 95% and a confidence interval of 2.

lesion. Decayed, filled and extracted/missing (due to caries) teeth were recorded in a modified WHO Oral Health Assessment Form.

DMFT (for permanent dentition) and dmft (for primary dentition) describe the number, or the prevalence, of caries in an individual. DMFT and dmft are methods to numerically express the caries experience and are obtained by calculating the number of decayed (D), missing (M), and filled (F) teeth (T).

#### **2.3.1 The prevalence of caries of preschool children**

In the sample, 28.6% of the children were with no observable clinical signs of caries (dmft =0) at the age of two. As expected, this percentage decreased with increasing age. Only 2.1% of six-year-old children were caries-free. The mean dmft in preschool children was 5.6. The lowest mean dmft was seen in two-year-old children (2.1), while the highest were in five- and six-year-olds (8.1 and 7.9, respectively). (Fig. 1)

Fig. 1. Mean dmft of preschool children by age groups

As expected, the mean dmft among preschool children increased with age, with significant statistical differences between adjacent age groups (two-year-olds vs. three-year-olds, threeyear-olds vs. four-year-olds, and four-year-olds vs. – p<0.001), except between five-yearolds and six-year-olds (p>0.5). An ANOVA test showed statistical differences between all of the age groups (F=204.59, p<0.001).

The greatest contribution to the dmft index was untreated caries, which varied from 2.04 for two-year-olds to 6.37 for five-year-olds. A slight decrease was showed among six-year-old children. Six-year-old children showed a slight decrease (6.09) (Fig. 1).

Oral Health Care in Children – A Preventive Perspective 25

rampant clinical progression makes ECC a serious public health problem. Due to varying clinical, etiological, localization, and course features, this pathology is found under different names such as labial caries (LC), caries of incisors, nursing bottle mouth, rampant caries (RC), nursing bottle caries (NBC), nursing caries, baby bottle tooth decay (BBTD), early childhood caries (ECC), rampant infant and early childhood dental decay, and severe early childhood caries (SECC) (James 1957; Goose 1967; Fass 1962; Winter et al.1966; Derkson & Ponti 1982; Ripa 1988; Arkin 1986; Bruered et al. 1989; Kaste & Gift 1995; Tinanoff et al. 1998;

According to Davis, the definition of this pathology has always been complex and "difficult to be described, but when it is seen, you know what it's about" (Davis 1998). Up to now there have been many proposals for definition and diagnostic criteria, described in detail by

The preferred and most commonly used term today is early childhood caries (ECC), proposed by the Centers for Disease Control and Prevention (CDC) (Kaste et al. 1996). Numerous biological, psychosocial, and behavioral risk factors are involved in the etiology of ECC, supporting the multifactorial character of the disease (Wyne 1999; Seow 1998). Based on this concept, dental caries can be defined as demineralization of tooth tissue consequent to a dental infection that is dependent on frequent exposure to fermentable carbohydrates and is influenced by saliva and fluoride and other trace elements (Drury et al. 1999). Dietary habits are also deeply implicated in the development of ECC, despite the fact that it is considered an infectious disease (Lopez 2000). Consumption of sweets with high concentrations of glucose, saccharine, or fructose, especially if taken in processed juices (Newbrun 1982), and their prolonged intake play an important role in caries development in

To evaluate the prevalence of ECC and various caries risk factors such as quantity of cariogenic *Streptococcus mutans* colonies, oral hygiene, sweets preference, bottle feeding in preschool children, and fluoride use, we have conducted a study at our preschool children

In this study we have included 1,008 children of both sexes, from 1 to 6 years of age, from 9 kindergartens of Prishtina, capital of Kosovo. The sample was random, representing 80% of all kindergarten children. The sample size was calculated with a confidence level of 95% and

ECC was defined as "initial occurrence of caries in cervical region of at least two maxillary incisors." Using a careful lift-the-lip examination, the presence or absence of ECC was recorded depending on the presence of "noncavity caries/white spot lesions" or "cavity caries." With the aim of studying the clinical and etiological aspects of ECC, a sub-sample of children with ECC was included for further analysis. The latter part of the examination, which included the clinical study of ECC development (according to ECC stages), determination of bacterial colony sampling, oral hygiene index (OHI), and filling out of the questionnaire, was conducted in the Pediatric Dentistry Clinic of the School of

Children with ECC were examined using the light of the dental unit, with dental mirror and probe. All examinations were carried out by Prof Begzati, with intra-examiner reliability of

kappa = 0.95 based on the examination of 15 children of different ages.

Horowitz 1998; Drury et al. 1999).

children with ECC (Wendt 1991).

(Begzati et al. 2010).

Dentistry.

a confidence interval of 2.

**3.2 Dental examination and diagnostic criteria of ECC** 

Ismail & Sohn 1999.

#### **2.3.2 Caries prevalence of school children**

The percentage of children with DMFT=0 at the age of six was 13.3%, and as expected, this decreased with age. At 14 years old, only 0.9% were with no observable clinical signs of caries. The mean DMFT index was 4.86 for all school children. The increase in the mean DMFT was related to age, increasing from 2.36 for 7-year-olds to 6.91 for 14-year-olds. There was no significant difference between the genders for any age group.

The mean DMFT of school children increased with age, with a statistically significant difference between the age groups tested with ANOVA (F=290.83, p<0.001).

The differences between adjacent age groups showed a difference for 7-year-olds vs. 8-yearolds, 9-year-olds vs. 10-year-olds, 10-year-olds vs. 11-year-olds, 11-year-olds vs. 12-yearolds, and 12-year-olds vs. 13-year-olds (p<0.0001). There was no difference for 8-year-olds vs. 9-year-olds (p>0.05) or 13-year-olds vs. 14-year-olds (p>0.05).

The greatest contribution to the DMFT index was untreated caries, which varied from 2.10 for 7-year-olds to 5.00 for 14-year-olds (Figure 2).

Fig. 2. Mean DMFT of school children by age groups

#### **3. Early childhood caries**

#### **3.1 Definition of Early childhood caries (ECC)**

The oral health of children is especially aggravated with the occurrence of the so-called early childhood caries. During the promotion of oral public health in urban kindergartens, the presence of extensive dental disease at children, known as early childhood caries (ECC), was recorded. ECC is an acute, rapidly developing dental disease occurring initially in the cervical third of the maxillary incisors, destroying the crown completely. Early onset and

The percentage of children with DMFT=0 at the age of six was 13.3%, and as expected, this decreased with age. At 14 years old, only 0.9% were with no observable clinical signs of caries. The mean DMFT index was 4.86 for all school children. The increase in the mean DMFT was related to age, increasing from 2.36 for 7-year-olds to 6.91 for 14-year-olds. There

The mean DMFT of school children increased with age, with a statistically significant

The differences between adjacent age groups showed a difference for 7-year-olds vs. 8-yearolds, 9-year-olds vs. 10-year-olds, 10-year-olds vs. 11-year-olds, 11-year-olds vs. 12-yearolds, and 12-year-olds vs. 13-year-olds (p<0.0001). There was no difference for 8-year-olds

The greatest contribution to the DMFT index was untreated caries, which varied from 2.10

The oral health of children is especially aggravated with the occurrence of the so-called early childhood caries. During the promotion of oral public health in urban kindergartens, the presence of extensive dental disease at children, known as early childhood caries (ECC), was recorded. ECC is an acute, rapidly developing dental disease occurring initially in the cervical third of the maxillary incisors, destroying the crown completely. Early onset and

**7y 8y 9y 10y 11y 12y 13y 14y age groups**

was no significant difference between the genders for any age group.

vs. 9-year-olds (p>0.05) or 13-year-olds vs. 14-year-olds (p>0.05).

for 7-year-olds to 5.00 for 14-year-olds (Figure 2).

Fig. 2. Mean DMFT of school children by age groups

**0**

**2**

**4**

**6**

**8**

**10**

**12**

**14**

**3.1 Definition of Early childhood caries (ECC)** 

**3. Early childhood caries** 

difference between the age groups tested with ANOVA (F=290.83, p<0.001).

**2.3.2 Caries prevalence of school children** 

rampant clinical progression makes ECC a serious public health problem. Due to varying clinical, etiological, localization, and course features, this pathology is found under different names such as labial caries (LC), caries of incisors, nursing bottle mouth, rampant caries (RC), nursing bottle caries (NBC), nursing caries, baby bottle tooth decay (BBTD), early childhood caries (ECC), rampant infant and early childhood dental decay, and severe early childhood caries (SECC) (James 1957; Goose 1967; Fass 1962; Winter et al.1966; Derkson & Ponti 1982; Ripa 1988; Arkin 1986; Bruered et al. 1989; Kaste & Gift 1995; Tinanoff et al. 1998; Horowitz 1998; Drury et al. 1999).

According to Davis, the definition of this pathology has always been complex and "difficult to be described, but when it is seen, you know what it's about" (Davis 1998). Up to now there have been many proposals for definition and diagnostic criteria, described in detail by Ismail & Sohn 1999.

The preferred and most commonly used term today is early childhood caries (ECC), proposed by the Centers for Disease Control and Prevention (CDC) (Kaste et al. 1996).

Numerous biological, psychosocial, and behavioral risk factors are involved in the etiology of ECC, supporting the multifactorial character of the disease (Wyne 1999; Seow 1998). Based on this concept, dental caries can be defined as demineralization of tooth tissue consequent to a dental infection that is dependent on frequent exposure to fermentable carbohydrates and is influenced by saliva and fluoride and other trace elements (Drury et al. 1999). Dietary habits are also deeply implicated in the development of ECC, despite the fact that it is considered an infectious disease (Lopez 2000). Consumption of sweets with high concentrations of glucose, saccharine, or fructose, especially if taken in processed juices (Newbrun 1982), and their prolonged intake play an important role in caries development in children with ECC (Wendt 1991).

To evaluate the prevalence of ECC and various caries risk factors such as quantity of cariogenic *Streptococcus mutans* colonies, oral hygiene, sweets preference, bottle feeding in preschool children, and fluoride use, we have conducted a study at our preschool children (Begzati et al. 2010).

In this study we have included 1,008 children of both sexes, from 1 to 6 years of age, from 9 kindergartens of Prishtina, capital of Kosovo. The sample was random, representing 80% of all kindergarten children. The sample size was calculated with a confidence level of 95% and a confidence interval of 2.

#### **3.2 Dental examination and diagnostic criteria of ECC**

ECC was defined as "initial occurrence of caries in cervical region of at least two maxillary incisors." Using a careful lift-the-lip examination, the presence or absence of ECC was recorded depending on the presence of "noncavity caries/white spot lesions" or "cavity caries." With the aim of studying the clinical and etiological aspects of ECC, a sub-sample of children with ECC was included for further analysis. The latter part of the examination, which included the clinical study of ECC development (according to ECC stages), determination of bacterial colony sampling, oral hygiene index (OHI), and filling out of the questionnaire, was conducted in the Pediatric Dentistry Clinic of the School of Dentistry.

Children with ECC were examined using the light of the dental unit, with dental mirror and probe. All examinations were carried out by Prof Begzati, with intra-examiner reliability of kappa = 0.95 based on the examination of 15 children of different ages.

Oral Health Care in Children – A Preventive Perspective 27

N 27 25 Mean dmft ± SD 5.1 ± 1.8 8.8 ± 0.7

Initial stage (N, %) (27) 100% (0) 0% Circular stage (N, %) / (7) 28% Destructive stage (N, %) / (5) 20% Radix relicta stage (N, %) / (9) 36% Extraction (N, %) / (4) 16%

The clinical course /ECC stages were not equally distributed. The most commonly present stage was that of radix relicta (41.7%), while the stage that appeared least frequently was the initial stage (15.4%), or 27 out of 150 children with ECC. There was a significant difference between the stages of ECC (P < 0.0001). Twenty-five of the 27 children with ECC in the initial stage were reexamined 1 year after the baseline examination (2 children did not appear for reexamination due to address change). The 1-year reexamination showed that the initial stage had advanced to the circular stage in 28% of children, destructive stage in 20%,

Mean age of subjects with initial stage of ECC was 2 ± 0.7. Mean dmft on reexamination

Scientific research suggests that the development of ECC occurs in 3 stages. The first stage is characterized by a primary infection of the oral cavity with ECC. The second stage is the proliferation of these organisms to pathogenic levels as a consequence of frequent and prolonged exposure to cariogenic substrates. Finally, a rapid demineralization and

A 1-year follow-up of ECC development from the initial stage, representing decay at the enamel level and its progression to more destructive stages, shows even development in all affected teeth. It is quite an acute development, because in 2/3 of the children, the ECC has progressed to more complicated stages destructive and radix relicta stages. Within 1 year, the dmft values have increased to 3.7. Consecutively, these children commonly experience pain from pulpitis, gangrene, and apical periodontitis. Also, these conditions are often followed by abscesses and cellulitis, sometimes with phlegmona, seriously endangering the child's general health. De Grauwe, in describing the progression of ECC, has noticed that the development of caries from the enamel to the dentin level can occur within 6 months (De

The rapid development of ECC and its clinical appearance, especially in primary incisors, identifies it in its initial stages as a risk factor for future caries in the primary and permanent

Children with congenital heart anomalies are frequent patients in our departments, some of them exhibiting severe ECC. There is strong evidence that untreated dental disease is an important etiological factor in the pathogenesis of infective endocarditis, a condition that

radix relicta stage in 36%, and having been extracted due to ECC in 16% of children.

cavitation of the enamel occurs, resulting in rampant dental caries (Berkowitz 2003).

Baseline Reexamination

Table 2. ECC progression from initial stage at 1-year follow-up

showed an increase from 5.1 to 8.8 (P < 0.001).

**3.2.3 Clinical consequences of ECC** 

ECC stages

Grauwe 2004).

dentitions (Al-Shalan et al. 1997).

still carries a high risk of mortality (Child 1996).

#### **3.2.1 ECC prevalence**

The prevalence of ECC varies in different countries, which may depend on the diagnostic criteria. While in some developed countries having advanced programs for oral health protection, the prevalence of ECC is around 5% (Derkson & Ponti 1982; Ripa 1988; Kaste et al. 1996; Davenport 1990; Hinds & Gregory 1995). In some countries of Southeastern Europe (Kosovo's neighbors), this prevalence reaches 20% (Bosnia) and 14% (Macedonia) (Huseinbegović 2001, Apostolova et al. 2003). Much higher ECC prevalence has been reported for such places as Quchan, Iran (59%) (Mazhari et al. 2007) and Alaska (66.8%) (Kelly & Bruerd 1987). At American Indian children the prevalence is 41.8% [23]. Similarly, in North American populations, the prevalence at high-risk children ranges from 11% to 72% (Berkowitz 2003).

In our study, from the total 1,008 examined children aged 1-6 years, the caries prevalence expressed in terms of the caries index per person, or dmft > 0, was 86.31%, with a mean dmft of 5.8. The prevalence of ECC was 17.36%, or 175 out of 1,008 examined children. The sub-sample of children with diagnosed ECC consisted of 150 children out of 175 invited for further analysis. Twenty-five children of this group from different kindergartens didn't show up in the Department. The mean age of children with ECC was 3.8 ± 1.2 years. The mean dmft in children with ECC was 11 ± 3.6. There was no statistical difference of ECC prevalence between genders (t test = 1.81, P = 0.07). As expected, the lowest mean dmft score was found at age 2 (6.47 ± 2.13), with an age-related increase in dmft of 12.8 at age 6 (Table 1). In comparing the mean dmft in ECC children with respect to age, there was a significant statistical difference between age 2 and ages 4, 5, and 6. (One-Way ANOVA test F = 16, P < 0.001).


Table 1. Mean dmft in children with ECC

#### **3.2.2 Clinical course of ECC**

In order to explain the clinical course of ECC, we propose the following stages in the occurrence and progression of carious lesions in ECC:

ECCi (initial stage)-white spot lesion or initial defect in enamel of cervix.

ECCc (circular stage)-lesion in the dentin and circular distribution of this lesion proximally.

ECCd (destructive stage)-destruction of more than half the crown without affecting the incisal edge.

ECCr (radix relicta stage)-total destruction of the crown.

The development of ECC on the maxillary incisors (at least 2) from its initial stage was monitored after a reexamination 1 year later (Table 2).

The prevalence of ECC varies in different countries, which may depend on the diagnostic criteria. While in some developed countries having advanced programs for oral health protection, the prevalence of ECC is around 5% (Derkson & Ponti 1982; Ripa 1988; Kaste et al. 1996; Davenport 1990; Hinds & Gregory 1995). In some countries of Southeastern Europe (Kosovo's neighbors), this prevalence reaches 20% (Bosnia) and 14% (Macedonia) (Huseinbegović 2001, Apostolova et al. 2003). Much higher ECC prevalence has been reported for such places as Quchan, Iran (59%) (Mazhari et al. 2007) and Alaska (66.8%) (Kelly & Bruerd 1987). At American Indian children the prevalence is 41.8% [23]. Similarly, in North American populations, the prevalence at high-risk children ranges from 11% to

In our study, from the total 1,008 examined children aged 1-6 years, the caries prevalence expressed in terms of the caries index per person, or dmft > 0, was 86.31%, with a mean dmft of 5.8. The prevalence of ECC was 17.36%, or 175 out of 1,008 examined children. The sub-sample of children with diagnosed ECC consisted of 150 children out of 175 invited for further analysis. Twenty-five children of this group from different kindergartens didn't show up in the Department. The mean age of children with ECC was 3.8 ± 1.2 years. The mean dmft in children with ECC was 11 ± 3.6. There was no statistical difference of ECC prevalence between genders (t test = 1.81, P = 0.07). As expected, the lowest mean dmft score was found at age 2 (6.47 ± 2.13), with an age-related increase in dmft of 12.8 at age 6 (Table 1). In comparing the mean dmft in ECC children with respect to age, there was a significant statistical difference between age 2 and ages 4, 5, and 6. (One-Way ANOVA test F

> **Age (N) dmft ± SD**  2 (22) 5.5 ± 2.1 3 (42) 9.7 ± 3.4 4 (38) 12.8 ± 2.6 5 (36) 12.9 ± 2.7 6 (12) 12.8 ± 1.3 Total (150) 11 ± 3.6

In order to explain the clinical course of ECC, we propose the following stages in the

ECCc (circular stage)-lesion in the dentin and circular distribution of this lesion proximally. ECCd (destructive stage)-destruction of more than half the crown without affecting the

The development of ECC on the maxillary incisors (at least 2) from its initial stage was

**3.2.1 ECC prevalence** 

72% (Berkowitz 2003).

= 16, P < 0.001).

Table 1. Mean dmft in children with ECC

occurrence and progression of carious lesions in ECC:

ECCr (radix relicta stage)-total destruction of the crown.

monitored after a reexamination 1 year later (Table 2).

ECCi (initial stage)-white spot lesion or initial defect in enamel of cervix.

**3.2.2 Clinical course of ECC** 

incisal edge.


Table 2. ECC progression from initial stage at 1-year follow-up

The clinical course /ECC stages were not equally distributed. The most commonly present stage was that of radix relicta (41.7%), while the stage that appeared least frequently was the initial stage (15.4%), or 27 out of 150 children with ECC. There was a significant difference between the stages of ECC (P < 0.0001). Twenty-five of the 27 children with ECC in the initial stage were reexamined 1 year after the baseline examination (2 children did not appear for reexamination due to address change). The 1-year reexamination showed that the initial stage had advanced to the circular stage in 28% of children, destructive stage in 20%, radix relicta stage in 36%, and having been extracted due to ECC in 16% of children.

Mean age of subjects with initial stage of ECC was 2 ± 0.7. Mean dmft on reexamination showed an increase from 5.1 to 8.8 (P < 0.001).

#### **3.2.3 Clinical consequences of ECC**

Scientific research suggests that the development of ECC occurs in 3 stages. The first stage is characterized by a primary infection of the oral cavity with ECC. The second stage is the proliferation of these organisms to pathogenic levels as a consequence of frequent and prolonged exposure to cariogenic substrates. Finally, a rapid demineralization and cavitation of the enamel occurs, resulting in rampant dental caries (Berkowitz 2003).

A 1-year follow-up of ECC development from the initial stage, representing decay at the enamel level and its progression to more destructive stages, shows even development in all affected teeth. It is quite an acute development, because in 2/3 of the children, the ECC has progressed to more complicated stages destructive and radix relicta stages. Within 1 year, the dmft values have increased to 3.7. Consecutively, these children commonly experience pain from pulpitis, gangrene, and apical periodontitis. Also, these conditions are often followed by abscesses and cellulitis, sometimes with phlegmona, seriously endangering the child's general health. De Grauwe, in describing the progression of ECC, has noticed that the development of caries from the enamel to the dentin level can occur within 6 months (De Grauwe 2004).

The rapid development of ECC and its clinical appearance, especially in primary incisors, identifies it in its initial stages as a risk factor for future caries in the primary and permanent dentitions (Al-Shalan et al. 1997).

Children with congenital heart anomalies are frequent patients in our departments, some of them exhibiting severe ECC. There is strong evidence that untreated dental disease is an important etiological factor in the pathogenesis of infective endocarditis, a condition that still carries a high risk of mortality (Child 1996).

Oral Health Care in Children – A Preventive Perspective 29

was 98%. The lowest class (Class 1) was recorded in 5% of the children with ECC, while classes that represent higher risk for caries (Classes 2 and 3) were present in 34% and 59%,

*S. mutans* N % Mean dmft ± SD *T*test

Class 1 8 5% 5.4 ± 2.0 *P*<0.001

< 105(0 and 1) 11 7% 4.7 ± 1.1 *T*=5.5 ≥ 10 *P*<0.001 5(2 and 3) 139 93% 11.5 ± 3.2

Only 11 children with ECC exhibited a low level of *S. mutans* colonies (CFU < 105), with the mean dmft of this group being 4.7. The groups with higher CFU of *S. mutans* (Classes 2 and 3), representing 93% of the children, had a mean dmft of 11.5 ±3. Comparing the mean dmft of children with ECC by *S. mutans* classes of CFU showed a significant difference between

Considerable epidemiological studies have established a positive correlation between early childhood caries and *S. mutans* (Matee et al. 1992; Li et al. 2000; Berkowitz, 1996; Beighton et

In a study, parents and kindergarten teachers were asked to fill out a questionnaire about child's dietary habits, including questions regarding frequency of sweets consumption throughout the day, as well as the type of sweets. Parents answered questions about bottle feeding: first use, duration, manner, and fluid content. They were also asked if they put their

We found that the frequency of sweets consumption in approximately 93% of the children was 1–3 or more times a day. Sweets consumption between meals and during kindergarten hours was common**.** There was a statistical correlation between daily sweets consumption

In our study, the frequency of sweets consumption of children with ECC was very high. It is of great concern that kindergartens as educational institutions do not have a more serious approach to a healthy diet and reduction of food containing sugar. On the contrary, at least once a day, sweet food (jam, chocolate, cream, biscuits, or cake) is served to children. Also, serving of this food is very common between meals. The literature shows the high caries values in children who have frequently used sweets (Holbrook et al. 1989), it also shows a

Class 0 3 2% 3 ± 0

Class 2 51 34% 9.1 ± 3.0 Class 3 88 59% 12.8 ± 2.5

Total 150 100% **11 ±3.6** 

Table 3. *S. mutans* distribution in children with ECC

Class 1 and Classes 2 and 3 (t = 5.5, P < 0.001).

**3.3.3 Dietary habits in children with ECC** 

**Sweets consumption in children with ECC** 

and dmft in children with ECC (F = 7.26, *P* < 0.001).

high consumption of sweets between meals (Ölmez et al. 2003).

children to sleep with a bottle.

respectively, of children with ECC (Table 3).

 **class** 

al. 2004).

