Suzanne C. Boulter, MD

A new clinical report published in Pediatrics entitled "Management of Dental Trauma in a Primary Care Setting" expands the knowledge base for pediatricians who care for children in the primary care setting (2014;133:e466-e476). Recommendations for pediatricians go beyond caries preventive messages (brush, floss, limit juice consumption, no bottles in bed, first dental visit at 1 year of age) to include triage and screening for dental trauma in our patients.

Dental trauma is the second most common injury in children aged 0-6 years, and 25% of all school-age children experience dental trauma.

Recommendations to share with parents include anticipatory guidance in several key areas: household safety (gates on stairways, furniture protectors, removal of tripping hazards); mouth guards for competitive/contact sports; and management of dental injuries.

An estimated 20%-30% of all dental injures are sports-related injuries, and the preparticipation sports physical is an ideal time to incorporate injury prevention messages, such as the importance of wearing mouth guards during all practices and games. Custom-fit mouth guards offer the most protection, but use of any mouth guard is preferable to none. Although the U.S. National Collegiate Athletic Association requires mouth guards for only four sports (ice hockey, lacrosse, field hockey, and football), the American Dental Association recommends the use of mouth guards in 29 sports and activities, according to the report.

As pediatric primary care providers are often the first responders for dental injuries, the report provides guidance for initial assessment and recommendations for triage, basing urgency for dental evaluation on injury type. As survival of the tooth is time dependent, it is critical that first responders provide timely and appropriate care. Key skills include determining whether the injured tooth is a primary or permanent tooth (both age of the patient and size of the tooth are factors), and a recommendation to take a photo of the injured tooth. Clinical recommendations vary depending on whether a primary or permanent tooth has been traumatized. The guideline includes excellent photographs and drawings of dental trauma classifications, and denotes injuries that need immediate referral to a dentist versus those that can be managed by the primary care physician.

When evaluating dental injuries, it is imperative to adhere to a systematic approach to avoid an oversight. This includes, but is not limited to, the mechanism and nature of the dental injury, need for a tetanus booster, and consideration of both the possibility of head injury and child abuse.

Dental trauma can be classified into the following categories: concussion, subluxation, luxation, extrusion, intrusion, avulsions, and fractures. Primary teeth that avulse should not be replaced, due to concern for damaging the underlying permanent tooth. Permanent teeth that avulse should be immediately put back in place; these teeth need to be handled by the crown portion only and not the root, which contains fibroblasts necessary for reimplantation. Dirty avulsed permanent teeth can be placed in milk, a balanced salt solution, or saliva (but not water) until the patient can be seen by the dentist.

Conventional intraoral radiographs remain the optimal study for evaluating injured teeth, with less radiation exposure than a computed tomography scan. These studies will be performed at the dental office.

Prophylactic systemic antibiotics are not routinely warranted after dental trauma care, except following reimplantation of a primary avulsed tooth.

Encourage a soft diet and avoidance of non-nutritive sucking (digit or pacifier) for 10 days following most dental injuries

Potential trauma sequelae that should be discussed with caregivers include crown discoloration, root resorption, fixation of the tooth to the underlying bone, and pulpal necrosis.

These guidelines present new and important information for the primary care pediatrician, who will see many examples of dental trauma in their practice. Recommendations regarding care by the primary care physicians and immediate or routine referral to the dentist will be a helpful adjunct to comprehensive patient care.

Dr. Boulter is adjunct professor of pediatrics and community and family medicine at the Geisel School of Medicine at Dartmouth, Hanover, N.H. Dr. Clark is an associate professor of pediatrics at Albany (N.Y.) Medical College, and serves as the chief editor for both Smiles for Life: A National Oral Health Curriculum and Protecting All Children’s Teeth (PACT): AAP’s Pediatric Oral Health Training Program for Physicians. Both Dr. Boulter and Dr. Clark were members of the 2012-2013 AAP Section on Oral Health Executive Committee and involved in developing the clinical report.

A new clinical report published in Pediatrics entitled "Management of Dental Trauma in a Primary Care Setting" expands the knowledge base for pediatricians who care for children in the primary care setting (2014;133:e466-e476). Recommendations for pediatricians go beyond caries preventive messages (brush, floss, limit juice consumption, no bottles in bed, first dental visit at 1 year of age) to include triage and screening for dental trauma in our patients.

Dental trauma is the second most common injury in children aged 0-6 years, and 25% of all school-age children experience dental trauma.

Recommendations to share with parents include anticipatory guidance in several key areas: household safety (gates on stairways, furniture protectors, removal of tripping hazards); mouth guards for competitive/contact sports; and management of dental injuries.

An estimated 20%-30% of all dental injures are sports-related injuries, and the preparticipation sports physical is an ideal time to incorporate injury prevention messages, such as the importance of wearing mouth guards during all practices and games. Custom-fit mouth guards offer the most protection, but use of any mouth guard is preferable to none. Although the U.S. National Collegiate Athletic Association requires mouth guards for only four sports (ice hockey, lacrosse, field hockey, and football), the American Dental Association recommends the use of mouth guards in 29 sports and activities, according to the report.

As pediatric primary care providers are often the first responders for dental injuries, the report provides guidance for initial assessment and recommendations for triage, basing urgency for dental evaluation on injury type. As survival of the tooth is time dependent, it is critical that first responders provide timely and appropriate care. Key skills include determining whether the injured tooth is a primary or permanent tooth (both age of the patient and size of the tooth are factors), and a recommendation to take a photo of the injured tooth. Clinical recommendations vary depending on whether a primary or permanent tooth has been traumatized. The guideline includes excellent photographs and drawings of dental trauma classifications, and denotes injuries that need immediate referral to a dentist versus those that can be managed by the primary care physician.

When evaluating dental injuries, it is imperative to adhere to a systematic approach to avoid an oversight. This includes, but is not limited to, the mechanism and nature of the dental injury, need for a tetanus booster, and consideration of both the possibility of head injury and child abuse.

