Well-child care often includes oral health assessments and interventions. The primary care clinician may also be involved with oral care when there is an unidentified source of fever or pain, especially in a non-verbal child, or when there are specific mouth complaints. Common oral health issues in all children include thrush in infants, tooth decay (40% of children ages 2-11 years), and dental injuries. These oral health issues can cause pain, increase the risk of systemic infections, affect eating habits, sleep, smiling, and social interactions, and have an impact on family finances. Additional dental and oral health challenges can occur in children and youth with special health care needs (CYSHCN).

This resource includes information about the diagnosis and management of common oral health problems that occur in all children and adolescents with special health care needs. The related resource, Dental and Oral Health Screening, contains information for primary care clinicians about relevant screening and assessment, anticipatory guidance, indications for fluoride supplements, and in-office application of varnishes when indicated.

Other Names & Coding

Normal teeth development
Primary teeth usually develop between 6-12 months of age, while adult teeth begin erupting between ages 5 and 7 years and finish by ages 13 to 14 years.

Common oral health issues in children and youth with special health care needs
Common issues in children with special health care needs include poor oral hygiene, bruxism, drooling, traumatic dental injuries, and malocclusion. Some conditions can increase the risk of bleeding or infection, and these risks should be discussed with the patient’s specialist (e.g., cardiologist for those with heart conditions) prior to any dental procedure.

Prophylactic antibiotics
Minor dental procedures usually do not require prophylactic antibiotics. However, invasive procedures or procedures done on children at especially high risk for infection (e.g., certain cardiac conditions, compromised immunity, or prosthetic materials in the body) can warrant antibiotic prophylaxis. Amoxicillin is typically the drug of choice.

Access to dental care
Medicaid and the Children’s Health Insurance Program (CHIP) are major sources of coverage for pediatric dental care. For those who do not have dental insurance, the PCP should provide information for a local, publicly funded, or charity-care dental office.

Krol DM, Whelan K.
Maintaining and Improving the Oral Health of Young Children.
Pediatrics. 2023;151(1). PubMed abstract

Clark MB, Keels MA, Slayton RL.
Fluoride use in caries prevention in the primary care setting.
Pediatrics. 2020;146(6). PubMed abstract / Full Text

Children and youth with special health care needs may face oral health challenges related to:

• Inability to perform self-care
• Medical devices that impact oral health
• Medications that have adverse effects on oral health
• Seizures
• ADHD
• Gingival hyperplasia
• Overcrowding of teeth or malocclusion
• Oral aversions from previous medical procedures or sensory defensiveness
• Xerostomia (dry mouth)
• Dietary factors
• Gastroesophageal reflux disease or vomiting
• Enamel hypoplasia (particularly in premature infants)
• Bruxism
• Lack of access to dentists with appropriate skills

Physical examination should include visual inspection of the mouth for:

• Thrush
• Tooth decay/white spot lesions
• Gingivitis/gum disease
• Abscesses
• Tongue-tie or ankyloglossia
• Tooth discoloration
• Tongue plaques
• Canker sores
• Cold sores
• Chipped teeth
• Jaw pain
• Halitosis
• Tumors
• Plaque build-up
• Presence of prior fillings
• Abnormal tooth eruption

Signs of normal and abnormal tooth eruption

• Permanent teeth erupt in a pattern similar to that of the primary teeth.
• The permanent teeth typically begin erupting between ages 5 and 7 years and finish by ages 13 to 14 years.
• Although some infants develop natal or neonatal teeth, this type of eruption is uncommon.
• Delayed tooth eruption in children >12 months old may be the result of a medical condition and should be evaluated. Referral is warranted if a child has no teeth by 18 months of age. [American: 2017]

The primary care clinician usually treats common conditions affecting the tongue, cheeks, and lips. Primary care clinicians can also provide anticipatory guidance regarding the teeth and gums. Guidance can be found at Dental and Oral Health Screening. However, a general dentist provides care for most conditions affecting the teeth and gums of most children. Encourage families to establish a dental home by 12 months of age (and as early as 6 months of age) and monitor for regular dental visits. [American: 2005] A dental home is a primary care dental provider with a comprehensive and up-to-date approach to pediatric dental care and referring to dental specialists as needed. [EQIPP: 2017]

A pediatric dentist has special training in meeting the needs of infants, children, and adolescents, particularly children with special health care needs who may have complex oral health challenges or who have a hard time cooperating with an oral exam or procedures. Rarely, an oral surgeon is required to provide care for severe conditions. When necessary, help the family select a pediatric dentist who can perform full sedation for evaluations and procedures. The primary care clinician can assist parents with identifying a dentist covered through their insurance plan. (See Services below.)

