Oral and dental health promotion for children’s nurses
Intended for healthcare professionals
Evidence and practice    

Oral and dental health promotion for children’s nurses

Sarah Najim Dentist, paediatric dentistry, Guy’s and St Thomas’ NHS Foundation Trust, London, England
Mohammed Ali General practitioner, NHS North West London Integrated Care System, London, England
Nabina Bhujel Dentist, paediatric dentistry, Guy’s and St Thomas’ NHS Foundation Trust, London, England

Why you should read this article:
  • To identify the importance of prioritising oral and dental health education for children, starting from birth, to prevent tooth decay and promote overall well-being

  • To be aware of advice that can be shared with parents to improve their child’s oral and dental health

  • To recognise the crucial role of nurses, midwives and community practitioners in promoting oral health in early childhood, particularly as children’s exposure to dentists is usually delayed

Tooth decay remains one of the most common preventable oral health concerns in children. After birth, advice to caregivers predominantly focuses on medical health with little attention paid to dental health. Before discharge from the maternity unit and during future hospital and community appointments, opportunistic dental advice should be provided by midwives, nurses and health visitors where possible, with the aim of preventing early onset dental disease. Registering with a dentist at birth is crucial due to long NHS dental waiting lists. Simple advice on toothbrushing should be offered, including brushing twice a day with a soft toothbrush using an age-appropriate amount of fluoride toothpaste. Mothers should be provided with information on the benefits of breastfeeding for oral health alongside tailored preventive care. Appropriate advice on bottle-feeding and weaning is required, including minimising the use of added sugar, drinking from free-flow cups after six months of age, and discouraging the use of milk bottles at bedtime and in general after one year of age. Written visual summaries can be shared with parents to consolidate verbal advice on oral and dental health.

Nursing Children and Young People. doi: 10.7748/ncyp.2024.e1498

Peer review

This article has been subject to open peer review and checked for plagiarism using automated software

Correspondence

sarah.najim@gstt.nhs.uk

Conflict of interest

None declared

Najim S, Ali M, Bhujel N (2024) Oral and dental health promotion for children’s nurses. Nursing Children and Young People. doi: 10.7748/ncyp.2024.e1498

Published online: 05 February 2024

Oral and dental health education is essential for all children. In the UK, many patients, children and adults, are unable to access dental care and may only seek treatment when they are already in pain, resulting in adverse health outcomes such as infection, decay and premature tooth loss (Spiller et al 2019). Therefore, healthcare teams must aim to engage and educate caregivers on oral health guidance from the neonatal age.

In England, almost 90% of hospital tooth extractions among children from birth to five years old are due to preventable tooth decay (Public Health England (PHE) 2019). Despite improvements in children’s oral health, significant disparities persist and tooth extractions remain the most common hospital procedure for children aged six to ten years (PHE 2019). Oral health is one of the five key clinical areas of health inequalities in NHS England’s Core20PLUS5 approach to addressing the backlog of hospital tooth extractions for children aged under ten years (NHS England 2022a). According to the 2019-20 oral health survey of three-year-old children in England, those living in the most deprived areas were almost three times as likely to have tooth decay (16.6%) as those living in the least deprived areas (5.9%) (PHE 2020). The premature loss of baby teeth may adversely affect the health and alignment of a child’s permanent teeth (Law 2013).

Tooth decay can lead to challenges with eating and sleeping, resulting in at least 60,000 missed school days per year due to hospital extractions alone (PHE 2019). The prevention of tooth decay involves reducing sugar consumption and practising daily oral hygiene (PHE 2019).

Advice for new parents predominantly focuses on feeding, sleeping, recognising signs of illness, education on sudden infant death syndrome (SIDS), and nappy and hygiene care (NHS England 2022b). While these are all paramount, more parental awareness of preventive dental advice is also required. This article aims to discuss oral and dental health advice, in particular the opportunistic advice that children’s nurses and community practitioners can provide to caregivers before discharge of newborns and during future hospital and/or community appointments.

Role of children’s nurses and community practitioners

Parents and children have significantly more contact with health visitors, community nurses and school nurses than they do with dental professionals. These healthcare professionals should therefore aim to use such contacts to provide early oral health promotion advice and signposting that parents may not have otherwise received. There is a drive in the NHS to ‘make every contact count’, a policy which intends to maximise the opportunity for health promotion in routine health and care interactions (PHE 2016).

During unscheduled care in the hospital setting, children’s nurses, particularly those working on inpatient wards, have a significant role in oral health promotion. Important initiatives such as Mini Mouth Care Matters have been developed and tailored to nurses in the hospital setting, with the aim of improving the oral health of hospitalised children (Devalia et al 2019). This is particularly important given that there is evidence that hospitalisation is associated with a deterioration in patients’ oral health which, in turn, can lead to an increase in hospital-acquired infections, suboptimal nutritional intake and longer hospital stays (Terezakis et al 2011).

