Tooth decay in the early years

While there have been significant improvements in oral health in recent years, tooth decay remains a serious problem for young children. A child in England has a tooth removed in hospital every ten minutes due to preventable tooth decay, according to new figures published by Public Health England (PHE). Early years providers are being called on to play an important role in oral health education and to support families in the fight against tooth decay. Elizabeth Walker looks at the current advice on tackling this entirely preventable disease.

Key facts

Tooth extraction remains one of the most common reasons for hospital admissions in children. The latest PHE figures reveal that 141 children a day in England, some just one year old, are having teeth removed. This means around 60,000 days are missed from school during the year, and children with tooth decay suffer from pain as well as problems with eating and sleeping. The cost to the NHS is £3.4bn a year.

PHE are using the new figures and its Change4Life campaign to coincide with the launch of the Government’s Soft Drinks Industry Levy and to remind parents that soft drinks are the main source of sugar that children consume. While the tax on high-sugar drinks is a response to the obesity crisis, there is also great concern about children’s dental health.

In other research, the first survey of three-year-olds by PHE shows that 12% had evidence of tooth decay with on average three teeth affected. Significant regional variations were found and children in deprived areas were more likely to show signs of tooth decay. Researchers also said that some children had a particular type of decay known as early childhood caries, which affects the upper front teeth and spreads quickly to other teeth. It is linked to the consumption of sugary drinks in baby bottles or sipping cups.

In addition, the Child Dental Health Survey found that, by the age of five, nearly a third (31%) of children had obvious decay in their milk teeth. Despite overall improvements in child oral health, these figures are clearly highlighting the need for more to be done to prevent this serious disease in such young children.

Causes of tooth decay

Tooth decay is caused by consuming too many sugary foods and drinks too often, as well as poor oral hygiene. Unless this is addressed, there is a much higher risk of further tooth decay in permanent adult teeth and throughout later life.

The current high level of tooth extractions in hospital requiring general anaesthetic is being largely blamed on children consuming too many sweets and soft drinks. Most of the children admitted to hospital need between four and eight of their baby teeth extracted, although some are having all 20 taken out. Parents are being urged to ban fruit juice and fizzy drinks from the dinner table and to stick to water wherever possible. A glass of fruit juice has five teaspoons of sugar, while cola has eight teaspoons and this makes it easy for anybody to exceed the recommended adult daily limit of six teaspoons of sugar before even eating.

Many children have poor dental health because there is misunderstanding about the importance of looking after children's early milk teeth and gums. Many parents don't recognise that they should take steps against tooth decay in children’s first milk teeth as they are under the impression it doesn’t matter as they will fall out. However, severe tooth decay at a young age can have negative consequences in later life and lead to higher incidences of oral health problems in adulthood, as well as being a painful and distressing experience for the child at the time.

Current advice

Tooth decay can be prevented by eating a healthy balanced diet that limits the amount of foods and drinks that are high in sugar, and also by brushing teeth for two minutes twice a day, once before bed, using fluoride toothpaste. There is a much higher risk of tooth decay if sugary drinks are given to children so these should be avoided. Breast feeding provides the best nutrition for babies and the healthiest drinks for young children aged one to two years old are full fat milk and water, and from two years old, semi-skimmed milk and water, as long as they are a good eater. It is never too early to take a child to the dentist and ideally it should be as soon as the first milk teeth appear. Dentists can identify and treat tooth decay at the earliest stage and advise parents on tooth brushing and the prevention of tooth decay. It also helps young children to become familiar with the environment at the dentist and is useful practise for when they may need future preventative care.

To keep children’s teeth healthy, parents and carers of young children are recommended to:

  • provide a healthy diet and reduce the amount and how often sugary foods and drinks are given to children

  • limit drinks between meals to milk and water as these are safest for teeth

  • avoid adding sugar to weaning foods or drinks

  • aim to introduce drinking from a free-flow cup from six months of age, and stop feeding from a bottle from 12 months old

  • start brushing children’s teeth as soon as the first tooth appears and supervise their tooth brushing until they are seven or eight years old

  • brush children’s teeth twice daily, including just before bed, using at least 1000ppm (parts per million) fluoride toothpaste

  • from the age of three, use only a pea-sized amount of fluoride toothpaste, for younger children a smear

  • encourage children not to swallow toothpaste while brushing, and to spit, not rinse, after brushing — to give the fluoride more time to protect teeth

  • change toothbrushes every three months, or sooner if the bristles splay

  • guide children’s hands so they can feel the correct movement and use a mirror to help them see exactly where the brush is cleaning their teeth

  • make tooth brushing as fun as possible by using an egg timer to time it for about two minutes

  • use only sugar-free medicines

  • ensure children are registered with dental services as soon as the first tooth appears; from then on, children should visit the dental practice every six months (or as advised by the dental team) for clinical care and advice on how to protect their teeth.

Recommended practice for early years provisions

Early years provisions can play a key role in oral health education and in supporting parents in the fight against tooth decay. The National Institute for Health and Care Excellence (NICE) has urged local authorities to consider supervised tooth-brushing and fluoride varnishing programmes in nurseries and primary schools in areas where children are at high risk of poor oral health. Targeted at children from the age of three, NICE recommends that the scheme would be used to establish and promote good tooth-brushing habits. Early years staff would be expected to supervise children from the age of three brushing their teeth every day, as well as working with parents to encourage good dental care at home.

Resources for a supervised toothbrushing programme for two to four-year-olds are also available on the Foundation Years website, including a presentation for staff, story sack ideas and an information booklet designed for both practitioners and parents.

Daily tooth brushing may not be feasible in all early years provisions but there are other ways that staff can help to prevent tooth decay affecting the children in their care. Good practice includes:

  • providing healthy well-balanced meals and snacks and avoiding food with a high sugar content by following the Voluntary Food and Drink Guidelines for Early Years Settings in England

  • understanding and checking food labels

  • banning sugary soft drinks and juices and only providing water and milk throughout the day

  • working with parents to encourage children to drink from a beaker or trainer cup from the age of 12 months

  • encouraging tooth brushing twice a day

  • promoting good dental health through related fun activities and by inviting a local dentist to visit the children

  • providing parents and carers with information and advice on dental care for children

  • encouraging all families to register their children with a dentist as soon as their first tooth appears.

Further information