 **values in CFU/mL saliva** 

#### **3.3 Risk factors of caries in general and of ECC in particular 3.3.1 Contagious nature of ECC**

There are many different types of microorganisms inhabiting the oral cavity, whose existence is maintained through ecological mechanism. This mechanism includes: saliva, crevicular gingival fluid, antimicrobial components of these fluids, intermicrobial synergism and antagonism, food, tooth, etc.

The presence of microorganisms in the dental plaque depends on the presence of cariogenic bacteria in saliva. Their amount in saliva depends on the secretion level, enzyme presence, as well as on mechanisms with synergistic or antagonistic action. The microorganisms initially present in saliva and afterwards adhering to the tooth surface cannot express their cariogenic action separately or in small amounts. Their cariogenic effect is higher as their affinity to create bacterial colonies increases. Of the great interest in the cariogenesis process are only two bacterial genera: mutant streptococci and lactobacills (Norman & Franklin 1999).

A very important role in occurrence of ECC is attributed to the bacterium *Streptococcus mutans*-called "the window of infection" (Caufield et al. 1993) in that it is responsible for the primary oral infection in the first phase of ECC (Berkowitz 1980; Berkowitz et al. 1996).

Mother is regarded as the so called "window of infection" of *S. mutans* transmission to the newborn.

As the data from the literature show, the role of S mutans in the etiology of ECC, especially in the initial phase, is very crucial (Berkowitz 1980, Caufield et al. 1993). These data also demonstrate the high prevalence of this bacterium in preschool children. *S. mutans* is found at the earliest ages, with the prevalence of 53% in 6- to 12-month-old children (Milgrom et al. 2000), 60% in 15-month-olds (Karn et al. 1988), 67% in 18-month-old Swedes (Hallonsten et al. 1995), and 94.7% in 3- to 4-year-old Chinese (Li et al. 1994).

Almost all preschool urban Icelandic children were found to carry *S mutans* (Holbrook 1993). According to the studies of Ge and Caufield, all S-ECC children were S mutanspositive (Ge et al. 2008). Borutta 2002, found that in 80% of children (3 years old) diagnosed with caries, the presence of *S. mutans* was demonstrated, while higher counts of this bacterium were found in children with ECC. The high prevalence of *S. mutans* was also demonstrated in our study: 98% of preschool children. Expressed in colony-forming units (CFU/mL saliva), 93% of the ECC children in our study had a high *S. mutans* counts (CFU > 105). Higher salivary counts of *S. mutans* have been correlated with high dmft values (11.5) in our study. This significant correlation between high dmft or caries experience and high *S. mutans* counts has been demonstrated in other studies (Köhler et al. 1988; Köhler et al. 1995; Twetman & Frostner 1991; Maciel et al. 2001).

#### **3.3.2** *S. mutans* **prevalence in children with ECC**

In this study the presence of *S. mutans* was determined by using the CRT bacteria test (Ivoclar Vivadent, Liechtenstein) on the saliva previously stimulated by chewing paraffin. Bacterial counts were recorded as colony-forming units per milliliter (CFU/mL) of saliva. The number of bacterial colonies was graded as follows:

Class 0 and Class 1 (CFU < 105/mL saliva), and Class 2 and Class 3 (CFU ≥ 105/mL saliva), according to the manufacturers' scoring-card (Ivoclar-Vivadent, Lichtenstein).

In younger subjects, with less saliva collected, the modified spatula method was used.

The results showed that only a small number of children (2%) with ECC exhibited the absence of *S. mutans* (Class 0). In other words, *S. mutans* prevalence in children with ECC

There are many different types of microorganisms inhabiting the oral cavity, whose existence is maintained through ecological mechanism. This mechanism includes: saliva, crevicular gingival fluid, antimicrobial components of these fluids, intermicrobial synergism

The presence of microorganisms in the dental plaque depends on the presence of cariogenic bacteria in saliva. Their amount in saliva depends on the secretion level, enzyme presence, as well as on mechanisms with synergistic or antagonistic action. The microorganisms initially present in saliva and afterwards adhering to the tooth surface cannot express their cariogenic action separately or in small amounts. Their cariogenic effect is higher as their affinity to create bacterial colonies increases. Of the great interest in the cariogenesis process are only two bacterial genera: mutant streptococci and lactobacills (Norman & Franklin 1999). A very important role in occurrence of ECC is attributed to the bacterium *Streptococcus mutans*-called "the window of infection" (Caufield et al. 1993) in that it is responsible for the primary oral infection in the first phase of ECC (Berkowitz 1980; Berkowitz et al. 1996). Mother is regarded as the so called "window of infection" of *S. mutans* transmission to the

As the data from the literature show, the role of S mutans in the etiology of ECC, especially in the initial phase, is very crucial (Berkowitz 1980, Caufield et al. 1993). These data also demonstrate the high prevalence of this bacterium in preschool children. *S. mutans* is found at the earliest ages, with the prevalence of 53% in 6- to 12-month-old children (Milgrom et al. 2000), 60% in 15-month-olds (Karn et al. 1988), 67% in 18-month-old Swedes (Hallonsten et

Almost all preschool urban Icelandic children were found to carry *S mutans* (Holbrook 1993). According to the studies of Ge and Caufield, all S-ECC children were S mutanspositive (Ge et al. 2008). Borutta 2002, found that in 80% of children (3 years old) diagnosed with caries, the presence of *S. mutans* was demonstrated, while higher counts of this bacterium were found in children with ECC. The high prevalence of *S. mutans* was also demonstrated in our study: 98% of preschool children. Expressed in colony-forming units (CFU/mL saliva), 93% of the ECC children in our study had a high *S. mutans* counts (CFU > 105). Higher salivary counts of *S. mutans* have been correlated with high dmft values (11.5) in our study. This significant correlation between high dmft or caries experience and high *S. mutans* counts has been demonstrated in other studies (Köhler et al. 1988; Köhler et al. 1995;

In this study the presence of *S. mutans* was determined by using the CRT bacteria test (Ivoclar Vivadent, Liechtenstein) on the saliva previously stimulated by chewing paraffin. Bacterial counts were recorded as colony-forming units per milliliter (CFU/mL) of saliva.

Class 0 and Class 1 (CFU < 105/mL saliva), and Class 2 and Class 3 (CFU ≥ 105/mL saliva),

In younger subjects, with less saliva collected, the modified spatula method was used. The results showed that only a small number of children (2%) with ECC exhibited the absence of *S. mutans* (Class 0). In other words, *S. mutans* prevalence in children with ECC

according to the manufacturers' scoring-card (Ivoclar-Vivadent, Lichtenstein).

**3.3 Risk factors of caries in general and of ECC in particular** 

al. 1995), and 94.7% in 3- to 4-year-old Chinese (Li et al. 1994).

Twetman & Frostner 1991; Maciel et al. 2001).

**3.3.2** *S. mutans* **prevalence in children with ECC** 

The number of bacterial colonies was graded as follows:

**3.3.1 Contagious nature of ECC** 

and antagonism, food, tooth, etc.

newborn.


was 98%. The lowest class (Class 1) was recorded in 5% of the children with ECC, while classes that represent higher risk for caries (Classes 2 and 3) were present in 34% and 59%, respectively, of children with ECC (Table 3).

Table 3. *S. mutans* distribution in children with ECC

Only 11 children with ECC exhibited a low level of *S. mutans* colonies (CFU < 105), with the mean dmft of this group being 4.7. The groups with higher CFU of *S. mutans* (Classes 2 and 3), representing 93% of the children, had a mean dmft of 11.5 ±3. Comparing the mean dmft of children with ECC by *S. mutans* classes of CFU showed a significant difference between Class 1 and Classes 2 and 3 (t = 5.5, P < 0.001).

Considerable epidemiological studies have established a positive correlation between early childhood caries and *S. mutans* (Matee et al. 1992; Li et al. 2000; Berkowitz, 1996; Beighton et al. 2004).

#### **3.3.3 Dietary habits in children with ECC**

In a study, parents and kindergarten teachers were asked to fill out a questionnaire about child's dietary habits, including questions regarding frequency of sweets consumption throughout the day, as well as the type of sweets. Parents answered questions about bottle feeding: first use, duration, manner, and fluid content. They were also asked if they put their children to sleep with a bottle.

#### **Sweets consumption in children with ECC**

We found that the frequency of sweets consumption in approximately 93% of the children was 1–3 or more times a day. Sweets consumption between meals and during kindergarten hours was common**.** There was a statistical correlation between daily sweets consumption and dmft in children with ECC (F = 7.26, *P* < 0.001).

In our study, the frequency of sweets consumption of children with ECC was very high. It is of great concern that kindergartens as educational institutions do not have a more serious approach to a healthy diet and reduction of food containing sugar. On the contrary, at least once a day, sweet food (jam, chocolate, cream, biscuits, or cake) is served to children. Also, serving of this food is very common between meals. The literature shows the high caries values in children who have frequently used sweets (Holbrook et al. 1989), it also shows a high consumption of sweets between meals (Ölmez et al. 2003).

Oral Health Care in Children – A Preventive Perspective 31

Kosovo's municipal drinking water may highly influence caries prevalence rates in

Nutritional counseling, fluoride therapy, and oral hygiene may be required to prevent development of carious lesions in children. In the case of high-risk patients such as children with ECC with a predominance of high salivary counts of *S. mutans*, the use of either the antibacterial rinse chlorhexidine gluconate or the oral health care gel chlorhexidine has been

The oral health promotion and preventive measures are also influenced by social and economical factors. Statistical data from our country such as: large families (with average size of 6.5 members), high unemployment rate (in 2008 it marked 45.4%, for female 56.4%), high birth rate (16%) and the lowest economical growth in the region (Statistical Office of Kosovo 2008), represent some of the aggravating factors when dealing with the health issues of the population, including oral health issues. Given the complexity of factors associated with ECC, it is unfortunate that most of the interest has only been from dental organizations. The critical change needed to accomplish the necessary research for the prevention of ECC should be expanding our network by involving other health professionals, community leaders, national organizations serving children, and political

Early childhood caries (ECC) is a health problem with biological, social and behavioral determinants. Intervention treatment does not resolve this problem. It is difficult, sometimes

The only safest way is prevention of this complex pathology. European Academy of

• Oral health assessments with counseling at regularly scheduled visits during the first

• Children's teeth should be brushed daily with a smear of fluoride toothpaste as soon as

• Professional applications of fluoride varnish are recommended at least twice yearly in

• Parents of infants and toddlers should be encouraged to reduce behaviours that

Based on these recommendations, we will describe detailed preventive measures: primary prevention – prenatal and postnatal care; and secondary prevention – parents' and dental

• It should begin during prenatal period and it consists of pregnant woman's needs'

• Proper quality of food for the newborn during the enamel maturation phase;

Pediatric Dentistry (2008) has recommended general strategies for ECC prevention:

year of life are an important strategy to prevent ECC.

promote the early transmission of mutans streptococci.

fulfillment with necessary and healthy products;

children.

suggested (Featherstone 2004).

**3.3.6 Social factors** 

leaders (Ismail 1998).

impossible and expensive.

they erupt.

professionals' role.

**3.4.1 Primary prevention** 

**3.4 Preventive measures for ECC** 

groups or individuals at risk.

• Fluoridation of newly-erupted teeth; • Antimicrobial therapy with chlorhexidine.

#### **Bottle feeding in children with ECC**

Another important factor in the etiology of ECC is bottle feeding, which is accompanied by high salivary counts of *S. mutans*. The relationship between bottle usage and salivary counts of *S. mutans* has been reported (Mohan et al. 1998). In our children, the duration of bottle feeding with sweetened milk or juice is very long, wherein nearly 4/5 of children are bottle fed from 1 to 3 and more years. Most of the children with ECC represent subjects who are bottle fed up to age 2 (48%) and 3 and up (39%). Of the children with ECC, 6% were not bottle fed and 7% were bottle fed up to age 1**.** Comparing the dmft of children with ECC with regard to duration of bottle feeding shows statistical correlation (F = 20.83, *P* < 0.001).

Another harmful practice is putting children to sleep with a juice-filled bottle, which is practiced in 2/3 of children with ECC, although Johnsen (1982) has reported that 78% of parents of children with ECC had attempted to substitute water for a cariogenic liquid (e.g., apple juice, formula) in the bedtime nursing bottle. A review of the literature from the etiological point of view of ECC shows that "the use of a bottle at night" is not the only cause of ECC (Plat & Cebazas 2000).

#### **3.3.4 Tooth brushing and the OHI in children with ECC**

Regarding tooth brushing parents and kindergarten teachers were asked to fill out a questionnaire about the: frequency, parents' participation during brushing, how it was controlled, and use of fluoride-containing toothpaste and fluoride tablets.

The OHI was determined by using the Plaque Test (Ivoclar Vivadent) according to the Greene-Vermilion index.

There is a high level of negligence in the oral hygiene of our children. More than half do not brush their teeth at all, exhibiting a very high OHI (1.52). No child recorded OHI-1. Although a dmft of 13 was found in children with OHI-3, no significant difference was found when comparing the dmft with respect to OHI (F = 2.52, *P* = 0.085).

The importance of the primary dentition of oral health promotion must be focused on the education of mothers to motivate their children for oral hygiene. Unfortunately, we found "bad conviction" of mothers regarding primary teeth that they will be replaced, thus neglecting the care for children's teeth. Data from the literature show that cooperation of mothers is very important in overcoming the belief that the deciduous dentition can be neglected (Rasmund & Tracy 2003).

Regarding the frequency of tooth brushing, around 52% of the children did not brush at all, but there was no statistical difference in dmft in terms of frequency of brushing (F = 2.10, *P* = 0.106).

Oral hygiene habits established at the age of 1 can be maintained throughout early childhood (Wendet 1995).

#### **3.3.5 Fluoride use**

From the answers of mothers regarding fluoride use, we ascertained a considerable lack of knowledge about the benefits of this agent in maintaining healthy tooth structure. This information gap can be inferred from their answers. When asked, "Do you give fluoride tablets to your child?" their answers were stated as if they have been asked about some medication: "I give those tablets to my child as needed." The absence of fluoride in Kosovo's municipal drinking water may highly influence caries prevalence rates in children.

Nutritional counseling, fluoride therapy, and oral hygiene may be required to prevent development of carious lesions in children. In the case of high-risk patients such as children with ECC with a predominance of high salivary counts of *S. mutans*, the use of either the antibacterial rinse chlorhexidine gluconate or the oral health care gel chlorhexidine has been suggested (Featherstone 2004).

#### **3.3.6 Social factors**

30 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

Another important factor in the etiology of ECC is bottle feeding, which is accompanied by high salivary counts of *S. mutans*. The relationship between bottle usage and salivary counts of *S. mutans* has been reported (Mohan et al. 1998). In our children, the duration of bottle feeding with sweetened milk or juice is very long, wherein nearly 4/5 of children are bottle fed from 1 to 3 and more years. Most of the children with ECC represent subjects who are bottle fed up to age 2 (48%) and 3 and up (39%). Of the children with ECC, 6% were not bottle fed and 7% were bottle fed up to age 1**.** Comparing the dmft of children with ECC with regard to duration of bottle feeding shows statistical correlation (F = 20.83,

Another harmful practice is putting children to sleep with a juice-filled bottle, which is practiced in 2/3 of children with ECC, although Johnsen (1982) has reported that 78% of parents of children with ECC had attempted to substitute water for a cariogenic liquid (e.g., apple juice, formula) in the bedtime nursing bottle. A review of the literature from the etiological point of view of ECC shows that "the use of a bottle at night" is not the only

Regarding tooth brushing parents and kindergarten teachers were asked to fill out a questionnaire about the: frequency, parents' participation during brushing, how it was

The OHI was determined by using the Plaque Test (Ivoclar Vivadent) according to the

There is a high level of negligence in the oral hygiene of our children. More than half do not brush their teeth at all, exhibiting a very high OHI (1.52). No child recorded OHI-1. Although a dmft of 13 was found in children with OHI-3, no significant difference was

The importance of the primary dentition of oral health promotion must be focused on the education of mothers to motivate their children for oral hygiene. Unfortunately, we found "bad conviction" of mothers regarding primary teeth that they will be replaced, thus neglecting the care for children's teeth. Data from the literature show that cooperation of mothers is very important in overcoming the belief that the deciduous dentition can be

Regarding the frequency of tooth brushing, around 52% of the children did not brush at all, but there was no statistical difference in dmft in terms of frequency of brushing (F = 2.10,

Oral hygiene habits established at the age of 1 can be maintained throughout early

From the answers of mothers regarding fluoride use, we ascertained a considerable lack of knowledge about the benefits of this agent in maintaining healthy tooth structure. This information gap can be inferred from their answers. When asked, "Do you give fluoride tablets to your child?" their answers were stated as if they have been asked about some medication: "I give those tablets to my child as needed." The absence of fluoride in

**Bottle feeding in children with ECC** 

cause of ECC (Plat & Cebazas 2000).

neglected (Rasmund & Tracy 2003).

childhood (Wendet 1995).

**3.3.5 Fluoride use** 

*P* = 0.106).

Greene-Vermilion index.

**3.3.4 Tooth brushing and the OHI in children with ECC** 

controlled, and use of fluoride-containing toothpaste and fluoride tablets.

found when comparing the dmft with respect to OHI (F = 2.52, *P* = 0.085).

*P* < 0.001).

The oral health promotion and preventive measures are also influenced by social and economical factors. Statistical data from our country such as: large families (with average size of 6.5 members), high unemployment rate (in 2008 it marked 45.4%, for female 56.4%), high birth rate (16%) and the lowest economical growth in the region (Statistical Office of Kosovo 2008), represent some of the aggravating factors when dealing with the health issues of the population, including oral health issues. Given the complexity of factors associated with ECC, it is unfortunate that most of the interest has only been from dental organizations. The critical change needed to accomplish the necessary research for the prevention of ECC should be expanding our network by involving other health professionals, community leaders, national organizations serving children, and political leaders (Ismail 1998).

#### **3.4 Preventive measures for ECC**

Early childhood caries (ECC) is a health problem with biological, social and behavioral determinants. Intervention treatment does not resolve this problem. It is difficult, sometimes impossible and expensive.

The only safest way is prevention of this complex pathology. European Academy of Pediatric Dentistry (2008) has recommended general strategies for ECC prevention:


Based on these recommendations, we will describe detailed preventive measures: primary prevention – prenatal and postnatal care; and secondary prevention – parents' and dental professionals' role.

#### **3.4.1 Primary prevention**


Oral Health Care in Children – A Preventive Perspective 33

ligament is situated in the space between the roots of the teeth and the lamina dura or the alveolar bone proper. The alveolar bone surrounds the tooth to a level approximately 1mm

The portions of the principal fibers of the periodontal ligament which are embedded in the

The cementum is a special mineralized tissue covering the root surfaces. It has many features in common with bone tissue. It contains no blood or lymph vessels, has no innervation, does not undergo physiologic resorption or remodeling, but is characterized by continuing deposition throughout life. It attaches the periodontal ligament fibers to the root

Different forms of cementum have been described, such as acellular, extrinsic fiber cementum; cellular, mixed stratified cementum; and cellular, intrinsic fiber cementum.

The alveolar process is defined as the parts of the maxilla and the mandible that form and

Together with the root cementum and the periodontal membrane, the alveolar bone constitutes the attachment apparatus of the teeth, the main function of which is to distribute

The classification of periodontal diseases (Flemmig 1999) was revised in a workshop (AAP classification of periodontal diseases) that took place in 1999. This classification includes

Inflammatory alterations of gingiva are found among the majority of children in the primary dentition. The prevalence of gingivitis reaches its maximum at around 11 years among girls,

Studies from 24 European countries from 1982 to 1992 (Sheiham et al. 2002) using



Community Periodontal Index of Treatment Needs (CPITN) showed these results:

and resorb forces generated by, for example, mastication and other tooth contacts.

root cementum and in the alveolar bone proper are called *Sharpey's fibers*.

and contributes to the process of repair after damage to the root surface.

apical to the cemento-enamel junction.

**4.1.3 Root cementum** 

**4.1.4 Alveolar bone** 

eight main categories: - Gingival diseases - Chronic periodontitis - Aggressive periodontitis

East Europe

Europe

support the sockets of the teeth.

**4.2 Classification of periodontal diseases** 


**4.3 Prevalence of periodontal diseases** 



whereas among boys 2 years later (Massler et al. 1952)

#### **3.4.2 Secondary prevention**

	- breast-feeding of the baby;
	- the use of cup instead of the bottle as early as possible;
	- not sleeping with bottle in mouth;
	- avoid the use of fabricated juices or soda;
	- the use of natural, a little sweetened, juice or tea, or just water;
	- avoid the discontinuation of bottle use by the method "bottle is gone";
	- reduce the liquid in the bottle, gradually by night,
	- reduce sweets as much as possible;
	- no sweets between meals;
	- daily tooth brushing, at least twice a day, obligatory before going to bed.

Professional educational activities targeting primary health care providers (pediatricians, internists, family physicians, obstetricians, mid-level medical practitioners:


#### **4. Gingivitis and periodontitis**

The periodontium, also known as "the supporting structures of the teeth", comprises a developmental, biologic, and functional unit, which undergoes certain changes with age and is subjected to morphologic changes related to functional alterations.

The attachment of the tooth to the bone tissue of the jaws and maintenance of the oral cavity masticatory mucosa surface's integrity are the main functions of the periodontium.

The periodontium (περι = around, οδονσ = tooth) comprises the following tissues 1) the gingiva, 2) the periodontal ligament, 3) the root cementum, and 4) the alveolar bone.

#### **4.1 Normal anatomy**

#### **4.1.1 Gingiva**

In the coronal direction the coral pink gingiva terminates in the free gingival margin, which has a scalloped outline. In the apical direction the gingiva is continuous with the loose, darker red alveolar mucosa (lining mucosa) from which the gingiva is separated by a, usually, easily recognizable borderline called either the mucogingival junction (arrows) or the mucogingival line. Since the hard palate and the maxillary alveolar process are covered by the same type of masticatory mucosa, there is no mucogingival line present in the palate. Two parts of the gingiva can be differentiated: 1) the *free gingiva* and 2) the *attached gingiva*.

#### **4.1.2 Periodontal ligament**

The soft, richly vascular and cellular connective tissue which joins the root cementum with socket wall and surrounds the roots of the teeth is the periodontal ligament. The periodontal ligament is situated in the space between the roots of the teeth and the lamina dura or the alveolar bone proper. The alveolar bone surrounds the tooth to a level approximately 1mm apical to the cemento-enamel junction.

The portions of the principal fibers of the periodontal ligament which are embedded in the root cementum and in the alveolar bone proper are called *Sharpey's fibers*.

#### **4.1.3 Root cementum**

32 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

• Mothers' education on recognizing the first signs of ECC using "lift-the-lip" technique.

• Parents should be encouraged to avoid bad feeding habits of their children and give

The aim of this measure is early detection of the so-called **"white spot"**.

• the use of cup instead of the bottle as early as possible;

• reduce the liquid in the bottle, gradually by night,

• snacking behaviors that promote good oral health, and

is subjected to morphologic changes related to functional alterations.

• referral to the dentist by 12 months of age.

• the use of natural, a little sweetened, juice or tea, or just water;

• avoid the discontinuation of bottle use by the method "bottle is gone";

• daily tooth brushing, at least twice a day, obligatory before going to bed.

internists, family physicians, obstetricians, mid-level medical practitioners:

Professional educational activities targeting primary health care providers (pediatricians,

The periodontium, also known as "the supporting structures of the teeth", comprises a developmental, biologic, and functional unit, which undergoes certain changes with age and

The attachment of the tooth to the bone tissue of the jaws and maintenance of the oral cavity

The periodontium (περι = around, οδονσ = tooth) comprises the following tissues 1) the

In the coronal direction the coral pink gingiva terminates in the free gingival margin, which has a scalloped outline. In the apical direction the gingiva is continuous with the loose, darker red alveolar mucosa (lining mucosa) from which the gingiva is separated by a, usually, easily recognizable borderline called either the mucogingival junction (arrows) or the mucogingival line. Since the hard palate and the maxillary alveolar process are covered by the same type of masticatory mucosa, there is no mucogingival line present in the palate. Two parts of the gingiva can be differentiated: 1) the *free gingiva* and 2) the *attached gingiva*.

