Colgate Oral Health Dialogue – 2017- Risk Assessment for Early Childhood Caries

Lina Maria Marin DDS, MSc, PhD (C)

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Dental caries is a biofilm-sugar dependent disease 1Fejerskov O. Changing paradigms in concepts on dental caries: consequences for oral health care. Caries Res 2004;38(3):182-91. that leads to a progressive dissolution of mineralized dental tissues (enamel, dentin, and cementum) until a carious lesion is clinically visible. Despite a worldwide decline in dental caries largely due to the widespread use of fluoridated toothpaste, 2Rølla G, Ogaard B, Cruz R de A. Clinical effect and mechanism of cariostatic action of fluoride-containing toothpastes: a review. Int Dent J 1991;41(3):171-4. the prevalence of early childhood caries (ECC) has remained constant over time. 3Dye BA, et al. Prevalence and measurement of dental caries in young children. Pediatr Dent 2015;37(3):200-16. This condition constitutes the most common chronic non-infectious disease in developed 4U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. and developing countries, 5Holm AK. Caries in the preschool child: international trends. J Dent 1990;18(6):291-5.affecting mainly young children from disadvantaged socio-economic families 3Dye BA, et al. Prevalence and measurement of dental caries in young children. Pediatr Dent 2015;37(3):200-16. and from specific racial/ethnic minority backgrounds. 3Dye BA, et al. Prevalence and measurement of dental caries in young children. Pediatr Dent 2015;37(3):200-16.,6Ricks TL, et al. The Indian Health Service early childhood caries (ECC) collaborative: a 5-year summary. Pediatr Dent 2015;37(3):275-80. ECC also affects young children’s quality of life 7Easton JA, et al. Evaluation of a generic quality of life instrument for early childhood caries-related pain. Community Dent Oral Epidemiol 2008;36(5):434-40. and is the main predictive factor of caries incidence in the permanent dentition. 8Mejàre I, et al. Caries risk assessment: a systematic review. Acta Odontol Scand 2014;72(2):81-91.

Key reasons for the continuing prevalence of ECC in toddlers and young children include caries experience, dietary habits, plaque accumulation, fluoride exposure, and oral hygiene. 9Fontana M, Zero DT. Assessing patients’ caries risk. J Am Dent Assoc 2006;137(9):1231-9. To prevent and manage existing carious lesions, all general dentists and dental hygienists should perform an ECC risk assessment in everyday practice. This assessment will help healthcare professionals use a risk-based, patient-centered, decision-making process, and will aid in determining the frequency of recall examinations. 9Fontana M, Zero DT. Assessing patients’ caries risk. J Am Dent Assoc 2006;137(9):1231-9.,10Kühnisch J, et al. Best clinical practice guidance for management of early caries lesions in children and young adults: an EAPD policy document. Eur Arch Paediatr Dent 2016;17(1):3-12.

With the aim of assisting clinicians to diagnose ECC risk in young children, this paper describes the causative and protective factors relevant to ECC development. A practical guideline to assess ECC risk, and an evidence-based clinical protocol for the management of ECC are also presented.

The Caries Process

For carious lesions to develop, it is necessary to have biofilm (plaque) accumulation on dental surfaces and frequent ingestion of fermentable sugars, 11Cury JA, Tenuta LMA. Enamel remineralization: controlling the caries disease or treating early caries lesions? Braz Oral Res 2009;23(Suppl 1):23-30. mainly sucrose. 12Paes Leme AF, et al. The role of sucrose in cariogenic dental biofilm formation – new insight. J Dent Res 2006;85(10):878-87. However, it is important to emphasize that dental caries cannot be considered an infectious and transmissible disease, since the bacteria found in a dental biofilm are part of the resident oral microflora. 1Fejerskov O. Changing paradigms in concepts on dental caries: consequences for oral health care. Caries Res 2004;38(3):182-91.,13Marsh PD. Microbial ecology of dental plaque and its significance in health and disease. Adv Dent Res 1994;8(2):263-71. Some bacteria in the biofilm will metabolize fermentable sugars and produce acids 14Stephan RM. Changes in hydrogen-ion concentration on tooth surfaces and in carious lesions. J Am Dent Assoc 1940;27(5):718-23. that may cause a progressive demineralization of enamel, dentin, and cementum, and lead to the development of carious lesions. In the absence of frequent fermentable sugar consumption, acid production is lower and saliva can buffer and wash away acidic metabolic products from the mouth. 13Marsh PD. Microbial ecology of dental plaque and its significance in health and disease. Adv Dent Res 1994;8(2):263-71. Saliva can also restore some of the minerals lost during each demineralization period, 15Stookey GK. The effect of saliva on dental caries. J Am Dent Assoc 2008;139(Suppl2):11S-7. remineralizing these tissues and maintaining a balance between health and disease.

