**4.2.4 Dietary fluoride supplements (tablets, drops, vitamins plus fluoride, lozenges)**

The recent data on the value of fluorides administered during pregnancy fails to disclose any valid evidence to support such use even in non-fluoridated areas. *Fluoride ingestion by pregnant women does not benefit the teeth of their offspring, at least not the permanent teeth* (Sa Roriz Fonteles et al., 2005). In a recent panel by American Dental Association Council on Scientific Affairs, the following questions were addressed about the usage of fluoride supplements: When and for whom should the supplements be prescribed, and what should be the recommended dosage schedule for them?. The panel concluded that dietary fluoride supplements *should be prescribed only for children who are at high risk of developing caries and whose primary source of drinking water is deficient in* fluoride (Rozier et al., 2010). Supplements if indicated should be prescribed in accordance with the dosages recommended in Table 3 (AAPD, 2002). The natural (e.g. water) and cumulative (e.g. consumption amount of fluoride-rich foods, sources of drinking water) fluoride concentrations, should be determined and analyzed before fluoride prescripton. These clinical recommendations should be integrated with the practitioner's professional judgment and the patient's needs and preferences. Providers should carefully monitor the patient's adherence to the fluoride dosing schedule to maximize the potential therapeutic benefit.


Table 3. Dietary fluoride supplementation schedule (\*=drinking water fluoride concentration).

#### **4.3 Sugar alcohols, casein phosphopeptides**

Partial sugar substitution with polyols is an important dietary tool in the prevention of dental caries that should be used to enhance existing fluoride-based caries prevention

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

**4.2.4 Dietary fluoride supplements (tablets, drops, vitamins plus fluoride, lozenges)**  The recent data on the value of fluorides administered during pregnancy fails to disclose any valid evidence to support such use even in non-fluoridated areas. *Fluoride ingestion by pregnant women does not benefit the teeth of their offspring, at least not the permanent teeth* (Sa Roriz Fonteles et al., 2005). In a recent panel by American Dental Association Council on Scientific Affairs, the following questions were addressed about the usage of fluoride supplements: When and for whom should the supplements be prescribed, and what should be the recommended dosage schedule for them?. The panel concluded that dietary fluoride supplements *should be prescribed only for children who are at high risk of developing caries and whose primary source of drinking water is deficient in* fluoride (Rozier et al., 2010). Supplements if indicated should be prescribed in accordance with the dosages recommended in Table 3 (AAPD, 2002). The natural (e.g. water) and cumulative (e.g. consumption amount of fluoride-rich foods, sources of drinking water) fluoride concentrations, should be determined and analyzed before fluoride prescripton. These clinical recommendations should be integrated with the practitioner's professional judgment and the patient's needs and preferences. Providers should carefully monitor the patient's adherence to the fluoride

a pediatric dentist for appropriate application of the varnish.

dosing schedule to maximize the potential therapeutic benefit.

**Age LESS than 0.3 ppm** 

**4.3 Sugar alcohols, casein phosphopeptides** 

concentration).

**F\*** 

Table 3. Dietary fluoride supplementation schedule (\*=drinking water fluoride

Partial sugar substitution with polyols is an important dietary tool in the prevention of dental caries that should be used to enhance existing fluoride-based caries prevention

Birth-6 mos 0 0 0 6 mos-3 yrs 0.25 mg 0 0 3 yrs-6yrs 0.50 mg 0.25 mg 0 6 yrs up to at least 16 yrs 1.00 mg 0.50 mg 0

**0.3-0.6.ppm F\*** 

**MORE than 0.6 ppm F\*** 

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**

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; Saied-Moallemi et al., 2008).

