Oral health is an important part of general health and wellbeing and should not be considered in isolation. Whilst there have been welcome improvements in the oral health of children in England, significant inequalities remain. Oral disease can have detrimental effects on an individual’s physical and psychological well-being and reduces quality of life (Figure 1).
The World Health Organisation defines oral health as ‘a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual's capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing. The mouth is affected by diseases such as dental caries and periodontal disease and other conditions such as trauma, mouth cancer and developmental abnormalities, all of which can have an adverse effect on an individual’s well-being’ (WHO, 2012).
As well as causing pain or infection, poor oral health can be associated with low weight and failure to thrive in infancy. The impacts are not only limited to the individual but also the family and society, including school absence, and the need for parents to take time off work to attend dental appointments. Good oral health can therefore contribute to school readiness.
Risk factors for oral diseases include poor diet, particularly diets high in quantity and frequency of sugar consumption, poor oral hygiene, tobacco use and harmful alcohol use. These are also risk factors for the four leading chronic diseases – cardiovascular diseases
, chronic respiratory diseases and diabetes
– and oral diseases can be associated with chronic disease.
The mouth is affected by diseases such as dental caries and periodontal (gum) disease and other conditions, such as trauma, mouth cancer and developmental abnormalities, all of which can have an adverse effect on an individual’s wellbeing.
Dental Caries (Tooth Decay)
Dental caries is the most common disease of the dental tissues and affects the majority of the population. It is caused by bacteria in the mouth utilizing sugars in the diet as a source of food and producing acids as a by-product. The acids dissolve away the tooth substance leading to dental decay, abscess formation and eventually tooth loss. A diet rich in sugars which are consumed frequently throughout the day provides a favourable environment for the development of dental caries and eventual tooth loss. Very young children often have no alternative but to undergo a general anaesthetic to have multiple diseased teeth removed. There is substantial evidence to show that people from socially deprived backgrounds experience considerably more dental disease than other members of the population due to lack of opportunities that would enable them to improve their oral health. The main issues are poor diet and limited access to fluorides and dental care.
Tooth decay is the most common hospital diagnosis in children aged 5-9 years and the number one reason for admission to hospitals in England (Health & Social Care Information Centre 2015b). Dental treatment under general anaesthesia, often the only way to treat very young children and those with disabilities, presents a small but real risk of life-threatening complications for children. It is estimated that poor dental health costs the NHS £3.4 billion annually (Public Health England 2014).
Periodontal (gum) disease affects the structures which support the teeth; these are the tissues and ligaments which secure the teeth to the jaw bones. This disease is caused by a build-up of plaque around the teeth leading to the development of inflammation. The gums become swollen and bleed spontaneously. In susceptible individuals the disease progresses by destroying the supporting structures of the teeth, the teeth become loose and if unchecked the disease results in tooth loss.
Teeth may be traumatised as a result of accidents and participation in contact sports. The upper incisor teeth are at greatest risk and experience most damage.
Mouth cancer is the major fatal condition which affects the oral tissues. There is a high risk of developing mouth cancer in people who smoke and those who consume excessive amounts of alcohol. Amongst people living in the UK who originate from South Asia, the use of Pan (leaf of the vine, Piper betel, areca nut, slaked lime (calcium hydroxide) and spices) is linked to very high levels of mouth cancer.
Developmental abnormalities of the oral-facial tissues
Although not the result of disease processes, defects in the development of oral tissues and facial skeleton may result in teeth being displaced sufficiently that the malocclusion produced impacts on oral health. Significantly adverse alignment of children’s teeth makes them more susceptible to physical disease, trauma and also impacts on personal appearance, leading to potentially low self-esteem. There are a large number of rare genetic conditions which affect the teeth and facial skeleton. The most common are clefts of the lip and/or palate.
Population groups at increased risk of oral disease
Pregnant and nursing mothers
Although some women are at greater risk of some oral conditions (periodontal problems and erosion due to vomiting) during pregnancy, the more significant reason for engaging these expectant and new mothers is the potential to impact on the health and oral health of the child as part of the life-course.
