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Оглавление3EDUCATING PARENTS: ORAL HYGIENE AND PROPHYLAXIS
“The older the children, the greater the worries.”
ANONYMOUS
This chapter briefly addresses issues that, based on experience, frequently preoccupy parents and which they often ask about in the explanatory discussion with their dentist. First and foremost among these is oral hygiene and prophylaxis. Parents want to know what they should be doing to prevent caries. That being said, not all parents are as motivated as the next, so we as pediatric dentists need to do our best to advocate for the oral health of our young patients.
ORAL HYGIENE
There is a great deal of uncertainty among parents about oral hygiene for babies and infants. The most common elements of uncertainty include when to start oral hygiene, when and what kind of toothpaste to use, and what to do if the child struggles. It is our job to give parents answers and encourage them. This section includes tips about oral hygiene, divided into age groups.
Infants and toddlers (0–3 years)
Brushing the teeth often works well in babies without any problems. They open their mouths as a reflex when lying on their backs in a slightly overstretched position and, as babies will explore everything with their mouths in the oral phase, a toothbrush can be a welcome diversion. Babies and infants can either be laid on the lap with their head on their parent’s knees (Fig 3-1a) or on a changing table so that the parent can brush their teeth (Figs 3-1b and 3-1c).
Fig 3-1 Infant tooth brushing. (a) The child lies on the parent’s lap. With this positioning, really good brushing can be done, especially with little children. (b and c) Brushing an 8-month-old baby’s teeth on a changing table.
Unfortunately, this phase comes to an end with some children or there are phases when oral hygiene is more difficult to carry out. Then parents all report the same thing: the little ones cry, resist, and thrash about. We should encourage parents in these phases to press on caringly but consistently with what daily oral hygiene involves. In the author’s opinion, giving up and skipping brushing cannot and must not be an option. We can be supportive with tips to simplify brushing and prevent possible refusal:
• First, parents can naturally get babies used to mommy and daddy wanting to take a look in their mouth. Using fun gloves specifically designed for this purpose, they can massage the alveolar ridge, for instance, which also helps prevent teething troubles. There are also special dental wipes with xylitol that can be used from day 1 to wipe the baby’s mouth and accustom them to a routine. They taste good and reduce bacteria at the same time. The earlier children get used to it, the easier it will be to maintain this ritual.
• Babies can be given toothbrushes as marvelous teething aids to play with (under supervision, of course). As soon as the infant starts walking, they should not be allowed to walk or run around with their toothbrush in their mouth. They can suffer serious injuries when they fall.
• Once the first tooth actually erupts, it is advisable to have two toothbrushes: one to distract and occupy the child and one for the parents to brush their child’s teeth.
• The teeth should be cleaned twice a day. Whether with fluoride toothpaste or without is dependent on the information provided by the parents in the fluoride history (see section “Fluorides”).
• Parents should be cautious in the anterior dentition around the labial frenum. In nearly all infants this extends deeply. Hence, if parents clean the front teeth horizontally and bump up against the labial frenum, this might be painful for the child. The lift-the-lip technique can be used to avoid this. It involves gently pulling the top lip upward with one hand as the anterior teeth are being cleaned with the other hand (see Fig 3-2).
• Of course, brushing the teeth can be accompanied by singing, little hand puppets, or similar distractions. There are no limits to people’s creativity.
• It is important to establish brushing as a daily ritual. The earlier and the more confidently this is achieved, the faster more difficult phases can be overcome.
• It is not about sticking to a schedule. In the author’s opinion, how long it takes with babies and infants is initially of secondary importance; much more important than time is that all existing teeth are thoroughly cleaned from all sides.
• Often the first primary molar has already erupted when the primary canine starts to erupt. If the molar is brushed normally during this time, the eruption site of the canine might be painfully manipulated. For that reason, it is recommended that the primary molar be brushed crosswise.
• The author recommends brushing children’s teeth while they are lying down. On the one hand you have better lighting for the maxillary arch and therefore a better view, and on the other hand this position is a good desensitizing method for future visits to the dentist.
Fig 3-2 Lift-the-lip technique for atraumatic cleaning of the labial surfaces of the maxillary anterior teeth.
WHEN BRUSHING IS A STRUGGLE
At routine checkups, many parents report that brushing their child’s teeth is a daily struggle and they are helplessly seeking tips and tricks to avoid a “wrestling match.” What worked entirely fine when the child was an infant has suddenly become an ordeal for all concerned. Parents do not always manage to motivate their little ones to brush or have their teeth brushed with patience and fun by including play. Especially with the youngest children, discussions or positive reinforcement with different reward systems are only possible to a limited extent.
Nonetheless, a solution must be found, because not brushing for days or weeks is not an option in terms of the child’s well-being and oral health. The solution is simple: Parents just have to persevere. The more calmly and confidently parents act, the quicker this period of refusal from children is over. Refusal to brush may be a child’s way of expressing desire for independence, which can turn other everyday situations (eg, diaper changing, hair washing, nail cutting, or buckling up in the car) into minor challenges. It is important for parents to understand that this autonomy phase is a completely normal developmental step after the first birthday. It is crucial that children get plenty of praise when they cooperate. This daily ritual does not have to be a struggle. It must be made clear to parents that they alone (and not the child) have to decide what is necessary for their child’s health. If parents cannot manage to brush their infants’ teeth for as long as a minute, how is a dentist meant to carry out a filling treatment?
Preschoolers and kindergartners (3–6 years)
Children of this age group will also have phases now and again when brushing is difficult. The cause of caries can easily be explained in an age-appropriate way to this age group—unlike babies—by using stories; it can also be made clear why cleaning their teeth is so important. This is the perfect time to institute sticker charts at home for positive reinforcement. This is a very good way of tackling difficult times and establishing daily oral hygiene as a positive way to close the day. A few more tips:
• With little children it is advisable to do follow-up brushing as the parent. Most toddlers and young children will want to brush their teeth themselves, but they do not have the dexterity or patience to do the job well. The lift-the-lip technique can still be used with this age group to atraumatically clean the anterior teeth (Fig 3-2). Regardless of whether a manual or electric toothbrush is used for follow-up brushing, ultimately only one thing counts: getting rid of the plaque! For the same reasons as mentioned earlier, it is recommended that the teeth are brushed while the child is lying down.
• Dental floss should be used for the interdental spaces in mouths with crowding and a complete dentition. There are child-themed floss holders for this purpose, which make it easy for flossing to become part of the routine (Fig 3-3).
• Parents should make sure their children have a mirror in the bathroom at the right height for them to be able to see themselves. Parents are often unaware that it is helpful for little ones to see themselves when brushing.
• On the question of whether a manual toothbrush or an electric toothbrush is better, the author recommends choosing the one where the motivation of the child is highest. It is important that children are shown the correct brushing technique for their toothbrush and that they are regularly checked to make sure that they are using it correctly. The author has also found that a constant change between manual and electric toothbrush usually results in a poorer cleaning result.
Fig 3-3 Dental floss is important if there is crowding, especially once molar eruption is completed.
Schoolchildren (6+ years)
Many parents think that once their child starts school, oral hygiene is now a given. But that is not the case. Parents should perform follow-up cleaning of their children’s teeth until the child has reached the age of 9 or 10 years. Only then are their fine motor skills so fully developed that they are largely able to do brushing at home by themselves. In the individual prophylaxis sessions at the dentist’s office, specific brushing training can be performed, and again it is necessary to decide which is more appropriate for the patient: a manual or an electric toothbrush. At home parents can continually check the success of brushing with staining solutions or tablets (Fig 3-4). Visual feedback is far more successful with children than lengthy explanations.
Fig 3-4 Illustration of plaque- disclosing solution that turns plaque pink for easy visualization. (Reprinted from Terry DA. What’s in Your Mouth? Chicago: Quintessence, 2013.)
Parents also need to be made aware of the eruption of the first and second permanent molars because no primary tooth will fall out prior to their eruption. It is very important to brush these permanent teeth crosswise during their long eruption phase because the bristles of the toothbrush will not reach their surface if the tooth has not yet reached the occlusal level.
Teenagers
In this sometimes very tricky phase when teenagers are resistant to advice, it can occasionally be very difficult to motivate patients. Good oral hygiene is crucial, especially for children with braces. If the oral hygiene is poor and the child is wearing braces, then the orthodontist should consider taking them off. Besides that, parents often have to be reminded to come back to the family dentist after orthodontic therapy. Many parents think that the orthodontist also takes care of the prophylaxis, but that is not the case.
Many parents come into the practice with the words ”Please have a serious word with my child. He or she won’t brush.” The author refuses to do so in her role as a dental practitioner. It is not our job to raise our patients but to motivate them through positive reinforcement. What is the point of giving patients a good talking-to every 6 months if oral hygiene at home goes down the drain in between? This is why it is important to get the parents on board as allies during this phase. Regular individual prophylaxis measures and, if necessary, professional teeth cleaning can prevent dental and periodontal diseases in this phase of life. The highest priority, however, is to remotivate parents and adolescents so that oral hygiene at home is ensured between recall appointments.
PROPHYLAXIS
It is essential when treating pediatric patients to address the cause of caries and, ideally, eliminate it completely. Pediatric dentistry is not just a symptomatic “drill and fill” procedure but far more than that. Because each child is different, caries is multifactorial, and there is no panacea that works for every patient, we need to actively seek out discussion with our pediatric patients and their parents, reconsider our strategies, remotivate both child and parent, reassess our approaches, and, to the best of our knowledge and belief, choose and adopt an individual prophylaxis strategy for each particular patient. After all, what works wonderfully for one patient may fail completely with the next.
A huge range of prophylactic measures and products are available to us (dietary and drinking advice, professional tooth cleaning, at-home hygiene instructions, sealants, fluorides, etc), and it is our job to make use of these options in an individualized way according to the patient’s needs. While many of the elements of dental prophylaxis are performed by dental hygienists or dental assistants, we as dentists have the responsibility to ensure that parents and children are continually remotivated and informed. We have to decide on and arrange regular recall intervals. It is proven that practices with a functioning recall and prophylaxis system have decreased incidence of caries and improved satisfaction among patients, not to mention that a well-implemented recall system is economically viable. Especially for families with difficult social or personal circumstances, it is extremely important to secure a recall schedule. Often times these children must be given extra instruction and motivation for carrying out their own oral hygiene because these steps are not being implemented rigorously by their parents. Unfortunately, caries is still a social condition.
Special equipment or materials are not necessarily required for prophylaxis in childhood. It is more important to get the parents on board and simplify and shorten the existing prophylactic steps so that they succeed in a child-appropriate way. This requires a colleague with a knack for dealing with children as well as some specific further training in this field. Prophylaxis for our young patients should be fun, pain-free, and not take too long.
TIP FOR PROPHYLAXIS WITH CHILDREN
It is important, especially in pediatric dentistry, to make compromises without losing sight of the final goal. If a child does not want to have his or her teeth cleaned, it often works if the assistant uses their electric toothbrush instead of the prophy angle. Even the child’s own toothpaste can be used to clean the teeth. The main goal is that the plaque is removed so that the fluoride varnish can be applied and work. There are also inexpensive, child-friendly materials that improve compliance (eg, prophy angles that look like animals, flavored fluoride varnish, colored gloves, masks with painted faces). Sometimes it’s the little things that make all the difference.
Talking to parents
Sometimes the discussion with parents is a greater challenge than treating their children. This is partly due to a generation of parents who are confused, for instance, because of the widely varying sources of information or who increasingly question our scientifically based measures. Another factor is that the timing of the visit to the dentist may be unfavorable—for instance, if a strong and acute need for treatment already exists.
It is not always easy to convey sometimes very extensive information to parents in a focused, concise, and understandable manner so that they are able to follow the advice when they get home. A lot of parents only remember the last three sentences of a far-ranging discussion with the dentist. Why is that?
On the one hand, a visit to the dentist is stressful for many parents. Not only because they have to get one or more children there on time and they have to cope with the waiting time and any boredom that may be building up, but because visiting the dentist is associated with stress and anxiety for many parents themselves, and now they are managing the anxiety of their children as well. All these factors can diminish parents’ attention during an extensive explanatory discussion. This is why it is so important to keep the discussion brief and individualized, for example, based on the completed medical history form. A good method is to check the completed medical form for risk factors (eg, frequent juice drinking or oral hygiene that is performed only by the child) and mark them before we retrieve the child from the waiting room. Then we can concentrate on the risk factors and age-appropriate facts to discuss with the parents rather than telling them information they do not need at this point. The main goal should be to gain the loyalty of future parents, young parents with their babies, and the children themselves right from the very beginning in order to accompany them into a healthy life. Children are not able to take responsibility for their own oral hygiene—we have to get the parents on board from the very beginning. This is the only way we can monitor and influence children’s oral health, which is an integral part of any healthy physical development.
Now and then parents are profoundly confused because they get contradictory advice from midwives, pediatricians, dentists, and, last but not least, from the Internet. This is why it is all the more important for the dental team to give consistent advice as the authority responsible for dental health.
Fluorides
Fluorides are the most important pillar of caries prevention. They are safe in the concentrations we use and prescribe, their action has been repeatedly proved scientifically, and in our dental practices we see the positive effects of prophylaxis and treatment with fluorides every day. In the dental practice, the medical history form should include questions about possible sources of fluoride (toothpaste, supplements prescribed by a pediatrician, mouthwashes, fluoride water intake) and the frequency of their use. Parents must be told about the consequences of avoiding fluoridation (increased caries risk) and about the consequences of overdosing (fluorosis).
The American Academy of Pediatrics recommends that fluoridated toothpaste be used for all children starting at tooth eruption.1 Only a smear (the size of a grain of rice) should be used to the age of 3 years, after which a pea-sized amount is appropriate until age 6 (Fig 3-5). These small amounts may reduce the risk of fluorosis, according to the American Academy of Pediatric Dentistry (AAPD).2 The teeth should be brushed twice a day. Furthermore, professionally applied fluoride varnish is recommended every 3 to 6 months starting at tooth emergence.
Fig 3-5 Examples of a smear (a) and pea-sized amount (b) of toothpaste.
