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Tooth Talk
Teaching your child proper “mouth” care will lead to better overall health
By Marguerite DiMarco, Ph.D., MSN, CPNP
Dental decay is chronic and prevalent in children — five times more common than asthma. The rate of dental decay in young children has not decreased over the past ten years, despite improvements for older children. Because young children visit their health care provider more than they see their dentist, it is important that health care providers are knowledgeable about dental decay, disease prevention and family treatment. Here are specific prevention and intervention strategies recommended by the American Academy of Pediatrics (AAP) and by the pocket guide Bright Futures in Practice: Oral Health.
Diet and Oral Health
Providing dietary guidelines for the best oral health in children should be part of general health counseling. The recent policy statement from the AAP on prevention of pediatric overweight and obesity stressed concerns about health problems in overweight children, including heart, growth and mental health problems, and the importance of promoting healthy eating. Sugar from foods, juice and sugar-sweetened beverages increases the risk of tooth decay. Cavity risk is greatest when sugars are eaten often and remain in the mouth for long periods. Sucrose is the most decay-causing sugar, because it can cause germs to stick to teeth. Although starch-rich foods pose a lower cavity risk, cereals, crackers, cookies, potato and corn chips also cause tooth decay as they stick to teeth. Human milk alone does not promote tooth decay, but breastfed infants are at risk for cavities when they have sugary liquids, foods with sugars and starch-rich foods.
 Parents and caregivers should decrease sugar intake in foods and drinks. Here are recommendations for reducing the risk of cavities and ensuring the best possible health:
• Breastfeed infants during the first year of life and beyond, as desired by mother and baby.
• After nursing, remove the breast from a sleeping infant’s mouth. Clean gums and
teeth after feedings and before bedtime with a nonfluoride tooth and gum cleaner.
• Don’t allow a baby/toddler to sleep with a bottle. Any bottle taken to bed should contain only water.
• Limit sugary foods and drinks to mealtimes, and don’t allow a child to drink from a sippy cup/bottle all day long.
• Avoid carbonated beverages such as soda pop and juice drinks, which contain high fructose corn syrup and citric acid that breaks down the tooth enamel.
• Encourage children to drink only water and milk between meals.
• Offer children fruits, and avoid fruit snacks and chewy, sugary foods.
• Limit the intake of 100-percent fruit juice to no more than four ounces per day.
• Support eating patterns consistent with U.S. Department of Agriculture MyPyramid guidelines (www.mypyramid.gov).
Best Use of Fluorides
Fluoride — a naturally occurring element — has been important in decreasing cavities. Fluoride is most effective if it is applied directly on the teeth. It can be added to your water supply (check and see if your community has fluoride added to the water). Water fluoridation is a cost-effective way of preventing cavities, with the lifetime cost per person equaling less than the cost of one cavity filling. Fluoridated water is the cheapest and most effective way to deliver no cavities benefits to communities.
Professionally applied topical fluorides (PATFs) are most effective in preventing cavities and must be applied at regular intervals. PATFs include gel, foam, in-office rinse and varnish, and are safe and effective. Varnishes have the advantage of sticking to the tooth surface, decreasing the possibility of swallowing and increasing the amount of contact between the fluoride and tooth surface. In temporary teeth, varnish effectiveness (measured by percent of cavity reduction) ranges from 30 percent to 63.2 percent.
Finally, self-administered fluorides, including dietary fluoride vitamins and fluoridated toothpaste, have proven effective, providing the fluoride is used in correct amounts. In children and adolescents, fluoride toothpastes, mouth rinses and gels reduce dental cavities to a similar extent.
