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ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. BMI: Body mass
index. CRA: Caries-risk assessment. ECC: Early childhood caries.
HPV: Human papilloma virus. PRA: Periodontal-risk assessment.
SHCN: Special health care needs. U.S.: United States.
Purpose
The American Academy of Pediatric Dentistry (AAPD)
intends these recommendations to help practitioners make
clinical decisions concerning preventive oral health inter-
ventions, including anticipatory guidance and preventive
counseling, for infants, children, and adolescents.
Methods
This document was developed by the Clinical Affairs
Committee, adopted in 1991
1
, and last revised by the Council
on Clinical Affairs in 2018
2
. This update used electronic
database and hand searches of articles in the medical and dental
literature using the terms: periodicity of dental examinations,
dental recall intervals, preventive dental services, anticipatory
guidance and dentistry, caries-risk assessment, early childhood
caries, dental caries prediction, dental care cost eectiveness
and children, periodontal disease and children and adolescents
United States (U.S.), pit-and-ssure sealants, dental sealants,
uoride supplementation and topical uoride, dental trauma,
dental fracture and tooth, nonnutritive oral habits, treatment of
developing malocclusion, removal of wisdom teeth, removal of
third molars; elds: all; limits: within the last 10 years, humans,
English, and clinical trials; birth through age 18. From this
search, 2,502 articles matched these criteria and were evaluated
by title and/or abstract. When data did not appear sucient or
were inconclusive, recommendations were based upon expert
and/or consensus opinion by experienced researchers and
clinicians.
Background
Professional dental care is necessary to maintain oral health.
3
e AAPD emphasizes the importance of initiating profes-
sional oral health intervention in infancy and continuing
through adolescence and beyond.
4
e periodicity of profes-
sional oral health intervention and services is based on a
patient’s individual needs and risk indicators.
5-10
Each age
group, as well as each individual child, has distinct develop-
mental needs to be addressed at specic intervals as part of a
comprehensive evaluation.
4,11-13
Continuity of care is based on
the assessed needs of the individual patient and assures appro-
priate management of all oral conditions, dental disease, and
Latest Revision
2022
Periodicity of Examination, Preventive Dental
Services, Anticipatory Guidance
/
Counseling, and
Oral Treatment for Infants, Children, and Adolescents
How to Cite: American Academy of Pediatric Dentistry. Periodicity
of examination, preventive dental services, anticipatory guidance/
counseling, and oral treatment for infants, children, and adolescents.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2023:288-300.
Abstract
This best practice presents recommendations about anticipatory guidance and timing of other clinical modalities which promote oral health
during infancy, childhood, and adolescence. The guidance, though modifiable to children with special health needs, focuses on healthy,
normal-developing children and addresses comprehensive oral examination, assessment of caries risk, periodontal risk assessment,
professional preventive procedures, fluoride supplementation, radiographic examination, anticipatory guidance, preventive counseling,
sealant placement, treatment of dental disease, trauma, treatment of developing malocclusions, evaluation of third molars, and transition to
adult care. These preventive recommendations may be applied for the following age groups: six to 12 months, 12 to 24 months, 24 months
to six years, six to 12 years, and 12 years and older. The guidance emphasizes the importance of very early professional intervention and
continuity of care based upon the individualized needs of the child.
The document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and recommendations regarding oral health services and counseling for pediatric dental
patients.
KEYWORDS: ADOLESCENT DENTISTRY; ANTICIPATORY GUIDANCE; CARIES-RISK ASSESSMENT; DENTAL REFERRAL; FLUORIDE SUPPLEMENT; ORAL HYGIENE
COUNSELING; PERIODICITY OF EXAMINATION; PREVENTIVE DENTISTRY
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THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 289
injuries.
14-20
e early dental visit to establish a dental home
provides a foundation upon which a lifetime of preventive
education and oral health care can be built.
21
e early estab-
lishment of a dental home has the potential to provide more
eective and less-costly dental care when compared to dental
care provided in emergency care facilities or hospitals.
21-25
Anticipatory guidance and counseling are essential components
of the dental visit.
4,11,12,21,24-29
e dental home also can inu-
ence general health by instituting additional practices related
to general health promotion, disease prevention, and screening
for non-oral health related concerns. For example, oral health
professionals can calculate and monitor body mass index
(BMI) to help identify children at risk for obesity and provide
appropriate referral to pediatric or nutritional specialists.
28
Collaborative eorts and eective communication between
medical and dental homes are essential to prevent oral disease
and promote oral and overall health among children. Medical
professionals can play an important role in children’s oral
health by providing primary prevention and coordinated care.
Equally, dentists can improve the overall health of children
not only by treating dental disease, but also by proactively
recognizing child abuse, preventing traumatic injuries through
anticipatory guidance, preventing obesity by longitudinal
dietary counseling, and monitoring of weight status.
30
In addi-
tion, dentists can have a signicant role in assessing immuni-
zation status and developmental milestones for potential
delays, as well as making appropriate referral for further
neurodevelopmental evaluations and therapeutic services.
31
e unique opportunity that dentists have to help address
overall health issues strengthens as children get older since
frequency of well-child medical visits decreases at the same
time the frequency of dental recall visits increases. Research
shows that children aged six- to 12-years are, on average, four
times more likely to visit a dentist than a pediatrician.
32,33
Recommendations
is document addresses periodicity and general principles of
examination, preventive dental services, anticipatory guidance/
counseling, and oral treatment for children who have no
contributory medical conditions and are developing normally.
Accurate, comprehensive, and up-to-date medical, dental, and
social histories are necessary for correct diagnosis and eective
treatment planning. Recommendations may be modied to
meet the unique requirements of patients with special health
care needs (SHCN).
34
Clinical oral examination
e rst examination is recommended at the time of the
eruption of the rst tooth and no later than 12 months of
age.
4,21,24,25
e developing dentition and occlusion should be
monitored throughout eruption at regular clinical examina-
tions.
29
Evidence-based prevention and early detection and
management of caries/oral conditions can improve a child’s
oral and general health, well-being, and school readiness.
7,26,35-38
e number and cost of dental procedures among high-risk
children is less for those seen at an earlier age versus later,
conrming the fact that the sooner a child is seen by a dentist,
the less treatment needs they are likely to have in the future.
39
On the other hand, delayed diagnosis of dental disease can
result in exacerbated problems which lead to more extensive
and costly care.
10,35,40-43
Guidance of eruption and development
of the primary, mixed, and permanent dentitions contributes
to a stable, esthetic, and functional occlusion.
11,29
Components of a comprehensive clinical examination
include:
• general health/growth assessment (e.g., height, weight,
BMI calculation, vital signs);
• pain assessment;
• extraoral soft tissues examination;
• temporomandibular joint assessment;
• intraoral soft tissues examination;
• oral hygiene and periodontal-risk assessment;
• intraoral hard tissue examination;
• assessment of the developing occlusion;
• radiographic assessment, if indicated;
• caries-risk assessment; and
• assessment of cooperative potential/behavior of child.
44
Based upon the visual examination, the dentist may employ
additional diagnostic aids (e.g., photographs, pulp vitality
testing, laboratory tests, study casts).
10,15,44-46
e interval of examination should be based on the child’s
individual needs or risk status/susceptibility to disease; some
patients may require examination and preventive services at
more or less frequent intervals, based upon historical, clinical,
and radiographic ndings.
8-10,18,20,26,47-49
While the prevalence
of caries has decreased in primary teeth, the prevalence of
having no caries in the permanent dentition remains un-
changed; caries remains a health problems facing infants,
children, and adolescents in America.
37
Caries lesions are
cumulative and progressive and, in the primary dentition, are
highly predictive of caries occurring in the permanent denti-
tion.
6,50
Reevaluation and reinforcement of preventive activities
contribute to improved instruction for the caregiver of the
child or adolescent, continuity of evaluation of the patient’s
health status, and potentially allaying anxiety and fear for the
apprehensive child or adolescent.
