CME

Earn Category I CME credit by reading this article and the article beginning on page 46 and successfully
completing the posttest on page 51. Successful completion is defined as a cumulative score of at least 70%  
correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME
credit by the AAPA. The term of approval is for 1 year from the publication date of July 2012.

Learning objectives
●● Describe the concept of a dental home for children
●● Perform an appropriate oral health risk assessment and physical examination for children
●● Recognize effective preventive strategies and treatment for dental decay/caries as well as when a
referral to a dental professional is appropriate

Maximizing oral health in children:

A review for physician assistants
Too many children do not have access to dental care, but primary care physician assistants
can easily add an oral health assessment to their usual examinations.

Christopher R. Castellano, PA-C; Denise Rizzolo, PA-C, PhD

E
arly childhood caries (ECC) have been on the
rise, with the prevalence of ECC in children
aged 2 to 5 years increasing from 24% in 1988-
1994 to 28% in 1999-2004.1 Oral health in
young children is a concern not only for pediat-
ric dentists but also for primary health care providers: many
children do not have access to dental insurance or pediatric
dental specialists, and dental caries among children in the
United States are the single most common childhood dis-
ease—5 times more common than asthma and 7 times more
common than hay fever.2

© Figures 1, 3, and 4 reprinted with permission of Joanna Douglass, BDS, DDS,

A dental professional can prevent caries in children with
continuous and proactive dental health care comprising
periodic examinations and preventive treatments. In 2000,
however, the US Surgeon General reported that more
than 108 million children and adults lacked dental insur-
ance. This is 2.5 times greater than the number of people
and Smiles for Life (www.smilesforlifeoralhealth.org).

who lacked medical insurance.2 Without dental insurance,

many children will not see a pediatric dentist for appropri-
ate services and treatment. In 2003, only 38% of children
aged 2 to 17 years who were classified as low income were
seen for a dental checkup, while 60% of all middle- and
high-income children in the same age group had a routine
checkup.3 Additionally, there is a great discrepancy with
regard to oral health disparities. Non-Hispanic blacks,
Latinos, American Indians, and Alaskan natives generally
have the poorest oral health of racial and ethnic groups in
the United States. Furthermore, the greatest racial and eth-
nic disparity among children aged 2 to 4 years and aged 6
to 8 years is seen in Mexican American and non-Hispanic
black children.4 Figure 1. Lap-to-lap examination

28 JAAPA • july 2012 • 25(7) • www.jaapa.com
 Because so many children lack dental insurance, PAs can TABLE 1. Common medications causing xerostomia
work collaboratively with dentists and help provide oral ACE inhibitors Beta blockers
health assessments and examinations during well-patient
Alpha blockers Calcium channel blockers
visits. This can expedite treatment when needed and
decrease the extent of dental disease, while improving over- Analgesics Diuretics
all prognosis and reducing health care costs that may result Anticholinergics Muscle relaxants
with untreated and advanced dental disease. PAs can play
Antipsychotics Sedatives
a significant role in children’s oral health by providing oral
examinations and referrals, being proactive in identifying Anxiolytics
risk factors, and offering preventive care and education on Reprinted with permission from Essary AC, for the Clinical and Scientific Affairs Council of
personal hygiene and proper brushing techniques as well as the AAPA (CSAC). Oral health: caring for primary care patients. JAAPA. 2011;24(5):27-28.

