It is critical to consider an infant oral care program in the context of a participating pair or mother-and-child dyad, which includes comprehensive maternal perinatal oral healthcare, counseling, and treatment (Ramos-Gomez et al. 2012). Indeed, caries is a transmissible, infectious disease and generally, colonization of mutans streptococci (MS) in the oral cavity of children is the result of transmission of these organisms from the child’s primary caregiver; numerous studies showed that a direct relationship exists between MS levels in adult caregivers and that of caries prevalence in their children. Factors influencing colonization include frequent sugar exposure in the infants and habits that allow salivary transfer from mother/caregiver to infants. Maternal factors, such as high levels of MS, poor oral hygiene, low socioeconomic status, low education level, and frequent snacking, increase the risk of bacterial transmission to her infant (Tinanoff et al. 2002; Seki et al. 2006; Douglass et al. 2008; da Silva Bastos Vde et al. 2015).

In the light of these facts, dental professionals must recognize the essential role a mother/caregiver plays in ensuring her child’s oral health (Albino and Tiwari 2016). Improving expectant mothers’ and caregiver’s oral health by reducing pathogenic bacteria levels in their own mouths will delay the acquisition of oral bacteria and the development of early childhood caries in their children, and an effective perinatal program should institute practices such as therapeutic interventions and lifestyle modification counseling both during pre- and postpartum to reduce maternal MS and lactobacilli levels (Ramos-Gomez et al. 2012). Education aims also to inform the mother/caregiver of simple items such as using the same spoon may lead into early contamination.

Although the relationship between the presence of plaque and caries is not as clear as with gingivitis, there is clear evidence that the presence of plaque makes teeth more at risk of caries (Zenkner et al. 2013). It is illusionary to think that toothbrushing even combined with flossing results in a perfect plaque removal; nevertheless regular disruption of biofilm has been shown to play a key role in maintaining oral health in general and in caries prevention in particular. Effective toothbrushing depends on a number of factors including motivation, knowledge, and manual dexterity. Classically, toothbrushing is recommended at least twice a day (after breakfast and at bedtime); frequency can be increased according to the patient need (in case of orthodontic appliances favoring plaque stagnation and retention) and compliance. Emphasis has to be on frequency of the toothbrushing more than on the technique, as there is no consensus yet on the effectiveness of different methods/techniques; nevertheless, the Bass method is the most popular (Muller-Bolla and Courson 2013). For young patients, toothbrushing has to be supervised by an adult (for better plaque removal and to avoid ingestion of fluoride toothpaste). Manual toothbrushing is the method with the better cost-effectiveness ratio; nevertheless, powered (or “electric”) toothbrushes were shown to provide a significantly better plaque removal in both short and long terms. Dental floss must be used once a day (Yaacob et al. 2014; Re et al. 2015). Other tooth-cleaning tools, like waxed dental floss, dental picks, sticks, mini-brushes, oral irrigator (with low water pressure), may be useful to optimize plaque removal in proximal areas (Berchier et al. 2008; Slot et al. 2008). Toothpaste and toothbrushing cannot be considered separately; even though toothbrushing without fluoride toothpaste helps improve oral hygiene and gingival health, it has no caries-preventive effect.

Frequent snacking is not only strongly associated with increased risk of dental caries progression, but also with type 2 diabetes and obesity. Snacking has gained an increasing role as a risk indicator for caries development (Lingström et al. 1994). Energy-dense, low-nutrient-dense foods are often characterized by a high content of added sugar, but several modern snack products such as chips (crisps), popcorn, and shrimp crackers, while not sweet, are still potentially cariogenic due to their content of extensively hydrolyzed starch (Lingström et al. 2000, 2003). Moreover, sweetened and flavored beverage consumption has increased dramatically over the past decades in most of the industrialized countries and particularly in the USA with carbonated soft drinks being consumed the most frequently and most often by children, teens, and young adults (Reddy et al. 2015). It is interesting to notice that different snacking patterns have been reported based on household income: individuals with income at or below the poverty line in the USA more frequently consumed potato chips, fried potatoes, whole milk, and fruit drinks, whereas those with higher incomes consumed more grain-based salty snacks, fruits, skim milk, soft drinks, coffee, and tea (Johansson et al. 2010).

