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Dental Examination

The age-appropriate dental examination – What should I expect at my child’s first visit?

We have carefully designed our office to be a child-friendly, comfortable and fun environment. We complete our dental examination in an age-appropriate manner and work closely with children to gain their trust. We welcome your input on how you think your child will do best. With tender loving care and respect for your child’s own rhythm, we encourage your child to watch one of our stuffed animals have a “tooth check”. Then we give your child oral hygiene instructions and explain how we count teeth. We also explain how our dental “tools” are used.

When your child feels relaxed and ready, we proceed with the appointment. Children over three are usually very comfortable sitting in the dental chair alone. For toddlers and infants, we use a “knee-to-knee” technique with one parent’s help. In this position, your baby can see you while we complete the exam. Many babies accept this procedure happily, but even if there is a little fussing, the procedure only takes a few minutes.

Understanding Dental Cavities

Cavities or caries are holes in teeth that are caused by a group of germs. The most serious bacteria in this group is called mutans streptococcus. These groups of bacteria feed on sugar that is introduced to the mouth by dietary intake. Higher sugar intake means more bacteria. What makes these types of germs damaging is that they produce acid that eats away at the structure of teeth by depleting the calcium in the tooth. They also create plaque, which is a glue-like layer that allows more bacteria to stick to the tooth surfaces. It appears as a yellowish film that builds up on teeth and contains enamel-eroding acids. (reference 1-3) The first stage to a cavity is having this sticky film on a tooth surface cause topical damage to the underlying enamel. If plaque is not removed and calcium levels are not restored in the tooth surface, a chalky white spot will appear. This is the first sign of a cavity. (reference 4) Once the area without calcium becomes big enough, the surface of the tooth collapses creating a hole. The hole is the cavity. It can first appear as a honey colored defect. At this point, the bacteria is highly active and will continue to breakdown the tooth if the area is not treated. Many parents don’t even notice these stages of the disease and are only able to visualize the cavity when the damage is severe or if it eventually turns dark in color. Treating the first sign of cavities means we are able to manage the DISEASE before we have to deal with what the disease is causing, which is the actual cavities. This approach is called the medical approach to dental disease. (reference 5) Although bacteria is a key factor is dental disease, it is not the only factor in causing cavities. Genetics plays a roll as well. Teeth that are poorly formed during pregnancy and early childhood are more prone to problems. Saliva is another important factor. The type, consistency and flow rate of saliva interferes with the caries process as well. (reference 6)

Babies are not born with bacteria in their mouths. However, they can easily acquire it. The source is simply someone who already has high levels of this bacteria and can easily transmit the germs. This is usually the baby’s mother but could be the father or caregiver. It could also be a sibling who has a high cavity rate. It can happen by eating from the same spoon as the baby or letting your toddler use your toothbrush. The higher the cavity rate for parents, the more chance they will pass the germs along to their child. (reference 7,8) The easiest way to prevent this is to make sure that parents maintain optimum oral health levels. Once a child’s mouth has become colonized with mutans streptococcus, he or she will become prone to cavities in both baby and permanent teeth. (reference 9) If you have trouble with your teeth, you will need to monitor your child’s oral health closely.

Prevention

Research shows that pregnant women’s oral health can affect the future of their babies’ teeth. (reference 10) Optimum oral health for expecting mothers gives their babies a better chance at warding off decay. This can affect infants because they have a lesser chance of becoming infected with harmful bacteria through their mothers. Although starting dental prevention as early as pregnancy sounds strange, please remember that your child’s primary (baby) and permanent teeth are actually forming during this time. The period beginning with the completion of the 20-28th week of gestation and ending 1-4 weeks after birth is referred to as the “perinatal period”. The American Academy of Pediatric Dentistry (AAPD) recognizes that perinatal oral health, along with infant oral health, is one of the key factors in enhancing the opportunity for a child to have a lifetime free from preventable oral disease. Getting your teeth cleaned and addressing any dental problems before and during pregnancy is highly important. Optimum oral care and a healthy diet during pregnancy will help you and your baby together. Substances that control bacterial growth can help keep harmful bacteria at bay. Fluoride rinses and chewing gums containing Xylitol are simple ways to accomplish oral health that can be incorporated in a daily hygiene routine. (reference 11)