The decision to use fluoride therapy must balance the risk of cavities against that of enamel fluorosis (spotting of the developing enamel of the teeth caused by too much fluoride swallowing). Children at increased risk for cavities should use more fluoride therapy. Cavity risk and sources of dietary fluoride (e.g., water supplies, toothpaste) should be considered before taking fluoride therapies. Parents using bottled water may deprive their infant or child of the fluoride in tap water. Drinking fluoridated water (via a community fluoridated water source) to prevent tooth decay is preferred. Families using bottled water should drink a brand in which fluoride is added at a concentration of approximately 0.7 to 1.2 mg/L (ppm). Giving an infant six months or older fluoride supplements should only be done as recommended by a dentist or other provider, based on the child’s risk of developing tooth decay and the known level of fluoride in his drinking water. With topical applications of fluoride varnish, there is less of a chance a child will develop a fluorosis or overdose of fluoride as the varnish sticks to teeth and is not swallowed.
Tips for Promoting Oral Health
 • Teach mouth hygiene. The AAP and the AAPD (pediatric dentists) recommend making an appointment for your infant’s first dentist visit by 12 months, thereby establishing a dental home. Children should brush their teeth at least twice daily, with a parent watching and assisting until age seven. For very young children under two who have an increased cavity risk, use a pea-sized amount of toothpaste or an amount equal to the child’s fifth-digit fingernail (small smear). Begin flossing as soon as teeth are in contact with other teeth and when surfaces of touching teeth can no longer be cleansed with a toothbrush. For children ages two and above, brushing teeth with no more than a pea-sized amount of fluoridated toothpaste twice a day (after breakfast and before bed) and making sure the child spits out the tooth paste after brushing but not rinsing with water, is recommended. The small amount of fluoridated toothpaste that remains in the mouth helps prevent tooth decay. For effective plaque removal, make sure you brush the child’s teeth. Because brushing requires good fine motor control, young children cannot clean their teeth without help. After children improve their fine motor skills (e.g., the ability to tie their shoelaces) — typically by age seven or eight — they can clean their teeth effectively, but with parental supervision.
• Realize that some sucking habits are harmful. Use of pacifiers in the first year of life may prevent sudden infant death syndrome, but sucking habits (e.g., pacifiers or thumb/fingers) may be associated with dental problems, depending on their frequency, duration and intensity. Some problems persist past stopping the habit. Professional evaluation is needed for sucking habits that continue beyond age three. Your health care provider may be able to make your child stop by talking about the problems the habit causes. A mitten or sock placed on the hand at night can also be effective. Stress to the child that this is not a punishment. You can offer a reward for discontinuing the habit within a specified time period (the reward must be good for the child). Charting small successes, such as placing colored stars on a calendar for each day the child does not suck a pacifier or thumb, may help. Finally, your child’s dentist can place an object in the mouth that interferes with sucking.
• Follow age-appropriate rules for preventing dental injury. Cover sharp corners of household furniture at your toddler’s walking level, be aware of electrical cord risk for mouth injury and always use car safety seats. Properly fitted mouth guards are a must for children during sports that carry a risk of oral injury. If a permanent tooth is knocked out, you should take the following steps:
1. Find the lost tooth.
2. Hold it by the crown (top part) only, not by the root.
3. Rinse it under cold water gently if the root is dirty, but do not scrub.
4. Reinsert it into the socket quickly, making sure that the front of the tooth is facing you.
5. Take the child to the dentist immediately. If it is not possible to replace the tooth, place it in a container of water or in a cold, wet cloth. Because of the danger of damaging the underlying permanent teeth, never attempt to reinsert a lost baby tooth. If a tooth is fractured or chipped, the parent or other responsible adult should do the following: Rinse the child’s mouth with water, apply cold washcloths to the cheek to reduce swelling and take the child to the dentist immediately.
•Practice dental care. Visit the dentist twice a year, brush teeth thoroughly twice a day with fluoridated toothpaste and floss daily. Once an infant is born, avoid testing the temperature of the bottle with the mouth, sharing utensils (e.g., spoons) or cleaning a pacifier or a bottle nipple orally. This will help prevent the spread of germs that cause tooth decay to your child via saliva.
Marguerite (Peg) DiMarco, Ph.D., MSN, CPNP, is an Assistant Professor at The University of Akron, College of Nursing, where she has coordinated the Pediatric Nurse Practitioner Program since 1996.
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