evidence-based

Care Sheet

Dental Caries in Children and Adolescents

What We Know
 Dental caries, also known as tooth decay or cavities, is considered the most prevalent infectious disease in
children. Dental caries occurs primarily due to overgrowth of oral bacteria, especially Streptococcus mutans,
which can form plaque. The bacteria produce acids that lower pH levels and result in tooth demineralization
and decay(1, 2, 5, 8, 10, 11)

Untreated dental caries can result in pain; infection; tooth abscess or loss; altered chewing, eating, and
sleeping patterns; edentulism (i.e., total tooth loss); and can negatively impact quality of life (QOL). Early
tooth loss is associated with speech difficulties, self esteem issues, increased risk for caries in permanent
teeth, and malalignment and crowding of permanent teeth(1, 2, 5)

Dental caries can develop as soon as teeth erupt. Caries that occur in infancy and young childhood have a
lifelong negative impact on dentition and are more virulent than those that occur in adulthood(1)

Dental caries in primary teeth is no less harmful than that affecting permanent teeth, and in fact, it may
be considered more harmful because it occurs during a period when childhood growth may be negatively
impacted and when young children are particularly vulnerable to systemic infection(1, 11)

Bacterial colonization of the oral cavity with S. mutans occurs prior to tooth eruption from either vertical
transmission from mother to infant(1, 2, 7, 8, 11)
 In the United States, dental caries is the most common chronic childhood disease, and is linked with parental
poverty and low educational status(1, 2, 5, 11)

ICD-9
521.0

ICD-10
K02

ICD-10-CAN
K02

40% of U.S. children have dental caries by kindergarten age(1)

80% of patients with caries are children and adolescents from low-income families(4)
Caries is 32% more likely to occur in infants from families of low socioeconomic status, whose mothers
have low educational levels, and whose diets are high in sugar(1)

Although caries is more prevalent among poorer children, prevalence is increasing among children of all
socioeconomic levels in the U.S.(6)

The U.S. National Health and Nutrition Examination Survey (NHANES) found that, during the period of
19992004, 53% of poor and 31% of non-poor male children aged 28 years had dental caries in primary
teeth. This represents a significant increase from the numbers of poor and non-poor male 28 year-olds
with caries from 19881994 (45% and 23%, respectively)

Authors
Carita Caple, RN, BSN, MSHS
Tanja Schub, BS

Reviewers
Kathleen Walsh, RN, MSN, CCRN
Cinahl Information Systems
Glendale, California
Nursing Practice Council
Glendale Adventist Medical Center
Glendale, California

Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems

Overall, fewer children developed caries in permanent teeth in the last decade; exceptions are poor

White and Mexican children who have seen an increase in caries in permanent teeth
 Additional risk factors for dental caries include

high levels of S. mutans in the oral cavity. Transmission of S. mutans commonly occurs by sharing
utensils, which places children at risk of developing dental caries when mothers or siblings have a high
level of the bacterium(8, 10, 11)

frequent consumption of foods that are high in refined carbohydrates (e.g., sugars [sucrose, fructose,
glucose]) and use of unfluoridated water. Other dietary practices that increase the risk of developing dental
caries include(2, 5, 8, 11)

infants and children who are bottle-fed with sweetened milk or fruit juice
a maternal diet high in refined carbohydrates
lack of or irregular dental visits, delay in professional teeth cleaning, ineffective toothbrushing (e.g.,
infrequent), and using unfluoridated toothpaste(5)

Fluoridated toothpaste is recommended for use by children aged 6 years. Use in younger children
should be monitored closely to avoid dental fluorosis (i.e., discoloration and damage to tooth enamel
February 10, 2012

caused by excess fluoride)(2)

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 untreated maternal caries; the presence of 6 or more untreated caries in a mother is associated with a tripling of risk for caries in her children(7)
insufficient tooth enamel (e.g., the effects of gastroesophageal reflux disease [GERD] can erode tooth enamel) or saliva due to medical conditions (e.g.,
diabetes mellitus, type 1), as a side of effect of certain medications (e.g., antihistamines), or in children who have received radiation treatment(8)
 Prevention of dental caries includes the following strategies:

Dental caries can be prevented by professional application of topical fluoride gels and varnish, and twice daily brushing beginning as soon as teeth erupt(2, 8)
Fluoride supplements (e.g., drops, tablets, lozenges) have not been shown to decrease the incidence of dental caries in primary teeth but are effective
in decreasing the incidence in permanent teeth

Water fluoridation and school-based dental sealant programs have been shown to be helpful in preventing dental caries in children and adolescents(2, 3, 4)
Researchers who studied children aged 515 years in Australia found that rates of dental caries were 28.7% higher in deciduous teeth and 31.6%
higher in permanent teeth in children living in areas with low fluoride concentrations in the water (< 0.3 parts per million [ppm]) compared with those
living in areas with optimally fluoridated water ( 0.7 ppm)(3)

