Chapter 10- Children’s teeth.

In the year 17/18 there were 59,314 extractions of children’s teeth in hospital [figures from public health England pub 6.3.19], 38,384 were due to caries/ tooth decay, a totally preventable disease [the rest will be accidents or orthodontics]. 9/10 hospital admissions in the 0-5 age group were for extractions due to tooth decay. Still the most common hospital procedure in 6-10 year olds.

In the year 16/17 it cost the NHS £36m to extract 49,911 rotten teeth in under 18’s [figures pub 3/01/18].

By no stretch of the imagination could this possibly be acceptable in a developed country, indeed in any country. In the UK we have an enviable public health system, free schooling for under 18’s, private nurseries, schools and private healthcare for those who choose and it all runs as a homogeneous whole with the public able to dip in and out as they choose. The information about the causes of tooth decay has been freely available in the public domain for a long time. How has it got to this?

Poor dental health limits children’s ability to eat, play, socialise and speak normally. Not to mention pain, infection, fear, a general anesthetic and 60,000 days lost schooling among the nation’s children!

80% of the care of your teeth is you [or in the case of children you as a parent] but to do that you need the relevant information in the first place and you need to make the right choices.

Something has to change and that change has to start as soon as a child is born. In fact it has to start before then with maternal health.

In 2017 Public Health England published the 3rd edition of ‘Delivering Better Oral Health- an evidence based toolkit for prevention’. [Just put it into Google]. Public Health England ‘exists to protect the nation’s health and well-being and reduce health inequalities’. This document will tell you everything you need to know about the care of teeth, it will tell you how much and what type of toothpaste to use for every age group, the fluoride content of every toothpaste you can think of including own brands and lots of other important useful information.

When it comes to children however I suggest you also visit the British Society of Paediatric Dentistry’s website on www.bspd.co.uk . There is a patients section and you can download ‘A practical guide to children’s teeth’. There is also a brilliant ‘guide for parents of children with autism’.

Tooth decay is prevented by 3 measures- cutting down on the amount and frequency of sugar consumption, practicing good oral hygiene, the use of fluoride toothpaste.

Baby [ also known as first, milk, deciduous] teeth are important. Many people believe that because they fall out it they don’t need to worry about them. Completely false! They are important for eating obviously but they also help the development of speech, eating behaviors and they hold the space for when the permanent teeth come through. Besides which you don’t want your baby/ child to go through the pain and misery of tooth decay, abscesses, sleepless nights due to pain, endless visits to the dentist, extractions, general anesthetics etc.

YOUR CHILD’S HEALTH IS YOUR RESPONSIBILITY. THE DENTAL TEAM IS THERE TO HELP YOU BUT IT’S YOU WHO LOOKS AFTER YOUR CHILD’S HEALTH AND WELFARE. PLEASE LOOK AFTER THEIR TEETH.

Caring for your small child‘s teeth.

Take your child to the dentist by the time they are one. See www.dentalcheckbyone.co.uk Your dental team is there to help and advise you on care of your children’s teeth. Please, please, please take your child to the dentist.

Toothbrushing.

Start brushing your child’s teeth twice a day as soon as they get one [usually about 6 months]- so it becomes a normal part of life like brushing their hair or putting their shoes on. Parents/Carers should brush or supervise tooth brushing till age 7. Children who have supervised brushing have 56% less cavities. [we are aiming for 100%]. Brush last thing at night and at one other time.

With a little one start by doing it when they are relaxed- perhaps in the bath. If you bath with them get them to lie back on your tummy so you can see what you are doing.

When they get a bit older clean your teeth together sometimes so they can copy you.

When they are a toddler a good way to clean their teeth is to sit on the loo [with the lid down obviously] and get them to lie back in your lap, much easier for you to see what you are doing than face on, you can also grab them with your knees!

For up to 3 years a smear of tooth paste on a small headed brush. Use a toothpaste with no less than 1,000 ppm [parts per million]. Read the back of the tube or check contents on Delivering Better Oral Health.

Don’t use a fruit flavored tooth paste, you will never get them off it and on to an adult toothpaste when they are older.

With a baby if you find a toothbrush difficult you can buy little flannel type finger mitts to clean their teeth.

