**3.5 Local and systemic factors that influence tooth eruption**

Local factors which influence tooth eruption are ankylosed primary and permanent teeth, and ankylosis of primary molars with absence of permanent successors. Local factors generally cause delayed teeth eruption (Ertugrul et al., 2002). Referral to a pediatric dentist is recommended for appropriate treatment.

General factors associated with altered tooth eruption are Down syndrome (Trisomy 21 syndrome), cleidocranial dysplasia, congenital hypothyroidism (Cretinism), juvenile hypothyrodism, hypopituitarism, and achondroplastic dwarfism. Sporadic delayed eruption of teeth frequently occurs in children with Down syndrome. The first primary teeth may not appear until 2 years of age, and the dentition may not be complete until 5 years of age. The eruption generally follows an abnormal sequence and some of the primary teeth may be retained until 15 years of age (Jara et al., 1993; Ondarza et al., 1997). The prevalence and severity of early onset periodontal disease in children with Down syndrome are much

What is the Role of Pediatricians on Oral Health? 145

exclude sugar from the diet but rather to make the patient eat sugar in a sensible way sugar discipline (reasonable amounts and mainly at meal times). This also introduces the concept that it may be possible to substitute sucrose by substances which will impart sweetness but are not cariogenic, which is covered in more detail in section 4.3. However, a comparable study on human subjects will probably never be repeated as it would now be regarded as unethical to alter diets experimentally in directions likely to increase caries. Sugars integrated into the cellular structure of food (e.g. in fruit) are called *intrinsic sugars*. Sugars present in a free form (e.g. table sugar) or added to food (sweets, biscuits, etc.) are called *extrinsic sugars*. These are more readily available for metabolism by the oral bacteria. Therefore, they are potentially more cariogenic. Milk contains lactose. It is not generally regarded as cariogenic. Cheese and yoghurts, without added sugars, may also considered safe for teeth (Ahola et al., 2002). Bread, peanuts (not for children under 5 years), and sugarfree drinks are some examples of foods and drinks with low potential for dental caries. Thus the most damaging sugars for dental health are *non-milk extrinsic sugars (NMES)* (Moynihan, 2002). Both frequency and amount of sugars are associated with dental caries. However, at the level of the individual patient, it is more practical to advise limiting frequency of intake. Since frequency and amount of sugar consumed are closely associated and repeated sugar intakes mean several acid attacks on the teeth giving demineralization, efforts to reduce frequency should be made. Additionally, selecting food products that only lead a slight and/or short pH drop (above critical pH at which the enamel starts to dissolve around pH 5.5) is another measurement to reduce the unwanted local effects of diet with respect to caries. Many common food products containing fermentable carbohydrates can lead to a pH

Raw starch (e.g. raw vegetables) is of low cariogenity. Cooked and highly refined (e.g crisps) can cause caries, and combinations of cooked starch and sucrose (e.g. cakes, biscuits, sugared breakfast cereals) can be highly cariogenic. Fruits contain sugar (fructose, sucrose, and glucose) but fresh fruits appear to have low cariogenity. However, the same cannot be said for fruit juice. The juicing process releases the sugars from the whole fruit, and these drinks are potentially cariogenic. Dried fruits are also cariogenic since they are sticky, tending to adhere to teeth, and the drying process releases some of the intrinsic sugars (Moynihan, 2002). Some children have particular risk to caries because of dietary factors. These children should at least sound warning bells in the pediatrician's mind as well as

• Infants and toddlers provided with a feeding bottle at bedtime, or bottle hung up in the

• Children with an increased frequency of eating because of a medical problem, e.g.

