Children’s Oral Health & the
Primary Care Provider
Oral Screening Exam
Module 3
Module 3 Objectives:
 Learn to perform a knee-to-knee oral screening
exam for infants & toddlers
 Learn helpful tips to gain access to a child’s mouth &
restrain a child’s body movements during an oral
screening exam
 Learn to identify clinical findings predictive of high
caries risk for infants & toddlers
 Learn to identify caries in its different stages
(non-cavitated (white spots) vs. cavitated lesions)
Knee-to-Knee Oral
Screening Exam
Step 1: Child is held facing caregiver
in a straddle position
Step 2: Child leans back
onto examiner while
caregiver holds child’s
hands and legs
Step 3: Provider performs
exam while caregiver
effectively restrains child’s
hands and legs
Equipment for the Oral
Screening Exam
 Disposable gloves
 Good light source
 Disposable mirror (optional)
 Toothbrush or gauze (for plaque removal)
Performing an Oral Screening Exam
 Place the child in the knee-to-knee position
 Restrain child’s head and body movements
 Lift the child’s upper lip and lower child’s
lower lip
Lift-the-Lip Procedure
Knee-to-Knee Position: Dental Setting
Double-click the picture to begin the video clip
Knee-to-Knee Position: Medical Setting
Double-click the picture to begin the video clip
What Clinical Findings Are
Predictive of High Caries Risk?
Previous Caries Experience
 One of best predictors of future caries
 For children under age 5, a history of decay should
automatically classify a child as high risk
 Not useful caries-risk predictor
for infants and toddlers
(insufficient time for ECC
to be expressed)
Visible Plaque
 One of the best predictors of future caries risk in
young children
 Screening for visible plaque is easy and inexpensive
Dental Plaque
Dental Plaque
White Spot Lesions
 Also referred to as non-cavitated lesions
 Initial stage (precursor) of the caries process
 Equivalent to caries for infants and toddlers
Chalky, white spots on primary teeth are
demineralized areas and are considered early decay
White Spot Lesions
Are often:
 Observed next to the gum line
 Accompanied by plaque
 Accompanied by bleeding gums (gingivitis)
Chalky, white spots on primary teeth are demineralized
areas and are considered early decay
Figure 1
From White Spots to
Frank Caries
Figure 2
Figure 3
 Yellow arrows show white spot lesions (non-cavitated) close to
the gum line
 Green arrow and circle show an area where the enamel is
starting to break down and a frank cavity (cavitated lesion) is
starting to develop
 Yellow arrows show white spot lesions
(non-cavitated lesions)
 Green arrow show frank cavities
(cavitated lesions)
 All pictures show advanced frank cavities (cavitated lesions) that have
reached the nerve (pulp) of the teeth. These children are in pain and need
immediate and/or emergency dental treatment
 Green arrow shows the presence of an abscess due to a necrotic tooth
Enamel Defects &
Stained Pits and Fissures
 Enamel hypoplasia
 Stained pit and fissure surfaces of primary teeth
 Consider these indicative of increased caries risk
Enamel Hypoplasia
Stained Pits
and Fissures
Presence of Braces
and Oral Appliances
Caries Risk Assessment
and Management
 Any observable decay or demineralization (white spots):
- Refer for dental care as soon as possible
 Any factors on the oral screen (or parent interview) that
increase the child’s risk for caries:
- Refer for dental care
 Uncertain caries risk:
- Refer for dental care
 Refer to your I-Smile Coordinator for care, assistance with

referrals & to ensure dental care is established
Re-assess to ensure the child has been evaluated by a
dentist & has established regular dental care
I-Smile Coordinators
I-Smile coordinators are dental hygienists who serve as
prevention experts and liaisons between families, health care
professionals, and dental offices to ensure completion of dental
care. Coordinators are located in regional public health
agencies and provide local community support throughout
Iowa. I-Smile Coordinators can:
• Assist with dental referrals for young children.
• Provide Medicaid dental billing information.
• Offer education for healthcare professionals regarding children’s oral
health, including screening and fluoride varnish training.
I-Smile Coordinator contact information can be found at:
www.idph.state.ia.us/hpcdp/oral_health.asp or
I-Smile hotline 1-866-528-4020
Summary: Oral Screening Exam
 Use the knee-to-knee position for oral screening
exams
 Clinical findings predictive of high caries risk for
infants and toddlers:
 previous caries experience
 visible plaque
 white spot lesions
 enamel defects
 stained pits and fissures
 oral appliances
Summary: Oral Screening Exam
 During an oral screening exam remember to:
 Restrain the child’s head and body
movements
 “Lift-the-lip”: lift the upper lip & pull down the
lower lip to examine the child’s teeth
 Dry the child’s teeth to examine for white spot
lesions
 Remove plaque using a toothbrush or gauze
to examine for possible white spot lesions
under plaque
Summary: Oral Screening Exam
 Refer a child for dental care as soon as possible
if any caries or white spot lesions are observed
 Refer for dental care if any of the clinical findings
predictive of high caries risk are observed and/or if
you are uncertain of the child’s caries risk
 Refer to your I-Smile Coordinator for care & to
ensure dental care is established