The soft, richly vascular and cellular connective tissue which joins the root cementum with socket wall and surrounds the roots of the teeth is the periodontal ligament. The periodontal

masticatory mucosa surface's integrity are the main functions of the periodontium.

gingiva, 2) the periodontal ligament, 3) the root cementum, and 4) the alveolar bone.

**3.4.2 Secondary prevention** 

effort for proper feeding: • breast-feeding of the baby;

• not sleeping with bottle in mouth; • avoid the use of fabricated juices or soda;

• reduce sweets as much as possible;

• Necessary consultations with the dentist -

• early identification of disease, • fluoride supplements as appropriate,

• healthful feeding practices,

**4. Gingivitis and periodontitis** 

**4.1 Normal anatomy 4.1.1 Gingiva** 

**4.1.2 Periodontal ligament** 

• no sweets between meals;

The cementum is a special mineralized tissue covering the root surfaces. It has many features in common with bone tissue. It contains no blood or lymph vessels, has no innervation, does not undergo physiologic resorption or remodeling, but is characterized by continuing deposition throughout life. It attaches the periodontal ligament fibers to the root and contributes to the process of repair after damage to the root surface.

Different forms of cementum have been described, such as acellular, extrinsic fiber cementum; cellular, mixed stratified cementum; and cellular, intrinsic fiber cementum.

#### **4.1.4 Alveolar bone**

The alveolar process is defined as the parts of the maxilla and the mandible that form and support the sockets of the teeth.

Together with the root cementum and the periodontal membrane, the alveolar bone constitutes the attachment apparatus of the teeth, the main function of which is to distribute and resorb forces generated by, for example, mastication and other tooth contacts.

#### **4.2 Classification of periodontal diseases**

The classification of periodontal diseases (Flemmig 1999) was revised in a workshop (AAP classification of periodontal diseases) that took place in 1999. This classification includes eight main categories:


#### **4.3 Prevalence of periodontal diseases**

Inflammatory alterations of gingiva are found among the majority of children in the primary dentition. The prevalence of gingivitis reaches its maximum at around 11 years among girls, whereas among boys 2 years later (Massler et al. 1952)

Studies from 24 European countries from 1982 to 1992 (Sheiham et al. 2002) using Community Periodontal Index of Treatment Needs (CPITN) showed these results:


Oral Health Care in Children – A Preventive Perspective 35

DeStefano et al (1993) in a prospective group of 9760 subjects found a nearly two-fold higher risk of **coronary heart disease** for patients with periodontal infection. But other studies have failed to document this association, indicating that this association is more complex and

Another systemic consequence that may be attributed to the periodontal disease is **preterm low birth-weight**. It has been hypothesized that women with preterm labor may be indirectly affected through remote infections, one of which is periodontal disease (McGregor et al. 1988). In a pioneer study conducted by Offenbacher et al. (1996) with 124 subjects it was found that periodontitis, defined as 60% and more sites with attachment loss of 3 and more millimeters, conferred 7.9 fold risk for preterm low birth weight cases. A study in Kosovo with 200 parturients has acquired results of lower odd ratio (more than 3 fold), but significantly higher with women with periododntitis compared with women with no

Good health is a major resource for social, economic and personal development. Political, economic, social, cultural, environmental, behavioral and biological factors can enhance or impair health. Health promotion action aims at making these conditions conducive to health. Health promotion therefore goes beyond health care. It puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health

An important role in the oral health promotion activities, besides dental professionals, belongs to the kindergarten and school teachers, as well as mothers at home. Surely, mother's role is very important and decisive in child's education, not only from the aspect of

Health care for children cannot be designed without understanding their vulnerability and essential link to parents. Health professionals, educators, and researchers must partner with parents in all activities related to children's health, from clinical care to community programs to policy planning. Parental oral disease, attitudes, and past experiences with dental care have a direct impact on their own and their developing child's oral health. Disease transmission, the practice of oral home care, and development of healthy attitudes towards oral health are all impacted by family factors. (Wendy &

It is of the greatest interest to maintain mother's oral health during pregnancy. In our studies we have found that oral health problems among pregnant women are as common as among children. Oral health should be an integral part of prenatal care. Improving oral health during pregnancy not only enhances the overall health of women, but also

Because of the complexity of factors related to dental caries, the role of oral health education

In order to explain the mother's importance, respectively her knowledge related to oral health promotion, we have conducted a study in our country. Mothers who accompanied their children to the University Dentistry School of Kosovo, Pedodontics Department, were interviewed. The aim of our study was to determine the caries experience and parental

consequences of their decisions and to accept their responsibilities for health.

conditional (Hujoel et al. 2000).

periodontitis (Meqa 2007).

oral health.

Mouradian 2001).

**5.1 Mother's knowledge regarding oral health care** 

contributes to improving the oral health of their children.

is believed to be very important, especially for mothers.

**5. Oral Health promotion** 


The Third National Health and Nutrition Examination Survey (NHANES III) as the largest population-based study during 1988-1994 showed that periodontitis affected at least 35% of US population between 30 and 90 years of age, with mild form in 22% and advanced form in 13%. The severe forms of periodontitis affected more men than women, and more African-Americans and Hispanics than Caucasians.

Tooth loss may be the definitive consequence of destructive periodontal disease. Teeth lost due to periodontal disease's consequences are evidently not in agreement with registration in epidemiological surveys. The prevalence and the severity of the disease may, thus, be underestimated.

The so-called histologically healthy gingiva is possible only under experimental conditions and is attained by prolonged and overall nonexistence of microbial plaque. Thus, the more appropriate term used to express the health of gingiva is clinically normal gingiva, which almost always is followed by a polymorphonuclear granulocyte and lymphocyte infiltrate.

The form of periodontal disease that affects the primary dentition, the condition formerly called prepubertal periodontitis, has been reported to appear in both a generalized and a localized form (Page et al. 1983).

#### **4.4 Risk factors for periodontitis**

There is an abundance of both empirical evidence and substantial theoretical justification for accepting the widespread belief that many diseases have more than one cause, i.e. that they are of multifactorial etiology (Kleinbaum et al. 1982).

In a relatively large number of cross-sectional studies, multiple risk putative risk factors for periodontal disease have been examined (Beck et al. 1990, Grossi et al. 1994, Horning et al. 1992, Ismali & Szpunar 1990).

#### **4.4.1 Tobacco smoking**

The biological possibility of a connection between tobacco smoking and periodontitis was found on the potential effects of several tobacco-related substances, notably nicotine, carbon monoxide and hydrogen cyanide. Data from the NHANES III study (Tomar & Asma 2000) suggested that 42% of periodontitis cases in the USA can be attributed to current smoking, and 11% to former smoking.

#### **4.4.2 Diabetes mellitus**

Diabetes as a risk factor for periodontitis has been addressed and debated for several years (Genco & Loe 1993), but recently, a number of biological mechanisms have been identified, by which the disease may contribute to impaired periodontal conditions. Examiners showed that diabetics were three times more likely to suffer from periodontal disease than nondiabetics (Emrich et al. 1991).

#### **4.5 Periodontal disease and risk for systemic disease**

Besides the risk from periodontitis deriving from the systemic diseases, it has been suggested that periodontal diseases may represent a possible risk factor for systemic diseases. Emerging facts show that periodontal diseases, in fact, have systemic consequences.

DeStefano et al (1993) in a prospective group of 9760 subjects found a nearly two-fold higher risk of **coronary heart disease** for patients with periodontal infection. But other studies have failed to document this association, indicating that this association is more complex and conditional (Hujoel et al. 2000).

Another systemic consequence that may be attributed to the periodontal disease is **preterm low birth-weight**. It has been hypothesized that women with preterm labor may be indirectly affected through remote infections, one of which is periodontal disease (McGregor et al. 1988). In a pioneer study conducted by Offenbacher et al. (1996) with 124 subjects it was found that periodontitis, defined as 60% and more sites with attachment loss of 3 and more millimeters, conferred 7.9 fold risk for preterm low birth weight cases. A study in Kosovo with 200 parturients has acquired results of lower odd ratio (more than 3 fold), but significantly higher with women with periododntitis compared with women with no periodontitis (Meqa 2007).

#### **5. Oral Health promotion**

34 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices


The Third National Health and Nutrition Examination Survey (NHANES III) as the largest population-based study during 1988-1994 showed that periodontitis affected at least 35% of US population between 30 and 90 years of age, with mild form in 22% and advanced form in 13%. The severe forms of periodontitis affected more men than women, and more African-

Tooth loss may be the definitive consequence of destructive periodontal disease. Teeth lost due to periodontal disease's consequences are evidently not in agreement with registration in epidemiological surveys. The prevalence and the severity of the disease may, thus, be

The so-called histologically healthy gingiva is possible only under experimental conditions and is attained by prolonged and overall nonexistence of microbial plaque. Thus, the more appropriate term used to express the health of gingiva is clinically normal gingiva, which almost always is followed by a polymorphonuclear granulocyte and lymphocyte infiltrate. The form of periodontal disease that affects the primary dentition, the condition formerly called prepubertal periodontitis, has been reported to appear in both a generalized and a

There is an abundance of both empirical evidence and substantial theoretical justification for accepting the widespread belief that many diseases have more than one cause, i.e. that they

In a relatively large number of cross-sectional studies, multiple risk putative risk factors for periodontal disease have been examined (Beck et al. 1990, Grossi et al. 1994, Horning et al.

The biological possibility of a connection between tobacco smoking and periodontitis was found on the potential effects of several tobacco-related substances, notably nicotine, carbon monoxide and hydrogen cyanide. Data from the NHANES III study (Tomar & Asma 2000) suggested that 42% of periodontitis cases in the USA can be attributed to current smoking,

Diabetes as a risk factor for periodontitis has been addressed and debated for several years (Genco & Loe 1993), but recently, a number of biological mechanisms have been identified, by which the disease may contribute to impaired periodontal conditions. Examiners showed that diabetics were three times more likely to suffer from periodontal disease than non-

Besides the risk from periodontitis deriving from the systemic diseases, it has been suggested that periodontal diseases may represent a possible risk factor for systemic diseases. Emerging facts show that periodontal diseases, in fact, have systemic

CPITN-4.

underestimated.

Americans and Hispanics than Caucasians.

localized form (Page et al. 1983).

**4.4 Risk factors for periodontitis** 

1992, Ismali & Szpunar 1990).

**4.4.1 Tobacco smoking** 

and 11% to former smoking.

diabetics (Emrich et al. 1991).

consequences.

**4.4.2 Diabetes mellitus** 

are of multifactorial etiology (Kleinbaum et al. 1982).

**4.5 Periodontal disease and risk for systemic disease** 

Good health is a major resource for social, economic and personal development. Political, economic, social, cultural, environmental, behavioral and biological factors can enhance or impair health. Health promotion action aims at making these conditions conducive to health. Health promotion therefore goes beyond health care. It puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health.

An important role in the oral health promotion activities, besides dental professionals, belongs to the kindergarten and school teachers, as well as mothers at home. Surely, mother's role is very important and decisive in child's education, not only from the aspect of oral health.

Health care for children cannot be designed without understanding their vulnerability and essential link to parents. Health professionals, educators, and researchers must partner with parents in all activities related to children's health, from clinical care to community programs to policy planning. Parental oral disease, attitudes, and past experiences with dental care have a direct impact on their own and their developing child's oral health. Disease transmission, the practice of oral home care, and development of healthy attitudes towards oral health are all impacted by family factors. (Wendy & Mouradian 2001).

#### **5.1 Mother's knowledge regarding oral health care**

It is of the greatest interest to maintain mother's oral health during pregnancy. In our studies we have found that oral health problems among pregnant women are as common as among children. Oral health should be an integral part of prenatal care. Improving oral health during pregnancy not only enhances the overall health of women, but also contributes to improving the oral health of their children.

Because of the complexity of factors related to dental caries, the role of oral health education is believed to be very important, especially for mothers.

In order to explain the mother's importance, respectively her knowledge related to oral health promotion, we have conducted a study in our country. Mothers who accompanied their children to the University Dentistry School of Kosovo, Pedodontics Department, were interviewed. The aim of our study was to determine the caries experience and parental

Oral Health Care in Children – A Preventive Perspective 37

gingival bleeding or toothaches, their visits to the dentist were very rare, with only 21% seeking help from the dentist. Another factor driving maternal negligence towards their own oral health was the inadequate level of preparedness among healthcare personnel, as well as their hesitant attitudes. Pregnant mothers who neglect to address their oral health issues may face consequences in their general health status, as well as in oral health status, with frequent dental caries, erosions, and periodontal disease. According to the U.S. Department of Health and Human Services, improving oral health during pregnancy not only enhances the overall health of women, but also contributes to improved oral health for

Pregnancy and early childhood are particularly important times to access oral health care because the consequences of poor oral health can have a lifelong impact (US Department of

Dental problems such as caries, erosion, epulis, periodontal infection, loose teeth, and illfitting crowns, bridges, and dentures may have special significance during pregnancy

The bacteria responsible for periodontal disease are capable of producing a variety of chemical inflammatory mediators such as prostaglandins, interleukins and tumor necrosis

Data from the literature have shown that oral health problems are common in pregnant women and in young children (Crall 2005). Untreated cavities in mothers may be associated with the risk of caries in children. Finally, untreated oral infections may become systemic problems during pregnancy and may even contribute to preterm birth (Lewit & Monheit

Periodontal disease is caused by gram-negative anaerobic bacteria. Studies have suggested that periodontal infections may contribute to the birth of preterm/low birth weight babies

In our study, the prevalence of premature births is 9%, and it has been reported that

Improving the oral health of pregnant women prevents complications of dental diseases during pregnancy, has the potential to decrease early childhood caries and may reduce preterm and low birth weight deliveries. Assessment of oral health risks in infants and young children, along with anticipatory guidance, has the potential to prevent early

Regarding the issue of parental effort on seeking professional advice from the dentist, the data from the literature do not show satisfactory levels in other countries. Even in the developed nations, there is a dominant perception that children do not need early dental

For instance, Dr. Horowitz has stated that "*it is pretty hard for the parent to believe that the child should be sent to the dentist after the first tooth has erupted, and maybe earlier. A mistake that I made by myself, relying in my dentist's advice not sending my child to the dentist before he turns three. Later I realized that it was a mistake*" Reagan continues to cite authors Horowitz and Hale, who think that an important attention should be paid to the first dental visit and suggest that "the dental

community needs to step forward and encourage these early visits" (Regan 2002).

their children. Oral health should be an integral part of prenatal care.

factor that can directly affect the pregnant woman (Romero et al. 2004).

children born prematurely have a higher prevalence of ECC.

visits because they will subsequently lose their baby teeth.

Health and Human Services, 2000)

(Casassimo 1996, Gajendra 2004).

1992).

(Geopfert et al. 2004).

childhood caries.

**5.3.1 First dental visit** 

**5.3 Postnatal health education** 

knowledge regarding primary preventive measures for dental caries in children, mainly from the educational perspective of mothers in Kosovo. Data related to the following information was collected: social (mother's age, economic status, mother's level of education, employment, number of children in the family), dental experiences (dental visits, reasons of the visits), oral hygiene (daily frequency, knowledge of tooth brushing techniques, tooth brushing duration), feeding habits (sugar consumption, bottle feeding), fluoride and antimicrobial agents use, knowledge on their role in dental health, and pregnancy (prenatal control, premature birth).

There is no doubt of the importance of the maternal role in maintaining good oral health among their children. The mother's level of education is quite important, especially in our country, where women do not have a sufficient level of education. According to the official data, nearly half of all women completed only their primary education (44.9%) while only 7.2% finished high school or obtained a university degree. Unfortunately, even in this century, illiteracy exists in Kosovo, with the level ranging from 2% to 4%. The number of illiterate women is almost three times higher than that of men. Demographic data are characterized by a high birth rate (15.7%), equivalent to an average of three children per mother. Social data show low employment rates among women. The unemployment rate is approximately 62% for women and 35% for men. Even though female presence is very high in trade and services such as health or education, oral health education has been mostly neglected (Kosovo Statistical Office 2008).

The results of our examination have shown that maternal effort, as well as their knowledge of oral health protection for their children, is largely inadequate. This inadequacy also has been reflected in the dental status of the children, with a mean dmft 6.3. The highest mean dmft was recorded among children whose mothers finished primary and secondary school while a lower mean dmft (4.5) was recorded among children whose mothers finished high school or obtained a university degree. Although mothers with higher educational levels had more knowledge, as evidenced by the lower mean dmft, it was still high according to WHO standards. When the dmft index structure was analyzed, 78% of the teeth were decayed, 16% were extracted, and only 6% were filled. The children's dental health status was even worse given the high prevalence of ECC (above 21%), with a mean dmft of 11 for these cases.

The dental experiences of our children, for nearly two-thirds of all respondents, unfortunately involved visits to the dentist only when the pain appeared.

Our examination was based on maternal levels of knowledge regarding oral health (over 600 interviewed mothers), especially since they play crucial roles in educating their children. However, we made an attempt to raise the attention of not only mothers, but also of health professionals regarding the importance of the early prevention of dental and oral diseases in children through pre- and postnatal health education.

#### **5.2 Prenatal health education**

Health education ought to start during the prenatal period. It consists of regular OB/GYN visits and adequate access to necessary medical advice for both maternal and pediatric health. Unfortunately, only 8% of the mothers sought advice from their obstetrician regarding oral health protection measures for their future child. Nearly three-quarters of the mothers neglected their own oral health by not visiting the dentist during their pregnancies. Even though mothers reported occasional discomfort regarding their oral health, such as

knowledge regarding primary preventive measures for dental caries in children, mainly from the educational perspective of mothers in Kosovo. Data related to the following information was collected: social (mother's age, economic status, mother's level of education, employment, number of children in the family), dental experiences (dental visits, reasons of the visits), oral hygiene (daily frequency, knowledge of tooth brushing techniques, tooth brushing duration), feeding habits (sugar consumption, bottle feeding), fluoride and antimicrobial agents use, knowledge on their role in dental health, and

There is no doubt of the importance of the maternal role in maintaining good oral health among their children. The mother's level of education is quite important, especially in our country, where women do not have a sufficient level of education. According to the official data, nearly half of all women completed only their primary education (44.9%) while only 7.2% finished high school or obtained a university degree. Unfortunately, even in this century, illiteracy exists in Kosovo, with the level ranging from 2% to 4%. The number of illiterate women is almost three times higher than that of men. Demographic data are characterized by a high birth rate (15.7%), equivalent to an average of three children per mother. Social data show low employment rates among women. The unemployment rate is approximately 62% for women and 35% for men. Even though female presence is very high in trade and services such as health or education, oral health education has been mostly

The results of our examination have shown that maternal effort, as well as their knowledge of oral health protection for their children, is largely inadequate. This inadequacy also has been reflected in the dental status of the children, with a mean dmft 6.3. The highest mean dmft was recorded among children whose mothers finished primary and secondary school while a lower mean dmft (4.5) was recorded among children whose mothers finished high school or obtained a university degree. Although mothers with higher educational levels had more knowledge, as evidenced by the lower mean dmft, it was still high according to WHO standards. When the dmft index structure was analyzed, 78% of the teeth were decayed, 16% were extracted, and only 6% were filled. The children's dental health status was even worse given the high prevalence of ECC (above 21%), with a mean dmft of 11 for

The dental experiences of our children, for nearly two-thirds of all respondents,

Our examination was based on maternal levels of knowledge regarding oral health (over 600 interviewed mothers), especially since they play crucial roles in educating their children. However, we made an attempt to raise the attention of not only mothers, but also of health professionals regarding the importance of the early prevention of dental and oral diseases in

Health education ought to start during the prenatal period. It consists of regular OB/GYN visits and adequate access to necessary medical advice for both maternal and pediatric health. Unfortunately, only 8% of the mothers sought advice from their obstetrician regarding oral health protection measures for their future child. Nearly three-quarters of the mothers neglected their own oral health by not visiting the dentist during their pregnancies. Even though mothers reported occasional discomfort regarding their oral health, such as

unfortunately involved visits to the dentist only when the pain appeared.

children through pre- and postnatal health education.

**5.2 Prenatal health education** 

pregnancy (prenatal control, premature birth).

neglected (Kosovo Statistical Office 2008).

these cases.

gingival bleeding or toothaches, their visits to the dentist were very rare, with only 21% seeking help from the dentist. Another factor driving maternal negligence towards their own oral health was the inadequate level of preparedness among healthcare personnel, as well as their hesitant attitudes. Pregnant mothers who neglect to address their oral health issues may face consequences in their general health status, as well as in oral health status, with frequent dental caries, erosions, and periodontal disease. According to the U.S. Department of Health and Human Services, improving oral health during pregnancy not only enhances the overall health of women, but also contributes to improved oral health for their children. Oral health should be an integral part of prenatal care.

Pregnancy and early childhood are particularly important times to access oral health care because the consequences of poor oral health can have a lifelong impact (US Department of Health and Human Services, 2000)

Dental problems such as caries, erosion, epulis, periodontal infection, loose teeth, and illfitting crowns, bridges, and dentures may have special significance during pregnancy (Casassimo 1996, Gajendra 2004).

The bacteria responsible for periodontal disease are capable of producing a variety of chemical inflammatory mediators such as prostaglandins, interleukins and tumor necrosis factor that can directly affect the pregnant woman (Romero et al. 2004).

Data from the literature have shown that oral health problems are common in pregnant women and in young children (Crall 2005). Untreated cavities in mothers may be associated with the risk of caries in children. Finally, untreated oral infections may become systemic problems during pregnancy and may even contribute to preterm birth (Lewit & Monheit 1992).

Periodontal disease is caused by gram-negative anaerobic bacteria. Studies have suggested that periodontal infections may contribute to the birth of preterm/low birth weight babies (Geopfert et al. 2004).

In our study, the prevalence of premature births is 9%, and it has been reported that children born prematurely have a higher prevalence of ECC.

Improving the oral health of pregnant women prevents complications of dental diseases during pregnancy, has the potential to decrease early childhood caries and may reduce preterm and low birth weight deliveries. Assessment of oral health risks in infants and young children, along with anticipatory guidance, has the potential to prevent early childhood caries.

#### **5.3 Postnatal health education**

#### **5.3.1 First dental visit**

Regarding the issue of parental effort on seeking professional advice from the dentist, the data from the literature do not show satisfactory levels in other countries. Even in the developed nations, there is a dominant perception that children do not need early dental visits because they will subsequently lose their baby teeth.

For instance, Dr. Horowitz has stated that "*it is pretty hard for the parent to believe that the child should be sent to the dentist after the first tooth has erupted, and maybe earlier. A mistake that I made by myself, relying in my dentist's advice not sending my child to the dentist before he turns three. Later I realized that it was a mistake*" Reagan continues to cite authors Horowitz and Hale, who think that an important attention should be paid to the first dental visit and suggest that "the dental community needs to step forward and encourage these early visits" (Regan 2002).