What is the Role of Pediatricians on Oral Health? 151

(include pregnancy and first month of birth) and addresses the health of both mother and infant. Mother's or caregiver's teeth must be examined infants whose mothers have high levels of untreated dental caries are at greater risk of acquiring organisms. General approach which have been used to prevent ECC include training of mothers or caregivers to follow healthy dietary and feeding habits to prevent the development of ECC, early screening for signs of caries development (starting from about 7 to 8 month of age) to identify infants who are at risk developing ECC and assisting in providing information for parents about promoting oral health. Pediatricians can give the following recommendations for prevention

• Mothers should be encouraged to have infants drink from a cup as they approach their

• An attempt should be made to assess and decrease the mother's/primary caregiver's mutans streptococci level to decrease the transmission of cariogenic bacteria, • Stop saliva-sharing activities, such as tasting food before feeding and sharing

Fig. 4. Child's teeth with ECC. Observe the different phases of development (Quoted from Losso EM, Tavares MCR, da Silva JYB, Urban C (2009). Severe early childhood caries: an

**4.4.2 Initial acquisition of Mutans Streptococci (MS) by infants from their mothers** 

MS, consisting mainly of the species Streptococcus mutans and Streptococcus sobrinus, are commonly cultured from the mouths of infants, with prevalence of infection ranging from around 30 % in 3 month old predentate children to over 80 % in 24 month old children with primary teeth. MS is usually transmitted to children through their mothers. Domejean et al. (2010) indicated that MS can colonize horizontal as well as vertical transmission does occur.

of ECC to mothers and caregivers (AAPD, 2003b):

first birthday,

toothbrushes.

integral approach, *J Pediatr* 4, 295-300.

• Elimination of active dental caries lesions, gingival disease,

avoided after the first primary tooth begins to erupt,

• Using fluoride and clorhexidine (Toothpaste, mouthwash, gel, varnish), • Twice daily tooth brushing of the dentate infant (around 7th month of age), • Oral health evaluation of the infant by a pediatric dentist before the first birthday, • Infants should not be put to sleep with a bottle and nocturnal breastfeeding should be

• Infants should be weaned from the bottle at 12 to 14 months of age,

#### **4.4.1 Feeding baby (Early Childhood Caries-ECC)**

Early childhood caries (ECC) is defined as 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 71-month or younger child. In children younger than 3 years of age, any sign of tooth smooth surface caries is indicative of severe early childhood caries (S-ECC) (AAPD, 2003a). ECC has been found in general population but is more prevalent in low socioeconomic groups. It is 5 times more common than asthma, 7 times more common than hay fever, and 14 times more common than chronic bronchitis (Filstrup et al., 2003). The clinical appearance of the teeth in ECC is typical and follows a specific pattern: There is usually early and progressive carious lesions of the primary upper incisors in first years of age followed by the involvement of the upper and lower first primary molars, and the upper canines and sometimes lower canines (according to the sequence of eruption). The lower incisors are usually unaffected because of salivary flow from sub-lingual glands, and the contact of the tongue and lips at the time of feeding that covers the lower incisors. Therefore, milk and carbohydrates spread over all teeth except the lower incisors and prevent pudding or gathering of milk around these teeth (Tinanoff et al., 1998). The American Academy of Pediatric Dentistry (AAPD) has recognized the unique and virulant nature of ECC and accepted it as a serious public health problem. The presence of high levels of ECC, despite a reduction in permanent-dentition caries through fluoridation of water and use of fluoridated toothpastes, begs for a broader look at social and behavioral factors that correlate with this form of the disease. ECC not only affects teeth, but also may lead to more widespread health issues such as: chewing difficulty, malnutrition, gastrointestinal disorders, delayed or insufficient growth (especially in regard to the height and/or weight gain), poor speech articulation, low self-esteem and social ostracism. Additionally, repeated prescriptions of antibiotics, severe pain, sepsis and even death may also be observed. ECC is an infectious disease. Mutans Streptococci (streptococcus mutans and Streptococcus sobrinus species) are the most likely causes ECC and Lactobacilli participates in the development of the lesions and play role in lesion progression not its initiation (Parisotto et al., 2010). Bifidobacteria are asoosicated with S-ECC. S. mutans and S. sobrinus are also associated with lesion recurrence. Diet also plays an important role in the acquisition and clinical expression of the disease. Children with S-ECC, had higher scores of cariogenic bacteria for between-meal juice, solid retentive foods, and eating frequency than caries-free children. S. mutans positive children with ECC consume more cariogenic foods compared to caries-free children (Palmer et al., 2010). Acquisition may occur via vertical (from mother to child) or horizontal transmission (transmission of microbes between members of a group) (Berkowitz, 2006). Further details on vertical transmission of microorganisms will be presented in the following section. Risk factors for ECC are cariogenic bacteria, inappropriate feeding practices, social variables (education, lack of fluoride, access to healthcare, lack of health insurance, Treatment of ECC is generally problematic and costly because the cooperation of babies is low. Additionally within the first year after dental caries treatments, 40% recurrence rate has been reported around restored teeth and occurrence of new decays is common (Graves et al., 2004). Primary pediatric care providers are more likely to have earlier contact with children. Therefore, pediatricians as well as primary care health professionals will be responsible for the prevention of ECC. The diagnosis of impaired dentition and related prevention and outcomes should be included in their curricula. Primary prevention of ECC begins in the prenatal and perinatal periods