Establishing a dental home when your baby is born is very important. Prevention requires early examination to assess your baby’s actual risk of developing dental caries. The American Academy of Pediatric Dentistry (AAPD) has stressed the importance of a dental exam by the time the first tooth erupts and no later than one year of age. The AAPD has developed a special list called the “Caries-risk Assessment Tool” (CAT) for infants, children and adolescents. By using this assessment, we can categorize your infant, according to our findings, in a low, moderate or high caries risk category. By doing so, we are able to formalize an individualized prevention or treatment plan to minimize the risk of future dental disease. This plan is altered as your child grows. (reference 12) Parents are counseled about their child’s future dental development to know what to expect. Prevention plans include a comprehensive oral hygiene regimen, a diet evaluation, specific dental procedures such as sealants (which are a protective coating placed in the deep grooves of molars to seal them), and an individual recall schedule based on the needs of each patient. Studies have shown that the earlier a child gets a cavity, the stronger and more resistant the bacteria that cause it are. Controlling these stronger strains of bacteria is not easy. If they are not controlled, dental disease continues to affect your child’s mouth as they start to get their permanent teeth. (reference 13) It is important to understand that first permanent molars can erupt as early as five years old in some children.

Find a dental home when your child is born. Visiting a pediatric dentist for guidance at this time is very important. This is when we discuss oral hygiene, how to care for your baby’s mouth, what to expect when teething occurs, how to avoid trauma as your child learns to crawl and take those first steps, bottles, pacifiers and proper diet counseling among other topics.

Proper feeding habits should be established for young infants. The goal is get your baby used to separating eating and sleeping. This pattern is very important once the teeth erupt. Cleaning your baby’s mouth after feeding with a soft cloth will make tooth brushing seem more familiar later.

Begin brushing your child’s teeth at least twice a day as soon as they erupt and continue to help with brushing through the toddler years. Most children will learn how to brush their teeth by age 4-5. However, parental supervision is necessary to make sure brushing is done properly.

Begin flossing your child’s teeth as soon as you see a contact point or tight spot between any two teeth. Toothbrush bristles are not able to clean contact points where two teeth touch but harmful bacteria can lodge there. A very common contact point in babies is between the upper front teeth.

Healthy eating habits lead to healthy teeth. Reducing and controlling sugar intake, snacking, and continued juice drinking is important to stop the growth of cavity-causing bacteria.

For your child’s snack, choose nutritious foods such as vegetables, low-fat yogurt, and low-fat cheese, which are healthier and better for children’s teeth.

Continue with recommended recalls at your dental home as your child grows.

A great way to motivate your child to prevent cavities by brushing their teeth is to use our “I Brush My Teeth” charts (one example at the left, the rest are in our photo gallery).

Dental Caries

If your child is diagnosed with cavities, a comprehensive treatment plan needs to be presented. Because the cause of the disease is bacterial, restoring the cavities is not enough. The treatment plan must address controlling the germs and identifying the steps for prevention of future decay. If this is not done, your child will continue to develop new cavities in untreated areas. The age of your child is also very important. The younger your child is, the more challenging it is to control the caries process. Children who develop cavities younger than 71 months of age are suffering from what the American Academy of Pediatric Dentistry (AAPD) defines as “Early Childhood Caries” (ECC). The condition was previously called “baby bottle caries” because it was so often seen in children who nursed at-will through the day or at night time. Young children require special techniques to complete their dental treatment. These techniques may include behavior guidance or various forms of sedation. It is important to keep the dental experience as pleasant as possible to maintain your child’s comfort and trust during future visits.