51
Individuals with SHCN
may require individualized preventive and treatment strategies
that take into consideration the unique needs and disabilities
of the patient.
34
Caries-risk assessment (CRA)
Risk assessment is a key element of contemporary preventive
care. CRA should be performed as soon as the rst primary
tooth erupts and be reassessed periodically by dental and
medical providers.
6,27
e goal is to prevent disease by identi-
fying patients at high risk for caries and developing individual-
ized preventive measures and caries management, as well as
determining appropriate periodicity of services.
27,52,53
Given
that the etiology of dental caries is multifactorial and complex,
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current caries-risk assessment models entail a combination of
factors including diet, fluoride exposure, host susceptibility,
and microora analysis and consideration of how these factors
interact with social, cultural, and behavioral factors. More
comprehensive models that include social, political, psycho-
logical, and environmental determinants of health also are
available.
54-57
CRA forms and caries management protocols
aim to simplify and clarify the process.
6,27,58,59
Sucient evidence demonstrates certain groups of children
at greater risk for development of early childhood caries
(ECC) would benet from infant oral health care.
60-64
Infants
and young children have unique caries-risk factors such as
ongoing establishment of oral ora and host defense systems,
susceptibility of newly erupted teeth, and development of
dietary habits. Because the etiology of ECC is multifactorial
and signicantly inuenced by health behaviors,
65
preventive
messages for expectant parents and parents of very young
children should target factors known to place children at a
higher risk for developing caries (e.g., early Mutans strepto-
cocci transmission, poor oral hygiene habits, nighttime feeding,
high frequency of sugar consumption).
26,36,57,66
Motivational
problems may develop when parents/patients are not interested
in changing behaviors or feel that the changes require excessive
effort. Parental attitude, self-efficacy, and intention have a
strong correlation to oral hygiene practices in preschoolers.
67
erefore, health care professionals should utilize preventive
approaches based on psychological and behavioral strategies.
Moreover, they should communicate their recommendations
eectively so parents/patients perceive them as behaviors worth
pursuing. Motivational interviewing and self-determination
theory are examples of eective motivational approaches for
caries prevention that share similar psychological philoso-
phies.
68-74
Studies have reported caries experience in the primary
dentition as a predictor of future caries.
75,76
Early school-aged
children are at a transitional phase from primary to mixed
dentition. ese children face challenges such as unsupervised
toothbrushing and increased consumption of cariogenic foods
and beverages while at school, placing them at a higher risk
for developing caries.
77-79
erefore, special attention should
be given to school-aged children regarding their oral hygiene
and dietary practices. e use of newer technology including
cellular telephones (e.g., text messaging, apps) may provide
an additional intervention to improve adherence to oral hygiene
protocols in children and adolescents.
80
Adolescence can be a time of heightened caries activity due
to an increased number of tooth surfaces in the permanent
dentition and intake of cariogenic substances, as well as low
priority for oral hygiene procedures.
11,55,56
Risk assessment can
assure preventive care (e.g., water fluoridation, professional
and home-use fluoride and antimicrobial agents, frequency
of dental visits) is tailored to each individual’s needs and direct
resources to those for whom preventive interventions provide
the greatest benet.
11,81,82
Because a child’s risk for developing
dental disease can change over time due to changes in habits
(e.g., diet, home care), oral microora, or physical condition,
risk assessment must be documented and repeated regularly
and frequently to maximize eectiveness.
13,27
Periodontal-risk assessment (PRA)
Periodontal-risk assessment is an important component of the
routine examination of pediatric patients. e gingival and
periodontal tissues are subject to change due to normal growth
and development. PRA identies risk factors that place
individuals at increased risk of developing gingival and
periodontal diseases and pathologies, as well as factors that in-
uence the progression of the disease. Risk factors for peri-
odontal disease may be biological, environmental (social), and
behavioral.
83
Probing assessments should be initiated after the
eruption of the rst permanent molars and incisors as tolerated
by the child.
49
Probing of primary teeth may be indicated
when clinical and radiographic ndings indicate the presence
of periodontal pathology. Bleeding on probing primary teeth
during early childhood, even at a low number of sites, is
indicative of high susceptibility to periodontal diseases due to
the age-dependent reactivity of the gingival tissues to plaque.
84
PRA can improve clinical decision making and allow the
implementation of individualized treatment planning and
proactive targeted interventions.
85
Maintenance of gingival
and periodontal health during childhood and adolescence can
help assure periodontal health as an adult.
49
Prophylaxis and professional topical uoride treatment
e interval for frequency of professional preventive services is
based upon assessed risk for caries and periodontal disease.
5,8-10,
12,13,27,49,58-60
Prophylaxis aids in plaque, stain, and calculus re-
moval, as well as in educating the patient on oral hygiene
techniques and facilitating the clinical examination.
12
Gingivitis
is common in children and adolescents and usually responds
to the implementation of therapeutic measures and routine
maintenance.
49
Hormonal uctuations, including those occur-
ring during the onset of puberty and pregnancy, can modify
the gingival inammatory response to dental plaque.
86
ere-
fore, recognizing modifying factors that may result in the
development of periodontal disease is important.
49
Children who exhibit higher risk of developing caries or
periodontal disease would benet from recall appointments
at greater frequency than every six months (e.g., every three
months).
5,8,10,12,13,27,49,59
is allows increased professional uoride
therapy application, professional assessment of oral hygiene,
and opportunity to foster improvement of oral health by
demonstrating proper oral hygiene techniques, in addition to
microbial monitoring, antimicrobial therapy reapplication, and
reevaluating behavioral changes for eectiveness.
5,12,59,87-90
An
individualized preventive plan increases the probability of good
oral health by demonstrating proper oral hygiene methods/
techniques and removing plaque, stain, and calculus.
8,90
Fluoride contributes to the prevention, inhibition, and
reversal of caries.
91-93
Professional topical uoride treatments
should be based on caries-risk assessment.
21,27,92,94
Plaque and
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the enamel pellicle are not a barrier to topical uoride uptake.
12
Consequently, patients who receive rubber cup dental prophy-
laxis or a toothbrush prophylaxis before uoride treatment
exhibit no dierences in caries rates.
94,95
Precautionary measures
should be taken to prevent swallowing of any professionally-
applied topical uoride. Children at high caries risk should
receive greater frequency of professional topical uoride appli-
cations (e.g., every three months).
91,94,96-98
Ideally, this would
occur as part of a comprehensive preventive program in a
dental home.
21
Fluoride supplementation
The AAPD encourages optimal fluoride exposure for every
child, recognizing community water uoridation as the most
benecial and cost-eective preventive intervention.
91
Fluoride
supplementation should be considered for children at moder-
ate to high caries risk when uoride exposure is not optimal.
27
Determination of dietary uoride sources (e.g., drinking water,
toothpaste, foods, beverages) before prescribing supplements
is required and can help reduce intake of excess uoride.
91
In
addition, supplementation should be in accordance with the
guidelines recommended by the AAPD
91
and the American
Dental Association
99,100
.
Radiographic assessment
Radiographs are a valuable adjunct in the oral health care of
infants, children, and adolescents to diagnose and monitor oral
diseases and evaluate dentoalveolar trauma, as well as monitor
dentofacial development and the progress of therapy.
47,48
Timing of initial radiographic examination should not be based
on the patient’s age, but upon each child’s individual circum-
stances.
47,48
e need for dental radiographs can be determined
only after consideration of the patient’s medical and dental
histories, completion of a thorough clinical examination, and
assessment of the patient’s vulnerability to environmental
factors that aect oral health.
47
Every eort must be made to
minimize the patient’s radiation exposure by applying good
radiological practices (e.g., use of protective aprons, thyroid
collars, rectangular collimation) and by following the as low
as reasonably achievable (ALARA) principle.
47,101
Anticipatory guidance/counseling
Anticipatory guidance is the process of providing practical
and developmentally-appropriate information about children’s
health to prepare parents for signicant physical, emotional, and
psychological milestones.