Fluoride is a naturally occurring substance. In the correct concentration it inhibits demineralisation, enhances remineralisation and inhibits plaque bacteria. It is at its most effective when applied topically ie. toothpaste.

When you have finished brushing get them to spit not rinse so you leave a little film of protective fluoride on their teeth.

Brush an hour before they go to bed so they get an hour of normal salivary flow before they go to sleep.

A very useful little book that you might find helpful if tooth brushing is a bit of a battle is ‘How to clean your teeth’. It’s colourful, short and well-illustrated so it’s very easy for small children to follow. It sets a routine and a plan to follow making tooth brushing a smoother, educational activity rather than a battle between parent and child. It is published by Little Learners with assistance from The Oral Health Foundation visit www.dentalhealth.org to buy.

Toothpaste amounts for different age groups-

Under 3 yrs.

A little smear of fluoride toothpaste containing at least 1,000 ppm, supervised brushing.

Children 3-6 years.

Use a pea sized amount of fluoride toothpaste containing more than 1,000 ppm.

Brushing should be supervised by a parent or carer ‘till age 7 [as a rough rule of thumb if they are manually dextrous enough to tie their own shoe laces or write their name legibly].

Children 7 years and young adults.

Use a toothpaste containing 1,350-1,500 ppm fluoride.

Two minutes twice a day, spit don’t rinse.

Tooth brushing is mandatory not optional.

Food and drink.

Breast milk is best for your baby’s teeth. Soya based infant milk is cariogenic [cavity forming] and should only be used where medically indicated.

From 6 months your baby should be introduced to drinking from a cup and the use of a bottle discontinued after 1 year. Unless you are out and don’t want spillages try not to use a feeder cup after 1 year.

Never leave a baby with a bottle or a trainer cup for long periods of time or at sleep time.

Never dip a dummy or a bottle teat in something sweet or fruit based- honey, jam or syrup.

Only put water or milk in a bottle, do not add anything like sugar, honey or syrup.

It’s also recommended that parents do not clean a dropped dummy or bottle by putting it in their own mouths. You pass on bacteria to your child which otherwise not be present in their mouths.

Once they are on to a cup give only milk or water to drink. If very occasionally they have juice [at a party say] make sure it’s with a meal. Avoid juice, squash, flavored milks and smoothies- you’ll also save yourself a fortune! Fizzy drinks, juice, smoothies are all high in acid and damage teeth.

Do not add sugar to weaning foods.

Beware labeling on drinks which says ‘tooth kind’ this makes it sound like its doing your child some good and the more you drink it the greater the beneficial effects. It’s not tooth kind, it’s just not as bad as all the rest! Beware the wording on advertising and packaging.

Don’t forget their 5 a day. This should be 3 veg and 2 fruit. This is the least, aim for more. Fresh fruit and veg protect against a host of diseases. No more than 1 piece of citrus fruit a day. Different fruit and veg have different vitamins and minerals in them- mix up the colours. If you are giving a small child a piece of fruit, an apple say, cut it up, a whole apple is a very daunting prospect to a small child with little teeth. A whole apple is, I should think proportionally about as big as a whole melon to you. It’s a waste of money for your two year old to take 2 bites out of an apple and discard the rest, cut it up into slices they can more easily manage.

Limit sugar to meal times only.

There are different types of sugars- sucrose, glucose, maltose, lactose, fructose etc and they all have different ‘rot’ rates. Sucrose is the worst [cakes, sweets, biscuits etc].

Read food labels carefully, many foods and drinks contain sugars they may be listed on the ingredients as;- glucose, glucose syrup, fructose, concentrated fruit juice, sucrose, dextrose, honey, inverted sugar, maltose, hydrolysed starches, molasses, treacle, corn syrup etc. These are all sugars and cause decay.

The use of the following expressions on food/drink packaging does not mean they are safe for teeth:- no added sugar, no artificial sweetener, sugar free, low sugar, ‘lite’ etc.

Cheese is a good, high energy food for toddlers, non-cavity forming and may be active against caries.

Good snacks for in between meals;- toast, sandwiches, Pitta bread, bread sticks, cream crackers, rice cakes, crisp bread, oat cakes, nuts [not for under 5’s], plain yogurt or fromage frais with chopped fruit.