In the authors’ clinical experience, children with special needs, such as those with learning disabilities or looked-after children, may be regarded as high-risk patients, and therefore usually require specialised attention and support in all aspects of care, including their oral health. Nurses have a crucial role in identifying these patients and developing relationships based on trust, empathy and effective communication. This will better equip nurses to provide targeted interventions, including tailored guidance on oral health. By collaborating with community teams such as local learning disability teams and GPs with specialist learning disability input, as well as social services and dental professionals, nurses can ensure that these children and their caregivers receive the necessary information and support to maintain optimal oral health.

Key points

  • Tooth decay and oral health disparities among children in the UK are a significant concern, with a focus on the importance of early oral health education

  • Hospital tooth extractions for children aged under ten years are a prevalent issue, with children living in deprived areas having higher rates of tooth decay

  • Health visitors, community nurses and school nurses can use contacts with parents and children to provide early oral health promotion advice

  • The article details advice for parents on registering with a dentist early, proper toothbrushing practices, the benefits of breastfeeding, and the importance of limiting sugar intake through weaning and bottle-feeding, with visual aids to support oral health education

Registering with a dentist

From the point of the child’s birth, midwives, neonatal nurses and health visitors should remind caregivers regularly to register their baby promptly with a dentist and schedule their first dental visit before the child’s first birthday. There is growing evidence of better oral health outcomes for children who attend the dentist earlier in life (Bhaskar et al 2014). Only 3% of children in England have seen a dentist by the age of one year (Salomon-Ibarra et al 2019). It is therefore important that caregivers are advised to visit a dentist with the child as soon as possible because, in the authors’ experience, registering with an NHS dentist can be challenging due to long waiting lists. Even if the child’s first teeth have not yet erupted, an early dental appointment is beneficial for familiarising the child with the dental environment, reducing the risk of future dental phobia and providing a critical opportunity for tailored oral hygiene and diet advice.

Toothbrushing

Community and hospital nurses, midwives and health visitors should all have a fundamental understanding of toothbrushing practices, given that they will be in closer contact with children early on in life before they have ever visited a dentist.

They should remind caregivers to begin brushing their child’s teeth as soon as they erupt. Normally, the first baby teeth erupt at about six months of age. However, very occasionally teeth may erupt natally or neonatally. Natal or neonatal teeth may bear some resemblance to typical baby teeth, but they often have some abnormalities in formation and structure, including in the quality of the dentine (the main supporting structure of the tooth) and enamel (the protective outer covering of the tooth). The teeth may also be mobile, which can potentially be an aspiration risk. Other significant complications may arise, including difficulty feeding, ulceration of the soft tissue and laceration of the mother’s nipple during breastfeeding. In cases of natal or neonatal teeth, immediate referral to a paediatric dentist is required, with extraction of these teeth being highly likely. However, if the natal or neonatal tooth does not impede feeding and remains asymptomatic, invasive treatment may not be necessary and excellent preventive measures should be incorporated by the caregiver, as identified below (Holden et al 2022).

The Delivering Better Oral Health toolkit includes up-to-date, evidence-based guidance for improving oral health (PHE 2021). Although this toolkit is aimed at dental professionals there are many relevant sections that can be used by children’s nurses and health visitors, who will have regular early contact with children and their caregivers.

For children aged up to three years their teeth must be brushed twice a day using (PHE 2021):

  • A toothpaste that contains at least 1,000ppm (parts per million) of fluoride.

  • A soft toothbrush last thing at night before bedtime and on one other occasion.

  • Only a smear (a grain of rice) of toothpaste (Figure 1)

  • For children aged three to six years, a pea-sized amount of toothpaste should be used (PHE 2021) (Figure 1).

Figure 1.

A smear of toothpaste for children aged 0-3 years (left), and a pea-sized amount for children aged 3-6 years (right)

ncyp.2024.e1498_0001.jpg

For children from birth to six years who are at high risk of tooth decay it is recommended that they use toothpaste that contains 1,350 to 1,500ppm fluoride (PHE 2021). In addition, these children should have regular check-ups with their dentist, who should apply fluoride varnish to their teeth at least twice a year or up to four times a year (PHE 2021).

Encouraging children to enjoy brushing their teeth can be a common challenge. To establish the habit early on, caregivers should incorporate toothbrushing into the child’s daily routine from the outset. The caregiver can brush their own teeth together with the child, using songs and games as motivation, and must always then assist the child with their own brushing.

For babies, a helpful method is to sit the baby on the caregiver’s knee with their head resting against the caregiver’s chest (Figure 2).

Figure 2.

