The American Academy of Pediatric Dentistry (AAPD) recommends that children establish a dental home by age 1 or within 6 months of their first tooth erupting.1 A dental home is the ongoing relationship between an oral health professional and a patient, inclusive of all aspects of oral health care.2 However, parents and caregivers may be unaware of this recommendation or feel that a dental visit in the first year of life is too early, despite its documented benefits.3
Dental sales reps should know that the purpose of the age 1 dental visit is for clinicians to perform a comprehensive examination and caries risk assessment, identify early signs of pathology (including caries), apply fluoride, and deliver patient education. A better understanding of this visit will help sales reps hone their sales pitches to better align with their customers’ individualized patient needs — and with a focus on prevention.
Given their frequent interaction with infants and young children, pediatricians and other health professionals also play an important role in promoting oral health; as such, oral health screenings, fluoride application and caries risk assessment are standard protocol in well-child visits.4 Because caries and early loss of primary teeth can affect learning, communication, nutrition, overall well-being, and other activities necessary for growth and development, every health professional should be prepared to answer questions about why it is important to invest time, energy and resources into baby teeth.
It was widely believed that, in light of the expansion of pediatric dental coverage under the Affordable Care Act (ACA), the number of pediatric patients seeking dental care would increase. However, there are limited and mixed data about whether the ACA has improved access to care for pediatric patients.5 Regardless, it is the job of a well-prepared dental practice to be ready to provide age-specific oral health care instructions and preventive education for their patients. And sales reps should know what this encompasses, as opportunity to sell into this protocol exists.
Here is what a typical pediatric dental visit should comprise, after a thorough parent/caregiver interview that includes medical/dental histories; dietary information and habits; oral hygiene practices; fluoride use; previous trauma; and any other pertinent concerns:
- Caries risk assessment
- Fluoride application
- Age-appropriate anticipatory guidance
- Radiographs, when indicated
Oral health professionals then use information from the patient interview in conjunction with clinical findings to determine caries risk. Using the caries risk assessment and caries assessment tools (CAT), clinicians are able to determine the likelihood of a child developing caries.6,7 Dentists can then use these data to create a patient-tailored approach to caries prevention. And sales reps can arm them with the caries prevention tools they need.
ORAL HEALTH EDUCATION
Because parents/caregivers are primarily responsible for influencing diet and hygiene practices among pediatric patients, clinicians are encouraged to engage and allow them to observe proper hygiene techniques, identify teeth with significant plaque accumulation, pinpoint teeth with early or advanced caries, and discuss other conditions of concern during the prophylaxis and exam. Sales reps should know that both plaque-disclosing solutions and hand mirrors play an important role in the education process. Then, based on evaluation of oral hygiene and caries risk assessment, as well as the overall diagnosis, the dental team will summarize the findings, develop a preventive/treatment plan, and determine which recommendations to suggest.
Another approach is motivational interviewing and self-management goals to elicit behavior change and increase compliance with recommendations.8,9 This approach engages the parent/caregiver to connect with self-identified goals to strengthen the intrinsic motivation for positive and realistic changes.10 That’s because an extensive list of recommendations can be overwhelming — especially for first-time parents or children having their first dental exam. In fact, studies indicate that oral health instructions should identify one or two key goals through the motivational interviewing process described above.6 At subsequent appointments, progress toward meetings these goals can be revisited. When they are achieved, new goals can be established.
POINT OF SALE | PREVENTIVE PRODUCTS FOR THE WIN
- Sales reps can aim their sales pitches at prevention and the products that assist in this goal.
- Prophylaxis and in-office fluoride treatments are used in every pediatric dental practice; capitalize on this knowledge to make a sale.
- Radiographs may be indicated in practices with pediatric patients, and ancillary products designed especially for little mouths come in handy.
- Oral health professionals exercising prevention also commonly utilize fluoride varnish, restorative materials, handpieces, and sedation products.
- Anesthesia should be used with great caution.
- Manual and power toothbrushes, 2-minute timers, fluoride toothpaste, mouthrinse and floss are commonly discussed products in the pediatric setting, collectively compromising a great opportunity for sales.
- In-office visual aids are heavily relied upon for the purpose of patient education.
