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Lesson 4: Risk Factors For Dental Decay

Overview: The health care provider explores the risk factors and risk behaviors associated with dental decay.

Goals: The health care provider will be able to describe:

¬ The relationship of the parents/caregivers oral hygiene and caries statusand the development of dental disease in children.

¬ The distinction between amounts of sugars consumed and frequency ofsugar consumption.

¬ Feeding practices that influence the development or prevention of decay.

¬ The use of sippy cups and methods used for transitioning to a regular cup.

¬ The importance of effective oral hygiene.

¬ The positive results regarding the consumption of fluoridated water orfluoride supplements in the reduction of dental decay

Key Terms:

Mutans Streptococci: bacteria that is primarily implicated in thedevelopment of tooth decay

Systemic Fluoride: ingested fluoride that helps enamel of developingteeth become stronger and more resistant to decay

(i.e. fluoridated water or fluoride drops or tablets)

Topical Fluoride: fluoride in contact with teeth once they have eruptedin the mouth that helps enamel become moreresistant to decay or helps to remineralize enamelthat has started to decalcify (i.e. fluoride toothpaste,fluoride mouthrinse, fluoride treatment at the dentaloffice)

Feeding Practices

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Breastfeeding, for many reasons, is clearly the preferred method for feeding aninfant. Breastfeeding provides many nutritional and developmental advantages.Nevertheless, breast milk does contain sugars, (natural, not refined) and somebabies who nurse for long periods throughout the day or night may develop toothdecay. Babies should be removed from the breast when they finish feeding toprevent prolonged pooling of these sugars around the teeth. Breastfeeding isassociated with a lower risk of developing dental decay as compared to bottle-feeding.

If bottle-feeding, the bottle should be thought of as a means of delivering a meal,and not used as a pacifier. A child should not be allowed to drink from a bottlethroughout the day. The parent/caregiver should hold the infant while feeding andthen lay the infant down with a favorite stuffed animal, blanket or somethingcomforting rather than lay the infant down with a bottle containing milk, formula,juice, Kool-aid, or other sweetened liquid.

Snacking

A healthy snack may be considered a small meal. In fact, frequent consumption ofsmall amounts of food may be especially important for a toddler’s nutrition, becausetoddlers often have small appetites at mealtime due to their stomach’s limitedcapacity.

• Snacking should be limited to nutrient dense foods that are low in refinedsugar.

• The child should snack at regular intervals between meals, not ad libthroughout the day, and not too close to mealtime. This method is better forthe child developmentally and nutritionally and is better for the teeth, as well.Water should be the “snack” liquid of choice, leaving the fruit juices, milk andother sweetened liquids for the meals.

• Frequent snacking (grazing) throughout the day creates a constantenvironment ideal for the development of bacteria and the acids that damage

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the tooth enamel and cause decay. If frequent food consumption isnecessary for the child’s nutrition, be certain that the child’s teeth are brushed2-3 times per day.

Eating habits begin to develop early and are easily influenced by caregivers. If acaregiver uses food to control a child’s behavior, such as giving a favorite treat forgood behavior, the child learns that foods are rewards. This may cause the child toprefer these foods at the expense of the nutritious foods they need.

Unacceptable Practices

¬ Some caregivers will fill a bottle with cereal and make the hole in the nipplelarger, so that a child can feed from the bottle rather than taking the time to feedthe child with a spoon. This practice further concentrates pooled carbohydratesaround the teeth.

¬ Dipping a pacifier in honey, sugar or other sweet substance to calm a baby byenticing him to take it is unacceptable. The increased consumption of sugar canmore readily lead to decay.

¬ If a child goes to bed each night or is pacified during the day by sucking on asweet drink or a high carbohydrate formula, the child learns to comfort himselfwith sweetened and high carbohydrate foods in later childhood.

¬ Caregivers should not put the spoon that is used to feed the child into their ownmouths first. Doing so will transfer the bacteria that cause decay into the child’smouth.

Cup Use

Switch to a regular, small cup as soon as possible.

• A child should be encouraged to start using a cup as soon as they can sit upunassisted. Even at an early age children can be trained to use a cup withhelp.

• Assisting children with learning to use a regular cup is a nice way forparents/caregivers to spend time and bond with children.

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Bottle

- feeding vs. “Sippy Cup”

R ISK F ACTORS FOR D ENTAL D ECAY

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• Sippy cups should not be used as a bottle substitute and should not becarried by the child during the day filled with anything other than a smallamount of water.

• Drinks of milk and juice should be provided only at mealtimes or scheduledsnack time.

• Toddlers and preschoolers need no more than 4-8 ounces of juice and 16-24ounces of milk per day.

Oral Hygiene and Other Preventive Measures

Cleaning a baby’s gums and teeth is recognized as an important factor in reducingthe amount of bacteria in one’s mouth, preventing dental decay and formingappropriate behaviors. At least once daily the baby’s mouth should be wiped with asoft cloth or “baby tender”. When the first tooth erupts, and from this time forward, asmall soft bristled toothbrush should be used daily.

Toddlers and preschoolers should have their teeth brushed at least twice a day.

• A small, pea sized amount of fluoride toothpaste should be used beginning atapproximately age 2. Children need assistance with brushing until at leastage 7 or 8, and frequently longer.

• Flossing should begin as soon as two teeth have erupted next to each other.

If fluoridated water is not available, fluoride supplements should be prescribed basedon the dietary fluoride supplement schedule. Systemic fluoride can reduce the riskof dental decay by up to forty percent.

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Dietary Fluoride Supplement Schedule

Age

Fluoride SupplementFluoride ion level in drinking water (ppm)1

< 0.3 ppm 0.3 – 0.6 ppm > 0.6 ppm

Birth – 6 months None None None

6 months – 3 years 0.25 mg/day2 None None3 – 6 years 0.50 mg/day 0.25 mg/day None

6 – 16 years 1.0 mg/day 0.50 mg/day None

1 0.1 part per million (ppm) = 1 milligram/liter2 2.2 milligrams sodium fluoride contains 1 milligram fluoride ion.

Other Risk Factors

Individuals with the following characteristics are at higher risk for developing dentaldecay:

• Racial/ethnic minority

• Low income

• Limited or no dental insurance

• Less than high school education of parents/caregivers

• Special health care needs

Recent research indicates that determination of levels of bacteria in the mouth(mutans streptococci) in infancy may prove to be an excellent predictor for earlychildhood decay, and may enable early and effective risk management and diseaseprevention.