Apart from the biological factors involved in the dental caries process described above, environmental, behavioral, and socio-economic determinants also play crucial roles in the process of caries development, both at the individual and population level. 1Fejerskov O. Changing paradigms in concepts on dental caries: consequences for oral health care. Caries Res 2004;38(3):182-91.

Early Childhood Caries (ECC)

Dental caries affecting toddlers and young children presenting as a progressive pattern of tooth decay is known as early childhood caries (ECC). 16Kaste LM, Gift HC. Inappropriate infant bottle feeding status of the Healthy People 2000 objective. Arch Pediatr Adolesc Med 1995;149(7):786-91. Two types of ECC are recognized: ECC and severe ECC (S-ECC). To diagnose ECC, a child younger than six years of age should have a DMF-S score greater than or equal to one, meaning that any primary tooth could have one or more decayed (cavitated or non-cavitated) white spot lesions, be missing (due to caries), or have restored tooth surfaces. 17American Academy of Pediatric Dentistry. Definition of early childhood caries (ECC). Pediatr Dent 2010;32 (Spec Iss):15. Available at: http://www.aapd.org/assets/1/7/D_ECC.pdf. Accessed March 14, 2017.
A diagnosis of S-ECC differs depending on clinical findings and the child’s age. S-ECC requires the presence of any cavitated/non-cavitated carious lesion on a smooth surface or a DMF-S ≥ 4 in children younger than three years of age, a DMF-S ≥ 5 in 4-year-olds, or a DMF-S ≥ 6 in 5-year-olds. A child between 3 and 5 years of age having one or more decayed (cavitated), missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth is diagnosed with S-ECC (Figure 1). 17American Academy of Pediatric Dentistry. Definition of early childhood caries (ECC). Pediatr Dent 2010;32 (Spec Iss):15. Available at: http://www.aapd.org/assets/1/7/D_ECC.pdf. Accessed March 14, 2017.

figure-1a
Figure 1a.
S-ECC in a 3-year-old child with non-cavitated white spot carious lesions in anterior maxillary teeth and canines, and a cavitated lesion in a posterior maxillary left tooth. Photo: Dr. Sandra Hincapié Narváez.

figure-1b

Figure 1b.
S-ECC in a 2-year-old child with non-cavitated white spot carious lesions in anterior teeth, canines, and posterior teeth, as well as cavitated lesions in anterior maxillary teeth. Photo: Dr. Sandra Hincapié Narváez.

The precise determination of ECC prevalence over time has been challenging due to different descriptive terms used in the literature: early childhood caries (ECC), dental caries in young children, baby bottle tooth decay (BBTD), or nursing bottle caries (NBC). In addition, there is no standardization for the diagnostic criteria and the number of teeth used to report ECC prevalence. 3Dye BA, et al. Prevalence and measurement of dental caries in young children. Pediatr Dent 2015;37(3):200-16. It is estimated that from 1988 to 1991, 23% of US children between 2 and 5 years of age had experienced dental caries, and about 18% had untreated carious lesions. More recent data (from 2011 to 2012) showed that the prevalence of caries remained constant at 23%, and 10% of young children had untreated lesions. The most affected teeth are the primary maxillary anteriors, contributing 50% of the overall prevalence of ECC in this population.

ECC Risk Factors

ECC risk factors may be grouped as follows: causative factors (caries experience, dietary habits, plaque accumulation) and protective factors (fluoride exposure, oral hygiene). 9Fontana M, Zero DT. Assessing patients’ caries risk. J Am Dent Assoc 2006;137(9):1231-9.

Caries Experience. Previous caries experience is a strong causative factor, since the presence of earlier or currently existing carious lesions denotes a cumulative history of risk factor exposure. 18Fontana M. The clinical, environmental, and behavioral factors that foster early childhood caries: evidence for caries risk assessment. Pediatr Dent 2015;37(3):217-25. The probability that sound surfaces or non-cavitated white spot lesions will progress to more severe cavitated lesions is higher if a child has cavitated lesions together with non-cavitated white spot lesions. 19Guedes RS, et al. Risk of initial and moderate caries lesions in primary teeth to progress to dentine cavitation: a 2-year cohort study. Int J Paediatr Dent 2016;26(2):116-24. Although ECC experience constitutes the highest risk for caries incidence in the permanent dentition, 8Mejàre I, et al. Caries risk assessment: a systematic review. Acta Odontol Scand 2014;72(2):81-91. it is important to assess the risk factors that led to the development of previous ECC. 20Vadiakas G. Case definition, aetiology and risk assessment of early childhood caries (ECC): A revisited review. Eur Arch Paed Dent 2008;9(9):114-25. This requires determining if existing lesions are active or inactive, because the presence of active lesions constitutes an increased risk for ECC. 10Kühnisch J, et al. Best clinical practice guidance for management of early caries lesions in children and young adults: an EAPD policy document. Eur Arch Paediatr Dent 2016;17(1):3-12.

Dietary Habits. Prolonged bottle-feeding and bedtime use of a nursing bottle or a sippy-cup with sugared drinks (sugar-added infant formula, sugar-added milk, chocolate milk, soft drinks, juices), as well as in-between meal consumption of sugar-containing snacks or drinks are causative risk factors for ECC development. 21Tinanoff NT, et al. Current understanding of the epidemiology mechanism, and prevention of dental caries in preschool children. Pediatr Dent 2002;24(6):543-51. In these cases, the cariogenicity of the dental biofilm significantly increases due to frequent and prolonged exposure to fermentable sugars. Reduced salivary flow rates during sleep mean dietary sugars and their acidic metabolic products remain in the biofilm for longer periods. The presence of a baby bottle nipple into the mouth restricts the salivary flow rate over the labial surfaces of incisors and the palatal surfaces of maxillary teeth. 22Bowen WH. Response to Seow: biological mechanisms of early childhood caries. Community Dent Oral Epidemiol 1998;26(1 Suppl):28-31. Although breast-feeding had been thought to cause ECC, it was recently demonstrated that breast milk alone does not contribute to this condition. 23Neves PA, et al. Breastfeeding, dental biofilm acidogenicity, and early childhood caries. Caries Res 2016;50(3):319-24.

Plaque Accumulation. Even though the presence of dental biofilm is necessary for caries development, 11Cury JA, Tenuta LMA. Enamel remineralization: controlling the caries disease or treating early caries lesions? Braz Oral Res 2009;23(Suppl 1):23-30. biofilm alone is not enough to establish the caries risk of an individual since the frequent ingestion of fermentable sugars must be present as well. 11Cury JA, Tenuta LMA. Enamel remineralization: controlling the caries disease or treating early caries lesions? Braz Oral Res 2009;23(Suppl 1):23-30.
However, biofilm accumulation on dental surfaces is a risk factor strongly associated with ECC development, and salivary levels of cariogenic bacteria like mutans streptococci may also be considered a causative factor for ECC. 24Alaluusua S, Malmivirta R. Early plaque accumulation – A sign for caries risk in young children. Community Dent Oral Epidemiol 1994;22(10):273-6.,25Roeters J, et al. Dental caries and its determinants in 2- to-5-year old children. ASDC J Dent Child 1995;62(6):401-8. Moreover, biofilm accumulation may be a greater risk factor in teeth having developmental structural defects that make effective plaque removal more difficult.

Fluoride Exposure and Oral Hygiene. Fluoride exposure and oral hygiene are protective risk factors for ECC development. When dental biofilm is totally removed, the saliva contacts the demineralized tooth surface and promotes its remineralization. 15Stookey GK. The effect of saliva on dental caries. J Am Dent Assoc 2008;139(Suppl2):11S-7.
Saliva’s remineralizing ability can be increased by the presence of fluoride. 11Cury JA, Tenuta LMA. Enamel remineralization: controlling the caries disease or treating early caries lesions? Braz Oral Res 2009;23(Suppl 1):23-30. However, biofilm can only be completely removed after a professional dental cleaning. In addition, to control the demineralization rate of dental surfaces covered by the remaining biofilm after tooth brushing, it is mandatory that small concentrations of fluoride are kept constantly in the mouth. 26Ögaard B, et al. Microradiographic study of remineralization of shark enamel in a human caries model. Scand J Dent Res 1988;96(3):209-211. This is achievable with the use of fluoridated toothpaste (1000 ppm or greater). 27Marinho VC, et al. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2003;(1):CD002278.,28Walsh T, et al. Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2010;(1):CD007868.,29dos Santos AP, et al. A systematic review and metaanalysis of the effects of fluoride toothpastes on the prevention of dental caries in the primary dentition of pre-school children. Community Dent Oral Epidemiol 2013;41(1):1-12. Access to professional (fluoridated gel or varnish) 30Tenuta LM, et al. Fluoride release from CaF2 and enamel demineralization. J Dent Res 2008;87(11):1032-6. or collective (fluoridated water or salt) 31Petersen PE, Lennon MA. Effective use of fluorides for the prevention of dental caries in the 21st century: the WHO approach. Community Dent Oral Epidemiol 2004;32(5):319-21. methods of fluoride delivery are also highly recommended.

ECC Risk Assessment

Caries risk assessment (CRA) is the clinical process of establishing the probability of an individual patient to develop carious lesions over a certain period, or the probability that there will be a change in the severity or activity of lesions already present. 32Twetman S, et al. Risk assessment: can we achieve consensus? Community Dent Oral Epidemiol 2013;41(1):64-70. The assessment of ECC risk should be an essential component of everyday practice, allowing clinicians to determine a risk-based, patient-centered, decision-making protocol to prevent and manage ECC. 9Fontana M, Zero DT. Assessing patients’ caries risk. J Am Dent Assoc 2006;137(9):1231-9. Also, CRA examination would assist clinicians planning for the frequency of recall examinations based on a personalized analysis of each patient’s needs. 10Kühnisch J, et al. Best clinical practice guidance for management of early caries lesions in children and young adults: an EAPD policy document. Eur Arch Paediatr Dent 2016;17(1):3-12. This assessment should be done periodically for children in their first year, as soon as the first tooth erupts. 18Fontana M. The clinical, environmental, and behavioral factors that foster early childhood caries: evidence for caries risk assessment. Pediatr Dent 2015;37(3):217-25.

Different tools are currently available to assess caries risk in young children, 18Fontana M. The clinical, environmental, and behavioral factors that foster early childhood caries: evidence for caries risk assessment. Pediatr Dent 2015;37(3):217-25. and the use of structured forms may assist clinicians in the CRA process. These forms should encompass an assessment of child-associated clinical, environmental, and behavioral factors, including caries experience, dietary habits, social background, oral hygiene habits, as well as any relevant medical history. 18Fontana M. The clinical, environmental, and behavioral factors that foster early childhood caries: evidence for caries risk assessment. Pediatr Dent 2015;37(3):217-25. Factors associated with parents/caregivers should also be considered, mainly their caries experience and educational level.

Recently, the American Academy of Pediatric Dentistry (AAPD) published guidelines on caries risk assessment, 33American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent 2013;35(5):E157-64. including risk assessment forms for infants and children (Table 1) that can be used by dental professionals.

Table-1
Table 1
Caries Risk Assessment Form for 0–5-Year-Olds33American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent 2013;35(5):E157-64.

