Bright Futures

in Practice:

ORAL HEALTH

Pocket Guide

Bright Futures in Practice: Oral Health

Pocket Guide

Paul Casamassimo, D.D.S.

Katrina Holt, M.P.H., M.S., R.D.

Editors

Supported by

Maternal and Child Health Bureau

Health Resources and Services Administration

U.S. Department of Health and Human Services

Published by

National Maternal and Child Oral Health Resource Center

Georgetown University
Cite as

Casamassimo P, Holt K, eds. 2004. Bright Futures in Practice: Oral Health—Pocket Guide. Washington, DC: National Maternal and Child

Oral Health Resource Center.

Bright Futures in Practice: Oral Health—Pocket Guide © 2004 by National Maternal and Child Oral Health Resource Center, Georgetown

University.

Library of Congress Control Number: 2004112811

This publication was made possible by grant number H47MC00048 and purchase order number 03-0271P from the Health Resources

and Services Administration’s (HRSA’s) Maternal and Child Health Bureau (MCHB) to Georgetown University. The publication was 

developed by the National Maternal and Child Oral Health Resource Center (OHRC) working in collaboration with the Bright Futures

Education Center. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S.

Department of Health and Human Services, HRSA, or MCHB.

An electronic copy of this publication is available from the OHRC Web site at http://www.mchoralhealth.org. Permission is given to

photocopy this publication. Requests for permission to use all or part of the information contained in this publication in other ways

should be sent to the address below. Those wishing to use materials not produced by OHRC that are included in this publication

must request permission from the original source.

National Maternal and Child Oral Health Resource Center

Georgetown University

Box 571272

Washington, DC 20057-1272

(202) 784-9771

(202) 784-9777 fax

E-mail: info@mchoralhealth.org

Web site: http://www.mchoralhealth.org
iii

Introduction........................................................... 1

Components of Oral Health Supervision.............. 7

Oral Health Supervision ...................................... 17

Pregnancy and Postpartum ................................... 18

Infancy .................................................................. 24

Early Childhood..................................................... 34

Middle Childhood ................................................. 46

Adolescence .......................................................... 58

Risk Assessment ................................................... 67

Risk Assessment Tables .......................................... 68

Caries-Risk Assessment Tool (CAT) ......................... 76

Appendices .......................................................... 81

Tooth Eruption Chart ............................................ 82

Systemic Fluoride Supplements: 

Recommended Dosage ...................................... 84

Glossary ................................................................ 85

Resources .............................................................. 88

TABLE OF CONTENTS

INTRODUCTION
2

INTRODUCTION

The Bright Futures project was initiated in

1990 by the Health Resources and Services

Administration’s (HRSA’s) Maternal and

Child Health Bureau (MCHB). The mission

of the Bright Futures project is to promote

and improve the health and well-being of

infants, children, and adolescents. This is

achieved through the development of educational materials and through fostering

partnerships. Bright Futures provides comprehensive, culturally effective, familycentered, community-based child health

supervision guidelines consistent with the

needs of families and health professionals.

The Bright Futures guidelines provide the

foundation for a coordinated series of educational materials for health professionals

and families.

Recognizing oral health as a vital component of health, HRSA’s MCHB sponsored the

development of Bright Futures in Practice:

Oral Health. The information contained in

Bright Futures in Practice: Oral Health—Pocket

Guide is excerpted from Bright Futures in

Practice: Oral Health, the cornerstone document Bright Futures: Guidelines for Health

Supervision of Infants, Children, and Adolescents, and other sources. The pocket guide

is designed to be a useful tool for a wide

array of health professionals including dentists, dental hygienists, physicians, physician

assistants, nurses, dietitians, and others to

address the oral health needs of infants,

children, and adolescents.

This pocket guide offers health professionals an overview of preventive oral

health supervision for five developmental

periods—pregnancy and postpartum,
3

infancy, early childhood, middle childhood,

and adolescence. Although age groupings

are designed to take advantage of naturally

occurring milestones, many oral health

issues cut across multiple developmental

periods. The information presented in the

pocket guide is intended as an overview

rather than as a comprehensive description

of pediatric oral health. The information

does not prescribe a specific regimen of

care but builds upon existing guidelines

and treatment protocols such as those recommended by the American Academy of

Pediatric Dentistry, the American Academy

of Pediatrics, the American Academy of

Family Physicians, and the American

Dietetic Association.

Optimal oral health for infants, children,

and adolescents can be achieved through

an effective partnership between families,

oral health professionals (e.g., dentists,

dental hygienists), and other health professionals (e.g., obstetricians/gynecologists, pediatricians, family physicians,

physician assistants, nurse practitioners,

nurses, dietitians). Health professionals

need to help families understand the 
4

causes of oral disease, especially tooth

decay, and how to reduce or prevent oral

disease and injury in their infants, children, and adolescents.

Resistance to tooth decay in infants, children, and adolescents is determined partly

by physiology and partly by behaviors.

The younger the child when tooth decay

begins, the greater the risk of future

decay. Therefore, delaying the onset of

tooth decay may reduce long-term risk for

decay. For this reason, the time to begin

preventing oral disease, especially tooth

decay, is when teeth begin to erupt.

The first oral examination should occur

within 6 months of the eruption of the first

primary tooth, and no later than age 12

months. Thereafter the child or adolescent

should be seen according to a schedule

recommended by the dentist, based on the

child’s or adolescent’s individual needs and

susceptibility to disease.

When an oral examination by a dentist is

not possible, an infant should begin to

receive oral health risk assessments by age

6 months by a pediatrician or other qualified health professional. Infants within one

of the risk groups listed below should be

entered into an aggressive anticipatory

guidance and intervention program administered by a dentist as soon as possible. Risk

groups are as follows:

• Infants with special health care needs

• Infants of mothers with a high rate of

tooth decay

• Infants with demonstrable tooth decay,

plaque, demineralization, and/or 

staining

• Infants who sleep with a bottle
5

• Late-order offspring

• Infants from families of low socioeconomic status

All infants, children, and adolescents need

a dental home. A dental home is a comprehensive, continuously accessible, and

affordable source of oral health care under

the supervision of a dentist. The first visit

establishes the dental home. This visit presents an opportunity to implement preventive health practices and reduce the risk for

preventable oral disease.

A dental home should be able to provide

the following:

• An accurate risk assessment for oral diseases and conditions

• An individualized preventive dental

health program based on risk assessment

• Anticipatory guidance about growth and

development issues (e.g., teething;

thumb, finger, or pacifier habits; feeding

practices)

• A plan for emergency dental trauma

management

• Information about proper care of teeth

and oral soft tissues

• Information about proper nutrition and

dietary practices

• Comprehensive oral health care in accordance with accepted guidelines and

periodicity schedules for pediatric oral

health

• Referrals to other dental specialists, such

as endodontists, oral surgeons, orthodontists, and periodontists, when care

cannot be provided directly within the

dental home
6

If the infant, child, or adolescent does

not have a dental home, help parents find

a source of care by doing the following:

• Provide a referral to a dentist in your

community. Contact your state or local

pediatric dental society or dental society

or pertinent national organizations for a

list of such dentists. The following

national organizations may be helpful in

locating dentists:

American Academy of Pediatric Dentistry

211 East Chicago Avenue, Suite 700

Chicago, IL 60611-2663

(312) 337-2169

To find a pediatric dentist:

http://www.aapd.org/finddentist

American Dental Association

211 East Chicago Avenue

Chicago, IL 60611-2678

(312) 440-2500

http://www.ada.org

To find a dentist:

http://www.ada.org/public/disclaimer.asp

• Work with local agencies to determine an

infant’s, child’s, or adolescent’s eligibility

for public assistance programs such as

Medicaid or the State Children’s Health

Insurance Program or other source of

funding for oral health care, and help

families enroll in these programs or

obtain such funding.
COMPONENTS OF ORAL HEALTH SUPERVISION
8

Optimal oral health supervision for infants, children, and adolescents should contain

the following components:

Components of Oral Health Supervision Provided by Oral Provided by Other 

Health Professionals Health Professionals

Family preparation ✔ ✔

Interview questions ✔ ✔

Risk assessment ✔ ✔

Screening, including recognizing and reporting of ✔ ✔

suspected child abuse/neglect

Examination, including periodontal assessment ✔

and treatment for oral disease and injury

Preventive procedures (application of dental sealants ✔ ✔

or topical fluoride varnishes, gels, or foams) as 

approved by state practice acts or regulations

Anticipatory guidance ✔ ✔

Measurable outcomes ✔ ✔

Referrals, as needed ✔ ✔

COMPONENTS OF ORAL HEALTH SUPERVISION
9

Family Preparation

Just as health professionals prepare for

oral health supervision, families need to

prepare, too. Families can gather health

information, prepare questions, and complete forms in anticipation of the visit. This

step is an essential component of oral

health supervision, and health professionals should give the family information

about how to prepare.

Interview Questions

The interview addresses key issues (e.g.,

oral development, teething/tooth eruption, oral hygiene, feeding and eating

practices, exposure to fluoride, and injury

prevention) during the health supervision

visit. The interview needs to pick up information from previous health supervision

visits as well as to address current issues

specific to the age and development of

the infant, child, or adolescent. Health

professionals need to assess whether the

child, adolescent, or family has assumed

personal responsibility for oral health and

demonstrates mastery and consistent use

of preventive oral health care techniques.

As the child, and later the adolescent,

becomes more responsible, health professionals should discuss these issues directly

with the child or adolescent.

Risk Assessment

Risk assessment, which can be conducted

by oral health and other health professionals, is based on the premise that not all

infants, children, and adolescents are

equally likely to develop oral health problems. Thus, individuals at high risk for
10

tooth decay likely need more, and more

complex, preventive oral health care and

treatment than those at lower risk. Oral

health risk assessment involves identifying

an individual’s risk or protective factors

that may impact oral health. Use the tables

shown on pages 68–75 to assess the

infant’s, child’s, or adolescent’s risk and

protective factors for oral health issues.

