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Dental Screening and Risk Assessment
for the Very Young Child
Michael J. Kanellis, DDS, MS
Department of Pediatric Dentistry, University of Iowa College of Dentistry
Fall 1999
Tooth decay remains one of the most common diseases of childhood. It is even more prevalent among
children from low-income families -- 80% of decay occurs in just 25% of American children. These
children also develop caries at an earlier age.
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The first step in preventing dental decay is to screen children to identify those who
are at risk. The American Academy of Pediatric Dentistry (AAPD) recommends that
children be examined by a dentist when they are a year old, or within 6 months of the
eruption of the first tooth. However, most low-income, high-risk children do not see a
dentist before the age of three. In Iowa, that may be due in part to the fact that
fewer than half of all dentists see Medicaid patients. To complicate matters further, a
1995 survey of Iowa dentists found that only 26% were willing to provide dental exams
to very young children.
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For all of these reasons, it is important that non-dentists -- dental hygienists, physicians,
nurses, and other health care providers -- provide dental screenings as part of a young child’s
health care. Whenever possible, each child should also be referred to a dentist, so that each will
have a "dental home" throughout childhood.
The dental screening
An oral screening exam should:
- Determine the state of the child’s oral health
- Identify abnormalities or pathologies, including caries
- Provide instruction in how to prevent dental disease
- Capitalize on "teachable moments" during which anticipatory guidance can be provided to the child’s parents
Screenings can typically be carried out with a small armamentarium -- a mouth mirror, soft
toothbrush, rubber gloves, and a light source. Children younger than three are often uncooperative
during oral exams. Parents need to be reassured that crying is normal, and that the exam will not
hurt the child.
To proceed with a dental screening:
- With gloved hands, retract the lips from the teeth and evaluate for plaque.
- Use a soft toothbrush to brush all surfaces of the teeth, removing any plaque, and examine all tooth surfaces.
- Use the dental mirror to carefully examine the back (inside) surface of the upper front teeth. This is where baby bottle tooth decay often appears first.
- Following brushing, all teeth should have a uniform healthy white appearance. Any stains, discolored areas, holes, or chalky-white areas are cause for concern.
Caries risk assessment
Most children enrolled in EPSDT are from low-income families, and are thus at higher risk for dental
decay than other children. Not all low-income children experience similar levels of dental disease,
however. Individual risk assessment allows interventions to be targeted to the children who need it
most.
Tooth decay results from the interaction of bacteria, dietary carbohydrates, and tooth enamel.
Decay can appear on a tooth's chewing surface, or on one of the "smooth surface" sides
of a tooth. Some indications that a child is at risk for caries include:
History of previous caries. One of the best predictors of future caries is a
history of dental decay. With children under the age of 5, a history of caries automatically
places a child at very high risk for future decay. Evidence of previous caries includes
current untreated caries (visible "holes" or cavities in the teeth) as well as
fillings or caps.
Stained fissures. When cavities begin on the chewing surface, the first visible
sign of decay is often stained grooves that cannot be adequately cleaned with a toothbrush.
Deep crevices on the chewing surfaces of teeth can trap food and bacteria and lead to decay.
The pit and fissure surfaces of baby teeth are generally not stained in appearance, and
therefore discoloration in these sites that cannot be removed with a toothbrush should be
viewed with suspicion.
White spot lesions. The first signs of a cavity starting on a smooth tooth
surface is the formation of a "white spot lesion." These pre-cavity lesions result
from enamel being demineralized by the acid produced by bacteria contained in plaque. These
lesions are generally found near the gum line where plaque accumulates, and look chalky and
white.
Visible plaque. Plaque appears as a soft, white- or tooth-colored coating that
generally accumulates first near the gum line. Research indicates that the presence of visible
plaque on the teeth of young children is a reliable indicator of caries risk.
Perceived risk by health professionals. Many dentists, hygienists and other
health professionals can predict caries risk status with a high degree of reliability. An
examiner's "gut reaction" regarding a child’s risk for caries should not be
ignored.
Establishing a "dental home"
Whenever possible, each child screened should be referred to a dentist. It is important to establish
a dental home for each child, one that will provide diagnostic, preventive, restorative, and
emergency care throughout childhood.
References
American Academy of Pediatric Dentistry Home Page, at
http://aapd.org, has information for children,
parents, teachers, and health care providers.
"Dispelling the myth that 50 percent of U.S. school children have never had a cavity"
(1995). Public Health Report 110:522-30.
"Socio-demographic distribution of pediatric dental caries..." (1998). Journal of the
American Dental Association 129:1229-38.
"Risk assessment and caries protection" (1998). Journal of Dental Education
62:762-770.
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