4,11,21,102,103
Individualized discussion
and counseling should be an integral part of each visit. Topics
should include oral hygiene practices, oral/dental development
and growth, speech/language development, nonnutritive habits,
diet and nutrition, injury prevention, tobacco/nicotine product
use, substance misuse, and intraoral/perioral piercing and oral
jewelry/accessories.
4,11,17,21,29,102-111
Anticipatory guidance regarding the characteristics of a
normal healthy oral cavity should commence during infant
oral health visits and continue throughout follow-up dental
visits. is allows parents to quantify any changes such as, but
not limited to, growth delays, traumatic injuries, and poor
oral hygiene or presence of caries lesions. Educating parents
regarding tooth development and chronology of eruption can
help them better understand the implications of delayed or
accelerated tooth emergence. Parents also need to be informed
about the benets of topical uorides for newly erupted teeth
which may be at greater risk of developing caries, especially
during the posteruption maturation process.
102
Assessment of
each child’s developmental milestones (e.g., ne/gross motor
skills, language, social interactions) is crucial for early recog-
nition of potential delays and appropriate referral to therapeutic
services.
31
Speech and language are integral components of a
child’s early development.
108
Abnormal delays in speech and
language production can be recognized early with referral made
to address these concerns. Communication and coordination
of appliance therapy with a speech and language professional
can assist in the timely treatment of speech disorders.
108
Oral habits (e.g., nonnutritive sucking: digital and pacier
habits; bruxism; tongue thrust swallow and abnormal tongue
position; self-injurious/self-mutilating behavior) may apply
forces to teeth and dentoalveolar structures. Although early
use of pacifiers and digit sucking are considered normal,
pacier use beyond 18 months can inuence the developing
orofacial complex.
112
Increased overjet and Class II malocclu-
sion are more strongly associated with a nger habit versus a
pacifier habit.
113,114
Children having a nonnutritive sucking
habit beyond age three have a higher incidence of maloc-
clusions.
29,112
Early dental visits provide an opportunity to
counsel parents to help their children stop sucking habits before
malocclusion or skeletal dysplasias occur.
29,112
For school-aged
and adolescent patients, counseling regarding any existing
habits (e.g., ngernail biting, clenching, bruxism), including the
potential immediate and long-term eects on the craniofacial
complex and dentition, is appropriate.
29
Management of an
oral habit can include patient/parent counseling, behavior
modification techniques, appliance therapy, or referral to
other providers including, but not limited to, orthodontists,
psychologists, or otolaryngologists.
29
Oral hygiene counseling involves the parent and patient.
Initially, oral hygiene is the responsibility of the parent. As the
child develops, home care can be performed jointly by parent
and child. When a child demonstrates the understanding and
ability to perform personal hygiene techniques, the health
care professional should counsel the child. e eectiveness of
home care should be monitored at every visit and includes a
discussion on the consistency of daily oral hygiene preventive
activities, including adequate uoride exposure.
5,8,11,27,91,115
The development of dietary habits and childhood food
preferences appears to be established early and may aect the
oral health as well as general health and well-being of a
child.
116
The establishment of a dental home no later than
12 months of age allows dietary and nutrition counseling to
occur early. is helps parents to develop proper oral health
habits early in their child’s life, rather than trying to change
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established unhealthy habits later. During infancy, counseling
should focus on breastfeeding, bottle or no-spill cup usage,
concerns with nighttime feedings, frequency of in-between
meal consumption of sugar-sweetened beverages (e.g., sweet-
ened milk, soft drinks, fruit-flavored drinks, sports drinks)
and snacks, as well as special diets.
28,117
Excess consumption of
carbohydrates, fats, and sodium contribute to poor systemic
health.
118-120
Dietary analysis and the impact of dietary choices
on oral health, malnutrition, and obesity
121,122
, as well as
quality of life, should be addressed through nutritional and
preventive oral health.
28,123
e U.S. Departments of Health
and Human Services and Agriculture provide dietary guidelines
for Americans two years of age and older every ve years to
promote a healthy diet and help prevent chronic diseases.
123
Traumatic dental injuries in the primary and permanent
dentition occur with great frequency with a prevalence of
one-third of preschool children and one-fourth of school-age
children.
20,124
Facial trauma that results in fractured, displaced,
or lost teeth can have signicant negative functional, esthetic,
and psychological eects on children.
125
Practitioners should
provide age-appropriate injury prevention counseling for oro-
facial trauma.
17,103
Initial discussions should include advice
regarding play objects, paciers, car seats, and electrical cords. As
motor coordination develops and the child grows older, the
parent/patient should be counseled on additional safety and
preventive measures, including use of protective equipment (e.g.,
athletic mouthguards, helmets with face shields) for sporting
and high-speed activities (e.g., baseball, bicycling, skiing, four-
wheeling). Dental injuries could have improved outcomes not
only if the public were aware of rst-aid measures and the need
to seek immediate treatment, but also if the injured child had
access to emergency care at all times. Caregivers report that,
even though their children had a dental home, they have
experienced barriers to care when referred outside of the dental
home for emergency services.
126
Barriers faced by caregivers
include availability of providers and clinics for delivery of
emergency care and the distance one must travel for treatment.
erefore, primary care providers should inform parents about
ways to access emergency care for dental injuries and provide
telephone numbers to access a dentist, including for after-
hours emergency care.
110
Teledentistry may serve as an adjunct
with time-sensitive injuries or when unexpected circumstances
result in diculties accessing care.
127
Smoking and smokeless tobacco use almost always are ini-
tiated and established in adolescence.
111,128,129
In 2020, 6.7
percent of middle school students and 23.6 percent of high
school students reported current tobacco product use.
130
e
most common tobacco products used by middle school and
high school students were reported to be e-cigarettes, cigarettes,
cigars, smokeless tobacco, hookahs, pipe tobacco, and bidis
(unltered cigarettes from India).
130
E-cigarette decreased from
27.5 to 19.6 percent among high school students and from
5.3 to 4.7 percent among middle school students from 2019
to 2020.
130
e recent decline reversing previous trends may be
attributable to multiple factors including increasing the age of
sale of tobacco products from 18 to 21 years.
130
Children may
be exposed to opportunities to experiment with other sub-
stances that negatively impact their health and well-being.
Practitioners should provide education regarding the serious
health consequences of tobacco use and exposure to secondhand
smoke.
104,130
e practitioner may need to obtain information
regarding tobacco use and alcohol/drug misuse condentially
from an adolescent patient.
11,107
When tobacco or substance
abuse has been identied, practitioners should provide brief
interventions for encouragement, support, and positive rein-
forcement for avoiding substance use.
104,107
If indicated, dental
practitioners should provide referral to primary care providers
or behavioral health/addiction specialists for assessment and/
or treatment of substance use disorders.
107
Human papilloma virus (HPV) is associated with several
types of cancers, including oral and oropharyngeal cancers.
131,132
Seventy percent of oropharyngeal cancers in the U.S. are caused
by HPV, and the number of oropharyngeal cancers is increasing
annually.
132
Evidence supports the HPV vaccine as a means to
lessen the risk of oral HPV infection.
131,133
e vaccine provides
the greatest protection when administered at ages nine through
12.
132
As adolescent patients tend to see the dentist twice
yearly and more often than their medical care provider, this
is a window of opportunity for the dental professional to
counsel patients and parents about HPV’s link to oral cancer
and the potential benets of receiving the HPV vaccine.
134
Complications from intraoral/perioral piercings can range
from pain, infection, and tooth fracture to life-threatening
conditions of bleeding, edema, and airway obstruction.
106
Edu-
cation regarding pathologic conditions and sequelae associated
with piercings should be initiated for the preteen child and
parent and reinforced during subsequent periodic visits. e
AAPD strongly opposes the practice of piercing intraoral and
perioral tissues and use of jewelry on intraoral and perioral
tissues due to the potential for pathological conditions and
sequelae associated with these practices.
106
Treatment of dental disease/injury
Health care providers who diagnose oral disease or trauma
should either provide therapy or refer the patient to an
appropriately-trained individual for treatment.