Oral Health Care in Children – A Preventive Perspective 39

pathology. The term 'baby bottle tooth decay' was proposed by the Healthy Mothers - Healthy Babies Coalition as an alternative that would be more appropriate for patient acceptance and focus increased attention on the potential harms of using a nursing bottle

More recent evidence suggests that taking a bottle to bed may be a stronger predictor of

*Sweets consumption* – There was a high percentage of sweets consumption among our children. Unfortunately, even though over 70% of mothers are aware that sweets can damage the children's teeth, they do not give efforts to reduce this habit. Nearly 90% of the children consumed sweets at least once a day. Another serious factor is that sweets were consumed in between meals among 2/3 of children. In developed countries, advanced preventive programs focused on reducing the consumption of sweets. Data from the literature indicate that only 21% and 45% of children in Finland and Denmark, respectively, consumed sweets once a week (Matilla et al. 2000). The consumption of sweets containing sucrose constituents may be considered an important factor in the occurrence of caries **(**Marthaler 1990)**.** The association between the intake of sucrose and dental caries has been well established in numerous studies, conducted mainly in northern and western European countries and in North America (Rugg-Gunn 1993). On the other hand, authors have reported that with the correct implementation of preventive and educational measures, there was a reduction in the development of caries, despite continued consumption of

Kosovar cuisine is similar to that in the Middle and Near East, especially regarding sweets, with relatively frequent and high amounts of starch. The mechanism by which the starch added to sucrose increases the cariogenic potential of foods could be that the presence of starch increases the retention time of the food in the mouth (Lingstrom et al. 1993). Additionally, there are some indications that starch can increase acid production from

Studies in the literature have reported a correlation between the consumption of sweets and *S. mutans* colonies, especially associated with high counts. It is obvious that there could be a threshold for the number of oral *S. mutans* colonies that eventually allow fermentable

Whether the child will start tooth brushing at an early age depends on maternal habits. Cleansing of the baby teeth should be started by the time of eruption of the first primary tooth. A small piece of clean gauze or a small toothbrush can be used. The child imitates parental behaviours, including oral hygiene habits. In a study in England, Witlle (1988) reported that 60% of children started brushing their teeth from the age of one; presumably,

Another study in England reported that in 80% of cases, mothers brushed the teeth of their

A study conducted in Bosnia, a country that is geographically close to Kosovo, concluded that only 3% of the parents assisted their children with their first tooth brushing efforts

In our study, 38% of the mothers stated that their children did not brush their teeth at all. Over 90% had no knowledge regarding proper tooth brushing techniques. Mothers rarely

frontal tooth ECC patterns than previously believed (Douglass et al. 2001).

(Arkin 1986).

sucrose containing foods (Marthaler 1990).

**5.3.4 Mother knowledge regarding oral hygiene** 

their teeth were initially brushed by their parents.

children (Holt RD et al. 1996).

**(**Huseinbegović 2001**)**.

sucrose when both nutrients are present together (Glor et al. 1988).

carbohydrates to exert harmful effects on teeth (Garsia-Closas et al. 1997).

We found that 18% of the mothers had no idea when their children should visit a dentist, while more than half believed that their children should first visit a dentist when they are three years old. Unfortunately, a considerable portion of mothers (18%) believe that the first visit to the dentist should occur only when the child is in pain.

While the common perception 30 years ago was that the first dental visit should occur at the age of three, today it is preferred that the first visit occur before the child's first birthday, specifically between 6 and 12 months of age.

#### **5.3.2 Mother's knowledge about contagious nature of dental caries**

It is already understood that dental caries is a contagious disease. There are many ways of transmission from the mother's mouth to the child's mouth, such as by kissing or when mothers "clean" their children's pacifiers or taste their children's juice or food (Berkowitz 1983). This bad habit was also recorded in our study. When mothers were asked whether they cleaned their baby's pacifiers or tasted the fluid from their baby's bottle, 35% confirmed such behaviors. According to the results of our study, mothers were not aware of this bacterium and the ways of it's transmission in the child's mouth.

Previously, it was believed that mutans streptococci were not present in a child's mouth until the eruption of the first tooth. However, some recent examinations have proven that high *S. mutans* levels may be observed in some children before their first birthday (Plotzitza et al. 2002). *S*. *mutans* was also found in the dental plaque of 12-month-old babies (Habibian et al. 2002).

Data from the literature have confirmed such a correlation; if the mother's SM count is low, the child's count is low as well, and vice versa (Köhler & Andreen 1984). Nevertheless, this hypothesis needs further clarification.

#### **5.3.3 Mother's knowledge regarding feeding habits**

*Bottle feeding* – It has been demonstrated that bottle feeding may contribute to dental caries, especially early childhood caries (ECC). The relationship between bottle usage and high salivary levels of the cariogenic bacteria *S. mutans* has been reported (Mohan et al. 1998). Surprisingly, even though a considerable number of mothers in our study were unemployed and did not send their children to kindergarten, they fed their children with bottles (65%). Unfortunately, maternal knowledge regarding the role of bottle feeding in the occurrence of ECC was generally low (12%). An unfavourable practice involves mothers' putting their children to sleep with milk- or juice-filled bottles, which was practiced for 74% of the children. Other authors have also reported on this bad practice (Jonsen 1988). Several studies have reported that the majority of the U.S. preschool population take, or have taken, a bottle to bed (Kaste & Gift 1995).

In one study of children in the U.S. Head Start programs, a surprisingly high proportion (69%) of the children without maxillary anterior caries reported taking a bottle to bed, while 86% of the children with maxillary anterior caries reported taking a bottle to bed (O'Sullivan & Tinanoff 1993).

In another study, 90% of the children in a population with and without caries were bottlefed between 12 and 18 months of age, although the prevalence of nursing caries was only 20% (Serwint et al. 1993).

The importance of bottle feeding with the occurrence of caries (especially in early and rampant occurrence in very young children) is reflected in the terminology of this

We found that 18% of the mothers had no idea when their children should visit a dentist, while more than half believed that their children should first visit a dentist when they are three years old. Unfortunately, a considerable portion of mothers (18%) believe that the first

While the common perception 30 years ago was that the first dental visit should occur at the age of three, today it is preferred that the first visit occur before the child's first birthday,

It is already understood that dental caries is a contagious disease. There are many ways of transmission from the mother's mouth to the child's mouth, such as by kissing or when mothers "clean" their children's pacifiers or taste their children's juice or food (Berkowitz 1983). This bad habit was also recorded in our study. When mothers were asked whether they cleaned their baby's pacifiers or tasted the fluid from their baby's bottle, 35% confirmed such behaviors. According to the results of our study, mothers were not aware of this

Previously, it was believed that mutans streptococci were not present in a child's mouth until the eruption of the first tooth. However, some recent examinations have proven that high *S. mutans* levels may be observed in some children before their first birthday (Plotzitza et al. 2002). *S*. *mutans* was also found in the dental plaque of 12-month-old babies (Habibian

Data from the literature have confirmed such a correlation; if the mother's SM count is low, the child's count is low as well, and vice versa (Köhler & Andreen 1984). Nevertheless, this

*Bottle feeding* – It has been demonstrated that bottle feeding may contribute to dental caries, especially early childhood caries (ECC). The relationship between bottle usage and high salivary levels of the cariogenic bacteria *S. mutans* has been reported (Mohan et al. 1998). Surprisingly, even though a considerable number of mothers in our study were unemployed and did not send their children to kindergarten, they fed their children with bottles (65%). Unfortunately, maternal knowledge regarding the role of bottle feeding in the occurrence of ECC was generally low (12%). An unfavourable practice involves mothers' putting their children to sleep with milk- or juice-filled bottles, which was practiced for 74% of the children. Other authors have also reported on this bad practice (Jonsen 1988). Several studies have reported that the majority of the U.S. preschool population take, or have taken,

In one study of children in the U.S. Head Start programs, a surprisingly high proportion (69%) of the children without maxillary anterior caries reported taking a bottle to bed, while 86% of the children with maxillary anterior caries reported taking a bottle to bed (O'Sullivan

In another study, 90% of the children in a population with and without caries were bottlefed between 12 and 18 months of age, although the prevalence of nursing caries was only

The importance of bottle feeding with the occurrence of caries (especially in early and rampant occurrence in very young children) is reflected in the terminology of this

visit to the dentist should occur only when the child is in pain.

**5.3.2 Mother's knowledge about contagious nature of dental caries** 

bacterium and the ways of it's transmission in the child's mouth.

specifically between 6 and 12 months of age.

hypothesis needs further clarification.

a bottle to bed (Kaste & Gift 1995).

& Tinanoff 1993).

20% (Serwint et al. 1993).

**5.3.3 Mother's knowledge regarding feeding habits** 

et al. 2002).

pathology. The term 'baby bottle tooth decay' was proposed by the Healthy Mothers - Healthy Babies Coalition as an alternative that would be more appropriate for patient acceptance and focus increased attention on the potential harms of using a nursing bottle (Arkin 1986).

More recent evidence suggests that taking a bottle to bed may be a stronger predictor of frontal tooth ECC patterns than previously believed (Douglass et al. 2001).

*Sweets consumption* – There was a high percentage of sweets consumption among our children. Unfortunately, even though over 70% of mothers are aware that sweets can damage the children's teeth, they do not give efforts to reduce this habit. Nearly 90% of the children consumed sweets at least once a day. Another serious factor is that sweets were consumed in between meals among 2/3 of children. In developed countries, advanced preventive programs focused on reducing the consumption of sweets. Data from the literature indicate that only 21% and 45% of children in Finland and Denmark, respectively, consumed sweets once a week (Matilla et al. 2000). The consumption of sweets containing sucrose constituents may be considered an important factor in the occurrence of caries **(**Marthaler 1990)**.** The association between the intake of sucrose and dental caries has been well established in numerous studies, conducted mainly in northern and western European countries and in North America (Rugg-Gunn 1993). On the other hand, authors have reported that with the correct implementation of preventive and educational measures, there was a reduction in the development of caries, despite continued consumption of sucrose containing foods (Marthaler 1990).

Kosovar cuisine is similar to that in the Middle and Near East, especially regarding sweets, with relatively frequent and high amounts of starch. The mechanism by which the starch added to sucrose increases the cariogenic potential of foods could be that the presence of starch increases the retention time of the food in the mouth (Lingstrom et al. 1993). Additionally, there are some indications that starch can increase acid production from sucrose when both nutrients are present together (Glor et al. 1988).

Studies in the literature have reported a correlation between the consumption of sweets and *S. mutans* colonies, especially associated with high counts. It is obvious that there could be a threshold for the number of oral *S. mutans* colonies that eventually allow fermentable carbohydrates to exert harmful effects on teeth (Garsia-Closas et al. 1997).

#### **5.3.4 Mother knowledge regarding oral hygiene**

Whether the child will start tooth brushing at an early age depends on maternal habits. Cleansing of the baby teeth should be started by the time of eruption of the first primary tooth. A small piece of clean gauze or a small toothbrush can be used. The child imitates parental behaviours, including oral hygiene habits. In a study in England, Witlle (1988) reported that 60% of children started brushing their teeth from the age of one; presumably, their teeth were initially brushed by their parents.

Another study in England reported that in 80% of cases, mothers brushed the teeth of their children (Holt RD et al. 1996).

A study conducted in Bosnia, a country that is geographically close to Kosovo, concluded that only 3% of the parents assisted their children with their first tooth brushing efforts **(**Huseinbegović 2001**)**.

In our study, 38% of the mothers stated that their children did not brush their teeth at all. Over 90% had no knowledge regarding proper tooth brushing techniques. Mothers rarely

Oral Health Care in Children – A Preventive Perspective 41

strategies and objectives on prevention of oral disease through oral health promotion. Thus, it may be of a great interest for the readers to get familiar with these WHO

The objectives of the WHO Global Oral Health Program (ORH), one of the technical programs within the Department of Chronic Diseases and Health Promotion (CHP), have been reoriented according to the new strategy of disease prevention and promotion of health. Greater emphasis is put on developing global policies in oral health promotion and oral disease prevention, coordinated more effectively with other priority programs of CHP

Several principles form the basis for the carried out work. The WHO Oral Health Program works on building oral health policies towards effective control of risks to oral health, based on the common risk factors approach. The focus is on modifiable risk behaviors related to

Oral health is part of total health and essential to quality of life and WHO projects intend to translate the evidence into action programs. The Oral Health Program therefore gives priority to integration of oral health with general health programs before community or national levels. The WHO Oral Health Program works from the life-course perspective, currently the community programs for improved oral health of the elderly and of children is given high priority. The implementation of school oral health programs within the framework of the WHO Health Promoting Schools Initiative is supported and guidelines are developed. Oral health systems reorientation towards prevention and health promotion is recommended in light of the Ottawa Charter, the primary health care concept and the Jakarta Declaration on leading Health Promotion into the 21st Century. In addition, global goals for oral health by the year 2020 strive for development of quality of oral health systems. The Program works on application of evidence-based strategies in oral health promotion, prevention and treatment of oral diseases worldwide, health systems research and development. Emphasis is also given on prevention and care of oral mucosal lesions, including oral cancer and oral manifestations of HIV/AIDS, cranio-facial disorders, trauma

WHO's goals are to build healthy populations and communities and to combat ill health. Four strategic directions provide the broad framework for focusing WHO's technical work,

• Reducing oral disease burden and disability, especially in poor and marginalized

• Promoting healthy lifestyles and reducing risk factors to oral health that arise from

• Developing oral health systems that equitably improve oral health outcomes, respond

• Framing policies in oral health, based on integration of oral health into national and community health programs, and promoting oral health as an effective dimension for

diet, nutrition, use of tobacco and excessive consumption of alcohol, and hygiene.

**6.1 The objectives of the WHO Global Oral Health Program (ORH)** 

strategies and objectives.

and injuries.

populations.

**(www.who.int/oral\_health/strategies\_2010)** 

and other clusters and with external partners.

**6.2 Oral health within WHO strategic directions** 

development policy of society.

which also have implications for the Oral Health Program.

environmental, economic, social and behavioral causes.

to people's legitimate demands, and are financially fair.

assisted their children during tooth brushing (5%). Studies in the literature show a strong relationship between the poor maternal oral health and the prevalence of caries in their children (Dye et al. 2011).

#### **5.3.5 Fluoride and antimicrobial agent utilization**

Fluoride, the key agent in battling caries, works primarily by topical action: inhibition of demineralization and enhancement of re-mineralization. Fluoride incorporated during tooth development is insufficient to play significant role in caries protection. Fluoride is needed regularly throughout life to protect teeth against caries. It is now realized that the most important action mechanism of fluoride takes place on the enamel surface of the tooth. Fluoride inhibits the loss of minerals and promotes the re-mineralization process. The data from literature demonstrated the importance of fluoridation on the prevention of dental caries. Preschool children from Ireland showed a very low mean dmft (0.9), largely because their drinking water was regularly fluoridated (Marthaler et al. 1996).

A study in Tennessee, USA, reported a mean dmft of 4.15 for the fluoridated communities and a mean dmft of 7.49 for the non-fluoridated communities (David et al. 2001).

Recommendations for fluoride supplementation can be made based on the fluoride content of the water, the child's age, and the child's caries risk. Among all endogenous and exogenous methods, the most effective method is water fluoridation. The drinking water in Kosovo is insufficient and has a fluoride level of less than 0.3 mg/l; however, the optimal range is between 0.8 and 1.5 mg/l.

In the absence of fluoridated water, fluoride tablets may be used. Weintraub (1999) claims that "before you think of any preventive measure, *put fluoride salts on the teeth*"*.* 

The systemic and topical use of fluoride is the most effective measure to prevent dental caries. Exposure to topical fluoride via fluoridated toothpaste twice a day is a major component of caries prevention therapy. Fluoride varnish may be applied with a soft brush, and reapplication is recommended every 3 to 6 months.

Antimicrobial treatment of caries is based on the use of two well-known agents (fluoride and chlorhexidine) for achieving selective antimicrobial control of carious microflora. Fluoride and chlorhexidine have an antimicrobial action against M. Streptococci that is significantly higher than that which they have against other non-cariogenic bacterial species. A combination of fluoride varnish and chlorhexidine application is used to lower the mutans streptococci count. Another successful antibacterial therapy against cariogenic bacteria is treatment with a chlorhexidine gluconate rinse or gel.

Mothers from our study had not used fluoride and any antimicrobial agents (e.g., chlorhexidine), nor did they have any knowledge regarding their utilization. The data from literature have confirmed the positive antibacterial role of chlorhexidine in *S. mutans* colonies' destruction. Antimicrobial treatment strategy has become a real concern for many dental professionals. A multitude of clinical trials confirms the caries-inhibiting effect of chlorhexidine (Zhang at al. 2006).

#### **6. Oral health strategies**

The initiatives undertaken by WHO, have global impact on the national and international policy development, one of which is the WHO Global Oral Health Program.

High prevalence of oral diseases, such as dental caries, is not only individual preoccupation, but also a serious public health problem. WHO is continuously developing

assisted their children during tooth brushing (5%). Studies in the literature show a strong relationship between the poor maternal oral health and the prevalence of caries in their

Fluoride, the key agent in battling caries, works primarily by topical action: inhibition of demineralization and enhancement of re-mineralization. Fluoride incorporated during tooth development is insufficient to play significant role in caries protection. Fluoride is needed regularly throughout life to protect teeth against caries. It is now realized that the most important action mechanism of fluoride takes place on the enamel surface of the tooth. Fluoride inhibits the loss of minerals and promotes the re-mineralization process. The data from literature demonstrated the importance of fluoridation on the prevention of dental caries. Preschool children from Ireland showed a very low mean dmft (0.9), largely because

A study in Tennessee, USA, reported a mean dmft of 4.15 for the fluoridated communities

Recommendations for fluoride supplementation can be made based on the fluoride content of the water, the child's age, and the child's caries risk. Among all endogenous and exogenous methods, the most effective method is water fluoridation. The drinking water in Kosovo is insufficient and has a fluoride level of less than 0.3 mg/l; however, the optimal

In the absence of fluoridated water, fluoride tablets may be used. Weintraub (1999) claims

The systemic and topical use of fluoride is the most effective measure to prevent dental caries. Exposure to topical fluoride via fluoridated toothpaste twice a day is a major component of caries prevention therapy. Fluoride varnish may be applied with a soft brush,

Antimicrobial treatment of caries is based on the use of two well-known agents (fluoride and chlorhexidine) for achieving selective antimicrobial control of carious microflora. Fluoride and chlorhexidine have an antimicrobial action against M. Streptococci that is significantly higher than that which they have against other non-cariogenic bacterial species. A combination of fluoride varnish and chlorhexidine application is used to lower the mutans streptococci count. Another successful antibacterial therapy against cariogenic

Mothers from our study had not used fluoride and any antimicrobial agents (e.g., chlorhexidine), nor did they have any knowledge regarding their utilization. The data from literature have confirmed the positive antibacterial role of chlorhexidine in *S. mutans* colonies' destruction. Antimicrobial treatment strategy has become a real concern for many dental professionals. A multitude of clinical trials confirms the caries-inhibiting effect of

The initiatives undertaken by WHO, have global impact on the national and international

High prevalence of oral diseases, such as dental caries, is not only individual preoccupation, but also a serious public health problem. WHO is continuously developing

policy development, one of which is the WHO Global Oral Health Program.

and a mean dmft of 7.49 for the non-fluoridated communities (David et al. 2001).

that "before you think of any preventive measure, *put fluoride salts on the teeth*"*.* 

children (Dye et al. 2011).

range is between 0.8 and 1.5 mg/l.

chlorhexidine (Zhang at al. 2006).

**6. Oral health strategies** 

and reapplication is recommended every 3 to 6 months.

bacteria is treatment with a chlorhexidine gluconate rinse or gel.

**5.3.5 Fluoride and antimicrobial agent utilization** 

their drinking water was regularly fluoridated (Marthaler et al. 1996).

strategies and objectives on prevention of oral disease through oral health promotion. Thus, it may be of a great interest for the readers to get familiar with these WHO strategies and objectives.

#### **6.1 The objectives of the WHO Global Oral Health Program (ORH) (www.who.int/oral\_health/strategies\_2010)**

The objectives of the WHO Global Oral Health Program (ORH), one of the technical programs within the Department of Chronic Diseases and Health Promotion (CHP), have been reoriented according to the new strategy of disease prevention and promotion of health. Greater emphasis is put on developing global policies in oral health promotion and oral disease prevention, coordinated more effectively with other priority programs of CHP and other clusters and with external partners.

Several principles form the basis for the carried out work. The WHO Oral Health Program works on building oral health policies towards effective control of risks to oral health, based on the common risk factors approach. The focus is on modifiable risk behaviors related to diet, nutrition, use of tobacco and excessive consumption of alcohol, and hygiene.

Oral health is part of total health and essential to quality of life and WHO projects intend to translate the evidence into action programs. The Oral Health Program therefore gives priority to integration of oral health with general health programs before community or national levels. The WHO Oral Health Program works from the life-course perspective, currently the community programs for improved oral health of the elderly and of children is given high priority. The implementation of school oral health programs within the framework of the WHO Health Promoting Schools Initiative is supported and guidelines are developed. Oral health systems reorientation towards prevention and health promotion is recommended in light of the Ottawa Charter, the primary health care concept and the Jakarta Declaration on leading Health Promotion into the 21st Century. In addition, global goals for oral health by the year 2020 strive for development of quality of oral health systems. The Program works on application of evidence-based strategies in oral health promotion, prevention and treatment of oral diseases worldwide, health systems research and development. Emphasis is also given on prevention and care of oral mucosal lesions, including oral cancer and oral manifestations of HIV/AIDS, cranio-facial disorders, trauma and injuries.

#### **6.2 Oral health within WHO strategic directions**

WHO's goals are to build healthy populations and communities and to combat ill health. Four strategic directions provide the broad framework for focusing WHO's technical work, which also have implications for the Oral Health Program.


Oral Health Care in Children – A Preventive Perspective 43

serious public health problem. The presence of dental caries, especially of ECC, may reflect on the oral health status of children in countries with insufficient health system and inefficient primary dentistry. Early Childhood Caries (ECC) is a public health problem with biological, social and behavioral determinants. The preventive activities must start at an early age. Home-care methods are more than necessary. Primary prevention must start in the prenatal stage to fulfill the needs of pregnancy. Parents should be encouraged to avoid bad feeding habits and to instruct and supervise their children in tooth brushing. Mothers should be instructed to use the lift-the-lip technique to spot the white-spot lesions as first signs of dental caries. Newly erupted teeth must be treated with fluoride agents, and, as needed, antimicrobial agents containing chlorhexidine and thymol. Further investigation is needed to assess the effectiveness of new intervention strategies beyond traditional

measures that are not strictly dependent on access to dental professional providers.

implemented continuously.

**8. References** 

2003.

Education is the essential pillar of the preventive measures. The main role in this pillar plays mother's education, respectively her knowledge regarding the oral health. Unfortunately, an overall preventive program in oral health promotion, including oral health education, is absent in many underdeveloped countries. There are some negative indicators that contribute to the low levels of oral health knowledge, such as the lack of curriculum subjects on oral health, the lack of training and seminars on the issue, insufficient print materials for educational purposes, the lack of information for pregnant women, and negligence by dentists regarding measures for mothers to educate their children. Although some mothers with higher educational levels were highly motivated to improve their children's oral health, much more needs to be accomplished. Institutional efforts towards maternal and pediatric oral health education must be implemented immediately. Permanent and sustained oral health promotion organized with the participation of the entire civil society, with the mandatory presence of key stakeholders in the areas of education and healthcare, represent one of the highest priorities. The WHO strategies and objectives implementation regarding oral health promotion should be understood in the right manner and should be

AAP Workshop on the Classification of Periodontal Diseases 1999. In: Flemmig, T.M. (1999).

Apostolova, D., Asprovsa, V. & Simovska N (2003). Circular caries-ECC-a problem at the

Arkin, E.B. (1986). The Healthy Mothers, Healthy Babies Coalition: four years of progress.

Beck, J.D., Koch, G.G., Rozier, R.G. & Tudor, G.E. (1990). Prevalence and risk indicators for

Beighton, D., Brailsford, S., Samaranayake, L.P., Brown, J.P., Ping, F.X., Grant-Mills, D.,

earliest age. *8th Congress of the Balkan Stomatological Society,* (Abstract Book) Tirana,

periodontal attachment loss in a population of older community-dwelling blacks

Harris, R., Lo, E.C., Naidoo, S., Ramos-Gomez, F., Soo, T.C., Burnside, G. & Pine, C.M. (2004). A multi-country comparison of caries-associated microflora in demographically diverse children. *Community Dental Health,* Vol. 21, pp. 96–101.