Dental trauma can be classified into the following categories: concussion, subluxation, luxation, extrusion, intrusion, avulsions, and fractures. Primary teeth that avulse should not be replaced, due to concern for damaging the underlying permanent tooth. Permanent teeth that avulse should be immediately put back in place; these teeth need to be handled by the crown portion only and not the root, which contains fibroblasts necessary for reimplantation. Dirty avulsed permanent teeth can be placed in milk, a balanced salt solution, or saliva (but not water) until the patient can be seen by the dentist.

Conventional intraoral radiographs remain the optimal study for evaluating injured teeth, with less radiation exposure than a computed tomography scan. These studies will be performed at the dental office.

Prophylactic systemic antibiotics are not routinely warranted after dental trauma care, except following reimplantation of a primary avulsed tooth.

Encourage a soft diet and avoidance of non-nutritive sucking (digit or pacifier) for 10 days following most dental injuries

Potential trauma sequelae that should be discussed with caregivers include crown discoloration, root resorption, fixation of the tooth to the underlying bone, and pulpal necrosis.

These guidelines present new and important information for the primary care pediatrician, who will see many examples of dental trauma in their practice. Recommendations regarding care by the primary care physicians and immediate or routine referral to the dentist will be a helpful adjunct to comprehensive patient care.

Dr. Boulter is adjunct professor of pediatrics and community and family medicine at the Geisel School of Medicine at Dartmouth, Hanover, N.H. Dr. Clark is an associate professor of pediatrics at Albany (N.Y.) Medical College, and serves as the chief editor for both Smiles for Life: A National Oral Health Curriculum and Protecting All Children’s Teeth (PACT): AAP’s Pediatric Oral Health Training Program for Physicians. Both Dr. Boulter and Dr. Clark were members of the 2012-2013 AAP Section on Oral Health Executive Committee and involved in developing the clinical report.

A new clinical report published in Pediatrics entitled "Management of Dental Trauma in a Primary Care Setting" expands the knowledge base for pediatricians who care for children in the primary care setting (2014;133:e466-e476). Recommendations for pediatricians go beyond caries preventive messages (brush, floss, limit juice consumption, no bottles in bed, first dental visit at 1 year of age) to include triage and screening for dental trauma in our patients.

Dental trauma is the second most common injury in children aged 0-6 years, and 25% of all school-age children experience dental trauma.

Recommendations to share with parents include anticipatory guidance in several key areas: household safety (gates on stairways, furniture protectors, removal of tripping hazards); mouth guards for competitive/contact sports; and management of dental injuries.

An estimated 20%-30% of all dental injures are sports-related injuries, and the preparticipation sports physical is an ideal time to incorporate injury prevention messages, such as the importance of wearing mouth guards during all practices and games. Custom-fit mouth guards offer the most protection, but use of any mouth guard is preferable to none. Although the U.S. National Collegiate Athletic Association requires mouth guards for only four sports (ice hockey, lacrosse, field hockey, and football), the American Dental Association recommends the use of mouth guards in 29 sports and activities, according to the report.

As pediatric primary care providers are often the first responders for dental injuries, the report provides guidance for initial assessment and recommendations for triage, basing urgency for dental evaluation on injury type. As survival of the tooth is time dependent, it is critical that first responders provide timely and appropriate care. Key skills include determining whether the injured tooth is a primary or permanent tooth (both age of the patient and size of the tooth are factors), and a recommendation to take a photo of the injured tooth. Clinical recommendations vary depending on whether a primary or permanent tooth has been traumatized. The guideline includes excellent photographs and drawings of dental trauma classifications, and denotes injuries that need immediate referral to a dentist versus those that can be managed by the primary care physician.

When evaluating dental injuries, it is imperative to adhere to a systematic approach to avoid an oversight. This includes, but is not limited to, the mechanism and nature of the dental injury, need for a tetanus booster, and consideration of both the possibility of head injury and child abuse.

Dental trauma can be classified into the following categories: concussion, subluxation, luxation, extrusion, intrusion, avulsions, and fractures. Primary teeth that avulse should not be replaced, due to concern for damaging the underlying permanent tooth. Permanent teeth that avulse should be immediately put back in place; these teeth need to be handled by the crown portion only and not the root, which contains fibroblasts necessary for reimplantation. Dirty avulsed permanent teeth can be placed in milk, a balanced salt solution, or saliva (but not water) until the patient can be seen by the dentist.

Conventional intraoral radiographs remain the optimal study for evaluating injured teeth, with less radiation exposure than a computed tomography scan. These studies will be performed at the dental office.

Prophylactic systemic antibiotics are not routinely warranted after dental trauma care, except following reimplantation of a primary avulsed tooth.

Encourage a soft diet and avoidance of non-nutritive sucking (digit or pacifier) for 10 days following most dental injuries

Potential trauma sequelae that should be discussed with caregivers include crown discoloration, root resorption, fixation of the tooth to the underlying bone, and pulpal necrosis.

These guidelines present new and important information for the primary care pediatrician, who will see many examples of dental trauma in their practice. Recommendations regarding care by the primary care physicians and immediate or routine referral to the dentist will be a helpful adjunct to comprehensive patient care.

Dr. Boulter is adjunct professor of pediatrics and community and family medicine at the Geisel School of Medicine at Dartmouth, Hanover, N.H. Dr. Clark is an associate professor of pediatrics at Albany (N.Y.) Medical College, and serves as the chief editor for both Smiles for Life: A National Oral Health Curriculum and Protecting All Children’s Teeth (PACT): AAP’s Pediatric Oral Health Training Program for Physicians. Both Dr. Boulter and Dr. Clark were members of the 2012-2013 AAP Section on Oral Health Executive Committee and involved in developing the clinical report.

When I trained in pediatrics, education about children’s oral health for pediatricians was lacking, especially for children under age 3. At that time it wasn’t common practice to look at the teeth and oral cavity; we looked beyond those structures to the throat, as we assumed the teeth were someone else’s responsibility.