Comprehensive evaluation and treatment of expectant mothers and oral health counseling on the etiology of caries and how to prevent transmission of S.
mutans to infants is essential to reduce risk for infant and childhood caries(1, 2)

Investigators in clinical trials that evaluated methods to prevent childhood caries have identified the following successful preventive therapies:
Xylitol oral syrup given 23 times per day (total daily dose of 8 grams) was shown to be effective in reducing dental caries in children aged 915 months(12)
Professional application of resin-based sealants on first molars was more effective than fluoride applications in preventing dental caries in children
and adolescents(9)

What We Can Do
 Learn about the incidence, risk factors, and prevention of dental caries in children and adolescents; share this knowledge with your colleagues
 Request referrals for dental sealant programs or to low-cost dental clinics, if available
 Educate mothers about the risk of transmitting oral bacteria to their children, the need for regular dental checkups beginning at age 6 months, the need to
avoid sharing utensils, and the importance of minimizing consumption of sugary drinks and foods(1, 2, 5)
 Inform parents to(1, 2, 4, 5)

clean young childrens (age 2 and under) teeth twice daily with a soft brush or washcloth, and floss regularly. Fluoridated toothpaste should be added by
age 2 years; however, children should use no more than a pea-sized amount of toothpaste each time they brush to avoid fluorosis

avoid giving bottles that contain sweetened milk or fruit juice between meals or at bedtime
teach older children and adolescents to independently practice good oral hygiene and dietary habits, and to use a fluoridated toothpaste and mouth rinse
beginning at age 6

Parents of children < 6 years of age should monitor the use of fluoridated toothpaste to confirm children are adequately rinsing and expectorating

Coding Matrix

References

References are rated in order of strength:

1. American Academy of Pediatric Dentistry. (2009). Guideline on infant oral health care. Retrieved from http://www.aapd.org/media/Policies_Guidelines/G_InfantOralHealthCare.pdf (G)

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster

presentations or other such materials

CP Conference proceedings, abstracts, presentations

2. American Academy of Pediatrics, Committee on Native American and Child Health, Canadian Paediatric Society, First Nations, Inuit and Mtis Committee. (2011). Policy
statement: Early childhood caries in indigenous communities. Pediatrics, 127(6), 1190-1198. (G)
3. Armfield, J. M. (2010). Community effectiveness of public water fluoridation in reducing childrens dental disease. Public Health Reports, 125(5), 655-664. (R)
4. U.S. Centers for Disease Control and Prevention. (2010). Preventing dental caries with community programs. Retrieved from
http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/oh.pdf (GI)
5. Duffin, S. (2009). Managing caries in the high-risk child. Compendium of Continuing Education in Dentistry, 30(2), 106-108, 110, 112 passim. (GI)
6. Dye, B. A., Arevalo, O., & Vargas, C. M. (2010). Trends in paediatric dental caries by poverty status in the United States, 1988-1994 and 1999-2004. International Journal of
Paediatric Dentistry, 20(2), 132-143. (R)
7. Dye, B. A., Vargas, C. M., Lee, J. J., Magder, L., & Tinanoff, N. (2011). Assessing the relationship between childrens oral health status and that of their mothers. Journal of the
American Dental Association, 142(2), 173-183. (R)
8. DynaMed. (2012, January 4). Dental caries. Ipswich, MA: EBSCO Publishing. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=dme&AN=113996&site=dynamed-live&scope=site (GI)
9. Hiiri, A., Ahovuo-Saloranta, A., Nordblad, A., & Mkel, M. (2010). Pit and fissure sealants versus fluoride varnishes for preventing dental decay in children and adolescents.
Cochrane Database of Systematic Reviews, (3), CD003067. (SR)
10. Hong, X., & Hu, D. Y. (2010). Salivary Streptococcus mutans level: Value in caries prediction for 11-12-year-old children. Community Dental Health, 27(4), 248-252. (R)
11. Marrs, J.-A., Trumbley, S., & Malik, G. (2011). Early childhood caries: Determining the risk factors and assessing the prevention strategies for nursing intervention. Pediatric
Nursing, 37(1), 9-15. (RV)
12. Milgrom, P., Ly, K. A., Tut, O. K., Mancl, L., Roberts, M. C., Briand, K., & Gancio, M. J. (2009). Xylitol pediatric topical oral syrup to prevent dental caries: A double-blind
randomized clinical trial of efficacy. Archives of Pediatric and Adolescent Medicine, 163(7), 601-607. (RCT)