Health professionals may refer to the

Caries-Risk Assessment Tool (CAT) developed by the American Academy of

Pediatric Dentistry to assist in classifying

risk of tooth decay in infants, children,

and adolescents based on environmental,

physical, and overall health factors (see

Caries-Risk Assessment Tool [CAT] on

pages 76–79).
11

Screening

Health professionals can perform a

screening of the lips, tongue, teeth, gums,

inside of the cheeks, and roof of the

mouth to identify oral disease, especially

tooth decay, or other oral conditions (e.g.,

delayed tooth eruption or premature tooth

loss, abscesses, trauma) and to provide

guidance for management. An oral health

screening takes only 2 or 3 minutes.

Screenings are not examinations and do

not involve making diagnoses that lead to

treatment plans. Only an oral health professional (a dentist or a dental hygienist

who is qualified according to state practice

acts or regulations to perform preliminary

examinations) has the education, training,

and tools needed to conduct oral health

examinations.

A dental chair is not needed to perform a

screening. For infants and children under

age 3, the health professional and the parent should sit face to face with their knees

touching, with the child placed in the

health professional’s and the parent’s lap.

The child’s head should be nestled securely

against the health professional’s abdomen,

with the child facing the parent. By age 3,

children are able to lie flat on an examination table or to sit in front of the parent,

with both the child and the parent facing

the health professional so that the parent

can help position and steady the child. For

older children and adolescents, the parent’s assistance is not necessary.

With a gloved hand, the health professional lifts the lip, views and feels the soft

tissues, and views the teeth and the entire
12

mouth. Almost any type of lighting, such

as a flashlight, a portable gooseneck lamp,

an examination light, or a headlamp, will

work for a screening. A tongue depressor

or toothbrush can be used to move the

tongue and view the teeth. A dental mirror

or other similar-sized mirror can make it

easier to see behind the teeth and to perform a more thorough screening, but such

a mirror is not necessary.

When performing the oral health screening, health professionals should

• Note whether the infant, child, or adolescent is currently in pain or has an abscess

on the gums above or below the teeth.

An abscess may look like a “gum boil”

and may or may not have localized or

generalized swelling with or without pus

draining from the area. If the infant,

child, or adolescent is in pain or has an

abscess, refer to a dentist immediately.

• Check whether tooth eruption and loss

are proceeding according to schedule (see

Tooth Eruption Chart on pages 82–83).

• Check the teeth for plaque and food

debris.

• Note whether any teeth appear to have

unusual color or shape.

• Note whether any teeth have untreated

decay. Tooth decay may occur on any

tooth surface. Tooth decay initially

appears as a chalky white area on the

enamel. More advanced tooth decay

appears as cavities or stains. When decay

is observed, refer the infant, child, or

adolescent to a dentist. Discolored teeth

may be difficult to attribute to tooth

decay. When in doubt, refer to a dentist.
13

• Note whether any dental trauma has

occurred. If the teeth are prematurely

missing, refer the infant, child, or adolescent to a dentist for space management.

If trauma may be the result of physical

abuse, record observations and call the

local social service agency.

Health professionals should document

oral health history, clinical findings, and

recommended follow-up in the infant’s,

child’s, or adolescent’s permanent health

record.

Examination

An oral examination includes a complete

clinical oral assessment and appropriate

diagnostic testing, including x-rays and

other tests. The examination also includes

an assessment of the infant’s, child’s, or

adolescent’s risk for developing oral 

diseases and a

determination

of an appropriate prevention

plan and interval for periodic

reevaluation

based on that

assessment. If

stains or other

deposits are

present, they

may be removed by the dentist or dental

hygienist. Another appointment will be

scheduled if other treatment needs exist.

Preventive Procedures

Health professionals, as approved by

state practice acts or regulations, can

assess the infant’s, child’s, or adolescent’s
14

exposure to systemic and topical fluoride,

apply dental sealants or topical fluoride

(e.g., varnishes, gels, foams), and prescribe

systemic fluoride supplements, if indicated.

Anticipatory Guidance

Anticipatory guidance refers to the key

information (e.g., about oral development, teething and tooth eruption, oral

hygiene, feeding and eating practices,

exposure to fluoride, and injury prevention) provided to the family about the

infant’s, child’s, or adolescent’s current

oral health and what to expect during the

next developmental stage. The guidance

should be modified based on risk assessment responses. When providing anticipatory guidance, health professionals are

encouraged to discuss age-related risk and

protective factors. Working in partnership

with the family, health professionals can

be remarkably effective in promoting

health. Creating opportunities for

thoughtful dialogue between families and

health professionals is one of the most
15

effective ways to establish trust and build

a partnership that promotes health and

prevents illness or injury. Older children

and adolescents, as they mature, should

actively participate in the health partnership and should assume increasing responsibility for their own health.

Measurable Outcomes

The success of oral health supervision can

be measured by whether the parent(s),

infant, child, or adolescent has achieved 

certain outcomes. In quality assurance, outcomes are important measurable health

indicators that both health professionals and

families can identify and track. Outcomes

also help oral health professionals determine

the necessary periodicity for subsequent 

visits and help health professionals provide

anticipatory guidance. Examples of outcomes are (1) good oral hygiene as measured by a periodic plaque score, (2) the

absence of tooth decay, (3) obtaining and

using prescribed fluoride, and (4) using a

mouth guard during sports.

Referrals

Because infants, children, and adolescents often do not visit an oral health professional on a regular basis, it is critical

that other health professionals who have

frequent contact with infants, children,

and adolescents be able to help prevent or

reduce the risk of oral disease, especially

tooth decay, and to provide referrals to a

dentist for intervention and/or treatment.

Conversely, oral health professionals may

be the “first line” in assessing the overall

health and well-being of infants, children,

and adolescents. Oral health professionals
16

can make referrals to other health professionals and can reinforce preventive messages about developmental milestones,

nutrition, non-nutritive sucking, injury, and

other health issues such as tobacco use.
ORAL HEALTH SUPERVISION
18

PREGNANCY AND 

POSTPARTUM

Health professionals should select the

information in this section that is most

appropriate, using clinical judgment to

decide what is timely and relevant for

each individual pregnant woman or new

mother (or other intimate caregiver).

Family Preparation

To help prepare families for oral health

supervision visits, health professionals can

provide pregnant women and new mothers (or other intimate caregivers) with a list

of topics to discuss at the next visit. Topics

may include the following:

• Changes in the teeth or the gums

• Oral hygiene practices (frequency, 

problems)

• Use of fluoridated water for drinking and

cooking

• Fluoride use (fluoridated toothpaste)

• Eating practices

• Illnesses or infections

• Use of medications (over the counter and

prescription)

PREGNANCY AND POSTPARTUM
19

Interview Questions

Following are examples of questions that

health professionals may use to ask pregnant women and new mothers (or other

intimate caregivers) during the first 30

months of the child’s life. In addition to asking these or other interview questions, discuss any issues or concerns the family has.

• Are you brushing and flossing regularly?

• Do you know the fluoride status of your

drinking water?

• Have you had any problems with your

gums or teeth?

• Do you have any problems with your gums

or teeth?

• Does your family have any inherited 

problems/diseases affecting the teeth?

• As your child grows up, do you think you

can help your child prevent tooth decay?

What kinds of things do you want to do to

protect your child’s teeth?

Examination

Pregnant women and new mothers (or

other intimate caregivers) should be seen

according to a schedule recommended by

the dentist, based on the individual’s needs

or susceptibility to disease.

Anticipatory Guidance

Discuss with Pregnant Women and

New Mothers (or Other Intimate

Caregivers):

Oral Hygiene

• Brushing teeth thoroughly twice a day

(after breakfast and before bed) with

fluoridated toothpaste, and flossing

daily. Spitting out the toothpaste after

PREGNANCY AND POSTPARTUM
20

brushing, but not rinsing with water.

The small amount of fluoridated toothpaste that remains in the mouth helps

prevent tooth decay.

• Rinsing every night with an alcohol-free

over-the-counter fluoridated mouth rinse.

• Using certain over-the-counter and 

prescription medications can decrease

salivary flow and increase risk for dental

caries and gingivitis.

• Visiting a dentist for an examination and

restoration of all active decay as soon as

feasible. Hormonal changes (increases in

estrogen and progesterone) that occur

during pregnancy can increase a

woman’s risk for developing gingivitis.

With gingivitis, the gums become

inflamed, swollen, and sensitive and

tend to bleed.

Nutrition

• Eating healthy foods such as fruit, vegetables, grain products (especially whole

grain), and dairy products (milk, cheese,

cottage cheese, and unsweetened

yogurt) during meals and snacks. Limit

eating (grazing) in between.

• Eating foods containing sugar at mealtimes only, and limiting the amount.

Frequent consumption of foods high in

sugar, such as candy, cookies, cake,

sweetened beverages (e.g., fruit drinks,

soda), and fruit juice, increases the risk

for tooth decay. In addition, frequent

consumption of foods that easily adhere

to the tooth surface, such as dried fruit,

fruit roll-ups, and candy, increases the

risk for tooth decay. When checking for

sugar, looking beyond the sugar bowl

PREGNANCY AND POSTPARTUM
21

and candy dish. A variety of foods contain one or more types of sugar, and all

types of sugars can promote tooth

decay.

• Choosing fruit rather than fruit juice.

Drinking fruit juice at mealtimes only, if

at all.

• Avoiding carbonated beverages during

pregnancy and for the first 30 months of

the infant’s life.

• Drinking fluoridated water (via a community fluoridated water source) to prevent tooth decay; for families that prefer

bottled water, drinking a brand in which

fluoride is added at a concentration of

approximately 0.7 to 1.2 mg/L (ppm) is

recommended.

• Once the infant is born, avoiding testing

the temperature of the bottle with the

mouth, sharing utensils (e.g., spoons),

or orally cleaning a pacifier or a bottle

nipple. This practice helps prevent transmission of bacteria that cause tooth

PREGNANCY AND POSTPARTUM
22

decay from the parent, especially the

mother, to the child via saliva.

Injury Prevention

• Wearing a safety belt while riding or

driving in a vehicle. If you are driving,

insisting that your passengers also wear

safety belts.

• Wearing protective gear (e.g., mouth

guard, face protector, helmet) when participating in physical activities or sports

that could potentially result in injuries to

the mouth, such as biking or playing

baseball or soccer.

• Avoiding oral piercings, which can damage teeth and gums.

Substance Use

• Not smoking cigarettes or using spit

tobacco.

PREGNANCY AND POSTPARTUM
23

Outcomes • Pregnant women and new mothers (or

other intimate caregivers) are under the

care of an oral health professional.