The type and frequency of carbohydrates consumed is of major importance when dealing with caries prevention (Peres et al. 2016); but other important dietary factors are consistency and degree of retention.

Dietary counseling should aim at reducing both the amount and the frequency of carbohydrate intake (Table 19.2).

Fluoride toothpaste sold without restriction over the counter is currently the most widespread fluoride delivery method for individuals and the evidence for its caries-preventive effect in both primary and permanent dentitions is strong (Fédération Dentaire Internationale 2015; Marinho et al. 2003a, b, 2004a, b; Marthaler 2003). Recommendations concern all patients whatever the age and the WHO states that, for public health, based on scientific evidence, every effort must be made to develop affordable fluoridated toothpastes for use in developing countries (Petersen and Lennon 2004). Moreover, its use in combination with water or salt fluoridation is safe.

Recommendations have to be adjusted according to age and risk level. Thus most of the current recommendations consider concentration of fluoride as well as the amount must be adjusted to age (a smear of toothpaste for children up to 3 years old and a pea-size amount after 3 years of age, for example, for the recent recommendations edited by the Scottish Intercollegiate Guidelines Network), particularly for young children to prevent from fluorosis (from fluoride swallowing and ingestion) whom require supervised toothbrushing by an adult (parents, caregivers) (Scottish Intercollegiate Guidelines Network 2014). Moreover, in order to maximize the topical effect of the fluoride toothpastes, patients should be encouraged to spit out excess toothpaste and not rinse with water after brushing. It has to be noted that fluoride toothpaste at a concentration below 1,000 ppm has not been demonstrated to be effective in caries control. In Europe, toothpaste now commonly contains 1,450 ppm fluoride in some form, whereas in other countries they tend to be at 1,000 ppm F.

More recently, toothpaste combining fluoride (1,450 ppm) and arginine (1.5 %) has been developed and studied toward its potential caries-preventive effect, assuming that arginine as an alkali-generating substrate could further counter the acid accumulation within the oral biofilm and thus serves as a promising approach to caries prevention and management. In vitro results showed that the combinatory application of fluoride and arginine has a potential synergistic effect in maintaining a healthy oral microbial equilibrium and thus represents a promising ecological approach to caries management (Zheng et al. 2015). In vivo results support the conclusion that dentifrices containing 1.5 % arginine, an insoluble calcium compound, and 1,450 ppm fluoride may provide significantly greater protection against caries lesion cavitation, in a low to moderate caries risk population, than dentifrices containing 1,450 ppm fluoride alone (Kraivaphan et al. 2013; Li et al. 2015) (Table 19.3).

The evidence indicates that, for preventing caries in children and adolescents, toothpastes of at least 1,000 ppm fluoride should be used. From 1,000 ppm fluoride, there is a dose-response relationship for caries prevention that should be taken into account when advising children from 3 to 6 years old at high risk for caries. For younger children, consideration should be given, when brushing with concentrations greater than 1,000 ppm fluoride, to their risk of developing mild fluorosis; a risk-benefit decision needs to be discussed with parents/guardians.

For high-risk patients presenting with non-cavitated carious lesions (aged over 6 years) or high-risk patients having root caries lesions (when roots are exposed), toothpaste with 5,000 ppm fluoride has been shown to be superior for caries control compared to 1,450 ppm F toothpaste (Nordstrom and Birkhed 2010; Ekstrand et al. 2013; Srinivasan et al. 2014).

The most commonly used and evaluated concentration of fluoride in varnish vehicles is 22,600 ppm (Marinho et al. 2002a, 2003a, 2004a, b, 2013; Twetman 2015b). Its use for high-caries-risk patient is recommended at least 2 times per year (maximum 4 times per year). Fluoride varnish is a delivery system easily used by a dental practitioner or another trained professional (e.g., dental hygienists, dental therapists, pediatricians) whatever the age of the patient (even for infants) by bypassing the risk of ingestion and thus the risk of fluorosis. Several systematic reviews and meta-analysis on the topics have been published describing the effectiveness of fluoride varnishes (Marinho et al. 2002a, 2003a, 2004a, b, 2013; Twetman 2015b).