Teeth are comprised of two hard layers surrounding a soft core. The first hard layer is the visible white layer called enamel. The underlying hard layer is called dentin and is yellow. The soft core is known as the dental pulp and is made up of blood vessels and nerve bundles. The holes caused by the caries process can be limited to the outer enamel layer. They may also include the underlying dentin layer or extend into the dental pulp. The treatment of the cavity depends on its depth. Unlike permanent teeth, primary or baby teeth have thin outer hard layers making it easier for the cavity to extend into the tooth’s pulp. Cavities that are limited to the hard layers are cleaned and filled with special dental materials. When a cavity extends into the dental pulp, removal of the diseased pulp will be necessary to preserve the tooth. This procedure is called a “pulpotomy” or a “baby root canal” in primary teeth. A special medicament is placed in the pulp area and the tooth is then ideally restored with a little cap. Our office offers cosmetic pediatric dentistry utilizing tooth-colored fillings and restorations.

Other Dental Problems

Gingivitis is an inflammation of the gums. It can lead to periodontitis which is a more severe condition that includes inflammation of the tooth’s supporting tissues of bone and ligament. Periodontitis is a major cause of tooth loss and can be associated with several systemic diseases. The cause of gingivitis and periodontitis is bacterial but the groups of germs creating these problems are different than those that cause dental decay. However, good oral hygiene and an individualized dental plan are also important in stopping this type of oral disease. Careful assessment of your child and your family history are needed to create an individualized treatment plan. (reference 14)

Oral habits are abnormal, frequently repeated, developed actions that are related to your child’s mouth. Habits are difficult to stop and can be associated with dental problems. Oral habits include but are not limited to:

1. Prolonged pacifier use / thumb sucking:

Sucking is a natural reflex and infants and young children may use thumbs, fingers, pacifiers and other objects on which to suck. It may make them feel secure and happy, or provide a sense of security at difficult periods. Since thumb sucking is relaxing, it may induce sleep. Thumb sucking that persists beyond the eruption of the permanent teeth can cause problems with the proper growth of the mouth and tooth alignment. How intensely a child sucks on fingers or thumbs will determine whether or not dental problems may result. Children who rest their thumbs passively in their mouths are less likely to have difficulty than those who vigorously suck their thumbs. Children should cease thumb sucking by the time their permanent front teeth are ready to erupt. Usually, children stop between the ages of two and four. Peer pressure causes many school-aged children to stop. Pacifiers are no substitute for thumb sucking. They can affect the teeth essentially the same way as sucking fingers and thumbs. However, use of the pacifier can be controlled and modified more easily than the thumb or finger habit. Here are a few suggestions to help your child overcome thumb sucking:

Children who are sucking for comfort will feel less of a need when their parents provide comfort.

Reward children when they refrain from sucking during difficult periods, such as when being separated from their parents.

If these approaches don’t work, remind your child of their habit by bandaging the thumb or putting a sock on the hand at night. Also visit our photo gallery for our “No Thumb Sucking For Me” chart that we have devised to help.

Habit appliances are available for older children who are willing but unable to quit the habit.

2. Tongue thrusting / abnormal swallowing:

Irregular swallowing patterns can cause shifting in the position of your child’s teeth. Some children continue to use their tongues the same way they needed to when they were infants and didn’t have their teeth yet. The tongue played an important role in closing the gaps between the baby’s gum pads. However, when teeth erupt, swallowing patterns mature. Some children are unable to make this shift and cause changes to their front teeth by applying too much tongue pressure. Certain dental appliances and coaching can correct these conditions.

3. Bruxing or teeth grinding

Bruxism or night-time grinding of teeth is noticed by the noise created when a child grinds on their teeth during sleep. This grinding wears the child’s teeth which eventually get shorter. The cause is not really known. One theory involves a psychological component. Stress due to a new environment, changes at home or school can influence a child to grind their teeth. Another theory relates to pressure in the inner ear at night. If there are pressure changes, (like in an airplane during take-off and landing) the child will grind by moving the jaw to relieve this pressure. The majority of cases do not require any treatment and most children outgrow the condition. If excessive wear of the teeth is present, a mouth guard may be indicated in specific cases.