135
Immediate
intervention is necessary to prevent further dental destruction,
as well as more widespread health problems. Postponed treat-
ment can result in exacerbated problems that may lead to the
need for more extensive care.
24,36,37,42
Early intervention could
result in savings of health care dollars for individuals, com-
munity health care programs, and third-party payors.
23,31,32,36
Treatment of developing malocclusion
Guidance of eruption and development of the primary, mixed,
and permanent dentitions is an integral component of com-
prehensive oral health care for all pediatric dental patients.
29
Dentists have the responsibility to recognize, diagnose, and
manage or refer abnormalities in the developing dentition as
dictated by the complexity of the problem and the individual
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THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 293
clinician’s training, knowledge, and experience.
135
Early diag-
nosis and successful treatment of developing malocclusions
can have both short-term and long-term benefits, while
achieving the goals of occlusal harmony and function and
dentofacial esthestics.
136
Early treatment is benecial for many
patients but is not indicated for every patient. When there is
a reasonable indication that an oral habit will result in un-
favorable sequelae in the developing permanent dentition, any
treatment must be appropriate for the child’s development,
comprehension, and ability to cooperate. Use of an appliance
is indicated only when the child wants to stop the habit and
would benefit from a reminder.
29
At each stage of occlusal
development, the objectives of intervention/treatment include:
(1) managing adverse growth, (2) correcting dental and skeletal
disharmonies, (3) improving esthetics of the smile and the
accompanying positive eects on self-image, and (4) improving
the occlusion.
29
Sealants
A 2016 systematic review concluded sealants are eective in
preventing and arresting pit-and-ssure occlusal caries lesions
of primary and permanent molars in children and adolescents
and can minimize the progression of noncavitated occlusal
caries lesions.
137
ey are indicated for primary and permanent
teeth with pits and ssures.
137
At-risk pits and ssures should
be sealed as soon as possible. Because caries risk may increase
at any time during a patient’s life due to changes in habits
(e.g., dietary, home care), oral microora, or physical condi-
tion, unsealed teeth subsequently might benet from sealant
application.
138
The need for sealant placement should be
reassessed at periodic preventive care appointments. Sealants
should be monitored and repaired or replaced as needed.
138-140
ird molars
Panoramic or periapical radiographic assessment is indicated
during late adolescence to assess the presence, position, and
development of third molars.
47,48
Impacted third molars are
potentially pathologic; a 2016 study found the incidence of
cysts or tumors associated with impacted mandibular third
molars to be 0.41-0.71 percent in patients younger than 30
years.
141
A decision to remove or retain third molars should
be made before the middle of the third decade.
142,143
Con-
sideration should be given to removal when there is a high
probability of disease or pathology or the risks associated
with early removal are less than the risks of later removal.
29,
143,144
Treatment should be provided before pathologic condi-
tions adversely aect the patient’s oral or systemic health.
142,143
Postoperative complications for removal of
impacted third
molars are low when performed at an early age.
145
A Cochrane
review in 2012 reported no difference in late lower incisor
crowding with removal or retention of asymptomatic im-
pacted third molars.
146
When a decision is made to maintain
disease-free impacted wisdom teeth, clinical and radiographic
monitoring is appropriate to prevent undesirable outcomes.
147
Referral for regular and periodic dental care
As adolescent patients approach the age of majority, educating
the patient and parent on the value of transitioning to a dentist
who is experienced in adult oral health can help minimize
disruption of high-quality, developmentally-appropriate health
care. At the time agreed upon by the patient, parent, and
pediatric dentist, the patient should be referred to a specic
practitioner in an environment sensitive to the adolescent’s
individual needs.
11,148
Until the new dental home is established,
the patient should maintain a relationship with the current
care provider and have access to emergency services. For the
patient with SHCN, in cases where it is not possible or desired
to transition to another practitioner, the dental home can
remain with the pediatric dentist, and appropriate referrals
for specialized dental care should be recommended when
needed.
148
Proper communication and records transfer allow
for consistent and continuous care for the patient.
44
Recommendations by age
Six to 12 months
1. Complete the clinical oral examination with adjunctive
diagnostic tools (e.g., radiographs as determined by child’s
history, clinical ndings, and susceptibility to oral disease)
to assess oral growth and development, pathology, and/or
injuries; provide diagnosis.
2. Complete a caries-risk assessment.
3. Provide oral hygiene counseling for parents, including
the implications of the oral health of the caregiver.
4. Clean teeth and remove supra- and subgingival stains or
deposits as indicated.
5. Assess the child’s exposure to systemic and topical uorides
(including type of infant formula used) and exposure to
uoridated toothpaste and provide counseling regarding
uoride.
6. Assess appropriateness of feeding practices, including
bottle and breastfeeding, and provide counseling as
indicated; provide dietary counseling related to oral
health.
7. Provide age-appropriate injury prevention counseling for
orofacial trauma.
8. Provide counseling for nonnutritive oral habits (e.g.,
digit, pacifiers).
9. Provide required treatment or appropriate referral for any
oral diseases or injuries.
10. Provide anticipatory guidance.
11. Assess overall growth and development, and make appro-
priate referral to therapeutic services if needed.
12. Consult with the child’s physician as needed.
13. Determine the interval for periodic reevaluation.
12 to 24 months
1. Repeat the procedures for ages six to 12 months every
six months or as indicated by the child’s individual needs
or risk status/susceptibility to disease.
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2. Assess appropriateness of feeding practices (including
bottle, breastfeeding, and no-spill training cups) and
provide counseling as indicated.
3. Review patient’s uoride status and provide parental
counseling.
4. Provide topical uoride treatments every six months or
as indicated by the child’s individual needs or risk
status/susceptibility to caries.
Two to six years
1. Repeat the procedures for 12 to 24 months every six
months or as indicated by the child’s individual needs
or risk status/susceptibility to disease, including peri-
odontal conditions. Provide age-appropriate oral hygiene
instructions.
2. Assess diet and body mass index to identify patterns
placing patients at increased risk for dental caries or
obesity. Provide counseling or appropriate referral to a
pediatric or nutritional specialist as indicated.
3. Scale and clean the teeth every six months or as indicated
by individual patient’s needs.
4. Provide pit-and-ssure sealants for caries-susceptible
anterior and posterior primary and permanent teeth.
5. Provide counseling and services (e.g., mouthguards) as
needed for orofacial trauma prevention.
6. Assess developing dentition and occlusion and provide
assessment/treatment or referral of malocclusion as
indicated by individual patient’s needs.
7. Provide required treatment or appropriate referral for any
oral diseases, habits, or injuries as indicated.
8. Assess speech and language development and provide
appropriate referral as indicated.
Six to 12 years
1. Repeat the procedures for ages two to six years every
six months or as indicated by child’s individual needs.
2. Complete a periodontal-risk assessment that may include
radiographs and periodontal probing with eruption of
rst permanent molars.
3. Provide substance abuse counseling (e.g., smoking,
smokeless tobacco) and referral to primary care providers
or behavioral health/addiction specialists if indicated.
4. Provide education and counseling regarding HPV and the
benets of the HPV vaccine.
5. Provide counseling on intraoral/perioral piercing.
12 years and older
1. Repeat the procedures for ages six to 12 years every six
months or as indicated by the child’s individual needs
or risk status/susceptibility to disease.
2. During late adolescence, assess the presence, position, and
development of third molars, giving consideration to
removal when there is a high probability of disease or
pathology or the risks associated with early removal are
less than the risks of later removal.
3. At an age determined by patient, parent, and pediatric
dentist, refer the patient to a general dentist for continuing
oral care.
References
1. American Academy of Pediatric Dentistry. Periodicity of
examination, preventive dental services, and oral treat-
ment for children. Reference Manual 1991-1992.
Chicago, Ill.: American Academy of Pediatric Dentistry;
1991:38-9.
2. American Academy of Pediatric Dentistry. Periodicity
of examination, preventive dental services, anticipatory
guidance/counseling, and oral treatment for infants,
children, and adolescents. Pediatr Dent 2018;40(6):
194-204.