Fluoride varnishes have also their indications in the field of secondary prevention for non-cavitated carious lesion (one application per week during 6 to 8 weeks up to remineralization).

They are indicated for moderate or high-caries-risk patients older than 6 years, as the young patient is not able to spit out the fluoride solution; when prescribed for children, an adult must supervise their use (Scottish Intercollegiate Guidelines Network 2014). Fluoride mouthwashes have been shown to have a clear caries prevention effect in the absence of daily fluoride toothpaste use; nevertheless, there were inconsistent results when viewed against the background of fluoride toothpaste use (Marinho et al. 2003a, c, 2004a, b; Twetman 2015b).

The effectiveness of fluoride gels as caries-preventive agents has been reported in both deciduous and permanent teeth (Marinho et al. 2002b, 2003a, 2004a, b, 2015). They are indicated for high-caries-risk patients aged 6 years. High-concentration fluoride gels (≥12,300 ppm) may be applied in disposable trays, which fit loosely over the teeth. Several guidelines recommend the alternative use of fluoride gels to fluoride varnish, but there is no clinical evidence in favor of one or the other. Some other recommendations, such as in Scotland (Scottish Intercollegiate Guidelines Network 2014) or Australia (Australian Dental Association 2012), recommend their use only in the absence of fluoride toothpaste. The European Association of Paediatric Dentistry (EADP) (European Association of Paediatric Dentistry 2009) or the New Zealand Guidelines Group (Ministry of Health New Zealand 2009) recommend that the patient should sit in upright position, should not swallow, and must be allowed to expectorate freely after application (teeth should be wiped at the end of the session with gauze; refrain from eating or drinking for 20–30 min after application). In general, fluoride gels are less recommended than fluoride varnishes; this may be explained by the limitation due to age but also by the limited distribution at professional concentrations (≥12,300 ppm) in some countries like in France, for example, and the additional cost represented by the individualized tray.

A literature review published in 2004 proposed to assess the caries-preventive effect of one fluoridated topical agent to another. It concluded that fluoride toothpastes in comparison to mouthrinses or gels appear to have a similar degree of effectiveness for the prevention of dental caries in children in permanent teeth. It also reported that there was no clear suggestion that fluoride varnish is more effective than mouthrinses; moreover, the evidence for the comparative effectiveness, on temporary teeth, of fluoride varnishes and gels and mouthrinses and gels is inconclusive; nevertheless, a tendency of a superior effect of fluoride varnish is suggested (Marinho et al. 2004a).

Another literature review from the same team compared the caries prevention effectiveness of two topical fluoride agents combined with one of them alone, and it appears that mouthrinses, gels, or varnishes used in addition to fluoride toothpaste achieve a modest reduction in caries compared to toothpaste used alone (the prevented fraction was increased about 10 %) (Marinho et al. 2004b).

Slow-release fluoride devices (e.g., slow-dissolving fluoride-releasing glass beads) have been more recently proposed for the prevention, the arrest, or the reversal of the progression in both temporary and permanent teeth carious lesions. So far, there is insufficient evidence to determine whether slow-release fluoride devices (such as glass beads) help reduce dental decay (retention of the beads is a problem) (Chong et al. 2014).

The prescription of fluoride supplements like tablets, drops, chewing gums, and lozenges is subordinated by several factors: the patient age, his/her individual caries risk level, the level of fluoride in drinking water, and the determination of dietary fluoride (in order to prevent intake of excess fluoride) (European Association of Paediatric Dentistry 2009). A 2011 literature review and meta-analysis showed that fluoride supplements are associated with a caries increment reduction when used in permanent teeth versus no other preventive fluoride treatment. The preventive effect was not significantly different when fluoride supplements were compared to other fluoridated topic agents. Unfortunately, many of the studies included in the cited review had been conducted at a time when topical fluorides were not widely used suggesting that there is a lack of evidence from the review to make actual good recommendations because, at the present time, the effect of fluoride supplements in children using fluoride toothpastes on a regular basis would probably be limited (Tubert-Jeannin et al. 2011).

Furthermore, when the fluoride supplements were compared with the use of topical fluorides (toothpastes, varnishes, rinses) or with the use of other preventive measures (xylitol lozenges), there was no differential effect (Table 19.4).