REFERENCE MANUAL V 37 / NO 6 15 / 16

Guideline on Infant Oral Health Care

Originating Committee
Clinical Affairs Committee – Infant Oral Health Subcommittee
Review Council
Council on Clinical Affairs

Adopted
1986

Revised
1989, 1994, 2001, 2004, 2009, 2011, 2012, 2014*

Purpose result in significant pain and potentially life-threatening in-

The American Academy of Pediatric Dentistry (AAPD) recog- fection, and diminish overall quality of life.12-21 Since medical
nizes that infant oral health is one of the foundations upon health care professionals are far more likely to see new mothers
which preventive education and dental care must be built to and infants than are dentists, it is essential that they be aware
enhance the opportunity for a lifetime free from preventable of the infectious etiology and associated risk factors of ECC,
oral disease. The AAPD proposes recommendations for pre- make appropriate decisions regarding timely and effective
ventive strategies, oral health risk assessment, anticipatory intervention, and facilitate the establishment of the dental
guidance, and therapeutic interventions to be followed by home.4,22-25
dental, medical, nursing, and allied health professional programs.
Dental caries
Methods Dental caries is a common chronic infectious transmissible
This guideline is an update of the previous Guideline on In- disease resulting from tooth-adherent specific bacteria, pri-
fant Oral Health Care, revised in 2009. This revision included marily mutans streptococci (MS), that metabolize sugars to
a hand search of literature as well as a new search of the produce acid which, over time, demineralizes tooth structure.26
®
MEDLINE/PubMed electronic database using the following
parameters: Terms: infant oral health, infant oral health care,
MS generally is considered to be the principal group of bac-
terial organisms responsible for the initiation of dental caries.27
and early childhood caries; Fields: all; Limits: within the last MS colonization of an infant may occur from the time of
10 years, humans, English, and clinical trials. Papers for review birth.28-34 Significant colonization occurs after dental eruption
were chosen from the resultant list of 449 articles and from as teeth provide non-shedding surfaces for adherence. Other
references within selected articles. When data did not appear surfaces also may harbor MS.32,35,36 For example, the furrows
sufficient or were inconclusive, recommendations were based of the tongue appear to be an important ecological niche in
upon expert and/or consensus opinion by experienced re- harboring the bacteria in predentate infants.33,35
searchers and clinicians. Vertical transmission of MS from mother to infant is well
documented.37-39 Genotypes of MS in infants appear identical
Background to those present in mothers in 17 reports, ranging from 24
The Centers for Disease Control and Prevention reports that to 100 percent. 39 The higher the levels of maternal salivary
caries is the most prevalent infectious disease in our nation’s MS, the greater the risk of the infant being colonized. 40
children.1 More than 40 percent of children have caries by the Along with salivary levels of MS, mother’s oral hygiene, perio-
time they reach kindergarten.2 In contrast to declining pre- dontal disease, snack frequency, and socioeconomic status also
valence of dental caries among children in older age groups, are associated with infant colonization.36 Reports indicate that
the prevalence of caries in poor US children under the age horizontal transmission (ie, transmission between members of
of five is increasing.3 Early childhood caries (ECC) and the a group such as siblings of a similar age or children in a day-
more severe form of ECC (S-ECC) can be particularly virulent care center) also may be of concern.41-44 Dental caries is a dis-
forms of caries, beginning soon after tooth eruption, developing ease that generally is preventable. Early risk assessment allows
on smooth surfaces, progressing rapidly, and having a lasting for identification of parent-infant groups who are at risk for
detrimental impact on the dentition.4-9 This disease affects the ECC and would benefit from early preventive intervention.
general population but is 32 times more likely to occur in in- The ultimate goal of early assessment is the timely delivery
fants who are of low socioeconomic status, who consume a of educational information to populations at high risk for
diet high in sugar, and whose mothers have a low education developing caries in order to prevent the need for later
level.10,11 Caries in primary teeth can affect children’s growth, surgical intervention.

* The 2014 revision is limited to use of fluoridated toothpaste in young children.

