Dr. Gregory Psaltis

8733 Fernwood St. NE

Olympia, WA    98516

Phone and FAX:   (360)  413-5760






Baby Steps

Infant and Preschool Care for the General Dentist



  I.  Initial comments about infant and preschool care

      A. Dental Home should be established no later than ____________________

            1. Recommendation grew out of Surgeon General C Everett L Koop’s 2000 report,   

                which connected ______________________ with ________________________

            2. Why start by this age of a child?

                a. Percentage of children who experience caries by age 5: __________________

                b. Unique caries-risk factors for young children

                     i. Ongoing establishment of oral flora

                     ii. Susceptibility of newly erupted teeth

                     iii. Development of dietary habits

                c. Age when high-risk dietary practices appear to be established: ______________

                d. Newly erupted teeth are at risk for caries because of ______________________

            3. If you cannot/will not see children at 6-12 months

                 a. Do NOT say, “We don’t see children until age _________.”

                 b. Recommend an exam with a pediatric dentist

      B. Importance of infant oral health

            1. Strep mutans colonies begin as soon as __________________________

            2. Appropriate fluoride regimens enhance caries resistance

            3. Caries risk assessment is a critical tool in establishing ____________________

            4. Injury prevention counseling can be provided                                           

            5. Parents can be advised of importance of brushing and flossing

            6. Immature enamel is not as mineralized or resistant to bacteria

            7. Physical transmission modes of MS can be explained to parents

            8. Physicians are now more aware of oral health


II.  Infant Oral Health

      A. Establish a Dental Home

            1. Is all-inclusive of all aspects of oral health among all involved parties

            2. Leads to heightened awareness of issues impacting dental health of children

            3. Modeled on the American Academy of Pediatrics definition of  a medical home

            4. Advantages of Dental Home:

                a. Cost-effective

                b. Higher quality of care

                c. More likely to provide ________________________________

                d. Creates time-critical opportunities to reduce risk of oral diseases

            5. Dental Home provides:

                a. Preventive services

                b. Comprehensive assessment of diseases and conditions

                c. Caries-risk assessment

                d. Anticipatory guidance for ____________________________

                e. Plan for acute trauma

                f. Information about proper _____________________________

                g. Diet counseling

                h. Appropriate referrals

            6. Establishing a Dental Home

                a. Eruption of first tooth or no late than 12 months

                b. Follows AAP policy of medical home

                c. Shown to be cost-effective

                d. Provides comprehensive oral health care

                e. Enables individualized preventive plans

      B. Oral Risk Assessment

            1. One of the primary goals is to identify and minimize causative factors

            2. Emphasizes treatment of disease process rather than the _______________

            3. Helps patient understand disease process and preventive steps

            4. Customizes preventive program

            5. Anticipates caries ____________________________

            6 Specific risk associations

a.     Sugar-caries relationship may not be as great as previously thought

b.     Evidence suggests night-time use of a bottle is a factor

c.     Socioeconomics plays an _____________________ role

d.     Lack of fluoride and regular brushing are both predictors

      C. Teething

            1. Educate parents regarding expected time or arrival of teeth

            2. Delineate ___________________ from ____________________

            3. Oral analgesics and chilled rings for pain are recommended

            4. Topical anesthetics are to be discouraged due to ________________________

      D. Oral hygiene

            1. Implement upon eruption of ________________________

            2. Use of soft toothbrush is recommended

            3. Start flossing as soon as adjacent tooth surfaces cannot be brushed

            4. Toothbrushing is to be done _______ times daily

            5. Discuss after-nursing cleaning

      E. Diet

            1. High-sugar diets are usually established by 12 months of age

            2. Frequent night-feeding and/or ad-lib nursing associated with ECC

            3. Juices are not recommended for night-time feeding

            4. Two other factors in increased caries rate are:

               ___________________________ and _______________________________

            5. Diet Counselling relative to obesity

                a. Increased sugar consumption is also linked to obesity

                b. Prevalence of obesity has _______________ for 6-11 year olds in past 25 years

                c. Prevalence of obesity has _______________ for 12-19 year olds in past 25 years

                d. Obesity predisposes to Type 2 diabetes, heart disease, respiratory, orthopedic and

                    liver problems


            6. U.S. Department of Agriculture “Dietary Guidelines for Americans,” 2007

                a. Eat a variety of foods

                b. Balance foods eaten with ____________________________

                c. Eat adequate calories to support normal growth up to a healthy weight

                d. Include plenty of vegetables, fruits and _______________________

                e. Use sugar and salt in moderation

            7. Human breast milk

                a. Uniquely superior in nutrition and, by itself, is ____________________

                b. In combination with other carbohydrates is _______________________

                c. Frequent night-bottle and adlib nursing are associated with, but not consistently 

                   linked to ECC

e.     Studies reveal that breastfeeding may be protective against ______________

