In part 2 of our series, dental expert Alison Cairns looks at how maintaining good dental habits when starting school can pay dividends for future health prospects bites1 

Alison M CairnsBDS, MSc, MFDS, RCSEd, M Paed Dent, FDS (Paed Dent), RCPSG, Dip Ac Prac, FHEA Senior Clinical University Teacher/Honorary Consultant in Paediatric Dentistry, University of Glasgow 

Key points 

  • All school age children should brush their teeth twice daily for two minutes each time
  • Children under seven or eight should be supervised when brushing their teeth
  • Emphasising a lovely smile and fresh breath will appeal more to children than the benefits of disease prevention
  • If orthodontic appliances, such as braces, are fitted the dentist should ensure the child has a clear understanding of the appropriate cleaning methods. 

All school age children should be encouraged to brush their teeth at least twice daily - ideally once in the morning and last thing at night. A pea sized amount of fluoridated toothpaste (1000ppm for children under six years old and 1350- 1500ppm for over sixes) is recommended and the child should be asked to spit out any excess. They should avoid rinsing with water, leaving the remaining fluoride in the oral cavity for longer, increasing its effectiveness. It is unlikely children will possess the manual dexterity to effectively clean their own teeth until they are around seven or eight years old. Therefore, children in the younger age group should be supervised by an adult who should then go over any missed areas. School age children should be encouraged to take a systematic approach to brushing their teeth, concentrating on a few teeth at a time before moving on. A manual toothbrush held at a 45 degree angle and directed into the necks of the teeth where they meet the gums is known as the Modified Bass Technique and is proven to be more effective than a horizontal scrub technique1. 

Time it right For optimal cleaning, teeth should be brushed for at least two minutes. Encouragement tools include use of an egg timer or the child being asked to brush for the length of time a favourite tune is played. Most electric toothbrushes also have an internal timer. A small headed multi-tufted manual brush, when used correctly, is perfectly adequate for effective toothbrushing. However, a Cochrane Systematic Review2 has shown that using an electric toothbrush with a rotation oscillation action (where the round head of the brush spins one way then the other) can increase the effectiveness of brushing and reduce gingivitis. Powered toothbrushes can sometimes also act as a motivational tool for the child. Powered brushes or manual brushes with a modified grip can be useful where manual dexterity is a problem due to medical compromise or disability. bites3 

Tackling dental caries   

Oral health specialists make frequent visits to schools. They teach children about good oral health and give advice on oral hygiene and diet. Children should be encouraged to receive a personal tooth-brushing lesson from their dentist, hygienist or oral health nurse. When discussing oral health with school age children, it is often more helpful to dwell on having a nice smile and fresh breath rather than the prevention of disease as this tends to appeal more to their priorities. Children at high risk of developing dental caries should be encouraged to attend their dental practice for a regular professional application of fluoride varnish. In some cases these fluoride applications may be received via school visits, such as in the Scottish Childsmile programme. A dental practitioner may also prescribe a high-dose fluoride toothpaste for children over 10 years of age, which is not usually available over the counter.  From the age of six, children can also be advised to use a 0.5% daily fluoride mouthwash. In this case it is important to ensure that the child can fully expectorate the liquid. They should be encouraged to use the mouthwash once daily at an alternative time from tooth brushing, as this will guarantee that the teeth are covered in fluoride three times per day. Following the use of fluoride mouthwash the child should be discouraged from eating or drinking for at least 30 minutes, as this will maximise the benefit of the fluoride3,4. Mouthwashes which do not contain fluoride have not been proven to have a significant benefit to oral health and can be costly; care should also be taken to ensure any formulation used is alcohol-free.  

