Why paediatric oral care is so important

Article by Dr Martie Conradie, MBChB (UP), Diploma in Child Health (SA), Diploma in HIV Management (SA)

No baby or toddler will take responsibility for their dental health, even adults struggle. But this article might give you an interesting view on paediatric oral care, or maybe it will give you the motivation to have patience with a toddler refusing to brush teeth or making a fuss about using the toothpaste with the wrong picture on it.

A little bit about teeth

Teeth usually do not become visible until babies are about 6-12 months old. Thereafter the first tooth starts breaking through and you have several sleepless nights trying to comfort a little one struggling to understand the discomfort. Most kids have their first full set of 20 teeth by the time they are 3 years old. From about 5-6 years these teeth start falling out one by one, and the tooth fairy (or mouse) might become a regular visitor for a few years.

Primary teeth fall out when the permanent teeth are ready to come out. By about 12-13 years old, most kids will have lost all their baby teeth and will proudly display a set of permanent teeth. Most people will have four wisdom teeth that appear in the back of the jaw when they are 17-25 years old and often these create so much havoc that they are rather removed.

To understand dental health, you have to know a little bit about what teeth are made up of.

The crown of each tooth is the part that is visible outside the gums and it is covered with enamel. Enamel is a very hard and shiny substance and acts as a tooth’s personal bodyguard. It is mostly made up of calcium and phosphate, like your bones, but it is stronger because of certain proteins and crystallites that form part of it.

Below the enamel, there is dentin. This makes up the largest part of the tooth and it is nearly as hard as enamel. This protects the innermost part of the tooth called the pulp. Pulp is where nerve endings and blood supply are found and is therefore the part that senses when you drink a hot drink, bite into ice cream or when you get a cavity. The pulp goes all the way down into the root of the tooth which is under the gum. The root anchors the tooth to the jawbone and is made up of cementum. About a third of a tooth is below the gums which is why you also have to keep your gums healthy.

The process of decay

Unfortunately, enamel is not invincible. It can chip or crack and its worst enemy is plaque. Plaque contains millions of bacteria from nearly 300 different species. The main culprit for poor dental health is Streptococcus mutans – it even sounds scary! It converts sugar and other carbohydrates into acids, and this eats away at your enamel. This is referred to as the cariogenic process.

Some risk factors for cavity development in children include the following:

• Family members with cavities
• Eating and drinking a lot of sugary foods and drinks. “Sticky sugars”, such as toffees and dried fruit which stays in the mouth for long could do serious damage.
• Children with special health care needs
• Wearing braces or orthodontic appliances
• Drinking sugar-containing liquid in a sippy-cup for a prolonged period or letting babies fall asleep while drinking from a bottle.

The extent of poor dental health in kids

The number one dental problem in pre-schoolers is tooth decay. Although the rates of dental caries have significantly declined among school-going children since 1970, the rates of caries in children of 2-5 years old have actually increased.

A few facts:

• One out of 10 two-year-olds have one of more cavities.
• By three years old, 28% of children have one or more cavities.
• By age five, nearly 50% have one or more cavities.

These are not comforting statistics and it is even worse in children from low-income families.

The good news is that cavities are preventable.

Reasons to prioritise oral care during early development

Except for the fact that a healthy oral environment in a child will promote healthy development of adult teeth, there are a few other reasons to take care of your child’s teeth:

• Losing a baby tooth due to decay could increase the risk of crowding problems with adult teeth.
• Speech development: different sounds are created while moving the tongue to different locations against their teeth. Speech difficulty is a possibility if too many teeth are lost during the vital stages of speech development.
• Concentration and learning: when the decay of a tooth results in a foul taste in the mouth, irritation felt by the tongue or actual pain, it will affect a child’s ability to learn.
• Healthy smile: even a young child will want a healthy smile. If a decaying tooth is very visible, that child is unfortunately likely to be the target of mean words. In older children this becomes even more important since how they feel about their bodies can have a major impact on their mental health.
• Chewing: baby teeth are needed to be able to chew food properly.

Facts a parent or caregiver should know

Your child’s dental care starts even before birth.

Primary caregivers can transmit the bacteria which colonises a child’s oral cavity. Colonisation is inevitable but delaying it has been shown to be beneficial to oral health. Factors that influence colonisation include frequent sugar exposure in infants and habits that allow salivary transfer from mothers to infants. If a mom has poor oral hygiene, low socioeconomic status or frequently has unhealthy snacks, the risk of bacterial transmission to their infants are increased and it has even been shown that the infants in these cases test with high levels of Streptococcus mutans, even before their first tooth has erupted.

