Oral Health

Well-child care often includes oral health assessments and interventions. The primary care clinician may also be involved with oral care when there is an unidentified source of fever or pain, especially in a non-verbal child, or when there are specific mouth complaints. Common oral health issues in all children include thrush in infants, tooth decay (40% of children ages 2-11 years), and dental injuries. These oral health issues can cause pain, increase the risk of systemic infections, affect eating habits, sleep, smiling, and social interactions, and have an impact on family finances. Additional dental and oral health challenges can occur in children and youth with special health care needs (CYSHCN).

This resource includes information about diagnosis and management of common oral health problems that occur in all children and adolescents with special health care needs. The related resource, Dental and Oral Health Screening, contains information for primary care clinicians about relevant screening and assessment, anticipatory guidance, indications for fluoride supplements, and in-office application of varnishes when indicated.

CPT Coding
99188, Application of topical fluoride varnish by a physician or other qualified health care professional

For a detailed list of additional codes, see Coding Fact Sheets (AAP) and select "Oral Health."

Oral Health Problems in CYSHCN

Compared to other patients, CYSHCN may face additional oral health challenges related to:

  • Inability to perform self-care
  • Medical devices that impact oral health
  • Medications that have adverse effects on oral health
  • Seizures
  • ADHD
  • Gingival hyperplasia
  • Overcrowding of teeth or malocclusion
  • Oral aversions from previous medical procedures or sensory defensiveness
  • Xerostomia (dry mouth)
  • Dietary factors
  • Gastroesophageal reflux disease or vomiting
  • Enamel hypoplasia (particularly in premature infants)
  • Bruxism
  • Lack of access to dentists with appropriate skills

Physical Examination

Physical examination should include visual inspection of the mouth for:

  • Thrush
  • Tooth decay/white spot lesions
  • Gingivitis/gum disease
  • Abscesses
  • Tongue-tie or ankyloglossia
  • Tooth discoloration
  • Tongue plaques
  • Canker sores
  • Cold sores
  • Chipped teeth
  • Jaw pain
  • Halitosis
  • Tumors
  • Plaque build-up
  • Presence of prior fillings
  • Abnormal tooth eruption

Signs of normal and abnormal tooth eruption

  • Permanent teeth erupt in a pattern similar to that of the primary teeth.
  • The permanent teeth typically begin erupting between ages 5 and 7 years and finish by ages 13 to 14 years.
  • Although some infants develop natal or neonatal teeth, this type of eruption is uncommon.
  • Delayed tooth eruption in children >12 months old may be the result of a medical condition and should be evaluated. Referral is warranted if a child has no teeth by 18 months of age. [American: 2017]

Treatment & Management

The primary care clinician will usually treat common conditions affecting the tongue, cheeks, and lips. For most children, a general dentist provides care for most conditions affecting the teeth and gums. Encourage families to establish a dental home by 12 months of age (and as early as 6 months of age) and monitor for regular dental visits. [American: 2005] A dental home is a primary care dental provider with a comprehensive and up-to-date approach to pediatric dental care and referring to dental specialists as needed. [EQIPP: 2017]

A pediatric dentist has special training in meeting the needs of infants, children, and adolescents, particularly children with special health care needs who may have complex oral health challenges or who have a hard time cooperating with an oral exam or procedures. Rarely, an oral surgeon is required to provide care for severe conditions. When necessary, help the family select a pediatric dentist who can perform full sedation for evaluations and procedures. The primary care clinician can assist parents with dental insurance in identifying a dentist who is covered through their insurance plan.

Condition-Specific Guidance

Hematologic conditions: Children with bleeding disorders should be evaluated by a hematologist prior to dental procedures at risk for bleeding, such as tooth extraction.
Cardiac conditions: Primary care clinicians should follow advice from the child’s pediatric cardiologists regarding prophylaxis. The following are at highest risk and need consideration of antibiotic prophylaxis prior to invasive dental procedures:
  • Prosthetic cardiac valve
  • Previous infective endocarditis
  • Congenital heart disease (CHD) with one of the following:
    • Unrepaired cyanotic CHD, including palliative shunts and conduits
    • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
    • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device
  • Cardiac transplantation recipients who develop cardiac valvulopathy see all pediatric cardiology providers
Compromised immunity: Primary care clinicians should follow advice from the child’s pediatric specialists regarding antibiotic prophylaxis for procedures in these specific conditions. [Clinical: 2016]
  • Immune suppression (e.g., HIV/AIDS, SCIDS, neutropenia, undergoing chemotherapy or chronic use of steroids, or stem cell or solid organ transplant)
  • Autoimmune conditions (e.g., juvenile arthritis or lupus)
  • Sickle cell anemia or diabetes
  • Asplenia
  • Head and neck radiation
  • Bisphosphonate use
Vascular shunts for hydrocephalus: Primary care clinicians should follow advice from the child’s pediatric neurosurgeon regarding antibiotic prophylaxis for procedures for children with vascular shunts including ventriculo-atrial, -cardiac, or –venous, but not ventriculoperitoneal (lower risk).
Prosthetic joints and rods: Primary care clinicians should follow advice from the child’s pediatric specialists regarding prophylaxis in these specific conditions for those with a prosthetic joint or history of full joint replacement, Harrington rods (in the spine), or external fixation devices, or a history of a previous prosthetic joint infection. Highest risk patients for a hematogenous total joint infection include those with prosthetic joint replacement, previous prosthetic joint infection, inflammatory arthropathies (e.g., rheumatoid arthritis, systemic lupus erythematosus), megaprosthesis, hemophilia, malnourishment, and compromised immunity. [Clinical: 2016] Most patients with a history of orthopedic implants or joint surgery with indwelling components like pins, plates, or screws will not need antibiotic prophylaxis.