ancillary guidance about flossing, fluoride treatments, and

antibacterial mouth rinses to both children and their fami-
lies. In order to increase access to dental care, PAs should
keep abreast of information on oral health conditions and
their treatment, as they may be the first or only clinicians to
evaluate some patients.
THE PATIENT-CENTERED MEDICAL HOME
In 1992, the American Academy of Pediatrics (AAP)
created the concept of a medical home in which children
would receive organized, readily available health care
through the establishment of an ongoing relationship
between caregiver and practitioner.5 Within the medical
home should be a dental home that would include a net-
work of practitioners specializing in proactive dental care
ranging from preventive oral care and education to emer-
gency dental services requiring advanced care and quick
referrals to pediatric dental specialists.
Clinicians would establish a schedule for early oral exam-
inations, assess risk, and provide parental education. The
American Academy of Pediatric Dentistry (AAPD) recom-
mends that the first dental examination occur as early as
age 6 months and no later than 1 year.6 Examinations at 6
months are recommended to provide anticipatory guidance
to caregivers, because this is the age at which initial tooth
eruption begins. By age 3 years, 5% to 10% of preschool
children have oral health issues, and by age 5 years, 60%
of school-age children will have experienced dental caries.5
More than 50% of all children aged 3.5 years and younger
have their first health care encounter for a dental-related
illness in the emergency room (ER).7 Prevention, risk fac-
tor assessment, and early detection of caries can reduce the
number of school-age children with caries. Prompt checkup
visits have the benefits of early intervention.
CONSEQUENCES OF POOR ORAL HYGIENE
Poor oral health and dental illness, specifically in low-
income areas, can have a major impact on a child’s well-
being. For example, if an infection or tooth decay is left
untreated, the resulting pain can lead to problems in eating,
speaking, and attending to learning.8 Cavities can cause
extreme pain, difficulty chewing, malnourishment, and
poor weight gain. If a child is in pain due to dental disease,
school attendance, along with mental and social well-being
while at school, can be negatively affected.9 Socioeconomic
outcomes of oral health disease can diminish quality of
life in both child and caregiver and cause physical and
developmental delays, days of restricted activity (eg, missed
schooldays, missed workdays on the part of the caregiver),
and increased health care costs.10
Additionally, untreated dental carries can lead to abscess
formation, which can require costly hospital treatment and
care. A study by Pettinato and colleagues demonstrated that
inpatient hospital treatment of acute dental conditions without
prior preventive measures resulted in higher costs than pro-
viding anticipatory outpatient dental care in children at risk of
dental caries. The authors found that the costs of managing
dental caries-related symptoms on an inpatient basis were 10
times those of providing preventive dental care for these same
patients.11 In children at increased risk of poor oral health,
early intervention and prompt referral to a dentist is more
cost-effective and can improve a child’s quality of life.
Continued on page 30

Key Points
■■ Nondentist health care clinicians may be the first or only clinicians to evaluate the oral health of some children.
■■ A dental home would provide a network of practitioners specializing in proactive dental care ranging from preventive oral care and
education to emergency dental services requiring advanced care and quick referrals to pediatric dental specialists.
■■ By the age of 3 years, 5% to 10% of preschool children have oral health issues, and by age 5 years, 60% of school-age children will
have experienced dental caries.
■■ More than 50% of all children aged 3.5 years and younger have their first health care encounter for a dental-related illness in the
emergency room (ER).
■■ In children at increased risk of poor oral health, early intervention and prompt referral to a dentist is more cost-effective and can
improve a child’s quality of life.