Clinical Management of ECC

Caries risk assessment is highly important to establish patient-centered decision making for the management of ECC. The progression of dental caries can be controlled, arrested, or even reversed if the biofilm is totally or partially removed from the dental surfaces, or if the metabolic processes of dental biofilm formation are modified. 34Fejerskov O. Pathology of dental caries. In: Dental Caries – The Disease and its Clinical Management. 3 rd Ed. Fejerskov O, Nyvad B, Kidd E, eds. Oxford, Wiley Blackwell, Ch 5, 2015. Management of ECC should focus on the modification of causative factors and the promotion of protective factors.

ECC carries significant dental, medical, social, and quality-of-life consequences, 7Easton JA, et al. Evaluation of a generic quality of life instrument for early childhood caries-related pain. Community Dent Oral Epidemiol 2008;36(5):434-40.,35Casamassimo PS, et al. Beyond the DMFT: the human and economic cost of early childhood caries. J Am Dent Assoc 2009;140(6):650-7. and for this reason the AAPD has published evidence-based clinical management guidelines to assist dental practitioners in treatment planning. 33American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent 2013;35(5):E157-64. These guidelines are summarized in Tables 2 and 3. Although the AAPD recommends the use of 0.5% fluoride gel/toothpaste on 3–5 year olds at high risk of ECC development, this recommendation does not yet have supporting scientific evidence, and the risk of swallowing the product may outweigh its benefits. 36Weyant RJ, Tracy SL, Anselmo T, et al. Topical fluoride for caries prevention. J Am Dent Assoc 2013;144(11):1279-91. For this reason, the guideline presented here was modified, recommending the use of conventional fluoridated toothpastes by young children at any risk category.

Table-2
Table 2
Caries Management Protocol for 1–2-Year-Olds33American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent 2013;35(5):E157-64.
Table-3
Table 3
Caries Management Protocol for 3–5-Year-Olds33American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent 2013;35(5):E157-64.

Conclusion

The appropriate assessment of caries risk in toddlers and young children is a key step to help control the incidence of cavitated and non-cavitated white spot carious lesions, and to promote the arrest or even the reversal of existing lesions. This goal may be achieved by managing the caries risk factors at a personal level, using evidence-based clinical management guidelines that are customized to patients’ individual needs.