• Pregnant women and new mothers (or

other intimate caregivers) are informed

of preventive dentistry and oral development issues.

• Pregnant women and new mothers (or

other intimate caregivers) understand

and practice good oral hygiene and eating behaviors.

• Pregnant women and new mothers (or

other intimate caregivers) have no oral

disease or injury.

PREGNANCY AND POSTPARTUM
INFANCY

Health professionals should select the

information in this section that is most

appropriate, using clinical judgment to

decide what is timely and relevant for

each individual infant and family.

Family Preparation

To help prepare families for oral health

supervision visits, health professionals can

provide parents with a list of topics to discuss at the next visit. Topics may include

the following:

• Changes in the teeth and the mouth

• Oral hygiene practices (frequency, problems)

• Use of fluoridated water for drinking, 

cooking, or formula preparation

• Fluoride use (fluoridated toothpaste, 

fluoride supplements)

• Use of bottle or cup by infant

• Feeding practices

24

INFANCY • 0–11 MONTHS
• Non-nutritive sucking (pacifier, thumb, 

finger)

• Illnesses or infections

• Medications

• Injuries to the teeth or the mouth

• Use of tobacco by parents

Interview Questions

Following are examples of questions that

health professionals may use. In addition

to asking these or other interview questions, discuss any issues or concerns the

family has.

• Does Felicity have any teeth?

• Do you clean Alexander’s gums and teeth?

How do you do that? How has this been

going?

• Do you use toothpaste?

• Are you breastfeeding, bottle feeding, or

both? How is feeding going?

• How well does Julia fall asleep? Do you

give her a bottle in bed?

• Does Thomas use a pacifier? Does he suck

his thumb or finger?

• Do you put Celeste in a safety seat when

she rides in a vehicle?

• Do you have a family dentist? Did you see

a dentist during your pregnancy?

• Has Carlos been to the dentist? Does he

have a dental home? If not, have you

made an appointment for his first dental

visit?

• Has Natalie been to a health professional?

If not, have you made an appointment for

her first health supervision visit?

25

INFANCY • 0–11 MONTHS
Risk Assessment

Use the tables and tool shown on pages

68–79 to assess the infant’s risk and protective factors for oral health issues.

Screening

Visually inspect the lips, tongue, teeth,

gums, inside of the cheeks, and roof of

the mouth (see pages 11–13).

Examination

The first oral examination should occur

within 6 months of the eruption of the

first primary tooth, and no later than age

12 months.

26

INFANCY • 0–11 MONTHS
Anticipatory Guidance

Discuss with Parents:

Oral Hygiene

• Making an appointment for the infant’s

first oral examination within 6 months of

the eruption of the first primary tooth,

and no later than age 12 months, thereby establishing a dental home.

• After the initial dental visit, making the

next appointment for the infant according

to the schedule recommended by the

dentist, based on the infant’s individual

needs or susceptibility to disease.

• For infants with special health care

needs, making appointments for more

frequent dental visits as directed by the

dentist based on the infant’s needs or

susceptibility to disease. Obtaining 

special oral health equipment (e.g., a

mouth prop) to brush the infant’s teeth.

• Cleaning the infant’s gums with a clean

damp cloth or toothbrush and plain water

after each feeding. Using a soft-bristled

toothbrush with a small head, preferably

one designed specifically for infants.

• Brushing the infant’s teeth as soon as the

first tooth erupts, usually around age 6

to 10 months, twice a day (after breakfast and before bed). Using a soft-bristled

toothbrush with a small head, preferably

one designed specifically for infants, and

plain water. Lifting the lip to brush at the

gum line and behind the teeth. Not giving the infant anything to eat or drink

(except water) after brushing at night.

• For infants at increased risk for tooth

decay, consulting with a dentist or 

27

INFANCY • 0–11 MONTHS
physician about brushing their teeth

with fluoridated toothpaste.

• Becoming familiar with the normal

appearance of the infant’s gums and

teeth so that problems can be identified

if they occur (see Tooth Eruption Chart

on pages 82–83). Checking the infant’s

gums and teeth about once a month by

lifting the infant’s lip to look for decay

on the outside and inside surfaces of the

teeth.

• Giving the infant age 6 months or older

fluoride supplements only as recommended by a dentist or physician based

on the infant’s risk for developing tooth

decay and the known level of fluoride in

the infant’s drinking water (see Systemic

Fluoride Supplements: Recommended

Dosage on page 84).

• If the infant has sore gums caused by

tooth eruption, giving the infant a clean

teething ring, cool spoon, or cold wet

washcloth. Other options include giving

the infant a chilled teething ring or simply rubbing the infant’s gums with a

clean finger.

Nutrition

• Breastfeeding the infant exclusively for

approximately the first 6 months of life

and continuing to breastfeed until age

12 months or as long as the mother and

infant wish to continue.

• For mothers who cannot breastfeed or

choose not to breastfeed, feeding the

infant a prepared infant formula. No

additional nutrients are needed.

• Avoiding testing the temperature of the

bottle with the mouth, sharing utensils

28

INFANCY • 0–11 MONTHS
(e.g., spoons), or orally cleaning a pacifier or a bottle nipple. This practice helps

prevent transmission of bacteria that

cause tooth decay from the parent,

especially the mother, to the child via

saliva.

• Not putting the infant to sleep with a

bottle or sippy cup or allowing frequent

and prolonged bottle feedings or use of

sippy cups containing beverages high in

sugar (e.g., fruit drinks, soda, fruit juice),

milk, or formula during the day or at

night to prevent sugary fluids from pooling around the teeth, which can increase

the infant’s risk for tooth decay.

• Holding the infant while feeding. Making

sure to never prop a bottle (that is, use

pillows or any other objects to hold a

bottle in the infant’s mouth).

• Never adding cereal to a bottle. This

causes sugary fluids to pool around the

teeth. Feeding the infant solid foods

with a spoon or fork, or, once the infant

is able, encouraging self-feeding.

• Introducing a small cup when the infant

can sit up without support.

• Weaning the infant from the bottle as

the infant begins to eat more solid foods

and drink from a cup. Beginning to wean

the infant gradually, at about age 9 to 10

months. By age 12 to 14 months, most

infants can drink from a cup.

• Not introducing juice into infants’ diets

before age 6 months. Serving the infant

juice in a cup, and limiting juice to 4 to

6 oz per day. Serving 100-percent fruit

juice or reconstituted juice.

29

INFANCY • 0–11 MONTHS
• For infants ages 6 months and older,

serving age-appropriate healthy foods

during planned meals and snacks, and

limiting eating (grazing) in between.

• Serving foods containing sugar at mealtimes only (not between meals), and

limiting the amount. Frequent consumption of foods high in sugar, such as

candy, cookies, cake, sweetened beverages (e.g., fruit drinks, soda), and fruit

juice, increases the risk for tooth decay.

In addition, frequent consumption of

foods that easily adhere to the tooth surface, such as fruit-roll-ups and candy,

increases the risk for tooth decay. When

checking for sugar, looking beyond the

sugar bowl and candy dish. A variety of

foods contain one or more types of

sugar, and all types of sugars can promote tooth decay.

• Drinking fluoridated water (via a community fluoridated water source) to prevent tooth decay; for families that prefer

bottled water, drinking a brand in which

fluoride is added at a concentration of

approximately 0.7 to 1.2 mg/L (ppm) is

recommended.

Non-Nutritive Sucking

Sucking is a natural reflex for infants.

Most infants require some amount of additional sucking beyond that needed for

nourishment. This type of sucking, known

as non-nutritive sucking, provides emotional benefits, enabling the infant to calm himself/herself and focus attention. If parents

choose to have their infant suck a pacifier,

health professionals can advise them to

take certain safety precautions. The following precautions are recommended:

30

INFANCY • 0–11 MONTHS
• Never attaching a pacifier to a ribbon or

string around the infant’s neck.

• Making sure the pacifier is of sturdy,

one-piece construction and that the

material is flexible, firm, and not brittle.

• Keeping the pacifier clean.

• Not dipping a pacifier in sweetened

foods (e.g., sugar, honey, syrup) to

encourage sucking.

• Never orally cleaning a pacifier before

giving it to an infant.

Injury Prevention

• Being aware that injuries to the head,

face, and mouth are common among

infants.

• Learning how to prevent oral injuries

and how to handle oral emergencies.

Because of the danger of damaging the

underlying permanent teeth, never

attempting to reinsert an avulsed (lost)

primary tooth. It is impossible to relocate the tooth accurately, and there is

danger of pushing it too far into the soft

alveolar bone.

• Always keeping one hand on an infant

on high places such as changing tables,

beds, sofas, or chairs.

• Using a rear-facing infant-only or convertible car safety seat that is reclined at

the angle specified by the manufacturer

in the back seat of the vehicle at all

times. Infants should ride rear facing

until they are at least age 1 and weigh

at least 20 lbs. Most infant-only car safety seats accommodate infants up to 20

to 22 lbs, and many convertible seats

allow infants up to 33 to 35 lbs to ride

rear facing.

31

INFANCY • 0–11 MONTHS
• Not placing an infant at any age in a

shopping cart. Instead, consider using a

stroller or a backpack or frontpack while

shopping with an infant.

• Using safety locks on cabinets. Keeping

all poisonous substances, medicines,

cleaning agents, health and beauty aids,

and paints and paint solvents locked in a

safe place.

• Keeping pet food and dishes out of

reach. Not permitting the infant to

approach the pet while it is eating.

• Keeping appliances and dangling telephone, electric, blind, and drapery cords

out of reach.

• Locking doors or using safety gates at

the top and bottom of stairs, and using

safety locks and safety devices on windows above the ground floor.

• Supervising the infant on the stairs or

furniture.

• Not giving toys small enough to be

placed in the mouth. Making sure that

toys do not have parts that can become

detached. Keeping toys with small parts

or sharp edges out of reach.

• Making sure that playgrounds are carefully maintained and that equipment is

in good condition. All playground equipment should be surrounded by a soft

surface (e.g., fine, loose sand; wood

chips; wood mulch) or by rubber mats

manufactured for this use. 

• Supervising the infant on playground

equipment. Making sure infants play

only on developmentally appropriate

equipment.

