Update on Dental Hygiene Roles in Pediatric Dentistry

The dental hygienist plays a significant role in pediatric dentistry, whether in general practice, a specialized pediatric practice, or a public health setting. The dental hygienist is frequently the prevention specialist in the practice, focusing on oral hygiene and good dietary habits. Additionally, the hygienist may provide treatment such as sealants, scaling, root planing, and restorative care including local anesthesia, depending on the state practice act. The recommendation for parents to establish a dental home by a child's first birthday¹ means that dental hygienists are now likely to see more and more young children. It is important for dental hygienists to have the skills needed to guide both young children and their parents through a dental hygiene appointment, whether it be for preventive care or for treatment of restorative needs.

Behavior Guidance

Knowing how to work with children is important to the enjoyment of providing them care. Dental hygienists need to cultivate skills and techniques to guide the behavior of young children, especially when introducing them to the dental environment and to new procedures. A review of communication strategies that are considered basic behavior guidance techniques by the American Academy of Pediatric Dentistry (AAPD) may be helpful.² Dental hygienists frequently use tell-show-do, specific direction (e.g., "I need you to keep your hands on your tummy.") followed by positive reinforcement (e.g., "Good job! I really like the way you keep your hands on your tummy!"), distraction, and storytelling. Distraction may include playing audio or video media or something as simple as providing a stuffed animal to hold. Hygienists may enhance the patient's sense of control by giving them a signaling technique to use (e.g., "raise your hand") to indicate pain or need for a break. Another method to enhance control is to give the child the role of helper. For example, the child may hold "Mr. Thirsty," also known as the saliva ejector. The use of age-appropriate language is important, and euphemisms such as Mr. Thirsty, "raincoat" for rubber dam, and "astronaut mask" for nitrous hood can be helpful. Voice control and nonverbal communication are also important means of behavior guidance. Voice control is a deliberate change of volume or tone to gain the child's attention and make clear the adult-child roles. Nonverbal communication through facial expression, body language, and appropriate contact should demonstrate warmth and acceptance of the child.

While the above communication strategies are considered basic behavior guidance techniques by the AAPD, the use of nitrous oxide/oxygen inhalation is also considered a basic behavior guidance technique, albeit a pharmacological one.² In at least 34 states dental hygienists can administer nitrous oxide/oxygen (N2O) to patients including to children.³ Depending on the needs of the child and the treatment to be performed, this may be a useful technique to employ with parental permission. In addition to being an anxiolytic, it provides a degree of analgesia and reduces the gag reflex and movement generally while increasing tolerance to lengthy appointments.²

Anticipatory Guidance

The concept of anticipatory guidance may be new to some dental hygienists. While behavior guidance is communication directed toward the child, anticipatory guidance is communication directed toward the child's parents or caregivers. This three-way interaction between the child, parent, and provider is known as the pediatric dentistry triangle, and the dental hygienist must learn equally well to communicate with the child's parents as with the child. Parents/caregivers are essential to an understanding of the child's health and habits, especially those of young children. As the recommendation to establish a dental home by 12 months is becoming more accepted by medical and dental providers and families alike, more dental hygienists will see very young children, and their parents will be an integral part of the care team. Parents often expect to be involved in their child's care even as their children get older.

Anticipatory guidance provides parents with information and advice about what to expect developmentally, their role in prevention of oral diseases, and the oral health risks to watch for as children get older.¹ During a prevention appointment, the dental hygienist should provide parents with anticipatory guidance in the following six primary areas.

