Cutting your teeth on Ireland's dental service

Up to half of children in Ireland have tooth decay by the age of five yet the public dental screening service does not kick in until at least the age of seven

WHEN PARENTS celebrate the milestone of their baby’s first tooth at about six months, the prospect of bringing the child to the dentist seems very far off.

Certainly, if they take their lead from the public dental service in this country, it is not something to think about until well into primary school.

But in fact the Irish Dental Association recommends that children are brought for their first check-up by the age of one.

In the US, where it was recently reported that dental decay is on the rise in pre-school children for the first time in 40 years, both the American Academy of Paediatrics and the American Academy of Paediatric Dentistry stress the importance of children having a “dental home” by their first birthday. They are then more likely to receive appropriate preventive and routine oral healthcare.

Up to half of children in Ireland have tooth decay by the age of five yet the public dental screening service does not kick in until at least the age of seven.

So, for the first few years of a child’s life, parents are on their own when it comes to monitoring dental health and it is up to them to seek professional help – if they can afford it.

Many dental practices are happy to see very young children but may refer them to a paediatric dentist if there is a problem. You can go straight to a paediatric dentist yourself (see "find a dentist" on dentist.ie), although there are only about 20 of these specialised practices in the State so you may have to travel.

The HSE dental screening service aims to cover children in second, fourth and sixth classes, with follow-up treatment as required. But this target is often not achieved as resources vary widely from region to region. (Although in at least one area, Dún Laoghaire in Co Dublin, screening is offered at an earlier age.)

“Current practice is also to provide emergency dental services to children outside these school-going ages, including pre-school children,” according to a spokeswoman for the HSE.

The Irish Dental Association, which has been calling for an audit of public dental services available to children, says that the ban on recruitment in the HSE has resulted in the closure of some dental clinics.

“Denying our children and special needs patients proper dental care is a shocking indictment of our healthcare system,” comments the association’s incoming president, Dr Andrew Bolas.

Every parent should be aware of the care available for their children, he points out.

“Unfortunately, there is little or no public information available to parents to let them know what level of service is being provided in their area.”

Paediatric dentist Margaret Tuite has seen a definite increase in dental decay among the two to five age group at her private practice in Mount Merrion, Dublin, over recent years.

“After the advent of fluoride in water and fluoride in toothpaste it seemed we had a good lid on caries [tooth decay or a cavity],” she says. But over the past 10 years that appears to have changed for the worse, which she attributes to the modern diet and a change in child-rearing practices.

The “grazing” lifestyle that has developed in many households can be the dental downfall of even very young children, she argues.

It is not necessarily the quantity of sugary foods consumed that has the most impact on teeth but rather the frequency with which they are eaten.

This applies not only to what are regarded as unhealthy snacks, such as chocolate, sweets and biscuits, but is also an issue when it comes to what are viewed as healthy fillers, such as dried fruit, juices and yogurts.

“All children can have juice, all children can have sugar, all children can have chocolate – there is no need for a prohibition on all those nice things,” says paediatric dentist Rose-Marie Daly, who has a practice in Tralee, Co Kerry. “The problem is how frequently they eat them.”

Research shows that healthy saliva can overcome the challenge posed to the teeth by up to five food intakes a day, provided the teeth are brushed with fluoridated toothpaste twice a day.

More instances of eating will increase the risk of caries developing.

“We all have bacteria in our mouths and when you ingest sugar the bacteria feed on the sugar and produce acid,” she explains.

The acid, which leaches ions out of the enamel, is neutralised by healthy saliva and this helps to remineralise the teeth.

“You have a constant dynamic flux in the mouth – where the saliva has to remineralise every time the mouth demineralises.

“If you go over the magic number, the ratio will fall in favour of demineralisation and that’s when cavities start.”

This is why it is a good idea, if children are having a treat, to give it to them no more than half an hour after dinner.

“There is lots of healthy saliva in the mouth at that time and it also means there is only one acid challenge as opposed to two,” says Daly.

Tooth decay is the most common chronic disease of childhood, yet it is a completely preventable disease – at least in the ideal world.

Tuite’s maxim is that “early attention [and] maximum prevention brings minimum intervention” – and that has to be from the very beginning, she stresses, even when your baby is all gums (see panel).

You might think that decay in baby teeth is not a major problem, as the child is going to lose them anyway, but that would be a mistake. For a start, says Daly, there is a very strong link between children’s general health and wellbeing and their dental health.

“If children have untreated decay in their teeth, there is strong evidence now to show that it affects their overall growth and development.”

Cavities in the baby teeth are also likely to be detrimental to the permanent teeth that follow. Millions of bacteria live in those cavities and, when the adult teeth grow into the mouth, they are more likely to be affected by decay because of the extra bacteria in the mouth.

Dental decay can result in facial swelling and Daly sees about half a dozen cases a year where this is so bad the children need to be admitted to hospital. “It can be potentially life-threatening if they get a blood-borne infection or if it embarrasses the airway.”

Baby teeth also play an important role in helping the jaws and the adult teeth develop into the right position.

“If they are lost early, this can create problems in how the adult teeth align themselves. Often the loss of baby teeth can lead to orthodontic problems down the road.”

