Introduction

Does baby teeth really matters for the child?

Primary or "baby" teeth are important for many reasons. Not only do they help children speak clearly and chew naturally, they also aid in forming a path that permanent teeth can follow when they are ready to erupt. Infant Oral Health is an invaluable foundation step. Better what timing exists, than to initiate the preventive measures in its truest form i.e. ‘primordial’ or ‘primary prevention’. Parents think of their newborn as having no teeth. But the 20 primary teeth that will erupt in the next two and half years are already present at birth in their jawbone. Time and again, measures initiated before the onset of the disease have proven to be effective.

What is the need for infant oral health care?

Oral mucosa is the first in the body where microorganisms are seen to be established soon after birth within 6-8 hours. The primary dentition is more prone to dental caries than the permanent dentition. This could be due to:

1. Relatively poor crystallinity and lesser thickness of enamel in primary teeth
2. More cariogenic challenges
3. Non-availability of fluoride in systemic form

That is why, to prevent or early detection of infectious diseases, injuries and abnormal habits, we need to take care of infant oral health.

• Infectious Disease of the Oral Cavity: Streptococcus Mutans is a primary causative factor in the initiation of caries and is transmitted from the mother to the infant. These gather a foothold in the mouth immediately after the eruption of the teeth. With weaning and adoption of a cariogenic diet, caries may develop and cause severe and rapid destruction of the hard tissues, if left unchecked.
• Traumatic Injuries: With lack of motor coordination, trauma to the developing primary dentition, may also occur.
• Habits: Such as thumb sucking usually have their inception at this stage and may persist to cause several dental problems.
• Handicapped children: Cleft lip and palate cases and other such children requiring special attention, may do right from the birth.

Problem such as speech, language would require early detection.

Goals of Infant Oral Health

The goals can be summarized by the following six tenets [Nowak (1997)]

1. Break the cycle of Early Childhood Caries
2. Disrupt the Acquisition of harmful Micro-flora
3. Manage the risk/benefit of habits
4. Establish a dental home for health or harm
5. Impart optimal fluoride protection
6. Use anticipatory guidance to arm parents in the therapeutic alliance

Break the cycle of Early Childhood Caries:

Early childhood caries remains a problem for many children. In many studies it is shown that by the age of 5 years as many as half of children have experienced dental caries. In subpopulations of poor and minority children, the rate is higher and the condition begins earlier. Of more concern is the cyclic nature of early childhood caries in which children afflicted remains at risk throughout childhood, even when preventive services are available.

Disrupt the Acquisition of harmful Microflora:

If you've had problems with cavities, take special care to avoid sharing your mouth's bacteria with your infant. Recent research suggests that children are inoculated with caries initiating bacteria by caretakers, primarily mothers. The transmission may occurs if you taste the child's food with a spoon that you then use to feed your child, allow your child to suck on his or her finger after putting it in your mouth. On the plus side of this acquisition model is the potential to prevent transmission, reduce the parent’s bacterial inoculums or use antibacterial chemotherapeutic agents to eliminate the infection before it becomes chronic and leads to dental caries.

Manage the risk/benefit of habits:

Infant oral health permits the dentist to enter the habit continuum while it still provides a benefit to the child and work with the family to mitigate deleterious effects and transition the child out of the habit. The outcomes are a gentle waning of the habit and no need to intervene to remedy such effects as crossbite or open-bite.

Establish a dental home for health or harm:

The concept of a dental home has been suggested as a means to focus preventive, treatment and referral services to optimize oral health. Prevention focuses on the establishment and maintenance of good oral hygiene, optimizing systemic and topical fluoride exposure and eliminating high frequency or prolonged exposure to simple sugars in the diet. Prevention is the foundation for the establishment of a “dental home” by 1 year of age.

Impart optimal fluoride protection:

Fluoride remains dentistry’s best preventive tool and optimal fluoride exposure is a tenet of early intervention. The current concern about fluorosis (tooth staining due to excessive fluoride) is during the period when teeth are at greatest risk, in the first 3 years of life.

Use anticipatory guidance to arm parents in the therapeutic alliance:

Parental involvement has become a tenet of child health care. Because infant is so heavily weighted toward risk assessment and protective factors at home, the parent becomes a co-therapist. In the first 3 years of life, there is no routine preventive message as the child develops a full primary dentition, becomes mobile and makes his or her first forays away from the family in day care. The dentist must empower the parent to provide prevention but even more to anticipate the oral health implications in the rapidly changing child.