Oral development

Dental hygienists who see preschool-age children and younger should be familiar with the age at which primary teeth erupt and exfoliate. Having a chart handy will be helpful to parents who want to know if teeth are erupting "on time" or are delayed. It is important for parents to understand that-while the primary first molars erupt on average a little after the first birthday, and the second primary molars erupt around the second birthday, with the canines appearing at about a year and a half-all these teeth will remain in the mouth and not be exfoliated for 8 to 10 more years in order to guide the permanent teeth into the mouth. These teeth will be in the mouth long after permanent incisors have replaced the exfoliated primary incisors and the permanent first molars have erupted. Parents should know that if the primary teeth develop decay, the bacteria that cause tooth decay can infect the permanent teeth. Therefore, protecting the health of primary teeth from the time they first erupt is crucial for healthy permanent teeth.¹

Oral hygiene

Parents should be instructed to begin cleaning their infants' teeth with the eruption of the first tooth.⁴ A wet washcloth, gauze, or child's toothbrush can be used. The primary mandibular and maxillary incisors are the first to erupt between approximately 6 and 12 months. The maxillary incisors are particularly vulnerable to decay because the shallow vestibule makes access to the gingival margin-where plaque collects and the enamel is thinnest-difficult. Parents need to learn to lift the lip for two reasons, adequate brushing and to examine the teeth for any signs of color change, white spots, or staining that can indicate the initial signs of dental caries. It has been shown that by using the lift-the-lip technique, parents can be taught to recognize the early signs of tooth decay. If children have closed contacts, parents can be shown how to use flossers or floss picks to clean between those teeth. Parents are likely to be surprised to learn that they not only need to supervise toothbrushing once children take an interest in brushing their own teeth, but they also must "take a turn" brushing their children's teeth thoroughly at least once a day until children develop fine motor skills at about the age of 7 or 8 years.

Fluoride exposure

The AAPD recommends that all children have their teeth brushed with fluoride toothpaste twice a day from the time of first tooth eruption.⁴ This may be confusing to parents who will commonly see fluoride-free toothpaste on store shelves for children 2 years of age and under. Dental hygienists need to be prepared to explain the significance of fluoride to newly erupted teeth and that the amount used is very important. The recommendation is for a smear of toothpaste the size of a grain of rice up to the age of 3 years and the size of a pea from 3 to 6 years of age⁴(Figure 1). While it is advised for older children to spit but not rinse after brushing, so a little fluoride remains in the mouth, children under 6 years of age cannot purposefully expectorate.^4,5

Dental hygienists will want to know if the child lives in an area with community water fluoridation, if they drink bottled or tap water, and whether the tap water is filtered. The Centers for Disease Control and Prevention (CDC) guidelines indicate that fluoride supplementation should only be used for children without access to community water fluoridation.⁵ The American Dental Association (ADA) guidelines recommend supplementation only for children at high risk of dental caries.⁶ If supplementation is indicated, it should be used until at least 16 years of age. Drops and tablets are available to be used according to the child's developmental age. Hygienists should be aware that though minimal compliance is required on the part of the child, the parent must fill the prescription regularly and remember to administer the supplement daily.⁵

Healthy dietary habits

A diet high in carbohydrates shifts the oral microbiome to one high in cariogenic bacteria and is therefore a primary risk factor for dental caries. Dental hygienists can offer practical advice when making parents aware that not only sugar causes dental caries. Foods that do not taste sweet but contain carbohydrates and starches-such as crackers, unsweetened cereal, pasta, fruit juices, and dried fruit-can be problematic, depending on when and how frequently they are consumed. Advice will include an emphasis on drinking water and milk, avoiding the introduction of fruit juice before age 1, and limiting the consumption of fruit juices to 100% juice 4 ounces per day for ages 1-3 years, and 4-6 ounces per day through age 6 years.⁴ Bottles, especially at nighttime, and sippy cups should only contain water except at meals, and the AAPD recommends drinking from an uncovered cup by the first birthday.⁴ The logic is that this necessitates the child being stationary as at mealtime or snack time, and the consumption of food and drink is limited to a discrete time so that teeth are not constantly facing an acid challenge throughout the day. Continuous snacking is unhealthy. Ideally snacks should be limited to less than three per day, with an emphasis on replacing carbohydrates with cheese, fruit, vegetables, and nuts when possible. When it is not possible for children to brush their teeth after meals and snacks, they should be encouraged to rinse with water. In addressing healthy dietary habits with parents and the recommendation to limit added sugar to less than 10% of daily caloric intake, dental hygienists can emphasize that what is good for the teeth is good for the body.⁵ When multiple health care providers address a common cause of both dental disease and childhood obesity, this is known as the common risk factor approach.