Orthodontics

Developing malocclusions, or bad bites, can be recognized as early as 2-3 years of age. Often, early steps can be taken to reduce the need for major orthodontic treatment at a later age. Because pediatric dentists are the oral care providers for children of these ages, we are trained to recognize, prevent and treat these early problems in an age-appropriate way. Guiding dental growth and development is part of the individualized plan that we tailor specifically to fit your child’s needs. Orthodontic treatment can be accomplished in several stages:

Stage I – Early Treatment: This period of treatment encompasses ages 2 to 6 years. At this young age, we are concerned with underdeveloped dental arches, the premature loss of primary teeth, and harmful habits such as finger or thumb sucking. Treatment initiated in this stage of development is often very successful and many times, though not always, can eliminate the need for future orthodontic/orthopedic treatment.

Stage II – Mixed Dentition: This period covers the ages of 6 to 12 years, with the eruption of the permanent incisor (front) teeth and 6 year molars. Treatment concerns deal with poor jaw relationships, crowding and dental realignment problems. When indicated, this is an excellent stage to start treatment because your child’s hard and soft tissues are usually very responsive to orthodontic or orthopedic forces.

Stage III – Adolescent Dentition: This stage deals with the permanent teeth and the development of the final bite relationship. Although various problems can be treated or reduced in the first two stages of treatment, working closely with the orthodontist during this stage is important. The goal is that your child has a beautiful, healthy smile for life.

Special Needs Patients

The American Academy of Pediatric Dentistry (AAPD) defines persons with special health care needs as individuals who have a physical, developmental, mental, sensory, behavioral, cognitive or emotional impairment or liming condition that requires medical management, health care intervention, and/or use of specialized services programs. Health care for special needs patients is beyond that considered routine and requires specialized knowledge, increased awareness and attention, and accommodation. (reference 15) Children with special needs are at increased risk for oral diseases. (reference 16) It is important to understand your child’s specific oral and dental needs early in order to maintain optimum health. Prevention of dental problems is very important.

Find a dental home to be part of the team that cares for your child.

An assessment of your child’s risk for developing dental disease is necessary.

An oral hygiene plan that addresses your child’s specific needs must be implemented.

An individualized treatment plan will address any existing problems. This plan not only includes treating present issues but also considers future prevention. A team approach that includes your family, your pediatrician, occupational therapist and other health care providers that care for your child is needed.

Nutrition

Healthy eating habits lead to healthy teeth. Like the rest of the body, the teeth, bones and soft tissues of the mouth need a well-balanced diet. It is important to establish a healthy feeding pattern when your baby is born. When teething starts, proper feeding habits along with good oral hygiene will stop dental cavities from forming. Infants that are breast-fed receive the best form of nutrition. Human breast milk is not a cause of cavities on its own. (reference 17) However, problems can occur when carbohydrates are introduced to your child’s diet while they are still nursing. Baby formula, carbohydrates and sugars can cause cavities when at-will feeding occurs continuously during the day or at night. Salivary flow, which helps wash away these sugars is very low during the night. This means sugars remain on the tooth surfaces for longer times allowing the bacteria to form harmful acids.

If your toddler has not yet given up the bottle, be sure that it contains only water at naps and bedtime. Avoiding repetitive drinking of sugary fruit juices and sweetened beverages is very important. Children should eat a variety of foods from the five major food groups. Please know that most packaged snack foods that children eat can lead to cavity formation. Chips, cookies and candies are loaded with sugar. The more frequently a child snacks, the greater the chance is for tooth decay. How long food remains in the mouth also plays a role. For example, hard candy and sticky caramels stay in the mouth a long time. The bacteria can use these sugars for longer time periods causing longer acid attacks on tooth enamel. If your child snacks, choose nutritious foods such as vegetables, low-fat yogurt, and low-fat cheese, which are healthier and better for children’s teeth. For more nutritional information, please visit http://www.choosemyplate.gov/