CARIES MANAGEMENT STRATEGIES
Approaches to treatment vary and are influenced by many factors. Sales reps are better positioned to sell when they understand to whom the dentist is catering when making product recommendations.
One important reason for early and regular dental visits is to identify incipient lesions so clinicians can attempt to arrest or recalcify them with fluoride varnish and favorable home care.11 Adjuncts to fluoride therapy include the use of chlorhexidine gluconate and povidone iodine.12 While these are effective for reducing the bacterial load, there is mixed evidence supporting their use as anti-caries strategies.13–16 A child with an active caries process is considered high risk and should be seen on a three- to six-month schedule.6 Children who are low risk require less frequent recare appointments.
When a lesion has become cavitated, clinicians must decide whether treatment is necessary or if restorative therapy can be delayed. This decision is based on the rate and extent of decay, and the likelihood the child will cooperate during treatment.17 Such patients may require interim restorations with the use of a spoon or slow-speed handpiece for caries excavation, followed by placement of a restorative material, such as glass ionomer.18 The goal is to remove the most active part of the lesion,19 avoid the use of anesthetic agents, and buy time for the patient to reach an age where he or she can cooperate for a definitive restoration. If a child has advanced treatment needs and/or does not have the means to cooperate for restorative care, advanced behavior guidance — such as protective stabilization, moderate sedation or general anesthesia — may be necessary.20 Due to recent media attention and studies of safety concerns with moderate sedation and general anesthesia in children — particularly repeat exposures and exposure early in life — dentists are advised to exercise extreme caution.21
The U.S. Food and Drug Administration (FDA) has granted a “breakthrough therapy” designation to silver diamine fluoride (SDF) 38% for use in arresting caries in children and adults. This agent was previously cleared by the FDA for treating dentinal hypersensitivity. Although silver-based products have a long history of use in medicine and dentistry, SDF was not given FDA clearance for dental use in the United States until 2014. Initial research into its capacity to inhibit caries progression is promising. It can be used by dental and nondental providers in the secondary and tertiary treatment of caries. Most protocols for SDF were once empirical in nature.22 The AAPD recently released evidence-based guidelines developed from the results of trials,23 confirming SDF appears to be a cost-effective and easy-to-use option for caries management.24
Again, the purpose of early dental care is to prevent the onset of disease. If primary prevention is not successful, the hope is that early and regular dental visits will slow caries progression and allow for early detection.11
Up to 90% of caries in school-aged children occur in pits and fissures. In 2016, the American Dental Association and AAPD concluded that: (1) sealants are effective in preventing and arresting pit-and-fissure lesions of primary and permanent molars in children and adolescents; (2) they can minimize the progression of noncavitated occlusal caries lesions; and (3) there is insufficient evidence to support one type of sealant material over others.25 Sealants on at-risk molars provide a cost-effective way to reduce the risk of caries in these teeth. Subsequent recalls should include verifying the sealant is still present and replacing or repairing sealants when appropriate. Though sealants provide a means of reducing caries in pits and fissures, it is important to remind parents/caregivers that sealants do not prevent gingival disease or reduce the risk of caries to smooth surfaces.
This discussion reflects the spectrum of caries management, with the least invasive approach being watchful observation of early lesions, along with the application of fluoride (or other medicaments, such as SDF), and the most invasive being treatment under moderate sedation or general anesthesia.17,18 Sealants may be a means of primary and secondary prevention in at-risk pits and fissures.
INVENTIONS FOR PREVENTION
Brushing with fluoride toothpaste twice daily and daily flossing are two easy ways to prevent oral health disparities, however, based on limited data, compliance remains low.26 Clinicians hear from parents/caregivers many reasons for nonadherence,27 such as uncooperative children, busy schedules, the belief that caries are inevitable, and lack of oral health knowledge, among others.28 The AAPD recommends the use of fluoride-containing toothpaste for dentate children of any age.29 Recent changes in the recommendation stating that fluoride toothpaste is universally indicated for all children, regardless of caries risk, is a common point of confusion for parents/caregivers, medical professionals and even some dental providers. This is particularly important as fewer people drink municipally available, optimally fluoridated water due to concerns about water safety.