• Children with an increased carbohydrate intake due to a medical problem, e.g. Chron's disease, chronic renal failure, other chronic illnesses, malnutrition, or failure to welfare • Children who are on medications causing reduced salivary flow, irradiation to the

• Children on long term and/or multiple medications: Are these sugar-based and/or do

of about 4 after their consumption.

region of salivary glands

they cause dry mouth?.

dentist's (Fejerskov & Kidd, 2003; Vadiakas, 2008):

• Infant and toddlers with prolonged breast-feeding on demand

cot for use during the night with a sugar-containing liquid

gastrointestinal disease, eating disorders, uncontrolled diabetes

higher compared to normal healthy and other mentally disabled children. A high prevalence of necrotizing ulcerative gingivitis is also reported (Carlstedt et al., 1996; Cichon et al., 1998). These higher prevalence relating periodontal diseases cannot only be explained by poor oral hygiene alone and may be the result of impaired immune responses and deficient phagocytic systems (Morinushi et al., 1997). Dental caries susceptibility is usually low in those with Down syndrome (Davidovich et al., 2010). Cleidocranial dysplasia (osteodentin dysplasia) has dental significance. The patients exhibit mandibular prognathism. The maxilla tends to be short vertically but not in sagittal way. The development of the dentition is delayed. One of the distinguishing characteristics is the presence of supernumerary teeth (Richardson & Deussen, 1994). The pediatric dentist serves as the coordinator of overall oral health care and disease prevention during an extended treatment regimen that usually includes two surgical interventions and three stages of orthodontic surgery. Hypothyroidism whether it occurs at birth or juvenile stage, causes delayed primary and permanent teeth eruption, and delayed primary teeth exfoliation (Mganga & Chindia, 1990). Hypopituitarism also causes delayed teeth eruption. Primary teeth may not undergo resorption but instead retained throughout the life of the patient. The underlying permanent teeth will develop but do not erupt (Conley et al., 1990). Delayed teeth eruption has been linked to other disorders, such as fibromatosis gingivae, chondroectodermal dysplasia, Gardner syndrome.

#### **4. Provision of a caries control measurements**

#### **4.1 Cariogenic diet (reduction in the intake of freely fermentable carbohydrates)**

Diet refers to the habitual allowance of food and drink taken by any person from day to day. Thus, the diet may exert an effect on caries locally in the mouth by reacting with the enamel surface and by serving as a substrate for cariogenic microorganisms. The food per se does not cause dental caries. Diet operates via the bacteria and the result may be a low pH at which the tooth starts to dissolve. The role of diet for proper tooth formation is a separate issue.

The consumption of sugar in substantial amounts is a recent trend in many areas of the world. Evidence linking caries and sugar has been evaluated from communities with low sugar consumption, and the results from severe dietary restrictions in many countries since 1940s. Another piece of evidence linking diet and caries concerns the rare hereditary disease fructose intolerance, which is caused by an inborn error of metabolism. Ingestion of foods containing fructose or sucrose causes severe nausea because of lack a certain liver enzyme. Consequently children with this disease avoid to eat these foods. The caries experience of them is considerably low, indicating that a group of children who are not able to tolerate many sugary foods are unlikely to develop much caries. There have been a number of noninterventional studies and animal experiments to relate dietary habits to the high prevalence of dental caries. According to a WHO study group, very little caries occurs in children when the national consumption level of sugar is below 10 kg per caput per annum (i.e., about 30 g/day), but a steep increase may occur from 15 kg upwards (WHO, 2003). Interventional human studies also designed in Sweden and Finland. Dentists now base much of dietary advice on the results of these two interventional studies, indicating that *the frequency of sugar intake should be reduced to confine sugar to meal times as much as possible.* The goal is not to

higher compared to normal healthy and other mentally disabled children. A high prevalence of necrotizing ulcerative gingivitis is also reported (Carlstedt et al., 1996; Cichon et al., 1998). These higher prevalence relating periodontal diseases cannot only be explained by poor oral hygiene alone and may be the result of impaired immune responses and deficient phagocytic systems (Morinushi et al., 1997). Dental caries susceptibility is usually low in those with Down syndrome (Davidovich et al., 2010). Cleidocranial dysplasia (osteodentin dysplasia) has dental significance. The patients exhibit mandibular prognathism. The maxilla tends to be short vertically but not in sagittal way. The development of the dentition is delayed. One of the distinguishing characteristics is the presence of supernumerary teeth (Richardson & Deussen, 1994). The pediatric dentist serves as the coordinator of overall oral health care and disease prevention during an extended treatment regimen that usually includes two surgical interventions and three stages of orthodontic surgery. Hypothyroidism whether it occurs at birth or juvenile stage, causes delayed primary and permanent teeth eruption, and delayed primary teeth exfoliation (Mganga & Chindia, 1990). Hypopituitarism also causes delayed teeth eruption. Primary teeth may not undergo resorption but instead retained throughout the life of the patient. The underlying permanent teeth will develop but do not erupt (Conley et al., 1990). Delayed teeth eruption has been linked to other disorders, such as fibromatosis gingivae, chondroectodermal dysplasia,

