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Two consultant paediatric dentists explain the particular dental problems children with clefts have and give advice on how to reduce decay

Professor Richard Welbury, Professor of Peadiatric Dentistry, Glasgow Dental SchoolDr Jackie Smallridge, Consultatnt in Paediatric Dentistr, South Thames Cleft Unit 

Why are cleft children special with regard to their dental care?  They are often disenchanted with hospital appointments and hospital care and going to the dentist may be seen by them as an extension of this. From the dentist's point of view, cleft children often have narrow crowded arches and access to the mouth and the teeth can be a practically difficult. Added to this is the fact that tooth position may make it difficult for the child and parent to keep the teeth clean and decay free with normal tooth brushing techniques. All these facts acting together make the cleft child at 'high risk' of developing decay. The answer to these problems is to prevent any dental decay occurring in the first place!

The aim of Paediatric Dentistry as a speciality in the care of children with clefts is to:  keep them caries free and hence free of pain and the need for fillings or extractions by avoiding extractions to maintain the bone in which teeth are embedded and to reduce potential orthodontic crowding to present a confident and informed child to our orthodontic colleagues.

There is variation by countries in the amount of dental decay within the UK. In 1993 the UK National Survey showed that whilst 45% of all 5 year olds had caries, the individual figures were 43%  (England), 51% (Wales), 55% (Scotland), and 60% (Northern Ireland). This all amounts to a very large amount of decay in children who are often too young to allow them to co-operate with routine dental care. If care is to be provided it requires time to allow for age, knowledge of behaviour management techniques that can be employed for young children, and a current knowledge of recent less interventional restorative procedures and materials. The inherent difficulty in treating decay in such young children under the current general dental services has lead to a situation where a lot of decay is just not treated. For instance in Glasgow the amount of teeth that are actually filled as a proportion of all the decayed teeth in 5 year olds is only 8.9%.

So why is there so much decay. Is preventative advice being ignored? Is advice not started early enough? Is it delivered correctly?  Preventative advice about foods and drinks that cause decay needs to be started early by Health Visitors. Good habits that are started early become incorporated into every day personal regimes. This advice about foods and drinks can be carried on by early registration with a dental practice as soon as teeth begin to erupt at 6 months. It is essential that everyone in the cleft team from birth onwards is giving the same advice. The question then after the advice has been given is who best delivers the preventive service. The answer is unequivocal - THE PARENTS.

Who, then, best delivers the restorative service?

The dentist that can deliver the service in a large number of cases will be the family dental practitioner. It is only natural that the child will often prefer to be seen by the family dentist along with their parents and siblings. However there are many cases where treatment is not straightforward or easy where more specialised care either in the Community Dental Service or by a Specialist or Consultant in Paediatric Dentistry is necessary. It is the responsibility of the Consultant in Paediatric Dentistry to facilitate this treatment in a location as close to the family home as possible to minimise disruption.

Paediatric Dentistry aims to see all cleft children at key times in their dental development. Initially we like to meet parents and their children in the first year of life while teeth are starting to erupt so that we can identify high risk children, endorse correct preventative dietary advice, make sure appropriate fluoride paste and supplementation advice is given, and check that the parent is managing to brush the teeth at the correct times. In addition we need to make sure that the child has been registered with a family dentist. If not we can advise where nearby services are available. Ideally the next meeting with the child should be when all the primary teeth have erupted at age 3 so we can make sure all the advice given previously continues to be heeded. There is evidence that the major increase in caries in young children occurs between 3.5-4.5 years and we need to do as much as we can to prevent this. Our next contact with the child is then at 5 years prior to the eruption of the permanent teeth. Once again it is our aim to make sure that the permanent teeth erupt into an environment that is likely to keep them caries free and to advise of the need to place fissure sealants into the biting surfaces of permanent molars as they erupt. At 7.5 years and 10 years we again check that everything possible is being done to maintain the child caries and pain free. Once the cleft child is over 16 then paediatric dentists together with orthodontists can facilitate specialist adult restorative treatment should that be required. Any such treatment is greatly helped if the oral hygiene is of a high standard, and no teeth have been lost to decay.

Dental prevention

Many different factors contribute to dental disease. Some things are well known like "sweets can damage your teeth"; others are less commonly acknowledged like "drinking milk at nighttimes can damage your teeth". As paediatric dentists we try not only to increase awareness generally about what contributes to dental decay and gum disease but also to try and tailor advice to each individual child.

