Why should we "caries" about children's oral health?

Dr Thomas Cromarty ST6

​Session delivered by:
Sara Hughes – Speciality Reg in Paediatric Dentistry,
University Dental Hospital Cardiff

​Earlier on in the month I was able to attend an incredibly enlightening session on Oral Health in Paediatric patients. Aside from teaching me how to brush my own teeth properly at the age of thirty-five, there were some really useful nuggets of information. Especially for questions which my friends who are parents ask, starting “You’re a Paediatric doctor, you should know this” (Spolier..often I have no idea). Well when it comes to kids and teeth, now I do, and in 5 minutes so will you. I thought it would be easiest to go for a Q&A format, so I’ll jump straight in.

“My child is X years old, should she have all her teeth yet?

Turns out that apart from the Natal Teeth which you sometimes see whilst on the Post-Natal ward (check it’s not loose and airway obstructable, then send to a dentist):

• The first teeth usually come through at 6 months.
• You get a full set of primary teeth (20 teeth, EDCBA,ABCDE) by six months
• The full rack of secondary gnashers (32 teeth, 87654321,12345678) by age twelve.

BabyCenter – Baby Teeth Order of Appearance
​

“What is dental caries (decay)?

 Eat sugar -> Bacteria in the mouth use the sugar to produce acid -> Acid then demineralises the enamel -> Hole is formed. Think of it like the “Battle of the Bouche”, with protective factors versus destructive factors. On the good side we have Saliva (buffers the acid), Fluoride (strengthens enamel) and a healthy diet (low sugar, coarse food cleanses teeth). On the bad side there are caries causing bacteria, xerostomia (low saliva levels) and poor diet (high sugar).

“I take it I can clean my child’s dummy by sucking on it myself?

​Actually No, the bacteria which are implicated in causing caries are acquired, and usually from adults that can transfer the bacteria to the child. So please don’t recommend doing that.
 
“Yeah, the baby teeth aren’t in good nick, but we’ll sort out his teeth cleaning when the adult teeth come through….we cool?”
 
Decay and Caries in the baby tooth can track down to the adult tooth and affect the development of the crown, making it more likely to break down and need extraction. Also, if baby teeth need to be removed prematurely, adult teeth then drift in and either can’t erupt or erupt abnormally, causing “crowding” of teeth. Sometime adult teeth to be removed as well.

Figure 1. The baby tooth above the adult tooth (circled) was removed so hasn’t erupted properly due to drift of the tooth to the right.

“My child has a massive sweet tooth,
is it better to allow a high sugar intake infrequently or frequent low sugar intakes

​Answer: Frequency is worse than Total amount

​The ‘Stephan Curve’ (above) shows that after sugary foods/drinks, bacteria use the sugar which makes acid (lowering the pH). When the pH in the mouth is below the ‘Critical pH’ of 5.5 then tooth decay happens. The longer cumulative time the mouth’s pH is in the ‘critical zone’ then the worse the decay. So you can compare a day without sugary snacks Versus a day with sugary snacks! (below).

 
How big is the problem? What are the REAL stats? (UK data from 2013)

​8 year olds: 46% have ‘Obvious evidence of dental decay’
Socio-Economic Inequality:
57% (children who qualified for free school meals)
45% (did not qualify for free school meals)
 
12 year olds: >30% had obvious decay in the permanent teeth
15 year olds: >40% had obvious decay in the permanent teeth

“Ok so they have bad teeth, but it’s only their teeth, give me a break!!”

​Dental Health DOES impact on General Health!
Children with decay and tooth pain who are not used to visiting the dentist are scared, so don’t tell their parents and suffer in silence. Some of these effects can be seen below:

“What resources can I visit for information?”

​ Sugar Smart app: This breaks down daily recommendations into sugar cubes rather than grams, which is much easier to understand.
NHS food factsis useful: Maximum Daily allowance of sugar in children is 4-7 cubes (each cube is 4g sugar)

“What is the biggest problem?

​Drinks!Fizzy drinks, Fruit juices.
Hidden sugars:Tomato Ketchup (not so bad when consumed with a meal). Petit Filous (1.5 sugar cubes each)
Dried Fruit:Lots of sugar and sticks to teeth as well

“So, what are the take home messages?

• Reinforce key messages
• Brush Twice a Day
• Use fluoride toothpaste
  1. If child <3yr – 1000ppm fluoride
  2. >3 – 1350 – 1500ppm fluoride (adult concentration
• Spit! Don’t rinse.
• Do not eat or drink after brushing at night

 
2. Give Tooth Friendly Advice:

• Keep foods and drinks containing sugar to mealtimes only
• Drink only milk or water between meals
• Do not eat or drink after brushing at night
  • No bottles of squash or juice in bed to sleep
  • Cut the top off the teat, off to transition off bottles
• Stop bottle/breast feeding from 12 months – Use expressed milk in a free flow cup
  1. Breastmilk does have lots of sugar so try to avoid giving breastmilk as going to sleep. Milk will be left on the teeth and increase chances of decay. Drink breast milk then brush teeth. (Milk in the day much safer!)

”Bottle Caries” where milk sits on the teeth overnight (and saliva reduction is low)

​Remember: Sugar free squash  or just no added sugar

3. Recommend  safe snacks

• Raw Vegetables
• Fresh fruit
• Savoury foods

4. Encourage regular dental visits
Ask the question as part of your regular history taking E.g. Who is their Dentist?  - Just asking the question can be enough
“How often?” - depends on risk level, 6/12 to 18/12.

Toothpaste

​Unflavoured & Non-foaming (SLS free) for children with autism. (e.g. OraNurse)
DO NOT Recommend: Fluoride-free toothpastes, Toothpastes containing baking soda (stains only), Charcoal toothpastes.

Brushing Aids

• 3-sided toothbrush – great if mouth not open that wide (get to back of the mouth)
• Finger toothbrush for babies

Brushing advice

• As soon as 2 front teeth appear.
• Put in parents lap then facing the mirror, more natural position
• Circular, rather than back and forth
• No need to rinse
• Twice daily
• Use new technology & aids.  e.g. Games/Songs – such as Brush DJ

Referral Pathways

​Check that the patient has a Dentist. Otherwise can register with NHS Direct.
Other Options:

• General Practice
• Community Dental Service – can do domiciliary check-up.
• Hospital Service – Check if there is an electronic Referral System?

If there is significant swelling or severe pain, then contact Max Fax

“Any other useful tips for doctors?

• Safeguarding: Think about ‘Dental Neglect’ - Continuous poor management may be present with other safeguarding issues.
• Dental check by 1yr campaign in England. The earlier they get used to it the better.
• Chewing gum: With sugar is bad. But otherwise, it stimulates saliva and can be good.
• Help the pH of the mouth. Have some cheese/milk or rinse with water after a meal to help neutralise the acidity.