A child's oral health is recognised as being a contributing factor to their healthy development. The World Health Organization (WHO) defines oral health as being free from chronic mouth and facial pain, cancers, infection and other conditions that may inhibit a person's ability to chew, bite, smile or speak (WHO, 2018). Oral health problems include gum disease, tooth decay (Figure 1), tooth loss and other oral mucosal diseases.
Tooth decay is the most common oral disease affecting children and young people in England and is considered to be mostly preventable (Public Health England (PHE), 2016a). It is considered to be a public health priority linked to childhood obesity and is also connected to factors such as health inequality.
Poor oral health in children impacts on both the child and their family. Tooth decay, otherwise known as dental caries, is the most common reason for 5–9 year olds in England to be admitted to hospital (Health and Social Care Information Centre (HSCIC), 2015). These admissions are often for the removal of teeth under general anaesthesia. For example, in 2015, more than 602 000 children and young people aged 0–19 years were admitted to hospital to have teeth removed under general anaesthesia (HSCIC, 2015).
Children with dental caries suffer a range of symptoms and difficulties (Box 1). Poor oral health can be a significant indicator of wider health and social issues. For example, dental neglect may be part of a safeguarding issue, which must be considered by practitioners.
Dental caries are caused by a range of complex factors. However, on a basic level the bacteria in the mouth break down food, especially carbohydrates, leading to acid production, which can demineralise teeth. With continued demineralisation tooth structures are destroyed, resulting in the development of cavities, then possibly tooth loss and systemic infection (WHO, 2018).
The National Dental Epidemiology Programme reports data indicating that the oral health of 5 year olds across the UK is improving. However, there remains significant concern regarding the oral health of the nation's children. In 2015, 24.7% of 5 year olds started school with dental caries (PHE, 2016a). In those children, 3–4 teeth will, on average, be affected.
As with many areas of health, the wider determinants need to be considered and there are variations across the UK. Evidence suggests that deprivation and ethnicity both affect the data recorded. Children who attend specialist schools who have dental caries were twice as likely to have had one or more teeth extracted (PHE, 2015).
Brushing children's teeth
PHE (2017) guidance suggests that, as soon as the first tooth appears (which is usually at around 6 months), a child should have their teeth brushed at least twice a day using fluoride toothpaste. The recommendations are to do so in the morning and evening.
The reason for brushing teeth before bed is that fluoride continues to protect teeth throughout sleep. Children tend to need support brushing their teeth effectively until around the age of 7 years. However, this depends on a child's stage of development and maturity. The guidance (PHE, 2017) also suggests that, between the ages of 0 and 6 years, children should use toothpastes containing 1350–1500 parts per million fluoride. The amounts needed are shown in Figure 2 (a smear of toothpaste for 0-3 year olds) and Figure 3 (pea-sized for 3-6 year olds).
Health education and promotion
Health education should be given to families regarding a healthy diet. This includes the reduction of sweet foods and drinks in the diet. It is important to highlight to parents and carers that this includes reducing the consumption of fruit juices and smoothies. Practitioners should also consider the sugar content of prescribed and over-the-counter medications and seek sugar-free alternatives.
Families should also be informed about the oral health risks associated with bottle use. Bottle feeding should be discouraged from 12 months old (PHE, 2017). Visiting the dentist should be promoted from the time the first teeth appear. Dental reviews should occur as often as advised by the dentist and are free for children under 18 years of age. The dentist may apply a fluoride varnish to children aged over 3 years to protect their teeth (PHE, 2017).
There is a range of public health interventions related to oral health (Box 2), and national and local government policy has a key role to play (PHE, 2014a). The recent government action to address childhood obesity will also impact on oral health, as both share a common risk factor; the consumption of sugars. It is argued that if the nation is to make significant changes in the oral health of its children, there needs to be a reduction in the consumption of free sugars (those added to foods by manufacturers) and increased access to fluoride. Godson et al (2018) stated that oral health improvement should be everyone's business.
Water fluoridation
Evidence from global research has repeatedly shown that water fluoridation is a safe and effective public health intervention (PHE, 2014b). This intervention does not rely on individual behaviour change, which can be challenging. Fluoride reduces the likelihood of developing dental caries and reduces the severity of the condition where it exists.
All water supplies contain some naturally occurring fluoride. Currently, in the UK, about 10% of the population drink fluoridated water compared with 70% of the population in the US (PHE, 2016b). When comparing children who reside in areas where water is fluoridated with those where it is not, the data is stark. Five year olds in fluoridated areas were 28% less likely to have had tooth decay in their baby teeth than those in non-fluoridated areas and 12 year olds in fluoridated areas were 21% less likely to have had tooth decay in their permanent teeth than those in non-fluoridated areas PHE, 2016b).
The debate regarding fluoridation usually centres around cost, benefit and ethical implications.
Making every contact count
All nurses have an important role in ‘making every contact count’ (NHS England, 2016). This should include having the knowledge and skill to promote evidence-based messages and to support families to take action on their oral health. This will also require a nurse to consider assessing and supporting behaviour change.
At times, practitioners will need to have the confidence to refer children and their families to local dental services. Research indicates that this remains a challenge, for example one-third of health visitors have never received oral health training (Oge et al, 2018).
Public Health England's health guidance on child oral health provides some useful information (PHE, 2019).
Conclusion
Poor oral health can lead to number of health problems—in children this is primarily dental caries. Routine oral hygiene and advice regarding sugar intake can support the oral health of a child. It is important to recognise that children should grow up with good oral health and that dental caries are mostly preventable.