3. U.S. Department of Health and Human Services. Oce
of the Surgeon General. A National Call to Action to
Promote Oral Health. Rockville, Md.: U.S. Department
of Health and Human Services, Public Health Service,
National Institutes of Health, National Institute of
Dental and Craniofacial Research; 2003. Available at:
“https://www.ncbi.nlm.nih.gov/books/NBK47472/”.
Accessed March 2, 2022.
4. American Academy of Pediatric Dentistry. Perinatal and
infant oral health care. e Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:277-81.
5. Pienihakkinen K, Jokela J, Alanen P. Risk-based early
prevention in comparison with routine prevention of
dental caries: A 7-year follow-up of a controlled clinical
trial; clinical and economic results. BMC Oral Health
2005;5(2):1-5.
6. Fontana M, González-Cabezas C. e clinical, environ-
mental, and behavioral factors that foster early childhood
caries: Evidence for caries risk assessment. Pediatr Dent
2015;37(3):217-25.
7. Fontana M. Noninvasive caries risk-based management
in private practice settings may lead to reduced caries ex-
perience over time. J Evid Based Dent Pract 2016;16(4):
239-42.
8. Beil HA, Rozier RG. Primary health care providers’ advice
for a dental checkup and dental use in children. Pediatrics
2010;126(2):435-41.
9. Patel S, Bay C, Glick M. A systematic review of dental
recall intervals and incidence of dental caries. J Am Dent
Assoc 2010;141(5):527-39.
10. Pahel BT, Rozier RG, Stearns SC, Quiñonez RB. Eec-
tiveness of preventive dental treatments by physicians for
young Medicaid enrollees. Pediatrics 2011;127(3):682-9.
11. American Academy of Pediatric Dentistry. Adolescent oral
health care. e Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:282-91.
BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE
/
COUNSELING AND TREATMENT
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 295
12. American Academy of Pediatric Dentistry. Policy on the
role of dental prophylaxis in pediatric dentistry. The
Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2022:
67-9.
13. Ramos-Gomez FJ, Crystal YO, Ng MW, Crall JJ, Feath-
erstone JD. Pediatric dental care: Prevention and manage-
ment protocols based on caries risk assessment. J Calif
Dent Assoc 2010;38(10):746-61.
14. American Academy of Pediatric Dentistry. Pediatric
restorative dentistry. e Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:401-14.
15. American Academy of Pediatric Dentistry. Acquired tem-
poromandibular disorders in infants, children, and ado-
lescents. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:442-50.
16. American Academy of Pediatric Dentistry. Management
considerations for pediatric oral surgery and oral pathol-
ogy. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:484-94.
17. American Academy of Pediatric Dentistry. Policy on pre-
vention of sports-related orofacial injuries. e Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:121-6.
18. Bourguignon C, Cohenca N, Lauridsen E, et al. Interna-
tional Association of Dental Traumatology guidelines for
the management of traumatic dental injuries: 1. Fractures
and luxations. Dent Traumatol 2020;36(4):324-30.
19. Fouad AF, Abbott PV, Tsilingaridis G. International Asso-
ciation of Dental Traumatology guidelines for the
management of traumatic dental injuries: 2. Avulsion of
permanent teeth. Dent Traumatol 2020;36(4):331-42.
20. Day PF, Flores MT, O’Connell AC, et al. International
Association of Dental Traumatology guidelines for the
management of traumatic dental injuries: 3. Injuries in the
primary dentition. Dent Traumatol 2020;36(4):343-9.
21. American Academy of Pediatric Dentistry. Policy on the
dental home. e Reference Manual of Pediatrc Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:21-2.
22. Kempe A, Beaty B, Englund BP, et al. Quality of care and
use of the medical home in a state-funded capitated
primary care plan for low-income children. Pediatrics
2000;105(5):1020-8.
23. American Academy of Pediatrics Council on Children
with Disabilities. Care coordination: Integrating health
and related systems of care for children with special health
care needs. Pediatrics 2005;116(5):1238-44.
24. Berg JH, Stapleton FB. Physician and dentist: New initi-
atives to jointly mitigate early childhood oral disease.
Clin Pediatr 2012;51(6):531-7.
25. American Academy of Pediatrics. Maintaining and im-
proving the oral health of young children. Pediatrics 2014;
134(6):1224-9.
26. American Academy of Pediatric Dentistry. Policy on early
childhood caries (ECC): Consequences and preventive
strategies. e Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:90-3.
27. American Academy of Pediatric Dentistry. Caries risk
assessment and management for infants, children, and
adolescents. e Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:266-72.
28. American Academy of Pediatric Dentistry. Policy on
dietary recommendations for infants, children, and
adolescents. e Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:96-100.
29. American Academy of Pediatric Dentistry. Management
of the developing dentition and occlusion in pediatric
dentistry. e Reference Manual of Pediatric Dentistry.
Chicago Ill.: American Academy of Pediatric Dentistry;
2022:424-41.
30. Tseng R, Vann WF Jr, Perrin EM. Addressing childhood
overweight and obesity in the dental oce: Rationale and
practical guidelines. Pediatr Dent 2010;32(5):417-23.
31. Scharf RJ, Scharf GJ, Stroustrup A. Developmental
milestones. Pediatr Rev 2016;37(1):25-37.
32. Brown E, Jr. Children’s Dental Visits and Expenses, United
States, 2003. Statistical Brief #117. March, 2006. Agency
for Healthcare Research and Quality, Rockville, Md.
Available at: “http://meps.ahrq.gov/mepsweb/data_les/
publications/st117/stat117.shtml”. Accessed March 2,
2022.
33. Selden TM. Compliance with well-child visit recommen-
dations: Evidence from the Medical Expenditure Panel
Survey, 2000-2002. Pediatrics 2016;118(6):e1766-78.
34. American Academy of Pediatric Dentistry. Management
of dental patients with special health care needs. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2022:302-9.
35. American Academy of Pediatric Dentistry. Policy on early
childhood caries (ECC): Unique challenges and treatment
options. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:94-5.
36. Clarke M, Locker D, Berall G, Pencharz P, Kenny DJ,
Judd P. Malnourishment in a population of young chil-
dren with severe early childhood caries. Pediatr Dent
2006;28(3):254-9.
37. Dye BA, Mitnik GL, Iafolia TJ, Vargus CM. Trends in
dental caries in children and adolescents according to
poverty status in the United States from 1999 through
2004 and from 2011 through 2014. J Am Dent Assoc
2017;148(8):550-74.
References continued on the next page.
BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE
/
COUNSELING AND TREATMENT
296 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
38. Jackson SL, Vann WF, Kotch J, Pahel BT, Lee JY. Impact
of poor oral health on children’s school attendance and
performance. Amer J Publ Health 2011;10(10):1900-6.
39. Nowak AJ, Casamassimo PS, Scott J, Moulton R. Do
early dental visits reduce treatment and treatment costs
for children? Pediatr Dent 2014;36(7):489-93.
40. Davis EE, Deinard AS, Maiga EW. Doctor, my tooth
hurts: e costs of incomplete dental care in the emergency
room. J Pub Health Dent 2010;70(3):205-10.
41. Kobayashi M, Chi D, Coldwell SE, Domoto P, Milgrom
P. e eectiveness and estimated costs of the access to
baby and child dentistry programs in Washington State.
J Am Dent Assoc 2005;136(9):1257-63.
42. Lee JY, Bouwens TJ, Savage MF, Vann WF Jr. Examining
the cost-eectiveness of early dental visits. Pediatr Dent
2006;28(2):102-5, discussion 192-8.
43. American Academy of Pediatrics. Early childhood caries
in indigenous communities. Pediatr Dent 2011;127(6):
1190-8.
44. American Academy of Pediatric Dentistry. Recordkeeping.
e Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2022:
521-8.
45. Yepes JF, Dean JA. Examination of the mouth and relevant
structures. In: Dean JA, ed. McDonald and Avery’s Den-
tistry for the Child and Adolescent. 11th ed. St. Louis,
Mo.: Elsevier Co; 2020:3-19.