A baby sitting on his caregiver’s knee while his first teeth are brushed

ncyp.2024.e1498_0002.jpg

Another method is to lie the baby flat on their back while the caregiver sits behind them to brush their teeth (Figure 3).

Figure 3.

A baby lying flat on his back while his caregiver brushes his first teeth from behind

ncyp.2024.e1498_0003.jpg

For older children, the caregiver can stand behind the child and gently tilt their head backwards while brushing their teeth (Figure 4).

Figure 4.

A caregiver tilting the child’s head backwards as they brush

ncyp.2024.e1498_0004.jpg

When brushing, small circular motions should be used to cover all surfaces of the teeth. Afterwards, the child should be encouraged to spit out the toothpaste. The mouth should not then be rinsed with water, because this would wash away the fluoride, which is protective for the teeth. The child should not eat or lick the toothpaste from the tube (PHE 2021). Children should be assisted with toothbrushing until they are at least seven years old, since they generally lack the dexterity to brush effectively on their own before this age (Elison et al 2014). A toothbrush should be replaced when the bristles become excessively splayed (Figure 5).

Figure 5.

Splayed (left) and non-splayed toothbrushes (right)

ncyp.2024.e1498_0005.jpg

Children with learning disabilities may require customised tools and techniques. They may benefit from using specialised toothbrushes with small silicone bristles or soft three-sided designs (Figure 6), which can aid in desensitising the child. A regular toothbrush requires each side of the tooth to be brushed individually (the outside surface, the biting surface and the inner side). However, a three-sided toothbrush can brush all three surfaces of the tooth at once, thereby making brushing quicker for a child who might otherwise not tolerate a thorough clean.

Figure 6.

Three-sided toothbrush

ncyp.2024.e1498_0006.jpg

In cases where a child bites down hard or refuses to keep their mouth open, a silicone mouth prop can be useful (Geary et al 2000). Toothpaste is also available in a variety of flavours and colours, and for children who may experience sensory overload, unflavoured and non-foaming toothpaste (without sodium lauryl sulphate) may be beneficial (Warren Center 2023). If a child cannot tolerate the use of any toothbrush, then the use of a clean cloth or wet gauze wrapped around the caregiver’s finger with a small amount of toothpaste can be used to brush the child’s teeth.

It is also important that caregivers maintain their own optimal oral hygiene, since children can acquire bacteria from adults who share food, utensils or mouth kisses with their children, which can subsequently lead to dental decay (Tham et al 2015).

Breastfeeding

Breastfeeding is the optimal way to provide nutrition for infants and offers lifelong benefits for their health (Victora et al 2016, Thompson et al 2017). Midwives have an important role in promoting breastfeeding immediately after birth and in offering valuable support to parents during this process (Renfrew et al 2014).

Research has shown that breastfed babies have lower rates of respiratory and gastrointestinal infections (Frank et al 2019). Breastfeeding is also protective against SIDS (Thompson et al 2017) and can help to protect the mother from chronic diseases such as diabetes mellitus and cardiovascular disease (Victora et al 2016).

Immediate breastfeeding within the first hour of birth is linked to successful and continued breastfeeding. However, less than half (47.2%) of newborns from low- to middle-income countries are put to the breast within this time frame (Pérez-Escamilla et al 2023), and many babies also receive prelacteal feeds (foods other than breast milk offered during the first three days after delivery). Prelacteal feeds can delay breastfeeding and have a negative effect on lactation, leading to premature supplementation or cessation of breastfeeding (Pérez-Escamilla et al 2022).

In terms of oral health, direct breastfeeding has an important influence on craniofacial structure and reduces the risk of malocclusion (misalignment of the teeth) by widening the palate (Peres et al 2015). The infant’s oral microbiota (a collection of microorganisms that naturally inhabit the oral cavity) may result from the breast milk microbiome (the genetic material of microorganisms present in breast milk, which can influence the health and development of the infant who consumes it), and there is some evidence to suggest that an adult’s overall oral microbiota composition can be affected by their feeding type as an infant (Eshriqui et al 2020).

Although breast milk contains substances that inhibit the growth and adhesion of the cariogenic bacteria which attack dental enamel (Richards 2016), no definitive optimal weaning times or breastfeeding practices have been established to address the risk of dental caries. Nocturnal breastfeeding may, in theory, increase the risk of dental caries by exposing teeth to sugars. However, this can be challenged as direct breastfeeding, which requires a deep latch of the areola, does not allow milk to pool in a baby’s mouth since it requires active suckling. This is unlike bottle-feeding, where milk can flow without the need for the baby to suckle and swallow reflexively (Erickson and Mazhari 1999).

There is a consensus that breastfeeding up to 12 months of age is not associated with an increased risk of dental caries and may even offer some protection compared with formula, as breast milk can inhibit the growth of cariogenic bacteria (Richards 2016). Breastfeeding should therefore be encouraged and supported to ensure optimal health for mother and child, and to prevent dental caries and other chronic diseases.