Digital Images

Radiographs (x-rays) are a vital and necessary part of your child’s dental examination. Without them, certain dental conditions can and will be missed. Radiographs allow to diagnose and treat conditions that cannot be detected during a visual examination. They are needed to survey cavities and erupting teeth, to diagnose bone diseases, to evaluate the results of an injury, and to plan orthodontic treatment. The American Academy of Pediatric Dentistry (AAPD) recommends radiographs for initial examinations and at 6-12 month intervals for children at high risk of decay when proximal tooth surfaces cannot be visualized. (reference 18) Although the amount of radiation received in a dental radiographs is extremely small, we have taken extra precautions to protect our families from radiation exposure. Our facility is completely computerized utilizing the latest dental technologies. We offer digital radiography for both intra-oral and extra-oral views.

Flouride

According to the American Academy of Pediatric Dentistry (AAPD), the adjustment of the fluoride level in community water supplies to optimal concentration is the most beneficial and inexpensive method of reducing the occurrence of caries. (reference 19) Fluoride is an important part of the crystalline structure of enamel and makes teeth less soluble to decay acids. The enamel can incorporate fluoride at different stages of tooth development. This means systemic and topical fluoride can be beneficial.

Fluoridated Drinking Water: Some local water companies provide tap water naturally high in fluoride. However, if you have a home filter of the reverse osmosis type, this fluoride will be removed by the filtering process. In other areas it is necessary to purchase bottled fluoridated water. All major suppliers have fluoridated water for home delivery. Bottled water with fluoride is available at most markets. The most common brands are Sparkletts with Fluoride (1.0 mg/L), Dannon Fluoride to Go (1.0 mg/L) and Gerber Baby Water (0.5 mg/L). Fluoridated water can be used for drinking and cooking. Frequency is more important than the amount of water consumed. Ideal fluoride content is 0.8-1.0mg/L of fluoride except for water used to reconstitute powdered baby formula, which should not have fluoride content greater than 0.5mg/L.

Toothpaste: Use an American Dental Association (ADA) approved toothpaste for brushing your child’s teeth. Do not start fluoridated toothpaste until two years of age because the fluoride concentration is high and young children can swallow it. A half-pea sized amount of paste is sufficient for small children.

Fluoride Rinse: Once your child has learned how to expectorate properly, a fluoride rinse may be added to the oral hygiene plan. It is important that your child is able to spit out the rinse because swallowing it would cause ingestion of high levels of fluoride.

Professional Applications: Higher concentrations of fluoride treatment are available for professional use in the dental office. The newest type of these products comes in a varnish form and is able to stick to your child’s teeth for several hours providing more benefit to the enamel. Applications are part of a comprehensive prevention program in the dental home. (reference 20,21)

Supplements: A careful evaluation of all sources of fluoride, your child’s risk for cavities and the frequency of dental visits is required before your child is placed on fluoride supplements. Fluoride works in optimal concentrations. If fluoride levels are too low, the benefits are reduced. If fluoride levels are too high, there will be a risk of fluorosis. Fluorosis is a chalky white or brown discoloration of the permanent teeth. Many children often get more fluoride than their parents realize. Being aware of a child’s potential sources of fluoride can help parents prevent the possibility of this problem.

Other fortifying agents

  1. Xylitol: A sugar alcohol used as a sweetener in products aimed to improve oral health. The American Academy of Pediatric Dentistry (AAPD) recognizes the benefits of xylitol on the oral health of infants, children, adolescents, and persons with special health care needs. Xylitol is available in toothpastes, chewing gum, mints and oral baby wipes (Spiffies TM). Wipes can be used to cleanse babies’ mouths after feeding to establish an oral hygiene routine. Xylitol reduces plaque formation and is antimicrobial. (reference 22)
  2. CPP-ACP (casein phosphopeptide and amorphous calcium phosphate) in MI paste TM : A milk protein that allows calcium and phosphate to be available in the mouth. This allows the tooth surfaces to use these substances to chemically repair surface damage of the enamel. The product is flavored and very simple to apply.
  3. Chlorhexidene Antibacterial Rinse: Reduces cavity-causing bacteria in plaque and controls bacteria that causes gum disease or gingivitis and periodontitis.
  4. Ozone (O3) therapy: Ozone is an antibacterial agent that has had many medical applications over the years. Ozone was introduced to dentistry in the last decade as a potential healing and disinfecting agent.