46. Fontana M. Patient evaluation and risk assessment. In:
Little JW, Falace DA, Miller CS, Rhodus, NL eds. Den-
tal Management of the Medically Compromised Patient.
9th ed. St. Louis, Mo.: Elsevier; 2018:2-17.
47. American Academy of Pediatric Dentistry. Prescribing
dental radiographs for infants, children, adolescents, and
individuals with special health care needs. e Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:273-6.
48. American Dental Association, U.S. Department of Health
and Human Services. Dental Radiographic Examinations:
Recommendations for Patient Selection and Limiting
Radiation Exposure. Revised 2012. Available at: “https://
www.fda.gov/media/84818/download”. Accessed June 22,
2022.
49. American Academy of Pediatric Dentistry. Risk assessment
and management of periodontal diseases and pathologies
in pediatric dental patients. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2022:466-83.
50. Tagliaferro EP, Pereina AC, Meneghin MDC, Ambrosono
GBM. Assessment of dental caries prediction in a seven-
year longitudinal study. J Pub Health Dent 2006;66(3):
169-73.
51. American Academy of Pediatric Dentistry. Behavior
guidance for the pediatric dental patient. e Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:321-39.
52. Crall JJ, Quiñonez RB, Zandona AF. Caries risk assess-
ment: Rationale, uses, tools, and state of development. In:
Berg JH, Slayton RL, eds. Early Childhood Oral Health,
2nd ed. Hoboken, N.J.: John Wiley & Sons, Inc.; 2016:
193-220.
53. Fontana M, Zero DT. Assessing patients’ caries risk. J
Am Dent Assoc 2006;137(9):1231-9.
54. American Academy of Pediatric Dentistry. Policy on
social determinants of children’s oral health and health
disparities. e Reference Manual of Pediatric Dentistry.
Chicago Ill.: American Academy of Pediatric Dentistry;
2022:29-33.
55. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Inuences
on children’s oral health: A conceptual model. Pediatrics
2007;120(3):e510-20.
56. Lee JY, Divaris K. e ethical imperative of addressing
oral health disparities: A unifying framework. J Dent Res
2014;93(3):224-30.
57. Seow KW. Environmental, maternal, and child factors
which contribute to early childhood caries: A unifying
conceptual model. Int J Paediatr Dent 2012;22(3):
157-68.
58. Domejean S, White JM, Featherstone JD. Validation of
the CDA CAMBRA caries risk assessment: A six year
retrospective study. J Calif Dent Assoc 2011;39(10):
709-15.
59. Ramos-Gomez F, Ng MW. Into the future: Keeping
healthy teeth caries free: Pediatric CAMBRA protocols. J
Calif Dent Assoc 2011;39(10):723-33.
60. Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors
for dental caries in young children: A systematic review of
the literature. Community Dent Health 2004;21(suppl):
71-85.
61. Ramos-Gomez FJ. A model for community-based pedi-
atric oral health: Implementation of an infant oral care
program. Int J Dent 2014;2014:156821.
62. Southward LH, Robertson A, Edelstein BL. Oral health
of young children in Mississippi Delta child care centers.
A second look at early childhood caries risk assessment. J
Public Health Dent 2008;68(4):188-95.
63. Nunn ME, Dietrich T, Singh HK, Henshaw MM, Kres-
sin NR. Prevalence of early childhood caries among very
young urban Boston children compared with U.S.
children. J Public Health Dent 2009;69(3):156-62.
64. Weber-Gasparoni K, Kanellis MJ, Qian F. Iowa’s public
health-based infant oral health program: A decade of
experience. J Dent Educ 2010;74(4):363-71.
65. Jiang S, McGrath C, Lo E, Ho S, GaoX. Motivational
interviewing to prevent early childhood caries: A random-
ized control trial. J Dent 2020;97(6):1-7.
66. Plutzer K, Keirse MJ. Incidence and prevention of early
childhood caries in one- and two-parent families. Child
Care Health Dev 2011;37(1):5-10.
BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE
/
COUNSELING AND TREATMENT
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 297
67. Smith S, Kroon J, Schwarzer R, Hamilton K. Parental
social cognitive correlates of preschoolers’ oral hygiene
behavior: A systematic review and meta-analysis. Soc Sci
Med 2020;264:113322.
68. Halvari AEM, Halvari H, Bjørnebekk G, Deci EL. Self-
determined motivational predictors of increases in dental
behaviors, decreases in dental plaque, and improvement
in oral health: A randomized clinical trial. Health Psychol
2012;31(6):777-88.
69. Harrison RL, Veronneau J, Leroux B. Effectiveness of
maternal counseling in reducing caries in Cree children. J
Dent Res 2012;91(11):1032-7.
70. Ismail AI, Ondersma S, Jedele JM, Little RJ, Lepkowski
JM. Evaluation of a brief tailored motivational interven-
tion to prevent early childhood caries. Community Dent
Oral Epidemiol 2011;39(5):433-48.
71. Miller WR, Rollnick S. Meeting in the middle: Motiva-
tional interviewing and self-determination theory. Int J
Behav Nutr Phys Act 2012;2(9):25.
72. Riedy C, Weinstein P, Manci L, et al. Dental attendance
among low-income women and their children following a
brief motivational counseling intervention: A community
randomized trial. Soc Sci Med 2015;144:9-18.
73. Weber-Gasparoni K, Reeve J, Ghosheh N, et al. An eec-
tive psychoeducational intervention for early childhood
caries prevention: Part I. Pediatr Dent 2013;35(3):241-6.
74. Weber-Gasparoni K, Warren JJ, Reeve J, et al. An eective
psychoeducational intervention for early childhood caries
prevention: Part II. Pediatr Dent 2013;35(3):247-51.
75. Mejàre I, Axelsson S, Dahlén D, et al. Caries risk-assessment:
A systematic review. Acta Odontol Scand 2014;72(2):
81-91.
76. Lin Y, Chou C, Lin Y. Caries experience between primary
teeth at 3-5 years of age and future caries in the permanent
rst molars. J Dent Sci 2021;16(3):899-904.
77. American Academy of Pediatric Dentistry. Policy on
snacks and sugar-sweetened beverages sold in schools.
e Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2022:
101-2.
78. Marshall TA, Levy SM, Broffitt B, et al. Dental caries
and beverage consumption in young children. Pediatrics
2003;112(3Pt1):e184-e191.
79. Chankanka O, Marshall TA, Levy SM, et al. Mixed denti-
tion cavitated caries incidence and dietary intake fre-
quencies. Pediatr Dent 2011;33(3):233-40.
80. Sharif M, Newton T, Cunningham S. A systematic review
to assess interventions delivered by mobile phones in
improving adherence to oral hygiene advice for children
and adolescents. Br Dent J 2019;227(5):375-82.
81. Featherstone JDB, Chaffee B. The evidence for caries
management by risk assessment (CAMBRA). Adv Dent
Res 2018;29(1):9-14.
82. Warren JJ, Van Buren JM, Levy SM, et al. Dental caries
clusters among adolescents. Community Dent Oral
Epidemiol 2017;45(6):538-44.
83. Elangovan S, Novak KF, Novak MJ. Clinical risk assess-
ment. In Newman MG, Takei HH, Klokkevold PR,
Carranza FA. eds. Newman and Carranza’s Clinical Peri-
odontology. 13th ed. Philadelphia, Pa.: Elsevier 2019:
410-2.
84. Bimstein E, Huja Pe, Ebersole JL. e potential lifespan
impact of gingivitis and periodontitis in children. J Clini
Pediatr Dent 2013;38(2):95-9.
85. Douglass CW. Risk assessment and management of
periodontal disease. J Am Dent Assoc 2006;137(Suppl):
7S-32S.
86. American Academy of Pediatric Dentistry. Oral health
care for the pregnant pediatric dental patient. The
Reference Manualof Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2022:292-301.
