Oral Dental Care Recommendations for Children
Children should have their first dental examination within 6 months of the first tooth eruption but no later than 12 months of age, with twice-daily fluoridated toothpaste brushing starting immediately when the first tooth appears. 1, 2
Timing of First Dental Visit
The American Academy of Pediatric Dentistry (AAPD) recommends establishing a dental home by 12 months of age, specifically within 6 months of the first primary tooth eruption. 1, 3 This represents a significant departure from the traditional recommendation of waiting until 3 years of age, which often results in extensive carious lesions and abscesses that could have been prevented with earlier intervention. 1
The rationale for early dental visits is compelling: by 3 years of age, poor oral hygiene or improper feeding habits may have already severely compromised oral health, making prevention far more difficult. 1 For high-risk populations, particularly Indigenous children who experience earlier tooth eruption and earlier bacterial colonization, the concept that "two is too late" is critical—preventive interventions must begin even earlier to be successful. 1, 2
Home Oral Hygiene Practices
Toothbrushing Protocol
Begin supervised twice-daily brushing with fluoridated toothpaste immediately when the first tooth erupts. 1, 2 The specific amounts are:
- Children under 36 months: Rice grain-sized portion of fluoridated toothpaste 1, 4
- Children 36 months and older: Green pea-sized portion of fluoridated toothpaste 1
This recommendation applies to all children, regardless of risk status, and should not be delayed. 2, 4
Age-Specific Oral Hygiene Instructions
The AAPD provides age-specific home oral hygiene instructions that should be followed throughout childhood, though the specific details are referenced in the guidelines. 1 The key principle is that oral health care begins with the very first tooth, not at some arbitrary later age. 2, 3
Fluoride Interventions
Fluoride Varnish Application
Fluoride varnish should be applied starting with the first tooth eruption, then every 3-6 months thereafter. 1, 4 This can be provided by:
- Dental health professionals in dental settings 1
- Non-dental health care providers (pediatricians, family physicians, nurse practitioners) in primary care settings 1
- Trained lay workers in community settings 1
The involvement of non-dental providers is particularly important because primary care physicians see infants far more frequently than dentists in the first year of life, creating critical opportunities for preventive intervention. 1, 3
Fluoride Supplementation
Fluoride works both systemically (incorporated into developing teeth) and topically (in saliva and plaque) to prevent caries. 3 However, fluoride supplements should only be prescribed when drinking water fluoride levels are suboptimal, and water testing should be performed before prescribing. 3
Communities should ensure access to fluoridated water and know their water supply's fluoridation level. 1
Dietary and Feeding Counseling
Prevention of Nursing Caries
Counsel parents to avoid prolonged bottle feeding and frequent consumption of sugar-containing drinks and sugary snacks. 1, 4 Prolonged feeding provides fermentable carbohydrates that create an acidogenic environment, promoting enamel demineralization and caries formation. 3
Early childhood caries (also called nursing caries or baby-bottle tooth decay) affects 1-11% of urban infants and is directly associated with prolonged feeding practices. 3
Breastfeeding Recommendations
Promote exclusive breastfeeding for the first 6 months and continued breastfeeding until 12 months of age. 1 This recommendation balances the nutritional and immunological benefits of breastfeeding with oral health considerations.
Caries Risk Assessment and Anticipatory Guidance
Discuss oral health during every well-child care visit, including caries risk assessment (CRA) and anticipatory guidance on oral hygiene and diet, starting with the first tooth eruption. 1
The critical "window of infectivity" for cariogenic bacteria (Streptococcus mutans) occurs between 19-31 months of age, making early preventive intervention essential. 3 Infants acquire cavity-causing bacteria primarily from their mothers, and colonization requires the presence of erupted teeth. 3
Parental Education Focus
Mothers are the primary source of children's dental knowledge and the main transmitters of cariogenic bacteria. 3 Poor oral hygiene and dietary habits in caregivers directly correlate with infant caries development. 3 Therefore, prenatal and preconception oral health screening, anticipatory guidance, and referral for dental care should be provided to pregnant women. 1
Advanced Caries Management
For children who develop early childhood caries despite preventive efforts:
- Silver diamine fluoride (SDF) should be incorporated into caries management protocols to decrease or arrest caries progression and reduce reliance on general anesthesia for operative repair. 1
- Interim therapeutic restoration should be considered as part of caries management protocols. 1
- Sealants on primary molars should be used to prevent caries and the need for operative repair. 1
Common Pitfalls to Avoid
Do not wait until age 2 or 3 years for the first dental visit. The traditional approach of waiting until children are "more manageable" results in missed opportunities for prevention and often means intervening only after significant disease has developed. 1
Do not delay fluoridated toothpaste use due to concerns about fluorosis. The rice grain-sized amount recommended for children under 36 months minimizes fluorosis risk while providing critical caries protection. 1
Do not assume that primary care physicians will handle all oral health needs. While physicians play a crucial role in early screening and education, establishment of a dental home with a dentist is essential for comprehensive care. 1, 3
Do not neglect maternal oral health. Addressing the mother's oral health during pregnancy and the postpartum period is a critical component of preventing infant caries, as mothers are the primary source of bacterial transmission. 1, 3
Role of Primary Care Providers
Primary care providers (pediatricians, family physicians, nurse practitioners) are uniquely positioned to deliver preventive oral health care because they see infants more frequently than dentists in the first year of life. 1, 3 Dental caries remains the single most common childhood disease that is not self-limited or amenable to antibiotics, affecting 56% of children by age 9 years. 3
Primary care providers should: