Kids get the brush off

Media item: article

Date published: 11 September 2012

Subject: children's oral health

This page records the media item. The original article is the property of its publisher and is not reproduced here.

The underlying problem

Tooth decay is the most common chronic disease of childhood in Australia, and it is almost entirely preventable. A significant number of Australian children have experienced decay in their baby teeth by the time they start school, and dental conditions are among the leading causes of preventable hospital admission for young children — because treating extensive decay in a small child often requires a general anaesthetic. Protecting your child from dental disease and How does tooth decay develop? set out the mechanism.

None of that is inevitable. It is the product of a small number of habits, most of them established before the age of three.

When to start, and what to do at each age

Before the first tooth

Wipe the gums with a clean damp cloth after feeds. This is as much about establishing that something happens in the mouth every day as about hygiene. Baby teething: signs, symptoms and treatments covers what is happening underneath.

First tooth to age 3

Start brushing as soon as the first tooth appears — usually around six months, though the range is wide and late eruption is generally normal. The order of baby teeth is the sequence to expect.

Use a smear of low-fluoride children's toothpaste, a small soft brush, twice a day. How do I get my child to brush their teeth? and Kids' teeth cleaning tips are the practical guides, and the archive's own item on the same fight is Stop brushing battles.

On the first dental visit, two positions are in circulation. Smile Solutions recommends from age three — and sooner if there is any sign of decay, white or brown marks, or a family history of early decay. Widely used professional guidance recommends a first check by about the first birthday, or within six months of the first tooth. See Children’s Dentistry, which sets out both, along with First visit to the dentist and When should a child first visit the dentist?.

Either way, the purpose is not to find problems in a small child; it is to check development, look at habits and diet, and make the dental surgery an ordinary, unfrightening place before there is ever anything wrong. Children whose first visit happens because something hurts learn a very different lesson. Picking the right dentist for your child and Paediatric Dentists cover who sees them.

Ages 3 to 6

Move to a pea-sized amount of children's toothpaste. Encourage spitting; do not rinse with water afterwards — rinsing washes away the fluoride that would keep working. On choosing one, see Selecting a toothpaste: fluoride or non-fluoride.

An adult should brush or supervise brushing until at least age 7 or 8. The usual rule of thumb is that a child cannot brush effectively until they can tie their own shoelaces — it is a manual dexterity threshold, not a maturity one. Which toothbrushes do dentists recommend? is worth reading before buying one.

Start flossing where teeth touch each other, because a toothbrush cannot reach between them — see Is flossing really that important?.

Ages 6 to 12

The first permanent molars arrive at about age 6, usually behind the baby teeth without anything falling out first — which is why they are so often missed and so often the first permanent teeth to decay. They have deep grooves, and fissure sealants on them are one of the best-evidenced preventive measures available. See The role of fissure sealants in children's teeth and Who is a suitable candidate for dental sealants?. On the teeth being lost at the same time, My child has a loose tooth.

Move to standard family fluoride toothpaste from about age 6.

An orthodontic assessment identifies the small number of children who benefit from early intervention. Smile Solutions recommends this at around age 9 to 10; widely used professional guidance suggests around age 7 or 8. Most children need nothing done at either age. See When should I take my child to an orthodontist? and Children's Braces and Invisalign.

Teenagers

The risk profile changes rather than disappears: sports drinks, energy drinks and soft drinks, snacking, less supervision, and orthodontic appliances that make cleaning harder. See Are sports drinks linked to poor dental health in athletes? and Victorians, soft drinks and tooth decay.

A custom-fitted mouthguard for contact sport is worth the cost. Boil-and-bite guards fit poorly and provide substantially less protection, and a knocked-out or fractured front tooth in a fifteen-year-old is a lifetime of restorations. See Sport Mouthguards, Should my child wear a mouthguard? and A new mouthguard: chemist or dentist?.

Baby teeth matter, and this is the misconception that causes the most harm

"They're only baby teeth, they'll fall out anyway" is the single most damaging idea in children's dentistry.

Baby teeth:

Hold the space for the permanent teeth. One lost early lets the neighbouring teeth drift in and close the gap, so the permanent tooth arrives with nowhere to go — which is one of the common origins of crowding that later needs orthodontics. See Why do teeth shift? and What is malocclusion of the teeth?.
Are needed for eating and speech development.
Hurt when they decay, and abscess when they are left. Dental pain causes lost sleep and lost school — see Are dental abscesses painful?.
The last of them are not lost until around age 12. A decayed molar in a five-year-old has seven years to cause trouble.
Can damage the permanent tooth developing directly beneath. Infection at the root of a baby tooth sits right against the developing crown of its successor. Where the enamel itself has formed poorly, see My child has chalky teeth — now what?.

The habits that cause the damage

Frequency beats quantity. Every exposure to sugar produces an acid attack lasting 20–40 minutes. Constant grazing and sipping never lets the mouth recover. How does sugar affect your dental health? and Dental Health Week: protect kids from the sugar bandits cover this.

The specific patterns that do the most harm:

A bottle at bedtime containing anything but water. Milk, formula and juice all contain fermentable sugars, saliva flow falls during sleep, and the liquid pools around the upper front teeth. This produces a recognised and severe pattern of early childhood decay.
A sippy cup of juice or cordial carried around all day.
Fruit juice treated as healthy. It is sugar in solution with acid; whole fruit is not the same thing. Water and plain milk are the only drinks a child needs. See How does acidic food affect your teeth? and Six foods to avoid for healthy teeth.
Dried fruit as a snack. Sticky, retentive and concentrated — worse for teeth than most confectionery. The same logic applies at Halloween.
Sharing spoons and cleaning a dummy in your own mouth, which transmits cariogenic bacteria from carer to child — the same transmission described in Can you catch dental decay from someone else's toothbrush?.
Medicine sweetened with sugar given nightly and long-term — ask the pharmacist for a sugar-free formulation where one exists.

Fluoride, plainly

Fluoride toothpaste is the single most effective thing you can do. Melbourne's water supply is fluoridated, and water fluoridation remains the most cost-effective population measure available. See The benefits of fluoride and Fluoridated water: is it good for you?.

The balance to hold: too little fluoride means decay; far too much during the years teeth are forming causes fluorosis, permanent white or brown mottling — see What causes white spots on teeth?. That is why children's toothpaste is lower-strength, why the amount is a smear then a pea, and why a child should be taught to spit rather than swallow.

Store toothpaste out of reach. Children eat it.

The money, which is the part most people miss

The Child Dental Benefits Schedule provides Medicare-funded basic dental treatment — examinations, cleans, fillings, extractions, radiographs — for eligible children, up to a capped amount over a two-year period. See the CDBS page and How does the Child Dental Benefits Schedule operate?.

Eligibility depends on the family receiving certain government payments, and the child's age. The scheme is significantly under-claimed — a large share of eligible families never use it, usually because they do not know it exists.

Check eligibility through Services Australia or myGov. It covers basic treatment; it does not cover orthodontics — for what that costs, see the Price Guide and The cost of braces.

Victoria also provides public dental services for eligible children, and school dental programs operate in some areas.

Two things about fear

Dental anxiety is usually learned, and often inherited from a parent. The most useful things an adult can do are: do not describe your own bad experiences in front of the child, avoid words like "hurt", "needle" and "drill" in reassurance (children hear the noun, not the negation), and take them for check-ups when nothing is wrong, so that the surgery is a familiar place before it is ever a necessary one. See Combating dental anxiety in children, How Smile Solutions can help manage your child's dental anxiety and Dental Anxiety.

A knocked-out permanent tooth is an emergency. Handle it by the crown, not the root; if it is dirty rinse it briefly in milk or saline; put it back in the socket immediately if you can, otherwise store it in milk — saliva or saline if there is no milk, and plain water only as a last resort, because the one real absolute is never to let the tooth dry out — and get to a dentist straight away. The variable that matters is how long the tooth spends out of the mouth and dry, not the total time elapsed. A knocked-out baby tooth is not replanted — doing so can damage the permanent tooth developing beneath — but should still be assessed. See A knocked-out tooth, A knocked-out baby tooth: what do I do? and Emergency Dentistry.