Periodontitis. *Ann Periodontol*, Vol. 4, pp. 32-37.

*Public Health Repository,* Vol. 101, pp. 147-156.

and whites. Journal of Periodontology Vol. 61, pp. 521-528.

In accordance with WHO overall priorities, the Global Oral Health Program has adopted the following priorities and strategic orientations.

#### **6.3 Strategies and approaches in oral disease prevention and health promotion**

Priority is given to diseases linked by common, preventable and lifestyle related risk factors (e.g. unhealthy diet, tobacco use), including oral health.

High relative risk of oral disease relates to socio-cultural determinants such as poor living conditions; low education; lack of traditions, beliefs and culture in support of oral health. Communities and countries with inappropriate exposure to fluorides imply higher risk of dental caries and settings with poor access to safe water or sanitary facilities are environmental risk factors to oral health as well as general health.

#### **6.4 Health promotion and oral health**

The WHO Oral Health Program applies the philosophy "think globally - act locally". The development of program for oral health promotion in targeted countries focuses on:


#### **7. Conclusion**

Oral health is integral to general health and should not be considered in isolation. Oral diseases have detrimental effects on an individual's physical and psychological well-being and reduce quality of life. The commonest disease is dental caries. Other important conditions are gum (periodontal) disease. Dental caries is one of the most prevalent diseases among children worldwide. Its lack of treatment and complications that may occur can endanger general health. The development of dental caries is a dynamic process. Caries progression or reversal is determined by the balance between protective and pathological factors in the mouth. The most important component in the treatment of the caries disease is prevention. Understanding the balance between pathological factors and protective factors is the key to successful prevention of caries. Analyzing the etiology, prevalence, clinical specifics, consequences and complications, caries in general and ECC in particular are estimated as serious diseases, which represent not only health problem, but also a great serious social and economic problem. A well-recognized association exists between socioeconomic status and oral health, and trends suggest that disease is increasingly concentrated in the lower income groups. However, oral diseases are largely preventable. In underdeveloped countries, oral health consequences due to dental caries also represent a

In accordance with WHO overall priorities, the Global Oral Health Program has adopted the

High relative risk of oral disease relates to socio-cultural determinants such as poor living conditions; low education; lack of traditions, beliefs and culture in support of oral health. Communities and countries with inappropriate exposure to fluorides imply higher risk of dental caries and settings with poor access to safe water or sanitary facilities are

The WHO Oral Health Program applies the philosophy "think globally - act locally". The

• Identification of health determinants; mechanisms in place to improve capacity to

• Implementation of community-based demonstration projects for oral health promotion,

• Building capacity in planning and evaluation of national program for oral health promotion and evaluation of oral health promotion interventions in operation. • Development of methods and tools to analyze the processes and outcomes of oral

• Establishment of networks and alliances to strengthen national and international actions for oral health promotion. Emphasis is also given to the development of networks for exchange of experiences within the context of the WHO Mega Country

Oral health is integral to general health and should not be considered in isolation. Oral diseases have detrimental effects on an individual's physical and psychological well-being and reduce quality of life. The commonest disease is dental caries. Other important conditions are gum (periodontal) disease. Dental caries is one of the most prevalent diseases among children worldwide. Its lack of treatment and complications that may occur can endanger general health. The development of dental caries is a dynamic process. Caries progression or reversal is determined by the balance between protective and pathological factors in the mouth. The most important component in the treatment of the caries disease is prevention. Understanding the balance between pathological factors and protective factors is the key to successful prevention of caries. Analyzing the etiology, prevalence, clinical specifics, consequences and complications, caries in general and ECC in particular are estimated as serious diseases, which represent not only health problem, but also a great serious social and economic problem. A well-recognized association exists between socioeconomic status and oral health, and trends suggest that disease is increasingly concentrated in the lower income groups. However, oral diseases are largely preventable. In underdeveloped countries, oral health consequences due to dental caries also represent a

development of program for oral health promotion in targeted countries focuses on:

**6.3 Strategies and approaches in oral disease prevention and health promotion**  Priority is given to diseases linked by common, preventable and lifestyle related risk factors

following priorities and strategic orientations.

**6.4 Health promotion and oral health** 

Program.

**7. Conclusion** 

(e.g. unhealthy diet, tobacco use), including oral health.

environmental risk factors to oral health as well as general health.

design and implement interventions that promote oral health.

with special reference to poor and disadvantaged population groups.

health promotion interventions as part of national health program.

serious public health problem. The presence of dental caries, especially of ECC, may reflect on the oral health status of children in countries with insufficient health system and inefficient primary dentistry. Early Childhood Caries (ECC) is a public health problem with biological, social and behavioral determinants. The preventive activities must start at an early age. Home-care methods are more than necessary. Primary prevention must start in the prenatal stage to fulfill the needs of pregnancy. Parents should be encouraged to avoid bad feeding habits and to instruct and supervise their children in tooth brushing. Mothers should be instructed to use the lift-the-lip technique to spot the white-spot lesions as first signs of dental caries. Newly erupted teeth must be treated with fluoride agents, and, as needed, antimicrobial agents containing chlorhexidine and thymol. Further investigation is needed to assess the effectiveness of new intervention strategies beyond traditional measures that are not strictly dependent on access to dental professional providers.

Education is the essential pillar of the preventive measures. The main role in this pillar plays mother's education, respectively her knowledge regarding the oral health. Unfortunately, an overall preventive program in oral health promotion, including oral health education, is absent in many underdeveloped countries. There are some negative indicators that contribute to the low levels of oral health knowledge, such as the lack of curriculum subjects on oral health, the lack of training and seminars on the issue, insufficient print materials for educational purposes, the lack of information for pregnant women, and negligence by dentists regarding measures for mothers to educate their children. Although some mothers with higher educational levels were highly motivated to improve their children's oral health, much more needs to be accomplished. Institutional efforts towards maternal and pediatric oral health education must be implemented immediately. Permanent and sustained oral health promotion organized with the participation of the entire civil society, with the mandatory presence of key stakeholders in the areas of education and healthcare, represent one of the highest priorities. The WHO strategies and objectives implementation regarding oral health promotion should be understood in the right manner and should be implemented continuously.

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**3** 

*India* 

**Pediatric Dentistry** 

Mandeep S. Virdi

**– A Guide for General Practitioner** 

*PDM Dental College and Research Institute, Bahadurgarh, Haryana* 

Children a resource of the world are the promise of what our future is going to be. A healthy child is a better promise of a better world than an unhealthy child. Oral health is a very important aspect to ensure a healthy future therefore oral health for children is a worthy concern regardless of child's nationality, ethnicity or geographic location. Dentistry for children has come a long way from its humble beginning in 1924 with the publishing of first comprehensive text book on dentistry for children followed by formation of The American Academy of Pedodontics in the late forties, which was also recognized by council of dental education a part of the ADA to certify candidates to practice specialized dentistry for children. Mid eighties saw the present name American Academy of Pediatric Dentistry being adopted followed by defining pediatric dentistry which in the present day is defined as an age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those

Pediatric Dentistry as the definition implies is a body of knowledge that is dependent upon curriculum of other dental subjects along with the latest development happening in various specialties of dentistry. To be able to give primary, comprehensive and preventive oral health care to children of all ages the pediatric dentist relies on preventive dentistry, pulpal therapy, instrumentation and restoration of teeth, dental material, oral surgery, preventive and interceptive orthodontics, and principals of prosthetics. Besides the dental knowledge, a working knowledge is also required of pediatric medicine, general and oral pathology along with growth and development. For the development of appropriate preventive strategy it is imperative that the pediatric dentist have knowledge of nutrition and systemic as well as topical effects of fluoride. To be able to deal effectively with children behavior management and a thorough knowledge of psychological development is imperative because child needs

The prenatal period is a gestation of approximately nine months, beginning with the period of ovum that lasts for about two weeks and is marked by blast cyst getting attached to the wall of the uterus. This is followed by the period of embryo lasting for about next six weeks and is characterized by development of the organ systems. Following which the period of

**1. Introduction** 

with special health care needs1.

to be treated differently than the adult.

**1.1 Prenatal stage** 


## **Pediatric Dentistry – A Guide for General Practitioner**

Mandeep S. Virdi *PDM Dental College and Research Institute, Bahadurgarh, Haryana India* 

#### **1. Introduction**

50 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

Winter, G.B., Hamilton, M.C. & James, P.M.C. (1966). Role of comforter as en etiological

Whittle, J.G. & Whittle, K.W. (1988). Household income in relation to dental health and

World Health Organization (1997). *Oral Health surveys*. Basic Methods (4th ed.), World

World Health Organization (2008). *The World Oral Health Report 2003*. Continuous

World Health Organization (2010). http://www.who.int/oral\_health/strategies/

Wyne, A.H. (1999). Early childhood caries: nomenclature and case definition. *Community* 

Zhang, Q., van't Hof, M.A. & Truin, G.J. (2006). Caries-inhibiting effect of chlorhexidine varnish in pits and fissures. *Journal of Dental Research*, Vol. 85, pp.469–472.

en/orh\_report03\_en.pdf. Accessed October 15th, 2010.

hp/en/index.html. Accessed October 15th, 2010.

*Dentistry and Oral Epidemiology*, Vol. 7, pp. 313-315.

417, pp. 207-212.

Health Organization, Geneva.

pp. 150-154.

factor in rampant caries of deciduous dentition. *Archives of Diseases in Children*, Vol.

dental health behaviors: the use of super profiles. *Community Dental Health*, Vol. 15,

improvement of oral health in the 21st century – the approach of the WHO Global Oral Health Programme, http://www.who.int/oral\_health/media/

> Children a resource of the world are the promise of what our future is going to be. A healthy child is a better promise of a better world than an unhealthy child. Oral health is a very important aspect to ensure a healthy future therefore oral health for children is a worthy concern regardless of child's nationality, ethnicity or geographic location. Dentistry for children has come a long way from its humble beginning in 1924 with the publishing of first comprehensive text book on dentistry for children followed by formation of The American Academy of Pedodontics in the late forties, which was also recognized by council of dental education a part of the ADA to certify candidates to practice specialized dentistry for children. Mid eighties saw the present name American Academy of Pediatric Dentistry being adopted followed by defining pediatric dentistry which in the present day is defined as an age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs1.

> Pediatric Dentistry as the definition implies is a body of knowledge that is dependent upon curriculum of other dental subjects along with the latest development happening in various specialties of dentistry. To be able to give primary, comprehensive and preventive oral health care to children of all ages the pediatric dentist relies on preventive dentistry, pulpal therapy, instrumentation and restoration of teeth, dental material, oral surgery, preventive and interceptive orthodontics, and principals of prosthetics. Besides the dental knowledge, a working knowledge is also required of pediatric medicine, general and oral pathology along with growth and development. For the development of appropriate preventive strategy it is imperative that the pediatric dentist have knowledge of nutrition and systemic as well as topical effects of fluoride. To be able to deal effectively with children behavior management and a thorough knowledge of psychological development is imperative because child needs to be treated differently than the adult.

#### **1.1 Prenatal stage**

The prenatal period is a gestation of approximately nine months, beginning with the period of ovum that lasts for about two weeks and is marked by blast cyst getting attached to the wall of the uterus. This is followed by the period of embryo lasting for about next six weeks and is characterized by development of the organ systems. Following which the period of

Pediatric Dentistry

the early establishment of a dental home.

**3. Anticipatory guidance** 

enamel remineralization.

includes the following:

ECC.

MS.

following:

their infants.

– A Guide for General Practitioner 53

An oral health risk assessment for infants by 6 months of age allows for the institution of appropriate preventive strategies as the primary dentition begins to erupt. Caries risk assessment can be used to determine the patient's relative risk for caries. Even the most judiciously designed and implemented caries risk assessment tool, however, can fail to identify all infants at risk for developing ECC. In these cases, the mother may not be the colonization source of the child's oral flora, the dietary intake of simple carbohydrates may be extremely high, or other uncontrollable factors may combine to place the patient at risk for developing caries. Therefore, screening for risk of caries in the parent and patient coupled with oral health counseling, although a feasible and equitable approach to ECC control is not a substitute for the early establishment of the dental home. Whenever possible, the ideal approach to infant oral health care, including ECC prevention and management, is

General anticipatory guidance given by AAPD for the mother (or other intimate caregiver)

• Oral hygiene: Tooth-brushing and flossing by the mother on a daily basis are important

• Diet: Important components of dietary education for the parents include the cariogenicity of certain foods and beverages, role of frequency of consumption of these

• Fluoride: Using a fluoridated toothpaste approved by the relevant Dental Association and rinsing every night with an alcohol-free, over-the-counter mouth rinse containing 0.05% sodium fluoride have been suggested to help reduce plaque levels and help

• Caries removal: Routine professional dental care for the mothers can help keep their oral health in optimal condition. Removal of active caries with subsequent restoration is important to suppress maternal MS reservoirs and has the potential to minimize the transfer of MS to the infant, thereby decreasing the infant's risk of developing

• Delay of colonization: Education of the parents, especially mothers, on avoiding salivasharing behaviors (eg. sharing spoons and other utensils, sharing cups, cleaning a dropped pacifier or toy with their mouth) can help prevent early colonization of MS in

• Xylitol chewing gums: Evidence demonstrates that mothers' use of xylitol chewing gum can prevent dental caries in their children by prohibiting the transmission of

General anticipatory guidance for the young patient (0 to 3 years of age) includes the

• Oral hygiene: Oral hygiene measures should be implemented no later than the time of the eruption of the first primary tooth. Cleansing the infant's teeth as soon as they erupt with either a washcloth or soft toothbrush will help reduce bacterial colonization. Children's teeth should be brushed twice daily with fluoridated toothpaste and a soft, age-appropriate sized toothbrush. A "smear" of toothpaste is recommended for children less than 2 years of age, while a "pea-size" amount of paste is recommended

to help dislodge food and reduce bacterial plaque levels.

substances, and the demineralization/remineralization process.

fetus lasting right up to the delivery of the child is the time when maturation of the newly formed organs takes place.

The role of pediatric dentist starts at pre natal stage in guiding the expecting parents to maintain oral health as the mouth is an obvious portal of entry to the body, and oral health reflects and influences general health and well being. Maternal oral health has significant implications for birth outcomes and infant oral health. Maternal periodontal disease, that is, a chronic infection of the gingiva and supporting tooth structures, has been associated with preterm birth, development of preeclampsia, and delivery of a small-for-gestational age infant. Prematurely born children have higher prevalence of enamel defects. In very low birth-weight children, the prevalence of enamel defects could be even higher. Both systemic and local factors contribute to the etiology of dental defects.

Low birth-weight children are often intubated at birth, and left-sided defects on maxillary anterior teeth occurred twice as frequently as right-sided defects, probably the result of trauma from left sided laryngoscopy.

Maternal oral flora is transmitted to the newborn infant, and increased cariogenic flora in the mother predisposes the infant to the development of caries. It is intriguing to consider preconception, pregnancy, or intrapartum treatment of oral health conditions as a mechanism to improve women's oral and general health, pregnancy outcomes, and their children's dental health. However, given the relationship between oral health and general health, oral health care should be a goal in its own right for all individuals. Regardless of the potential for improved oral health to improve pregnancy outcomes, public policies that support comprehensive dental services for vulnerable women of childbearing age should be expanded so that their own oral and general health is safeguarded and their children's risk of caries is reduced. Oral health promotion should include education of women and their health care providers' ways to prevent oral disease from occurring, and referral for dental services when disease is present 2.

#### **2. Role of pediatric dentist at birth**

Infant oral health, along with perinatal oral health, is one of the foundations upon which preventive education and dental care must be built to enhance the opportunity for a lifetime free from preventable oral disease. Caries is perhaps the most prevalent infectious disease in children. Almost half children have caries by the time they reach kindergarten. Early childhood caries (ECC) can be a particularly virulent form of caries, beginning soon after tooth eruption, developing on smooth surfaces, progressing rapidly, and having a lasting detrimental impact on the dentition. This disease affects the general population but is more likely to occur in infants who consume a diet high in sugar, and whose mothers have a low education level. Caries in primary teeth can affect children's growth, result in significant pain and potentially life-threatening infection, and diminish overall quality of life.

Caries is a disease that is, by and large, preventable. Early risk assessment allows for identification of parent-infant groups who are at risk for ECC and would benefit from early preventive intervention. The ultimate goal of early assessment is the timely delivery of educational information to populations at high risk for developing caries in order to prevent the need for later surgical intervention.

fetus lasting right up to the delivery of the child is the time when maturation of the newly

The role of pediatric dentist starts at pre natal stage in guiding the expecting parents to maintain oral health as the mouth is an obvious portal of entry to the body, and oral health reflects and influences general health and well being. Maternal oral health has significant implications for birth outcomes and infant oral health. Maternal periodontal disease, that is, a chronic infection of the gingiva and supporting tooth structures, has been associated with preterm birth, development of preeclampsia, and delivery of a small-for-gestational age infant. Prematurely born children have higher prevalence of enamel defects. In very low birth-weight children, the prevalence of enamel defects could be even higher. Both systemic

Low birth-weight children are often intubated at birth, and left-sided defects on maxillary anterior teeth occurred twice as frequently as right-sided defects, probably the result of

Maternal oral flora is transmitted to the newborn infant, and increased cariogenic flora in the mother predisposes the infant to the development of caries. It is intriguing to consider preconception, pregnancy, or intrapartum treatment of oral health conditions as a mechanism to improve women's oral and general health, pregnancy outcomes, and their children's dental health. However, given the relationship between oral health and general health, oral health care should be a goal in its own right for all individuals. Regardless of the potential for improved oral health to improve pregnancy outcomes, public policies that support comprehensive dental services for vulnerable women of childbearing age should be expanded so that their own oral and general health is safeguarded and their children's risk of caries is reduced. Oral health promotion should include education of women and their health care providers' ways to prevent oral disease from occurring, and referral for dental

Infant oral health, along with perinatal oral health, is one of the foundations upon which preventive education and dental care must be built to enhance the opportunity for a lifetime free from preventable oral disease. Caries is perhaps the most prevalent infectious disease in children. Almost half children have caries by the time they reach kindergarten. Early childhood caries (ECC) can be a particularly virulent form of caries, beginning soon after tooth eruption, developing on smooth surfaces, progressing rapidly, and having a lasting detrimental impact on the dentition. This disease affects the general population but is more likely to occur in infants who consume a diet high in sugar, and whose mothers have a low education level. Caries in primary teeth can affect children's growth, result in significant pain and potentially life-threatening infection, and diminish overall quality of

Caries is a disease that is, by and large, preventable. Early risk assessment allows for identification of parent-infant groups who are at risk for ECC and would benefit from early preventive intervention. The ultimate goal of early assessment is the timely delivery of educational information to populations at high risk for developing caries in order to prevent

and local factors contribute to the etiology of dental defects.

formed organs takes place.

trauma from left sided laryngoscopy.

services when disease is present 2.

life.

**2. Role of pediatric dentist at birth** 

the need for later surgical intervention.

An oral health risk assessment for infants by 6 months of age allows for the institution of appropriate preventive strategies as the primary dentition begins to erupt. Caries risk assessment can be used to determine the patient's relative risk for caries. Even the most judiciously designed and implemented caries risk assessment tool, however, can fail to identify all infants at risk for developing ECC. In these cases, the mother may not be the colonization source of the child's oral flora, the dietary intake of simple carbohydrates may be extremely high, or other uncontrollable factors may combine to place the patient at risk for developing caries. Therefore, screening for risk of caries in the parent and patient coupled with oral health counseling, although a feasible and equitable approach to ECC control is not a substitute for the early establishment of the dental home. Whenever possible, the ideal approach to infant oral health care, including ECC prevention and management, is the early establishment of a dental home.

### **3. Anticipatory guidance**

General anticipatory guidance given by AAPD for the mother (or other intimate caregiver) includes the following:


General anticipatory guidance for the young patient (0 to 3 years of age) includes the following:

• Oral hygiene: Oral hygiene measures should be implemented no later than the time of the eruption of the first primary tooth. Cleansing the infant's teeth as soon as they erupt with either a washcloth or soft toothbrush will help reduce bacterial colonization. Children's teeth should be brushed twice daily with fluoridated toothpaste and a soft, age-appropriate sized toothbrush. A "smear" of toothpaste is recommended for children less than 2 years of age, while a "pea-size" amount of paste is recommended

Pediatric Dentistry

MANAGEMENT 1. Physician education

• **Bifid uvula** 

aneurysm.

excellent.

• **Hyperplastic labial frenum**  • **White Sponge Nevus** 

should not be performed before 4 years of age 4.

3. Monitor for appropriate weight gain if exclusively breastfeeding

attracted the attention of people dealing with cleft patients.

2. Parental education and reassurance

4. Complete fusion requires surgery • **Paramedian lip pits (congenital lip pits)** 

– A Guide for General Practitioner 55

defects, difficulty in breastfeeding, or dental problems. However, controlled trials on ankyloglossia have not been appropriately studied, and therefore indications for therapy remain controversial. The tip of the tongue normally grows until 4 years of age, and initial restrictions of movement may improve as the child gets older. Therefore, frenulectomy

PITS OF THE LOWER lip (fistulas of lower lip, paramedian sinuses of lower lip, humps of lower lip, labial cysts, etc.) is a very rare congenital malformation, first described by Demarquay in 1845. This minimally deforming anomaly is remarkable chiefly for its association with facial clefts. The fact that clefts that occur in families with the lip pits anomaly have a stronger familial tendency than clefts in families without lip pits has

A bifid or bifurcated uvula is a split or cleft uvula. Newborns with cleft palate also have a split uvula. The bifid uvula results from the incomplete fusion of the medial nasal and maxillary processes. Bifid uvulas have less muscle in them than a normal uvula, which may cause recurring problems with middle ear infections. While swallowing, the soft palate is pushed backwards, preventing food and drink from entering the nasal cavity. If the soft palate cannot touch the back of the throat while swallowing, food and drink can enter the nasal cavity. Splitting of the uvula occurs infrequently but is the most common form of mouth and nose area cleavage among newborns. Bifid uvula occurs in about 2% of the general population, although some populations may have a high incidence, such as Native Americans who have a 10% rate. Bifid uvula is a common symptom of the rare genetic syndrome Loeys-Dietz syndrome, which is associated with an increased risk of aortic

White sponge nevus (WSN), also known as Cannon's disease, hereditary leukokeratosis of mucosa and White sponge nevus of Cannon, is an autosomal dominant skin condition. Although congenital in most cases, it can first occur in childhood or adolescence. It presents in the mouth, most frequently as a thick bilateral white plaque with a spongy texture, usually on the buccal mucosa, but sometimes on the labial mucosa, alveolar ridge or floor of the mouth. The gingival margin and dorsum of the tongue are almost never affected. Although this condition is perfectly benign, it is often mistaken for leukoplakia. There is no treatment, but because there are no serious clinical complications, the prognosis is

**5. Normal teething and conditions associated with eruption of teeth** 

Teething is the process by which an infant's teeth erupt, or break through, the gums. Teething is also referred to as "cutting" of the teeth. Teething is medically termed odontiasis.

for children 2-5 years of age. Flossing should be initiated when adjacent tooth surfaces cannot be cleansed with a toothbrush.


#### **4. Birth to the eruption of first teeth**

Besides the anticipatory guidelines some time conditions are present which require immediate attention these could include developmental anomalies such as

#### • **Partial ankyglosia (tongue tie)**

Tongue-tie is a condition in which the lingual frenulum is either too short or anteriorly placed limiting the mobility of the tongue.