Toppings for the above- meat and fish spreads, cold meats, egg, tinned fish, marmite for over 6 mths, cheese/ cheese spread, humus, raw fruit, raw vegetables- carrot, cucumber celery etc

Most readily prepared yogurts or fromage frais contain sugar.

Dried fruit- raisins, sultanas etc are super concentrated sugar as they have had all the water taken out of them, they are also sticky. The cusps on children’s teeth are very pointy as they have not yet flattened out and worn down, raisins stick in-between them. Muesli bars and the like sold as a healthier alternative are often high in honey, dried fruits and glucose syrup. As such they are harmful to teeth if eaten in-between meals.

The worst type of snack you can give a small child is a carton of juice and a little box of raisins. Both are full of sugar and the juice is acidic.

Consuming too much sugar not only leads to tooth decay but increases the risk of obesity and Type 2 diabetes. Use the Change4Life food scanner app in order to see the sugar, salt and saturated fat content of food and drink when you shop. Get the kids to help you.

3 meals 2 snacks. Limit sugar to meal times only. 3 balanced meals a day see the ‘eat well plate’ [though it should not have raisins on it!].

Check you only use sugar free medicines, if your child has a long term health condition make sure you are prescribed the low sugar version of a drug if possible.

Teething Products.

Your baby is teething and you want to help them.

Please don’t use a teething products, 64% of teething products licenced for sale by the MHRA [Medicines and Healthcare Products Regulatory Agency] contain either sucrose or alcohol, some both, some also contain lidocaine a local anesthetic. Teething powders are classified as either homeopathic or herbal and gels with the exception of one [Nelsons] all hold full product licences. There are 14 products licenced for sale in the UK. 2 contain sucrose, half contain alcohol, and one homeopathic preparation contains both! None of the ones containing sucrose warn that they may be harmful to teeth.

Frequent intake of sugar is the main cause of tooth decay. Milk teeth are particularly susceptible as the enamel and dentine is immature and contains less mineral content than adult teeth. There is no scientific evidence that any of these products actually work.  Why take something that is potentially harmful when you don’t know if it’s going to work anyway? Sugar rots teeth, alcohol wakes your baby up, contrary to popular belief it arouses not sedates so it increases crying and poor sleeping, lidocaine is a drug [info from research paper pub BDJ Sept ‘19, author credited in bibliography].

Don’t do that to your baby.

The best thing to use is a teething ring you cool in the fridge. Don’t freeze it you will burn your baby’s gums.

Going to the Dentist.

How to find a nice dentist, same way you would find a nice plumber, builder, hairdresser or anything else. Ask your friends, neighbours, other parents at school, your local Mum’s club, your health visitor, Read the reviews on local forums but make your own mind up. Dentistry is a very personal thing what suits one person doesn’t suit another.

Go and have a look, is it clean and tidy, are the staff nice and helpful are they happy to answer your questions do they look child friendly. The staff are more important than the décor.

While if your tooth suddenly broke and you are about to go on holiday, you just want to go to someone competent, a family dentist is someone you are going to go to for a long time. You want someone you and your kids are going to get on with, someone with whom you can build up a report. Someone you feel is genuinely interested in helping you and your family look after your teeth.

You can go to a dentist anywhere you don’t have to be in a catchment like the doctors.

Children are entitled to free treatment at an NHS dental surgery up to the age of 18 and up to 19 if in full time education.

NHS dentistry is not free for adults, there is a scale of mandatory fees. Some people on certain benefits are able to claim free treatment. The rules are very strict and you will incur a hefty fine if you claim free treatment if you are not entitled to it. You may be asked to produce certain documents to prove your entitlement.

Treatment is free for pregnant and nursing mothers until their baby is a year.

Or you may for whatever reason and your budget allows decide to go to a private dentist. You might have gone to them since you were little and want your children to go to the same person.

Some private dentists have a children’s only NHS list. A dentist can only treat you under the NHS if they have an NHS contract. Someone has to pay them either you or the NHS.

Whatever or whoever you choose please take your child by the age of one- www.dentalcheckbyone.co.uk

First Visit.

When you go for their or your first visit go early, you will need to fill in a medical history form and various other forms. This also gives your child time to acclimatise themselves to their surroundings, play with the toys, look at the books etc. I like my little patients to feel at home.