Early childhood caries (ECC) is defined as 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 71-month or younger child. In children younger than 3 years of age, any sign of tooth smooth surface caries is indicative of severe early childhood caries (S-ECC) (AAPD, 2003a). ECC has been found in general population but is more prevalent in low socioeconomic groups. It is 5 times more common than asthma, 7 times more common than hay fever, and 14 times more common than chronic bronchitis (Filstrup et al., 2003). The clinical appearance of the teeth in ECC is typical and follows a specific pattern: There is usually early and progressive carious lesions of the primary upper incisors in first years of age followed by the involvement of the upper and lower first primary molars, and the upper canines and sometimes lower canines (according to the sequence of eruption). The lower incisors are usually unaffected because of salivary flow from sub-lingual glands, and the contact of the tongue and lips at the time of feeding that covers the lower incisors. Therefore, milk and carbohydrates spread over all teeth except the lower incisors and prevent pudding or gathering of milk around these teeth (Tinanoff et al., 1998). The American Academy of Pediatric Dentistry (AAPD) has recognized the unique and virulant nature of ECC and accepted it as a serious public health problem. The presence of high levels of ECC, despite a reduction in permanent-dentition caries through fluoridation of water and use of fluoridated toothpastes, begs for a broader look at social and behavioral factors that correlate with this form of the disease. ECC not only affects teeth, but also may lead to more widespread health issues such as: chewing difficulty, malnutrition, gastrointestinal disorders, delayed or insufficient growth (especially in regard to the height and/or weight gain), poor speech articulation, low self-esteem and social ostracism. Additionally, repeated prescriptions of antibiotics, severe pain, sepsis and even death may also be observed. ECC is an infectious disease. Mutans Streptococci (streptococcus mutans and Streptococcus sobrinus species) are the most likely causes ECC and Lactobacilli participates in the development of the lesions and play role in lesion progression not its initiation (Parisotto et al., 2010). Bifidobacteria are asoosicated with S-ECC. S. mutans and S. sobrinus are also associated with lesion recurrence. Diet also plays an important role in the acquisition and clinical expression of the disease. Children with S-ECC, had higher scores of cariogenic bacteria for between-meal juice, solid retentive foods, and eating frequency than caries-free children. S. mutans positive children with ECC consume more cariogenic foods compared to caries-free children (Palmer et al., 2010). Acquisition may occur via vertical (from mother to child) or horizontal transmission (transmission of microbes between members of a group) (Berkowitz, 2006). Further details on vertical transmission of microorganisms will be presented in the following section. Risk factors for ECC are cariogenic bacteria, inappropriate feeding practices, social variables (education, lack of fluoride, access to healthcare, lack of health insurance, Treatment of ECC is generally problematic and costly because the cooperation of babies is low. Additionally within the first year after dental caries treatments, 40% recurrence rate has been reported around restored teeth and occurrence of new decays is common (Graves et al., 2004). Primary pediatric care providers are more likely to have earlier contact with children. Therefore, pediatricians as well as primary care health professionals will be responsible for the prevention of ECC. The diagnosis of impaired dentition and related prevention and outcomes should be included in their curricula. Primary prevention of ECC begins in the prenatal and perinatal periods