Water fluoridation levels are also important. Each city, state, and county all have different levels of fluoride in the water, so it is advisable to contact your state or city water supply to check these levels. If the water is not fluoridated or insufficiently fluoridated, or even if the child simply does not drink it, fluoride supplements are recommended (Table 3-1). Fluoridated water should be used to mix formula for babies who are bottle-fed. The recommendations for fluoride administration at home and in the dental practice for high-risk children are given in chapter 7.
TABLE 3-1 Dietary fluoride supplementation schedule based on water fluoridation levels
| Age | < 0.3 ppm F | 0.3–0.6 ppm F | < 0.6 ppm F |
| Birth to 6 months | 0 | 0 | 0 |
| 6 months to 3 years | 0.25 mg | 0 | 0 |
| 3 to 6 years | 0.5 mg | 0.25 mg | 0 |
| 6 to at least 16 years | 1 mg | 0.5 mg | 0 |
If parents simply want to brush fluoride-free, they must be told about the increased risk of caries. It is indeed a fact that thorough oral hygiene and adequate caries prevention are possible even with fluoride-free toothpaste. As far as the author is concerned, there is no use trying to convince absolute fluoride opponents. However, it should be made absolutely clear that other caries-preventive measures (especially reducing daily sugar intake) must be taken to successfully prevent caries.
Along with careful oral hygiene, reducing sugar consumption is the only really efficient measure in prophylaxis without fluorides. Admittedly, parents easily underestimate what is meant by the term “sugar reduction.” The World Health Organization recommends maximum daily consumption of free sugars of 10% relative to total calorie intake. To achieve caries reduction, a reduction to 5% is probably required; that is equivalent to a total sugar quantity of 15 g for children.3 For comparison, one can of Coke contains approximately 35 g sugar, and one serving of the average breakfast cereal we find on most tables has about 10 g of sugar. These figures can make it clear to parents how difficult it is to reduce the quantities of sugar consumed so sharply that a caries-preventive effect is really noticeable. In other words, caries prophylaxis is possible without fluoride, but it is very difficult for most of the families we treat.
GRINDING TEETH
Many parents will tell you about the grinding sounds coming from their children, primarily at night. Prevalence rates in the literature range from 6% to 50%, which illustrates the inconsistent nature of the studies on this subject.4 Some natural abrasion of the primary teeth is physiologic as part of the dynamic growth and development process and may even be necessary to ensure proper jaw growth and physiologic alignment of the 6-year molars.5
In extremely rare cares, however, primary teeth exhibit levels of attrition that require treatment. In a review, Restrepo et al wrote that the available literature did not support demands to treat bruxism in children.6 Nevertheless, there are studies that provide evidence of pathologic causes of nocturnal bruxism. In a study from 2009, Serra- Negra et al discovered that children exhibiting certain personality traits (a high degree of responsibility and neuroticism) have a higher rate of nocturnal bruxism.7 DiFrancesco et al reported that children’s nocturnal tooth grinding significantly improved after tonsillectomy and adenoidectomy.8 This shows that nocturnal grinding can also be caused by myofunctional imbalances; the reasons for this can be various (eg, mouth breathing, adenoids, tongue-tie, etc) and must be examined.
If the levels of attrition are extremely high, dentists should carry out myofunctional diagnostics, check for tongue-tie, and, if necessary, consult an ENT (ear, nose, and throat) physician in an interdisciplinary approach to exclude any narrowing of the upper airways. Behavioral therapy measures for older children (stress reduction) are also a possibility. It is important to understand that tooth grinding in the permanent dentition can no longer be classified as a physiologic part of the growth process.
TEETHING
Teething is a common concern for parents because it results in lack of sleep for the whole family as well as various side effects during the developmental stage. While infants are teething, parents often report issues such as red cheeks, raised temperature or fever, diarrhea, tearfulness, increased salivation, nonspecific skin rash, increased cough, and general clinginess or whiny behavior. There are various measures that parents can take to relieve their child’s teething pains and these unpleasant side effects. Parents are often grateful for tips because they lessen their own sense of helplessness in dealing with an overtired, unhappy baby.
As a preventive measure, parents can regularly massage their infant’s gums with special teething gloves and mittens. Because this oral phase begins within the first year of a child’s life, most infants will allow these sorts of manipulations in the mouth without difficulty. These aids ensure that the gingiva is well perfused and, as a positive side effect, babies become accustomed early to oral hygiene rituals they will experience later.
Depending on the child’s age, parent preference, and the severity of the problems, mechanical aids or pain-relieving products can be used to soothe teething infants. Growth spurts are often accompanied by tooth eruption, which makes it difficult to differentiate which area of development is the source of discomfort for the child.