Pre-Natal Counselling

Good oral care starts from the beginning of your child's life. The best time to begin counselling parents and establishing a child’s dental preventive program is actually before the birth of the child. It is beneficial to begin at this time because for an expectant couple, particularly if the child is their first, this is a time in their lives when they are most receptive to preventive health recommendations. These parents to become actually aware of their child’s dependence on them for the entire child’s nurturing and health care needs. Parents have a strong instinct to provide the best that they can for the child. Counselling them for their own oral hygiene habits and the effect they can have on their children as a role models will aid in improving both the parents and child’s oral health. The child gets its calcium, phosphorus and other minerals during Odontogenesis from the mother’s blood stream. Hence, a nutritious balanced diet with adequate supplements of minerals and vitamins for expectant mothers must be recommended. Prenatal fluoride supplement to mothers in the dosage of 0.25- 1 mg daily has been shown to render some protection to primary teeth from caries. Even before his or her first teeth emerge, certain factors can affect their future appearance and health. For instance, tetracycline, a common antibiotic, can cause tooth discoloration. For this reason, they should not be used by nursing mothers or by expectant mothers in the last half of pregnancy.

How to proceed for infant oral health care?

Role of the Dentist

The Dentist is a valuable source of information, on a one to one basis or in small gatherings.

The timing of first visit: First dental visit should be within the first six months of the eruption of the first primary tooth. This in turn brings us to the queries of the parents as to when do teeth erupt. First tooth erupts at 6-10 month of age but this age varies greatly between children and a difference of 6-12 months can be considered normal.

Feeding practices

From nutritional point of view, breast milk has several systemic and immunologic advantages over proprietary formulas. However on the flip side, prolonged and at will breastfeeding, beyond the stipulated weaning time of the child, especially throughout the night and sometime throughout the day has been associated with the nursing caries.

Importance of weaning: Weaning is the process of expanding the diet to include foods and drinks other than breast milk or milk formula. It is suggested that vegetables be introduced before fruits so that the infant develops a habit to accept the vegetables, while the sweeter fruits are naturally welcomed. Wean baby from the bottle at 12 to 14 months of age.

Bottle Feeding: Often, parents who are too busy to deal with the crying child, try to quieten the child by using the bottle containing milk or other sweetened drinks as a pacifier. Thus when given frequently to the child before and during sleep has been seen to cause a devastating pattern of nursing caries. In this respect, the sugars taken before sleep, when little saliva cleansing action is present, should be assessed and highlighted to the parents.

Some important tips on Bottle feeding parents should be instructed to:

1. Provide some attention to the child
2. Remove the bottle immediately after feeding
3. Substitute the milk or unsweetened juices with plain boiled water
4. Encourage your baby to stay in upright position with a bottle
5. Use a bottle with a nipple that has a small hole to enable the infant to work with his muscles activity to get the milk from the bottle
6. Introduce a cup to drink as soon as possible
7. Bottle feeding be allowed at intervals but should not be used as a pacifier
8. Give water after feeding with the bottle and clean the mouth soon after feeding
9. Baby should begin using a cup at 6 months of age.

Pacifiers

Sucking is an innate reflex that babies develop and practice in the womb as they prepare for their first meal. While sucking is tailor-made for an infant’s nutrition, most children will also find comfort by sucking on hands, fingers or pacifiers. This "non-nutritive sucking" is soothing, but is it a problem, as it causes malocclusion and should be discouraged.

Oral Hygiene Practices

Plaque removal activities should begin on eruption of the first primary teeth. Some practitioners recommend cleaning and massaging of the gums before this to help in establishing a healthy oral flora and to aid in teething. The cleaning activity should be preferably performed after every meal or at least once in every day. Parents are advised to take care of the gum pads and teeth as they erupt, till the time where the child develops sufficient neuromuscular control to brush his teeth.

Position of the child while performing oral hygiene practices

1. Arm - Cradled position: Cradling the child with one arm while massaging the teeth and gingival tissue with the hand of the other may be the simplest and provide the infant with a strong sense of security.
2. Lap - To - Lap Position: Two adults sit with knees touching, using their laps as a table on which to rest the child. The adult on the right holds the child’s legs and arms while the adult on the left performs the oral hygiene procedures.