**4.4.1 Feeding baby (Early Childhood Caries-ECC)** 

(include pregnancy and first month of birth) and addresses the health of both mother and infant. Mother's or caregiver's teeth must be examined infants whose mothers have high levels of untreated dental caries are at greater risk of acquiring organisms. General approach which have been used to prevent ECC include training of mothers or caregivers to follow healthy dietary and feeding habits to prevent the development of ECC, early screening for signs of caries development (starting from about 7 to 8 month of age) to identify infants who are at risk developing ECC and assisting in providing information for parents about promoting oral health. Pediatricians can give the following recommendations for prevention of ECC to mothers and caregivers (AAPD, 2003b):


Fig. 4. Child's teeth with ECC. Observe the different phases of development (Quoted from Losso EM, Tavares MCR, da Silva JYB, Urban C (2009). Severe early childhood caries: an integral approach, *J Pediatr* 4, 295-300.

### **4.4.2 Initial acquisition of Mutans Streptococci (MS) by infants from their mothers**

MS, consisting mainly of the species Streptococcus mutans and Streptococcus sobrinus, are commonly cultured from the mouths of infants, with prevalence of infection ranging from around 30 % in 3 month old predentate children to over 80 % in 24 month old children with primary teeth. MS is usually transmitted to children through their mothers. Domejean et al. (2010) indicated that MS can colonize horizontal as well as vertical transmission does occur.

What is the Role of Pediatricians on Oral Health? 153

2003b). Therefore, pediatricians and primary health care providers must refer children to pediatric dentists in order to get them their regular dental visits. Objectives to be accomplished at the first visit: *Instruction of the parents in the use of oral hygiene procedures*, i*nfant dental examination and fluoride status review*, d*ietary issues related to nursing and bottle* 

Mouthrinsing for the prevention of dental caries in children and adolescents was established as a mass prophylactic method in the 1960s and has shown average efficacy of caries reduction between 20-50%. Commonly, weekly or twice monthly rinsing procedures using neutral 0.2% NaF solutions have been used in schools or institutions in areas with low fluoride concentrations in the drinking water. Today, when dental caries has declined substantially in the western countries, and relatively few individuals are suffering from caries, the efficiency of large scale mouthrinsing is questioned and more individual approaches of caries prevention strategies are needed. Therefore in high risk patients, daily mouthrinses using 0.05% NaF can be recommended combined with other selective preventive measures such as sugar restriction, improved oral hygiene, antibacterial treatments, and so forth. Mouthrinsing solutions have therefore been combined with antiplaque agents like chlorhexidine and other agents which can improve the caries preventive effect in high caries risk patients. Other agents than sodium fluoride have been used, such as stannous and amine fluoride with proven clinical effects. However, although a series of new formulas of mouthrinses containing fluoride combined with different antiplaque agents have shown promising antibacterial and antiplaque efficacy, their longterm clinical effects are sparsely documented. Acute and chronic side effects from established and recommended mouthrinsing routines are extremely rare but ethanol containing products should not be recommended to children for long-term use. (FDI

**5. Clinical assessment and management of the oral environment in a child** 

The likelihood is high that aggressive cancer treatment will have toxic effects on normal cells as well as cancer cells. The gastrointestinal tract, including the mouth, is particularly prone to damage. This is true whether the treatment is radiation or chemotherapy. Most patients being treated for head and neck cancer will experience some oral complications, and while most of these are manageable, complications can sometimes become severe enough that treatment must be completely stopped. In addition, surgical solutions to tumor removal may lead to oral and nutritional problems as well. The most common oral problems occurring after radiation and chemotherapy are *mucositis* (an inflammation of the mucous membranes in the mouth), *infection, pain,* and *bleeding*. Other possible complications might include dehydration and malnutrition, commonly brought on by difficulties in swallowing (dysphagia). Radiation therapy to the head and neck may injure the glands that produce saliva (xerostomia), or damage the muscles and joints of the jaw and neck (trismus). These treatments may also cause hypovascularization (reduction in blood vessels and blood supply) of the bones of the maxilla or mandible (the bones of the mouth). In addition, treatments may affect other forms of dental disease (caries, or soft tissue complications), or even cause bone death (osteonecrosis). By identifying patients at risk for oral complications, health care providers are able to start preventive measures before cancer therapy begins,

*caries.* 

Commision, 2002).