146 CLINICAL PRAC TICE GUIDELINES
 AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Anticipatory guidance Xylitol chewing gum: Evidence suggests that the use of xylitol
Caries-risk assessment for infants allows for the institution of chewing gum (at least two to three times a day by the mother)
appropriate strategies as the primary dentition begins to erupt. has a significant impact on mother-child transmission of MS
Even the most judiciously designed and implemented caries- and decreasing the child’s caries rate.51-53
risk assessment, however, can fail to identify all infants at risk
for developing ECC. In these cases, the mother may not be Recommendations for the infant’s oral health
the colonization source of the infant’s oral flora, the dietary Oral health risk assessment: Every infant should receive an oral
intake of simple carbohydrates may be extremely high, or health risk assessment from his/her primary health care pro-
other uncontrollable factors may combine to place the infant vider or qualified health care professional by six months of
at risk for developing dental caries. Therefore, screening for age. This initial assessment should evaluate the patient’s risk
risk of caries in the parent and infant, coupled with oral of developing oral diseases of soft and hard tissues, including
health counseling, is not a substitute for the early establish- caries-risk assessment, provide education on infant oral health,
ment of the dental home.40 The early establishment of a and evaluate and optimize fluoride exposure.
dental home, including ECC prevention and management, is Establishment of a dental home: Parents should establish a
the ideal approach to infant oral health care.25,37 The inclusion dental home for infants by 12 months of age.54,55 The initial
of education regarding the infectious and transmissible nature visit should include thorough medical (infant) and dental
of bacteria that cause ECC, as well as methods of oral health (parent and infant) histories, a thorough oral examination,
risk assessment, anticipatory guidance, and early intervention, performance of an age-appropriate tooth brushing demonstra-
into the curriculum of medical, nursing, and allied health tion, and prophylaxis and fluoride varnish treatment if
professional programs has shown to be effective in increasing indicated.55 In addition, assessing the infant’s risk of devel-
the establishment of a dental home.45,46 Recent studies, noting oping caries and determining a prevention plan and interval
that a majority of pediatricians and general dentists were not for periodic re-evaluation should be done. Infants should be
advising patients to see a dentist by one year of age, point to referred to the appropriate health professional if specialized
the need for increased infant oral health care education in intervention is necessary. Providing anticipatory guidance
the medical and dental communities.47,48 regarding dental and oral development, fluoride status, non-
nutritive sucking habits, teething, injury prevention, oral
Recommendations hygiene instruction, and the effects of diet on the dentition
Recommendations for parental oral health49 are also important components of the initial visit.
Oral health education: All primary health care professionals Teething: Teething can lead to intermittent localized discom-
who serve parents and infants should provide education on fort in the area of erupting primary teeth, irritability, and
the etiology and prevention of ECC. Educating the parent excessive salivation; however, many children have no apparent
on avoiding saliva-sharing behaviors (eg, sharing spoons and difficulties. Treatment of symptoms includes oral analgesics
other utensils, sharing cups, cleaning a dropped pacifier or toy and chilled rings for the child to gum.56 Use of topical anes-
with their mouth) can help prevent early colonization of MS thetics, including over-the-counter teething gels, to relieve
in infants. discomfort are discouraged due to potential toxicity of these
Comprehensive oral examination: Referral for a comprehensive products in infants.57-59
oral examination and treatment during pregnancy is especially Oral hygiene: Oral hygiene measures should be implemented
important for the mother. no later than the time of eruption of the first primary tooth.
Professional oral health care: Routine professional dental care Tooth-brushing should be performed for children by a parent
for the parent can help optimize oral health. Removal of twice daily, using a soft toothbrush of age-appropriate size and
active caries, with subsequent restoration of remaining tooth the correct amount of fluoridated toothpaste (see below in the
structure, in the parents suppresses the MS reservoir and Fluoride section).
minimizes the transfer of MS to the infant, thereby decreasing Diet: Epidemiological research shows that human milk and
the infant’s risk of developing ECC.50 breast-feeding of infants provide general health, nutritional,
Oral hygiene: Brushing with fluoridated toothpaste and floss- developmental, psychological, social, economic, and environ-
ing by the parent are important to help dislodge food and mental advantages while significantly decreasing risk for a
reduce bacterial plaque levels. large number of acute and chronic diseases.60 Human breast
Diet: Dietary education for the parents includes the cariogen- milk is uniquely superior in providing the best possible nutri-
icity of certain foods and beverages, role of frequency of tion to infants and has not been epidemiologically associated
consumption of these substances, and the demineralization/ with caries.61-63 Frequent night time bottle feeding with milk
remineralization process. and ad libitum breast-feeding are associated with, but not
Fluoride: Using a fluoridated toothpaste and rinsing with an consistently implicated in, ECC.64 Breastfeeding greater than
alcohol-free, over-the-counter mouth rinse containing 0.05 seven times daily after 12 months of age is associated with
percent sodium fluoride once a day or 0.02 percent sodium increased risk for ECC.65 Night time bottle feeding with juice,
fluoride rinse twice a day have been suggested to help reduce repeated use of a sippy or no-spill cup, and frequent in be-
plaque levels and promote enamel remineralization.22 tween meal consumption of sugar-containing snacks or drinks

CLINICAL PRACTICE GUIDELINES 147

REFERENCE MANUAL V 37 / NO 6 15 / 16

(eg, juice, formula, soda) increase the risk of caries.66,67 High- 3. Dye BA, Tan S, Smith V, et al. Trends in oral health status:
sugar dietary practices appear to be established early, by 12 United States, 1988-1994 and 1999-2004. National Center
months of age, and are maintained throughout early child- for Health Statistics. Vital Health Stat 2007;11(248).
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mended children one through six years of age consume no Pediatr Clin North Am 2000;47(5):1043-66.
more than four to six ounces of fruit juice per day, from a cup 5. Gray MM, Marchment MD, Anderson RJ. The relation-
(ie, not a bottle or covered cup) and as part of a meal or snack.70 ship between caries experience in deciduous molars at 5
Fluoride: Optimal exposure to fluoride is important to all den- years and in first permanent molars of the same child at
tate infants and children.71 Decisions concerning the admin- 7 years. Community Dent Health 1991;8(1):3-7.
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