Gardner syndrome.

**4. Provision of a caries control measurements** 

**4.1 Cariogenic diet (reduction in the intake of freely fermentable carbohydrates)** 

tooth starts to dissolve. The role of diet for proper tooth formation is a separate issue.

Diet refers to the habitual allowance of food and drink taken by any person from day to day. Thus, the diet may exert an effect on caries locally in the mouth by reacting with the enamel surface and by serving as a substrate for cariogenic microorganisms. The food per se does not cause dental caries. Diet operates via the bacteria and the result may be a low pH at which the

The consumption of sugar in substantial amounts is a recent trend in many areas of the world. Evidence linking caries and sugar has been evaluated from communities with low sugar consumption, and the results from severe dietary restrictions in many countries since 1940s. Another piece of evidence linking diet and caries concerns the rare hereditary disease fructose intolerance, which is caused by an inborn error of metabolism. Ingestion of foods containing fructose or sucrose causes severe nausea because of lack a certain liver enzyme. Consequently children with this disease avoid to eat these foods. The caries experience of them is considerably low, indicating that a group of children who are not able to tolerate many sugary foods are unlikely to develop much caries. There have been a number of noninterventional studies and animal experiments to relate dietary habits to the high prevalence of dental caries. According to a WHO study group, very little caries occurs in children when the national consumption level of sugar is below 10 kg per caput per annum (i.e., about 30 g/day), but a steep increase may occur from 15 kg upwards (WHO, 2003). Interventional human studies also designed in Sweden and Finland. Dentists now base much of dietary advice on the results of these two interventional studies, indicating that *the frequency of sugar intake should be reduced to confine sugar to meal times as much as possible.* The goal is not to exclude sugar from the diet but rather to make the patient eat sugar in a sensible way sugar discipline (reasonable amounts and mainly at meal times). This also introduces the concept that it may be possible to substitute sucrose by substances which will impart sweetness but are not cariogenic, which is covered in more detail in section 4.3. However, a comparable study on human subjects will probably never be repeated as it would now be regarded as unethical to alter diets experimentally in directions likely to increase caries. Sugars integrated into the cellular structure of food (e.g. in fruit) are called *intrinsic sugars*. Sugars present in a free form (e.g. table sugar) or added to food (sweets, biscuits, etc.) are called *extrinsic sugars*. These are more readily available for metabolism by the oral bacteria. Therefore, they are potentially more cariogenic. Milk contains lactose. It is not generally regarded as cariogenic. Cheese and yoghurts, without added sugars, may also considered safe for teeth (Ahola et al., 2002). Bread, peanuts (not for children under 5 years), and sugarfree drinks are some examples of foods and drinks with low potential for dental caries. Thus the most damaging sugars for dental health are *non-milk extrinsic sugars (NMES)* (Moynihan, 2002). Both frequency and amount of sugars are associated with dental caries. However, at the level of the individual patient, it is more practical to advise limiting frequency of intake. Since frequency and amount of sugar consumed are closely associated and repeated sugar intakes mean several acid attacks on the teeth giving demineralization, efforts to reduce frequency should be made. Additionally, selecting food products that only lead a slight and/or short pH drop (above critical pH at which the enamel starts to dissolve around pH 5.5) is another measurement to reduce the unwanted local effects of diet with respect to caries. Many common food products containing fermentable carbohydrates can lead to a pH of about 4 after their consumption.