Teething aids
Teething aids such as a chilled teething ring or washcloth can provide relief. When using teething rings, it is important to make sure the products are free of toxins. In tests, a few products have been found to contain phthalates (plasticizers); these certainly have no place inside a child’s mouth. Teething rings do not belong in the freezer because they will become too hard, potentially causing injury to the oral mucosa. Furthermore, freezing makes teething rings porous more quickly. The rings should be cleaned regularly under hot water. When using teething rings, parents should make sure they are not used habitually but in a focused, restrictive way and when required. Otherwise, they can prevent the child from maturing in a myofunctional sense.5
Local pain relievers
Many parents will ask about medicinal remedies for teething. While there are products available for such purpose, the US Food and Drug Administration (FDA) and the AAPD warn against their use due to their potential for toxicity.9,10 Further, pain-relieving teething gels that contain lidocaine or benzocaine are not recommended because they have only a limited duration of action, are hard to dose correctly, and most of the product is swallowed. A statement from the FDA in 2014 clearly advised against the use of 2% lidocaine in teething infants. The FDA had reviewed 22 cases in which serious medical incidents occurred in children in connection with lidocaine and reported convulsions, brain damage, and heart problems as consequences of overdosing. In addition, the FDA had already published a warning against benzocaine in 2011 because, when used topically, there were rare cases of life-threatening methemoglobinemia.11 As well as local anesthetics, the products contain preservatives with an appreciable potential for allergization, which argues against their use in children.
Systemic pain relievers
If teething aids do not work and there is a need for pain relief, then acetaminophen and ibuprofen are perfectly suitable for the systemic treatment of teething troubles. These oral analgesics are even endorsed by the AAPD.10 The relevant dosage instructions should be strictly followed. Administration of these analgesics will quickly and reliably get rid of pain for several hours. Ibuprofen additionally has an anti-inflammatory effect, and acetaminophen is antipyretic. Unlike topical gels, their systemic use eliminates pain for longer and more reliably, and precise dosing is guaranteed.
NATAL TEETH
The average age when the first primary teeth erupt is around 6 months. In isolated cases, eruption can occur in the first 4 weeks of life (neonatal teeth) or, by contrast, not until after the child’s first birthday. There are also rare cases of babies who are born with teeth. These natal teeth are mainly mandibular incisors and less commonly the maxillary incisors. In 95% of cases, it is not a matter of supernumerary tooth germs.12 As the roots are not developed or only in a very rudimentary way, the teeth are usually very loose, making it necessary to remove them (Fig 3-6). Their extraction will prevent them from being aspirated or becoming an obstacle to nursing or bottle feeding. Occasionally, they are also the reason for small mucosal lesions appearing at the tip of the tongue. Removal is done either with a swab or small bone nibbling forceps if the tiny teeth cannot be properly grabbed with just a swab. A topical anesthetic can be applied but is not necessarily required. If neonatal teeth are present that are firmly in place and are causing no discomfort, they can be left as they are.
Fig 3-6 Removed natal tooth. The mother attended the practice with the 5-day-old patient. Both mandibular lateral incisors were already present at birth, and one had already been removed by the midwife in the hospital. Removal of this tooth was done with a small bone nibbling forceps without local anesthetic. The newborn slept through the entire treatment.
PACIFIER USE AND THUMB SUCKING
One of the trickiest issues to navigate in pediatric dentistry is children sucking on their thumb and/or a pacifier. It starts with the question “What’s better?” The great advantage of a pacifier is surely that it can easily be removed when weaning the baby off it; the drawback is that it gets used more intensively than the thumb during the period of use.13 On the other hand, the thumb is more readily available to children than a pacifier and, unlike a pacifier, it obviously can never be taken away by a parent. Although in most cases the thumb is used for less time over the day, infants are still weaned off it much later, which can cause a number of malformations. Among 2- to 5-year-olds, thumb sucking is the most significant etiologic factor for an anterior open bite. This open bite can be symmetric or, less favorably, asymmetric. An open bite can cause speech disorders, esthetic impairments, changes in the swallowing pattern, myofunctional disorders, and difficulties in biting food with the anterior teeth.14 Obviously these anomalies can equally be caused by prolonged use of a pacifier. In answer to the question of which is preferred, use of a pacifier still tends to be preferred over thumb sucking. Regarding daily use of a pacifier, Dr Andrea Thumeyer wrote, “Use a pacifier as sparingly as a medicine.”15
Parents often ask whether their dentist can recommend a certain brand of pacifier to minimize these potential problems. In the author’s experience, this choice only partly lies in the hands of the parents because not every child will accept every pacifier. Pacifiers with a very narrow or soft shaft are usually recommended. However, all pacifiers (whether or not they are ergonomically designed) hold the tongue away from its physiologic resting position on the palate, which inevitably will lead to malformations if the pacifier is used too frequently and/or over a long period of time. Far more important than the shape or brand is instructing parents on restricting and limiting the use of pacifiers and when to begin the weaning process. Parents should continue using smaller pacifiers because the larger the pacifier, the greater the risk of malformation. Furthermore, heavy pacifier chains should be avoided because they increase the weight of the pacifier and also the forces acting on the teeth and surrounding structures. Furtenbach answers the question about the best pacifier with: “The best pacifier is the one you don’t give to your child.”5
Another key question is obviously when to wean children off pacifiers or thumb sucking. With regard to pacifiers, Schopf writes, “if weaning off this habit takes place by the age of 3 years, there is a significant and age-dependent increasing trend to avoidance of an open bite.”13 Weaning should thus be started around the child’s second birthday. From an orthodontist’s point of view, the pacifier should then be “disappeared.” For speech therapists, the optimum time to begin weaning is when the child starts to talk (varies between individuals, but generally between 7 and 12 months). If children are weaned off their pacifier too late, there is a risk that an open bite of the primary teeth will persist through to the mixed dentition. This is because, when they have been weaned off a pacifier, the tip of the tongue likes to occupy the space of the pacifier and the bite is no longer able to close.