Early in fetal development, the tongue is attached to the floor of the mouth. With cell death and atrophy, the only attachment is the frenulum. Tongue-tie results when the frenulum is short and this may limit the movement of the tongue. When there is an attempt to stick the tongue out, there may be a V shaped notch at the tip. The incidence is 0.5/1000 Physical exam will easily demonstrate the short or anteriorly placed lingual frenulum.

Years ago it was routine to clip the frenulum at the time of delivery. Midwives had a long sharp nail to cut the frenulum and obstetricians would inspect the mouth and cut the frenulum immediately after the delivery. Tongue-tie is associated with speech abnormalities especially lisping and inability to pronounce certain sounds.

Tongue-tie actually represents partial ankyloglossia and fusion represents complete ankyloglossia. Case reports indicate that squeals of ankyloglossia may include speech defects, difficulty in breastfeeding, or dental problems. However, controlled trials on ankyloglossia have not been appropriately studied, and therefore indications for therapy remain controversial. The tip of the tongue normally grows until 4 years of age, and initial restrictions of movement may improve as the child gets older. Therefore, frenulectomy should not be performed before 4 years of age 4.

#### MANAGEMENT

54 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

• Diet: High-risk dietary practices appear to be established early, probably by 12 months of age, and are maintained throughout early childhood. Frequent night time bottle feeding, ad libitum breast-feeding, and extended and repeated use of a sippy or no-spill cup are associated with, but not consistently implicated in ECC. Likewise, frequent consumption of snacks or drinks containing fermentable carbohydrates (e.g., juice, milk,

• Fluoride: Optimal exposure to fluoride is important to all dentate infants and children. The use of fluoride for the prevention and control of caries is documented to be both safe and effective. Twice-daily brushing with fluoridated toothpaste is recommended for all children as a preventive procedure. Professionally-applied fluoride, as well as at home fluoride treatments, should be considered for children at high caries risk based upon caries risk assessment. Systemically-administered fluoride should be considered for all children drinking fluoride deficient water (<0.6 ppm).Caution is indicated in the use of all fluoride-containing products. Fluorosis has been associated with cumulative fluoride intake during enamel development, with the severity dependent on the dose, duration, and timing of intake. Decisions concerning the administration of additional

• Injury prevention: Practitioners should provide age appropriate injury prevention counseling for orofacial trauma. Initially, discussions would include play objects,

• Non-nutritive habits: Non-nutritive oral habits (e.g., digit or pacifier sucking, bruxism, abnormal tongue thrust) may apply forces to teeth and dentoalveolar structures. It is important to discuss the need for early sucking and the need to wean infants from these

Besides the anticipatory guidelines some time conditions are present which require

Tongue-tie is a condition in which the lingual frenulum is either too short or anteriorly

Early in fetal development, the tongue is attached to the floor of the mouth. With cell death and atrophy, the only attachment is the frenulum. Tongue-tie results when the frenulum is short and this may limit the movement of the tongue. When there is an attempt to stick the tongue out, there may be a V shaped notch at the tip. The incidence is 0.5/1000 Physical

Years ago it was routine to clip the frenulum at the time of delivery. Midwives had a long sharp nail to cut the frenulum and obstetricians would inspect the mouth and cut the frenulum immediately after the delivery. Tongue-tie is associated with speech abnormalities

Tongue-tie actually represents partial ankyloglossia and fusion represents complete ankyloglossia. Case reports indicate that squeals of ankyloglossia may include speech

cannot be cleansed with a toothbrush.

formula, soda) also can increase the child's caries risk.

fluoride are based on the unique needs of each patient.

habits before malocclusion or skeletal dysplasia's occur.

immediate attention these could include developmental anomalies such as

exam will easily demonstrate the short or anteriorly placed lingual frenulum.

especially lisping and inability to pronounce certain sounds.

pacifiers, car seats, and electric cords.

**4. Birth to the eruption of first teeth** 

placed limiting the mobility of the tongue.

• **Partial ankyglosia (tongue tie)** 

for children 2-5 years of age. Flossing should be initiated when adjacent tooth surfaces


PITS OF THE LOWER lip (fistulas of lower lip, paramedian sinuses of lower lip, humps of lower lip, labial cysts, etc.) is a very rare congenital malformation, first described by Demarquay in 1845. This minimally deforming anomaly is remarkable chiefly for its association with facial clefts. The fact that clefts that occur in families with the lip pits anomaly have a stronger familial tendency than clefts in families without lip pits has attracted the attention of people dealing with cleft patients.

#### • **Bifid uvula**

A bifid or bifurcated uvula is a split or cleft uvula. Newborns with cleft palate also have a split uvula. The bifid uvula results from the incomplete fusion of the medial nasal and maxillary processes. Bifid uvulas have less muscle in them than a normal uvula, which may cause recurring problems with middle ear infections. While swallowing, the soft palate is pushed backwards, preventing food and drink from entering the nasal cavity. If the soft palate cannot touch the back of the throat while swallowing, food and drink can enter the nasal cavity. Splitting of the uvula occurs infrequently but is the most common form of mouth and nose area cleavage among newborns. Bifid uvula occurs in about 2% of the general population, although some populations may have a high incidence, such as Native Americans who have a 10% rate. Bifid uvula is a common symptom of the rare genetic syndrome Loeys-Dietz syndrome, which is associated with an increased risk of aortic aneurysm.

#### • **Hyperplastic labial frenum**

#### • **White Sponge Nevus**

White sponge nevus (WSN), also known as Cannon's disease, hereditary leukokeratosis of mucosa and White sponge nevus of Cannon, is an autosomal dominant skin condition. Although congenital in most cases, it can first occur in childhood or adolescence. It presents in the mouth, most frequently as a thick bilateral white plaque with a spongy texture, usually on the buccal mucosa, but sometimes on the labial mucosa, alveolar ridge or floor of the mouth. The gingival margin and dorsum of the tongue are almost never affected. Although this condition is perfectly benign, it is often mistaken for leukoplakia. There is no treatment, but because there are no serious clinical complications, the prognosis is excellent.

#### **5. Normal teething and conditions associated with eruption of teeth**

Teething is the process by which an infant's teeth erupt, or break through, the gums. Teething is also referred to as "cutting" of the teeth. Teething is medically termed odontiasis.

Pediatric Dentistry

child to choke.

to him.

esthetics.

aggression and hostility.

**6.1 Managing the developing occlusion** 

accuracy of diagnosis; appropriateness of treatment.

with their dental and skeletal sequelae.

**6. The primary dentition years** 

– A Guide for General Practitioner 57

nipple or use of a cup may reduce discomfort and improve feeding. Cold objects many help reduce inflammation as well, never put anything in a child's mouth that might enable the

The first primary tooth emerges at around six months of age and by three years root development is complete. This is the preschool years and children are called pre schoolers and they are increasing their cognitive abilities but still in the preconceptual stage and should be considered unsophisticated in thinking. This sophistication only develops during the period of intuitive thought where in the child learns the skills of writing and classification after four years of age and can follow dental instructions given

Another difference observed three years onwards is the development of self control where in these children can distract themselves for example when receiving anesthesia and can be tought to monitor there behavior and they may feel guilty if they are not following the expected norms. In clinical management terms the child is not emotionally mature but surely emotionally complex and will respond to praise and will hurt and respond to

Guidance of eruption and development of the primary, mixed, and permanent dentitions is an integral component of comprehensive oral health care for all pediatric dental patients. Such guidance should contribute to the development of a permanent dentition that is in a stable, functional, and esthetically acceptable occlusion. Early diagnosis and successful treatment of developing malocclusions can have both short-term and long term benefits while achieving the goals of occlusal harmony and function and dentofacial

Many factors can affect the management of the developing dental arches and minimize the overall success of any treatment. The variables associated with the treatment of the developing dentition that will affect the degree to which treatment is successful include, but are not limited to: chronological/mental/emotional age of the patient andthe patient's ability to understand and cooperate in the treatment; intensity, frequency, and duration of an oral habit; parental support for the treatment; compliance with clinician's instructions; craniofacial configuration; craniofacial growth; concomitant systemic disease or condition;

Anomalies of primary teeth and eruption may not be evident/diagnosable prior to eruption, due to the child's not presenting for dental examination or to a radiographic examination not being possible in a young child. Evaluation, however, should be accomplished when feasible. The objectives of evaluation include identification of: all anomalies of tooth number and size (as previously noted); anterior and posterior crossbites; presence of habits along

Oral Habits and posterior crossbites should be diagnosed and addressed as early as feasible8. Parents should be informed about findings of adverse growth and developing malocclusions. Interventions/treatment can be recommended if diagnosis can be made,

The onset of teething symptoms typically precedes the eruption of a tooth by several days. While a baby's first tooth can present between 4 and 10 months of age, the first tooth usually erupts at approximately 6 months of age. Some dentists have noted a family pattern of "early," "average," or "late" teethers.

A relatively rare condition, "natal" teeth, describes the presence of a tooth on the day of birth 7. The incidence of such an event is one per 2,000-3,000 live births. Usually, this single and often somewhat malformed tooth is a unique event in an otherwise normal child. Rarely, the presence of a natal tooth is just one of several unusual physical findings which make up a syndrome. If the possibility of a syndrome exists, consultation with a pediatric dentist and/or geneticist can be helpful. The natal tooth is often loose and is commonly removed prior to the newborn's hospital discharge to lessen the risk of aspiration into the lungs.

Teething is generally associated with gum and jaw discomfort as the infant's tooth prepares to erupt through the gum surface. As the tooth moves beneath the surface of the gum tissue, the area may appear slightly red or swollen. Sometimes a fluid-filled area similar to a "blood blister" or eruption hematoma may be seen over the erupting tooth. Some teeth may be more sensitive than others when they erupt. The larger molars may cause more discomfort due to their larger surface area that can't "slice" through the gum tissue as an erupting incisor is capable of doing. With the exception of the eruption of the third molars (wisdom teeth), eruption of permanent teeth rarely cause the discomfort associated with eruption of "baby" (primary or deciduous) teeth.

Teething may cause the following symptoms:

• increased drooling, restless or decreased sleeping due to gum discomfort, refusal of food due to soreness of the gum region, fussiness that comes and goes, bringing hands to the mouth, mild rash around the mouth due to skin irritation secondary to excessive drooling, and rubbing the cheek or ear region as a consequence of referred pain during the eruption of the molars.

Importantly, teething is not associated with the following symptoms: fever (especially over 101 F), diarrhea, runny nose and cough, prolonged fussiness, or rashes over the body.

Sometime minimal intervention may be required during teething in the form of certain overthe-counter medicines can be placed directly on the gums to help relieve pain. They contain medications that temporarily numb the gum tissue. They may help for brief periods of time but have a taste and sensation that many children do not like. It is important not to let the medicine numb the throat because that may interfere with the normal gag reflex and may make it possible for food to enter the lungs. Medicines that are taken by mouth to help reduce the pain.

Acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) can also help with pain. Ibuprofen should not be administered to infants younger than 6 months of age. Medications should be used only for the few times when other home-care methods do not help. Caution should be taken not to overmedicate for teething. The medicine may mask significant symptoms that could be important to know about.

Infant gums often feel better when gentle pressure is placed on the gums. For this reason, gently rubbing of the gums with a clean finger or having the child bite down on a clean washcloth. If the pain seems to be causing feeding problems, sometimes a different shaped

The onset of teething symptoms typically precedes the eruption of a tooth by several days. While a baby's first tooth can present between 4 and 10 months of age, the first tooth usually erupts at approximately 6 months of age. Some dentists have noted a family pattern of

A relatively rare condition, "natal" teeth, describes the presence of a tooth on the day of birth 7. The incidence of such an event is one per 2,000-3,000 live births. Usually, this single and often somewhat malformed tooth is a unique event in an otherwise normal child. Rarely, the presence of a natal tooth is just one of several unusual physical findings which make up a syndrome. If the possibility of a syndrome exists, consultation with a pediatric dentist and/or geneticist can be helpful. The natal tooth is often loose and is commonly removed prior to the newborn's hospital discharge to lessen the risk of aspiration into the

Teething is generally associated with gum and jaw discomfort as the infant's tooth prepares to erupt through the gum surface. As the tooth moves beneath the surface of the gum tissue, the area may appear slightly red or swollen. Sometimes a fluid-filled area similar to a "blood blister" or eruption hematoma may be seen over the erupting tooth. Some teeth may be more sensitive than others when they erupt. The larger molars may cause more discomfort due to their larger surface area that can't "slice" through the gum tissue as an erupting incisor is capable of doing. With the exception of the eruption of the third molars (wisdom teeth), eruption of permanent teeth rarely cause the discomfort associated with eruption of

• increased drooling, restless or decreased sleeping due to gum discomfort, refusal of food due to soreness of the gum region, fussiness that comes and goes, bringing hands to the mouth, mild rash around the mouth due to skin irritation secondary to excessive drooling, and rubbing the cheek or ear region as a consequence of referred pain during

Importantly, teething is not associated with the following symptoms: fever (especially over 101 F), diarrhea, runny nose and cough, prolonged fussiness, or rashes over the

Sometime minimal intervention may be required during teething in the form of certain overthe-counter medicines can be placed directly on the gums to help relieve pain. They contain medications that temporarily numb the gum tissue. They may help for brief periods of time but have a taste and sensation that many children do not like. It is important not to let the medicine numb the throat because that may interfere with the normal gag reflex and may make it possible for food to enter the lungs. Medicines that are taken by mouth to help

Acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) can also help with pain. Ibuprofen should not be administered to infants younger than 6 months of age. Medications should be used only for the few times when other home-care methods do not help. Caution should be taken not to overmedicate for teething. The medicine may mask significant symptoms that

Infant gums often feel better when gentle pressure is placed on the gums. For this reason, gently rubbing of the gums with a clean finger or having the child bite down on a clean washcloth. If the pain seems to be causing feeding problems, sometimes a different shaped

"early," "average," or "late" teethers.

"baby" (primary or deciduous) teeth.

the eruption of the molars.

could be important to know about.

Teething may cause the following symptoms:

lungs.

body.

reduce the pain.

nipple or use of a cup may reduce discomfort and improve feeding. Cold objects many help reduce inflammation as well, never put anything in a child's mouth that might enable the child to choke.

#### **6. The primary dentition years**

The first primary tooth emerges at around six months of age and by three years root development is complete. This is the preschool years and children are called pre schoolers and they are increasing their cognitive abilities but still in the preconceptual stage and should be considered unsophisticated in thinking. This sophistication only develops during the period of intuitive thought where in the child learns the skills of writing and classification after four years of age and can follow dental instructions given to him.

Another difference observed three years onwards is the development of self control where in these children can distract themselves for example when receiving anesthesia and can be tought to monitor there behavior and they may feel guilty if they are not following the expected norms. In clinical management terms the child is not emotionally mature but surely emotionally complex and will respond to praise and will hurt and respond to aggression and hostility.

#### **6.1 Managing the developing occlusion**

Guidance of eruption and development of the primary, mixed, and permanent dentitions is an integral component of comprehensive oral health care for all pediatric dental patients. Such guidance should contribute to the development of a permanent dentition that is in a stable, functional, and esthetically acceptable occlusion. Early diagnosis and successful treatment of developing malocclusions can have both short-term and long term benefits while achieving the goals of occlusal harmony and function and dentofacial esthetics.

Many factors can affect the management of the developing dental arches and minimize the overall success of any treatment. The variables associated with the treatment of the developing dentition that will affect the degree to which treatment is successful include, but are not limited to: chronological/mental/emotional age of the patient andthe patient's ability to understand and cooperate in the treatment; intensity, frequency, and duration of an oral habit; parental support for the treatment; compliance with clinician's instructions; craniofacial configuration; craniofacial growth; concomitant systemic disease or condition; accuracy of diagnosis; appropriateness of treatment.

Anomalies of primary teeth and eruption may not be evident/diagnosable prior to eruption, due to the child's not presenting for dental examination or to a radiographic examination not being possible in a young child. Evaluation, however, should be accomplished when feasible. The objectives of evaluation include identification of: all anomalies of tooth number and size (as previously noted); anterior and posterior crossbites; presence of habits along with their dental and skeletal sequelae.

Oral Habits and posterior crossbites should be diagnosed and addressed as early as feasible8. Parents should be informed about findings of adverse growth and developing malocclusions. Interventions/treatment can be recommended if diagnosis can be made,

Pediatric Dentistry

**6.3 Local anesthesia for children** 

– A Guide for General Practitioner 59

Local anesthetic administration is an important consideration in the behavior guidance of a pediatric patient9. Age-appropriate "nonthreatening" terminology, distraction, topical anesthetics, proper injection technique, can help the patient have a positive experience during administration of local anesthesia. In pediatric dentistry, the dental professional should be aware of proper dosage (based on weight) to minimize the chance of toxicity and the prolonged duration of anesthesia, which can lead to accidental lip or tongue trauma. Knowledge of the gross and neuroanatomy of the head and neck allows for proper placement of the anesthetic solution and helps minimize complications (eg, hematoma, trismus, intravascular injection). Familiarity with the patient's medical history is essential to decrease the risk of aggravating a medical condition while rendering dental care.

The application of topical anesthetic may help minimize discomfort caused during administration of local anesthesia. Topical anesthetic is effective on surface tissues (2-3 mm in depth) to reduce painful needle penetration of the oral mucosa A variety of topical

Injectable anesthetic available for dental usage include lidocaine, mepivacaine, articaine, prilocaine, and bupivacaine. Absolute contraindications for local anesthetics include a documented local anesthetic allergy. Local anesthetics without vasoconstrictors should be used with caution due to rapid systemic absorption which may result in overdose. Epinephrine decreases bleeding in the area of injection. Epinephrine concentrations of 1:50,000 may be indicated for infiltration in small doses into a surgical site to achieve

Dental caries, also known as tooth decay or a cavity, is a disease where bacterial processes damage hard tooth structure (enamel, dentin, and cementum). These tissues progressively break down, producing dental caries (cavities, holes in the teeth). Two groups of bacteria are responsible for initiating caries: Streptococcus mutans and Lactobacillus. If left untreated, the disease can lead to pain, tooth loss, infection, and, in severe cases, even death. Today, caries remains one of the most common diseases throughout the world. Cariology is the study of dental caries. One particular condition that is seen in this age group is the Early Child hood Caries (ECC). The disease of early childhood caries (ECC) is the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. In children younger than 3 years of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC). From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) surfaces

Reducing the mother's/primary caregiver's/sibling(s) MS levels (ideally during the prenatal period) to decrease transmission of cariogenic bacteria. Minimizing salivasharing activities (eg, sharing utensils) between an infant or toddler and his family/cohorts. Implementing oral hygiene measures no later than the time of eruption

anesthetic agents are available in gel, liquid, ointment, patch, and aerosol forms.

Appropriate medical consultation should be obtained when needed.

hemostasis but are not indicated in children to control pain.

The recommended method of preventing such a condition include

**6.4 Dental diseases in primary dentition years** 

**6.4.1 Dental caries** 

constitutes S-ECC10.

treatment is appropriate and possible, and parentsare supportive and desire to have treatment done.

Oral habits may apply forces to the teeth and dentoalveolar structures. The relationship between oral habits and unfavorable dental and facial development is associational rather than cause and effect. Habits of sufficient frequency, duration, and intensity may be associated with dentoalveolar or skeletal deformations such as increased overjet, reduced overbite, posterior crossbite, or long facial height. As preliminary evidence indicates that some changes resulting from sucking habits persist past the cessation of the habit, it has been suggested that early dental visits provide parents with anticipatory guidance to help their children stop sucking habits by age 36 months or younger.

#### **6.2 Managing developing malocclusion in primary dentition**

Anterior and posterior cross bites are malocclusions which involve one or more teeth in which the maxillary teeth occlude lingually with the antagonistic mandibular teeth. Dental crossbites result from the tipping or rotation of a tooth or teeth. The condition is localized and does not involve the basal bone. Skeletal cross bites involve disharmony of the craniofacial skeleton.

A simple anterior cross bite can be aligned as soon as the condition is noted, if there is sufficient space; otherwise, space needs to be created first. Such appliances as acrylic incline planes, acrylic retainers with lingual springs, or fixed appliances all have been effective. If space is needed, an expansion appliance also is required. Early correction of unilateral posterior crossbites has been shown to improve functional conditions significantly and largely eliminate morphological and positional asymmetries of the mandible.

Class II malocclusion (distocclusion) may be unilateral or bilateral and involves a distal relationship of the mandible to the maxilla or the mandibular teeth to maxillary teeth. This relationship may result from dental (malposition of the teeth in the arches), skeletal (mandibular retrusion and/or maxillary protrusion), or a combination of dental and skeletal factors. Early Class II treatment improves self-esteem and decreases negative social experiences. Incisor injury that is more severe than simple enamel fractures has been associated positively with increased overjet and prognathic position of the maxilla. Early treatment for Class II malocclusions can be initiated, depending upon patient cooperation and management this will result in an improved overbite, overjet, and intercuspation of posterior teeth and an esthetic appearance and profile compatible with the patient's skeletal morphology.

Class III malocclusion may be unilateral or bilateral and involves a mesial relationship of the mandible to the maxilla or mandibular teeth to maxillary teeth. This relationship may result from dental factors (malposition of the teeth in the arches), skeletal factors (asymmetry, mandibular prognathism, and/or maxillary retrognathism), or a combination of these factors. Treatment of Class III malocclusions is indicated to provide psychosocial benefits for the child patient by reducing or eliminating facial disfigurement and to reduce the severity of malocclusion by promoting compensating growth. Early Class III treatment in a growing patient will result in improved overbite, overjet, and intercuspation of posterior teeth and an esthetic appearance and profile compatible with the patient's skeletal morphology.

treatment is appropriate and possible, and parentsare supportive and desire to have

Oral habits may apply forces to the teeth and dentoalveolar structures. The relationship between oral habits and unfavorable dental and facial development is associational rather than cause and effect. Habits of sufficient frequency, duration, and intensity may be associated with dentoalveolar or skeletal deformations such as increased overjet, reduced overbite, posterior crossbite, or long facial height. As preliminary evidence indicates that some changes resulting from sucking habits persist past the cessation of the habit, it has been suggested that early dental visits provide parents with anticipatory guidance to help

Anterior and posterior cross bites are malocclusions which involve one or more teeth in which the maxillary teeth occlude lingually with the antagonistic mandibular teeth. Dental crossbites result from the tipping or rotation of a tooth or teeth. The condition is localized and does not involve the basal bone. Skeletal cross bites involve disharmony of the

A simple anterior cross bite can be aligned as soon as the condition is noted, if there is sufficient space; otherwise, space needs to be created first. Such appliances as acrylic incline planes, acrylic retainers with lingual springs, or fixed appliances all have been effective. If space is needed, an expansion appliance also is required. Early correction of unilateral posterior crossbites has been shown to improve functional conditions significantly and largely eliminate morphological and positional asymmetries of the

Class II malocclusion (distocclusion) may be unilateral or bilateral and involves a distal relationship of the mandible to the maxilla or the mandibular teeth to maxillary teeth. This relationship may result from dental (malposition of the teeth in the arches), skeletal (mandibular retrusion and/or maxillary protrusion), or a combination of dental and skeletal factors. Early Class II treatment improves self-esteem and decreases negative social experiences. Incisor injury that is more severe than simple enamel fractures has been associated positively with increased overjet and prognathic position of the maxilla. Early treatment for Class II malocclusions can be initiated, depending upon patient cooperation and management this will result in an improved overbite, overjet, and intercuspation of posterior teeth and an esthetic appearance and profile compatible with the patient's skeletal

Class III malocclusion may be unilateral or bilateral and involves a mesial relationship of the mandible to the maxilla or mandibular teeth to maxillary teeth. This relationship may result from dental factors (malposition of the teeth in the arches), skeletal factors (asymmetry, mandibular prognathism, and/or maxillary retrognathism), or a combination of these factors. Treatment of Class III malocclusions is indicated to provide psychosocial benefits for the child patient by reducing or eliminating facial disfigurement and to reduce the severity of malocclusion by promoting compensating growth. Early Class III treatment in a growing patient will result in improved overbite, overjet, and intercuspation of posterior teeth and an esthetic appearance and profile compatible with the patient's

their children stop sucking habits by age 36 months or younger.