**patient receiving cancer treatment** 

**5.1 The impact of cancer therapies on the oral cavity** 

The risk of transmission increases with high maternal salivary levels of MS and frequent inoculation. Köhler & Andreen (2010) reported that children colonised by MS at an early stage developed more caries than those colonised at a later stage and early maternal caries prevention is an efficient method to prevent early colonization of MS in their children. Factors that affect the colonization of MS may be divided into bacterial virulence, hostrelated and environmental factors. Complex interactions among these factors determine the success and timing of MS colonization in the child. As clinical studies have shown that caries risk is correlated with age at which initial MS colonization occurred, strategies for the prevention of dental caries should include timely control of colonization of the cariogenic bacteria in the mouths of young children.

#### **4.4.3 Mechanical and chemical home oral hygiene (reduction of dental plaque and microorganisms)**

Dentistry, particularly dentistry for children has come a long way toward reaching a ratio of 90% prevention to 10% treatment in many developed countries. At the core of this preventive approach is home oral hygiene and plaque control. The traditional focus of oral hygiene has been and will go on to be the control of the two most prevalent oral diseases, caries and periodontal disease. Although plaque control is essential for oral hygiene, it is important to realize that no clear relationship exists between plaque control and the prevention of caries (unlike with periodontal disease). As discussed previously in the section 2.1, the complex etiology of caries centers on the following factors: tooth susceptibility, bacterial plaque, refined carbohydrates, and time. Many other variables such as oral sugar clearance and salivary flow and pH, add to the complexity of the caries process. This complex etiology helps to explain the difficulty in demonstrating a relationship between oral hygiene practices and caries prevention. Despite this ambiguity, plaque control remains an essential element for oral health. In the absence of oral hygiene dental plaque accumulates leading to shifts in bacterial populations away from those associated with health. Plaque control efforts should be directed toward two goals: (1) limiting the numbers of mutans streptococci in plaque for prevention of caries by mechanical elimination of supragingival plaque (toothbrushing) and limitation of dietary sucrose, and (2) maintaining the predominantly gram-positive flora associated with gingival health by mechanical removal of plaque from the subgingival area (flossing) on a regular basis. Brushing twice daily with fluoride toothpaste has been advocated by the profession for many years, and this behavior is a routine part of many people's behavior. This daily brushing with fluoride toothpaste is believed to be the primary reason for the decline of caries observed in many populations since the 1970s. The behavior should not be taken for granted. Children should always be asked whether, and how often, they brush their teeth and what toothpaste they use. Most toothpastes contain fluoride, but not all, and it is important to check the fluoride concentration in toothpaste to administer proper dosage to the child. The use of chemotherapeutic agents, particularly chlorhexidine, can also play a role in maintenance of gingival health. The appropriateness and effectiveness of home oral hygiene procedures change throughout childhood. It is necessary to involve the parent at some level of the oral hygiene procedures. Age categories for specific home oral hygiene recommendations are prenatal period, infants (0-1 yrs), toddlers (1-3 yrs), preschoolers (3-6 yrs), school-aged children (6-12 yrs) and adolescents (12-19 yrs). The American academy of pediatric dentistry recommends that children have their first dental visit at approximately the time of eruption of the first tooth or, at the latest, by the age of 12 months (AAPD,

The risk of transmission increases with high maternal salivary levels of MS and frequent inoculation. Köhler & Andreen (2010) reported that children colonised by MS at an early stage developed more caries than those colonised at a later stage and early maternal caries prevention is an efficient method to prevent early colonization of MS in their children. Factors that affect the colonization of MS may be divided into bacterial virulence, hostrelated and environmental factors. Complex interactions among these factors determine the success and timing of MS colonization in the child. As clinical studies have shown that caries risk is correlated with age at which initial MS colonization occurred, strategies for the prevention of dental caries should include timely control of colonization of the cariogenic