Common questions

How bad is this actually, in numbers?

The ADA's figures give the scale the phrase "most common chronic disease of childhood" hides. Drawing on the Children and Young People Oral Health Tracker, it reports that "nearly 11 (10.8) in every 1,000 children aged 5-9 are hospitalized for potentially preventable problems due to dental conditions", and that "for Indigenous children this rises to 14.3 per 1,000 children." It also found "only 56% of children visit the dentist before age 5." On decay itself: 34% of children aged 5–6 have experienced decay in primary teeth and 27% aged 5–10 have untreated decay in primary teeth. Those hospital admissions are mostly general anaesthetics for extensive decay in small children.

My child only saw a dentist because something hurt. Have I already got this wrong?

No, and you are in the majority. The ADA reports that "one third (32%) of parents reported their child's first visit was for pain or a problem", and in a separate survey of 25,000 adults that 46% of first visits were for a check-up and 33% for pain or a problem. Its own comment on why that matters is worth quoting: "a first dental visit for a tooth ache may create a negative first experience. We don't want that to be your child's introduction to the dentist. It's important to see the dentist even if you think your child's teeth are healthy." The repair is simply the next few appointments — a check-up when nothing hurts, so the room stops being the place where pain happens.

Juice is made of fruit. Is it really the same as soft drink?

For teeth, close enough to matter. The World Health Organization's definition of free sugars — the ones that drive decay — expressly includes "sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates" alongside added sugars. Its recommendation is that limiting free sugars "to less than 10% of total energy intake – and ideally to less than 5% – minimizes the risk of dental caries throughout the life course." Whole fruit is different: the sugar is inside intact cell walls and comes with fibre and chewing.

The gap between knowing and doing is the striking part. In the ADA's survey, 87% of parents said they were aware these drinks lead to tooth decay — and 27% of children had fruit juice every day, with a further 38% between two and five times a week.

How much does the Child Dental Benefits Schedule actually pay, and what will it not cover?

Services Australia sets it at "up to $1,158 for each eligible child over 2 calendar years for basic dental services", with the cap "indexed yearly on 1 January". Basic covers "check-ups, X-rays, cleaning, fissure sealing, fillings, root canals, extractions."

Three limits catch families out. It does not cover "orthodontic dental work, cosmetic dental work" or "any dental services in a hospital" — so the general anaesthetic route is outside it. Unused money does not accumulate: "if you don't use the full amount within the 2 calendar years, you can't use the remaining funds." And there may be "item or time restrictions" on particular services, which Services Australia advises checking with the dentist before starting. Eligibility and the cap are theirs to set and they change; confirm through them or myGov.

A tooth was knocked out at sport and we did not get to a dentist for an hour. Is it too late to save it?

Probably not, and this is the most misunderstood point in dental first aid. The variable is extra-oral dry time — how long the tooth spent out of the mouth and dry — not the total time since the accident. A tooth kept moist for an hour is in a very different position from one that sat on a bench for twenty minutes.

The International Association of Dental Traumatology's guidance is that "the decision to replant a permanent tooth is almost always the correct decision even if the extra-oral dry time is more than 60 minutes." So go, and take the tooth. The storage order, best first: back in the socket, then milk, then a balanced salt solution such as HBSS, then saliva, then saline, and plain water only as a last resort. Handle it by the crown. A knocked-out baby tooth is never replanted — it can damage the permanent tooth forming beneath it — but still have the child seen. See Children’s Dental Emergencies.

Practical details

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000. Phone 13 13 96, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment. See also Our Location and Contact Us.

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This page records a published article and its date, with general information. It is a 2012 archive record rather than current clinical advice, and guidance, fees and services change — use the current service pages linked above. It is not a diagnosis or a treatment plan. Eligibility for the Child Dental Benefits Schedule is determined by Services Australia and changes; confirm current eligibility with them. Third-party published content is not reproduced.

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