Losing baby teeth  

From the age of six years, permanent teeth start to erupt. The lower central incisors are usually the most visible, as they are at the front of the mouth and cause the primary incisors to exfoliate. At around the same time, the first permanent molar teeth erupt behind the primary molars, although these can sometimes sneak in unnoticed! The position of these molar teeth makes them difficult for an average six year old to brush effectively - especially if they are not fully erupted - so parents and carers should be extra vigilant at this time. Children at risk of developing dental caries should have these teeth fissures sealed by a professional as soon as possible. From around the age of seven until 11 years, many parents show concern regarding the position of their children's front teeth.  

It is not uncommon for the new permanent teeth to have a less than ideal alignment. Indeed, this has been known as "the ugly duckling" stage! However, until the upper permanent canine teeth are fully erupted it can be hard to have a true understanding of the arrangement of the teeth.  bites2 

Orthodontic treatments  

For most children, an orthodontic assessment at around the ages of ten or 11 will determine whether any treatment should be carried out. For many older children and teenagers crowding and malalignment of the teeth will be a problem, but an assessment at this age will be timely enough to ensure that all possible orthodontic treatment avenues remain open. It is important to note that these patients will not be accepted for orthodontic treatment if they have less than immaculate oral hygiene. Once orthodontic appliances, such as braces, have been fitted it becomes even more complicated to keep the teeth clean, and if a high standard is not maintained the teeth can become damaged by the appliances. In cases such as this, orthodontic treatment may be abandoned. During this time adjuncts to oral health will be required such as interdental brushes and superfloss. Orthodontic treatment can last for a considerable amount of time and considerations with regard to time off school to make appointments should be made before embarking on such a lengthy course of treatment5.  

Teenagers and peer pressure  

It is important that children are made aware of the effects that food choices have on their dental, as well as general health4. In some cases there can be a dramatic change in a child's dietary habits when they proceed from primary to secondary school. At this time they are often given much more freedom over their food choices with lunch money spent as they see fit. Peer pressure at this stage can be extremely influential which sometimes means it may not be cool to select water and fruit over soft drinks and confectionary. In cases where diet or sugar-free drinks are selected there are still significant dental health implications6. Although these drinks do not contain sugars, which can cause dental caries, they are extremely acidic and lead to dental erosion, which is where the outer enamel of the tooth becomes demineralised, thinner and glassy looking. This leads to sensitivity and poor appearance, teeth become darker in colour as dentine shines through the now thinned enamel and the edges of the teeth are chipped away until correct crown height is lost. The teeth also typically have a smooth, glass-like appearance (see Fig. 1).

To avoid dental erosion, acidic food and drink should be kept to a minimum. Acidic foodstuffs should only be consumed along with a main meal and drinks should be taken through a straw. The straw should be placed on the tongue (not held in front of the anterior teeth) as this practice will minimise the amount of liquid actually coming into contact with the teeth. Children should be encouraged to avoid bad habits such as "frothing" where they swirl the acidic beverage round the mouth like mouthwash before swallowing. After consuming an acidic food or drink it is important not to brush the teeth for at least 30 minutes to one hour, as enamel is softer after an acidic attack and tooth brushing can cause damage at this stage. Twenty minutes is the time required for the pH levels in the mouth to return back to normal (neutral) levels. Instead, the child can be encouraged to neutralise the  acid by consuming a block of ham or cheese, or bychewing sugar-free gum for 20 minutes following meals.bites4 

Teenage dental woes  

For some children the cause of dental erosion may be due to gastric reflux due to a lax lower oesophageal sphincter (may be due to a variety of factors, including pregnancy, obesity, overeating, cerebral palsy, GORD, asthma). This condition requires referral to a physician, as well as a dental surgeon. Eating disorders, which are on the increase, can also lead to problems with dental erosion. Intentionally vomiting or ruminating will increase the levels of acid the teeth are exposed to. Eating disorders require a referral to psychological services, as well as remedial dental care and advice. Teenagers will not always admit to smoking, especially if they attend with their guardian. However you may be able to see the following signs on examination. Smoking has several intra-oral side effects including periodontal (gum) disease, staining of the dentition, bad breath and lesions of the oral mucosa including pre-cancerous and cancerous lesions. Teenagers should be offered smoking cessation advice and dental practitioners are trained in at least the initial stages of this process6,7.