Topical Fluoride

For children who do not eat or drink by mouth, such as when exclusively tube-fed, the risk of tooth decay is very low to not existing. This is because there is no substrate (carbohydrate= food/drink) for the bacteria that cause decay. So regular fluoride application does not have a significant impact on reducing caries. Fluoride varnish does help with tooth sensitivity, so after a deep cleaning it is a good idea for the dentist to apply it. Consider topical fluoride application in the medical home for children who have uncontrolled gastric reflux as this can increase sensitivity and erode enamel.

Prophylactic Antibiotics

Patients usually do not need prophylactic antibiotics for minor dental procedures, such as routine anesthetic injections through non-infected tissue, dental radiographs, placement of removable prosthodontic or orthodontic appliances or brackets, shedding of primary teeth, and bleeding from trauma to the lips or oral mucosa. [Wilson: 2007] Keep in mind that most systemic infections in these patients are NOT due to dental procedures. Good oral hygiene is the primary prevention tool.

Consider prescribing prophylactic antibiotics (table, below) for certain invasive dental procedures (manipulation of the gingival tissue or the peri-apical tooth area, or perforation of the oral mucosa) to patients at highest risk from a distant site infection in the body. [Wilson: 2007] The primary care clinician should discuss with the family the potential benefits and risks (including developing resistant bacteria) of prophylactic antibiotics for patients with any of the conditions described in the section above.

Antibiotic Prophylactic Regimens for Dental Procedures

Antibiotic Prophylaxis Regimens for Dental Procedures
• IM indicates intramuscular; IV, intravenous. • * Or other first-or second-generation oral cephalosporin in equivalent adult or pediatric dosage. • † Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin. Source: 2007 Endocarditis Prophylaxis Wallet Card (AHA)

Recommendations and further information about population, procedures, specific antibiotics, dosing, and timing are detailed in the 2007 American Heart Association guidelines. [Wilson: 2007]

Access to Dental Care

Access to Care

Three children wearing tooth shirts while a fourth child pretends to brush one of them with an oversized toothbrush
Medicaid and the Children’s Health Insurance Program (CHIP) are major sources of coverage for pediatric dental care. [Paradise: 2012] The Affordable Care Act expanded insurance coverage of pediatric oral health services; however, there are still children who are unable to access oral health care.

States define what constitutes “medically necessary” oral health services for Medicaid recipients. [U.S.: 2017] Some state Medicaid programs provide enhanced payments when a modifier (EP) is applied to the claim for specific oral health services during well-child visits. For those families without dental insurance, the primary care clinician should provide information for a local, publicly funded, or charity-care dental office.


Practice Guidelines

Casamassimo P, Holt K.
Bright Futures: Oral Health—Pocket Guide, 3rd edition.
2016; 3rd. Washington, DC: National Maternal and Child Oral Health Resource Center.; https://www.brightfutures.org/oralhealth/about.html

Moyer VA.
Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
Pediatrics. 2014;133(6):1102-11. PubMed abstract / Full Text


Oral Health Pocket Guide (Bright Futures)
Anticipatory guidance information, risk assessment guides, a fluoride supplement chart, and tools for improving the oral health of children from before birth to young adulthood.

Oral Health Practice Tools (AAP)
Many tools in Spanish and English to help with setting up your practice to include oral health, applying fluoride varnish, performing a risk assessment and an oral exam, helping families find a dental home, and providing patient education; American Academy of Pediatrics.

Services for Patients & Families in Rhode Island (RI)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: June 2019; last update/revision: February 2020
Current Authors and Reviewers:
Author: Jennifer Goldman, MD, MRP, FAAP
Reviewer: Jeri Bullock, DDS

Page Bibliography

American Academy of Pediatric Dentistry Council on Clinical Affairs.
Policy on the dental home.
Pediatr Dent. 2005;27(7 Reference):18-9. PubMed abstract / Full Text

American Academy of Pediatrics.
Protecting All Children's Teeth (PACT): A Pediatric Oral Health Training Program.
(2017) https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/O.... Accessed on June 2019.

Casamassimo P, Holt K.
Bright Futures: Oral Health—Pocket Guide, 3rd edition.
2016; 3rd. Washington, DC: National Maternal and Child Oral Health Resource Center.; https://www.brightfutures.org/oralhealth/about.html

Clinical Affairs Committee.
Guideline on Antibiotic Prophylaxis for Dental Patients at Risk for Infection.
Pediatr Dent. 2016;38(6):328-333. PubMed abstract / Full Text

Oral Health Online Course.
2017; American Academy of Pediatrics; https://www.aap.org/EQIPP-Oral-Health-Best-Practices

Moyer VA.
Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
Pediatrics. 2014;133(6):1102-11. PubMed abstract / Full Text

Paradise J.
Children and oral health: assessing needs, coverage, and access.
Policy Brief. 2012; 7681-04. Washington, DC: Kaiser commission on medicaid and the uninsured; https://www.kff.org/disparities-policy/issue-brief/children-and-oral-h...

U.S. Department of Health & Human Services.
Does Medicaid Cover Dental Care.
(2017) https://www.hhs.gov/answers/medicare-and-medicaid/does-medicaid-cover-.... Accessed on June 2019.

Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT.
Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.
J Am Dent Assoc. 2007;138(6):739-45, 747-60. PubMed abstract