32

INFANCY • 0–11 MONTHS
• Making sure that toys are soft (e.g., balls

not made with leather or hard materials).

• Not using an infant walker with wheels.

• Providing the infant’s caregivers with the

dentist’s emergency phone contacts,

and ensuring that the caregivers know

how to handle all emergencies.

Outcomes

• Parents and infant are under the care of

an oral health professional.

• Parents are informed of oral development

issues.

• Parents understand and practice good

oral hygiene, feeding, and eating 

behaviors.

• Parents establish a safe environment and

practice safety behaviors.

• Infant has no oral disease or injury.

33

INFANCY • 0–11 MONTHS
EARLY CHILDHOOD

Health professionals should select the

information in this section that is most

appropriate, using clinical judgment to

decide what is timely and relevant for

each individual child and family.

Family Preparation

To help prepare families for oral health

supervision visits, health professionals can

provide parents with a list of topics to discuss at the next visit. Topics may include 

the following:

• Changes in the teeth and the mouth

• Oral hygiene practices (frequency, 

problems)

• Use of fluoridated water for drinking,

cooking, or formula preparation

• Fluoride use (fluoridated toothpaste, 

fluoride supplements)

• Use of bottle or cup by child

• Feeding and eating practices

34

EARLY CHILDHOOD • 1–4 YEARS
• Non-nutritive sucking (pacifier, thumb,

finger)

• Illnesses or infections

• Medications

• Injuries to the teeth or the mouth

• Use of tobacco by parents

Interview Questions

Following are examples of questions that

health professionals may use. In addition to

asking these or other interview questions,

discuss any issues or concerns the family has.

• Do you help Lynne with brushing her

teeth? How has this been going?

• Does Jon’s brother have fillings? Have

you had any problems with your own

teeth?

• Are you using fluoridated toothpaste on

Benita’s teeth?

• Does Benita drink from a cup? Does she

take a bottle?

• How often does Marcos snack? What

does he usually eat?

• Does Marie use a pacifier? Does she suck

her thumb or finger?

• What would you do if Kevin knocked out

one of his teeth?

• Has Carlos been to the dentist? Does he

have a dental home? If not, have you

made an appointment for his first dental

visit?

• When was Tracy’s last visit to a health

professional? Is it time for her next

health supervision visit?

35

EARLY CHILDHOOD • 1–4 YEARS
Risk Assessment

Use the tables and tool shown on pages

68–79 to assess the child’s risk and protective factors for oral health issues.

Screening

Visually inspect the lips, tongue, teeth,

gums, inside of the cheeks, and roof of

the mouth (see pages 11–13).

Examination

The first oral examination should occur

within 6 months of the eruption of the

first primary tooth, and no later than age

12 months. Thereafter the child should be

seen according to a schedule recommended by the dentist, based on the child’s

individual needs and susceptibility to 

disease.

Anticipatory Guidance

Discuss with Parents:

Oral Hygiene

• If the child has not yet been to a dentist,

making an appointment for the child’s

first dental visit, thereby establishing a

dental home.

• After the initial dental visit, making the

next appointment for the child according to the schedule recommended by

the dentist, based on the child’s 

individual needs or susceptibility to 

disease.

• For children with special health care

needs, making appointments for more

frequent dental visits based on the

child’s individual needs or susceptibility

to disease. Obtaining special oral health

36

EARLY CHILDHOOD • 1–4 YEARS
equipment (e.g., a mouth prop) to

brush the child’s teeth.

• For children under age 2, brushing the

teeth with plain water twice a day (after

breakfast and before bed). For children

at increased risk for tooth decay, consulting with a dentist or physician about

brushing the teeth with a pea-sized

amount (small smear) of fluoridated

toothpaste.

• For children ages 2 and above, brushing

the teeth with no more than a pea-sized

amount (small smear) of fluoridated

toothpaste twice a day (after breakfast

and before bed). Making sure the child

spits out the toothpaste after brushing,

but does not rinse with water. The small

amount of fluoridated toothpaste that

remains in the mouth helps prevent

tooth decay.

• For effective plaque removal, making sure

that a parent brushes the child’s teeth.

Because brushing requires good fine

motor control, young children cannot

clean their teeth without parental help.

After children acquire fine motor skills

(e.g., the ability to tie their shoelaces),

typically by age 7 or 8, they can clean

their teeth effectively but should be

supervised by a parent.

• Becoming familiar with the normal

appearance of your child’s gums and

teeth so that problems can be identified

if they occur (see Tooth Eruption Chart

on pages 82–83). Checking the child’s

gums and teeth about once a month.

• Giving the child fluoride supplements

only as prescribed by a dentist or physician, based on the risk of developing

tooth decay and the known level of 37

EARLY CHILDHOOD • 1–4 YEARS
fluoride in the child’s drinking water (see

Systemic Fluoride Supplements: Recommended Dosage on page 84).

• Discussing with a dentist or other qualified health professional the need to

apply fluoride topically (via varnishes,

gels, foams), which renews the high levels of fluoride in the outer layer of the

tooth enamel. Topical fluoride may be

especially effective for children at high

risk for tooth decay because they have a

history of decay, are not exposed to

fluoridated water, snack frequently on

foods containing sugar, or have a medical

problem that decreases their resistance

to decay.

• Discussing with a dentist or other qualified health professional the need to

apply dental sealants (thin plastic coatings applied to pits and fissures on the

chewing surfaces of the teeth) to prevent

tooth decay by creating a physical barrier against dental plaque. Dental sealants

should be applied shortly after the teeth

erupt.

• If the child has sore gums caused by

tooth eruption, giving the child a clean

teething ring, cool spoon, or cold wet

washcloth. Other options include giving

38

EARLY CHILDHOOD • 1–4 YEARS
the child a chilled teething ring or simply rubbing the child’s gums with a

clean finger.

Nutrition

• Avoiding sharing utensils (e.g., spoons)

or orally cleaning a pacifier or a bottle

nipple. This practice helps prevent transmission of bacteria that cause tooth

decay from the parent, especially the

mother, to the child via saliva.

• Continuing to encourage the child to

drink from a cup. Weaning the child

from the bottle by age 12 to 14 months.

• Not putting the child to sleep with a

bottle or sippy cup or allowing frequent

and prolonged bottle feedings or use of

sippy cups containing beverages high in

sugar (e.g., fruit drinks, soda, fruit juice),

milk, or formula during the day or at

night to prevent sugary fluids from pooling around the teeth, which can increase

the child’s risk for tooth decay.

• Serving age-appropriate healthy foods

during planned meals and snacks, and

limiting eating (grazing) in between.

• Serving fruit, vegetables, grain products

(especially whole grain), and dairy products (milk, cheese, cottage cheese, and

unsweetened yogurt).

• Serving foods containing sugar at mealtimes only (not between meals), and

limiting the amount. Frequent consumption of foods high in sugar, such as

candy, cookies, cake, sweetened beverages (e.g., fruit drinks, soda), and fruit

juice, increases the risk for tooth decay.

In addition, frequent consumption of

foods that easily adhere to the tooth 

surface, such as fruit-roll-ups and candy, 39

EARLY CHILDHOOD • 1–4 YEARS
increases the risk for tooth decay. When

checking for sugar, looking beyond the

sugar bowl and candy dish. A variety of

foods contain one or more types of

sugar, and all types of sugars can promote tooth decay.

• Encouraging the child to eat fruit rather

than drink fruit juice.

• Serving the child juice in a cup, and limiting the child’s consumption of juice to

4 to 6 oz per day. Serving 100-percent

fruit juice or reconstituted juice.

• If the child drinks beverages between

meals, encouraging the child to drink

water or milk rather than fruit juice or

sweetened beverages (e.g., fruit drinks,

soda).

• Drinking fluoridated water (via a community fluoridated water source) to prevent tooth decay; for families that prefer

bottled water, drinking a brand in which

fluoride is added at a concentration of

approximately 0.7 to 1.2 mg/L (ppm) is

recommended.

Non-Nutritive Sucking

Sucking is a natural reflex for children.

Most children require some amount of 

additional sucking beyond that needed for

nourishment. This type of sucking, known

as non-nutritive sucking, provides emotional benefits, enabling the child to calm 

himself/herself and focus attention. If parents choose to have their child suck a pacifier, health professionals can advise them

to take certain safety precautions. The following precautions are recommended:

• Never attaching a pacifier to a ribbon or

string around the child’s neck.

40

EARLY CHILDHOOD • 1–4 YEARS
• Making sure the pacifier is of sturdy,

one-piece construction and that the

material is flexible, firm, and not brittle.

• Keeping the pacifier clean. • Not dipping a pacifier in sweetened

foods (e.g., sugar, honey, syrup) to

encourage sucking.

• Never orally cleaning a pacifier before

giving it to a child.

Injury Prevention • Being aware that injuries to the head,

face, and mouth are common among

children.

• Learning how to prevent oral injuries

and how to handle oral emergencies.

Because of the danger of damaging the

underlying permanent teeth, never

attempting to reinsert an avulsed (lost)

41

EARLY CHILDHOOD • 1–4 YEARS
primary tooth. It is impossible to relocate

the tooth accurately, and there is danger

of pushing it too far into the soft alveolar bone.

• Using an appropriate car safety seat in

the back seat of the vehicle at all times.

Children should ride rear facing until

they weigh at least 20 lbs; it is preferable

if they ride rear facing to the highest

weight and height allowed by the car

safety seat. Children who weigh at least

20 lbs should ride in a forward-facing

car safety seat (unless their rear-facing

car safety accommodates a higher

weight); most forward-facing seats have

a weight limit of 40 lbs, but a few have

higher weight limits. After a child

reaches the weight or height limit of

the forward-facing car safety seat, the

child should ride in a belt-postioning

booster seat with a lap and shoulder

belt.

• Not placing a child of any age in a shopping cart. Instead, consider using a

stroller or a backpack or frontpack while

42

EARLY CHILDHOOD • 1–4 YEARS
shopping with a

child.

• Using safety locks

on cabinets.

Keeping all poisonous substances,

medicines, cleaning agents, health

and beauty aids,

and paints and

paint solvents

locked in a safe place.

• Keeping pet food and dishes out of

reach. Not permitting the child to

approach the pet while it is eating.

• Keeping appliances and dangling telephone, electric, blind, and drapery cords

out of reach.