If your child is very young book an appointment at a good time of day when they will not be tired. First thing in the morning is best for little ones.

Don’t take them at a time of day when their blood sugar will be low, just before lunch or late afternoon- they will be less cooperative.

There are lots of books on the market about going to the dentist, make sure you have read a few at home or in the library.

When you arrive make sure they visit the loo, take their outer garments off, adjust their hair bobbles and have a drink if they want one etc so the time you are actually in the surgery is not taken up by trivia. See below attention span.

Get to know staffs names, so your child does as well, it will help to make them feel more at home.

I like the parents of small children not to bring other siblings or friends to the first same visit. It’s too distracting, I need to concentrate on them alone.

You have probably have heard of the expression ‘the terrible two’s- it exists because as we all know this age group of children can be difficult to deal with. They can’t communicate very well, are very dependent on their parents and do not share or play easily with others. Their favorite word is NO! Because young children cannot express themselves verbally their common response to anything unfamiliar is to cry. Don’t be alarmed, tears for all young children are normal not a sign that something is wrong. It is the only way they have of saying ‘where am I, who is this person, I don’t know what I’m supposed to do, I’ve never been here before, what is she saying to Mummy, I’m hungry, I’m tired, the suns in my eyes, I want to go home, where’s my special rabbit, when can we go to the park, I want to play with the toys etc.

Although your child is an individual for your dental visits to be a success it is important for you to recognise that there are well recognised stages of a child’s development. Your dentist is trained to understand this and to understand a child’s level of emotional development and maturity and so he or she knows what can be expected of a child in relation to their age. This means their behavior can be more easily predicted and correctly understood. We also know not to ask a question where the answer could be NO! as in ‘would you like to get up on the chair’.

I usually stage manage appointments. I tell the parent where to sit, where the child is to sit what to do. I’m not bossing anyone around but for example a child of 2 has an attention span of 1-5 minutes, the clock starts ticking as soon as a child enters the surgery. I don’t want to waste valuable time in discussion or ‘photo opportunities’, if there is anything that you are worried about or you feel you need to tell the dentist beforehand, perhaps about a previous bad experience or a very nervous child, phone in advance. No one will mind, after all it will make the dentists life easier. All surgeries and dentists will have their own protocols but they will all want to make your child’s visit a happy one.

All dentists are trained to talk to children in child friendly, non-emotive language, you do not need to translate. They will probably use a technique called- tell, show, do. Which means the dentist will tell your child what they are going to do, they will show them what they are going to do and then they will do it. You do not need to re explain it. For example if I am going to polish a child’s teeth I tell them I am going to do it, then I polish their finger nails, me and the child both counting as we go along and then I say ‘and now I’m going to polish 10 top teeth and 10 bottom teeth and I will do the counting’, then I do it. Simple as that!

A small child can only take one lot of input, let the dentist do the talking.

Dental visits for a small child are all about acclimatisation, I see all my little patients every 3 months so they get used to coming. You might think that your child will never have a problem with a tooth but they might come off their skate board when they are 6, it’s a lot easier to treat a child who knows you, likes you and trusts you than a frightened, worried child to whom you are a stranger.

So from when your child first visits the dentist will build up the things they do, little by little in the same order so the child gets used to what is going to happen. So with me if they are under 3 or so they sit on Mum/Dad/ Carers lap, then as they get older they get up on the chair by themselves, eventually when they are school age they come in to the surgery by themselves and I like the parent to encourage them to do, so they build up a personal relationship with me of their own. If your child is happy to enter the surgery by themselves let them. Children are not a fashion accessory, your function as a parent is to look after their health, welfare, education etc and teach your child how to deal with life- and that includes going to the dentist.

When your dentist has finished examining your child’s teeth they will probably be offered a sticker if they have been good. This is a reward for being good not a bribe to get them to behave, they will remember rewards- bribes do not work.

The choosing of the sticker is a very important part of the visit, we have stickers with topical cartoon characters and children like to collect the different sets. Little children like to stick them on their chest but I find older children like to take them home to decorate their lunch box, the fridge, their bed etc. The point of the choosing of the sticker is that while your child is distracted by this, to them, important procedure [administered by my nurse], I can talk to the parent about anything I feel they need to know while little ears are occupied.