Raw starch (e.g. raw vegetables) is of low cariogenity. Cooked and highly refined (e.g crisps) can cause caries, and combinations of cooked starch and sucrose (e.g. cakes, biscuits, sugared breakfast cereals) can be highly cariogenic. Fruits contain sugar (fructose, sucrose, and glucose) but fresh fruits appear to have low cariogenity. However, the same cannot be said for fruit juice. The juicing process releases the sugars from the whole fruit, and these drinks are potentially cariogenic. Dried fruits are also cariogenic since they are sticky, tending to adhere to teeth, and the drying process releases some of the intrinsic sugars (Moynihan, 2002). Some children have particular risk to caries because of dietary factors. These children should at least sound warning bells in the pediatrician's mind as well as dentist's (Fejerskov & Kidd, 2003; Vadiakas, 2008):


What is the Role of Pediatricians on Oral Health? 147

result in some mild enamel fluorosis (McDonagh et al., 2000). The technical operation of water-fluoridation systems should be monitored and recorded regularly to prevent toxic

Fluoride toothpaste is the most widely used method of applying fluoride to teeth by so far. It is commonly used at home. It also has been using in community and school-based preventive programs. A recent systematic review concluded its beneficial use in preventing caries in children and adolescents, but only significantly for fluoride concentrations of 1000 ppm and above (Wong et al., 2011). Brushing teeth with fluoride containing toothpaste twice per day is recommended. The patients should brush before bed as the paste provides fluoride concentrations in saliva while the child is asleep. The effectiveness of fluoride toothpaste is concentration dependent. The relative caries preventive effects of fluoride toothpastes of different concentrations increase with higher fluoride concentration. The decision of what fluoride levels to use for children under 6 years should be balanced with the risk of fluorosis (Walsh et al., 2010). Studies have shown that use of fluoride toothpaste from an earl age is associated with higher levels of very mild fluorosis. The very mild grades are not aesthetically compromising, the use of fluoride toothpastes should continue to be promoted in communities, where or not they are served with fluoridated water or salt (WHO, 1994). However, in a recent study, it was indicated that there was weak unreliable evidence that starting the use of fluoride toothpaste in children aged <12 months may be associated with an increased risk of fluorosis. The evidence if use begins between the age of 12 and 24 months is equivocal. If the risk of fluorosis is of concern, the fluoride level of toothpaste for young children (under 6 years of age) is recommended to be lower than 1000 parts per million (ppm). More evidence from studies with low risk of bias is needed (Rasines, 2010). The author agrees with some other author's suggestion that children under 6 should use an adult-concentration paste (1000-1500 ppm fluoride), but a small pea-sized portion of it. The child should be encouraged to spit out excess paste and not swallow it. Children's pastes (500 ppm fluoride or less) could be recommended for children at low risk of caries living in an area where the water contains fluoride (Kidd, 2005). Some conclusions made by the WHO expert committee in 1994 are everyone should be encouraged to brush Daily with a fluoride toothpaste, every effort must be made to develop affordable fluoridated toothpastes for general use in developing countries, fluoridated toothpaste tubes should carry advice that for children under the age of 6 years brushing should be supervised and only a very small amount (less than 5 mm) should be placed on the brush or the

**4.2.3 Professionally applied fluoride (fluoride varnish in the pediatrician office)** 

It has been previously reported that fluoride varnish (a concentrated form of sodium fluoride) reduced caries in the primary dentition by 33% and in the permanent dentition by 46% when compared with placebo (Morinho et al., 2011). Therefore, their wider use is encouraged by WHO (1994). Visits to primary care physicians and pediatricians are the norm during children's first few years of life in many countries. Surveys of pediatric primary care providers suggest that they are willing to provide preventive dental care for their pediatric patients (Pierce et al., 2002). Lewis et al found that 74 % of US pediatricians

effects of the element.

chewing-stick (WHO, 1994).