Some children with complex medical conditions may have trouble with regular toothbrushing at home, and modifications can help them maintain good oral hygiene (e.g., electric toothbrushes, modified toothbrushes, chlorhexidine mouth rinses, or sprays). [Levy: 2018] In other cases, where caregivers have adequate knowledge and do not seek care, dental neglect may be present. It is important for primary care providers to assess these situations and determine if a report to child protective services is needed when true neglect is diagnosed. [Fisher-Owens: 2017]

Condition-Specific Guidance

For children who do not eat or drink by mouth, such as when exclusively tube-fed, the risk of tooth decay is very low to non-existent. This is because there is no substrate (carbohydrate= food/drink) for the bacteria that cause decay. So, regular fluoride application does not have a significant impact on reducing caries. Fluoride varnish does help with tooth sensitivity, so after a deep cleaning, it is a good idea for the dentist to apply it. Consider topical fluoride application in the medical home for children with uncontrolled gastric reflux, as this can increase sensitivity and erode enamel.

The USPSTF recommended in 2014 that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B recommendation). All children 5 years and younger deserve to have the application of fluoride varnish fully covered per USPSTF recommendations, as part of health maintenance and preventive care. In additioin, fluoride varnish application should be a covered benefit and separately paid service (i.e., not considered incidental to the office visit). [Clark: 2020] Higher-risk children may require more frequent fluoride varnish. For example, consider more frequent topical fluoride applications in the medical home for children who have uncontrolled gastric reflux, as this can increase sensitivity and erode enamel. The table below from [Clark: 2020] provides condensed recommendations for the use of fluoride modalities in patients at low and high risk of caries.

Flouride for Low- and High- Risk Patients [Clark: 2020]

Patients usually do not need prophylactic antibiotics for minor dental procedures, such as routine anesthetic injections through non-infected tissue, dental radiographs, placement of removable prosthodontic or orthodontic appliances or brackets, shedding of primary teeth, and bleeding from trauma to the lips or oral mucosa. [Otto: 2021] [Wilson: 2021] Keep in mind that most systemic infections in these patients are NOT due to dental procedures. Good oral hygiene is the primary prevention tool.

Consider prescribing prophylactic antibiotics for certain invasive dental procedures (manipulation of the gingival tissue or the peri-apical tooth area or perforation of the oral mucosa) to patients at highest risk from a distant site infection in the body. [Otto: 2021] [Wilson: 2021] The primary care clinician should discuss with the family the potential benefits and risks (including developing resistant bacteria) of prophylactic antibiotics for patients with any of the conditions described in the section above.

The 2021 Endocarditis Prophylaxis Wallet Card (AHA) provides a table of antibiotic prophylactic regimens for dental procedures by situation, agent, and dose. Recommendations and further information about population, procedures, specific antibiotics, dosing, and timing are detailed in the 2007 American Heart Association guidelines. [Wilson: 2021]

Medicaid (see UT providers [10]) and CHIP, State Children's Health Insur Prog (see UT providers [4])
Medicaid and the Children’s Health Insurance Program (CHIP) are major sources of coverage for pediatric dental care. States define what constitutes “medically necessary” oral health services for Medicaid recipients. [U.S.: 2017] Some state Medicaid programs provide enhanced payments when a modifier (EP) is applied to the claim for specific oral health services during well-child visits. For those families without dental insurance, the primary care clinician should provide information for a local, publicly funded, or charity-care dental office.

The Affordable Care Act expanded insurance coverage of pediatric oral health services; however, there are still children who cannot access oral health care. Other services include:

• Pediatric Dentistry (see UT providers [50])
• Oral/Maxillofacial Surgery (see UT providers [8])
• General Dentistry (see UT providers [98])
• Healthcare, Dental > … (see UT providers [159])

99188, application of topical fluoride varnish by a physician or other qualified health care professional