However, data and experience have proven that baby teeth are valuable – and not just as a commodity to be funded by the tooth fairy when extruded! We now know that if children develop early childhood caries (ECC), they are more likely to develop cavities in their adult teeth, leading to pain and suffering, as well as difficulty in school and even in finding a job. Recent trends also show that children as young as 1 or 2 years are requiring general anesthesia for treatment of multiple cavities – procedures that could lead to complications or even death. Primary care providers and dentists need to work together to educate every parent about how to prevent ECC.

Photo: Courtesy Bryan Reimer

In an ideal world, there would be enough pediatric dentists or general dentists who are comfortable seeing kids under age 3 to meet the oral health preventive screening needs. But there are not enough of them, and because pediatricians see children 13 times for well-child visits in the first 3 years of life, it makes sense for us to assess for oral health risk factors and provide anticipatory guidance to families about diet, fluoride, and good oral hygiene. It also makes sense for us to advise the establishment of a dental home for all children starting at age 1. After the age of 3, if a child has been able to establish a dental home, he or she may actually see the dentist more often than the pediatrician and can receive oral health care in the dental setting.

The percentage of pediatricians incorporating oral health risk assessment into the well-child visit is increasing, but it is still not universal. Older pediatricians who have been doing well-child care visits for decades without it may not be eager to add something new. Payment is also an issue, but over the past 3 years the American Academy of Pediatrics (AAP), with funding from the Pew Charitable Trusts, has been able to advocate for payment from Medicaid in 44 states for pediatricians and other primary care medical providers to provide caries prevention services. The AAP continues to advocate for payment in the remaining states and from commercial medical and/or dental insurers.

On the policy front, several efforts have been underway. The AAP established the Section on Oral Health in 1999. Initially, the section was composed of only pediatric dentists, but now pediatricians are welcomed and encouraged to join. Many also are taking an active role in education and policy development. The group has authored two policy statements on oral health in the journal Pediatrics, and has several other policy statements in progress. Current policies include "Preventive Oral Health Intervention for Pediatricians," published in 2008 (Pediatrics 2008:122;1387-94), and "Oral Health Risk Assessment Timing and Establishment of a Dental Home," published in 2003 and reaffirmed in 2009 (Pediatrics 2003:111;1113-6).

In 2006, the AAP chose oral health as one of its strategic initiatives for children, and in 2008, hosted the National Summit on Childrens Oral Health, as well as Pediatrics for the 21st Century (PEDS 21), a symposium held during the AAP’s National Conference and Exhibition, focused on oral health with more than 700 pediatricians in attendance.

In 2009, the AAP received a grant from the American Dental Association Foundation to train pediatricians about oral health. Three annual 2-day meetings were held at AAP headquarters to train an identified oral health "champion" from the majority of AAP Chapters. The goal was for these Chapter Oral Health Advocates to return home and train pediatricians and others about the importance of oral health. They also have advocated at the local and state levels for children’s oral health issues.

Oral health is further solidified as a top child health issue with its inclusion in the "Bright Futures Guidelines for Health Supervision for Infants, Children, and Adolescents," 3rd ed., 2008, as one of the 10 key areas for health supervision. The Affordable Care Act also recommends that preventive care visits for children include Bright Futures recommendations. The AAP/Bright Futures Oral Health Risk Assessment Tool and Tutorial was developed in 2011, following field testing in practices around the country. Recently, it was sent to more than 20,000 practicing pediatricians for use in their practices.

In addition to performing risk assessment and applying fluoride varnish to at-risk children, pediatricians can give parents messages about good oral health, including:

• Brushing or wiping teeth after eating.

• Limiting juices to no more than 4 ounces a day.

• Restricting sippy cup usage to mealtime if the cup contains anything but water.

• Avoiding bottles in bed that contain anything other than water.

• Considering weaning off the bottle around 1 year.

• Limiting snacks to less than four per day, and making sure they are healthy.

• Educating about an adequate source of fluoride to strengthen the teeth, including fluoridated water and toothpaste.

• Recommending parental brushing of the child’s teeth twice a day until he or she can adequately perform without supervision (at around 6-8 years of age).

Brochures on oral health are available in the AAP Bookstore or in the Bright Futures Toolbox.

Pediatricians have both the opportunity and the responsibility to incorporate oral health into their well-child health supervision visits. The advice families get from the pediatrician during the first years of life can prevent suffering in young children due to ECC.

The AAP Childrens Oral Health website can help with excellent information and the tools needed for pediatricians to get started.

Dr. Boulter is an adjunct professor of pediatrics at Dartmouth Medical School in Hanover, N.H. She is a member of the executive committee of the AAP Section on Oral Health. Dr. Boulter was honored at the 2010 annual AAP meeting with the Oral Health Service Award. She said she had no relevant financial disclosures.

When I trained in pediatrics, education about children’s oral health for pediatricians was lacking, especially for children under age 3. At that time it wasn’t common practice to look at the teeth and oral cavity; we looked beyond those structures to the throat, as we assumed the teeth were someone else’s responsibility.

However, data and experience have proven that baby teeth are valuable – and not just as a commodity to be funded by the tooth fairy when extruded! We now know that if children develop early childhood caries (ECC), they are more likely to develop cavities in their adult teeth, leading to pain and suffering, as well as difficulty in school and even in finding a job. Recent trends also show that children as young as 1 or 2 years are requiring general anesthesia for treatment of multiple cavities – procedures that could lead to complications or even death. Primary care providers and dentists need to work together to educate every parent about how to prevent ECC.

Photo: Courtesy Bryan Reimer

In an ideal world, there would be enough pediatric dentists or general dentists who are comfortable seeing kids under age 3 to meet the oral health preventive screening needs. But there are not enough of them, and because pediatricians see children 13 times for well-child visits in the first 3 years of life, it makes sense for us to assess for oral health risk factors and provide anticipatory guidance to families about diet, fluoride, and good oral hygiene. It also makes sense for us to advise the establishment of a dental home for all children starting at age 1. After the age of 3, if a child has been able to establish a dental home, he or she may actually see the dentist more often than the pediatrician and can receive oral health care in the dental setting.