Preventive dental advice should start early and should be repeated at frequent intervals. In children with clefts as we are lucky enough to see them very early on in their life, we can start advice on good tooth cleaning habits as the first teeth are coming through and offer advice on eating habits which will be less harmful to the teeth.

Most preventive advice applies generally to all children but there are a few areas where children with clefts are more vulnerable and need extra help.

Around the area of the cleft there may be teeth that have not formed all their enamel properly or are at more awkward angles to get a toothbrush around and may collect more plaque on the rougher surface. It may be that the lip is tighter around the cleft area making it more difficult to move it away from the teeth so that they can be cleaned. The dentist should be able to show you how to clean this area, it may entail using a special little brush, it may also be useful to paint fluoride directly onto the teeth to strengthen what is there or even stick a small amount of plastic material into any grooves or defects in the enamel to stop food and plaque getting stuck.

Tooth brushing

Some of the most commonly asked questions about brushing are:

• When should I start?
• What brush should I use?
• How often should I brush?
• What toothpaste should I use?
• When are they old enough to brush for themselves?
• Should I use dental floss?

We shall try and answer these and many other points in the next few paragraphs.

We brush our teeth to get plaque off the teeth, and off the gums, to freshen breath and to apply the fluoride from the toothpaste onto the teeth.

Brushing should start as soon as the teeth come into the mouth. It should start with a soft brush with a very small brushing end but a handle big enough for an adult to hold e.g. the Oral B stage 1. Teeth should be brushed twice a day, in the morning and just before going to bed i.e. after the last drink of the day. Until the child is 7 a children's toothpaste is most suitable unless your child has already had dental decay problems in which case your dentist may recommend toothpaste with a higher fluoride level. Children very quickly want to be independent and it is great when they learn to dress themselves, and eat for themselves but tooth brushing is one area where they must not become independent too early. Unfortunately they don't really have the manual dexterity to brush efficiently for themselves until they are nine or ten!

A compromise has to be reached allowing some independence for the morning brush but with the parent still helping with the evening brushing. With the younger reluctant brushers having two toothbrushes may help letting them brush/chew on one whilst you brush around with the other. Even if they are reluctant to brush it is worth insisting, as prevention really is better than cure.

Flossing is not really necessary until the adult teeth come through. It can be fiddly to master, but gets to the area between the teeth where toothbrush bristles are too big to reach. If you don't floss about 40% of the plaque stays between your teeth even if you brush brilliantly!

Eating and drinking

Although tooth brushing is very important what we eat and drink has more relevance to whether we get decay or not. Because as we eat and drink we are not only feeding ourselves but also providing nutrients to the bacteria that live around the teeth. With these nutrients they produce the acids, which damage the teeth. The frequency with which we supply them with sugars in more important than the overall amount e.g. eating a packet of sweets one at a time throughout a day will cause more damage to the teeth than gobbling them all up at once. Let me explain more. Every time we eat or drink something with a form of sugar in, the acid produced by the bacteria attacks the teeth for about half an hour until the saliva has a chance to wash it away, if we have just three meals a day the teeth will be under attack for 90 minutes but conversely okay for 22 and a 1/2 hours. However if we have just three additional snacks a day e.g. midmorning, after school and at suppertime we double the time the teeth are under attack. The other thing to remember is that many foods contain hidden sugars e.g. tomato sauce, savoury biscuits such as Cheddars, Skips. If snacks are needed between meals and sometimes children do get very droopy or grumpy if they are hungry, then try to use something that does not contain sugars. Water or milk in the daytime are safe drinks, fresh fruit, bread sticks, rice cakes are safe foods. Some of the common pitfalls are dried fruit, little boxes of raisins etc seem like a good healthy option but unfortunately their natural sugars are oncentrated by drying and can cause problems. Drinks cause problems if they are constantly being sipped, juice in a bottle carried around all day, or in a beaker being constantly sipped will cause the same problems.

Night time milk is another thing that catches people out, milk as we have said is a good thing for children to drink BUT it does have a natural sugar in it called lactose which at night time where the saliva is not produced does cause tooth decay. So if children carry on having milk at nighttime or just before going to sleep they are at a greater risk of developing decay.

So a few hints to try to stick to:

• Eat only eat three meals a day
• If you have to snack go for sugar free things such as bread sticks or fresh fruit
• Be careful what you drink, constant sipping at a drink is likely to cause problems unless it is water
• Don't drink at bedtime.