87. Clerehugh V. Periodontal diseases in children and adoles-
cents. Br Dent J 2008;204(8):469-71.
88. Anderson MH, Shi W. A probiotic approach to caries
management. Pediatr Dent 2006;28(2):151-3.
89. Featherstone JDB. Caries prevention and reversal based
on the caries balance. Pediatr Dent 2006;28(2):128-32.
90. Clerehugh V, Tugnait A. Periodontal diseases in children
and adolescents: 2. Management. Dent Update 2001;28
(6):274-81.
91. American Academy of Pediatric Dentistry. Fluoride
therapy. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:317-20.
92. Adair SM. Evidence-based use of fluoride in contem-
porary pediatric dental practice. Pediatr Dent 2006;28
(2):133-42.
93. Tinanoff N. Use of fluoride. In: Early Childhood Oral
Health. Berg JH, Slayton RL, eds. Hoboken, N.J.: John
Wiley & Sons, Inc.; 2016:104-19.
94. Weyant RJ, Tracy SL, Anselmo TT, et al. Topical uoride
for caries prevention: Executive summary of the updated
clinical recommendations and supporting systematic
review. J Amer Dent Assoc 2013;144(11):1279-91.
95. Azarpazhooh A, Main PA. Ecacy of dental prophylaxis
(rubber-cup) for the prevention of caries and gingivitis:
A systematic review of the literature. Br Dent J 2009;
207(7):E14.
96. Featherstone JD, Adair SM, Anderson MH, et al. Caries
management by risk assessment: Consensus statement,
April 2002. J Calif Dent Assoc 2003;331(3):257-69.
97. Axelsson S, Söder B, Norderam G, et al. Eect of com-
bined caries-preventive methods: A systematic review of
controlled clinical trials. Acta Odontol Scand 2004;62
(3):163-9.
98. Källestål C. The effect of five years’ implementation of
caries-preventive methods in Swedish high-risk adoles-
cents. Caries Res 2005;39(1):20-6.
References continued on the next page.
BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE
/
COUNSELING AND TREATMENT
298 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
99. Rozier RG, Adair, S, Graham F, et al. Evidence-based
clinical recommendations on the prescription of dietary
fluoride supplements for caries prevention. J Am Dent
Assoc 2010;141(12):1480-9.
100. American Dental Association Council on Scientific
Aairs. Professionally-applied topical uoride: Evidence-
based clinical recommendations. J Am Dent Assoc 2006;
137(8):1151-9.
101. Campbell RE, Wilson S, Zhand Y, Scarfe WC. A survey on
radiation exposure reduction including rectangular col-
limation for intraoral radiography by pediatric dentists in
the United States. J Am Dent Assoc 2020;151(4):287-96.
102. Casamassimo PS, Nowak AJ. Anticipatory guidance. In:
Berg JH, Slayton RL, eds. Early Childhood Oral Health,
2nd ed. Hoboken, N.J.: John Wiley & Sons, Inc.; 2016:
169-92.
103. Sigurdsson A. Evidence-based review of prevention of
dental injuries. Pediatr Dent 2013;35(2):184-90.
104. American Academy of Pediatric Dentistry. Policy on
tobacco use. e Reference Manual of Pediatric Dentistry.
Chicago Ill.: American Academy of Pediatric Dentistry;
2022:103-7.
105. American Academy of Pediatric Dentistry. Policy on
electronic nicotine delivery systems (ENDS). e Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:108-11.
106. American Academy of Pediatric Dentistry. Policy on
intraoral/perioral piercing and oral jewelry/accessories.
e Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2022:
119-120.
107. American Academy of Pediatric Dentistry. Policy on
substance misuse in adolescent patients. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:112-6.
108. American Speech-Language-Hearing Association. How
Does Your Child Hear and Talk? Available at: “http://
www.asha.org/public/speech/development/chart/”.
Accessed March 2, 2022.
109. Lewis CW, Grossman DC, Domoto PK, Deyo RA. e
role of the pediatrician in the oral health of children: A
national survey. Pediatrics 2000;106(6):E84.
110. American Academy of Pediatric Dentistry. Policy on emer-
gency oral care for infants, children, adolescents, and
individuals with special health care needs. e Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:66.
111. American Lung Association. Stop Smoking. Available at:
“http://www.lung.org/stop-smoking/”. Accessed March 2,
2022.
112. American Academy of Pediatric Dentistry. Policy on
pacifiers. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:86-9.
113. Bishara SE, Watten JJ, Brott B, et al. Changes in the
prevalence of nonnutritive sucking patterns in the rst 8
years of life. Am J Orthod Dentofacial Orthop 2006;130
(1):31-6.
114. Cenci VS, Marciel SM, Jarrus ME, et al. Pacier-sucking
habit duration and frequency on occlusal and myofunc-
tional alterations in preschool children. Braz Oral Res
2015;29(1):1-7.
115. American Academy of Pediatric Dentistry. Policy on use
of uoride. e Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:70-1.
116. Kranz S, Smiciklas-Wright H, Francis LA. Diet quality,
added sugar, and dietary ber intakes in American pre-
schoolers. Pediatr Dent 2006;28(2):164-71.
117. Lott M, Callahan E, Walker Duy E, Story M, Daniels
S. Consensus statement. Healthy beverage consumption
in early childhood: Recommendations from key national
health and nutrition organizations. September, 2019.
Available at: “https//healthyeatingresearch.org/wp-
content/2019/09/HER-HealthyBeverage-Consensus
Statement.pdf”. Accessed March 16, 2022.
118. Drewnowski A. e cost of U.S. foods as related to their
nutritive value. Am J Clin Nutr 2010;92(5):1181-8.
119. Ervin RB, Kit BK, Carroll MD, Ogden CL. Consump-
tion of added sugar among U.S. children and adolescents,
2005-2008. NCHS Data Brief 2012;3(87):1-8.
120. Mobley C, Marshall TA, Milgrom P, Coldwell SE. The
contribution of dietary factors to dental caries and dis-
parities in caries. Acad Pediatr 2009;9(6):410-4.
121. Davidson K, Schroth R, Levi J, Yae A, Mittermuller B,
Sellers C. Higher body mass index associated with severe
early childhood caries. BMC Pediatrics 2016;16(137):
1-8.
122. Schroth R, Levi JA, Sellers EA, Friel J, Kliewer E, Moatt
M. Vitamin D status of children with severe early child-
hood caries: A case control study. BMC Pediatrics 2013;
13(174):1-8.
123. U.S. Department of Health and Human Services, U.S.
Department of Agriculture. 2020-2025 Dietary Guide-
lines for Americans, 9th ed. Washington, D.C.: U.S.
Department of Health and Human Services and U.S. De-
partment of Agriculture; 2020.
124. Glendor U. Epidemiology of traumatic injuries - A 12
year review of the literature. Dent Traumatol 2008; 24(6):
603-11.
125. Lee JY, Divaris K. Hidden consequences of dental trauma:
e social and psychological eects. Pediatr Dent 2009;
31(2):96-101.
126. Meyer BD, Lee JY, Lampiris LN, Mihas P, Vossers S,
Divaris K. “ey told me to take him somewhere else”:
Caregivers’ experiences seeking emergency dental care
for their children. Pediatr Dent 2017;39(3):209-14.
BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE
/
COUNSELING AND TREATMENT
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 299
127. American Academy of Pediatric Dentistry. Policy on
teledentistry. e Reference Manual of Pediatric Dentis-
try. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:50-1.
128. Albert DA, Severson HH, Andrews JA. Tobacco use by
adolescents: The role of the oral health professional in
evidence-based cessation program. Pediatr Dent 2006;
28(2):177-87.
129. U.S. Department of Health and Human Services. Pre-
venting Tobacco Use Among Youth and Young Adults: A
Report of the Surgeon General. Atlanta, Ga.: U.S. De-
partment of Health and Human Services, Centers for
Disease Control and Prevention, Oce on Smoking and
Health; 2012. Available at: “http://www.cdc.gov/tobacco
/data_statistics/sgr/2012/index.htm”. Accessed March 2,
2022.