After 12 months of age, the duration of breastfeeding and its association with dental caries become debatable. A systematic review and meta-analysis by Tham et al (2015) suggested that after 12 months of age, on-demand and nocturnal breastfeeding were associated with an increased risk of dental decay (Tham et al 2015). This led to a recommendation by the British Society of Paediatric Dentistry (BSPD) that consideration should be given to reducing on-demand and nighttime feeds after the age of 12 months (BSPD 2018).

More research is needed to understand the connection between prolonged and frequent nighttime breastfeeding and dental caries. With the current lack of evidence of the oral health consequences of breastfeeding after 12 months, caregivers could incorporate cleaning measures such as removing the remains of milk on the child’s teeth with a wet gauze after breastfeeding (Colombo et al 2019).

Parents may present to their midwife or health visitor with oral health concerns after their child reaches one year of age. While it is important to discuss the possible risks of nighttime breastfeeding on oral health, they must be guided by the consensus, which recommends breastfeeding up to at least two years of age (World Health Organization 2018).

Bottle-feeding

To promote optimal dental care for babies, midwives and health visitors should advise parents on preventive bottle-feeding measures to prevent decay even before teething begins. It is important to limit the contents of bottles to milk or water only (Kagihara et al 2009) and avoid dipping dummies in sugary substances (Reisine and Douglass 1998). It is not only the amount of sugar in sweet foods and drinks that matters, but also the frequency and duration of sugar consumption throughout the day. Sucking lollipops and drinking sugary beverages in bottles poses significant risks because they expose teeth to sugar for prolonged periods (Touger-Decker and van Loveren 2003).

Starting from six months of age, infants should be introduced to drinking from a free-flow cup at meals instead of a bottle because this can reduce the risk of tooth decay (Kagihara et al 2009). The continued use of a bottle teat or spout prolongs the exposure of teeth to drinks, which leads to dental issues (Touger-Decker and van Loveren 2003). Therefore, once teeth have erupted, a baby should never be put to bed with a milk bottle because this can significantly increase the risk of dental decay. The use of bottles in general should be discouraged after one year of age for the reasons mentioned above. Caregivers may find this stressful, since putting a baby to bed with a bottle can be an effective method for aiding sleep. However, it is important for nurses and midwives to educate caregivers about the risk of dental decay and encourage alternative methods.

Weaning

In England, children are consuming more than the average recommended amount of sugar daily (Amoutzopoulos et al 2020). To protect a baby’s teeth from decay, it is important to minimise the use of sugar in their food, because sugar is the primary cause of tooth decay. Wherever possible, sugar-free versions of medicines should be used. In addition, sugar-containing foods and drinks should be avoided at bedtime, when saliva flow is reduced and buffering capacity is lost (Baghlaf et al 2018). Saliva constantly bathes the teeth, functioning as a cleansing solution, a lubricant and a buffer. Salivary buffers can reverse the low pH in plaque and allow for oral clearance, thus preventing dental decay.

Acidic drinks like fruit juice and squash, as well as fizzy drinks, are particularly harmful to teeth and should be avoided (Shroff et al 2018). Generally, it is less harmful to consume drinks in one sitting, with a meal and through a straw, rather than sipping the drink throughout the day (Aswini et al 2005). It is preferable to choose drink options that contain naturally occurring sugars from whole fruits and milk, which are less likely to contribute to tooth decay (Moynihan 2016).

Visual aids

Sharing written information with parents after the birth of their child is an effective way to consolidate verbal advice on oral and dental health. Figure 7 is a poster devised by the authors providing a visual summary of the points discussed in this article.

Figure 7.

Oral and dental health poster for new parents

ncyp.2024.e1498_0007.jpg

It provides essential information and practical tips to caregivers, emphasising the importance of early dental care and oral hygiene practices. It identifies the significance of registering the baby with a dentist, and initiating toothbrushing as soon as teeth erupt. In addition, the poster can be used to educate parents about the benefits of breastfeeding for both general and oral health. By distributing visual aids such as this, children’s nurses can have a vital role in promoting oral health awareness among parents and fostering a positive foundation for their child’s dental well-being.

Conclusion

It is crucial to prioritise oral and dental health education for children, starting from birth, to prevent tooth decay and promote overall well-being. Initiatives should focus on encouraging caregivers to register their babies with a dentist early and schedule their first dental visit before their first birthday. Caregivers should be equipped with toothbrushing advice, including the recommended frequency, toothpaste fluoride content and techniques for different age groups. Breastfeeding should be promoted, because it offers numerous health benefits for both infants and mothers, including protection against dental caries. Weaning and bottle-feeding practices should minimise sugar consumption and avoid prolonged exposure of teeth to sugary substances.

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