The percentage of pediatricians incorporating oral health risk assessment into the well-child visit is increasing, but it is still not universal. Older pediatricians who have been doing well-child care visits for decades without it may not be eager to add something new. Payment is also an issue, but over the past 3 years the American Academy of Pediatrics (AAP), with funding from the Pew Charitable Trusts, has been able to advocate for payment from Medicaid in 44 states for pediatricians and other primary care medical providers to provide caries prevention services. The AAP continues to advocate for payment in the remaining states and from commercial medical and/or dental insurers.

On the policy front, several efforts have been underway. The AAP established the Section on Oral Health in 1999. Initially, the section was composed of only pediatric dentists, but now pediatricians are welcomed and encouraged to join. Many also are taking an active role in education and policy development. The group has authored two policy statements on oral health in the journal Pediatrics, and has several other policy statements in progress. Current policies include "Preventive Oral Health Intervention for Pediatricians," published in 2008 (Pediatrics 2008:122;1387-94), and "Oral Health Risk Assessment Timing and Establishment of a Dental Home," published in 2003 and reaffirmed in 2009 (Pediatrics 2003:111;1113-6).

In 2006, the AAP chose oral health as one of its strategic initiatives for children, and in 2008, hosted the National Summit on Childrens Oral Health, as well as Pediatrics for the 21st Century (PEDS 21), a symposium held during the AAP’s National Conference and Exhibition, focused on oral health with more than 700 pediatricians in attendance.

In 2009, the AAP received a grant from the American Dental Association Foundation to train pediatricians about oral health. Three annual 2-day meetings were held at AAP headquarters to train an identified oral health "champion" from the majority of AAP Chapters. The goal was for these Chapter Oral Health Advocates to return home and train pediatricians and others about the importance of oral health. They also have advocated at the local and state levels for children’s oral health issues.

Oral health is further solidified as a top child health issue with its inclusion in the "Bright Futures Guidelines for Health Supervision for Infants, Children, and Adolescents," 3rd ed., 2008, as one of the 10 key areas for health supervision. The Affordable Care Act also recommends that preventive care visits for children include Bright Futures recommendations. The AAP/Bright Futures Oral Health Risk Assessment Tool and Tutorial was developed in 2011, following field testing in practices around the country. Recently, it was sent to more than 20,000 practicing pediatricians for use in their practices.

In addition to performing risk assessment and applying fluoride varnish to at-risk children, pediatricians can give parents messages about good oral health, including:

• Brushing or wiping teeth after eating.

• Limiting juices to no more than 4 ounces a day.

• Restricting sippy cup usage to mealtime if the cup contains anything but water.

• Avoiding bottles in bed that contain anything other than water.

• Considering weaning off the bottle around 1 year.

• Limiting snacks to less than four per day, and making sure they are healthy.

• Educating about an adequate source of fluoride to strengthen the teeth, including fluoridated water and toothpaste.

• Recommending parental brushing of the child’s teeth twice a day until he or she can adequately perform without supervision (at around 6-8 years of age).

Brochures on oral health are available in the AAP Bookstore or in the Bright Futures Toolbox.

Pediatricians have both the opportunity and the responsibility to incorporate oral health into their well-child health supervision visits. The advice families get from the pediatrician during the first years of life can prevent suffering in young children due to ECC.

The AAP Childrens Oral Health website can help with excellent information and the tools needed for pediatricians to get started.

Dr. Boulter is an adjunct professor of pediatrics at Dartmouth Medical School in Hanover, N.H. She is a member of the executive committee of the AAP Section on Oral Health. Dr. Boulter was honored at the 2010 annual AAP meeting with the Oral Health Service Award. She said she had no relevant financial disclosures.

When I trained in pediatrics, education about children’s oral health for pediatricians was lacking, especially for children under age 3. At that time it wasn’t common practice to look at the teeth and oral cavity; we looked beyond those structures to the throat, as we assumed the teeth were someone else’s responsibility.

However, data and experience have proven that baby teeth are valuable – and not just as a commodity to be funded by the tooth fairy when extruded! We now know that if children develop early childhood caries (ECC), they are more likely to develop cavities in their adult teeth, leading to pain and suffering, as well as difficulty in school and even in finding a job. Recent trends also show that children as young as 1 or 2 years are requiring general anesthesia for treatment of multiple cavities – procedures that could lead to complications or even death. Primary care providers and dentists need to work together to educate every parent about how to prevent ECC.

Photo: Courtesy Bryan Reimer

In an ideal world, there would be enough pediatric dentists or general dentists who are comfortable seeing kids under age 3 to meet the oral health preventive screening needs. But there are not enough of them, and because pediatricians see children 13 times for well-child visits in the first 3 years of life, it makes sense for us to assess for oral health risk factors and provide anticipatory guidance to families about diet, fluoride, and good oral hygiene. It also makes sense for us to advise the establishment of a dental home for all children starting at age 1. After the age of 3, if a child has been able to establish a dental home, he or she may actually see the dentist more often than the pediatrician and can receive oral health care in the dental setting.

The percentage of pediatricians incorporating oral health risk assessment into the well-child visit is increasing, but it is still not universal. Older pediatricians who have been doing well-child care visits for decades without it may not be eager to add something new. Payment is also an issue, but over the past 3 years the American Academy of Pediatrics (AAP), with funding from the Pew Charitable Trusts, has been able to advocate for payment from Medicaid in 44 states for pediatricians and other primary care medical providers to provide caries prevention services. The AAP continues to advocate for payment in the remaining states and from commercial medical and/or dental insurers.

On the policy front, several efforts have been underway. The AAP established the Section on Oral Health in 1999. Initially, the section was composed of only pediatric dentists, but now pediatricians are welcomed and encouraged to join. Many also are taking an active role in education and policy development. The group has authored two policy statements on oral health in the journal Pediatrics, and has several other policy statements in progress. Current policies include "Preventive Oral Health Intervention for Pediatricians," published in 2008 (Pediatrics 2008:122;1387-94), and "Oral Health Risk Assessment Timing and Establishment of a Dental Home," published in 2003 and reaffirmed in 2009 (Pediatrics 2003:111;1113-6).

In 2006, the AAP chose oral health as one of its strategic initiatives for children, and in 2008, hosted the National Summit on Childrens Oral Health, as well as Pediatrics for the 21st Century (PEDS 21), a symposium held during the AAP’s National Conference and Exhibition, focused on oral health with more than 700 pediatricians in attendance.

In 2009, the AAP received a grant from the American Dental Association Foundation to train pediatricians about oral health. Three annual 2-day meetings were held at AAP headquarters to train an identified oral health "champion" from the majority of AAP Chapters. The goal was for these Chapter Oral Health Advocates to return home and train pediatricians and others about the importance of oral health. They also have advocated at the local and state levels for children’s oral health issues.

Oral health is further solidified as a top child health issue with its inclusion in the "Bright Futures Guidelines for Health Supervision for Infants, Children, and Adolescents," 3rd ed., 2008, as one of the 10 key areas for health supervision. The Affordable Care Act also recommends that preventive care visits for children include Bright Futures recommendations. The AAP/Bright Futures Oral Health Risk Assessment Tool and Tutorial was developed in 2011, following field testing in practices around the country. Recently, it was sent to more than 20,000 practicing pediatricians for use in their practices.

In addition to performing risk assessment and applying fluoride varnish to at-risk children, pediatricians can give parents messages about good oral health, including:

• Brushing or wiping teeth after eating.

• Limiting juices to no more than 4 ounces a day.

• Restricting sippy cup usage to mealtime if the cup contains anything but water.

• Avoiding bottles in bed that contain anything other than water.

• Considering weaning off the bottle around 1 year.

• Limiting snacks to less than four per day, and making sure they are healthy.

• Educating about an adequate source of fluoride to strengthen the teeth, including fluoridated water and toothpaste.

• Recommending parental brushing of the child’s teeth twice a day until he or she can adequately perform without supervision (at around 6-8 years of age).

Brochures on oral health are available in the AAP Bookstore or in the Bright Futures Toolbox.

Pediatricians have both the opportunity and the responsibility to incorporate oral health into their well-child health supervision visits. The advice families get from the pediatrician during the first years of life can prevent suffering in young children due to ECC.

The AAP Childrens Oral Health website can help with excellent information and the tools needed for pediatricians to get started.

Dr. Boulter is an adjunct professor of pediatrics at Dartmouth Medical School in Hanover, N.H. She is a member of the executive committee of the AAP Section on Oral Health. Dr. Boulter was honored at the 2010 annual AAP meeting with the Oral Health Service Award. She said she had no relevant financial disclosures.

America’s public education system is in crisis. Despite investing hundreds of billions of dollars each year in our schools, third grade reading scores and high school dropout rates have not improved.

A growing group of pediatricians believe they may have the answer – and it all begins at the 6-month well-child visit.

They are the front lines of Reach Out and Read, a national organization that prepares America’s youngest children to succeed in school by partnering with doctors to prescribe books and encourage families to read together.

Children in the Reach Out and Read program receive a brand-new, age-appropriate book at every regular check-up from 6 months old until they’re ready to enter kindergarten. Pediatricians also speak with parents at every visit about the importance of reading aloud and give them developmental guidance and tips for how to incorporate reading into their daily routine.

Reach Out and Read works. Fourteen peer-reviewed, published studies demonstrate the efficacy of the program. Parents served by Reach Out and Read are four times more likely to read to their young children (Am. J. Dis. Child. 1991;145:881-4), and their children enter kindergarten with larger vocabularies, stronger language skills, and a 6-month developmental edge (Pediatrics 2001;107:130-4).

Both the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners (NAPNAP) have officially endorsed the Reach Out and Read model of early literacy promotion, which is included in the official Bright Futures guidelines.

Today, 27,000 pediatricians, family physicians, and nurse practitioners are participating in Reach Out and Read. If our ultimate goal is to ensure that all children are prepared to achieve their enormous potential, then Reach Out and Read must become the standard of care for every pediatric provider nationwide. That’s because pediatricians have unrivaled access to children aged 5 years and under (96% of children in this age group see their doctor at least once annually).

The lack of exposure to books and reading has created a widespread school readiness gap. More than one-third (or 34%) of American children enter kindergarten without the basic language skills they will need to learn to read (Carnegie Foundation for the Advancement of Teaching, 1991).

Millions of those children will never catch up. In fact, 88% of first graders who are below grade level in reading will continue to read below grade level in fourth grade. (J. Educ. Psychol. 1988;80:437-47). And, according to the national 2010 Annie E. Casey KIDS COUNT Report and the National Assessment of Educational Progress (NAEP), 68% of American fourth graders, including a majority from every state, cannot read proficiently.

As the years go on, children with reading difficulties are at a higher risk for school failure, dropping out, juvenile delinquency, substance abuse, and teenage pregnancy.

Since its founding at Boston City Hospital (now Boston Medical Center) in 1989, Reach Out and Read has expanded to more than 4,600 hospitals, health centers, and clinics nationwide. Together, those programs serve 3.9 million children, including 33% of American children growing up in poverty.

I became a Reach Out and Read provider in 1998 and have since seen firsthand the joy that books bring to children. With Reach Out and Read, the book becomes an integral part of the developmental assessment at every well-child visit from 6 months to 5 years of age. Our residents also have embraced the concept of using a book both to assess development and to promote literacy to the families they serve.

At our clinical site in New Hampshire, we serve a large refugee population. I can remember one little boy from an African country who was reduced to tears when he inadvertently lost his book on his way to get an x-ray, and the smile on his face when we happily replaced the book for him.

As a result of the books, children learn to love school – and learning. They become lifelong readers. They’re better prepared to achieve their potential.

And it all starts with the turn of a page.

Reach Out and Read's website offers information for medical providers. Active Reach Out and Read providers also are eligible to participate in the program’s new Quality Improvement Project, which has been approved by the American Board of Pediatrics for 25 Category IV Maintenance of Certification points.

Dr. Boulter is an adjunct professor of pediatrics at Dartmouth Medical School, Hanover, N. H., and medical director for Reach Out and Read in that state.

America’s public education system is in crisis. Despite investing hundreds of billions of dollars each year in our schools, third grade reading scores and high school dropout rates have not improved.

A growing group of pediatricians believe they may have the answer – and it all begins at the 6-month well-child visit.

They are the front lines of Reach Out and Read, a national organization that prepares America’s youngest children to succeed in school by partnering with doctors to prescribe books and encourage families to read together.

Children in the Reach Out and Read program receive a brand-new, age-appropriate book at every regular check-up from 6 months old until they’re ready to enter kindergarten. Pediatricians also speak with parents at every visit about the importance of reading aloud and give them developmental guidance and tips for how to incorporate reading into their daily routine.

Reach Out and Read works. Fourteen peer-reviewed, published studies demonstrate the efficacy of the program. Parents served by Reach Out and Read are four times more likely to read to their young children (Am. J. Dis. Child. 1991;145:881-4), and their children enter kindergarten with larger vocabularies, stronger language skills, and a 6-month developmental edge (Pediatrics 2001;107:130-4).

Both the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners (NAPNAP) have officially endorsed the Reach Out and Read model of early literacy promotion, which is included in the official Bright Futures guidelines.

Today, 27,000 pediatricians, family physicians, and nurse practitioners are participating in Reach Out and Read. If our ultimate goal is to ensure that all children are prepared to achieve their enormous potential, then Reach Out and Read must become the standard of care for every pediatric provider nationwide. That’s because pediatricians have unrivaled access to children aged 5 years and under (96% of children in this age group see their doctor at least once annually).

The lack of exposure to books and reading has created a widespread school readiness gap. More than one-third (or 34%) of American children enter kindergarten without the basic language skills they will need to learn to read (Carnegie Foundation for the Advancement of Teaching, 1991).

Millions of those children will never catch up. In fact, 88% of first graders who are below grade level in reading will continue to read below grade level in fourth grade. (J. Educ. Psychol. 1988;80:437-47). And, according to the national 2010 Annie E. Casey KIDS COUNT Report and the National Assessment of Educational Progress (NAEP), 68% of American fourth graders, including a majority from every state, cannot read proficiently.

As the years go on, children with reading difficulties are at a higher risk for school failure, dropping out, juvenile delinquency, substance abuse, and teenage pregnancy.

Since its founding at Boston City Hospital (now Boston Medical Center) in 1989, Reach Out and Read has expanded to more than 4,600 hospitals, health centers, and clinics nationwide. Together, those programs serve 3.9 million children, including 33% of American children growing up in poverty.

I became a Reach Out and Read provider in 1998 and have since seen firsthand the joy that books bring to children. With Reach Out and Read, the book becomes an integral part of the developmental assessment at every well-child visit from 6 months to 5 years of age. Our residents also have embraced the concept of using a book both to assess development and to promote literacy to the families they serve.

At our clinical site in New Hampshire, we serve a large refugee population. I can remember one little boy from an African country who was reduced to tears when he inadvertently lost his book on his way to get an x-ray, and the smile on his face when we happily replaced the book for him.

As a result of the books, children learn to love school – and learning. They become lifelong readers. They’re better prepared to achieve their potential.

And it all starts with the turn of a page.

Reach Out and Read's website offers information for medical providers. Active Reach Out and Read providers also are eligible to participate in the program’s new Quality Improvement Project, which has been approved by the American Board of Pediatrics for 25 Category IV Maintenance of Certification points.

Dr. Boulter is an adjunct professor of pediatrics at Dartmouth Medical School, Hanover, N. H., and medical director for Reach Out and Read in that state.

America’s public education system is in crisis. Despite investing hundreds of billions of dollars each year in our schools, third grade reading scores and high school dropout rates have not improved.

A growing group of pediatricians believe they may have the answer – and it all begins at the 6-month well-child visit.

They are the front lines of Reach Out and Read, a national organization that prepares America’s youngest children to succeed in school by partnering with doctors to prescribe books and encourage families to read together.

Children in the Reach Out and Read program receive a brand-new, age-appropriate book at every regular check-up from 6 months old until they’re ready to enter kindergarten. Pediatricians also speak with parents at every visit about the importance of reading aloud and give them developmental guidance and tips for how to incorporate reading into their daily routine.

Reach Out and Read works. Fourteen peer-reviewed, published studies demonstrate the efficacy of the program. Parents served by Reach Out and Read are four times more likely to read to their young children (Am. J. Dis. Child. 1991;145:881-4), and their children enter kindergarten with larger vocabularies, stronger language skills, and a 6-month developmental edge (Pediatrics 2001;107:130-4).

Both the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners (NAPNAP) have officially endorsed the Reach Out and Read model of early literacy promotion, which is included in the official Bright Futures guidelines.

Today, 27,000 pediatricians, family physicians, and nurse practitioners are participating in Reach Out and Read. If our ultimate goal is to ensure that all children are prepared to achieve their enormous potential, then Reach Out and Read must become the standard of care for every pediatric provider nationwide. That’s because pediatricians have unrivaled access to children aged 5 years and under (96% of children in this age group see their doctor at least once annually).

The lack of exposure to books and reading has created a widespread school readiness gap. More than one-third (or 34%) of American children enter kindergarten without the basic language skills they will need to learn to read (Carnegie Foundation for the Advancement of Teaching, 1991).

Millions of those children will never catch up. In fact, 88% of first graders who are below grade level in reading will continue to read below grade level in fourth grade. (J. Educ. Psychol. 1988;80:437-47). And, according to the national 2010 Annie E. Casey KIDS COUNT Report and the National Assessment of Educational Progress (NAEP), 68% of American fourth graders, including a majority from every state, cannot read proficiently.

As the years go on, children with reading difficulties are at a higher risk for school failure, dropping out, juvenile delinquency, substance abuse, and teenage pregnancy.

Since its founding at Boston City Hospital (now Boston Medical Center) in 1989, Reach Out and Read has expanded to more than 4,600 hospitals, health centers, and clinics nationwide. Together, those programs serve 3.9 million children, including 33% of American children growing up in poverty.

I became a Reach Out and Read provider in 1998 and have since seen firsthand the joy that books bring to children. With Reach Out and Read, the book becomes an integral part of the developmental assessment at every well-child visit from 6 months to 5 years of age. Our residents also have embraced the concept of using a book both to assess development and to promote literacy to the families they serve.

At our clinical site in New Hampshire, we serve a large refugee population. I can remember one little boy from an African country who was reduced to tears when he inadvertently lost his book on his way to get an x-ray, and the smile on his face when we happily replaced the book for him.

As a result of the books, children learn to love school – and learning. They become lifelong readers. They’re better prepared to achieve their potential.

And it all starts with the turn of a page.

Reach Out and Read's website offers information for medical providers. Active Reach Out and Read providers also are eligible to participate in the program’s new Quality Improvement Project, which has been approved by the American Board of Pediatrics for 25 Category IV Maintenance of Certification points.

Dr. Boulter is an adjunct professor of pediatrics at Dartmouth Medical School, Hanover, N. H., and medical director for Reach Out and Read in that state.

America’s public education system is in crisis. Despite investing hundreds of billions of dollars each year in our schools, third grade reading scores and high school dropout rates have not improved.

A growing group of pediatricians believe they may have the answer – and it all begins at the 6-month well-child visit.

They are the front lines of Reach Out and Read, a national organization that prepares America’s youngest children to succeed in school by partnering with doctors to prescribe books and encourage families to read together.

Children in the Reach Out and Read program receive a brand-new, age-appropriate book at every regular check-up from 6 months old until they’re ready to enter kindergarten. Pediatricians also speak with parents at every visit about the importance of reading aloud and give them developmental guidance and tips for how to incorporate reading into their daily routine.

Reach Out and Read works. Fourteen peer-reviewed, published studies demonstrate the efficacy of the program. Parents served by Reach Out and Read are four times more likely to read to their young children (Am. J. Dis. Child. 1991;145:881-4), and their children enter kindergarten with larger vocabularies, stronger language skills, and a 6-month developmental edge (Pediatrics 2001;107:130-4).

Both the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners (NAPNAP) have officially endorsed the Reach Out and Read model of early literacy promotion, which is included in the official Bright Futures guidelines.

Today, 27,000 pediatricians, family physicians, and nurse practitioners are participating in Reach Out and Read. If our ultimate goal is to ensure that all children are prepared to achieve their enormous potential, then Reach Out and Read must become the standard of care for every pediatric provider nationwide. That’s because pediatricians have unrivaled access to children aged 5 years and under (96% of children in this age group see their doctor at least once annually).

The lack of exposure to books and reading has created a widespread school readiness gap. More than one-third (or 34%) of American children enter kindergarten without the basic language skills they will need to learn to read (Carnegie Foundation for the Advancement of Teaching, 1991).

Millions of those children will never catch up. In fact, 88% of first graders who are below grade level in reading will continue to read below grade level in fourth grade. (J. Educ. Psychol. 1988;80:437-47). And, according to the national 2010 Annie E. Casey KIDS COUNT Report and the National Assessment of Educational Progress (NAEP), 68% of American fourth graders, including a majority from every state, cannot read proficiently.

As the years go on, children with reading difficulties are at a higher risk for school failure, dropping out, juvenile delinquency, substance abuse, and teenage pregnancy.

Since its founding at Boston City Hospital (now Boston Medical Center) in 1989, Reach Out and Read has expanded to more than 4,600 hospitals, health centers, and clinics nationwide. Together, those programs serve 3.9 million children, including 33% of American children growing up in poverty.

I became a Reach Out and Read provider in 1998 and have since seen firsthand the joy that books bring to children. With Reach Out and Read, the book becomes an integral part of the developmental assessment at every well-child visit from 6 months to 5 years of age. Our residents also have embraced the concept of using a book both to assess development and to promote literacy to the families they serve.

At our clinical site in New Hampshire, we serve a large refugee population. I can remember one little boy from an African country who was reduced to tears when he inadvertently lost his book on his way to get an x-ray, and the smile on his face when we happily replaced the book for him.

As a result of the books, children learn to love school – and learning. They become lifelong readers. They’re better prepared to achieve their potential.

And it all starts with the turn of a page.

Reach Out and Read's website offers information for medical providers. Active Reach Out and Read providers also are eligible to participate in the program’s new Quality Improvement Project, which has been approved by the American Board of Pediatrics for 25 Category IV Maintenance of Certification points.

Dr. Boulter is an adjunct professor of pediatrics at Dartmouth Medical School, Hanover, N. H., and medical director for Reach Out and Read in that state.

America’s public education system is in crisis. Despite investing hundreds of billions of dollars each year in our schools, third grade reading scores and high school dropout rates have not improved.

A growing group of pediatricians believe they may have the answer – and it all begins at the 6-month well-child visit.

They are the front lines of Reach Out and Read, a national organization that prepares America’s youngest children to succeed in school by partnering with doctors to prescribe books and encourage families to read together.

Children in the Reach Out and Read program receive a brand-new, age-appropriate book at every regular check-up from 6 months old until they’re ready to enter kindergarten. Pediatricians also speak with parents at every visit about the importance of reading aloud and give them developmental guidance and tips for how to incorporate reading into their daily routine.

Reach Out and Read works. Fourteen peer-reviewed, published studies demonstrate the efficacy of the program. Parents served by Reach Out and Read are four times more likely to read to their young children (Am. J. Dis. Child. 1991;145:881-4), and their children enter kindergarten with larger vocabularies, stronger language skills, and a 6-month developmental edge (Pediatrics 2001;107:130-4).

Both the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners (NAPNAP) have officially endorsed the Reach Out and Read model of early literacy promotion, which is included in the official Bright Futures guidelines.

