Individualized oral health anticipatory guidance can minimize caries risk and improve health outcomes. Anticipatory guidance includes:

1. Teething: Discomfort associated with tooth emergence is a common concern. It is important to counsel that over-the-counter teething gels containing benzocaine are not recommended by the US Food and Drug Administration (FDA) because of potential for serious harm, including methemoglobinemia. Best practices for teething include massaging the gums with a wet washcloth or use of cool, solid (not fluid-filled) toys or teething rings that do not present a choking hazard. Oral pain medications, such as acetaminophen, should be used sparingly for severe pain.

2. Oral hygiene: Practices important in caries prevention include:

  • Toothpaste use: Fluoride toothpaste should be used for all children, starting from tooth emergence. Do not recommend fluoride-free “training toothpaste.” From tooth emergence and until age 3 years, a grain of rice-sized (or “dab”) amount of fluoride toothpaste should be used to brush teeth morning and night. For children aged older than 3 years, or when a child can effectively spit, a pea-sized amount of fluoride toothpaste should be applied to the toothbrush. Children should be encouraged to spit after brushing, but recommended amounts of toothpaste are not expected to cause fluorosis if swallowed. Like all other medications, toothpaste should be kept out of reach of small children.
  • Toothbrushing: Brush with proper technique for 2 minutes every morning and night using a soft bristled toothbrush. Children should be assisted with toothbrushing by an adult until aged 8 or 9 years. One effective AAP campaign encouraging brushing is "Brush, Book, Bed." This campaign encourages families to have a nightly bedtime routine of brushing followed by reading a book and promoting a regular sleep time at night.
  • Flossing: Flossing should begin at any age that teeth touch. The American Dental Association (ADA) recommends flossing once daily between teeth with an interdental cleaner. There is a clear disadvantage to leaving food stuck in teeth for long periods of time (including visual appearance and odor). Dexterity improves with maturity and flossing technique improves with practice.

3. Diet and feeding practices: Dietary choices influence overall health and dental caries risk. Oral health messaging will ideally begin prenatally, continue throughout pregnancy, and be emphasized with mothers on the postpartum unit because mothers want to know about all aspects of care of their newborn. Messaging during infancy should focus on encouraging breastfeeding, early cup introduction, discontinuing bottle use by aged 12 months (especially in bed), and recommending no fruit juice consumption during the first year of life. Messaging for older children includes choosing healthy beverages, especially plain water, and limiting carbonated and sugary beverages. Children should be encouraged to choose fresh fruits, vegetables, sugar-free whole-grain snacks, and to limit soda, candy, and sweets intake. Frequent intake of carbohydrates prevents neutralization of the acid produced by the oral bacteria by saliva; therefore, eating should be limited to 3 meals per day and 1 snack between meals.

4. Fluoride use: Fluoride aids in caries prevention. Topical sources of fluoride including toothpaste, varnish, rinses, and fluoridated tap water provide the main effect of caries prevention by inhibiting tooth demineralization, enhancing tooth remineralization, and inhibiting local bacterial metabolism. The systemic mechanism of fluoride (through dietary supplements) has a lesser effect than the topical effect. Systemic fluoride is incorporated into the tooth matrix during tooth development to reduce enamel solubility and prevent enamel breakdown. The AAP and the US Preventive Services Task Force (USPSTF) recommend use of supplemental fluoride for children aged 6 months to 16 years if the drinking water is deficient in fluoride. Further discussion regarding fluoride modalities is forthcoming in part 2 of this article appearing in the February 2019 issue of Contemporary Pediatrics.

5. Injury prevention: Almost 30% of children sustain a tooth injury during childhood, with peak injuries occurring between ages 2 to 3 years in the primary dentition and 8 to 9 years in the permanent dentition. Injury prevention recommendations regarding young children include keeping one hand on infants in high places to prevent falls, avoidance of walker use, and car seats rear facing until the child is aged 2 years. Mouthguards are recommended for older children who engage in contact sports. Mouthguards decrease the risk of fractured teeth and lips, tongue, face, and jaw injuries. Three types of mouthguard protection are available including stock, boil-and-bite, and custom mouthguards, with the latter providing the best protection.


Fluoride varnish is a highly concentrated form of topical fluoride that is applied to teeth during the clinical visit to inhibit or reverse white spot lesions on the teeth. The USPSTF recommends that primary care clinicians “apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption” through age 5 years. The varnish dose is 0.25 ml unidose 5% NaF (2.26% F) and frequency can range from every 3 to 6 months, based on the child’s caries risk considerations. A comprehensive discussion regarding fluoride varnish is included in the upcoming part 2 of this article in Contemporary Pediatrics, February 2019.


Dental referrals are not just for urgent treatment. All children should be seen by a dentist (establish a dental home) by age 12 months or as soon as possible after age 1 year and then routinely throughout childhood and adolescence. Dental referral is required for definitive treatment once a specific need has been identified.

Over the past decade, medical and dental community collaboration has increased referral of children for dental care. Early dental visits may decrease cost, lessen need for subsequent dental procedures, and enhance future preventive dental visits. Families should be informed of what to expect at dental visits.

Once a specific need has been identified, treatment occurs in the dental setting. Early cavities may be stabilized using fluoride-releasing restorative materials. Severe dental caries may require fillings and/or root canals, crowns, or tooth extraction with placeholders for permanent teeth eruption. The latter procedures often require use of sedation or general anesthesia with increased cost and risk of adverse events.

Silver diamine fluoride (SDF) is a newer modality to treat primary tooth cavities. It consists of a liquid containing silver particles that is applied to a cavity and acts as a physical barrier, provides antibacterial properties, and contains fluoride to strengthen enamel. The disadvantage is permanent black discoloration of the treated tooth surface; therefore, SDF is used most often to stabilize cavities in primary teeth and in children with increased risk for harm from an invasive dental procedure.

Oral Health Anticipatory Guidance