**4.2.2 Fluoride-containing toothpaste** 

Measures to reduce caries risk and/or to stop ongoing caries activity in children are:


It is neither necessary nor practical to stop children eating sweets completely. On the contrary, children should be encouraged to eat a balanced meal before any sweets are given. Friend and relatives should be encouraged to bring gifts rather than sweets. The consumption of bed-time snack or drink (other than water) should be strongly discouraged, since salivary flow is virtually absent at night and plaque pH may remain low for many hours.

All dental professionals are encouraged to share current best practice oral health prevention strategies with their local community medical providers especially with pediatricians (Huston & Wood, 2009).

#### **4.2 Clinical use of fluorides**

There is substantial evidence that fluoride, through different applications and formulas, works to control caries development. The first observations of fluoride's effects on dental caries were linked to fluoride naturally present in the drinking water, and then from controlled water fluoridation programs. Other systemic methods to deliver fluoride were later suggested, including dietary fluoride supplements such as salt and milk. These systemic methods are now being questioned due to the fact that many studies have indicated that fluoride*'s action relies mainly on its post-eruptive effect from topical contact with the tooth structure. It is known that even the methods of delivering* fluoride *known as 'systemic' act mainly through a topical effect when they are in contact with the teeth.* The effectiveness of water fluoridation in many geographic areas is lower than in previous eras due to the widespread use of other fluoride modalities. Nevertheless, this evidence should not be interpreted as an indication that systemic methods are no longer relevant ways to deliver fluoride on an individual basis or for collective health programs. *Caution must be taken to avoid excess ingestion of* fluoride *when prescribing* dietary fluoride *supplements for children in order to minimize the risk of* dental *fluorosis, particularly if there are other relevant sources of* fluoride *intake - such as drinking water, salt or milk and/or dentifrice (*Sampaio et al., 2011; Jimenez-Farfan et al., 2011). Safe and effective doses of fluoride can be achieved when combining topical and systemic methods. Before considering supplementing fluoride, recommendations on how to avoid excessive fluoride intake should be followed (Buzalaf & Levy, 2011).

#### **4.2.1 Communal water fluoridation**

Studies evaluating the effect of water fluoridation on dental caries show a reduction in both the primary and permanent dentitions of about 50%. Community water fluoridation is safe and cost-effective and therefore, should be introduced and maintained wherever socially acceptable and feasible. The optimum fluoride concentration will normally be within the range 0.5-1.0 mg/l (ppm). At this currently accepted optimal level, water fluoridation will

• Sugars should be eliminated as fast as possible from the oral cavity. Foods needing

It is neither necessary nor practical to stop children eating sweets completely. On the contrary, children should be encouraged to eat a balanced meal before any sweets are given. Friend and relatives should be encouraged to bring gifts rather than sweets. The consumption of bed-time snack or drink (other than water) should be strongly discouraged, since salivary flow is virtually absent at night and plaque pH may remain low for many

All dental professionals are encouraged to share current best practice oral health prevention strategies with their local community medical providers especially with pediatricians

There is substantial evidence that fluoride, through different applications and formulas, works to control caries development. The first observations of fluoride's effects on dental caries were linked to fluoride naturally present in the drinking water, and then from controlled water fluoridation programs. Other systemic methods to deliver fluoride were later suggested, including dietary fluoride supplements such as salt and milk. These systemic methods are now being questioned due to the fact that many studies have indicated that fluoride*'s action relies mainly on its post-eruptive effect from topical contact with the tooth structure. It is known that even the methods of delivering* fluoride *known as 'systemic' act mainly through a topical effect when they are in contact with the teeth.* The effectiveness of water fluoridation in many geographic areas is lower than in previous eras due to the widespread use of other fluoride modalities. Nevertheless, this evidence should not be interpreted as an indication that systemic methods are no longer relevant ways to deliver fluoride on an individual basis or for collective health programs. *Caution must be taken to avoid excess ingestion of* fluoride *when prescribing* dietary fluoride *supplements for children in order to minimize the risk of* dental *fluorosis, particularly if there are other relevant sources of* fluoride *intake - such as drinking water, salt or milk and/or dentifrice (*Sampaio et al., 2011; Jimenez-Farfan et al., 2011). Safe and effective doses of fluoride can be achieved when combining topical and systemic methods. Before considering supplementing fluoride, recommendations on how to avoid excessive fluoride intake should be followed (Buzalaf &