Several possible ways of weaning off a pacifier are described in the literature. Ultimately, however, success depends entirely on the parents’ persistence. It is helpful to link giving up the pacifier to a special day or holiday such as Christmas or Easter. Parents can persuade their child to give up their pacifier to a younger sibling or family member. If the parent explains that the younger child now needs the pacifier, the child may feel more inclined to part with it, now that they are more “grown up.” Another way to wean children off pacifiers is to send the pacifier to a “pacifier fairy” or hang it on a “pacifier tree.” A pacifier tree (sometimes referred to as a binky tree) is a tree that is full of old pacifiers that children have given up; these trees are usually in large cities. Parents can also trim the teat gradually or puncture it with holes to make sucking unattractive to the child. This approach works very well too.
It is much more difficult to wean children off thumb sucking. The average age when children stop sucking their thumb is 3.8 years.16 When children are aged between 0 and 3 years, it is a good idea for parents to praise them when they do not suck on anything (positive reinforcement). Between 3 and 5 years, behavioral therapy can be attempted with the dentist’s support. In doing this, the dentist should act as an ally on the side of the child, motivating rather than scolding. Parents can also put bandages on the thumb that gets sucked. These would come off if sucked, so parents can give their child a little prize if the bandage survives the day unharmed. The process, like weaning off any other sucking habit, should be accompanied by plenty of positive reinforcement. Commercial thumb-sucking liquids as a form of a negative reinforcement should not be used and have not proved effective in everyday practice. Binding fingers or hands is also counterproductive. For intractable cases, the use of devices such as an oral screen or therapeutic methods such as the myofunctional therapy described above should be considered.17
CARIES DUE TO BREASTFEEDING
Breastfeeding is best for mother and baby in many ways. From the dental and speech therapy perspective, breastfeeding is the best form of myofunctional and hence orthodontic prophylaxis. It strengthens the entire oral and perioral musculature, trains lip closure, encourages the sensitivity of the oral cavity, reinforces nasal breathing, prepares the tongue and lips for eventual articulation, strengthens the mother-baby bond, and promotes the baby’s socioemotional development. The latter also has a beneficial effect on later speech development.5 Therefore, pediatric dentists should definitely encourage their pregnant patients to breastfeed their children when asked for their opinion. Of course it is the individual decision of a mother if and how long she wants to breastfeed her child according to her own circumstances in life. It is your responsibility to address the scientific basis of why breastfeeding is recommended, but it is always best to approach this conversation with sensitivity.
In the dental context, prolonged and high-frequency breastfeeding at night has been viewed critically. While breast milk on its own does not increase the risk for early childhood caries (ECC), together with other carbohydrates, it has been classified as highly cariogenic in in vitro studies.18 Studies further prove that breastfeeding beyond 2 years markedly increases the risk of caries.19 However, several studies have reported that it is not the duration of breastfeeding that increases the risk of caries but instead the way in which breastfeeding is performed, specifically in frequent, short nighttime feeds.20,21 A meta-analysis from 2015 concluded that children who are breastfed beyond 12 months have a higher risk of caries and that the risk was also increased in this group if they were breastfed more frequently at night.22 As such, parents must be made aware that very frequent, short, nonnutritive nighttime breastfeeding episodes when primary teeth are present are indisputably a major risk factor and can be a contributory cause of ECC. But why is that?
Caries is a multifactorial disease that can be influenced by many factors. One cannot say definitively that breastfeeding will certainly cause caries if a baby is breastfed beyond 12 months of life. Many other factors play a role here. We pediatric dentists often see children in our practice who are breastfed far beyond that age and show no lesions whatsoever. But it is also an undisputed fact that very common, short, nonnutritive nocturnal breastfeeding episodes with existing primary teeth can be a major risk factor contributing to caries. We also see these patients again and again. The following factors are responsible for the increased caries risk:
• Oral hygiene is not possible at night.
• Salivation is strongly reduced, therefore only an insufficient buffering of the decreasing pH value is taking place.