Non-nutritive habits

Parents will appreciate advice on the sucking habits of children. Over 90% of children engage in non-nutritive sucking during the first year. This can include digit sucking (thumbs or fingers), or use of pacifiers, toys, blankets, etc. What determines whether the habit is detrimental is the frequency, duration, and intensity. On average children stop between 24 and 36 months. After this time the habit can have deleterious effects on the development of the oral structures. Finger or thumb sucking tend to persist longer than pacifier use and can cause greater malocclusions. Therefore, dental hygienists should advocate for stopping the habit no later than 36 months.^1,7 Useful recommendations to meet this challenge include encouragement with gentle reminders, as the child likely desires to break the habit. A simple technique can be adhesive tape to the finger or thumb as a reminder to break an unconscious habit. For more entrenched habits, the dentist can fabricate a fixed appliance that will discourage thumb or finger sucking.⁸

Injury and trauma prevention

Dental hygienists should remind parents that the use of toothpaste requires supervision and that it should be kept out of reach of young children. Parents should be cautioned, per the United States Food and Drug Administration (FDA), against using products containing benzocaine or homeopathic teething tablets and gels for children who are teething.⁷ Cool but not frozen pacifiers, teething rings without liquids, or wet washcloths can help until the discomfort passes in a couple of days. Injury prevention includes assuring that parents are using car seats and childproofing the home.¹ Toddlers are not unlikely to experience oral facial trauma when learning to walk. Older children are prone to injury from sports and activities, necessitating counseling on the use of mouthguards and helmets.⁷ Parents should be provided with a phone number to reach their established dental home in case of emergency.¹

Prevention Visits

Young children are dependent on their parents for their diet, oral hygiene, and fluoride exposure.⁷ Therefore, it is important for the parent to understand their role in their child's oral health, and it is incumbent on the dental hygienist to share practical means of fulfilling that role. For example, the prevention visit for children ages 2 years and younger will likely be conducted using the knee-to-knee position, as these children are in the pre-cooperative stage.⁷ The parent's assistance will be required to position the child, first placing the child on their lap facing them with the legs wrapped around the parent's waist and held firmly in place with the parent's elbows. The parent then tips the child back into the dental hygienist's lap while holding tight to the child's arms and hands. The hygienist sits facing the parent with their knees touching, forming a platform for the child to lie on. In this position the hygienist accomplishes a toothbrush prophy followed by fluoride application while demonstrating to the parent how the child's teeth can be brushed if the parent has assistance at home. If this position is not practical for the parent, the hygienist can offer other suggestions such as a changing table, countertop, or bed/sofa where the child's head can be placed in the parent's lap. The goal of this positioning is good visibility and the ability to stabilize the child. Bathrooms are to be avoided because they are crowded areas with hard surfaces not designed for infant safety.⁷

For preschool-age children (ages 3 to 5 years), cognitive development with increased understanding and language skills allows dental hygienists to use behavior guidance techniques to facilitate care. Frequently the parent can now assume the role of silent observer while the dental hygienist establishes rapport with the child. Each child's development and ability to cooperate will determine whether the child receives a toothbrush or rubber cup prophy. There is no difference in fluoride uptake or caries rate for these procedures, and the goal is for the child to have a positive experience.¹

Restorative Visits

As dental caries is the most common chronic disease of childhood, it is no surprise that children will need restorative treatment to address the symptoms of the disease. In many states, dental hygienists' scope of practice allows them to have an active role in this treatment. Forty-six states and the District of Columbia allow dental hygienists to administer local anesthesia to patients of all ages.⁹ A majority of states allow dental hygienists to be trained to place, carve, or contour restorations following cavity preparation by a dentist.¹⁰ Many expanded function programs for dental auxiliaries were established to address the lack of access to restorative care for children by training dental assistants and licensed hygienists to perform these restorative functions.