Studies evaluating the effect of water fluoridation on dental caries show a reduction in both the primary and permanent dentitions of about 50%. Community water fluoridation is safe and cost-effective and therefore, should be introduced and maintained wherever socially acceptable and feasible. The optimum fluoride concentration will normally be within the range 0.5-1.0 mg/l (ppm). At this currently accepted optimal level, water fluoridation will

Measures to reduce caries risk and/or to stop ongoing caries activity in children are:

• Number of meals and snacks should be kept on a low level.

• Chewing lead to an increased salivation, which is desirable.

active

hours.

Levy, 2011).

**4.2.1 Communal water fluoridation** 

(Huston & Wood, 2009).

**4.2 Clinical use of fluorides** 

• Low sugar consumption is desirable from a cariological point of view

result in some mild enamel fluorosis (McDonagh et al., 2000). The technical operation of water-fluoridation systems should be monitored and recorded regularly to prevent toxic effects of the element.

#### **4.2.2 Fluoride-containing toothpaste**

Fluoride toothpaste is the most widely used method of applying fluoride to teeth by so far. It is commonly used at home. It also has been using in community and school-based preventive programs. A recent systematic review concluded its beneficial use in preventing caries in children and adolescents, but only significantly for fluoride concentrations of 1000 ppm and above (Wong et al., 2011). Brushing teeth with fluoride containing toothpaste twice per day is recommended. The patients should brush before bed as the paste provides fluoride concentrations in saliva while the child is asleep. The effectiveness of fluoride toothpaste is concentration dependent. The relative caries preventive effects of fluoride toothpastes of different concentrations increase with higher fluoride concentration. The decision of what fluoride levels to use for children under 6 years should be balanced with the risk of fluorosis (Walsh et al., 2010). Studies have shown that use of fluoride toothpaste from an earl age is associated with higher levels of very mild fluorosis. The very mild grades are not aesthetically compromising, the use of fluoride toothpastes should continue to be promoted in communities, where or not they are served with fluoridated water or salt (WHO, 1994). However, in a recent study, it was indicated that there was weak unreliable evidence that starting the use of fluoride toothpaste in children aged <12 months may be associated with an increased risk of fluorosis. The evidence if use begins between the age of 12 and 24 months is equivocal. If the risk of fluorosis is of concern, the fluoride level of toothpaste for young children (under 6 years of age) is recommended to be lower than 1000 parts per million (ppm). More evidence from studies with low risk of bias is needed (Rasines, 2010). The author agrees with some other author's suggestion that children under 6 should use an adult-concentration paste (1000-1500 ppm fluoride), but a small pea-sized portion of it. The child should be encouraged to spit out excess paste and not swallow it. Children's pastes (500 ppm fluoride or less) could be recommended for children at low risk of caries living in an area where the water contains fluoride (Kidd, 2005). Some conclusions made by the WHO expert committee in 1994 are everyone should be encouraged to brush Daily with a fluoride toothpaste, every effort must be made to develop affordable fluoridated toothpastes for general use in developing countries, fluoridated toothpaste tubes should carry advice that for children under the age of 6 years brushing should be supervised and only a very small amount (less than 5 mm) should be placed on the brush or the chewing-stick (WHO, 1994).

#### **4.2.3 Professionally applied fluoride (fluoride varnish in the pediatrician office)**

It has been previously reported that fluoride varnish (a concentrated form of sodium fluoride) reduced caries in the primary dentition by 33% and in the permanent dentition by 46% when compared with placebo (Morinho et al., 2011). Therefore, their wider use is encouraged by WHO (1994). Visits to primary care physicians and pediatricians are the norm during children's first few years of life in many countries. Surveys of pediatric primary care providers suggest that they are willing to provide preventive dental care for their pediatric patients (Pierce et al., 2002). Lewis et al found that 74 % of US pediatricians