• Locking doors or using safety gates at

the top and bottom of stairs, and using

safety locks and safety devices on windows above the ground floor.

• Supervising the child on the stairs and

when climbing on and off furniture.

• Not giving toys small enough to be

placed in the mouth. Making sure that

toys do not have parts that can become

detached. Keeping toys with small parts

or sharp edges out of reach.

• Making sure that playgrounds are carefully maintained and that equipment is

in good condition. All playground equipment should be surrounded by a soft

surface (e.g., fine, loose sand; wood

chips; wood mulch) or by rubber mats

manufactured for this use.

43

EARLY CHILDHOOD • 1–4 YEARS
• Supervising the child on playground

equipment. Making sure children play

only on developmentally appropriate

equipment.

• Making sure that toys are soft (e.g., balls

not made with leather or hard materials).

• Ensuring that the child wears a bicycle

helmet, even on a tricycle.

• Providing the child’s caregivers with the

dentist’s emergency phone contacts,

and ensuring that the caregivers know

how to handle all emergencies.

44

EARLY CHILDHOOD • 1–4 YEARS
Outcomes • Parents and child are under the care of

an oral health professional.

• Parents are informed of oral development

issues.

• Parents understand and practice good

oral hygiene, feeding, and eating 

behaviors.

• Parents establish a safe environment and

practice safety behaviors.

• Child has no oral disease or injury.

45

EARLY CHILDHOOD • 1–4 YEARS
MIDDLE CHILDHOOD

Health professionals should select the

information in this section that is most

appropriate, using clinical judgment to

decide what is timely and relevant for

each individual child and family.

Family Preparation

To help prepare families for oral health

supervision visits, health professionals can

provide parents with a list of topics to discuss at the next visit. As the child becomes

more mature, ask the child questions

directly. Topics may include the following:

• Changes in the teeth and the mouth

• Oral hygiene practices (frequency, 

problems)

• Use of fluoridated water for drinking or

cooking

• Fluoride use (fluoridated toothpaste, 

fluoride supplements)

• Dental sealant use

• Eating practices

• Non-nutritive sucking (pacifier, thumb,

finger)

46

MIDDLE CHILDHOOD • 5–10 YEARS
• Illnesses or infections

• Medications

• Physical activity and sport participation

• Injuries to the teeth or the mouth

• Use of tobacco by parents or child

Interview Questions

Following are examples of questions that

health professionals may use. In addition

to asking these or other interview questions, discuss any issues or concerns the

family has. As the child becomes more

mature, ask the child questions directly.

To parent:

• How often does Sarah brush or floss her

teeth? Do you think it helps?

• Is Jee brushing and flossing his teeth

without being reminded?

• Has Andrea lost any teeth yet?

• Does Mark ever comment about his

teeth and how they look?

• How often does Selena see the dentist?

Does she have a dental home?

• Is your water fluoridated? Do you have

any questions about fluoride supplements, fluoride varnish, or dental

sealants?

• Does your child with special health care

needs require more assistance or special

equipment when brushing her teeth?

• Does Justin snack at school? After school?

What types of snacks are available for

Justin to eat?

• Does the school have vending machines?

If so, do they offer healthy beverage

choices such as water or milk?

47

MIDDLE CHILDHOOD • 5–10 YEARS
• Do you and your family members wear

safety belts in a car?

• Does Mary participate in physical activities and sports that could potentially

result in injuries to the mouth? Does she

wear protective gear (e.g., mouth guard,

face protector, helmet)?

• Do you understand what to do if Jon

knocks out one of his teeth?

• When was Elisa’s last visit to a health professional? Is it time for her next health

supervision visit?

To child:

• How often and when do you brush your

teeth? Floss? Do you think it helps?

• Do you think your teeth look okay?

• Do any of your teeth hurt?

• How many teeth have you lost?

• When was the last time you went to the

dentist?

• Do you snack at school? After school?

What do you eat?

• Do you wear a safety belt in a vehicle?

• Do you wear a helmet when riding a

bicycle?

• What sports do you play? Do you wear

protective mouth gear when you participate in contact sports?

• What do you think about smoking? Spit

tobacco? Did you smoke any cigarettes

in the last month? Use spit tobacco?

How often? 

48

MIDDLE CHILDHOOD • 5–10 YEARS
Risk Assessment

Use the tables and tool shown on pages

68–79 to assess the child’s risk and protective factors for oral health issues.

Screening

Visually inspect the lips, tongue, teeth,

gums, inside of the cheeks, and roof of

the mouth (see pages 11–13).

Examination

The child should be seen according to a

schedule recommended by the dentist,

based on the child’s individual needs and

susceptibility to disease.

Anticipatory Guidance

Discuss with Parents (as child

becomes more mature, direct

discussion toward the child):

Oral Hygiene

• Scheduling a dental visit for the child

according to the schedule recommended

by the child’s dentist, based on the

child’s individual needs or susceptibility

to disease.

• For children with special health care

needs, making appointments for more 

frequent dental visits based on the child’s

individual needs or susceptibility to disease. Providing more assistance with

brushing the child’s teeth, if needed, and

obtaining special oral health equipment

(e.g., a mouth prop) to complete the task.

49

MIDDLE CHILDHOOD • 5–10 YEARS
• Ensuring that the child brushes his or

her teeth twice a day (after breakfast

and before bed) with no more than a

pea-sized amount (small smear) of fluoridated toothpaste and that the child

flosses daily. Making sure the child spits

out the toothpaste after brushing but

does not rinse with water. The small

amount of fluoridated toothpaste that

remains in the mouth helps prevent

tooth decay. Because effective plaque

removal requires good fine motor control, young children cannot clean their

teeth without parental help. After children acquire fine motor skills (e.g., the

ability to tie their shoelaces), typically by

age 7 or 8, they can clean their teeth

effectively but should be supervised by 

a parent.

• Becoming familiar with the normal

appearance of your child’s gums and

teeth so that you can identify problems

if they occur (see Tooth Eruption Chart

on pages 82–83). Checking the child’s

gums and teeth about once a month.

• Giving the child fluoride supplements

only as prescribed by a dentist or physician, based on the risk of developing

tooth decay and the known level of 

fluoride in the child’s drinking water 

(see Systemic Fluoride Supplements:

Recommended Dosage on page 84).

• Discussing with a dentist or other qualified health professional the need to apply

fluoride topically (via varnishes, gels,

foams), which renews the high levels of

fluoride in the outer layer of the tooth

enamel. Topical fluoride may be especially

50

MIDDLE CHILDHOOD • 5–10 YEARS
effective for children at high risk for tooth

decay because they have a history of

decay, are not exposed to fluoridated

water, snack frequently on foods containing sugar, or have a medical problem that

decreases their resistance to decay.

• Discussing with a dentist or other qualified health professional the need to

apply dental sealants (thin plastic coatings applied to pits and fissures on the

chewing surfaces of the teeth) to prevent tooth decay by creating a physical

barrier against dental plaque, shortly

after the teeth erupt.

• Discussing with a dentist the need to

schedule a visit to the orthodontist to

have the child evaluated for braces.

Nutrition

• Serving healthy foods such as fruit, vegetables, grain products (especially whole

grain), and dairy products (milk, cheese,

cottage cheese, and unsweetened

yogurt) for meals and snacks. Limit eating (grazing) in between.

51

MIDDLE CHILDHOOD • 5–10 YEARS
• Serving foods containing sugar at mealtimes only (not between meals), and

limiting the amount. Frequent consumption of foods high in sugar, such as

candy, cookies, cake, sweetened beverages (e.g., fruit drinks, soda), and fruit

juice, increases the risk for tooth decay.

In addition, frequent consumption of

foods that easily adhere to the tooth 

surface, such as dried fruit, fruit-roll-ups,

and candy, increases the risk for tooth

decay. When checking for sugar, looking

beyond the sugar bowl and candy dish.

A variety of foods contain one or more

types of sugar, and all types of sugars

can promote tooth decay.

• Encouraging the child to eat fruit rather

than drink fruit juice.

• If the child drinks beverages between

meals, encouraging the child to drink

water or milk rather than fruit juice or

sweetened beverages (e.g., fruit drinks,

soda).

• If the school has vending machines,

encouraging the child to choose water or

milk rather than fruit juice or sweetened

beverages (e.g., fruit drinks, soda).

• Drinking fluoridated water (via a community fluoridated water source) to prevent tooth decay; for families that prefer

bottled water, drinking a brand in which

fluoride is added at a concentration of

approximately 0.7 to 1.2 mg/L (ppm) is

recommended.

Non-Nutritive Sucking

Although most children discontinue nonnutritive sucking behaviors on their own

before the permanent teeth begin to erupt,

some continue beyond that stage. If the child

52

MIDDLE CHILDHOOD • 5–10 YEARS
regularly engages in non-nutritive sucking

behaviors, gently intervene to help the child

stop. These methods are presented in the

order in which they should be attempted:

• Talking with the child. Discussing the

problems caused by the habit. Sometimes

this alone is enough to make the child

stop sucking.

• Using reminder therapy. This approach is

appropriate for children who want to

stop sucking but need some help. An

adhesive bandage secured with waterproof tape on the finger or thumb can

remind the child not to suck. A mitten

or sock placed on the hand at night can

also be effective. Stress to the child that

this is a reminder, not a punishment.

• Using a reward system. Under this system, the child, a parent, and the health

professional agree that the child will 

discontinue the habit within a specified

time period and will then receive a

reward. The reward must be motivating

to the child. Charting small successes

may help (e.g., placing colored stars on

a calendar for each day the child does

not suck a pacifier or his or her finger or

thumb).

• Physically interrupting the habit. If none

of the preceding methods are successful,

and the child truly wants to stop the

habit, two other methods can be tried:

(1) The child’s arm can be loosely

wrapped in an elastic bandage during

the night to prevent flexing the arm and

inserting the thumb or fingers into the

mouth. Stress to the parent that the

bandage should not be wrapped tightly.

(2) A dentist can place an appliance in

the mouth that interferes with sucking.

53

MIDDLE CHILDHOOD • 5–10 YEARS
Injury Prevention

• Learning how to prevent oral injuries

and handle oral emergencies, especially

the loss or fracture of a tooth. 

