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I wish I looked after my teeth: dental health in childhood

Brian Mouatt
CBE BDSEdin MGDS RCSEng FFGDP(UK)
Former Chief Dental Officer
Department of Health

There is no doubt that dentists, nurses and health visitors all have an important role to play in the improvement of oral health. It would be valuable to improve communication between nurses and dentists, both inside and outside their day-to-day work. Happy children and their mothers network like no other group. Baby and toddler groups, nurseries and preschools all interact with nurses, health visitors and midwives. Being part of this offers great opportunities for forward-looking people to have more effective and motivating interprofessional working relationships.

Start early
The opportunities for working together begin during the mother's pregnancy. This period leaves young mothers vulnerable to periodontal (gum) problems and the no-smoking message needs to be emphasised,(1) since smoking has been shown to be a contributory cause of the most serious gum conditions.
Dentists and dental team members immediately think of nursing caries as being the most high profile problem we have to check for in our infant patients. This shows itself as rampant dental decay of the milk teeth. It is associated with the overuse of sweet concentrated juices and pacifiers. This is sadly more common in some racial groups and in the socially and economically deprived. There are of course things that can be done, and the imaginatively produced leaflet "Looking After Your Baby's Teeth" is now available.(2) This contains simple, easily understood messages for these groups. The preventive measures are clear, as outlined in the leaflet, and every opportunity to reinforce them should be taken. We should always emphasise the use of fluoride toothpaste and control of frequency of sugar and starch intake.

The role of our genes
Some problems arise that are purely developmental. Genes have been identified that regulate tooth morphogenesis. But these often have multiple effects: for example, hypodontia and hypoplastic hair or ectodermal hypoplasia are all associated, or even cleft lip and palate.(3) These abnormalities have dental implications and are signs that specialist help is needed. There are a variety of other teething troubles that are often dealt with by others, importantly nurses and health visitors. The information that we can pass to each other about teething difficulties will help families and raise awareness of oral health issues. Some of the myths and old wives' tales persist even today. An excellent review of the folklore and current views on teething is to be found in a paper by Ashley.(4)

Common problems
Dentists, nurses and health visitors all have vital roles to play in the improvement of oral health. Let us work together and improve our interactivity. Some of the challenges we often face are described below.

Initial challenges
Sometimes shortly after birth, small keratinised white patches are seen in the palate. They are known as Epstein's pearls and can be mistaken for misplaced and unerupted teeth. They are in fact of no significance and will disappear in about 2 weeks. Occasionally teeth are found erupted at birth or shortly afterwards. These should also be left alone, except in very rare circumstances: for example, when feeding is seriously disrupted. Later, small eruption cysts may develop. Resist any temptation to open or cut them as infection may result. This consequence is sometimes seen in African communities and has cultural origins.

Pacifiers
Advice on pacifiers is usually welcome. The dental profession has become much more relaxed about the use of these aids to serenity and their design has also improved. Never hang a pacifier round an infant's neck with a ribbon or cord. This dangerous practice has been known to result in strangulation. The pacifier should be of modern, sturdy design with a shield or mouth guard incorporating ventilation holes. The nipple should be inspected frequently for wear and tear and the pacifier replaced if necessary. It is vital that the use of reservoir dummies or honey- or sugar-dipped nipples is never permitted.

Tongue-tie
Tongue-tie often worries parents. Most children grow out of it, but if it persists into the toddler stage, being aware of the problem and monitoring it is usually sufficient. Surgical intervention carries with it the risk of fibrous scarring, which can affect the later development of the teeth.

Teething
Pain associated with teething is best tackled by keeping the mouth very clean using damp gauze. Teething rings are useful to speed the process. The associated drooling is quite natural and can be ignored except for aesthetic reasons. Sometimes it helps if the teething ring is cooled in a refrigerator. If it is necessary to resort to medication, preparations of a sugar-free elixir of paracetamol are available and have been recommended by Steward.(5) Aspirin in any form is to be avoided for all children, due to the risk of Reye's syndrome.