130. Centers for Disease Control and Prevention. Tobacco use
among middle and high school students – United States,
2020. MMWR Morb Mortal Wkly Rep 2020;69(50):
1881-8.
131. Jiang S, Dong Y. Human papillomavirus and oral squa-
mous cell carcinoma: A review of HPV-positive oral
squamous cell carcinoma and possible strategies for
future. Curr Probl Cancer 2017:41(5):323-7.
132. National Cancer Institute. HPV and Cancer. Reviewed
October 25, 2021. Available at: “https://www.cancer.gov/
about-cancer/causes-prevention/risk/infectious-agents/
hpv-and-cancer”. Accessed March 9, 2022.
133. National Cancer Institute. Oral Cavity, Oropharyngeal,
Hypopharyngeal, and Laryngeal Cancers Prevention
(PDQ
®
)–Health Professional Version. Updated October
15, 2021. Available at: “https://www.cancer.gov/types/
head-and-neck/hp/oral-prevention-pdq#_223_toc”.
Accessed March 9, 2022.
134. American Academy of Pediatric Dentistry. Policy on
human papilloma virus vaccinations. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:117-8.
135. American Academy of Pediatric Dentistry. Policy on ethi-
cal responsibilities in the oral health care management
of infants, children, adolescents, and individuals with spe-
cial health care needs. e Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2022:184-5.
136. Dean JA, Walsh JS. Managing the developing occlusion.
In: Dean JA, ed. McDonald and Avery’s Dentistry for the
Child and Adolescent. 11th ed. St. Louis, Mo.: Elsevier;
2020:467-530.
137. Wright JT, Tampi MP, Graham L, et al. Sealants for
preventing and arresting pit-and-ssure occlusal caries in
primary and permanent molars. Pediatr Dent 2016;38
(4):282-308. Erratum in Pediatr Dent 2017;39(2):100.
138. Sasa I, Donly KJ. Dental sealants: A review of the
materials. Calif Dent Assoc J 2010;38(10):730-4.
139. Ignelzi M. Pit and fissure sealants - An ongoing com-
mitment. Calif Dent Assoc J 2010;38(10):725-8.
140. American Academy of Pediatric Dentistry. Policy on
third-party reimbursement of fees related to dental
sealants. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry;
2022:163-4.
141. Shin S, Choi E, Moon S. Prevalence of pathologies re-
lated to impacted mandibular third molars. Springerplus
2016:5(1):915.
142. Lieblich SE, Dym H, Fenton D. Dentoalveolar surgery.
J Oral Maxillofac Surg 2017;75(8):250-73.
143. American Association of Oral and Maxillofacial Surgeons.
Advocacy white paper on third molar teeth (2016). Avail-
able at: “https://www.aaoms.org/docs/govt_affairs/
advocacy_white_papers/management_third_molar_ white_
paper.pdf ”. Accessed March 2, 2022.
144. Klene CA, Ferneini EM, Bennett JD. Oral surgery in
the pediatric patient. In: Dean JA, ed. McDonald and
Avery’s Dentistry for the Child and Adolescent. 11th ed.
St. Louis, Mo: Elsevier; 2020:659-72.
145. Blondeau F, Daniel NG. Extraction of impacted mandibu-
lar third molars: Postoperative complications and their
risk factors. J Can Dent Assoc 2007;73(4):325.
146. Mettes TD, Ghaeminia H, Nienhuijs ME, Perry J, van
deer Sanden WJ, Plasschaert A. Surgical removal versus
retention for the management of asymptomatic impacted
wisdom teeth. Cochrane Database Syst Rev 2012;13(6):
CD003879. Available at: “https://repository.ubn.ru.nl/
bitstream/handle/2066/109646/109646.pdf;jsessionid=2F
32C887B9A7DF553B2B555F3522DBDB?sequence=1”.
Accessed March 6, 2022.
147. Ghaeminia H, Toedtling V, Tummers M, Hoppenreijs T,
Van der Sanden W, Mettes T. Surgical removal versus
retention for the management of asymptomatic disease-
free impacted wisdom teeth. Cochrane Database Syst Rev
2020;5:CD003879. Available at: “https://www.cochrane
library.com/cdsr/doi/10.1002/14651858.CD003879.pub5/
epdf/full”. Accessed March 6, 2022.
148. American Academy of Pediatric Dentistry. Policy on
transitioning from a pediatric to an adult dental home
for individuals with special health care needs. e Refer-
ence Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2022:172-5.
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COUNSELING AND TREATMENT
300 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
BEST PRACTICES: RECOMMENDED DENTAL PERIODICITY SCHEDULE
Recommended Dental Periodicity Schedule for Pediatric Oral Health Assessment, Preventive Services,
and Anticipatory Guidance/Counseling
Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally. These recommendations will need to be
modified for children with special health care needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric Dentistry emphasizes the importance of very early professional
intervention and the continuity of care based on the individualized needs of the child. Refer to the text of this best practice for supporting information and references.
AGE
6 TO 12 MONTHS 12 TO 24 MONTHS 2 TO 6 YEARS 6 TO 12 YEARS 12 YEARS
AND OLDER
Clinical oral examination
•• •• •• •• ••
Assess oral growth and development
0
•• •• •• •• ••
Caries-risk assessment
0
•• •• •• •• ••
Radiographic assessment
•• •• •• •• ••
Prophylaxis and topical uoride
•• •• •• •• ••
Fluoride supplementation
•• •• •• •• ••
Anticipatory guidance/counseling
80
•• •• •• •• ••
Oral hygiene counseling
Parent Parent Patient/parent Patient/parent Patient
Dietary counseling
10
•• •• •• •• ••
Counseling for nonnutritive habits
•• •• •• •• ••
Injury prevention and safety counseling
12
•• •• •• •• ••
Assess speech/language development
•• •• ••
Assessment developing occlusion
1
•• •• ••
Assessment for pit and ssure sealants
•• •• ••
Periodontal-risk assessment
•• •• ••
Counseling for tobacco, vaping, and
substance misuse
•• ••
Counseling for human papilloma virus/
vaccine
•• ••
Counseling for intraoral/perioral piercing
•• ••
Assess third molars
10
••
Transition to adult dental care
••
®
1 First examination at the eruption of the rst tooth and no later than 12 months. Repeat every six months or as indicated
by child’s risk status/susceptibility to disease. Includes assessment of pathology and injuries.
2 By clinical examination.
3 Must be repeated regularly and frequently to maximize effectiveness.
4 Timing, types, and frequency determined by child’s history, clinical ndings, and susceptibility to oral disease.
5 Consider when systemic uoride exposure is suboptimal. Up to at least 16 years.
6 Appropriate discussion and counseling should be an integral part of each visit for care.
7 Initially, responsibility of parent; as child matures, jointly with parent; then, when indicated, only child.
8 At every appointment; initially discuss appropriate feeding practices, then the role of rened carbohydrates and frequency
of snacking in caries development and childhood obesity. Monitor body mass index beginning at age two.
9 At rst, discuss the need for nonnutritive sucking: digits vs. paciers; then the need to wean from the habit before maloc-
clusion or deleterious effect on the dentofacial complex occurs. For school-aged children and adolescent patients, counsel
regarding any existing habits such as ngernail biting, clenching, or bruxism.
10 Initially paciers, car seats, play objects, electric cords; secondhand smoke; when learning to walk; with sports
and routine playing, including the importance of mouthguards; then motor vehicles and high-speed activities.
11 Observation for age-appropriate speech articulation and uency as well as achieving receptive and expressive
language milestones.
12 Identify: transverse, vertical, and sagittal growth patterns; asymmetry; occlusal disharmonies; functional status
including temporomandibular joint dysfunction; esthetic inuences on self-image and emotional development.
13 For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and
ssures; placed as soon as possible after eruption.
14 Periodontal probing should be added to the risk-assessment process after the eruption of the rst permanent
molars.
1
2
3
4
3,4
5
6
3,7
3,8
9
10
11
12
13
3,14