**4.4.3 Mechanical and chemical home oral hygiene (reduction of dental plaque and** 

Dentistry, particularly dentistry for children has come a long way toward reaching a ratio of 90% prevention to 10% treatment in many developed countries. At the core of this preventive approach is home oral hygiene and plaque control. The traditional focus of oral hygiene has been and will go on to be the control of the two most prevalent oral diseases, caries and periodontal disease. Although plaque control is essential for oral hygiene, it is important to realize that no clear relationship exists between plaque control and the prevention of caries (unlike with periodontal disease). As discussed previously in the section 2.1, the complex etiology of caries centers on the following factors: tooth susceptibility, bacterial plaque, refined carbohydrates, and time. Many other variables such as oral sugar clearance and salivary flow and pH, add to the complexity of the caries process. This complex etiology helps to explain the difficulty in demonstrating a relationship between oral hygiene practices and caries prevention. Despite this ambiguity, plaque control remains an essential element for oral health. In the absence of oral hygiene dental plaque accumulates leading to shifts in bacterial populations away from those associated with health. Plaque control efforts should be directed toward two goals: (1) limiting the numbers of mutans streptococci in plaque for prevention of caries by mechanical elimination of supragingival plaque (toothbrushing) and limitation of dietary sucrose, and (2) maintaining the predominantly gram-positive flora associated with gingival health by mechanical removal of plaque from the subgingival area (flossing) on a regular basis. Brushing twice daily with fluoride toothpaste has been advocated by the profession for many years, and this behavior is a routine part of many people's behavior. This daily brushing with fluoride toothpaste is believed to be the primary reason for the decline of caries observed in many populations since the 1970s. The behavior should not be taken for granted. Children should always be asked whether, and how often, they brush their teeth and what toothpaste they use. Most toothpastes contain fluoride, but not all, and it is important to check the fluoride concentration in toothpaste to administer proper dosage to the child. The use of chemotherapeutic agents, particularly chlorhexidine, can also play a role in maintenance of gingival health. The appropriateness and effectiveness of home oral hygiene procedures change throughout childhood. It is necessary to involve the parent at some level of the oral hygiene procedures. Age categories for specific home oral hygiene recommendations are prenatal period, infants (0-1 yrs), toddlers (1-3 yrs), preschoolers (3-6 yrs), school-aged children (6-12 yrs) and adolescents (12-19 yrs). The American academy of pediatric dentistry recommends that children have their first dental visit at approximately the time of eruption of the first tooth or, at the latest, by the age of 12 months (AAPD,

bacteria in the mouths of young children.

**microorganisms)** 

2003b). Therefore, pediatricians and primary health care providers must refer children to pediatric dentists in order to get them their regular dental visits. Objectives to be accomplished at the first visit: *Instruction of the parents in the use of oral hygiene procedures*, i*nfant dental examination and fluoride status review*, d*ietary issues related to nursing and bottle caries.* 

Mouthrinsing for the prevention of dental caries in children and adolescents was established as a mass prophylactic method in the 1960s and has shown average efficacy of caries reduction between 20-50%. Commonly, weekly or twice monthly rinsing procedures using neutral 0.2% NaF solutions have been used in schools or institutions in areas with low fluoride concentrations in the drinking water. Today, when dental caries has declined substantially in the western countries, and relatively few individuals are suffering from caries, the efficiency of large scale mouthrinsing is questioned and more individual approaches of caries prevention strategies are needed. Therefore in high risk patients, daily mouthrinses using 0.05% NaF can be recommended combined with other selective preventive measures such as sugar restriction, improved oral hygiene, antibacterial treatments, and so forth. Mouthrinsing solutions have therefore been combined with antiplaque agents like chlorhexidine and other agents which can improve the caries preventive effect in high caries risk patients. Other agents than sodium fluoride have been used, such as stannous and amine fluoride with proven clinical effects. However, although a series of new formulas of mouthrinses containing fluoride combined with different antiplaque agents have shown promising antibacterial and antiplaque efficacy, their longterm clinical effects are sparsely documented. Acute and chronic side effects from established and recommended mouthrinsing routines are extremely rare but ethanol containing products should not be recommended to children for long-term use. (FDI Commision, 2002).