- If a permanent tooth is knocked out,

the parent or other adult should 

(1) find the avulsed (lost) tooth, 

(2) hold it by the crown (top part)

only, not the root, (3) rinse it under

cold water gently if the root is dirty,

but do not scrub, (4) reinsert it into the

socket quickly, making sure that the

front of the tooth is facing you, and 

(5) take the child to the dentist immediately. If it is not possible to replace

the tooth, place the tooth in a container of cold milk or in a cold wet cloth

and take the child and the tooth to a

dentist immediately. 

- Because of the danger of damaging the

underlying permanent teeth, never

attempt to reinsert an avulsed (lost)

primary tooth. It is impossible to relocate the tooth accurately, and there is

danger of pushing it too far into the

soft alveolar bone.

54

MIDDLE CHILDHOOD • 5–10 YEARS
- If a tooth is fractured or chipped, the

parent or other adult should (1) rinse

the child’s mouth with water, (2) apply

cold compresses to the cheek to

reduce swelling, and (3) take the child

to the dentist immediately.

• Using an appropriate car safety seat in

the back seat of the vehicle at all times.

Children should ride in a forward-facing

car safety seat until they reach the

weight or height limit of the seat, after

which they should ride in a belt-positioning booster seat with a lap and

shoulder belt. Children should ride in a

booster seat until the vehicle’s safety belt

fits properly without a booster seat—

when the shoulder belt lies across the

chest, not the neck or the throat, the lap

belt is low and snug across the thighs,

not the stomach, and the child is tall

enough to reach the vehicle seat back

with the legs bent at the knees and feet

hanging down.

• Being aware that the risk of injury is

higher during periods of rapid growth.

55

MIDDLE CHILDHOOD • 5–10 YEARS
• Ensuring that the child wears protective

gear when participating in physical

activities or sports that could potentially

result in injuries to the mouth, such as

biking, riding a scooter, skateboarding,

in-line skating, or playing baseball, soccer, or lacrosse.

• Teaching the child about injury prevention, including the need to wear protective gear such as a mouth guard, a face

protector, and a helmet.

• Providing the child’s caregivers with the

dentist’s emergency phone contacts,

and ensuring that the caregivers know

how to handle oral emergencies.

Substance Use

• Teaching parents and children about the

dangers of cigarette smoking or using

spit tobacco.

56

MIDDLE CHILDHOOD • 5–10 YEARS
Outcomes • Parents and child are under the care of

an oral health professional.

• Parents and child are informed of oral

development issues.

• Parents and child understand and 

practice good oral hygiene and eating

behaviors.

• Parents establish a safe environment,

and parents and child practice safety

behaviors.

• Child has no oral disease or injury.

57

MIDDLE CHILDHOOD • 5–10 YEARS
ADOLESCENCE

Health professionals should select the

information in this section that is most

appropriate, using clinical judgment to

decide what is timely and relevant for the

adolescent and family.

Family Preparation

To help prepare families for oral health

supervision visits, health professionals can

provide adolescents with a list of topics to

discuss at the next visit. Topics may

include the following:

• Changes in the teeth or the mouth

• Oral hygiene practices (frequency, 

problems)

• Use of fluoridated water for drinking or

cooking

• Fluoride use (fluoridated toothpaste, fluoride supplements)

• Dental sealant use

58

ADOLESCENCE • 11–21 YEARS
• Eating practices

• Illnesses or infections

• Medications

• Physical activity and sports participation

• Injuries to the teeth or the mouth

• Use of tobacco by adolescent

Interview Questions

Following are examples of questions that

health professionals may use. In addition

to asking these or other interview questions, discuss any issues or concerns the

family has. Ask the adolescent questions

directly.

• How often do you brush and floss your

teeth? Do you think it helps?

• Do you think your teeth look okay?

• Have your wisdom teeth erupted?

• When was the last time you went to the

dentist?

• Do you snack at school? After school?

What do you eat or drink?

• Does your school have vending

machines? If so, do they offer healthy

beverage choices such as water or milk?

• Do you wear a safety belt while driving

or riding in a vehicle?

• Do you wear a helmet when riding a bicycle? An all-terrain vehicle? Motorcycle?

• Do you participate in physical activities

and sports that could potentially result

in injuries to the mouth? Do you wear

protective gear (e.g., mouth guard, face

protector, helmet)?

• Do you wear protective mouth gear

when you participate in contact sports?

59

ADOLESCENCE • 11–21 YEARS
• What have you heard about smoking or

spit tobacco?

• What do you think about smoking? Spit

tobacco? Did you smoke any cigarettes

in the last month? Use spit tobacco?

How often?

• When was your last visit to a health professional? Is it time for your next health

supervision visit?

Risk Assessment

Use the tables and tool shown on pages

68–79 to assess the adolescent’s risk and

protective factors for oral health issues.

Screening

Visually inspect the lips, tongue, teeth,

gums, inside of the cheeks, and roof of

the mouth (see pages 11–13).

Examination

The adolescent should be seen according to a schedule recommended by the

dentist, based on the adolescent’s individual needs and susceptibility to disease.

Anticipatory Guidance

Discuss with Adolescent and/or

Parents:

Oral Hygiene

• Scheduling a dental visit according to

the schedule recommended by your

dentist, based on your individual needs

and susceptibility to disease.

• If you have special health care needs,

making appointments for more frequent

dental visits based on your individual

needs and susceptibility to disease.

60

ADOLESCENCE • 11–21 YEARS
(after breakfast and before bed) with

fluoridated toothpaste, and flossing daily.

Spitting out the toothpaste after brushing, but not rinsing with water. The small

amount of fluoridated toothpaste that

remains in your mouth helps prevent

tooth decay.

• Becoming familiar with the normal

appearance of your gums and teeth so

that you can identify problems if they

occur (see Tooth Eruption Chart on

pages 82–83).

• Taking fluoride supplements only as prescribed by a dentist or physician, based

on the risk of developing tooth decay

and the known level of fluoride in your

drinking water (see Systemic Fluoride

Supplements: Recommended Dosage on

page 84).

• Discussing with a dentist or other qualified health professional the need to

apply fluoride topically (via varnishes,

61

ADOLESCENCE • 11–21 YEARS

Obtaining

assistance

with brushing your

teeth, if

needed, and

obtaining

special oral

health

equipment

(e.g., a

mouth prop)

to complete

the task.

• Brushing

your teeth

twice a day
gels, foams), which renews the high levels of fluoride in the outer layer of the

tooth enamel. Topical fluoride may be

especially effective for adolescents at

high risk for tooth decay because they

have a history of decay, are not exposed

to fluoridated water, snack frequently on

foods containing sugar, or have a medical problem that decreases their resistance to decay.

• Discussing with a dentist or other qualified health professional the need to

apply dental sealants (thin plastic coatings applied to pits and fissures on the

chewing surfaces of the teeth) to prevent

tooth decay by creating a physical barrier against dental plaque, shortly after

the teeth erupt.

• Discussing with a dentist the need to

establish a preventive oral health regimen, including an evaluation of the bite

and third molar development.

Nutrition

• Eating health foods such as fruit, vegetables, grain products (especially whole

grain), and dairy products (milk, cheese,

62

ADOLESCENCE • 11–21 YEARS
cottage cheese, and unsweetened

yogurt) for meals and snacks. Limit eating (grazing) in between.

• Eating foods containing sugar at mealtimes only (not between meals), and

limiting the amount. Frequent consumption of foods high in sugar, such as

candy, cookies, cake, sweetened beverages (e.g., fruit drinks, soda), and fruit

juice, increases the risk for tooth decay.

In addition, frequent consumption of

foods that easily adhere to the tooth surface, such as dried fruit, fruit-roll-ups,

and candy, increases the risk for tooth

decay. When checking for sugar, looking

beyond the sugar bowl and candy dish.

A variety of foods contain one or more

types of sugar, and all types of sugars

can promote tooth decay.

• Choosing fruit rather than fruit juice.

• Drinking water or milk between meals

rather than fruit juice or sweetened beverages (e.g., fruit drinks, soda).

• If the school has vending machines,

choosing water or milk rather than fruit

63

ADOLESCENCE • 11–21 YEARS
juice or sweetened beverages (e.g., fruit

drinks, soda).

• Drinking fluoridated water (via a community fluoridated water source) to prevent tooth decay; for families that prefer

bottled water, drinking a brand in which

fluoride is added at a concentration of

approximately 0.7 to 1.2 mg/L (ppm) is

recommended.

Injury Prevention

• Learning how to prevent oral injuries

and handle oral emergencies, especially

the loss or fracture of a tooth. 

- If a permanent tooth is knocked out,

you or an adult should (1) find the

avulsed (lost) tooth, (2) hold it by the

crown (top part) only, not the root, 

(3) rinse it under cold water gently if

the root is dirty, but do not scrub, 

(4) reinsert it into the socket quickly,

making sure that the front of the

tooth is facing you, and (5) go to the

dentist immediately. If it is not possible to replace the tooth, place the

tooth in a container of cold milk or in

64

ADOLESCENCE • 11–21 YEARS
a cold wet cloth and go to a dentist

immediately.

- If a tooth is fractured or chipped, you

or an adult should (1) rinse your mouth

with water, (2) apply cold compresses

to the cheek to reduce swelling, and

(3) go to the dentist immediately.

• Wearing a safety belt while riding or

driving in a vehicle. If you are driving,

insisting that your passengers also wear

safety belts.

• Wearing a helmet when riding a bicycle,

all-terrain vehicle, or motorcycle. Adolescents under age 16 should not ride an

all-terrain vehicle or motorcycle.

• Wearing protective gear when participating in physical activities or sports that

could potentially result in injuries to the

mouth, such as biking, skateboarding,

in-line skating, or playing baseball, soccer, or lacrosse.

• Avoiding oral piercings, which can damage teeth and gums.

Substance Use

• Not smoking cigarettes or using spit

tobacco.

65

ADOLESCENCE • 11–21 YEARS
Outcomes

• Parents and adolescent are under the

care of an oral health professional.

• Parents and adolescent are informed of

oral development issues.

• Parents and adolescent understand and

practice good oral hygiene and eating

behaviors.

• Parents and adolescent establish a safe

environment, and parents and adolescent

practice safety behaviors.

• Adolescent has no oral disease or injury.