Health-conscious parents who strive to get the much-promoted “five a day” into their children may have been dismayed at the recent warning by a UK dental expert that too much fruit and juice can cause dental erosion.

Secretary of the Irish Dental Association, Dr Michael Crowe, who studied nutrition before going into dentistry, says most dentists would not be advising anybody to consume less than five fruit and vegetables a day just because they are concerned about their oral health.

The increased consumption of fruit juices and cordials by young children is not good for oral health, nor is very frequent sucking on wedges of fruit.

“But eating five or six portions of fruit and veg a day is not going to be detrimental,” says Crowe. “It is to do with the way you consume it.”

Tuite, who believes juice is a “big, big issue” in the problems she sees among young children, advises parents to keep it, along with smoothies and yogurt drinks, as a treat, not as a daily snack. “Milk and water are safe drinks.”

She also urges parents of under fives to concentrate on giving hands-on assistance in cleaning their teeth.

“It may be a struggle, particularly with younger ones, but it is a struggle they have to win.”

'THE TOOTHPASTE TATES VERY NICE AND THE CLEANER DOESN'T TICKLE':

George O’Brien (six) is engrossed with Lego in the corner of the waiting room while his four-year-old sister Kate flits around the room asking questions. “When is he coming?” she demands to know. “Why is he taking so long?” echoes George. They have arrived a few minutes early for their first visit to a dentist and are impatient to get on with it.

Their mother, Eavan Sheehan, had been meaning to arrange for them to see a dentist for the past year. “I am very conscious of their teeth and general wellbeing.”

She contacted her local HSE dental services centre in Dún Laoghaire, Co Dublin, while George was in junior infants, and was told he would be screened in senior infants.

Now, two-thirds of the way through senior infants and still no sign of the HSE team at school, she decided to go private and chose Garry McMahon’s dental practice in Blackrock, Co Dublin on the basis of a personal recommendation.

She kept the build-up “low key”, explaining to the children that the dentist would be looking at their teeth and mentioning the pink liquid that would be there for rinsing their mouths.

The children show no signs of anxiety, bounding into the treatment room when the time comes. After the introductions, McMahon says that at this stage the parent usually returns to the waiting room and Sheehan duly disappears. “That’s not every parent’s choice,” he says, but he finds that generally children, unless they are very nervous, do better without the parent in the room.

There is not a bother on George as he clambers onto the reclining chair, while Kate looks on from a seat in the corner.

Lying still is one rule and keeping hands on the tummy at all times is the other rule, McMahon tells George as he inspects the boy’s open mouth, listing the teeth present to the nurse. He gives the odd tooth a little scrape – just to let the child feel an instrument in his mouth, he explains afterwards – before introducing the polisher. “You are doing very well on cleaning. Do Mum and Dad help you?”

“Sometimes,” says George who, minutes later, is a little concerned as he misses the basin when spitting out the pink mouth wash.

Then it is time to swap places and, with the wisdom of a veteran, George advises his sister that “the toothpaste tastes very nice and the cleaner doesn’t tickle”.

It is the same routine for the pre-schooler – although when the dentist asks her do Mum and Dad help her to brush, she chirps back: “Just today.” And, despite – or because of – what her brother said about the polisher not being ticklish, she giggles at the touch of it.

Sheehan is called back in to be told her children have lovely teeth, that the cleaning is quite good but that they do still need assistance. In a quick run over dietary issues, he says fizzy drinks are okay on a visit to a restaurant or at parties, “but not in the fridge at home”. When it comes to treats, guide them towards chocolate, keep off the sticky sweets, avoid lollipops and ice-cream is better than a packet of sweets.

After that gentle introduction to the world of dentistry, the children happily troop out with free brushes and pencils – and with their curiosity about that legendary pink liquid finally satisfied.

TEN TIPS FOR HEALTHY TEETH:

1. Even before children have teeth it’s important that their gums are clean. After a feed, wipe the gums with a piece of gauze or clean facecloth.

2. Once teething starts, keeping the gums clean eases your baby because “the more bacteria around the mouth, the more inflamed the gums get, the more sore they are”, says paediatric dentist Rose-Marie Daly.

3. Rubbing the gums with your finger will not only give them comfort but also help teeth to come up quicker.

4. When teeth start to appear, clean them twice a day – ideally get professional advice on how to do this.

5. Never put anything other than milk or water in a bottle and don’t let a baby keep a bottle of milk in the mouth when sleeping.

6. Bring your child to the dentist by 12 months of age; the frequency of visits after that will vary on advice.

7. Ditch the soother by age three as it can have an adverse effect on facial development, as can prolonged thumb-sucking.

8. Help children to clean their teeth up to at least seven years of age – or even on into double digits, say some dentists, depending on the child’s ability.

9. If your child gets a bang in the mouth, it is very important to go for a dental check-up as an injury to even a small baby tooth can have significant implications for the growth of the adult tooth behind it.

10. Finally, look after your own oral health as research has shown that parents with active tooth decay can pass on cavity-causing bacteria via saliva to their children.

swayman@irishtimes.com