            8. Other interesting articles

                a. Enzyme-inhibitory properties are associates with polyphenols. Two foods are:

                    __________________________ and ________________________________

                b. Parents’ behaviors influence their children’s ____________ and _____________

      F. Fluoride

            1. Optimal exposure is important to all infants and children with teeth

            2. Well documented as _____________ and ___________________________

            3. Individualize the plan for each patient

            4. Amount of fluoridated toothpaste is dependent upon the child’s _____________

            5. Fluoride ingestion

                a. Water fluoridation shows ______ reduction in caries without significant fluorosis

                b. Review all sources of fluoride (water, beverages, prepared foods and toothpaste)

            6. Mechanisms of action

                a. Enamel remineralization

                b. Altering bacterial metabolism

            7. Varnishes prevent or reverse enamel demineralization

            8. Toothpaste amounts

                a. A “smear” for the under-2-year old will provide approximately ______ mg

                b. A “pea-sized” amount for 2-5 year olds provides approximately ______ mg

                c. Ingested toothpaste was greater if a child uses fruit-flavored dentifrice

            9. Supplementation (assuming less than 0.3 ppm F in child’s diet)

                a. Birth to 6 months= none

                b. 6 months to 3 years= .25 mg F (.55 mg NaF)

                c. 3 years to 6 years= .5 mg F (1.1 mg NaF)

                d. 6 years to 16 years= 1 mg F (2.2 mg NaF)