Vulnerable Children and Young People
There is substantial evidence to show that people from vulnerable groups including people with physical and learning disabilities and complex health needs and those from socially deprived backgrounds experience considerably more dental disease than other members of the population (PHE, 2015). This can be due to lack of opportunities that would enable them to improve their oral health, including access to a healthy diet, fluoride and dental care.
Children in Care and safeguarding
Under the Children Act (1989), a child is legally defined as ‘looked after’ by a local authority if he or she is provided with accommodation for a continuous period of more than 24 hours or is subject to a care order or a placement order.
Nottingham City has the highest proportion of children (0-18 years) in care, 89 per 10,000 in the East Midlands (Nottingham City Council 2016). Statutory guidance under the care planning regulation
requires children in care to have the appropriate dental care needs met as part of their statutory health assessment. Frequent movement of children between different carers creates particular challenges for assessing and meeting health needs including dental check-ups and treatments. This is particular important when planning local service provision. Many children in care come from families from lower socio-economic groups, and it can therefore be anticipated that they may already be experiencing poor oral health, or be at risk of poor oral health (Scott & Hill 2006). In addition they are more likely to have greater health needs than their peers from the equivalent socio economic groups, resulting in significant health inequalities for children in care (Department of Health n.d.).
Young children in general are reliant upon their parents/carers to maintain their oral health. This includes managing oral hygiene, diet, and seeking treatment when required.
The National Institute for Health and Clinical Excellence (NICE) recognised dental neglect as a type of child neglect and made recommendations related to persistent failure by parents/carers to obtain dental treatment for a child’s dental decay, and that child maltreatment should be considered if a child has an oral injury and the explanation is absent or unsuitable.Neglect of a child’s oral health can lead to pain, failure to thrive and impaired quality of life.
Many general health conditions and oral diseases share common risk factors such as poor diet, smoking and alcohol misuse
. Oral diseases are largely preventable; and there is a need to put in place evidence-based interventions to achieve sustained and long-term improvements in oral health and reduce inequalities. In taking a ‘common risk factor approach’ to address these risk factors, general health will also be improved (Chestnutt 2016).
Sugars are the most important dietary factor contributing to dental caries and the evidence is strong of the association between dental caries and the daily total amount of sugar consumed together with the frequency of consumption of sugar containing fodd, drinks and snacks.
All age groups consume more sugar than the government’s recommended daily limit (10% of daily energy intake), which negatively impacts on tooth decay among other public health concerns .
Breastfeeding provides the best nutrition for babies and should be encouraged.It has been noted that breastfed children can develop dental caries, however prolonged and exclusive breastfeeding alone does not appear to be the cause (Kramer et al. 2007).
From six months of age infants should be introduced to drinking from a free-flow cup, and from age one year feeding from a bottle should be discouraged (DBOH, PHE, 2014). Persistent use of baby feeding bottles and use of non-free flow cups, particularly if they contain sweetened liquids are associated with increased risk of tooth decay.
Sugar should not be added to weaning foods or drinks (DBOH, 2014).Parents need to be supported to make considered choices when weaning children. Most commercially produced weaning foods contain higher levels of added sugars and sweeteners than home prepared food.
Prescription of sugar free medicines should be encouraged.
Tooth brushing should be encouraged as a normal part of a healthy lifestyle and a necessary life skill.It is essential for the physical removal of plaque to maintain gum health and also as a vehicle to introduce fluoride into the mouth.
Brushing should be introduced as soon as the first tooth erupts and parents/ carers should brush / supervise brushing.It is recommended that teeth are brushed with a family fluoride toothpaste twice a day (last thing at night before bed and on one other occasion). Toothpaste should contain no less than 1,000ppm. For children under 3 years only a smear should be used and a pea-sized amount for 3-6 year olds.
Access to Dental Care
Parents should be encouraged to take their children for regular visits to a dentist from an early age and before problems occur.
Encouraging such attendance of young children at a dental practice should be viewed primarily as an opportunity to provide:
tailored preventive advice and care, including the use of professionally applied preventive interventions such as fluoride varnish and
reinforce the development of good oral health habits from an early age.
Dental care should complement home and community based interventions.
Sadly for many children, their first experience of dental services is an emergency appointment in response to tooth ache as a result of dental decay. Lack of attendance for regular dental care, despite obvious need, is recognised as neglect under the UK guidelines (NICE, 2009).