• Breast milk contains approximately 7.2% lactose (for comparison, cow’s milk contains approximately 4.5%).
• Because it contains only small amounts of caries-inhibiting components such as calcium and phosphate, breast milk can reduce the intraoral pH below 5.5, which leads to a demineralization of the primary tooth enamel.20
Short and frequent nightly breastfeeding episodes beyond the first birthday of the child are usually more of a sleeping or calming aid that can be viewed independently of food intake. This nonnutritive sucking pattern is entirely different from a normal, nutritive breastfeeding sucking mechanism. It is characterized by a high sucking frequency but a low sucking activity, which means that only so-called “foremilk” (ie, the milk produced in the first nursing phase) is produced. In this milk, the lactose content is in aqueous solution, and thus available for bacteria to be metabolized, and rinses around the maxillary incisors.20 During nutritive breastfeeding, children suck much more vigorously, which leads to the production of so-called “hindmilk.” While this hindmilk contains the same amount of lactose as the foremilk, in hindmilk this lactose content is bound to fat molecules, so the harmful effect in the mouth is directly avoided because there is no enzyme in the mouth that is able to split fat components. The lactose content is only split off once it is in the stomach. In addition, during a nutritive sucking pattern the milk does not touch the teeth but is expressed at the palate and swallowed. With all these factors, comfort nocturnal breastfeeding can indeed be a caries risk factor. Furtenbach also wrote that “the breast is not to be used as a pacifier” because the physiologic oral flora needs rest.5 This is exactly the crucial point.
When highly frequent and prolonged breastfeeding is identified as a caries risk factor in a patient, we should encourage parents to reduce nighttime nursing, to quench baby’s thirst with water if possible, and to find ways to make it easier for baby to fall asleep without breastfeeding, primarily by establishing a different bedtime ritual that does not involve breastfeeding. Infants who are used to only falling asleep at the breast obviously find it harder to settle down again without the breast in occurring waking phases. Therefore, mothers are advised not to let their babies fall asleep at their breast from the age of about 6 months but rather to breastfeed, then brush the teeth before continuing to the rest of the bedtime ritual (singing, looking at books, etc). Moreover, we should check for lip and tongue-ties that might be an influencing factor as well. The question of caries risk is less about “how long” and more about “what form” breastfeeding takes.
It is important to discuss this highly sensitive subject with parents calmly and nonjudgmentally. Pediatric dentists, in particular, are often reproached for advising against breastfeeding. Especially in view of the multifactorial etiologic model of caries and the many advantages that breastfeeding affords mother and child, it is extremely important for our profession to encourage breastfeeding when appropriate. After all, socioeconomic status is more important as a caries risk factor than the source of a baby’s nutrition.23
While the decision about the duration of breastfeeding lies with each mother herself, all nursing mothers should be made aware of the subject and should be instructed on how to ensure good oral hygiene in their infant. We dentists should and indeed must contribute to this part of the parents’ education.
Bottle caries
Bottle-fed or formula-fed babies are just as susceptible to ECC from nighttime feedings or too-frequent “snacking” on the bottle during the day. A baby should never be sent to bed with a bottle of milk for nighttime soothing, and a bottle should not be used as a pacifier during the day. While these practices may seem convenient for parents to avoid nighttime wakings or fussy babies, it’s the frequency of feeding that can become a major risk factor for ECC.
The same is true for solid foods. Children do not have to eat or chew something throughout the whole day. It should be made clear to parents that eating and drinking should be offered numerous times throughout the day but should not be something that is carried out constantly. The oral flora needs rest for the saliva to buffer the decreasing intraoral pH and therefore to stop demineralization of the primary teeth.
DIETARY AND DRINKING HABITS
What children drink
The most important thing about dietary and drinking advice in relation to ECC is certainly educating parents about drinks and the frequency of consumption. Parents are sometimes concerned about how much liquid intake their child should have every day. As a result, they often give their children juice just to make sure they get enough to drink. But a glass of apple juice contains more sugar than the same amount of Coke; bearing that in mind, it is definitely not a good alternative.
In terms of whether or not children are drinking enough liquid, dentists can reassure parents that no child will voluntarily die of thirst! Children are not just taking in liquid when they drink but also nutrients in a bound form. Infants who are fully breastfed do not need any additional fluid intake. When more solid foods are introduced at about 7 months old, an additional fluid intake of approximately 200 mL/day should be provided in the form of water.24
Without a doubt, water is the best thirst quencher. Parents need to be told that taste is instilled or acquired in children. The sentence “My child doesn’t drink water” is merely the result of wrongly acquired drinking habits based on a bad example. The effect of parents as role models in training their children’s dietary and drinking habits is not to be underestimated. Flavored water is not, as many parents assume, a healthy alternative.
