Right from the Start: A New Initiative for Children's Oral Health Part Two: 60,000 Babies

Right from the Start: A New Initiative for Children's Oral Health Part Two: 60,000 Babies

Christopher E. Carroll, D.M.D.,* Teresa L. Fong, D.D.S.,** and James D. Nickman, D.D.S.†:

Introduction
The MDA’s Children’s Health Committee is asking for your help. With around 60,000 babies born each year in Minnesota, we are going to need every able-bodied dentist we can recruit in order to get these children examined before their first birthdays. That’s right, before their first birthday. Dentistry is so prevention-oriented that we all know intuitively that this makes perfect sense, and after all, how hard could it be? Those crazy pediatric dentists do it all the time.

Pediatric dentists don’t have any qualms or reservations about seeing infants. Quite the contrary, they are drawn to and relish the experience. Children and infants are what pediatric dentists are all about, and, let’s face it, nothing is cuter or more fun than a baby.

That doesn’t mean that this specialty cannot see why the generalist could have some uneasiness and trepidation when approaching the infant dental exam. For one thing, there is a whole new body of knowledge and set of guidelines to learn. Mastering the fluoride recommendations, risk assessments, dietary and (heaven forbid) breastfeeding advice, the child management techniques etc. can be quite daunting. There is a lot of new and potentially delicate material in there.

There are also the psychology and family dynamics to consider. The infant patient seems tiny and fragile, and isn’t going to understand anything you’re wanting to get across to him, particularly if it’s any kind of an abstraction. All of your jokes, if they are any more sophisticated than “peek-a-boo”, will fall completely fl at with them. But at least you will have a pretty good idea of where you stand when it comes to Junior.

The parents may prove to be more of a challenge. Who among us is objective about our own offspring? Some of us, even if we are not literally attached at the hip, do have boundary issues that make it difficult to separate ourselves from our own “flesh and blood”. The dentist may have to be juggling two or three delicate and sensitized psyches at the same time ... maybe four or five if the dentist and staff are to be included.

With this article, the Minnesota Dental Association is here to tell you “don’t worry”. For example, that part about the baby seeming tiny and fragile. If everyone at the infant oral exam were to tumble down a flight of stairs at the same time, which of the participants is the most likely to get up and walk away unscathed? That’s right. It’s the baby! That little person is the most pliant, resilient, forgiving and forgetful person in the room. If he or she gets a little upset, there is no long-term psychological scarring going on. When it’s over, it’s over, and if we let them, they’ll forget it.

 



The parents are going to be a little tougher, but with the right preparation and rhetoric, and by getting them involved, things can go smoothly with them as well. They are already invested enough to have brought the little one in, and they have entrusted him to you. You only need to bring them along a little further to get them completely comfortable with the whole experience.

Returning to the daunting amount of new material: We can ease your mind about that as well. This article is going to be chockfull and fairly complete, but at the end we will provide you with a brief “the least you need to know” section so that you’ll have plenty of material with which to get comfortably started. Evaluating the child’s current condition, making a quick assessment of his or her future risk, and getting the family on the right track does not require volumes of new knowledge and skills. It is mostly things that you have already mastered, and adding layers of sophistication will come naturally with time and experience.

In addition to helping you with this series of articles, we wish to come to you in person to assist you with this transition. The MDA has acquired the rights to use an infant exam training DVD that was developed by the Wisconsin Dental Association in conjunction with the American Academy of Pediatric Dentistry. It is about 35 minutes long, and is fairly complete. It covers every aspect from why we should be doing this to how we can code for it. If you have a local or district society or study club that would like to have an in-person presentation, just let us know and we’ll be happy to help you arrange it.

The Least You Need to Know:
Incorporating infant examinations into your practice is going to be much easier and much more fun than you realize. You are already master of most of the skill set needed to do it successfully and with facility. Your unique abilities will be indispensable for this important effort, and the MDA is eager to come to you to help you get started.

Rationale
A few years ago, one of the authors was moderating a conference on caries that was being held in Minneapolis. Several nationally renowned speakers were on the program. One of them was Art Nowak, a pediatric dentist from the University of Iowa. He was speaking on infant oral health, and he shared with the audience his personal “Ah ha!” moment.

Dr. Nowak was teaching at Pittsburg in 1967 and had a small practice on the side. A pediatrician in the same building, Dr. Jim Jackson, said to him, “You guys have it all wrong. Why are you waiting until they are three or four before you’ll see them? You’re missing the boat.”