**6.2 Managing developing malocclusion in primary dentition** 

treatment done.

craniofacial skeleton.

mandible.

morphology.

skeletal morphology.

#### **6.3 Local anesthesia for children**

Local anesthetic administration is an important consideration in the behavior guidance of a pediatric patient9. Age-appropriate "nonthreatening" terminology, distraction, topical anesthetics, proper injection technique, can help the patient have a positive experience during administration of local anesthesia. In pediatric dentistry, the dental professional should be aware of proper dosage (based on weight) to minimize the chance of toxicity and the prolonged duration of anesthesia, which can lead to accidental lip or tongue trauma. Knowledge of the gross and neuroanatomy of the head and neck allows for proper placement of the anesthetic solution and helps minimize complications (eg, hematoma, trismus, intravascular injection). Familiarity with the patient's medical history is essential to decrease the risk of aggravating a medical condition while rendering dental care. Appropriate medical consultation should be obtained when needed.

The application of topical anesthetic may help minimize discomfort caused during administration of local anesthesia. Topical anesthetic is effective on surface tissues (2-3 mm in depth) to reduce painful needle penetration of the oral mucosa A variety of topical anesthetic agents are available in gel, liquid, ointment, patch, and aerosol forms.

Injectable anesthetic available for dental usage include lidocaine, mepivacaine, articaine, prilocaine, and bupivacaine. Absolute contraindications for local anesthetics include a documented local anesthetic allergy. Local anesthetics without vasoconstrictors should be used with caution due to rapid systemic absorption which may result in overdose. Epinephrine decreases bleeding in the area of injection. Epinephrine concentrations of 1:50,000 may be indicated for infiltration in small doses into a surgical site to achieve hemostasis but are not indicated in children to control pain.

#### **6.4 Dental diseases in primary dentition years**

#### **6.4.1 Dental caries**

Dental caries, also known as tooth decay or a cavity, is a disease where bacterial processes damage hard tooth structure (enamel, dentin, and cementum). These tissues progressively break down, producing dental caries (cavities, holes in the teeth). Two groups of bacteria are responsible for initiating caries: Streptococcus mutans and Lactobacillus. If left untreated, the disease can lead to pain, tooth loss, infection, and, in severe cases, even death. Today, caries remains one of the most common diseases throughout the world. Cariology is the study of dental caries. One particular condition that is seen in this age group is the Early Child hood Caries (ECC). The disease of early childhood caries (ECC) is the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. In children younger than 3 years of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC). From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) surfaces constitutes S-ECC10.

The recommended method of preventing such a condition include

Reducing the mother's/primary caregiver's/sibling(s) MS levels (ideally during the prenatal period) to decrease transmission of cariogenic bacteria. Minimizing salivasharing activities (eg, sharing utensils) between an infant or toddler and his family/cohorts. Implementing oral hygiene measures no later than the time of eruption

Pediatric Dentistry

techniques.

Patients practiced.

**Fluoride application** 

Schedule.

amnesia, and gag reflex reduction.

**6.4.3 Preventing dental caries** 

cariogenic bacteria to their source of nutrients12.

*Systemically-administered fluoride supplements* 

*Professionally-applied topical fluoride treatment* 

*Fluoride-containing products for home use* 

greater than once daily brushing.

– A Guide for General Practitioner 61

explanation prior to its use to prevent misunderstanding. Distraction is another technique involving diverting the patient's attention from what may be perceived as an unpleasant procedure. Giving the patient a short break during a stressful procedure can be an effective use of distraction prior to considering more advanced behavior guidance

Some children may require a more advanced behavior management techniques using pharmacological agents such as conscious sedation, deep sedation or general anesthesia. Nitrous oxide/oxygen inhalation is a safe and effective technique of giving conscious sedation to reduce anxiety and enhance effective communication. Its onset of action is rapid, the effects easily are titrated and reversible, and recovery is rapid and complete. Additionally, nitrous oxide/oxygen inhalation mediates a variable degree of analgesia,

Some children and developmentally disabled patients require general anesthesia to receive comprehensive dental care in a safe and humane fashion. Many pediatric dentists (and others who treat children) have sought to provide for the administration of general anesthesia by properly-trained individuals in their offices or other facilities (eg, outpatient care clinics) outside of the traditional hospital setting. The Elective Use of Minimal, Moderate, and Deep Sedation and General Anesthesia in Pediatric Dental

Pit and fissure sealants has been described as a material placed into the pits and fissures of caries-susceptible teeth that micromechanically bonds to the tooth preventing access by

Fluoride supplements should be considered for all children drinking fluoride-deficient (<0.6 ppm) water. After determining the fluoride level of the water supply or supplies (either through contacting public health officials or water analysis), evaluating other dietary sources of fluoride, and assessing the child's caries risk, the daily fluoride supplement dosage can be determined using the Dietary Fluoride Supplementation

Professional topical fluoride treatments should be based on caries-risk assessment. A pumice prophylaxis is not an essential prerequisite to this treatment. Appropriate precautionary measures should be taken to prevent swallowing of any professionallyapplied topical fluoride. Children at moderate caries risk should receive a professional fluoride treatment at least every 6 months; those with high caries risk should receive greater frequency of professional fluoride applications (ie, every 3-6 months). Ideally, this would

Therapeutic use of fluoride for children should focus on regimens that maximize topical contact, preferably in lower-dose, higher-frequency approaches. Fluoridated toothpaste should be used twice daily as a primary preventive procedure. Twice daily use has benefits

occur as part of a comprehensive preventive program in a dental home.

of the first primary tooth. If an infant falls asleep while feeding, the teeth should be cleaned before placing the child in bed. Tooth brushing of all dentate children should be performed twice daily with a fluoridated toothpaste and a soft, age-appropriate sized toothbrush. Parents should use a 'smear' of toothpaste to brush the teeth of a childless than 2 years of age. For the 2-5 year old, parents should dispense a 'pea-size' amount of toothpaste and perform or assist with their child's tooth brushing. Flossing should be initiated when adjacent tooth surfaces can not be cleansed by a toothbrush. Establishing a dental home within 6 months of eruption of the first tooth and no later than 12 months of age to conduct a caries risk assessment and provide parental education including anticipatory guidance for prevention of oral diseases. Avoiding cariespromoting feeding behaviors. In particular: Infants should not be put to sleep with a bottle containing fermentable carbohydrates. Ad labium breast-feeding should be avoided after the first primary tooth begins to erupt and other dietary carbohydrates are introduced. Parents should be encouraged to have infants drink from a cup as they approach their first birthday. Infants should be weaned from the bottle at 12 to 14 months of age. Repetitive consumption of any liquid containing fermentable carbohydrates from a bottle or no-spill training cup should be avoided. Between-meal snacks and prolonged exposures to foods and juice or other beverages containing fermentable carbohydrates should be avoided.

#### **6.4.2 Behaviour management in dental clinic**

Safe and effective treatment of dental diseases often requires modifying the child's behavior. Behavior guidance is a continuum of interaction involving the dentist and dental team, the patient, and the parent directed toward communication and education. Its goal is to ease fear and anxiety while promoting an understanding of the need for good oral health and the process by which that is achieved. For treating children a variety of behavior guidance approaches are used it is important to, assess accurately the child's developmental level, dental attitudes, and temperament and to predict the child's reaction to treatment. The child who presents with oral/dental pathology and noncompliance makes the management more challenging. The pediatric dental staff can play an important role in behavior guidance. Communication may be accomplished by a number of means but, in the dental setting, it is affected primarily through dialogue, tone of voice, facial expression, and body language. One should communicate with the child patient briefly at the beginning of a dental appointment to establish rapport and trust. However, once a procedure begins, the dentist's ability to control and shape behavior becomes paramount, and information sharing becomes secondary11.

Various behavior management techniques such as Tell-show-do is used by many pediatric professionals. The technique involves verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell); demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, nonthreatening setting (show); and then, without deviating from the explanation and demonstration, completion of the procedure (do). The tell-show-do technique is used with communication skills (verbal and nonverbal) and positive reinforcement. Voice control is a controlled alteration of voice volume, tone, or pace to influence and direct the patient's behavior. Parents unfamiliar with this technique may benefit from an

Safe and effective treatment of dental diseases often requires modifying the child's behavior. Behavior guidance is a continuum of interaction involving the dentist and dental team, the patient, and the parent directed toward communication and education. Its goal is to ease fear and anxiety while promoting an understanding of the need for good oral health and the process by which that is achieved. For treating children a variety of behavior guidance approaches are used it is important to, assess accurately the child's developmental level, dental attitudes, and temperament and to predict the child's reaction to treatment. The child who presents with oral/dental pathology and noncompliance makes the management more challenging. The pediatric dental staff can play an important role in behavior guidance. Communication may be accomplished by a number of means but, in the dental setting, it is affected primarily through dialogue, tone of voice, facial expression, and body language. One should communicate with the child patient briefly at the beginning of a dental appointment to establish rapport and trust. However, once a procedure begins, the dentist's ability to control and shape behavior becomes paramount, and information sharing becomes

Various behavior management techniques such as Tell-show-do is used by many pediatric professionals. The technique involves verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell); demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, nonthreatening setting (show); and then, without deviating from the explanation and demonstration, completion of the procedure (do). The tell-show-do technique is used with communication skills (verbal and nonverbal) and positive reinforcement. Voice control is a controlled alteration of voice volume, tone, or pace to influence and direct the patient's behavior. Parents unfamiliar with this technique may benefit from an

fermentable carbohydrates should be avoided.

**6.4.2 Behaviour management in dental clinic** 

secondary11.

of the first primary tooth. If an infant falls asleep while feeding, the teeth should be cleaned before placing the child in bed. Tooth brushing of all dentate children should be performed twice daily with a fluoridated toothpaste and a soft, age-appropriate sized toothbrush. Parents should use a 'smear' of toothpaste to brush the teeth of a childless than 2 years of age. For the 2-5 year old, parents should dispense a 'pea-size' amount of toothpaste and perform or assist with their child's tooth brushing. Flossing should be initiated when adjacent tooth surfaces can not be cleansed by a toothbrush. Establishing a dental home within 6 months of eruption of the first tooth and no later than 12 months of age to conduct a caries risk assessment and provide parental education including anticipatory guidance for prevention of oral diseases. Avoiding cariespromoting feeding behaviors. In particular: Infants should not be put to sleep with a bottle containing fermentable carbohydrates. Ad labium breast-feeding should be avoided after the first primary tooth begins to erupt and other dietary carbohydrates are introduced. Parents should be encouraged to have infants drink from a cup as they approach their first birthday. Infants should be weaned from the bottle at 12 to 14 months of age. Repetitive consumption of any liquid containing fermentable carbohydrates from a bottle or no-spill training cup should be avoided. Between-meal snacks and prolonged exposures to foods and juice or other beverages containing explanation prior to its use to prevent misunderstanding. Distraction is another technique involving diverting the patient's attention from what may be perceived as an unpleasant procedure. Giving the patient a short break during a stressful procedure can be an effective use of distraction prior to considering more advanced behavior guidance techniques.

Some children may require a more advanced behavior management techniques using pharmacological agents such as conscious sedation, deep sedation or general anesthesia. Nitrous oxide/oxygen inhalation is a safe and effective technique of giving conscious sedation to reduce anxiety and enhance effective communication. Its onset of action is rapid, the effects easily are titrated and reversible, and recovery is rapid and complete. Additionally, nitrous oxide/oxygen inhalation mediates a variable degree of analgesia, amnesia, and gag reflex reduction.

Some children and developmentally disabled patients require general anesthesia to receive comprehensive dental care in a safe and humane fashion. Many pediatric dentists (and others who treat children) have sought to provide for the administration of general anesthesia by properly-trained individuals in their offices or other facilities (eg, outpatient care clinics) outside of the traditional hospital setting. The Elective Use of Minimal, Moderate, and Deep Sedation and General Anesthesia in Pediatric Dental Patients practiced.

#### **6.4.3 Preventing dental caries**

Pit and fissure sealants has been described as a material placed into the pits and fissures of caries-susceptible teeth that micromechanically bonds to the tooth preventing access by cariogenic bacteria to their source of nutrients12.

#### **Fluoride application**

#### *Systemically-administered fluoride supplements*

Fluoride supplements should be considered for all children drinking fluoride-deficient (<0.6 ppm) water. After determining the fluoride level of the water supply or supplies (either through contacting public health officials or water analysis), evaluating other dietary sources of fluoride, and assessing the child's caries risk, the daily fluoride supplement dosage can be determined using the Dietary Fluoride Supplementation Schedule.

#### *Professionally-applied topical fluoride treatment*

Professional topical fluoride treatments should be based on caries-risk assessment. A pumice prophylaxis is not an essential prerequisite to this treatment. Appropriate precautionary measures should be taken to prevent swallowing of any professionallyapplied topical fluoride. Children at moderate caries risk should receive a professional fluoride treatment at least every 6 months; those with high caries risk should receive greater frequency of professional fluoride applications (ie, every 3-6 months). Ideally, this would occur as part of a comprehensive preventive program in a dental home.

*Fluoride-containing products for home use* 

Therapeutic use of fluoride for children should focus on regimens that maximize topical contact, preferably in lower-dose, higher-frequency approaches. Fluoridated toothpaste should be used twice daily as a primary preventive procedure. Twice daily use has benefits greater than once daily brushing.

Pediatric Dentistry

seals the tooth from microleakage.

tooth from microleakage.

afforded13.

**6.5.1 Expected outcome of pulp therapy** 

– A Guide for General Practitioner 63

radiopaque base such as mineral trioxide aggregate (MTA)or calcium hydroxidemay be placed in contact with the exposed pulp tissue. The tooth is restored with a material that

A pulpotomy is performed in a primary tooth with extensive caries but without evidence of radicular pathology when caries removal results in a carious or mechanical pulp exposure. Thecoronal pulp is amputated, and the remaining vital radicularpulp tissue surface is treated with a long-term clinically successful medicament such as Buckley's Solution of formocresol or ferric sulfate. Electrosurgery also has demonstrated success. Gluteraldehyde and calcium hydroxide have been used but with less long-term success. MTA is a more

Nonvital pulp treatment for primary teeth diagnosed with irreversible pulpitis or necrotic pulp include Pulpectomy Pulpectomy is a root canal procedure for pulp tissue that is irreversibly infected or necrotic due to caries or trauma. The root canals are debrided and shaped with hand or rotary files. Followed by obturation bye resorbable material such as nonreinforced zinc/oxideeugenol, iodoform-based paste (KRI), or a combination paste of iodoform and calcium hydroxide. The tooth then is restored with a restoration that seals the

No post-treatment signs or symptoms such as sensitivity, pain, or swelling should be evident. There should be no radiographic evidence of pathologic external or internal root resorption or other pathologic changes. There should be no harm to the succedaneous tooth. A smooth transition from primary to permanent dentition should be

The greatest incidence of trauma to the primary teeth occurs at 2 to 3 years of age, when motor coordination is developing. Dental injuries can have improved outcomes if the public is made aware of first-aid measures and the need to seek immediate treatment. Because optimal treatment results follow immediate assessment and care, dentists have an ethical obligation to ensure that reasonable arrangements for emergency dental care are available. The history, circumstances of the injury, pattern of trauma, and behavior of the child and/or

After a primary tooth has been injured, the treatment strategy is dictated by the concern for the safety of the permanent dentition. If determined that the displaced primary tooth has encroached upon the developing permanent tooth germ, removal is indicated. In the primary dentition, the maxillary anterior region is at low risk for space loss unless the avulsion occurs prior to canine eruption or the dentition is crowded. Fixed or removable appliances, while not always necessary, can be fabricated to satisfy parental concerns for

When an injury to a primary tooth occurs, informing parents about possible pulpal complications, appearance of a vestibular sinus tract, or color change of the crown associated with a sinus tract can help assure timely intervention, minimizing complications for the developing succedaneous teeth. Also, it is important to caution parents that the primary tooth's displacement may result in any of several permanent tooth complications, including enamel hypoplasia, hypo calcification, crown/root dilacerations, or disruptions

recent material used for pulpotomies with a high rate of success.

**6.5.2 Acute dental trauma to primary teeth and management** 

esthetics or to return a loss of oral or phonetic function.

caregiver are important in distinguishing nonabusive injuries from abuse.

Additional at-home topical fluoride regimens utilizing increased concentrations of fluoride should be considered for children at high risk for caries.These may include overthe-counter or prescription strength formulations. Fluoride mouth rinses or brush-on gels may be incorporated into a caries-prevention program for a school-aged child at high risk.

#### **6.4.4 Management of dental caries**

Restorative treatment is based upon the results of an appropriate clinical examination and is ideally part of a comprehensive treatment plan. The treatment plan should take into consideration: developmental status of the dentition; caries-risk assessment, patient's oral hygiene, anticipated parental compliance and likelihood of timely recall,patient's ability to cooperate for treatment. The restorative treatment plan must be prepared in conjunction with an individually-tailored preventive program. Caries risk is greater for children who are poor, rural, or minority or who have limited access to care. Factors for high caries risk include decayed/missing/filled surfaces greater than the child's age, numerous white spot lesions, high levels of mutans streptococci, low socioeconomic status, high caries rate in siblings/parents, diet high in sugar, and/or presence of dental appliances. Studies have reported that maxillary primary anterior caries has a direct relationship with caries in primary molars, and caries in the primary dentition is highly predictive of caries occurring in the permanent dentition.

#### **6.5 Pulp therapy for primary teeth**

The primary objective of pulp therapy is to maintain the integrity and health of the teeth and their supporting tissues. It is a treatment objective to maintain the vitality of the pulp of a tooth affected by caries, traumatic injury, or other causes.

Vital pulp therapy for primary teeth diagnosed with a normal pulp or reversible pulpitis includes placement of a protective liner wich is a thinly-applied liquid placed on the pulpal surface of a deep cavity preparation, covering exposed dentin tubules, to act as a protective barrier between the restorative material or cement and the pulp. Placement of a thin protective liner such as calcium hydroxide, dentin bonding agent, or glass ionomer cement is at the discretion of the clinician. This placement in the deep area of the preparation is utilized to preserve the tooth's vitality, promote pulp tissue healing and tertiary dentin formation, and minimize bacterial microleakage.Adverse post-treatment clinical signs or symptoms such as sensitivity, pain, or swelling should not occur.

Indirect pulp treatment is a procedure performed in a tooth with a deep carious lesion approximating the pulp but without signs or symptoms of pulp degeneration. The caries surrounding the pulp is left in place to avoid pulp exposure and is covered with a biocompatible material. A radiopaque liner such as a dentin bonding agent, resin modified glass ionomer,calcium hydroxide, zinc oxide/eugenol,or glass ionomer cement is placed over the remaining carious dentin to stimulate healing and repair. Indirect pulp capping has been shown to have a higher success rate than pulpotomy in long term studies.It also allows for a normal exfoliation time. Therefore, indirect pulp treatment is preferable to a pulpotomy when the pulp is normal or has a diagnosis of reversible pulpitis.

Direct pulp cap can be done When a pinpoint mechanical exposure of the pulp is encountered during cavity preparation or following a traumatic injury, a biocompatible

Additional at-home topical fluoride regimens utilizing increased concentrations of fluoride should be considered for children at high risk for caries.These may include overthe-counter or prescription strength formulations. Fluoride mouth rinses or brush-on gels may be incorporated into a caries-prevention program for a school-aged child at high

Restorative treatment is based upon the results of an appropriate clinical examination and is ideally part of a comprehensive treatment plan. The treatment plan should take into consideration: developmental status of the dentition; caries-risk assessment, patient's oral hygiene, anticipated parental compliance and likelihood of timely recall,patient's ability to cooperate for treatment. The restorative treatment plan must be prepared in conjunction with an individually-tailored preventive program. Caries risk is greater for children who are poor, rural, or minority or who have limited access to care. Factors for high caries risk include decayed/missing/filled surfaces greater than the child's age, numerous white spot lesions, high levels of mutans streptococci, low socioeconomic status, high caries rate in siblings/parents, diet high in sugar, and/or presence of dental appliances. Studies have reported that maxillary primary anterior caries has a direct relationship with caries in primary molars, and caries in the primary dentition is highly predictive of caries occurring

The primary objective of pulp therapy is to maintain the integrity and health of the teeth and their supporting tissues. It is a treatment objective to maintain the vitality of the pulp of

Vital pulp therapy for primary teeth diagnosed with a normal pulp or reversible pulpitis includes placement of a protective liner wich is a thinly-applied liquid placed on the pulpal surface of a deep cavity preparation, covering exposed dentin tubules, to act as a protective barrier between the restorative material or cement and the pulp. Placement of a thin protective liner such as calcium hydroxide, dentin bonding agent, or glass ionomer cement is at the discretion of the clinician. This placement in the deep area of the preparation is utilized to preserve the tooth's vitality, promote pulp tissue healing and tertiary dentin formation, and minimize bacterial microleakage.Adverse post-treatment clinical signs or

Indirect pulp treatment is a procedure performed in a tooth with a deep carious lesion approximating the pulp but without signs or symptoms of pulp degeneration. The caries surrounding the pulp is left in place to avoid pulp exposure and is covered with a biocompatible material. A radiopaque liner such as a dentin bonding agent, resin modified glass ionomer,calcium hydroxide, zinc oxide/eugenol,or glass ionomer cement is placed over the remaining carious dentin to stimulate healing and repair. Indirect pulp capping has been shown to have a higher success rate than pulpotomy in long term studies.It also allows for a normal exfoliation time. Therefore, indirect pulp treatment is preferable to a

Direct pulp cap can be done When a pinpoint mechanical exposure of the pulp is encountered during cavity preparation or following a traumatic injury, a biocompatible

risk.

**6.4.4 Management of dental caries** 

in the permanent dentition.

**6.5 Pulp therapy for primary teeth** 

a tooth affected by caries, traumatic injury, or other causes.

symptoms such as sensitivity, pain, or swelling should not occur.

pulpotomy when the pulp is normal or has a diagnosis of reversible pulpitis.

radiopaque base such as mineral trioxide aggregate (MTA)or calcium hydroxidemay be placed in contact with the exposed pulp tissue. The tooth is restored with a material that seals the tooth from microleakage.

A pulpotomy is performed in a primary tooth with extensive caries but without evidence of radicular pathology when caries removal results in a carious or mechanical pulp exposure. Thecoronal pulp is amputated, and the remaining vital radicularpulp tissue surface is treated with a long-term clinically successful medicament such as Buckley's Solution of formocresol or ferric sulfate. Electrosurgery also has demonstrated success. Gluteraldehyde and calcium hydroxide have been used but with less long-term success. MTA is a more recent material used for pulpotomies with a high rate of success.

Nonvital pulp treatment for primary teeth diagnosed with irreversible pulpitis or necrotic pulp include Pulpectomy Pulpectomy is a root canal procedure for pulp tissue that is irreversibly infected or necrotic due to caries or trauma. The root canals are debrided and shaped with hand or rotary files. Followed by obturation bye resorbable material such as nonreinforced zinc/oxideeugenol, iodoform-based paste (KRI), or a combination paste of iodoform and calcium hydroxide. The tooth then is restored with a restoration that seals the tooth from microleakage.

#### **6.5.1 Expected outcome of pulp therapy**

No post-treatment signs or symptoms such as sensitivity, pain, or swelling should be evident. There should be no radiographic evidence of pathologic external or internal root resorption or other pathologic changes. There should be no harm to the succedaneous tooth. A smooth transition from primary to permanent dentition should be afforded13.