Cleaning of Infant Mouth

1. Gum Pads: The cleaning of gum pads should be started as early as within first week of birth. The parents can be instructed to:
   1. Lay the baby down with his head in your lap and feet pointing away
   2. Open the baby’s mouth and slide the forefinger inside along the cheek and press down on the back side of lower gum pad.
   3. Take a small gauge 2” x 2” between thumb and forefinger and wipe vigorously over the ridge of the baby’s top and bottom jaw
   4. Nowadays specially designed for infant toothbrushes, finger cots and wipe are available.
   5. Use adequate pressure just to remove the film that covers the child’s gum pad.
   6. Clean at least everyday twice after morning and last feed in the night.
   7. Spend at least 2-3 minutes in cleaning.
2. Teeth: The introduction of a moistened, soft bristled, child or infant sized toothbrush during this age is advisable only if the parents feel comfortable using the brush. The use of dentifrice is neither necessary nor advised as the foaming action of the paste tends to be objectionable to the infant. Because fluoride ingestion is possible so use of non-fluoridated tooth and gum cleanser may prove beneficial.

Anticipatory Guidance

It is defined as proactive counselling of parents and patients about developmental changes that will occur in the interval between health supervision visits that includes information about daily caretaking specific to that upcoming interval. Anticipatory Guidance is the complement to risk assessment addressing protective factors is aimed at preventing oral health problems. An example would be to discuss ambulation of the child at the initial dental visit and warn parents about possible tooth trauma that often occurs as the infant stands to walk.

Guidelines for Parents

Children are our most precious resource. Their optimal oral health should be provided not only on a therapeutic but also on a preventive basis early in life time.

1. Mother should have their own dental work completed to prevent passing decay-causing germs to their baby.
2. The parents should bring their child for his first dental visit early, i.e. within six month when the first tooth erupts.
3. Breast feed the baby but do not indulge at will. Hold baby while bottle feeding and do not prop the bottle and put baby in bed with a bottle but take the bottle away immediately after feeding.
4. Avoid frequent use of the bottle with sugared milk or drinks as this can lead to nursing bottle caries. Instead, give the child more attention.
5. Dilute the milk gradually in the bottle and end with plain water.
6. Start the child on semi-solid foods by 5-6 months and reduce the use of bottle or breast feeding.
7. Do not use pacifiers or dummies dipped in honey or other sugary items.
8. Avoid extended use of sugared medicines such as syrups.
9. Clean the gum and later teeth with a cloth or soft brush after every meal or before sleep. Examine the baby teeth by lifting the baby’s lip monthly to check for white or brown spots on front teeth. If you see any, take your child to the dentist.
10. Contact the dentist if there is any trauma to the baby’s teeth
11. Do ask dentist about fluoride drops when your baby is 6 months old. Parents should know about the benefits of fluoride and its proper use such as that used in infant formulas and dentifrices.
12. Half yearly visit to the dentist should be a routine.

References

1. American Academy of Pediatric Dentistry: Risk Assessment. ABCs of Infant Oral Health. Chicago 2000.
2. Ali Mentes. pH changes in dental plaque after using sugar- free pediatric medicine. J Clin Pediatric Dentistry 25(4):307-312,2001
3. McDonald, Avery, Dean. Dentistry for the Child and Adolescent. 8th edition; 2004; Mosby Publications
4. Nowak AJ. Rationale for the timing of the first oral evaluation. Pediatric Dentistry 19:8-11,1997.
5. Pinkham, Casamassimo, Fields, McTigue, Nowak. Pediatric Dentistry. Infancy through Adolescense. 4th edition;2005; Saunders Company
6. Richard R Welbury, Monty S. Duggal and Marie – Therese Hosey. Pediatric Dentistry. 3rd edition; 2005; Oxford
7. Ray E. Stewart. Pediatric Dentistry Scientific Foundations and Clinical Practice. 1st edition; 1982; Mosby Company
8. Shobha Tandon. Textbook of Pedodontics. 1st edition; 2001; Paras Publications
9. S.G Damle. Textbook of Pediatric Dentistry. 2nd edition; 2002; Arya Publishing House
10. Sidney B. Finn. Clinical Pedodontics. 4th edition; 2004; Saunders Company