www.jaapa.com • july 2012 • 25(7) • JAAPA 29
CME Pediatric oral health
PATHOPHYSIOLOGY OF DECAY
Dental caries are a chronic infectious disease of oral bacteria
that causes damage to the framework of teeth, resulting in
extreme pain and loss of function, and may spread. Teeth
are composed of three major layers: the enamel, the dentin,
and the pulp chamber. The enamel structure is composed
of hydroxyapatite, along with trace amounts of fluoride,
chloride, sodium, and magnesium. Although enamel is the
hardest mineralized substance in the body, it is still porous.
The dentin layer is less mineralized than enamel. The pulp
chamber is the innermost part of the tooth and houses
blood vessels and nerves.
Tooth decay begins on the outer enamel and continues
deeper into the tooth structures. Pain from tooth decay
occurs only when the infection has entered the pulp cham-
ber, by which time most of the tooth is destroyed. The prin-
cipal bacteria responsible for dental caries are Streptococcus
mutans and Streptococcus sobrinus.12 Colonization of these
bacteria occurs after birth through vertical transmission
from a caregiver.13 The bacteria are predominantly transmit-
ted from the mother or caregiver’s mouth into the child’s
mouth through direct contact, such as kissing or sharing
food. The bacteria initiate the decay of dental enamel by
metabolizing carbohydrates into acid, which then demin-
eralizes the tooth enamel. Demineralization causes the
enamel to weaken. Total destruction will inevitably lead to
a cavity.
The frequency and consistency of meals is a factor in
tooth decay. The bacteria will continue to metabolize sugar
into acid for 20 to 40 minutes after a meal containing car-
bohydrates. Therefore, cessation of demineralization will
occur only after acid production stops. The more frequently
carbohydrates are ingested, the greater the production of
acid leading to demineralization and the less time for remin-
eralization to occur.
Saliva provides protection against tooth decay by buffer-
ing acid production, which then allows remineralization of
the tooth enamel. Reduced saliva production decreases the
ability to buffer acid production, making teeth more suscep-
tible to decay. Xerostomia or decrease in saliva production
can be caused by several common classes of medications
Table 1.14 Fortunately, these medications are not commonly
used in children.
PHYSICAL EXAMINATION
The knee-to-knee position works best for the physical examina-
tion in infants and young children. The caregiver sits knee-to-
knee with the clinician, while the child sits in the caregiver’s lap
facing the examiner. The caregiver can then restrain the child’s
arms and head, while the examiner opens the child’s mouth
with a tongue blade. The child can also sit across the caregiv-
er’s lap, with his or her head leaning onto the examiner’s lap,
as the caregiver holds the child’s hands and legs so the exam-
iner can perform the oral examination (Figure 1). Assessment
includes observing the face and neck for symmetry and skin
lesions, the gums for irritation and infection as well as plaque
30 JAAPA • july 2012 • 25(7) • www.jaapa.com
© Photo Researchers, Inc. / Pascal Goetgheluck
Figure 2. Healthy teeth
and tartar along the gum line, the buccal mucosa for lesions,
the tongue, the palate, and the posterior pharynx. In addition,
the examiner should take note of the child’s hygiene as well as
palpate the neck for lymphadenopathy.
The examiner should assess the oral palate by lifting the
lip to inspect the soft-tissue structures of the buccal mucosa
and gingiva for any signs of irritation, infection, or bleed-
ing. This should be followed with an examination of the
teeth for presence of plaque, dental decay, or white spots;
defects in the tooth enamel; and/or the presence of dental
overcrowding.
Teeth should be creamy white in color with no signs of
irregularities, roughness, or color deviations (Figure 2).
White spots or lines are more easily seen when the teeth
are dry. They are the earliest indication of decay, which
resembles demineralized enamel (Figure 3). Left untreated,
white spots will eventually turn a yellowish color and
result in cavities. Brown spots indicate late signs of decay,
in which enamel has been lost and the underlying dentin
is exposed (Figure 4). Immediate dental referral and topical
fluoride treatments are necessary to halt progression of
the lesion.
RISK ASSESSMENT
An oral health risk assessment by a qualified clinician is
recommended for all children by the age of 6 months.6 At 2
months of age, parents should be educated by a clinician on