If a mom, even while pregnant, reduces bacteria levels in her own mouth it may delay the development of early childhood caries. Ways to do this include the following:

• Brush teeth with a fluoride toothpaste and floss at least twice a day
• Limit sugar intake
• If you have nausea, rinse your mouth with 1 teaspoon of baking soda in a glass of water after you get sick to wash the stomach acid away
• Chew sugar-free, xylitol-containing gum several times a day
• Do not miss your annual dental visit

Caring for your baby’s teeth

Here are a few tips:

• Do not share utensils or clean pacifiers by putting it in your mouth.
• Do not let anyone kiss your baby on the mouth.
• Avoid topical teething gels and powders. There have been warnings issued against several teething products and some have even been shown to increase the risk of seizures.
• Stop using pacifiers after the age of 2.
• Use a smear, the size of a grain of rice, of fluoridated toothpaste for children ages 1½-3 years old.
• Some dentists promote using a little xylitol gel (specifically developed for babies) when you clean babies’ gums.
• Do not put babies to bed with a bottle of milk or juice. These have natural and added sugars which coat the teeth the entire time they are sleeping.
• For prevention of caries, it is not advisable to bring your baby to bed with you to nurse at will throughout the night, especially once there is a tooth. The milk tends to pool in the baby’s mouth.
• Sipping all day on drinks other than water can result in decay.
• Gums can be wiped with a soft, clean cloth after the first morning feed and then right before bed. Once a tooth erupted, start brushing with a soft, small-bristled toothbrush and plain water twice a day.
• Start flossing once there are 2 teeth next to each other – there are really nice dental flossers available to make the process easier.

Caring for young kids’ teeth

Many of the tips for babies are also applicable to kids (and adults) too.

Here are a few more:

• Milk teeth matter. Go to the dentist to repair cavities and care for milk teeth as you would for permanent teeth.
• Snacking is becoming more common and when snacking all day, the result is continuous exposure to sugars. Try to avoid carbohydrate-rich snacks or those that can easily be trapped between teeth.
• Brush at least in the morning and evening for two minutes. This can be a really long time for a little one! Using something to count down the time works.
• Use a smear of fluoride toothpaste the size of a pea for children of about 3-5 years old and let them spit it out rather than to swallow. It will take a bit of time to teach them to rinse and spit but keep reiterating it.
• If your children want to brush their teeth themselves, let them have fun, but do a more thorough job after they are done.
• Supervise their brushing until at least 8 years old to ensure adequate cleaning.
• Floss between teeth once they touch each other.
• Discuss with the dentist whether they should consider applying a dental sealant or fluoride treatment.
• If your child doesn’t like a certain toothpaste, try another flavour…they should like brushing teeth.
• There are many opinions about brushing motion. Generally the circular motion is thought to be the best, but the important thing is to clean each tooth thoroughly.

Losing their baby teeth will make your children feel really grown up, but you might be a little uncertain about what to do with a loose tooth if it is the first tooth you’ve ever had to manage. Once a tooth becomes “wiggly”, here are a few things you can do:

• Continue normal brushing and flossing.
• Encourage them to personally remove the tooth if it is extremely loose. Kids will wiggle it with their tongues which expedites the process, but the process that happens inside the tooth to get it ready to fall out, happens at its own pace. Therefore it is not recommended to tie a string around the tooth to pull it out if it is not very loose.
• If it becomes necessary to help your child to finish the job at the final stages, you could pull the tooth out for them. Remove it with clean fingers or with moistened gauze. Apply a bit of pressure with gauze or tissue for a few minutes after pulling the tooth out. A little bleeding is normal for a few minutes and the area will be irritated for a few days. Contact the dentist if the bleeding does not stop or a portion of the tooth remained in the socket.
• Reassure them that it is normal to be toothless for a while.

Caring for your teenager’s teeth

Okay, so your teenager probably will not allow you to brush his or her teeth. Chances are that they will brush quickly in the morning and at night to at least prevent foul smelling breath but keep telling them to take time to do it thoroughly and to floss. Also arrange their dentist visits when it is time.

Importance of visiting the dentist

If you are like me, taking your kids to a dentist might be low on the to-do list while there is no toothache. However, it should really be a priority, like I have learned the hard way. And if your little one does have a few caries, do not feel like you have failed your child, just try to follow the advice of the dentist and have them filled or consider the preventive options that might be available for you child. Preventing caries are much more cost-effective and time-efficient than treating them once they occur.

It is recommended by several paediatric societies that a child should visit a dentist by the time they are one year old or within 6 months after their first tooth erupts.

Infants and toddlers are not expected to be cooperative during an oral examination, so do not be concerned about what the dentist will think if they cry or move around. Dentists are usually well-equipped to manage kids.

A child who is taken for dental visits regularly is more likely to have a good attitude about oral health providers.

May your kids benefit from you taking care of their teeth and I hope there will be no toothaches in your future.