If prevention is indeed the best medicine, then he was asking the right question. Good doctors treat disease, but great ones prevent it. If a child has caries at three, he or she has probably had caries going on since the eruption of the first tooth. Dr. Jackson was right. We have missed the boat for that child. Caries is the most common chronic disease among American children. It affects more than half of seven-year-olds, and is three times more prevalent than obesity, five times more prevalent than asthma, and seven times more prevalent than hay fever.1

After decades of decreasing caries rates among our nation’s children, caries for one group is surprisingly on the rise. When comparing the figures from 1988-1994 to those of 1999-2002, the CDC found a 15.2% increase in caries in children in the two- to five- year age group.2

The reasons for this trend are not known. Some speculate that the increased use of non-fluoridated bottled water may be a factor.3 Regardless, reversing this trend is well within our power if we are willing to see these children early enough.

There is ample reason why we should. Early childhood caries has been shown to affect children’s growth and development. Children afflicted with early childhood caries are significantly more likely to be less than 80% of their ideal weight.4 Early childhood caries can also cause significant pain, affect school performance, cause potentially life-threatening infections, and diminish overall quality of life.5

There is also a strong economic rationale for the infant dental exam. An influential study conducted by the University of North Carolina and published in the journal of the American Academy of Pediatrics looked back at 9,200 children born in 1992. It calculated the total expenditure for their dental care over their first five years of life. If the child was seen for his or her first preventive dental exam by age one, the cumulative five-year bill for all their care was $262. The older the child was at his or her initial preventive visit, the greater the cumulative five-year cost. If the first dental visit was deferred until the child was four to five years of age, the total cumulative cost of their care rose to $546 — more than double.6

More dramatic cost savings would be realized if the year one dental exam could prevent or at least significantly reduce the number of two- to five year old children requiring treatment in the operating room with the use of general anesthesia. The authors estimate that at least hundreds, and perhaps thousands, of Minnesota’s children are managed this way each year. With the combined dental, anesthesia, and hospital cost for these children being in the thousands of dollars each, the savings for Minnesota would be staggering — in the range of millions of dollars.

The Least You Need to Know: Caries is the most common chronic disease of childhood, and early childhood caries is on the rise again in America. Prevention is the best medicine, and the cheapest medicine as well. Data clearly show that the infant exam and timely care improve the growth, development, and well being of children and dramatically reduces the overall cost of dental care for both individuals and the greater society.

 

 


Perinatal Care
The perinatal period is defined as the weeks right before and the weeks right after the birth of the child. This is a time when the foundation could be laid for a lifetime free of dental disease for the new baby. If the baby is a first child for that mother, it is the general practicing dentist, not the pediatric dentist, who is going to get the first crack at it. Perinatal care revolves around two main objectives. The first is to optimize the oral health of the caregivers. The other is to equip the caregivers with the information they need to provide for the health of the child.

Poor periodontal health in an expectant mother has been shown to be associated with adverse outcomes in pregnancy. Preterm deliveries, low birth weight babies, and pre-eclampsia have all been linked to periodontal disease of the mother. Expectant mothers should be encouraged to overcome their reluctance to seek dental care and should be brought to optimal oral health.7-13

Another primary goal of perinatal care is to delay as much as possible the transmission and colonization of Mutans streptococci (MS) from the new mother to the child. The individual strain of MS found in the infant appears identical to that of the mother in the vast majority of instances. The higher the levels of maternal MS, the greater is the risk of the child being colonized early with the accompanying increased risk of caries.14,15

There are two main ways to help delay the transmission of mother’s MS to the child. The first is to reduce the mother’s reservoir of MS by dietary modification (i.e., reducing the frequency of carbohydrates), improved oral hygiene, restoring active carious lesions, and employing anticarious agents such as chlorhexidine, fluoride, or xylitol chewing gum. The other is to reduce behaviors that pass saliva from the mother to the child. These include sharing food and utensils or cleaning a dropped pacifier with the mouth.16

The Least You Need to Know: The perinatal period, the weeks right before and right after birth, is a window of opportunity to lay the foundation for the child’s optimal dental health. The first order of business is to optimize the health of the mother to insure a better pregnancy outcome, and to decrease the chances that Mutans streptococci is transferred to and colonized by the baby. This is also an opportune time to introduce the caregivers to proper home care for a newborn.

