Children's dental health: Paediatric dentists on how to avoid tooth decay  

One in three children has dental decay by the age of five. It's vital parents keep a close eye on their little ones' diet and practise oral hygiene from the time they cut their first tooth, say experts 

Dental decay affects one in three children by the time they’re five years old.

By the time children see paediatric dentist Dr Jennifer McCafferty, they won’t just have a problem with one tooth. “They’ll have multiple teeth in bother. I’ll see quite a number of cavities in the one child,” says McCafferty, who works at Citygate Specialist Dental Clinic, Cork.

McCafferty gets referrals from family dentists when patients are very young — and when the “extent of their dental needs” requires her services. “A large volume of children I see are treated under general anaesthetic in hospital. I see a lot of children with autism or where cooperation is limited.”

She has seen dental decay in children as young as one year, and in a typical week, she sees a significant number of three- to six-year-olds.

According to the study Fluoride And Caring for Children’s Teeth, 2013-17, which took place in primary schools in Dublin, Cork, and Kerry, dental decay affects one in three children by the time they’re five years — and it affects four in 10 children in their permanent teeth.

McCafferty wishes parents knew about the risk factors for childhood tooth decay and that they’d seek preventive care earlier.

She says parents can be quite surprised to find their child has dental issues they never suspected. “Until a dentist does a thorough examination, early cavities won’t be identified. Parents won’t see it by brushing their child’s teeth.

“So they won’t notice until the child develops pain and by the time that happens — and there’s infection — the cavity has been there a while. We’re catching it quite late.”

She says children should see the dentist by their first birthday so that parents can be advised about the pitfalls — particularly around diet but also in relation to tooth-brushing habits — that would predispose the child to dental decay.

“Management would then be a lot less complex, more straightforward. Children wouldn’t be missing time from school, parents wouldn’t be missing time from work and you’d have a less upset child,” says McCafferty, who has seen extreme cases where infection spreads from tooth to surrounding soft tissues in the face and the child becomes generally unwell and needs hospitalisation.

Dentist visits

Findings from the National Longitudinal Survey of Children in Ireland (Growing up in Ireland) show that less than 5% of children aged three years visit the dentist. Parents think this is a good thing but it isn’t, says Dr Dympna Kavanagh, chief dental officer at the Department of Health. “We want young children to establish a dental ‘home’, so they become familiar with going to the dentist when they don’t have a problem. So when they do have a problem, they won’t have any fear about going.”

Bringing your small child to the dentist early builds positive associations for the child, says McCafferty. “So going to the dentist is actually fun. They’re sitting up in the chair, getting their teeth counted and then getting a little sticker. Instead of a first visit where they’re in pain, the dentist’s poking at the [affected] tooth, they’ve had a few sleepless nights and everyone’s tired and stressed.”

Understanding the biology of the mouth and its role in digestion helps us see why some dietary habits are protective of children’s teeth — and others aren’t.

Dr Siobhán Lucey, senior lecturer in paediatric dentistry at UCC and consultant paediatric dentist at Cork University Dental School & Hospital, says it’s normal and perfectly healthy to have bacteria in our mouth. “The oral cavity is part of our gut,” she explains.

But some decay-inducing bacteria can metabolise free sugars to produce acid. “This lowers pH level in the mouth and causes mineral to be removed from tooth enamel, resulting in a cavity developing in a tooth. If there’s a high frequency of sugar intake, the balance tips in favour of dental decay.”

Lucey highlights saliva’s beneficial effect in the mouth. “It keeps teeth, gums, and the skin inside the mouth healthy. It keeps all these tissues lubricated and helps in keeping pH neutral. It helps to remineralise enamel after a sugar attack.”

She says children and adults can help maintain saliva’s protective role by remaining hydrated throughout the day.

Obvious culprit foods that put children at risk of tooth decay include chocolate, sweets, cakes, biscuits, cordials/squash, fizzy drinks, juices. “We suspect really sticky, chewy sweets may be the most harmful, but any sugar-containing food or drink can be as harmful as the next.”

Among these Lucey includes dried fruits, for example, raisins, yogurts with high sugar content, yogurt-covered/flavoured rice cakes, smoothies, many cereals, and milk alternatives, a lot of which are sweetened.

She recommends instead plain/natural/Greek yogurt with chopped-up fruit added in and porridge and low-sugar cereals (less than 5% added sugar) as breakfast options. Safe snacks would include popcorn, chopped veg, plain rice cakes, and corn cakes.

There has been a significant demand for dental services for children since the pandemic. Due to HSE staff redeployment during that period, fewer dental appointments were offered in 2020 and 2021. “It’s also reasonable to assume — during what was a challenging time for all of us — children got out of their normal routine,” says Lucey.

“Many schools have a healthy lunchbox policy and when children were at home, away from that structure, they may have increased their frequency of snacking.”

Warning that children who snack frequently are at higher risk of tooth decay, she says food and drink-free time is vital for healthy teeth. “Frequent snacking on sugar-containing food means an acid attack on our teeth. The pH will drop for about 40 minutes and that’s when the decay process can occur. The more regularly we allow this to happen, the more likely a cavity is because pH is low for most of the time,” she says, adding that the critical point at which decay can happen is when pH drops below 5.5.

Golden hour

Lucey suggests five food intakes daily for children: Breakfast, lunch, dinner, and two snacks, though water and milk are an exception and can be taken outside of the five. “It’s good to have a golden hour of food-free time before bed — once we sleep our saliva is naturally reduced, so children would have less ability to neutralise an acid attack.”

Other tooth-friendly tips include having treats as part of/at end of a meal (prevents extra acid attack when treat is taken separately), eating a bite of cheese post-treat, which helps neutralise acid in the mouth, and eating whole fruit rather than blending/liquidising it into juices/smoothies.

“The cell wall of fruit contains sugar. When liquidised, it’s released and becomes more readily available for bacteria. Also, when we chew whole fruit, saliva-production is stimulated, which is protective.”

The HSE recommends that all drinks, other than breastfeeds, should be taken from a cup or beaker by the age of one. At night in particular, milk sugars from a bottle can start tooth decay. “This is because they remain in baby’s mouth undisturbed because normal salivary production reduces at night,” says Lucey.

A myth still prevails that baby teeth aren’t important, whereas, says Lucey, they’ve an important role in function (eating, speaking), for aesthetics and for children’s self-esteem. “They also hold onto space for the adult teeth, so they help guide adult teeth into position.”

Until they’re two years old, children’s teeth should be brushed, using water. From age two, use fluoride toothpaste and make sure brushing’s done twice daily, including before bed. “Encourage children to spit out toothpaste afterwards, but not to rinse. Letting the residue remain allows the fluoride to have more benefit,” says Lucey.

The National Oral Health Policy, Smile agus Sláinte, was published in 2019. Access to early oral healthcare, especially advice and prevention, was identified as a priority action. Again, the pandemic has delayed implementation of the policy, though the Department of Health says it’s now a priority to “ensure implementation proceeds in earnest”.

A major aim is to minimise the necessity for general anaesthesia for tooth extraction. “We currently have 7,000 children waiting on general anaesthetic for removal of teeth,” says Kavanagh.

“We can’t measure how many nights’ sleep are lost, how many schooldays — and all the other impacts of pain and decay.”

It’s high time, she says, that we move from a system of ‘diagnosing and treating’ children’s dental health — and instead embrace a ‘proactive and preventative’ approach.