      G. Injury prevention

            1. Most common trauma occurs due to __________________

            2. Emphasize need for car seats

            3. Toothbrushes and pacifiers an be problems when children are running

            4. Electrical cords are potential problems

            5. Trauma can have negative psychological and esthetic effect on children

            6. Greatest incidence of trauma occurs at _____________ years of age

            7. Causes of dental trauma

                a. Falls

                b. Traffic accidents

                c. Violence

                d. Sports


      H. Non-nutritive habits

                        1. Can contribute to negative changes in occlusion and facial development

                        2. Early visits provides opportunity to encourage parents help them stop

                        3. Types of habits

                            a. Finger sucking

                            b. Pacifier usage

                            c. Nail biting

                            d. Tongue thrusting


III  Coaching the parents

      A. Etiology and prevention of ECC

            1. Explain roles of nursing and/or bottle feeding

            2. Discuss night-time feeding

            3. Educate them to avoid ____________________________________

      B. Comprehensive oral exam during preganancy

            1. Very important for the mothers

            2. Get active caries treated

            3. Keeping Strep Mutans down decrease chances of ECC

      C. Oral hygiene instructions

            1. Use fluoridated toothpaste

            2. Floss regularly

            3. Reduce levels of _________________________________

      D. Diet

            1. Explain cariogenicity of foods and beverages

            2. Discuss role of ____________________ of consumption of these foods

            3. Educate them about the process of demineralization

            4. There is a relationship between maternal oral health and children’s caries rate

            5. Parents’ smoking (not exactly diet) increased their children’s school absenteeism

      E. Fluoride

            1. Encourage use of fluoridated toothpaste

            2. Recommend rinsing with an OTC fluoride rinse ___________________

            3. Help them understand remineralization

            4. Kids have tremendous BS detectors in case you try to fake it

      F. Xylitol chewing gum

            1. Chewing with xylitol gum 2-3 times daily reduces mother-child MS transfer

            2. Children’s caries rate can possibly be reduced in this same way


IV. ECC- Early Childhood Caries

      A. Previously—bottle syndrome, nursing caries, baby bottle tooth decay

      B. Definition of ECC

            1. ______________ or more decayed, missing or filled primary tooth

            2. Child is under the age of ___________

      C. Definition of SEVERE ECC

            1. Any sign of smooth surface caries in a child younger than __________

            2. One of more DMF smooth surface in primary maxillary anteriors in ages ________

            3. DMF scores of >4 (age _________), >5 (age _________) or >6 (age _________)





V. Child development                     

      A. One year olds

            1. Learn by conditioning, when two stimuli are paired together

            2. _________________ behavior is likely to occur again

            3. Fear of strangers is very common

            4. They startle easily

      B. Two year olds

            1. Language skills begin to develop

            2. They will exert their ___________, testing their __________________________

            3. Role model observation is primary instructor for their own behaviors

            4. Discipline should not be _____________________

            5. Tantrums are normal and should best be left _____________________________

      C. Three year olds

            1. Increased ______________________ behavior demonstrated

            2. A unique identity begins to emerge

            3. Fear of strangers is replaced by greater capacity for _______________________

            4. New situations are less likely to have a negative effect

            5. They can understand ___________________________

      D. Preschoolers

            1. Ability to reason grows considerably

            2. Child becomes able to think with mental imagery or symbols

            3. They can group objects and use more complex thoughts

            4. Value system develops and ________________________ is shown



VI. Behavior Management of the Young Patient

A.   The three C’s are the critical elements of success

B.    Confident

1.     Be in charge

2.     Children can “smell _________________”

3.     Remain positive

4.     C-B-A

a.              If you can C__________________ of something

b.              Then you B__________________ in it

c.              You will A__________________ it

C.    Calm

1.     Keep voice quite

2.     Look at child (at eye level) when speaking

3.     Do not show ______________________________

4.     Nasal breathing is a way to calm yourself down

D.   Child-friendly

1.     Smile and engage the child

2.     Show-tell-do

3.     Terminology

a.     Descriptive terms

b.     Avoid ____________________ labels

c.     Child-friendly words

d.     Understandable



VII. Behavior Management of the Parents

      A. What we often expect is problems

      B. Parent guidelines

            1. Do not over-prepare

            2. Use our terminology

            3. Be an ________________________ only

            4. Leave when asked

            5. Do not make promises


VIII. Treatment Planning

       A. Must consider age of patient for length of visit

             1. Young children need shorter, earlier appointments

             2. Older children (6+) can handle longer, later appointments

       B. Number of visits

             1. Always try for 1 or 2 visits, with a maximum of 4

             2. Consolidate treatments during each visit

       C. Prioritizing

             1. Posteriors should always be treated first

                  a. Longevity of teeth

                  b. Chew food during child's growth

                  c. Less traumatic for treatment

                  d. Often NOT the parents' preference

             2. Anteriors should be saved for last                        

                  a. Function for speech and smiling are secondary to mastication

                  b. More difficult to treat comfortably

                  c. Incentive for parents to continue with treatment of posteriors

             3. Referral of abscessed teeth

                  a. Let oral surgeon complete care with general anesthetic

                  b. Have exodontia done out of your practice

       D. Sequencing of treatment

             1. Generally start with mandibular arch first, if possible

             2. Try to relieve pain at first visit

             3. Save short, simple quadrant for last, as that memory will be held


IX. Local anesthesia

A.   Infiltrations vs. Blocks

B.    Needles

1.  27 ga. short

2.  30 ga. short

3.  30 ga. extra short

C.    Septocaine 4%

1.  Especially effective for _________________________

2.  NOT recommended for children under __________ years of age

3.  NOT recommended for mandibular blocks

4.  Effective for hard-to-get-numb patients

5.  Maximum dose is _________mg per pound

D.   Lidocaine 2%

1.  For children under 3 years of age

2.  Exclusively for ______________________________

3.  Can be used for infiltrations, too

4.  Maximum dose is ___________mg per pound

E.    Topical Anesthetic

1.  Caine sticks

2.  Can give to kids for soft-tissue extractions at home

F.    Safety techniques

1.  Assistant hands of child’s forehead and child’s hands

2.  Mouth prop

G.   Terminology

H.   Management


X. Rubber Dam

       A. Advantages

             1. No tongues to lips to fight

             2. Maintains a _______________________

             3. Easier access

             4. Segregates work in child’s mind to “the other side”

       B. Currently consider the standard of care

       C. Useful clamps

             1. 8A for primary molars

             2. 14A for partially erupted permanent molars

             3. 3 for fully erupted permanent molars


XI. Stainless Steel Crowns Preparation and Placement

     A. Prep occlusal surface first with ___________________

          1. Reduce only about _______________—remove occlusal anatomy

          2. Reduces hemorrhage by avoiding gingiva

          2. Gives better idea of crown size

     B. Prep axial walls with 1170 thin tapered fissure bur

          1. Minimal reduction, but break proximal contacts

          2. Use wedges to _________________________________

          3. Place counter-bevels and modify prep to the shape of the SS crown

     C. Select crown size

          1. Should fit snugly, but must go all the way down

          2. Check for crown length- if tissue blanches, trim crown

          3. General rule is tissue should not blanch more than 1mm

     D. Shape crown

          1. Contouring pliers to basic curvature

          2. Crimping pliers to engage undercuts of prep

          3. With pre-crimped crowns, these steps are not necessary

     E. Cement crown

          1. RelyX Luting Plus cement

          2. ZnPO4 is OK


XII. Sedation

A.   Special requirements

1.   Training

2.   Monitoring

3.   Licensure and ___________________________

4.   Total focus

B.    Do not use sedation without being fully _____________________


                                                            Return to Course Outlines Page

                                                                                                                Go Back to Start Page