References

  • 1.Fejerskov O. Changing paradigms in concepts on dental caries: consequences for oral health care. Caries Res 2004;38(3):182-91.
  • 2.Rølla G, Ogaard B, Cruz R de A. Clinical effect and mechanism of cariostatic action of fluoride-containing toothpastes: a review. Int Dent J 1991;41(3):171-4.
  • 3.Dye BA, et al. Prevalence and measurement of dental caries in young children. Pediatr Dent 2015;37(3):200-16.
  • 4.U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
  • 5.Holm AK. Caries in the preschool child: international trends. J Dent 1990;18(6):291-5.
  • 6.Ricks TL, et al. The Indian Health Service early childhood caries (ECC) collaborative: a 5-year summary. Pediatr Dent 2015;37(3):275-80.
  • 7.Easton JA, et al. Evaluation of a generic quality of life instrument for early childhood caries-related pain. Community Dent Oral Epidemiol 2008;36(5):434-40.
  • 8.Mejàre I, et al. Caries risk assessment: a systematic review. Acta Odontol Scand 2014;72(2):81-91.
  • 9.Fontana M, Zero DT. Assessing patients’ caries risk. J Am Dent Assoc 2006;137(9):1231-9.
  • 10.Kühnisch J, et al. Best clinical practice guidance for management of early caries lesions in children and young adults: an EAPD policy document. Eur Arch Paediatr Dent 2016;17(1):3-12.
  • 11.Cury JA, Tenuta LMA. Enamel remineralization: controlling the caries disease or treating early caries lesions? Braz Oral Res 2009;23(Suppl 1):23-30.
  • 12.Paes Leme AF, et al. The role of sucrose in cariogenic dental biofilm formation – new insight. J Dent Res 2006;85(10):878-87.
  • 13.Marsh PD. Microbial ecology of dental plaque and its significance in health and disease. Adv Dent Res 1994;8(2):263-71.
  • 14.Stephan RM. Changes in hydrogen-ion concentration on tooth surfaces and in carious lesions. J Am Dent Assoc 1940;27(5):718-23.
  • 15.Stookey GK. The effect of saliva on dental caries. J Am Dent Assoc 2008;139(Suppl2):11S-7.
  • 16.Kaste LM, Gift HC. Inappropriate infant bottle feeding status of the Healthy People 2000 objective. Arch Pediatr Adolesc Med 1995;149(7):786-91.
  • 17.American Academy of Pediatric Dentistry. Definition of early childhood caries (ECC). Pediatr Dent 2010;32 (Spec Iss):15. Available at: http://www.aapd.org/assets/1/7/D_ECC.pdf. Accessed March 14, 2017.
  • 18.Fontana M. The clinical, environmental, and behavioral factors that foster early childhood caries: evidence for caries risk assessment. Pediatr Dent 2015;37(3):217-25.
  • 19.Guedes RS, et al. Risk of initial and moderate caries lesions in primary teeth to progress to dentine cavitation: a 2-year cohort study. Int J Paediatr Dent 2016;26(2):116-24.
  • 20.Vadiakas G. Case definition, aetiology and risk assessment of early childhood caries (ECC): A revisited review. Eur Arch Paed Dent 2008;9(9):114-25.
  • 21.Tinanoff NT, et al. Current understanding of the epidemiology mechanism, and prevention of dental caries in preschool children. Pediatr Dent 2002;24(6):543-51.
  • 22.Bowen WH. Response to Seow: biological mechanisms of early childhood caries. Community Dent Oral Epidemiol 1998;26(1 Suppl):28-31.
  • 23.Neves PA, et al. Breastfeeding, dental biofilm acidogenicity, and early childhood caries. Caries Res 2016;50(3):319-24.
  • 24.Alaluusua S, Malmivirta R. Early plaque accumulation – A sign for caries risk in young children. Community Dent Oral Epidemiol 1994;22(10):273-6.
  • 25.Roeters J, et al. Dental caries and its determinants in 2- to-5-year old children. ASDC J Dent Child 1995;62(6):401-8.
  • 26.Ögaard B, et al. Microradiographic study of remineralization of shark enamel in a human caries model. Scand J Dent Res 1988;96(3):209-211.
  • 27.Marinho VC, et al. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2003;(1):CD002278.
  • 28.Walsh T, et al. Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2010;(1):CD007868.
  • 29.dos Santos AP, et al. A systematic review and metaanalysis of the effects of fluoride toothpastes on the prevention of dental caries in the primary dentition of pre-school children. Community Dent Oral Epidemiol 2013;41(1):1-12.
  • 30.Tenuta LM, et al. Fluoride release from CaF2 and enamel demineralization. J Dent Res 2008;87(11):1032-6.
  • 31.Petersen PE, Lennon MA. Effective use of fluorides for the prevention of dental caries in the 21st century: the WHO approach. Community Dent Oral Epidemiol 2004;32(5):319-21.
  • 32.Twetman S, et al. Risk assessment: can we achieve consensus? Community Dent Oral Epidemiol 2013;41(1):64-70.
  • 33.American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent 2013;35(5):E157-64.
  • 34.Fejerskov O. Pathology of dental caries. In: Dental Caries – The Disease and its Clinical Management. 3 rd Ed. Fejerskov O, Nyvad B, Kidd E, eds. Oxford, Wiley Blackwell, Ch 5, 2015.
  • 35.Casamassimo PS, et al. Beyond the DMFT: the human and economic cost of early childhood caries. J Am Dent Assoc 2009;140(6):650-7.
  • 36.Weyant RJ, Tracy SL, Anselmo T, et al. Topical fluoride for caries prevention. J Am Dent Assoc 2013;144(11):1279-91.

Target audience: Dentists, dental assistants and hygienists


Release date: Tuesday, June 6, 2017
Expiration date: Saturday, June 6, 2020

“Colgate Oral Health Dialogue – 2017- Risk Assessment for Early Childhood Caries” is co-sponsored by Tribune Group GmbH. Tribune Group GmbH is a recognized ADA CERP and AGD PACE provider.