Now, when kids come to see me I give them a sheet of instructions about how to look after their teeth. This has their name on the top so they know it’s for them and it is for them, not for you. Stick it up in their bedroom and practice reading it with them so they know the information on it. I have different sheets of instructions for different age children, as a child gets older I put more science in it. One day they will grow up and you will launch them into the world. They need to know how to look after their teeth themselves and it is important that you help them. I am sure the dentist you choose will have a similar sort of system.

Your child is your responsibility as a parent/carer and the dental team’s job is to help you take care of their teeth.

Most of the adults I treat who are worried at the dentist are worried because of what happened to them as children. I don’t want that to happen to your child and nor do you. These notes are intended to achieve a good outcome for all of us- child, parents/carers and your dental team but most important of all

FOR YOUR CHILD.

What not to do at the Dentist.

I’ve put this at the end as I didn’t want to start off with the negatives.

The first thing to say is make sure everyone involved in a child’s care has read any information given. It’s no good if I give information to Mum and that information isn’t passed on to Dad/ other carers who might help look after a child or take them to the dentist. That person, nanny, childminder, grandparent might have had a very different experience at the dentist, may not understand the importance of oral health, may be of a different generation when dentistry was very different, something to be feared, when prevention was an unheard of word.

We want your child to love coming to the dentist, to look forward to it so don’t say ‘be a brave girl, there’s a brave girl/boy, you were so brave’. This implies there is something to be feared, you didn’t say that the first time you took them to the supermarket or the pictures so why say it when you go to the dentist. You are just putting a concept into their heads they have never even thought of. If you feel the need to congratulate them after a procedure say ‘clever’.

If your child needs to have something done, a filling say don’t pre explain from your own experience. Let the dentist explain the procedure in the correct non emotive language. You have not been trained to do this. The important thing with children is not to lie to them, they aren’t stupid, they just have less experience of the world. The dentist will explain the procedure in words that are truthful but sound pleasant.

Here is an example-

If a procedure requires an injection [local anaesthetic] I will say ‘I am going to put some magic cream on your skin and then I am going to make your little tooth go to sleep, I will show you what that feels like, give me your hand’, then I hold their hand gently and just pinch the skin on the back of it, try it yourself you will hardly feel it.  This is what the injection will feel like with a bit of  surface [topical] anaesthetic applied first. If this procedure is followed in a calm friendly manner I can give injections to very small children. I am not lying to the child, I am just telling them the truth but in a way that sounds pleasant not worrying.

If your child asks you in advance what is going to happen just say ‘I’m not sure darling but the dentist will explain to you’. Your dentist will have probably a well-practiced ‘script’ of explanations for every circumstance.

Sometimes with the best will in the world parents say things that completely contradict what I am about to say. So for example a parent might say ‘It won’t hurt darling’ when I am just about to explain that it might be ‘a little tweaky but it will be over in a jiff’ or ‘she’s finished now’ when I haven’t. Then the poor child doesn’t know who to believe, the parent/ carer or the dentist. It’s too confusing, you can’t have a 3 way conversation. Let the dentist do the talking. Your job is to be a silent supportive presence unless you are asked to do otherwise. Read a magazine, check your phone messages, occupy yourself- just be there!

SWITCH YOUR PHONE TO SILENT if you are in the surgery with your child. If you know you are expecting an important call which you must take, as in ‘life or death’ and no other reason, tell the dentist in advance and when it comes absent yourself as quietly and discreetly as you can.

Do not ever use any of these words when talking about anything to do with dental visits- pain, blood, prick, jab, needle, injection, drill.

NB only someone with parental responsibility can sign a medical history form, Mum, Dad or official carer/guardian. If your child [under 16] has to go to the dentist with someone else for some reason, you must go and sign the form beforehand. It is illegal for the dentist to treat your child without an updated medical history.

That’s enough of negatives, back to positives.

The dental profession wants your child to grow up happy, healthy, cavity and pain free and to enjoy and look forward to their visits to the dentist- please help us to make this possible.

THE MOST IMPORTANT PERSON IN THE ROOM IS YOUR CHILD.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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