66

ADOLESCENCE • 11–21 YEARS
RISK ASSESSMENT
68

RISK ASSESSMENT

RISK FACTORS 

Physical: Examples

*Previous dental caries experience

*High Streptococcus mutans count

History of tooth decay

Variations in tooth enamel; deep pits and 

fissures; anatomically susceptible areas

Special health care needs

Gastric reflux

Behavioral: Examples

*Frequent snacking

*Inadequate oral hygiene

Frequent or prolonged bottle feedings during

the day or night

Eating disorders (bulimia nervosa) including

self-induced vomiting

PROTECTIVE FACTORS 

Increased frequency of oral health supervision

Reduction of Streptococcus mutans count

Increased frequency of oral health supervision

Dental sealants (if possible) or observation

Preventive intervention to minimize effects

Management of condition

Reduction in snacking frequency

Good oral hygiene

Less-frequent and less-prolonged bottle 

feedings, and weaning from bottle by age 12

to 14 months

Referral for counseling

* Indicates an item that corresponds to American Academy of Pediatric Dentistry’s Caries-Risk Assessment Tool (CAT)

DENTAL CARIES RISK ASSESSMENT TABLE
69

RISK ASSESSMENT

RISK FACTORS 

Socioenvironmental: Examples

*Inadequate fluoride

*Poverty

Poor family oral health

High parental levels of bacteria 

(Streptococcus mutans)

Disease or Treatment Related: Examples

*Special carbohydrate diet

*Frequent intake of sugared medications

Orthodontic appliances

Reduced saliva flow from medication or 

irradiation

PROTECTIVE FACTORS 

Optimal systemic and/or topical fluoride

Access to care

Access to care and good oral hygiene

Good parental oral health and hygiene

Preventive intervention to minimize effects

Alternate medications or preventive 

intervention to minimize effects

Good oral hygiene for appliances

Saliva substitute

* Indicates an item that corresponds to American Academy of Pediatric Dentistry’s Caries-Risk Assessment Tool (CAT)

DENTAL CARIES RISK ASSESSMENT TABLE (CONTINUED)
70

RISK ASSESSMENT

RISK FACTORS 

Physical: Examples

*Gingivitis

*Puberty

*Pregnancy

Mouthbreathing

Malpositioned or crowded teeth

Genetic predisposition (e.g., Down or Papillon

Lefevre syndrome)

Anatomical variations (e.g., frenum)

Behavioral: Examples

*Inadequate oral hygiene

*Tobacco use

Birth control pills

PROTECTIVE FACTORS 

Treatment of disease

Preventive measures to address oral effects

Preventive measures to address oral effects

Management of mouthbreathing

Orthodontic care

Preventive intervention to minimize effects

Surgical correction

Good oral hygiene

Tobacco use cessation

Preventive measures to minimize effects

* Indicates an item that corresponds to American Academy of Pediatric Dentistry’s Caries-Risk Assessment Tool (CAT)

PERIODONTAL DISEASE RISK ASSESSMENT TABLE
71

RISK ASSESSMENT

RISK FACTORS 

Socioenvironmental: Examples

*Poverty

Poor family oral health

Disease or Treatment Related: Examples

*Infectious disease (e.g., HIV/AIDS)

*Medications (e.g., Dilantin)

*Unrestored or poorly restored tooth decay

Metabolic disease (e.g., diabetes, 

hypophosphatasia)

Neoplastic disease (e.g., leukemia or its 

treatment)

Injury

Nutritional deficiencies (e.g., vitamin C)

PROTECTIVE FACTORS 

Access to care

Access to care and good oral hygiene

Treatment of disease and preventive 

intervention to minimize effects

Preventive intervention to minimize effects

Properly contoured and finished restorations

Treatment of disease

Treatment of disease and preventive 

intervention to minimize effects

Use of age-appropriate safety measures and

treatment of injury

Good eating behaviors

* Indicates an item that corresponds to American Academy of Pediatric Dentistry’s Caries-Risk Assessment Tool (CAT)

PERIODONTAL DISEASE RISK ASSESSMENT TABLE (CONTINUED)
72

RISK ASSESSMENT

RISK FACTORS 

Physical: Examples

*Familial tendency for malocclusion

*Conditions associated with malocclusion

(e.g., cleft lip/palate)

Variations in development (e.g., tooth 

eruption delays and malpositioned teeth)

Congenital absence of teeth

Mouthbreathing

Muscular imbalances

Behavioral: Examples

Non-nutritive sucking habits in children ages 4

and above

PROTECTIVE FACTORS 

Early intervention

Early intervention

Early intervention

Early intervention

Management of mouthbreathing

Early therapy

Elimination of habit

* Indicates an item that corresponds to American Academy of Pediatric Dentistry’s Caries-Risk Assessment Tool (CAT)

MALOCCLUSION RISK ASSESSMENT TABLE
73

RISK ASSESSMENT

RISK FACTORS 

Disease or Treatment Related: Examples

*Loss of space owing to dental caries

*Skeletal growth disorders (e.g., renal disease)

Acquired problem from systemic condition or

its therapy

Musculoskeletal conditions (e.g., cerebral

palsy)

Injury

PROTECTIVE FACTORS 

Early intervention for dental caries

Dental intervention as a part of medical care

Dental intervention as a part of medical care

Dental intervention as a part of medical care

Use of age-appropriate safety measures (e.g.,

car safety seats, vehicle safety belts, stair gates,

mouth guards) and treatment of injury

* Indicates an item that corresponds to American Academy of Pediatric Dentistry’s Caries-Risk Assessment Tool (CAT)

MALOCCLUSION RISK ASSESSMENT TABLE (CONTINUED)
74

RISK ASSESSMENT

RISK FACTORS 

Physical: Examples

*Poor coordination (e.g., children with special

health care needs)

Protruding front teeth

Lack of protective reflexes

Behavioral: Examples

Failure to use age-appropriate safety measures

(e.g., car safety seats, stair gates, vehicle safety

belts, mouth guards)

Participation in contact physical activities and

sports

PROTECTIVE FACTORS 

Referral for appropriate physical therapy

Orthodontic care

Referral for appropriate therapy

Use of age-appropriate safety measures

Use of protective gear

* Indicates an item that corresponds to American Academy of Pediatric Dentistry’s Caries-Risk Assessment Tool (CAT)

INJURY RISK ASSESSMENT TABLE
75

RISK ASSESSMENT

RISK FACTORS 

Socioenvironmental: Examples

*Multiple family problems

*Child abuse or neglect

Substance use by child or adolescent

Substance abuse in family

Disease or Treatment Related: Examples

*Hyperactivity

Overmedication

PROTECTIVE FACTORS 

Referral for family counseling

Reporting of suspected abuse or neglect to

local social service agency

Referral for substance abuse counseling

Referral for substance abuse counseling

Management of condition

Adjustment of medications

* Indicates an item that corresponds to American Academy of Pediatric Dentistry’s Caries-Risk Assessment Tool (CAT)

INJURY RISK ASSESSMENT TABLE (CONTINUED)
76

RISK ASSESSMENT

Health professionals using the Caries-Risk Assessment Tool (CAT) should

1. Be able to visualize adequately an infant’s, child’s, or adolescent’s teeth and mouth and have access to a

reliable historian for nonclinical data elements.

2. Assess all three components of caries risk: clinical conditions, environmental characteristics, and general

health conditions.

3. Be familiar with footnotes that clarify use of individual factors in the CAT.

4. Understand that each infant’s, child’s, or adolescent’s ultimate risk classification is determined by the highest

risk category in which a risk indicator exists. That is, the presence of a single risk indicator in the “high-risk”

category results in a “high-risk” classification; the presence of a single risk indicator in the “moderate-risk”

category, with no indicator in the “high-risk” category, results in a “moderate-risk” classification; and no

indicators in the “moderate-risk” or “high-risk” categories results in a “low-risk” classification.

Users of the CAT must understand the following caveats:

1. The CAT provides a means of classifying caries risk at a point in time and, therefore, should be applied

periodically to assess changes in an infant’s, child’s, or adolescent’s risk status.

2. The CAT is intended for use when clinical guidelines call for caries risk assessment. Decisions about clinical

management of caries, however, are left to qualified dentists (ideally, the dentist at the infant’s, child’s, or

adolescent’s dental home).

3. The CAT can be used by both oral health and non-oral health professionals. It does not render a diagnosis.

However, health professionals using the CAT must be familiar with the clinical presentation of caries and

with factors related to caries initiation and progression.

CARIES-RISK ASSESSMENT TOOL (CAT)
77

RISK ASSESSMENT

Caries-Risk Assessment Tool

4. Since health professionals with differing skill levels working in a variety of settings will use the CAT,

advanced technologies, such as radiographic assessment and microbiologic testing (shaded areas), have

been included. However, such technologies are not essential for using the CAT.

Caries-risk indicators

Clinical conditions

Low risk

• No carious teeth in past

24 months

• No enamel demineralization (enamel caries

“white-spot lesions”)

• No visible plaque; no

gingivitis

Moderate risk

• Carious teeth in the past

24 months

• 1 area of enamel

demineralization (enamel

caries “white-spot

lesions”)

• Gingivitis*

(continued on next page)

High risk

• Carious teeth in the past

12 months

• More than 1 area of

enamel demineralization

(enamel caries “white-spot

lesions”)

• Visible plaque on anterior

(front) teeth

• Radiographic enamel

caries

• High titers of mutans

streptococci

• Wearing dental or

orthodontic appliances†

• Enamel hypoplasia‡
78

RISK ASSESSMENT

Caries-Risk Assessment Tool (continued)

Caries-risk indicators

Environmental

characteristics

General health conditions

Low risk

• Optimal systemic and

topical fluoride exposure§

• Consumption of simple

sugar or foods strongly

associated with caries

initiation primarily at

mealtimes||

• High caregiver

socioeconomic status¶

• Regular use of dental care

in an established dental

home

Moderate risk

• Suboptimal systemic

fluoride exposure with

optimal topical exposure§

• Occasional (i.e., 1-2)

between-meal exposures

to simple sugars or foods

strongly associated with

caries

• Midlevel caregiver

socioeconomic status (i.e.,

eligible for school lunch

program or SCHIP)

• Irregular use of dental

services

High risk

• Suboptimal topical

fluoride exposure§

• Frequent (i.e., 3 or more)

between-meal exposures

to simple sugars or foods

strongly associated with

caries

• Low-level caregiver

socioeconomic status (i.e.,

eligible for Medicaid)

• No usual source of dental

care

• Children with special

health care needs#

• Conditions impairing

saliva composition/flow**

Reproduced with permission from the American Academy of Pediatric Dentistry from Pediatric Dentistry Reference Manual

2003–2004 (25)7:18–20.
79

RISK ASSESSMENT

*Although microbial organisms responsible for gingivitis may be different than those primarily implicated in dental caries, the presence of gingivitis

is an indicator of poor or infrequent oral hygiene practices and has been associated with caries progression.