Sports Dentistry

It is estimated that 30 million children in the US participate in organized sports programs. (reference 23) All sporting activities have an associated risk of injuries due to falls, collisions, and contact with hard surfaces. The Academy for Sports Dentistry (ASD) recommends the use of a properly fitted mouthguard to help prevent broken teeth, injuries to the lips, tongue, face and jaw. A properly fitted mouth guard will stay in place while your child is wearing it, making it easy for them to talk and breathe. Due to the continuous growth changes in young children, mouthguards should be custom fitted and continuously checked by a pediatric dental home. Schools participating in sports must be prepared to manage bodily and facial injuries if they occur. An injury management plan must be prepared and implemented when necessary. For more information, please click on “post op and emergencies” from our menu buttons at the bottom.

Smiles Stages

Optimize your own oral health.

  • Find a dental home for your baby.
  • Establish a healthy feeding pattern by separating eating and sleeping. Keeping the bottle out of the crib allows the baby to learn to sleep through the night at a younger age, and avoids a later struggle over taking away the bedtime bottle.
  • Clean your baby’s gums with a soft gauze and water after each feeding.
  • Your baby’s teeth will usually erupt between 6-18 months of age. Teething rings are important to help the teeth work through the gums. Try cooling the teething ring in the refrigerator. Give the baby Tylenol Drops when needed, but be sure to stay within the guidelines on the bottle. A surface anesthetic preparation like “Ora-Gel for Teething” may be useful at bedtime or when the baby seems particularly upset, but it washes away in a short time. Be sure to use it according to the directions. As soon as the teeth penetrate the gums, the discomfort begins to go away. Use a soft infant toothbrush as soon as your baby starts teething. Toothpaste is usually not necessary at this stage.
  • Create an injury-proof environment in your car and home. Proper car seats, safety gates and padding on table edges are important.
  • Establish a dental home if not already available.
  • Try to switch the baby bottle with a sippy cup and reduce pacifier use.
  • If your toddler has not yet given up the bottle, be sure that it contains only water at naps and bedtime.
  • Brush your toddler’s teeth thoroughly twice a day. Toothpaste can be introduced.
  • Give your child healthy, tooth-friendly snacks and avoid repetitive sweetened beverages and sugary snacks.
  • Be aware of the fluoride content of the water that your child drinks. If it is below O.6mg/L, consider fluoridated bottled water.
  • Create an injury-proof environment in your car and home. Proper car seats, safety gates and padding on table edges are important.
  • Report any oral habits or suspicious spots on your toddler’s teeth to your dental home.
  • Make sure you are on scheduled visits to your dental home.
  • Supervise the brushing of your child’s teeth with appropriate amounts of fluoridated toothpaste at least twice a day.
  • Discuss healthy snacks with your child’s school and avoid repetitive sweetened beverages and sugary snacks. Sugars taken with other foods are less harmful so a rule of “no sugar between meals” is a good idea.
  • Ask your dental home about sealants to protect newly-erupted permanent molars.
  • Be aware of your child’s fluoride intake and discuss optimum levels with your dental home.
  • Discuss sports injuries with your child’s dental home and school to prevent possible accidents.
  • Discuss early orthodontics and the management of oral habits with your child’s dental home.
  • Make sure you are on scheduled visits to your dental home.
  • Add a fluoridated mouth rinse to your child’s oral hygiene plan and supervise its use.
  • Keep your child on track with healthy snacks and proper eating habits.