How they drink it
How children drink is also important. Roughly at the start of eating solids, children can learn how to drink from normal, thin-walled cups. At this age, infants cannot sit up by themselves yet, but if half-sitting with proper support for their head, they can drink out of a cup. It is entirely unnecessary to get infants accustomed to drinking from a bottle or from a training cup before transitioning to an open cup. Training cups like these prevent the development of a somatic swallowing pattern5 and can result in myofunctional and speech issues if the immature sucking pattern persists.25 If drinking in a sitting position is practiced, the cup should be well-filled, especially at the start because infants cannot yet tip their heads back to drink. Obviously they might spill a bit to begin with and even swallow the drink all at once, but parents will notice that drinking from a cup is a thoroughly intuitive process that children observe and imitate (Fig 3-7).
Fig 3-7 (a and b) Eight-month-old infant drinking from a normal, thin-walled cup.
If parents prefer a training cup while on the go, those without a spout or teat attachment are suitable. There are also leak-proof screwable cups for carrying around, enabling infants to drink quite normally from the edge.
TIPS FOR ENCOURAGING HEALTHY DRINKING HABITS
• Water, water, and more water: Parents greatly underestimate the erosive and cariogenic potential of juices and carbonated beverages. Children should primarily drink plain water (not flavored water).
• Be a role model: Mom and dad can hardly urge their child to drink water if they are drinking soda or iced tea.
• Use a regular cup: Sippy cups or other training cups can train the muscles improperly. Children should be introduced to a regular cup before their first birthday.
• Bottle use: It is extremely important not to let children constantly suck on a bottle. Even a bottle of milk or something similar as a bedtime ritual is dangerous and can lead to ECC very quickly. Children should be offered something to drink several times a day, but a bottle should not be a toy, a pacifier substitute, or a method to calm a child down.
Sugar and childhood obesity
American children consume too much sugar, and this is a leading contributing factor to childhood obesity. The US Centers for Disease Control and Prevention report childhood obesity at 18.5% in the United States (13.9% for 2- to 5-year-olds, 18.4% among 6- to 11-year-olds, and 20.6% among 12- to 19-year-olds), with greater percentages among Hispanic and non-Hispanic black populations.26 It is becoming increasingly apparent that the assumption in recent decades that fats are largely responsible for obesity cannot really be supported. Studies show that sugar in particular has a very negative influence on the overall metabolism. Even in experiments where the total calories remained the same but the amount of sugar was reduced, positive effects such as lowered blood sugar, lowered LDL cholesterol, lowered triglycerides, improved liver function, and lowered insulin levels became apparent quickly. In addition, the subjects under a low-sugar diet reacted much more strongly to satiety stimuli. This shows that “one calorie is not equal to one calorie.”27
Obesity and its accompanying symptoms are now among the most pressing health issues worldwide. In most cases, it is children who suffer from obesity for the rest of their lives, because, contrary to popular belief, people do not grow out of being overweight; rather it is a serious disease. While diet is not the only contributing factor to obesity, it is our responsibility as pediatric dentists to address it for the sake of our young patients’ health. Specifically, we can raise parents’ awareness of this subject and expose and thereby prevent possible dietary traps. These include too frequent and uncontrolled snacking between meals, portion sizes that are too big, and calorie intake that is too high (eg, when drinking smoothies or soft drinks). Parents should also be alerted to the tricks of the industry (“healthy” flavored water, extra-sweet products for children, and sweets at children’s eye level at every supermarket checkout). It is up to parents to make conscious choices to limit their child’s sugar intake. Of course some sweets are inevitable and perfectly fine in life, but the key is moderation.
TIPS FOR ENCOURAGING HEALTHY EATING HABITS
• Eat meals together as a family: It has been proven that children eat healthier when there is a dedicated meal time free of TV or other distractions.
• Be a role model: You cannot expect a child to eat healthily if the parent does not offer healthy choices or eats junk food themselves.
• Timing: Sugar-free breaks are important so that the teeth have time to remineralize and the saliva can buffer the acidic pH. Even healthy foods like fruit should be eaten in one sitting and not nibbled on throughout the day to prevent the accumulation of sugars on the teeth.
• Natural sugar is still sugar: Honey and other naturally sweet products are still full of sugar and should be moderated just like artificial sugars. While dried fruits can be a great snack, they are naturally sticky and adhere to the occlusal surfaces for a long time, so parents should limit their consumption.
• It’s all about moderation!
• Marketing to children: Products especially designed for children usually contain up to 20% more sugar than the normal alternative. Parents need to know this.
• Food consistency: The consistency of food is crucial for good teeth and jaw development. Children do not need smoothies or drinkable yogurts but rather things to chew on in order to develop jaw muscles.
REFERENCES
1. American Academy of Pediatrics. AAP Recommends Fluoride to Prevent Dental Caries. https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Recommends-Fluoride-to-Prevent-Dental-Caries.aspx