Providing local anesthesia and restorative care means dental hygienists must be able to guide both the child and the parent through the appointment. Children may be as young as preschool age and the hygienist must be able to explain the steps of the treatment to the parent in simple terms that can also be understood by the child, giving the child time to process the information. It is important to engage the child using one's best behavior guidance skills and give the child time to get on board with the process. In providing care for children, dental hygienists must remember they are not small adults and carefully plan and prepare for the treatment ahead of seating the child. The area and extent of treatment should be carefully determined, and the type and dose of local anesthesia should be calculated using the AAPD maximum recommended doses. It is important to monitor the child throughout the appointment, especially if N₂O is being used, and to keep the child engaged to distract from minor discomforts and a lengthy procedure.

Conclusion

Dental hygienists often receive training in the use of behavior guidance with pediatric patients but may not be aware of their role in communicating with parents and caregivers. When dental hygienists provide anticipatory guidance to parents, they reinforce the importance of oral health to the overall health of children. Dental hygienists are frequently the care providers who spend the most time with the patient and parent, giving hygienists the opportunity to learn about family circumstances and adapt advice and recommendations accordingly. The objective is to establish a therapeutic relationship with the child and parent that promotes the best possible oral health for the child.

About the Authors

Marilynn L. Rothen, RDH, MS
Clinical Professor
Department of Oral Health Sciences
School of Dentistry
University of Washington
Seattle, Washington

Joel H. Berg, DDS, MS
Professor Emeritus
Department of Pediatric Dentistry
School of Dentistry
University of Washington
Seattle, Washington

References

1. 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. American Academy of Pediatric Dentistry; 2022:253-265.

2. American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2022:321-339.

3. American Dental Hygienists' Association. Dental hygiene practice act overview: permitted functions and supervision levels by state. ADHA website. https://www.adha.org/wp-content/uploads/2023/01/ADHA_Practice_Act_Overview_8-2022.pdf. Revised August 2022. Accessed April 13, 2023.

4. American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): consequences and preventive strategies. The Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2022:90-93.

5. Tinanoff N. Chapter 12: Dental caries. In: Nowak AJ, Christensen JR, Mabry TR, et al, eds. Pediatric Dentistry: Infancy Through Adolescence. 6th ed. Saunders/Elsevier; 2018:169-179.

6. Rozier RG, Adair S, Graham F, et al. Evidence-based clinical recommendations on the prescription of dietary fluoride supplements for caries prevention: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2010;141(12):1480-1489.

7. Weber-Gasparoni K. Chapter 14: Examination, diagnosis, and treatment planning of the infant and toddler. In: Nowak AJ, Christensen JR, Mabry TR, et al, eds. Pediatric Dentistry: Infancy Through Adolescence. 6th ed. Saunders/Elsevier; 2018:200-215.

8. Fricker J, Kharbanda OP, Dando J. Chapter 14: Orthodontic diagnosis and treatment in the mixed dentition. In: Cameron AC, Widmer RP, eds. Handbook of Pediatric Dentistry. 4th ed. Mosby; 2013:409-445.

9. American Dental Hygienists' Association. Local anesthesia administration by dental hygienists-state chart. ADHA website. https://www.adha.org/wp-content/uploads/2022/12/ADHA_Local_Anesthesia_Chart_2021.pdf. Revised August 2021. Accessed April 13, 2023.

10. Rothen ML, Choi G, Kim AJ. Advances in the scope of restorative dental hygiene practice. ADHA Access. 2019;33(2):12-15.