†Orthodontic appliances include both fixed and removable appliances, space maintainers, and other devices that remain in the mouth continuously

or for prolonged time intervals and which may trap food and plaque, prevent oral hygiene, compromise access of tooth surfaces to fluoride, or 

otherwise create an environment supporting dental caries initiation.

‡Tooth anatomy and hypoplastic defects, such as poorly formed enamel, developmental pits, and deep pits, may predispose a child to develop

dental caries.

§Optimal systemic and topical fluoride exposure is based on the American Dental Association/American Academy of Pediatrics guidelines for 

exposure from fluoride drinking water and/or supplementation and use of a fluoride dentifrice.

||Examples of sources of simple sugars include carbonated beverages, cookies, cake, candy, cereal, potato chips, French fries, corn chips, pretzels,

breads, juices, and fruits. Clinicians using caries-risk assessment should investigate individual exposures to sugars known to be involved in caries 

initiation.

¶National surveys have demonstrated that children in low-income and moderate-income households are more likely to have dental caries and more

decayed or filled primary teeth than children from more affluent households. Also, within income levels, minority children are more likely to have

caries. Thus, sociodemographic status should be viewed as an initial indicator of risk that may be offset by the absence of other risk indicators.

#Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional

condition and who also require health and related services of a type or amount beyond that required by children generally.

**Alteration in salivary flow can be the result of congenital or acquired conditions, surgery, radiation, medication, or age-related changes in salivary

function. Any condition, treatment, or process known or reported to alter saliva flow should be considered an indication of risk unless proven 

otherwise.

APPENDICES
82

TOOTH ERUPTION CHART

APPENDICES

PRIMARY DENTITION

Upper Teeth Erupt Exfoliate

Central incisor 8-12 months 6-7 years

Lateral incisor 9-13 months 7-8 years

Canine (cuspid) 16-22 months 10-12 years

First molar 13-19 months 9-11 years

Second molar 25-33 months 10-12 years

Lower Teeth Erupt Exfoliate

Second molar 23-31 months 10-12 years

First molar 14-18 months 9-11 years

Canine (cuspid) 17-23 months 9-12 years

Lateral incisor 10-16 months 7-8 years

Central incisor 6-10 months 6-7 years
83

APPENDICES

PERMANENT DENTITION

Upper Teeth Erupt

Central incisor 7-8 years

Lateral incisor 8-9 years

Canine (cuspid) 11-12 years

First premolar (first bicuspid) 10-11 years

Second premolar (second bicuspid) 10-12 years

First molar 6-7 years

Second molar 12-13 years

Third molar (wisdom tooth) 17-21 years

Lower Teeth Erupt

Third molar (wisdom tooth) 17-21 years

Second molar 12-13 years

First molar 6-7 years

Second premolar (second bicuspid) 10-12 years

First premolar (first bicuspid) 10-11 years

Canine (cuspid) 11-12 years

Lateral incisor 8-9 years

Central incisor 7-8 years

Adapted with permission from the Arizona Department of Health Services, Office of Oral Health, courtesy of 

Don Altman, D.D.S., M.P.H. The assistance of the American Dental Hygienists’ Association is gratefully acknowledged.
84

APPENDICES

SYSTEMIC FLUORIDE SUPPLEMENTS: RECOMMENDED DOSAGE

Age

Newborn–6 months

6 months–3 years

3–6 years

6–16 years

< 0.3 ppm

None

0.25 mg/dayb

0.50 mg/day

1.0 mg/day

0.3–0.6 ppm

None

None

0.25 mg/day

0.50 mg/day

> 0.6 ppm

None

None

None

None

a1.0 ppm = 1 mg/L.

b2.2 mg sodium fluoride contains 1 mg fluoride ion.

Reproduced with permission from the American Dental Association from ADA Guide to Dental Therapeutics (2nd ed.).

Fluoride Ion Level in Drinking Watera
85

amalgam (silver filling): dental material used

to repair cavities

bacteria: microorganisms commonly referred

to as “germs” capable of producing disease

under the right conditions

bruxism: habitual grinding and clenching of

teeth, often unintentionally

carbohydrates: sugars and starches found in

many foods

caries (dental caries): infectious disease

process leading to tooth decay

cariogenic: decay-causing

cavity (carious lesion): hollow area or hole in

the tooth caused by bacterial acids that

attack the enamel

crown: the part of the tooth above the gum

line; also a restorative “cap” that covers a

cracked or broken tooth, unfixed by a filling

debris: soft foreign matter attached loosely to

tooth

deciduous teeth: see primary teeth

demineralization: loss of mineral from tooth

enamel during early stages of caries; may

appear as a small white area on tooth surface

dental home: a dentist who provides primary,

preventive, and maintenance oral health

services to an individual on a periodic basis

dental pulp: soft tissue inside the tooth that

contains nerves, blood vessels, and

connective tissue

GLOSSARY

APPENDICES
86

dental sealant: thin, plastic film that is painted

on chewing surfaces of back teeth (molars

and premolars) to prevent tooth decay

early childhood caries: in an infant or child up

to age 6, the presence of one or more

decayed teeth, missing teeth (resulting from

caries), or filled tooth surfaces

enamel: hard, glossy, white material that

covers the outside of the tooth

eruption: when a tooth emerges from the

gums

fissure: anatomic groove in the surface of a

tooth

fluoridation: addition of fluoride to

community water systems

fluoride: mineral that can be found in water

and toothpaste that helps prevent and

reduce tooth decay

fluoride varnish: lacquer containing 5 percent

sodium fluoride that is painted on teeth to

reduce tooth decay

fluorosis: condition that results from consuming

excessive fluoride; causes teeth to become

discolored and the enamel of the teeth to

look spotted, pitted, or stained

halitosis: bad breath

hard palate: roof of the mouth

incisors: teeth adapted for cutting or gnawing,

located at the front of the mouth

malocclusion (“bad bite”): teeth that fit

together poorly as a result of crowded,

missing, or crooked teeth; extra teeth; or a

misaligned jaw

molars: large, broad teeth at the back of the

mouth used for crushing and grinding food

APPENDICES
87

occlusion (“bite”): way teeth fit together

when jaws are closed

overbite: up-and-down (vertical) overlapping

of lower teeth by upper teeth

periodontal disease: bacterial infection of

supporting structures of the teeth (gums,

bones, and ligaments) which, if left

untreated, can destroy the support of the

teeth in their sockets, thus causing tooth loss

permanent teeth (adult teeth): second set of

teeth (32 in number) that come into the

mouth after the loss of the primary teeth

pit: small developmental indentation in the

crown of the tooth

plaque: thin, colorless, sticky film of bacteria

that forms on teeth; main cause of caries and

periodontal disease when allowed to remain

on teeth over a period of time

primary teeth (deciduous teeth): first set of

teeth (20 in number) that come into the

mouth, usually when an infant is around ages

6 to 10 months

remineralization: replacement of minerals into

the tooth’s enamel; reversal of

demineralization and thus of the decay

process

saliva: watery secretions of glands of the

mouth

Streptococcus mutans: type of bacteria

commonly found in the mouth, associated

with caries

tooth decay: see caries

APPENDICES
88

National Maternal and Child Oral Health

Resource Center

The National Maternal and Child Oral Health

Resource Center (OHRC) responds to the needs

of states and communities in addressing current and emerging public oral health issues.

OHRC supports health professionals, program

administrators, educators, policymakers, and

others with the goal of improving oral health

services for infants, children, adolescents, and

their families. OHRC collaborates with federal,

state, and local agencies; national and state

associations and organizations; and foundations to gather, develop, and share high-quality

information and materials. OHRC also maintains the online Bright Futures Oral Health

Toolbox to highlight materials that advance the

Bright Futures philosophy of promoting and

improving the oral health of infants, children,

and adolescents. OHRC is funded by the Health

Resources and Services Administration’s

Maternal and Child Health Bureau located at

Georgetown University.

National Maternal and Child Oral Health 

Resource Center

Georgetown University

Box 571272

Washington, DC 20057-1272

(202) 784-9771

(202) 784-9777 fax

E-mail: info@mchoralhealth.org

Web site: http://www.mchoralhealth.org

RESOURCES

APPENDICES
89

Bright Futures Education Center and 

Pediatric Implementation Project

The Bright Futures Education Center (BFEC)

implements strategies to enhance health professionals’ prevention and health promotion

efforts for infants, children, and adolescents, as

well as to enhance health professionals’ recognition and implementation of the Bright

Futures guidelines. BFEC activities include revising Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (2nd

ed., rev.); providing training and continuing

education on prevention and health promotion

content and philosophy; updating key Bright

Futures guidelines and tools; developing and

implementing an evaluation plan to assess and

monitor efforts; creating and distributing a tool

kit of Bright Futures materials; and tracking collaboration and partnerships of key child health

constituencies and Bright Futures supporters.

The Bright Futures Pediatric Implementation

Project (PIP) aims to improve prevention and

health promotion practices among all child and

adolescent health professionals through the

effective implementation of the Bright Futures

guidelines by developing practical strategies

and tools to overcome obstacles to prevention

and health promotion services within the medical home and to improve access to these services for children at the community and system

levels. The BFEC and the PIP are funded by the

Health Resources and Services Administration’s

Maternal and Child Health Bureau and are

located at the American Academy of Pediatrics.

Bright Futures Education Center and 

Pediatric Implementation Project

American Academy of Pediatrics

141 Northwest Point Boulevard

Elk Grove Village, IL 60007-1098

(847) 434-4223

(847) 228-7320 (fax)

E-mail: brightfutures@aap.org

Web site: http://www.brightfutures.aap.org

APPENDICES


BF0900025