It is not uncommon for older children and teenagers to be bothered by recurrent oral ulceration8. This often due to iron deficiency caused via the increased demands of the body during growth spurts, the onset of menarche or because of dietary avoidance. Blood samples can be taken to establish the ferritin levels in the blood and supplements prescribed.

Enamel defects  

Some children and teenagers will complain of unsightly marks on their teeth. In the absence of dental caries these marks are usually caused by enamel defects for which there are multiple causes9. Some possible causes of enamel defects include:

  • Congenital conditions such as amelogenesis Imperfect
  • Developmental defects such as molar-incisor hypomineralisation, chronological hypoplasia or fluorosis
  • Localised causes such as trauma or infection in the primary tooth/predecessor.

For some affected children these defects can be the cause of bullying and psychological trauma, the first sign is often refusal to produce a toothy smile in photographs. There are several treatment options available and these should be considered and instigated as soon as possible where psychological trauma is an issue. In cases where the child is unconcerned about the appearance of the teeth it is often prudent to await further development prior to treatment. There are many other dental anomalies which may present themselves in this age group. The most obvious of which is where a supernumerary tooth may be preventing the eruption of teeth in the normal permanent series10. This most commonly occurs in the upper anterior region. Where a child has had a front tooth in position for six months past the exfoliation date with no sign of the contralateral tooth, investigation should be instigated.

Dental trauma  

Dental trauma is also a common occurrence in this age group with 22 per cent of children affected11. Many of these traumatic incidences occur during sports so children should wear customised sports mouth guards. Customised guards produced by a dental practitioner will fit better and be more effective than standardised "boil and bite" mouth guards12.  In cases of dental trauma or neglect, childprotection issues should always be considered13

References 

1. Poyato-Ferrera M, Segura-Egea JJ, Bullón-Fernández P. Comparison of modified Bass technique with normal toothbrushing practices for efficacy in supragingival plaque removal. Int J Dent Hyg 2003; 1(2): 110-114

2. Robinson P, Deacon SA, Deery C et al. Manual versus powered toothbrushing for oral health. Cochrane Database of Systematic Reviews, 2005; Issue 2: CD002281

3. Scottish Dental Clinical Effectiveness Programme, Prevention and Management of Dental Caries in Children, 2010 www.sdcep.org. uk [Accessed Nov 2011]

4. Scottish Intercollegiate Guidelines Network (SIGN). Preventing dental caries in children at high risk. Targeted prevention of dental caries in the permanent teeth of 6-16 year olds presenting for dental care. 2000; Issue 47

5. British Society of Paediatric Dentistry: a policy document on dental erosion. 2008. Diagnosis, prevention and management of dental erosion. Int J Paed Dent. 18(1):29-38.

6. Stacey F, Heasman PA, Heasman L et al. Smoking cessation as a dental intervention - views of the profession. Br Dent J 2006; 201(2): 109-113

7. Raja A, Aukett J. Smoking cessation and the dental team. Dent Update 2006; 33(3): 175-176, 179-180, 183-184

8. Field EA, Brookes V, Tyldesley WR. 1992. Recurrent aphthous ulceration in children - a review. Int J Paediatr Dent 1992; 2(1): 1-10

9. Seow WK. Clinical diagnosis of enamel defects: pitfalls and practical guidelines. Int Dent J 1997; 47(3): 173-182

10. Mitchell L, Bennett TG. Supernumerary teeth causing delayed eruption - a retrospective study. Br J Ortho 1992; 19(1): 41-46

11. Andreasen JQ, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1972; 1(5): 235-239

12. Patrick DG, van Noort R, Found MS. Scale of protection and the various types of sports mouthguard. Br J Sports Med 2005; 39(5): 278-281

13. Child Protection and the Dental Team (COPDEND) 2006 www. cpdt.org.uk [Accessed Nov 2011]