What is the Role of Pediatricians on Oral Health? 149

programmes. Clinical studies have shown that xylitol, a natural, physiologic sugar alcohol of the pentitol type, can be used as a safe and effective caries-limiting sweetener. Habitual use of xylitol-containing food and oral hygiene adjuvants has been shown to reduce the growth of dental plaque, to interfere with the growth of caries-associated bacteria, to decrease the incidence of dental caries, and to be associated with remineralization of caries lesions. Other sugar alcohols that have been successfully used as sugar substitutes include D-glucitol (sorbitol), which, however, owing to its hexitol nature, normally has no strong effect on the mass and adhesiveness of bacterial plaque and on the growth of mutans streptococci. A tetritol-type alditol, erythritol, has shown potential as a non-cariogenic sugar substitute. Combinations of xylitol and erythritol may reduce the incidence of caries more effectively than either alditol alone (Makinen, 2011). Traditional delivering vehicles such as chewing-gums, hard candies and mints can only provide contact of the sugar substitutes with tooth surface for a few minute or even seconds. Therefore, novel delivery vehicles are still needed for the effective delivery of sugar substitutes before they can be considered as therapeutically effective.A group of peptides, known as casein phosphor peptide (CPP), have been shown to stabilize calcium and phosphate preserving them in an amorphous or soluble form known as amorphous calcium phosphate (ACP). Calcium and phosphate are essential components of enamel and dentine and form highly insoluble complexes, but in the presence of CPP they remain soluble and biologically available. This CPP-ACP complex applied to teeth by means of chewing-gum, toothpaste, lozenges, mouth rinses, or sprays is able to adhere to the dental biofilm and enamel hydroxyapatite providing bioavailable calcium and phosphate ions. When placed on the surface of a tooth with early carious lesions, pastes with CPP-ACP complexes can prevent tooth demineralization and improve enamel remineralization and enhance fluoride activity. Therefore, use of CPP-ACP based compounds offers a potential for use in the prevention of dental caries (Llena et al., 2009). Recently, probiotics have been investigating for dental caries prevention and inhibition. In caries, there are increases in acidogenic and acid-tolerating species such as mutans streptococci and lactobacilli, although other bacteria with similar properties can also be found and bifidobacteria, non-mutans streptococci, Actinomyces spp., Propionibacterium spp., Veillonella spp. and Atopobium spp. have also been implicated as significant in the aetiology of this disease (Aas et al., 2008). Therefore, to be able to develop probiotic or prebiotic interventions for applications in dental health care and to understand their mechanisms of action and potential risks, it is essential to have a clear understanding of the oral microbiota and their functions in dental/oral health and disease. However, some products have reached the market, there remains a paucity of clinical evidence to support the effectiveness of probiotics to prevent or treat caries (Meurman & Stomatova, 2007).

**4.4 Counseling families on basic oral hygiene** 

Saied-Moallemi et al., 2008).

The considerable potential of mothers should be a major focus of (oral) health professionals in developing oral health promotion programs for children and adolescents. Several maternal cognitive, behavioral, and psychosocial factors were associated with young children's brushing practices. Oral health-specific self-efficacy and knowledge measures are potentially modifiable cognitions and intervening on these factors could help foster healthy dental habits and increase children's brushing frequency early in life (Finlayson et al., 2007;

expressed a willingness to apply fluoride varnish (Lewis et al., 2000). In promoting preventive dental health, pediatricians benefit all children and particularly the underserved. Therefore, pediatricians will require adequate training in oral health in medical school, residency, and in continuing education courses. It has been recently reported that *multiple applications of* fluoride *at the time of primary tooth emergence seem to be most beneficial to prevent dental caries formation*. Referrals to dentists for treatment of existing disease detected by physicians during regular visits limited the cumulative reductions in caries-related treatments, but also contributed to improved oral health (Pahel et al., 2011). Twice yearly application of fluoride varnish is indicated for the children over 6 years exposed to a greater cariogenic challenge or (in exceptional cases) when it is difficult to control caries in children under 6 years. Non-dental health care professionals should seek a professional advice from a pediatric dentist for appropriate application of the varnish.
