Screen early
Oral health screening provided by the primary medical provider includes a caries risk assessment, anticipatory guidance to prevent disease, and referral to a dental home, which is essential to every well-child visit.

Dental home
Establish a dental home by 12 months old or earlier, starting at 6 months old based on risk and/or 6 months after the first tooth eruption.

Fluoride
Supplemental fluoride is recommended for those without adequate fluoride in community water supply. [Krol: 2023]

Davidson K.
Prevention of dental caries in children younger than 5 years: screening and interventions.
JAMA. 2021; https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/pr...

Krol DM, Whelan K.
Maintaining and Improving the Oral Health of Young Children.
Pediatrics. 2023;151(1). PubMed abstract

Bright Futures.
Promoting oral health: implementation tip sheet.
Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition. 2020. / Full Text

American Academy of Pediatric Dentistry.
Antibiotic prophylaxis for dental patients at risk for infection.
The Reference Manual of Pediatric Dentistry.. 2022;Chicago, Ill:500-6. / Full Text

The American Academy of Pediatrics recommends oral health-related anticipatory guidance to start during prenatal visits and continue at every well-child visit to adulthood. Dental caries risk assessment, fluoride varnish, and fluoride supplement in the medical home start at the 6- and 9-month well-child checks, depending on tooth eruption. [American: 2023] Referral to a pediatric or general dentist should be made at the 6-month well-child visit, with follow-up monitoring at subsequent well-child visits to ensure a dental home is established and utilized.

A caries risk assessment is recommended during the well-child visit if a dental home is not established or utilized for regular preventive check-ups. [Centers: 2004] The Oral Health Risk Assessment Tool (AAP) ( 302 KB) provides a brief questionnaire about risk factors, protective factors, and clinical findings (photos are included for reference) to establish an action plan and self-management goals.

For children who receive oral health screening from programs like Early Intervention, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), or Early Head Start, medical homes may choose to limit screening to questions about feeding problems, but should continue with anticipatory guidance including feeding habits. (Listings for these programs can be found below under Referrals and Services.)

Primary care clinicians can help prevent dental-related diseases in children by providing anticipatory guidance to parents, guardians, families, and children. [Clinical: 2016] Oral health anticipatory guidance starts at prenatal visits and continues through adulthood.

Common guidance includes:

• Wipe the infant's gums and tongue with a wet cloth after feeding.
• Brush your child's teeth twice daily using fluoride toothpaste.
  • Once teeth erupt, all children <3 years old should use a smear of fluoride toothpaste (about the size of a grain of rice), and older children should use a pea-sized amount.
  • Children need help brushing their teeth until they can do it well enough by themselves (usually about 8 years old).
• Floss daily.
• All family members should see a dentist twice a year for preventive care and cleaning, including professional cleaning.
• Bottles and sippy cups should not be propped or left with infants when caregivers are not actively feeding the child.
• Once teeth erupt, avoid nursing or feeding at night because the milk remaining in the mouth can lead to caries. The caregiver can offer water if the older infant or child is thirsty at night.
• Wean from bottle feeding by age 12 months.
• Discourage thumb-sucking after age 4 or 5 years.
• Provide healthy snacks (e.g., cheese, fruit, and vegetables).
• Prevent frequent snacking on sugar- and carbohydrate-containing foods.
• Minimize juice consumption to 0-6 ounces per day of 100% fruit juice; avoid soda, energy drinks, and other sweetened beverages.
• Drink and cook with fluoridated tap water if available.
• Consider fluoride mouthwash for children ≥6 years old. [Council: 2013]

For older children, also discuss:

• Reducing or eliminating consumption of energy drinks and sweetened beverages
• Wearing a mouth guard during contact sports
• Detrimental effects of smoking/tobacco use
• Detrimental effects of illegal drugs, including methamphetamines
• Detrimental effects of oral piercings
• Oral-related infections, including the risk of sexually transmitted illnesses that can affect the lips, mouth, and throat

Fluoride acts in 3 important ways to prevent caries: 1) by strengthening enamel, 2) by remineralizing enamel, and 3) by affecting microbial metabolism and reducing acid production by cariogenic bacteria. Systemic, fluoride in water or by supplement, and topical fluoride applications are the primary sources of fluoride. [American: 2021]

The U.S. Preventive Services Task Force (USPSTF) recommends clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride (<0.6 ppm Fl) and that clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (Grade B). All children 5 years and younger deserve to have the application of fluoride varnish (5% sodium fluoride) as part of health maintenance and preventive care. Fluoride varnish application should be a covered benefit and separately paid service (i.e., not considered incidental to the office visit). [Clark: 2020]

Higher-risk children may require more frequent fluoride varnish. For example, consider more frequent topical fluoride applications in the medical home for children with uncontrolled gastric reflux, as this can increase sensitivity and erode enamel. The table below from [Clark: 2020] provides condensed recommendations for fluoride modalities in patients with low and high caries risk.

The medical home should talk with families about establishing a dental home by 12 months of age (and as early as 6 months of age). [American: 2005] A dental home is a primary care dental provider with a comprehensive and up-to-date approach for preventing dental problems, providing anticipatory guidance about dental issues and nutrition and behaviors that affect dental care, assessing for adequate fluoride and prescribing supplements when indicated, administering topical fluoride applications, assessing and treating dental issues, placing sealants for high-risk children, and referring to dental specialists as needed for surgery or orthodontics. [EQIPP: 2017] The primary care clinician should assist parents with identifying an appropriate pediatric or general dentist office, keeping in mind the child’s age, health conditions, and behavior. The dental office’s participation with dental insurance carriers varies greatly and should be considered when making a referral.

Early Intervention for Children with Disabilities/Delays (see RI providers [13])
Early intervention (EI) are services provided through a family coaching method to help children with disabilities or delays meet goals in areas of development.

WIC Assistance (see RI providers [13])
Provides nutrition and breastfeeding services and supplemental foods to pregnant women, mothers, infants, and children up to their 5th birthday.

Head Start/Early Head Start (see RI providers [18])
Head Start provides comprehensive education, health, nutrition, and family services to poverty-level children and their families. Local grantees receive federal funding for Head Start (HS), Migrant/Seasonal Head Start (MSHS), and Early Head Start (EHS) programs, the latter serving children from birth to age three and expectant mothers.

Healthcare, Dental > … (see RI providers [66])
A directory of providers, addresses, and contact information.

Infective Endocarditis? (AHA)
A fact sheet about this condition and the importance of treatment; American Heart Association.