Caries Risk Assessment
Being forewarned is being forearmed, and being able to predict a child’s caries experience has obvious utility. This prompted the American Academy of Pediatrics, in 2002, to begin plugging all the available evidence into a predictive framework it called the Caries Risk Assessment Tool (CAT). Three categories of factors are gauged by the CAT: historical and environmental factors, clinical factors, and supplemental diagnostic tests. Historical and environmental factors include socioeconomic strata, fluoride exposure, the existence of special needs, and parental oral health. Clinical factors include amount and location of plaque, signs of decalcification or decay, enamel defects, and overly rich dental anatomy. Supplemental diagnostic testing includes radiographs and microbiological assessments.

The CAT can be used by researchers to assess the effectiveness of preventive strategies. It can be used by non-dental health care personnel for purposes of timely intervention and referral. It can be used by primary dental health care providers to tailor preventive measures, diagnostic tests, recall timing, and treatment decisions to more closely meet the needs of the patient.

The Least You Need to Know: In order to tailor preventive measures, diagnostic tests, recall timing, and treatment decisions to more closely meet the needs of the patient, it is helpful to gauge their relative risk for caries. One aspect of this is the clinical exam, and we dentists are all able to gauge the level of oral hygiene and the degree of disease just by looking. A familiarity with the AAPD’s Cariesrisk Assessment Tool (CAT) will be of further help to us in formulating a sense of how family, social, and environmental circumstances can influence a child’s cavity experience.

Preventive Strategies
Most of this is going to sound refreshingly familiar to you. We are all aware that caries is a nearly 100% preventable disease and that we are armed with the knowledge and tools to effectively combat it. Mostly for the sake of thoroughness, they will be listed here.

Oral Hygiene. Cleaning an infant’s teeth as soon as they appear is recommended to reduce the bacterial load. Whatever works is fair. If the parents wish to use a cloth, then that’s okay, though a soft brush will probably work better, and there is no real reason to delay using one. Twice a day is recommended, and it should include only the slightest smear of fluoridated toothpaste. If the child is over two, a pea-sized amount of toothpaste, twice a day, will not significantly add to his or her total fluoride load. Children should not be allowed to dispense their own toothpaste any more than they would be allowed to dispense their own Tylenol. Flossing tight, adjacent surfaces is to be encouraged.

Diet. The frequency of eating and drinking trumps perhaps all other factors concerning the promotion or prevention of dental caries. This is going to be a difficult point to get to sink in considering the inundation of misinformation from TV and other media. The parents will also cling to the strongly held misconception that a toothbrush is a panacea for “cavities” even though the brush per se has never been shown to have any effect on caries.

The public’s overemphasis on “good foods vs. bad foods” regarding the diet’s cavity-causing potential will be another tough nut to crack. The point will repeatedly need to be emphasized that it is the frequency much more than “what” or “how much” the child consumes that leads to caries.

This message is of critical importance concerning the nursing bottle and sippy cup. We all know that juice should be limited to one small, 4-6 ounce serving a day.17 That serving should be consumed quickly and not over an extended period of time, and it should never be consumed at bedtime.

Ad libitum breast-feeding past the first year and at bedtime has been associated with caries, especially when the diet starts to contain other foods. The American Academy of Pediatric Dentistry suggests that ad libitum nocturnal breast-feeding should be avoided once the teeth start arriving.18

 



Dietary Fluoride. Daily fluoride exposure has been a bedrock of primary prevention since the 1940s. Back then, however, it was a bit easier to figure out: one part per million in the communal water supply or failing that, prescribing the appropriate dose of supplemental fluoride.

These days it is a little more difficult. For one thing, we consume considerably more packaged and processed food that quite likely has come from fluoridated communities. This creates a “halo effect” for fluoride, carrying its effects far beyond its point of origin and into areas without communal water fluoridation. Adding
to the difficulty is our water: Is it from the well or the tap or out of a bottle or filtered and by what kind of filter and do they drink much water anyway? Add this to the fact that fluoridated and non-fluoridated areas are irregularly dispersed, are often in close proximity to one another, and that we and our kids are constantly on
the go between them. It can become difficult to calculate a proper dosage for supplementation.

If the child is home all day and has a suboptimal domestic water fluoride concentration, prescribe a daily supplement, beginning at six months of age, that corresponds to the recommendations on the ADA and AAPD chart. If the child is exposed to fluoride from other sources — i.e., school, day care, weekends with the other parent, and so on — then adjust his or her dosage downward as best you can calculate.