Most of the toothpastes on sale have fluoride in them. Fluoride can be incorporated into the enamel surface to make it harder and more resistant to attack by the acids therefore at the right amounts it is good stuff! Working out what is the right amount to have is the more difficult part. The water supplies around the UK have different amounts of fluoride that occurs naturally; in a few areas this natural amount is adjusted to bring it to what is considered to be the optimum amount to stop tooth decay with out any side effects. There is also the fluoride in the toothpaste to be considered, how much to put on the brush, which sort to use, whether your child spits most of it out or swallows it or even if they sneak back into the bathroom to eat it straight from the tube, it has been known!

Then there are the extra fluorides your dentist may recommend in the form of rinses, varnishes, gels, tablets or drops, Confused yet?

Let’s try to simplify things: 

• Use a child's toothpaste up to the age of 7 then change to an adult toothpaste
• Use a small pea sized blob of paste
• If your child has already experienced decay discuss with your dentist if additional fluoride is necessary. This can take the form of a tablet to be chewed each day (children 3-6 years) or as they become able to rinse their mouth more effectively in the form of a mouth rinse to be used daily (fluoride rinsing is particularly useful just before and during orthodontic treatment as braces on the teeth make it more difficult to clean well.)

Fissure Sealants

Fissure sealants are a thin layer of plastic painted on and then set to provide a covering of the deepest grooves on the biting surface of back teeth or any teeth where there are grooves in which plaque can sit. It is hard to brush plaque out of fissures because the toothbrush bristles are too big to fit into the grooves.

By inhibiting the build up of plaque in these grooves fissure sealants prevent dental decay. The best teeth for fissure sealing are the first adult molars that come up into the mouth at about 6 years old, they come behind the baby teeth and don't push any teeth out so it is important for us as parents to be aware that they are coming and also the second adult molars that came through at the back of the mouth at about age 12.

These teeth should be sealed as soon as the entire biting surface can be seen. It is a very simple, painless procedure to have done. First the tooth is cleaned with a brush then with a special cleaning gel, (tastes a bit like lemon juice) the gel is then washed off and the tooth must be kept dry whilst one or two layers are painted onto the tooth and set by shining a blue light onto it. It is important that the dentist checks at each check up that the sealant has not worn down and it may need to be topped up.

Gum chewing

Chewing gum deserves a mention here to as it is increasingly being promoted as a tooth "cleaning" product.

Chewing sugar free gum stimulates the saliva flow and in this way helps to clear away damaging acids more quickly. It must be sugar free gum, it must be started immediately after eating and the chewing must go on for a reasonable length of time 15-20 minutes.

Erosion

This is another way it which acids can attack teeth. This time the acid directly attacks the tooth surface and no bacteria are involved. Acidic food and drinks such as oranges, vinegar, fizzy drinks and fruit juices are acidic enough to start dissolving away enamel, another possible source of acid are the stomach acids if your child experiences reflux. Again the frequency of intake is important, if your child drinks coca cola every day then they may well be getting gradual erosion of the teeth, this may be noticeable if the biting edges of the front teeth become translucent or start to chip with out a bang on them. Erosion will be magnified if your child swishes the drink around the mouth.

Mouth Guards

Last but not least is trying to prevent trauma to the teeth. Accidents will always happen, and it is not always possible to prevent them. However when children are playing in situations where damage is more likely the extent of damage can be reduced if a mouth guard is worn. So wearing a mouth Guard during organised sports is a good thing. Most protection is obtained by wearing a custom made mouth guard, that is one that is made specifically to your child mouth after an impression of the teeth has been taken.

In Summary...

Tooth brushing

• Brush teeth twice a day.
• Use fluoride toothpaste.

Food and drink advice

• No night time drinks except water
• Bottle-feeding should be finished by age 18 months.
• Make between meal snacks sugar free
• Fruit, bread, some crisps, rice cakes.

Fluoride         

• Always use a fluoride toothpaste and discuss with your dentist if additional fluoride would be of benefit           
• Use a fluoride rinse around the time of any orthodontic treatment

 Chewing gum

• Sugar free gum chewing stimulates saliva     
• Children need to be old enough to chew for 15 minutes and not to swallow the gum

Acid erosion  

• If you eat or drink a lot of acidic things, ask your dentist to check your teeth for signs of early erosion    
• Avoid brushing your teeth straight after having something acidic as you may brush away softened enamel            

Mouth guards

• Wear a custom made mouth guard for all contact sports
• When your child is loosing baby teeth rapidly mouth guards will need regular checking and adjustment to keep a good fit

Fissure Sealants

• Properly applied sealants that are properly monitored prevent dental decay.
• Don't assume that because the teeth have fissure sealants you can forget about all the above.