Today, 27,000 pediatricians, family physicians, and nurse practitioners are participating in Reach Out and Read. If our ultimate goal is to ensure that all children are prepared to achieve their enormous potential, then Reach Out and Read must become the standard of care for every pediatric provider nationwide. That’s because pediatricians have unrivaled access to children aged 5 years and under (96% of children in this age group see their doctor at least once annually).

The lack of exposure to books and reading has created a widespread school readiness gap. More than one-third (or 34%) of American children enter kindergarten without the basic language skills they will need to learn to read (Carnegie Foundation for the Advancement of Teaching, 1991).

Millions of those children will never catch up. In fact, 88% of first graders who are below grade level in reading will continue to read below grade level in fourth grade. (J. Educ. Psychol. 1988;80:437-47). And, according to the national 2010 Annie E. Casey KIDS COUNT Report and the National Assessment of Educational Progress (NAEP), 68% of American fourth graders, including a majority from every state, cannot read proficiently.

As the years go on, children with reading difficulties are at a higher risk for school failure, dropping out, juvenile delinquency, substance abuse, and teenage pregnancy.

Since its founding at Boston City Hospital (now Boston Medical Center) in 1989, Reach Out and Read has expanded to more than 4,600 hospitals, health centers, and clinics nationwide. Together, those programs serve 3.9 million children, including 33% of American children growing up in poverty.

I became a Reach Out and Read provider in 1998 and have since seen firsthand the joy that books bring to children. With Reach Out and Read, the book becomes an integral part of the developmental assessment at every well-child visit from 6 months to 5 years of age. Our residents also have embraced the concept of using a book both to assess development and to promote literacy to the families they serve.

At our clinical site in New Hampshire, we serve a large refugee population. I can remember one little boy from an African country who was reduced to tears when he inadvertently lost his book on his way to get an x-ray, and the smile on his face when we happily replaced the book for him.

As a result of the books, children learn to love school – and learning. They become lifelong readers. They’re better prepared to achieve their potential.

And it all starts with the turn of a page.

Reach Out and Read's website offers information for medical providers. Active Reach Out and Read providers also are eligible to participate in the program’s new Quality Improvement Project, which has been approved by the American Board of Pediatrics for 25 Category IV Maintenance of Certification points.

Dr. Boulter is an adjunct professor of pediatrics at Dartmouth Medical School, Hanover, N. H., and medical director for Reach Out and Read in that state.

America’s public education system is in crisis. Despite investing hundreds of billions of dollars each year in our schools, third grade reading scores and high school dropout rates have not improved.

A growing group of pediatricians believe they may have the answer – and it all begins at the 6-month well-child visit.

They are the front lines of Reach Out and Read, a national organization that prepares America’s youngest children to succeed in school by partnering with doctors to prescribe books and encourage families to read together.

Children in the Reach Out and Read program receive a brand-new, age-appropriate book at every regular check-up from 6 months old until they’re ready to enter kindergarten. Pediatricians also speak with parents at every visit about the importance of reading aloud and give them developmental guidance and tips for how to incorporate reading into their daily routine.

Reach Out and Read works. Fourteen peer-reviewed, published studies demonstrate the efficacy of the program. Parents served by Reach Out and Read are four times more likely to read to their young children (Am. J. Dis. Child. 1991;145:881-4), and their children enter kindergarten with larger vocabularies, stronger language skills, and a 6-month developmental edge (Pediatrics 2001;107:130-4).

Both the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners (NAPNAP) have officially endorsed the Reach Out and Read model of early literacy promotion, which is included in the official Bright Futures guidelines.

Today, 27,000 pediatricians, family physicians, and nurse practitioners are participating in Reach Out and Read. If our ultimate goal is to ensure that all children are prepared to achieve their enormous potential, then Reach Out and Read must become the standard of care for every pediatric provider nationwide. That’s because pediatricians have unrivaled access to children aged 5 years and under (96% of children in this age group see their doctor at least once annually).

The lack of exposure to books and reading has created a widespread school readiness gap. More than one-third (or 34%) of American children enter kindergarten without the basic language skills they will need to learn to read (Carnegie Foundation for the Advancement of Teaching, 1991).

Millions of those children will never catch up. In fact, 88% of first graders who are below grade level in reading will continue to read below grade level in fourth grade. (J. Educ. Psychol. 1988;80:437-47). And, according to the national 2010 Annie E. Casey KIDS COUNT Report and the National Assessment of Educational Progress (NAEP), 68% of American fourth graders, including a majority from every state, cannot read proficiently.

As the years go on, children with reading difficulties are at a higher risk for school failure, dropping out, juvenile delinquency, substance abuse, and teenage pregnancy.

Since its founding at Boston City Hospital (now Boston Medical Center) in 1989, Reach Out and Read has expanded to more than 4,600 hospitals, health centers, and clinics nationwide. Together, those programs serve 3.9 million children, including 33% of American children growing up in poverty.

I became a Reach Out and Read provider in 1998 and have since seen firsthand the joy that books bring to children. With Reach Out and Read, the book becomes an integral part of the developmental assessment at every well-child visit from 6 months to 5 years of age. Our residents also have embraced the concept of using a book both to assess development and to promote literacy to the families they serve.

At our clinical site in New Hampshire, we serve a large refugee population. I can remember one little boy from an African country who was reduced to tears when he inadvertently lost his book on his way to get an x-ray, and the smile on his face when we happily replaced the book for him.

As a result of the books, children learn to love school – and learning. They become lifelong readers. They’re better prepared to achieve their potential.

And it all starts with the turn of a page.

Reach Out and Read's website offers information for medical providers. Active Reach Out and Read providers also are eligible to participate in the program’s new Quality Improvement Project, which has been approved by the American Board of Pediatrics for 25 Category IV Maintenance of Certification points.

Dr. Boulter is an adjunct professor of pediatrics at Dartmouth Medical School, Hanover, N. H., and medical director for Reach Out and Read in that state.