A simple means of monitoring the amount of fluoride that a child may potentially ingest is by controlling the amount of toothpaste placed on a toothbrush. Children younger than age 2 should have only a smear of toothpaste (0.125 gram), while children ages 2 to 5 should receive a pea-sized amount (0.25 gram).27 Sales reps can remind clinicians that appropriate, age-specific quantities should be demonstrated to parents/caregivers, who may have difficulty applying the correct amount.30 The fluoride content in most nonprescription pediatric and adult toothpaste is the same; the only difference is flavoring that may be more palatable to children. While fluoride-free “training toothpastes” are available, they are of little benefit and send the message that fluoride toothpastes are not safe for young children.29
Many dental practices “award” patients or parents/caregivers with a goodie bag containing a toothbrush, toothpaste, floss, mouthrinse and other kid-friendly products. Sales reps should know this can send mixed messages. While mouthrinses and novelty products might be fun to use, brushing with the proper frequency, duration and technique — and using fluoride toothpaste — is the best preventive measure.
The AAPD recommends flossing once the interproximal spaces between primary teeth are closed because they are no longer cleansable with a toothbrush.31 Knowing this, sales reps can pitch flossing aids, which may be easier for children or parents/caregivers to use.
Mouthrinse or fluoride rinse should never be a substitute for proper brushing and flossing; rather, they should only be used as adjuncts to an appropriate home-care regimen. Manual and electric toothbrushes can both be effective in plaque removal when used with the proper technique, duration and frequency.32 For this reason, one of the best giveaways in a goodie bag is a 2-minute timer. If electric toothbrushes bear a certain level of novelty, have built-in timers, and make the process fun for the children — thereby increasing compliance — clinicians may wish to recommend these products… and make a great sell as a rep.
Toothbrushing with a soft-bristled, appropriately sized toothbrush should begin when the first teeth begin to erupt.32 Initially, toothbrushing is performed solely by the parent/caregiver. Toddlers may enjoy chewing on toothbrushes, but it is important for parents/caregivers to continue to brush for the child, playing an active role until the child has developed sufficient manual dexterity. This normally occurs around age 8, but, even at this age, parents/caregivers need to reinforce brushing frequency and technique. One strategy that is mutually beneficial for children and parents/caregivers is to encourage brushing together. This not only reinforces brushing habits, it allows for direct supervision and for the adult to model appropriate technique. Although infant products with rubber bristles may serve as gum stimulators and teething toys, they are not particularly effective for plaque removal, consequently, they should not be used as substitutes for toothbrushes. Cold teething rings and other soft teething products stimulate the gums and may alleviate discomfort when primary teeth are erupting.33 Topical benzocaine products should not be used in children younger, however, due to the risk of methemoglobinemia.33
Sales reps can offer preventive products to their customers to assist oral health professionals with their mission to deliver effective dental care to children of all ages. Recent trends focus more on prevention, and many products exist that cater to this increasing need. Clinicians employ a variety of treatment modalities and caries control measures, depending on the rate and extent of patients’ decay. Oral health literacy and parent/caregiver engagement through motivational interviewing are essential to elicit behavior change, and hands-on tools will aid in delivery of such messaging. To increase the likelihood of compliance, the dental team can recommend various kid-friendly products, but emphasize that brushing with fluoride toothpaste and using floss regularly are the most effective anticaries hygiene practices.
The article was adapted from one previously published in Decisions in Dentistry.
- American Academy of Pediatric Dentistry. Policy on the dental home. Pediatr Dent. 2016;38:12.
- Nowak AJ, Casamassimo PS. The dental home: a primary care oral health concept. J Am Dent Assoc. 2002;133:93–98.
- Lee JY, Bouwens TJ, Savage MF, Vann WF Jr. Examining the cost-effectiveness of early dental visits. Pediatr Dent. 2006;28:102–105.
- Segura A, Boulter S, Clark M, et al. Maintaining and improving the oral health of young children. Pediatrics. 2014;134:1224–1229.
- Nasseh K, Vujicic M, O’Dell A. Affordable Care Act expands dental benefits for children but does not address critical access to dental care issues. Available at: ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0413_3.pdf. Accessed January 8, 2018.
- Ramos-Gomez FJ, Crall J, Gansky SA, Slayton RL, Featherstone JD. Caries risk assessment appropriate for age 1 dental visit (infants and toddlers). J Calif Dent Assoc. 2007;35:687–702.
- Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health Prev Dent. 2004;2 (Suppl 1):259–264.
- Weinstein P, Harrison R, Benton T. Motivating parents to prevent caries in their young children: one-year findings. J Am Dent Assoc. 2004;135:731–738.
- Kay EJ, Logam HL, Jakobsen J. Is dental health education effective? Systematic review of current evidence. Community Dent Oral Epidemiol. 1996;24:231–235.
- Rollnick S, Miller WR. What is motivational interviewing? Behav Cogn Psychother. 1995;23:325–334.
- Featherstone JD. Caries prevention and reversal based on the caries balance. Pediatr Dent. 2006;26:128–132.
- Milgrom P, Chi DL. Prevention-centered caries management strategies during critical periods in early childhood. J Calif Dent Assoc. 2011;39:735–741.
- Autio-Gold J. The role of chlor¬hexidine in caries prevention. Oper Dent. 2008;33:710–716.
- van Rijkom HM, Truin GJ, van’t Hof MA. A meta-analysis of clinical studies on the caries-inhibiting effect of chlorhexidine treatment. J Dent Res. 1996;75:79–795.
- Nowak A, Casamassimo PS. Using anticipatory guidance to provide early dental intervention. J Am Dent Assoc. 1995;126:1156–1163.
- Lopez L, Berkowitz R, Spiekerman C, Weinstein P. Topical antimicrobial therapy in the prevention of early childhood caries: a follow-up report. Pediatr Dent. 2002;24:204–206.
- Nelson T. The continuum of behavior guidance. Dent Clin North Am. 2013;57:129–143.
- American Academy of Pediatric Dentistry. Policy on early childhood caries: unique challenges and treatment options. Pediatr Dent. 2016;38:55–56.
- American Academy of Pediatric Dentistry. Policy on interim therapeutic restorations (ITR). Pediatr Dent. 2016; 38:50–51.
- American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent. 2011;33:161–173.
- Sun LS, Li G, Miller TL, et al. Association between a single general anesthesia exposure before age 36 months and neurocognitive outcomes in later childhood. J Am Dent Assoc. 2016;315:2312–2320.
- Horst JA, Ellenikiotis H, UCSF Silver Caries Arrest Committee, Milgrom PM. UCSF protocol for caries arrest using silver diamine fluoride: rationale, indications, and consent. J Calif Dent Assoc. 2016;44:16–28.
- Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent. 2017;39:135–145
- Cheng LL. Limited evidence suggesting silver diamine fluoride may arrest dental caries in children. J Am Dent Assoc. 2017;148:120–122.
- Wright JT, James JC, Fontana M, et al. Evidence-based clinical practice guideline for the use of pit-and-fissure sealants: a report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc. 2016;147:672–682.
- Inglehart M, Tedesco LA. Behavioral research related to oral hygiene practices: a new century model of oral health promotion. Periodontol 2000. 1995;8:15–23.
- Collett BR, Huebner CE, Seminario AL, Wallace, E, Gray KE, Speltz ML. Observed child and parent toothbrushing behaviors and child oral health. Int J Paediatr Dent.2016;26:184–192.
- Bakdash B. Current patterns of oral hygiene product use and practices. Periodontol 2000. 1995;8:11–14.
- American Academy of Pediatric Dentistry. Guideline on fluoride therapy. Pediatr Dent. 2016;38:181–184.
- Thomas AS. Graduate thesis: Parents’ interpretation of instructions to control fluoride toothpaste application. Available at: depts.washington.edu/mchprog/docs/abstracts/2011/ThomasAbstract.pdf. Accessed January 8, 2018.
- American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatr Dent. 2016;38:133–141.
- Robinson PG, Deacon SA, Deery C, et al. Manual versus powered toothbrushing for oral health. Cochrane Database Syst Rev. 2005;18.
- U.S. Food and Drug Administration. Benzocaine Topical Products: Sprays, Gels and Liquids — Risk of methemoglobinemia. 2011. Available at: nwcemss.org/assets/1/clinical_practice_alerts/Benzocaine_Topical_Products_4-11.pdf. Accessed January 8, 2018.