Staining
Parents often worry about stains. Generally there are three types, but caries must first be excluded. Green stain is usually removable with toothpaste and gauze. A black stain is a retained pellicle and is more difficult to remove. Professional cleaning may be needed. Some children exhibit an orange-coloured stain due to commensal chromogenic bacteria. Like the other superficial stains, it does no harm but may be a marker for future susceptibility to caries and calls for preventive advice and monitoring. Intrinsic stains and discolourations almost always need a professional assessment and may be due to fluorosis, enamel defects or now, mercifully rarely, inappropriate tetracycline prescribing.

Sucking
Sucking habits should be regarded as a necessary part of the teething process and should be discouraged only with gentle persuasion and not allowed to develop into a battle of wills. Usually the habit ceases naturally and has become less of a problem by the time the permanent teeth arrive. Persistent sucking habits after this may cause dental problems affecting the position of the teeth, and advice should be sought.

Preventive advice
Above all, the well-known preventive advice of brushing with fluoride toothpaste, minimising the frequency with which sugary and starchy foods and drinks are taken, and establishing a pattern of regular visits to the dentist remains paramount.

Arrival of the teeth
The eruption of the primary (milk) teeth begins any time between 4 and 6 months and continues until 2 years, by which time all 20 primary teeth are usually in place. In toddlers, regular toothbrushing habits should be established as soon as there are any teeth to brush! Tables 1 and 2 show the approximate times of eruption of both the primary and secondary teeth. It is worth remembering that the keystones of the dental arches, which dentists call the curved rows of teeth, are the first permanent molars, which erupt at about 6 years of age, although they have been developing and calcifying since birth. The loss of these teeth from dental decay is a dental disaster. Good nutrition is clearly a prerequisite for good teeth, right from the start.

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During the years from 6 to 12 there is a mixture of permanent teeth in the mouth. This is when there seems to be a jumble of gaps, wobbly teeth and teeth that seem too big. Dentists often refer to this as the "ugly duckling" stage after the Hans Christian Andersen fairy tale. Nature kindly rectifies this state of affairs, and later the "swan" emerges with beautiful teeth.
There is no doubt that an engaging smile and fine regular teeth are one of life's great assets. Celebrities recognised this many years ago! Sometimes, however, nature needs some help from the orthodontist. The child's normal family dentist will be keeping an eye on the development of the teeth and jaws, watching for any abnormalities and potential problems. In this country, overcrowding is the most common problem. Usually an orthodontic assessment is undertaken at around 9 years, but active treatment with braces is delayed until the age of 11-13 years when growth is most active and the important permanent teeth have erupted. However, it is never too early to ask the dentist about the appearance of a child's teeth; he or she will be able to advise on whether specialist care is needed and the best time to refer.
It goes without saying that kind, sensitive and friendly attitudes from the whole health team go a long way towards making first encounters with the dental profession pleasantly favourable and positively helpful. So let us talk more together and protect our children's birthright to healthy teeth and a happy smile.

References

  1. Moore S, Ide M, et al. Periodontal health of London women during early pregnancy. Br Dent J 2001;191:570-3.
  2. Mouatt RB, editor. Looking after your baby's teeth. London: The Sugar Bureau; 2002.
  3. Thesleff I. Genetic basis of tooth development and dental defects.Acta Odont Scand 2000;58:191-4.
  4. Ashley MP. It's only teething …a report of the myths and modern approaches to teething. Br Dent J 2001;191:4-8.
  5. Steward M. Infant care. Teething troubles. Community Outlook 1998;11:27-8.

Resources
British Dental Health Foundation
Smile House 2 East Union St Rugby
Warwickshire CV22 6AJ
T:0870 770 4000
F:0870 770 4010
E:mail@dentalhealth.org.uk
W:www.dentalhealth.org.uk
Smile-On Dentistry website for UK health professionals
W:www.smile-on.com
The Sugar Bureau
Duncan House
Dolphin Square
London SW1V 3PW
T:020 7828 9465
F:020 7821 5393
E:info@sugar-bureau.co.uk
W:www.sugar-bureau.co.uk