Crusade Against Cavities

Elizabeth Shick, DDS, MPH, Director, Cavity-Free at Three Program, Children's Hospital Colorado
Assistant Professor, Department of Pediatric Dentistry, University of Colorado School of Dentistry

With dental decay being the most common chronic childhood illness, Children's Hospital Colorado Dental Center has answered the call to fight cavities in young children. In response to recent statistics showing that dental caries is on the rise among two to five year olds, the Dental Center launched the Cavity-Free at Three Program last summer to provide dental care for underprivileged children in Colorado under three years old. The American Academy of Pediatric Dentistry (AAPD) and the American Academy of Pediatrics (AAP) have adopted guidelines recommending that all children establish a dental home and have their first dental visit upon eruption of their first tooth and by age one at the latest. Accordingly, the Cavity-Free at Three Program provides a dental home for any child in Colorado in need of routine dental care.

Dental caries

Many people don't realize that the earlier routine dental care begins, the better to instill preventive care early and educate caretakers about optimal oral health for their child. The

early dental visits are composed primarily of a caries risk assessment, oral health evaluation, dental exam, cleaning and fluoride application. Oral health counseling with caretakers consists of discussing risk factors such as past caries history, family history, diet, oral hygiene at home and fluoride exposure in an open dialogue with caretakers to encourage an honest exchange of information.

Dental caries is a slow progressive disease that may begin as early as the first tooth erupting. It is caused by a host of bacteria, but streptococcus mutans is the primary culprit. As we ingest foods rich in fermentable carbohydrates and sugars, the strep mutans metabolize them and release an acid by-product. It is this acid by-product that breaks down the enamel leading to decalcification and cavitation of the teeth. Decalcification presents as a chalky white line usually along the gingival margin (Figure 1) and marks the beginning of the caries process. Decalcification does not require restoration and the tooth may be remineralized thus halting further progression. 

The best way to arrest and remineralize the decalcified areas is by applying professional strength fluoride varnish to the area every three months and by changing risk factors at home that led to the problem.

If left untreated, decalcification may progress to cavitation (Figure 2). Cavitation is irreversible and eventually must be restored by the dentist.  

Untreated decay most often progresses and grows slowly over time leading to infection and other complications. Common sequelae of dental caries in children include costly and painful dental treatment, dental pain, infection, cellulitis, difficulty eating, poor weight gain, missed school days, impaired concentration in school and low self-esteem. Dental infection and cellulitis incurs high morbidity and often must be treated with antibiotic therapy and, if severe, incision and drainage.

Treatment of young children can be challenging as children are frequently pre-cooperative and are unable to tolerate traditional treatment in the dental office. When the dentist is unable to perform definitive treatment in the office setting, there are other options that may be considered. Conscious sedation employs a variety of oral medications and may be offered after considering the patient's health and airway status.

If no contraindications exist, the dentist may attempt dental treatment in the office after administering oral medications to the child.  Commonly used medications include Versed alone, Versed and Demerol, or a combination of Demerol, Vistaril and Chloral Hydrate.

If a child is not a candidate for sedation, treatment in the operating room under general anesthesia may be the only choice. This treatment option carries a higher burden of cost and health risks to the patient, but often is the only way to restore the teeth in an uncooperative child.

The role of prevention

Historically, dental education was geared toward treating caries in older children; some dentists are not comfortable seeing young children for routine dental care. The current paradigm is shifting from one of treating an existing problem to one of preventing the problem by earlier intervention. In an effort to create a new generation of dentists willing to open their practices to children of all ages, the Cavity-Free at Three Program serves to educate dental students so they may be more comfortable seeing patients under three years old. The program hosts a rotation for third year dental students as they complete the pediatric dentistry component of their dental education. Dental students rotate for two days during their third year and see only children under three years old to hone their prevention skills.

The infant oral health appointment consists primarily of counseling caretakers about the importance of oral health for their children and how to best prevent decay. Anticipatory guidance, or age appropriate counseling based on developmental milestones, includes a discussion of the risk factors.

Once these risk factors are reviewed, the healthcare provider will be able to classify the child as high, medium or low risk. High risk children are placed on a three month appointment frequency to return for counseling, exam, cleaning and fluoride. Low risk children may be seen every six months.

The Cavity-Free at Three Program also strives to educate physicians about the importance of infant oral health, how to perform oral health evaluations, how to apply fluoride varnish and when to make proper referrals to a dental home. As the program grows, the Cavity-Free at Three staff hopes to become more involved with Children's Hospital Colorado Pediatric Residency program so that all graduating pediatricians are comfortable with pediatric oral health. Training programs are also being developed for primary care providers and general dentists already practicing in the community. The Cavity-Free at Three Program will allow any healthcare provider to come and learn how to perform oral health evaluations on patients in a hands-on format at the dental center under the preceptorship of the program's director, Dr. Elizabeth Shick.

Important counseling points regarding infant oral health

Family history

• Ensure the entire family obtains dental care
• Cavities are caused by bacteria that can be spread from person to person

Diet

• Wean baby off the bottle at age one
• Never put baby to bed with a cup or bottle containing milk or juice (only water is OK)
• Limit juice intake to four to six ounces per day
• Limit snacking to twice a day
• Limit soda and tea intake
• Offer milk or juice with meals and water in between meals
• In between meals, put only water in a sippy cup if child carries it around
• Encourage more water intake
• Fluoride
   - Drink fluoridated water
   - Begin using toothpaste with fluoride when first tooth erupts

Oral hygiene

• Begin brushing with a toothbrush twice daily when the first tooth erupts
• See the dentist when the first tooth erupts or by age one at the latest
• Maintain regular dental visits every three to six months depending on risk

For more information

If you are interested in learning more about the Cavity-Free at Three Program or wish to receive infant oral health training, please contact the program's director, Elizabeth Shick, DDS, MPH at (720) 777-7038.