proper oral hygiene. Specifically, parents should be advised
against propping the bottle under the baby’s mouth while
in a supine position, as this increases the risk of a condition
called nursing bottle caries or milk teeth syndrome. A caries
risk assessment should be performed as early as 4 months
of age. The Caries-risk Assessment Tool (CAT) has been
published by the AAPD.15
The risk of caries is greatly increased in the child with a
history of previous caries, low socioeconomic and educa-
tion status, poor access to health care, inadequate fluoride
treatment, and/or poor oral hygiene. At age 6 to 9 months,
children should start using (with parental assistance) a
smear of fluoride toothpaste to brush their teeth as soon as
they erupt. Parents should introduce a cup for drinking at
 White line Early cavity
Figure 3. Early childhood caries
about 6 months of age or when the infant has the ability to
grasp a sippy, or no-spill, cup and begin to wean the toddler
from the bottle by the age of 1 year. Children older than 12
months should have regular dental checkups. Guidelines
and protocols are available in an article by Ramos-Gomez
and colleagues.16 A pocket guide to oral health is an impor-
tant aid for the clinician assessing pediatric patients and
available at the Smiles for Life Web site.
TOOTH ERUPTION
Primary tooth eruption occurs between the ages of 6 and
33 months, with central incisors being the first to erupt (as
early as 6 months of age) and the second molars being the
last to erupt (as late as 33 months of age). The primary
teeth are shed between the ages of 6 and 12 years, after
which the permanent teeth erupt; in some patients, the third
molars erupt as late as 21 years of age. Figure 5 provides
a diagram of the primary teeth and the ages at which they
erupt and are shed.
PREVENTION STRATEGIES
Limit carbohydrate consumption. The importance of
reducing dietary sugar should be emphasized to both care-
givers and children. Frequency of carbohydrate consump-
tion is the main contributor to an increased risk of dental
caries. Juice, soft drinks, and other sugary fruit drinks
given via a sippy cup increase the risk of dental caries
formation; therefore, sippy cups given to a child before he
goes to sleep should be filled only with water. As previous-
ly noted, parents should avoid bottle propping. Frequent
consumption of sugary snacks can also increase the risk of
dental caries in young children.17 The AAPD recommends
that children younger than 6 years consume no more than
4 to 6 oz of fruit juice from a bottle or sippy cup in any
24-hour period.12
Brushing and flossing. Teeth should be brushed and
flossed daily to help remove plaque. Bacteria live in plaque;
therefore, removing plaque will prevent tooth decay and
decrease the risk of dental caries.15 The importance of
removing plaque when it is soft is to prevent calculus forma-
tion, which is caused by the initial demineralization of tooth
Figure 4. Severe early childhood caries
enamel and eventual mineralization of plaque, a process
that can occur within 24 hours. Calculus is hard, cannot
be brushed away, and requires professional cleaning to be
removed. The formation of calculus creates an environment
in which bacteria flourish.
PAs can provide education about brushing teeth with
fluo­ride toothpaste and demonstrate to caregivers the
proper method in which the caregiver sits behind the child,
lifting the lips and brushing along the gums and teeth.
Proper technique requires a small circle pattern or back-and-
forth movements, also called the Bass technique. Children
should spit out toothpaste but not rinse after brushing to
increase fluoride exposure of the oral palate. Teeth should
be brushed once in the morning and once at bedtime, with
only a smear of toothpaste for children younger than 2
years of age and a pea-sized amount for children aged 2
years and older.6 No food or drink is permitted after brush-
ing at bedtime or for 30 minutes after brushing in the morn-
ing. Caregivers should continue brushing the teeth until
children are 6 years old, when they are responsible enough
to take over.
Fluoride supplementation and fluoride varnish. The use
of topical fluoride either in the form of a mouth rinse or
fluoride varnish or in toothpaste is known to reduce demin-
eralization of enamel and promote remineralization as well
as provide an antibacterial effect on teeth. Mouth rinse con-
taining 0.05% sodium fluoride used once a day or 0.02%
sodium fluoride used twice a day has been shown to reduce
plaque and promote enamel remineralization, leading to
fewer dental caries in children.6