One suggestion would be to take supplemental fluoride only on the days that they remain at home and skip the days they go to town. With enamel fluorosis on the rise, it may be best to estimate on the conservative side, and for some children, eliminate supplementation altogether.

One area of caution is the potential of f uorosis from powdered baby formula when it is reconstituted with optimally fluoridated water. The data is inconclusive for now, but caution is suggested. One should consider recommending that infant formula be reconstituted with non-fluoridated water.19

Miscellaneous. Space limits us from being completely thorough in covering all the questions that might arise during the baby exam. Speech development; tooth grinding; injury prevention (appropriate toys, car seats, electrical cords, etc.); non-nutritive sucking; that gap; this tag of tissue; those white patches; these red and bleeding gums; a dark tooth; bad breath; teething, and more may confront you. When someone throws a curve ball your way, you can always fall back on “That’s an excellent question. Let me get back to you on that.” Then give your friendly pediatric dental colleague a call.

The Least You Need to Know: As soon as the baby’s teeth arrive, they should be brushed twice a day with the least little smear of fluoridated toothpaste. After age two, it is safe to apply a pea-sized amount to the brush twice a day. The frequency of eating and drinking has been shown to contribute more to one’s caries experience than does the quantity or quality of our diets. Efforts should be made to limit the frequency with which food and drink passes the baby’s lips. Juice and other sweet beverages should be limited to one small, 4-6 ounce portion a day, and consumed in a reasonable amount of time. Prolonged or nocturnal bottle or sippy cup feedings are to be avoided, and the child should be transitioned to a cup around one year of age. Ad libitum nocturnal breast-feeding should be avoided once the teeth arrive. Daily fluoride ingestion is a bedrock of preventive dentistry and should be supplemented with drops or chewable tablets when needed. Calculating the proper dosage may be complicated by fluoride exposures away from home or by the use of bottled or filtered water. Consider total fluoride exposure before prescribing supplements, and err on the side of caution in order to avoid the risk of enamel fluorosis.

Conducting the Exam
One of the nice things about incorporating this new facet of dentistry into your practice is that there is no special equipment you need to purchase. About the only thing new that you will be needing is something you carry around with you all the time anyway, your knees.

When it comes to examining infants, practitioners and parents alike seem to be the most comfortable with the knee-to-knee approach. It does have a lot going for it. The child is well controlled and, except for the back of its head, is mostly in mother’s lap. This probably does not make any difference to the child, but it gets the parent involved and seems to make them more comfortable with the whole situation.

The knee-to-knee exam is very simple to do. Prepare the parents for the fact that Junior is probably going to “fuss a little bit”. On facing chairs or stools, sit kneecap-to-kneecap with the parent. Ask let’s say the mother to hold the child facing her and with its legs straddling her waist. Have her hold the child’s hands “firmly”. If the grip is loose, the child continually breaks free and is encouraged to struggle on. If the parent holds on “like they mean business”, the child is more likely to settle down and feel “This is where I’m supposed to be.” Have the parent lay the back of the child’s head down at your knees for easier access (not high up into your lap, which is awkward on two fronts). Get a good grip and look everything over, being careful to keep the mirror and your fingers out from between those sharp little incisors. Check the teeth for plaque, stains, white spot lesions, caries, or the enamel defects of hypoplasia or hypocalcification. If the little one will close his mouth, you may try making a cursory assessment of the developing occlusion by checking for overbites, cross-bites, open bites, or dental arch crowding. Also check the oral soft tissues and make a note of any anomalies in size, shape, color, or symmetry.

That’s it. Ninety seconds and you are done. The CDT coding for the exam is D0145: oral evaluation for a patient under three years of age and counseling with primary caregiver. It is further described as “Diagnostic services performed for a child under the age of three, preferably within the first six months of the eruption of the first primary tooth, including recording the oral and physical health history, evaluation of caries susceptibility, development of an preventive oral health regimen and communication with and counseling of the child’s parent, legal guardian and/or primary caregiver.20

The Least You Need to Know. The knee-to-knee exam is simple, well controlled, and everyone is comfortable with it. Sit kneecap-to-kneecap with the parent. Have her take control of the baby’s hands and lay the back of the head down at your knees. Get a good grip and conduct the exam being careful not to get either your mirror or fingers bitten. The CDT code for the infant exam is D0145.

Caries Diagnosis and Treatment
The earliest form of caries, white spot lesions, may require no clinical treatment at all. Reversing the habits that led to them and implementing preventive measures such as fluoride, oral hygiene, and especially dietary modification may be all that is ever needed for those teeth.

Once lesions have cavitated, it is possible to arrest them with stringent preventive measures, but some form of restorative is usually recommended. If there are only one or two small lesions, interim therapeutic restorations (ITR) are often a good solution.21 ITR is a method endorsed as a definitive restorative technique by the World Health Organization for populations with little access to dental facilities, and it has proven to be effective. In this instance we are using it as an interim procedure for caries control when a more definitive restoration might prove difficult to place.

The procedure involves using hand instruments or slow-speed rotary instruments and removing most of the caries, being more thorough at the periphery of the lesion. A resinmodified glass ionomer is then placed. If there is severe or rapidly advancing disease or if there is trauma or pain, the need for care becomes more urgent. Specialized behavioral management techniques may be required, such as protective stabilization, sedation, or even general anesthesia. This may be the time to refer.

The Least You Need to Know. The earliest form of caries, white spot lesions, may only require reversing the
habits that created them, instituting sound preventive practices, and monitoring the situation. Small, cavitated lesions can be successfully arrested by ITR — cleaning out most of the caries with hand or slow rotary instruments and placing a resinmodified glass ionomer. It may be best to consider referring cases with more severe or rapidly advancing disease.

Conclusions
There are around 60,000 babies born in Minnesota each year. Getting these babies seen and their families on the right path early is essential for the insurance of their optimal oral health. Your skills and services are indispensable. Welcome to the frontlines, and have fun. ■

THE LEAST YOU NEED TO KNOW
Introduction: Incorporating infant examinations into your practice is going to be much easier and much more fun than you realize. You are already master of most of the skill set needed to do it successfully and with facility. Your unique abilities will be indispensable for this important effort, and the MDA is eager to come to you to help you get started.

Rationale: Caries is the most common chronic disease of childhood and early childhood caries is on the rise again in America. Prevention is the best medicine, and the cheapest medicine as well. Data clearly show that the infant exam and timely care improve the growth and development and well-being of children and dramatically reduces the overall cost of dental care for both individuals and the greater society.

Perinatal Care: The perinatal period, the weeks right before and right after birth, is a window of opportunity to lay the foundation for a child’s optimal dental health. The first order of business is to optimize the health of the mother to insure better a pregnancy outcome, and to decrease the chances that Mutans streptococci is transferred to and colonized by the baby. This is also an opportune time to introduce the caregivers to proper home care for a new born.

Caries Risk Assessment: In order to tailor preventive measures, diagnostic tests, recall timing, and treatment decisions to more closely meet the needs of the patient, it is helpful to gauge their relative risk for caries. One aspect of this is the clinical exam, and we dentists are all able to gauge the level of oral hygiene and the degree of disease just by looking. A familiarity with the AAPD’s Cariesrisk Assessment Tool (CAT) will be of further help to us in formulating a sense of how family, social, and environmental circumstances can influence a child’s cavity experience.

Preventive Strategies: As soon as the baby’s teeth arrive, they should be brushed twice a day with the least little smear of fluoridated toothpaste. After age two, it is safe to apply a pea-sized amount to the brush twice a day.

The frequency of eating and drinking has been shown to contribute more to one’s caries experience than does the quantity or quality of our diets. Efforts should be made to limit the frequency that food and drink passes the baby’s lips. Juice and other sweet beverages should be limited to one small, 4-6 ounce serving a day, and consumed in a reasonable amount of time. Prolonged or nocturnal bottle or sippy cup feedings are to be avoided, and the child should be transitioned to a cup around one year of age. Ad libitum nocturnal breast-feeding should be avoided once the teeth arrive.

Daily fluoride ingestion is a bedrock of preventive dentistry and should be supplemented with drops or chewable tablets when needed. Calculating the proper dosage may be complicated by fluoride exposures away from home or by the use of bottled or filtered water. Consider total fluoride exposure before prescribing supplements, and err on the side of caution in order to avoid the risk of enamel fluorosis.

Conducting the Exam: The knee-to-knee exam is simple, well controlled, and everyone is comfortable with it. Sit kneecap-to-kneecap with the parent. Have them take control the baby’s hands and lay the back of the head down at your knees. Get a good grip and conduct the exam being careful not to get either your mirror or fingers bitten. The CDT code for the infant exam is D0145.