  • Ask your dental home about sealants if they have not already been placed.
  • Continue with optimum fluoride levels and add other protective agents according to the recommendations of your dental home.
  • If your child participates in organized sports, a comfortably fitting mouthguard needs to be worn. Encouraging other families with children on the team to do the same will motivate everyone to be safe.If orthodontic treatment is initiated, additional preventive measures against dental cavities and gum inflammation must be presented.
  • Counsel your child to help them avoid harmful habits such as tobacco and oral piercing.
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  2. Ismail AI, Sohn W. A systematic review of clinical diagnostic criteria of early childhood caries. J Public Health Dent 1999;59(3):171-91.
  3. Featherstone JD. The caries balance: Contributing factors and early detection. J Calif Dent Assoc 2003;31(2):129-33.
  4. Featherstone JD. The caries balance: The basis for caries management by risk assessment. Oral Health Prev Dent 2004;2(Suppl 1):259-64.
  5. Tsang P, Qi F, Shi W. Medical approach to dental caries: Fight the disease, not the lesion. Pediatr Dent 2006;28(2):188-91;discussion 192-8.
  6. Featherstone JD, Adair SM, Anderson MH, et al. Caries management by risk assessment: Consensus statement, April 2002. J Calif Dent Assoc 2003;31(3):257-69.
  7. Li Y, Caufield PW. The fidelity of initial acquisition of mutans streptococci by infrants from their mothers. J Dent Res 1995;74(2):681-5.
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  9. Peretz B, Ram D, Azo E, Efrat Y. Preschool caries as an indicator or future caries: A longitudinal study. Pediatr Dent 2003;25(2):114-8.
  10. Kohler B, Bratthal D, Krasse B. Preventive measures in mothers influence the establishment of the bacterium Streptococcus mutans in their infants. Arch Oral Biol 1983;(3):225-31.
  11. Isokangas P, Soderling E, Pienihakkinen K, Alanen P. Occurrence of dental decay in children after maternal consumption of xylitol chewing gum, a follow-up from 0-5 years of age. J Dent Res. 2000;79(11)1885-9.
  12. American Academy of Pediatric Dentistry (AAPD). Policy on use of a Caries-risk Assessment Tool (CAT) for infants, children, and adolescents. Pediatr Dent 2007; 29(suppl):29-33.
  13. Al-Shalan TA, Erickson PR, Hardie NA. Primary incisor decay before age 4 as a risk factor for future dental caries. Pediatr Dent 1997;19(1):37-41.
  14. American Academy of Periodontology. The pathogenesis of periodontal diseases (position paper). J Periodontol 1999;70:457-70.
  15. American Academy of Pediatric Dentistry (AAPD), Definition of special health needs patient. Pediatr Dent 2004;26(suppl):15.
  16. US Dept of Health and Human Services. Oral health in America: A report of the Surgeon General. Rockville, Md: US Dept of Human Services, National institute of Dental and Craniofacial Research, Nations Institutes of Health. 2000.
  17. Erickson PR, Mazhari E. Investigation of the role of human breast milk in caries development. Pediatr Dent 1999;21(2):86-90.
  18. American Academy of Pediatric Dentistry (AAPD). Guidelines on prescribing dental radiographs for infants, children, adolescents, and persons with special health care needs. Pediatr Dent 2007; 29(suppl):221-22.
  19. CDC. Recommendation for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep. August 17, 2001;50(RR14):1-42.
  20. Vaiduntam J. Fluoride varnishes: Should we be using them? Pediatr Dent 2002;22(6):513-6.
  21. Nowak AJ, Casamassimo PS. The dental home: A primary care oral health concept. J Am Dent Assoc 2002;133(1):93-8.
  22. Trahan L, Mouton C. Selection for Streptococcus mutans with an altered xylitol transport capacity in chronic xylitol consumers. J Dent Res 1987;66(5):982-8.
  23. Adirim T, Cheng T. Overview of injuries in the young athlete. Sports Med 2003;33(1)75-81.
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