Fluoride varnish is recommended for children at moderate
to high risk for caries. Fluoride varnish can slow, stop, and
SEE THE ONLINE VERSION
OF THIS ARTICLE TO LINK TO
Smiles for Life Web site
www.smilesforlifeoralhealth.org
Smiles for Life pocket guide to risk assessment
and fluoride supplementation
www.fmdrl.org/index.cfm?event=c.
getAttachment&riid=5588
www.jaapa.com • july 2012 • 25(7) • JAAPA 31
CME Pediatric oral health
Primary teeth
Upper teeth Erupt Shed
Lower teeth Erupt Shed
Figure 5. Schedule of tooth eruption in children
Figure 6. Moderate fluorosis
reverse dental disease by 40% to 50%.18 Remineralization
occurs when the tooth’s hydroxyapatite is replaced with
fluorapatite, which is more resistant to demineralization.
Application of fluoride varnish is simple and requires little
training and skill. Dental cleaning is not required prior
to application, and fluoride varnish dries immediately on
contact with saliva. With the application of varnish, remin-
eralization will slowly occur. Fluoride varnish can be applied
as often as every 3 months, but ideally, it should be applied
every 3 to 6 months in moderate- to high-risk patients.
In many states, application of fluoride varnish will be reim-
bursed only when it is applied once every 180 days from the
age of 6 months until age 3 years. If the child is at high risk
as determined by the CAT, fluoride varnish can be applied
after age 3 years. Fluoride varnish takes less than 2 minutes
to apply; the average reimbursement is about $26 per ap-
plication. Medicaid is now reimbursing primary care clini-
cians in 38 states for applying fluoride varnish to the teeth
of young children.19 Visit the Smiles for Life Web site, which
also provides teaching modules that include theoretical and
32 JAAPA • july 2012 • 25(7) • www.jaapa.com
practical information for applying fluoride varnish for novice
clinicians.
Fluoride is often added to the local water supply. Optimal
water fluoridation is 0.7 parts per million (ppm). Children
receiving adequate fluoride from drinking local tap water
should not be supplemented.20 Contact your local public
health department for current fluoridation levels of your
municipality’s drinking water. For children who are not
receiving enough fluoride from the water supply, the pocket
guide at the Smiles for Life Web site will help determine the
amount of fluoride to be supplemented.
While the use of fluoride greatly reduces the risk of car-
ies in children, intake of too much fluoride while teeth are
developing will cause fluorosis, which is discoloration of
teeth due to chronic fluoride exposure (Figure 6).
Other preventive measures. Preventive hygiene includes
chewing xylitol gum and using chlorhexidine wash (Peridex,
Periogard, generics) to reduce the transmission of bacteria
from the caregiver to infant during the postpartum peri-
od.21 Chewing xylitol gum at least two to three times a day
appears to prevent transmission of cariogenic bacteria from
caregiver to infant.6 This will reduce the development of
dental caries and formation of plaque while increasing flow
of saliva, which will help remineralize teeth.
FURTHER EDUCATION FOR PRACTITIONERS
According to the CDC, goals for 2012 include the pre-
vention and control of dental caries across all life stages,
increasing infrastructure capacity of state oral health pro-
grams, and improving the effectiveness and prevention of
disease transmission in a dental health care setting.22 The
Smiles for Life Web site provides free continuing medical
education credits to PAs, nurse practitioners, students, and
other clinicians. Smiles for Life is the nation’s only compre-
hensive oral health curriculum. Developed by the Society
Figure 5 reprinted with permission of Smiles for Life (www.smilesforlifeoralhealth.org) 
of Teachers of Family Medicine Group on Oral Health
and now in its third edition, this curriculum is designed to
enhance the role of primary care clinicians in the promotion
of oral health across the life span via the development and
dissemination of high-quality educational resources. JAAPA
Christopher Castellano graduated from the Seton Hall University PA ­program
in South Orange, New Jersey. Denise Rizzolo is an associate professor in the
Seton Hall PA program, works at the Care Station in Springfield, New Jersey,
Figure 6 © Photo Researchers, Inc. / Dr. P. Marazzi
and is an invited speaker for the AAPA Oral Health Chapter Series. The authors
have indicated no relationships to disclose relating to the content of this article.
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www.jaapa.com • july 2012 • 25(7) • JAAPA 33