Caries Diagnosis and Treatment: The knee-to-knee exam is simple, well controlled, and everyone is comfortable with it. Sit kneecap-to-kneecap with the parent. Have them take control the baby’s hands and lay the back of the head down at your knees. Get a good grip and conduct the exam being careful not to get either your mirror or fi ngers bitten. The CDT code for the infant exam is D0145.

Conclusions: There are around 60,000 babies born in Minnesota each year. Getting these babies seen and their families on the right path early is essential for the insurance of their optimal oral health. Your skills and services are indispensible. Welcome to the front lines, and have fun.

References
1. US Department of Health and Human Services: Oral Health in America: A Report of the Surgeon General. Rockville: National Institute of Dental and Craniofacial Research, National Institute of Health 2000; 308.
2. Centers for Disease Control: Morbidity and Mortality Weekly Report, August 26, 2005/Vol.54/No. SS3.
3. What’s New with Prevention: Dr. Mike Ignalzi, Minnesota Dental Association, Star of the North Meeting, April 23, 2010.
4. Acs G. Effects of nursing caries on body weight in a pediatric population. Pediatr Dent 1992;14:302 -305.
5. Guidelines on Infant Oral Health Care: Reference Manual, American Academy of Pediatric Dentistry, Vol. 31/No.6, 2009-10.
6. Savage MF, Lee JY, Kotch JB, Vann WF. Early preventive dental visits: effect on subsequent utilization and costs. Pediatrics 2004;114:418-423.
7. Dasanayake AP, Gennaro S, Hendricks-Munoz KD, CHHun N. Maternal periodontal disease, pregnancy, and neonatal coutcmoes. MCN Am J
Matern Child Nurs 2008;33(1):45-9.
8. Sacco G.Carmagnole D.Abati S et al. Periodontal disease and preterm birth relationship: A review of the literature. Minerva Stomatol 2008;57(5):233-50.
9. Silk H, Douglass AB, Douglass JM, Silk L. Oral health during pregnancy. Am Fam Physician 2008;77(8):1,139-44.
10. Xiong X, Buckens P, Fraser WD, Beck J, Offenbacher S. Periodontal disease and adverse pergnancy outcomes: A systematic review. BJOG
2006;113(2):135-43.
11. Siqueira FM, Cota LO, Costa JE, Haddad JP, Lana AM, Costa FO. Maternal periodontitis as a potential risk variable for preeclampsia: A casecontrol
study. J Periodontol 2008;79(2):207-15.
12. Oettinger-Barak O, Barak S, Ohel G et al. Severe pregnancy complication (preeclampsia) is associated with greater periodontal destruction. J
Periodontol 2005;76(1):134-7.
13. McKeown D. The link between periodontal disease and adverse birth outcomes. Toronto Staff Report 2006. Abailable at: http://www.toronto.
ca/legdocs/2006/agendas/committees/hl/hl060227/it002.pdf. Accessed June 23, 2006.
14. Li Y, Caufeld PW. The fidelity of initial acquisition of Mutans streptococci by infants from their mothers. J Dent Res 1995;74(2):681-5.
15. American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Classification, consequences, and prevention strategies. Pediatr
Dent 2008;29(suppl):39-41.
16. Guideline on Perinatal Oral Health Care: American Academy of Pediatric Dentistry Reference Manual: Vol 31/No. 6, 2009-10.
17. Healthy children: Where we stand: fruit juice. www.aap.org.
18 Hashim Mainar SM, Mohummed S. Diet Counseling During the Infant Oral Health Visit: Pediatr Dentistry 26:5, 2004.
19. Policy on Use of Fluoride: American Academy of Pediatric Reference Manual, Vol. 31/No. 6,2009-10.
20. Policy on Interim Therapeutic Restorations (ITR): American Academy of Pediatric Dentistry Reference Manual, Vol. 31/No. 6, 2009-10.
21. Current Dental Terminology, American Dental Association, 2009-2010.

 





*Dr. Carroll is a pediatric dentist in private practice in Winona, Minnesota.Email is pedsdent@hbci.com.
**Dr. Fong is chair of the Minnesota Dental Association’s Children’s Dental Health Committee. She is a pediatric dentist with Metropolitan Pediatric Dental Associates, Fridley, Minnesota. Email is tfsandrds@comcast.net.
†Dr. Nickman is a pediatric dentist with Metropolitan Pediatric Dental Associates, Fridley, Minnesota. Email is james.nickman@att.net.