#### **6.5.2 Acute dental trauma to primary teeth and management**

The greatest incidence of trauma to the primary teeth occurs at 2 to 3 years of age, when motor coordination is developing. Dental injuries can have improved outcomes if the public is made aware of first-aid measures and the need to seek immediate treatment. Because optimal treatment results follow immediate assessment and care, dentists have an ethical obligation to ensure that reasonable arrangements for emergency dental care are available. The history, circumstances of the injury, pattern of trauma, and behavior of the child and/or caregiver are important in distinguishing nonabusive injuries from abuse.

After a primary tooth has been injured, the treatment strategy is dictated by the concern for the safety of the permanent dentition. If determined that the displaced primary tooth has encroached upon the developing permanent tooth germ, removal is indicated. In the primary dentition, the maxillary anterior region is at low risk for space loss unless the avulsion occurs prior to canine eruption or the dentition is crowded. Fixed or removable appliances, while not always necessary, can be fabricated to satisfy parental concerns for esthetics or to return a loss of oral or phonetic function.

When an injury to a primary tooth occurs, informing parents about possible pulpal complications, appearance of a vestibular sinus tract, or color change of the crown associated with a sinus tract can help assure timely intervention, minimizing complications for the developing succedaneous teeth. Also, it is important to caution parents that the primary tooth's displacement may result in any of several permanent tooth complications, including enamel hypoplasia, hypo calcification, crown/root dilacerations, or disruptions

Pediatric Dentistry

individual's disease pattern and oral hygiene needs

acid-containing beverages and wellness considerations.

need is indicated throughout this phase.

**8. Restorative dentistry** 

**8.1 Periodontal disease** 

desirable.

oral hygiene.

– A Guide for General Practitioner 65

caries activity and periodontal disease due to an increased intake of cariogenic substances and inattention to oral hygiene procedures warrant a good oral hygiene through daily plaque removal, including flossing, with the frequency and pattern based on the

Diet management including diet analysis and modification can be very helpful to reduce the effect of carbohydrates, foods rich in sucrose and beverages with acidic Ph. A diet analysis should result in overall nutrient and energy needs calculation, psychosocial aspects of adolescent nutrition; dietary carbohydrate intake and frequency; intake and frequency of

Sealant placement is an effective caries-preventive technique that should be considered on an individual basis. Sealants have been recommended for any tooth, primary or permanent, that is judged to be at risk for pit and fissure caries. Caries risk may increase due to changes in patient habits, oral microflora, or physical condition, and unsealed teeth subsequently might benefit from sealant applications. Children at risk for caries should have sealants placed. An individual's caries risk may change over time; periodic reassessment for sealant

In cases where remineralization of noncavitated, demineralized tooth surfaces is not successful, as demonstrated by progression of carious lesions, dental restorations are necessary. Preservation of tooth structure, esthetics, and each individual patient's needs must be considered when selecting a restorative material. Molars with extensive caries or malformed, hypoplastic enamel—for which traditional amalgam or composite resin restorations are not feasible—may require full coverage restorations. Each restoration must be evaluated on an individual basis. Preservation of noncarious tooth structure is

Gingivitis characterized by the presence of gingival inflammation without detectable loss of bone or clinical attachment is common in children. Normal and abnormal fluctuation in hormone levels, including changes in gonadotrophic hormone levels during the onset of puberty, can modify the gingival inflammatory response to dental plaque. Similarly, alterations in insulin levels in patients with diabetes can affect gingival health. In both situations, there is an increased inflammatory response to plaque. However, the gingival condition usually responds to thorough removal of bacterial deposits and improved daily

Periodontitis aggressive periodontitis is more common in children and adolescents. Aggressive periodontitis can be localized or generalized. Localized aggressive periodontitis (LAgP) patients have interproximal attachment loss on at least two permanent first molars and incisors, with attachment loss on no more than two teeth other than first molars and incisors. Generalized aggressive periodontitis (GAgP) patients exhibit generalized interproximal attachment loss including at least three teeth that are not first molars and incisors. Successful treatment of aggressive periodontitis depends on early diagnosis, directing therapy against the infecting microorganisms and providing an environment for

in eruption patterns or sequence. The risk of trauma-induced developmental disturbances in the permanent successors is greater in children whose enamel calcification is incomplete.

#### **6.5.3 Managing premature loss of primary tooth**

The premature loss of primary teeth due to caries, trauma, ectopic eruption, or other causes may lead to undesirable tooth movements of primary and/or permanent teeth including loss of arch length. Arch length deficiency can produce or increase the severity of malocclusions with crowding, rotations, ectopic eruption, crossbite, excessive overjet, excessive overbite, and unfavorable molar relationships. It is recommended that space maintainers be used to reduce the prevalence and severity of malocclusion following premature loss of primary teeth. Space maintenance may be a consideration in the primary dentition after early loss of a maxillary incisor when the child has an active digit habit. An intense habit may reduce the space for the erupting permanent incisor.

#### **7. The transition from primary dentition to permanent dentition**

This period is characterized by having distinctive need due to: a potentially high caries rate; increased risk for traumatic injury and periodontal disease; a tendency for poor nutritional habits; an increased esthetic desire and awareness; complexity of combined orthodontic and restorative care (eg, congenitally missing teeth); dental phobia; potential use of tobacco, alcohol, and other drugs; (8) pregnancy; (9) eating disorders; and (10) unique social and psychological needs.

The management of these patients can be multifaceted and complex. An accurate, comprehensive, and up-to-date medical history is necessary for correct diagnosis and effective treatment planning. Familiarity with the patient's medical history is essential to decreasing the risk of aggravating a medical condition while rendering dental care. If the parent is unable to provide adequate details regarding a patient's medical history, consultation with the medical health care provider may be indicated. The practitioner also may need to obtain additional information confidentially from an adolescent patient.

#### **7.1 Management of dental caries during mixed dentition period**

Immature permanent tooth enamel,a total increase in susceptible tooth surfaces, and environmental factors such as diet, independence to seek care or avoid it, a low priority for oral hygiene, and additional social factors also may contribute to the upward slope of caries during this period. It is important to emphasize the positive effects that fluoridation, routine professional care, patient education, and personal hygiene can have in counteracting the changing pattern of caries this population.

Fluoridation has proven to be the most economical and effective caries prevention measure. Both systemic benefit of fluoride incorporation into developing enamel and, topical benefits can be obtained through optimally-fluoridated water, professionally-applied and prescribed compounds, and fluoridated dentifrices.

Oral Hygine with a fluoridated dentifrice and flossing can provide benefit through the topical effect of the fluoride and plaque removal from tooth surfaces.This time of heightened

in eruption patterns or sequence. The risk of trauma-induced developmental disturbances in the permanent successors is greater in children whose enamel calcification is

The premature loss of primary teeth due to caries, trauma, ectopic eruption, or other causes may lead to undesirable tooth movements of primary and/or permanent teeth including loss of arch length. Arch length deficiency can produce or increase the severity of malocclusions with crowding, rotations, ectopic eruption, crossbite, excessive overjet, excessive overbite, and unfavorable molar relationships. It is recommended that space maintainers be used to reduce the prevalence and severity of malocclusion following premature loss of primary teeth. Space maintenance may be a consideration in the primary dentition after early loss of a maxillary incisor when the child has an active digit habit. An

This period is characterized by having distinctive need due to: a potentially high caries rate; increased risk for traumatic injury and periodontal disease; a tendency for poor nutritional habits; an increased esthetic desire and awareness; complexity of combined orthodontic and restorative care (eg, congenitally missing teeth); dental phobia; potential use of tobacco, alcohol, and other drugs; (8) pregnancy; (9) eating disorders; and (10) unique social and

The management of these patients can be multifaceted and complex. An accurate, comprehensive, and up-to-date medical history is necessary for correct diagnosis and effective treatment planning. Familiarity with the patient's medical history is essential to decreasing the risk of aggravating a medical condition while rendering dental care. If the parent is unable to provide adequate details regarding a patient's medical history, consultation with the medical health care provider may be indicated. The practitioner also may need to obtain additional information confidentially from an

Immature permanent tooth enamel,a total increase in susceptible tooth surfaces, and environmental factors such as diet, independence to seek care or avoid it, a low priority for oral hygiene, and additional social factors also may contribute to the upward slope of caries during this period. It is important to emphasize the positive effects that fluoridation, routine professional care, patient education, and personal hygiene can have in counteracting the

Fluoridation has proven to be the most economical and effective caries prevention measure. Both systemic benefit of fluoride incorporation into developing enamel and, topical benefits can be obtained through optimally-fluoridated water, professionally-applied and prescribed

Oral Hygine with a fluoridated dentifrice and flossing can provide benefit through the topical effect of the fluoride and plaque removal from tooth surfaces.This time of heightened

incomplete.

psychological needs.

adolescent patient.

**6.5.3 Managing premature loss of primary tooth** 

intense habit may reduce the space for the erupting permanent incisor.

**7.1 Management of dental caries during mixed dentition period** 

changing pattern of caries this population.

compounds, and fluoridated dentifrices.

**7. The transition from primary dentition to permanent dentition** 

caries activity and periodontal disease due to an increased intake of cariogenic substances and inattention to oral hygiene procedures warrant a good oral hygiene through daily plaque removal, including flossing, with the frequency and pattern based on the individual's disease pattern and oral hygiene needs

Diet management including diet analysis and modification can be very helpful to reduce the effect of carbohydrates, foods rich in sucrose and beverages with acidic Ph. A diet analysis should result in overall nutrient and energy needs calculation, psychosocial aspects of adolescent nutrition; dietary carbohydrate intake and frequency; intake and frequency of acid-containing beverages and wellness considerations.

Sealant placement is an effective caries-preventive technique that should be considered on an individual basis. Sealants have been recommended for any tooth, primary or permanent, that is judged to be at risk for pit and fissure caries. Caries risk may increase due to changes in patient habits, oral microflora, or physical condition, and unsealed teeth subsequently might benefit from sealant applications. Children at risk for caries should have sealants placed. An individual's caries risk may change over time; periodic reassessment for sealant need is indicated throughout this phase.

#### **8. Restorative dentistry**

In cases where remineralization of noncavitated, demineralized tooth surfaces is not successful, as demonstrated by progression of carious lesions, dental restorations are necessary. Preservation of tooth structure, esthetics, and each individual patient's needs must be considered when selecting a restorative material. Molars with extensive caries or malformed, hypoplastic enamel—for which traditional amalgam or composite resin restorations are not feasible—may require full coverage restorations. Each restoration must be evaluated on an individual basis. Preservation of noncarious tooth structure is desirable.

#### **8.1 Periodontal disease**

Gingivitis characterized by the presence of gingival inflammation without detectable loss of bone or clinical attachment is common in children. Normal and abnormal fluctuation in hormone levels, including changes in gonadotrophic hormone levels during the onset of puberty, can modify the gingival inflammatory response to dental plaque. Similarly, alterations in insulin levels in patients with diabetes can affect gingival health. In both situations, there is an increased inflammatory response to plaque. However, the gingival condition usually responds to thorough removal of bacterial deposits and improved daily oral hygiene.

Periodontitis aggressive periodontitis is more common in children and adolescents. Aggressive periodontitis can be localized or generalized. Localized aggressive periodontitis (LAgP) patients have interproximal attachment loss on at least two permanent first molars and incisors, with attachment loss on no more than two teeth other than first molars and incisors. Generalized aggressive periodontitis (GAgP) patients exhibit generalized interproximal attachment loss including at least three teeth that are not first molars and incisors. Successful treatment of aggressive periodontitis depends on early diagnosis, directing therapy against the infecting microorganisms and providing an environment for

Pediatric Dentistry

care are given.

**9. References** 

Chicago, Ill; 2000

Review September 1995

Retrieved 2010-08-07

appropriate protective equipment.

– A Guide for General Practitioner 67

protective equipment such as face guards and mouthguards. Additionally, participation in leisure activities such as skateboarding, rollerskating, and bicycling also benefit from

To efficiently determine the extent of injury and correctly diagnose injuries to the teeth, periodontium, and associated structures, a systematic approach to the traumatized child is essential. Assessment includes a thoroughmedical and dental history, clinical and radiographic examination, and additional tests such as palpation, percussion, sensitivity, and mobility evaluation. Intraoral radiography is useful for the evaluation of dentoalveolar trauma. If the area of concern extends beyond the dentoalveolar complex, extra oral imaging may be indicated. Treatment planning takes into consideration the patient's health status and developmental status, as well as extent of injuries. Advanced behavior guidance techniques or an appropriate referral may be necessary to ensure that proper diagnosis and

Management of traumatized tooth can vary from simple restoration or re attachment of a broken fragment in a tooth that does not involve pulp to advanced pulpal and periodontal management where these are involved.The objective of such management should be to

Avulsion is the complete displacement of tooth out of socket. The periodontal ligament is severed and fracture of the alveolus may occur. The avulsed tooth should be replanted as soon as possible and then stabilized in its anatomically correct location to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity. The tooth has the best prognosis if replanted immediately. If the tooth cannot be replanted within 5 minutes, it should be stored in a medium that will help maintain vitality of the periodontal ligament fibers. The best (ie, physiologic) transportation media for avulsed teeth include (in order of preference) Viaspan™, Hank's Balanced Salt Solution (tissue culture medium), and cold milk. Next best would be a non-physiologic

[1] American Dental Association Commission on Dental Accreditation. Accreditation

[2] Kim A. Boggess and Burton L. Edelstein. Oral Health in Women During Preconception

[3] Increased prevalence of developmental dental defects in low birth-weight, prematurely

[4] Levy, Paul Tongue-tie, Management of Short SubLingual Frenulum. Pediatrics in

[5] Shu, M.D., Jennifer (April 12, 2010). "Will a bifid uvula cause any problems?". CNN.

[6] Terrinoni A, Rugg EL, Lane EB, et al (Mar 2001). "A novel mutation in the keratin 13 gene causing oral white sponge nevus". J. Dent. Res. 80 (3): 919–923.

standards for advanced specialty education programs in pediatric dentistry.

and Pregnancy: Implications for Birth Outcomes and Infant Oral Health. Matern

born children: a controlled study. W. Kim Seow, BDS, MDSc, FRACDS Carolyn Humphrys, BDSc David I. Tudehope, MBBS, FRACP. The American Academy of

maintain pulp vitality and restore normal esthetics and function.

medium such as saliva (buccal vestibule), physiologic saline, or water.

Child Health J. 2006 September; 10(Suppl 1): 169–174.

Pediatric Dentistry Volume 9 Number 3

healing that is free of infection. a combination of surgical or non-surgical root debridement in conjunction with antimicrobial (antibiotic) therapy.

Necrotizing periodontal diseases The two most significant findings used in the diagnosis of NPD are the presence of interproximal necrosis and ulceration and the rapid onset of gingival pain. Patients with NPD can often be febrile. Necrotizing ulcerative gingivitis/periodontitis sites harbor high levels of spirochetes and P. intermedia, and invasion of the tissues by spirochetes has been shown to occur. Factors that predispose children to NPD include viral infections (including HIV), malnutrition, emotional stress, lack of sleep, and a variety of systemic diseases. Treatment involves mechanical debridement, oral hygiene instruction, and careful follow-up.Debridement with ultrasonics has been shown to be particularly effective and results in a rapid decrease in symptoms. If the patient is febrile, antibiotics may be an important adjunct to therapy. Metronidazole and penicillin have been suggested as drugs of choice.

#### **8.2 Occlusal considerations**

Malocclusion can be a significant treatment need in the transition period as both environmental and genetic factors come into play. Although the genetic basis of much malocclusion makes it unpreventable, numerous methods exist to treat the occlusal disharmonies, temporomandibular joint dysfunction, periodontal disease, and disfiguration which may be associated with malocclusion. Temporomandibular disorders require special attention to avoid long-termproblems. Congenitally missing teeth present complex problem and often require combined orthodontic and restorative care for satisfactory resolution.

Positional Malocclusion problems that present significant esthetic, functional, physiologic, or emotional dysfunction are potential difficulties in mixed dentition. These can include single or multiple tooth malpositions, tooth/jaw size discrepancies, and craniofacial disfigurements. Treatment of malocclusion should be based on professional diagnosis, available treatment options, patient motivation and readiness, and other factors to maximize progress. If need be an orthodontist should be included for treatment.

Congenitally missing permanent teeth can have a major impact on the developing dentition. When treating patients with congenitally missing teeth, many factors must be taken into consideration including, but not limited to, esthetics, patient age, and growth potential, as well as periodontal and oral surgical needs. Evaluation of congenitally missing permanent teeth should include both immediate and long-term management.

Abnormal or ectopic eruption patterns of the permanent teeth can contribute to root resorption, bone loss, gingival defects, space loss, and esthetic concerns. Early diagnosis and treatment of ectopically erupting teeth can result in a healthier and more esthetic dentition. Prevention and treatment may include extraction of deciduous teeth, surgical intervention, and/or endodontic, orthodontic, periodontal, and/or restorative care.

#### **8.3 Traumatic injuries**

The most common injuries to permanent teeth occur secondary to falls, followed by traffic accidents, violence, and sports. All sporting activities have an associated risk of orofacial injuries due to falls, collisions, and contact with hard surfaces. It has been demonstrated that dental and facial injuries can be reduced significantly by introducing mandatory

healing that is free of infection. a combination of surgical or non-surgical root debridement

Necrotizing periodontal diseases The two most significant findings used in the diagnosis of NPD are the presence of interproximal necrosis and ulceration and the rapid onset of gingival pain. Patients with NPD can often be febrile. Necrotizing ulcerative gingivitis/periodontitis sites harbor high levels of spirochetes and P. intermedia, and invasion of the tissues by spirochetes has been shown to occur. Factors that predispose children to NPD include viral infections (including HIV), malnutrition, emotional stress, lack of sleep, and a variety of systemic diseases. Treatment involves mechanical debridement, oral hygiene instruction, and careful follow-up.Debridement with ultrasonics has been shown to be particularly effective and results in a rapid decrease in symptoms. If the patient is febrile, antibiotics may be an important adjunct to therapy. Metronidazole and

Malocclusion can be a significant treatment need in the transition period as both environmental and genetic factors come into play. Although the genetic basis of much malocclusion makes it unpreventable, numerous methods exist to treat the occlusal disharmonies, temporomandibular joint dysfunction, periodontal disease, and disfiguration which may be associated with malocclusion. Temporomandibular disorders require special attention to avoid long-termproblems. Congenitally missing teeth present complex problem and often require combined orthodontic and restorative care for satisfactory

Positional Malocclusion problems that present significant esthetic, functional, physiologic, or emotional dysfunction are potential difficulties in mixed dentition. These can include single or multiple tooth malpositions, tooth/jaw size discrepancies, and craniofacial disfigurements. Treatment of malocclusion should be based on professional diagnosis, available treatment options, patient motivation and readiness, and other factors to maximize

Congenitally missing permanent teeth can have a major impact on the developing dentition. When treating patients with congenitally missing teeth, many factors must be taken into consideration including, but not limited to, esthetics, patient age, and growth potential, as well as periodontal and oral surgical needs. Evaluation of congenitally missing permanent

Abnormal or ectopic eruption patterns of the permanent teeth can contribute to root resorption, bone loss, gingival defects, space loss, and esthetic concerns. Early diagnosis and treatment of ectopically erupting teeth can result in a healthier and more esthetic dentition. Prevention and treatment may include extraction of deciduous teeth, surgical intervention,

The most common injuries to permanent teeth occur secondary to falls, followed by traffic accidents, violence, and sports. All sporting activities have an associated risk of orofacial injuries due to falls, collisions, and contact with hard surfaces. It has been demonstrated that dental and facial injuries can be reduced significantly by introducing mandatory

progress. If need be an orthodontist should be included for treatment.

teeth should include both immediate and long-term management.

and/or endodontic, orthodontic, periodontal, and/or restorative care.

in conjunction with antimicrobial (antibiotic) therapy.

penicillin have been suggested as drugs of choice.

**8.2 Occlusal considerations** 

resolution.

**8.3 Traumatic injuries** 

protective equipment such as face guards and mouthguards. Additionally, participation in leisure activities such as skateboarding, rollerskating, and bicycling also benefit from appropriate protective equipment.

To efficiently determine the extent of injury and correctly diagnose injuries to the teeth, periodontium, and associated structures, a systematic approach to the traumatized child is essential. Assessment includes a thoroughmedical and dental history, clinical and radiographic examination, and additional tests such as palpation, percussion, sensitivity, and mobility evaluation. Intraoral radiography is useful for the evaluation of dentoalveolar trauma. If the area of concern extends beyond the dentoalveolar complex, extra oral imaging may be indicated. Treatment planning takes into consideration the patient's health status and developmental status, as well as extent of injuries. Advanced behavior guidance techniques or an appropriate referral may be necessary to ensure that proper diagnosis and care are given.

Management of traumatized tooth can vary from simple restoration or re attachment of a broken fragment in a tooth that does not involve pulp to advanced pulpal and periodontal management where these are involved.The objective of such management should be to maintain pulp vitality and restore normal esthetics and function.

Avulsion is the complete displacement of tooth out of socket. The periodontal ligament is severed and fracture of the alveolus may occur. The avulsed tooth should be replanted as soon as possible and then stabilized in its anatomically correct location to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity. The tooth has the best prognosis if replanted immediately. If the tooth cannot be replanted within 5 minutes, it should be stored in a medium that will help maintain vitality of the periodontal ligament fibers. The best (ie, physiologic) transportation media for avulsed teeth include (in order of preference) Viaspan™, Hank's Balanced Salt Solution (tissue culture medium), and cold milk. Next best would be a non-physiologic medium such as saliva (buccal vestibule), physiologic saline, or water.

#### **9. References**


**4** 

*Nigeria* 

**Gingivitis in Children and Adolescents** 

Gingivitis or inflammation of the gingiva, is the commonest oral disease in children and adolescents. It is characterized by the presence of gingival inflammation without detectable bone loss or clinical attachment loss. The causes and risks are as varied in children as in adults and range from local to systemic causes. The most important local predisposing factor in children is poor oral hygiene which stems from children's dependence on adults for assistance with routine oral hygiene. It also stems from age limitation in perception of

When plaque and food debris accumulate in poor oral hygiene, micro-organisms also accumulate and the process of inflammation starts. This leads to gingivitis, which, if not taken care of can progress to gradual destruction of supporting soft and hard tissues of the teeth. This is evident in the very young and those with disabilities, where manual dexterity

Gingivitis in children is also commonly seen during eruption and exfoliation of both primary and permanent teeth and exfoliation of primary teeth. This process, although physiological, if not managed carefully, may contribute to discomfort during tooth brushing, mastication and also cause restlessness in the affected children. During puberty, it may be a response to hormonal changes in the developing adolescent, though more

In children with compromised immunity, chronic malnutrition, exanthematous fevers such as malaria, measles or chicken pox, the gingivitis may be acute and necrotic. The systemic effect and local destruction of soft and hard tissues may contribute to increased morbidity

Habitually leaving the mouth open, either spontaneously or due to pathology in the oropharynx, may also contribute to gingivitis. During childhood and adolescence, appliances, either habit breakers or removable and fixed appliances may be required. Most children at this age present with gingivitis. This is a result of non compliance with routine tooth brushing which is further made difficult by orthodontic wires and elastics. One of the pre-conditions for appliance therapy is a commitment to efficient routine tooth brushing because the use of an appliance in the presence of plaque and debris accumulations is

Gingivitis may also be a complication of chronic use of certain medications whose side effects include dryness of the mouth. It predisposes to gingival inflammation which is due to a low output of saliva. This type of gingivitis is frequently encountered in children and

**1. Introduction** 

is not well developed.

the need for regular and efficient tooth brushing.

pronounced when there is plaque accumulation.

and poor aesthetics in affected children.

deleterious to the periodontal structures.

*Faculty of Dental Sciences, College of Medicine, University of Lagos* 

Folakemi Oredugba and Patricia Ayanbadejo

