Your Health

All smiles

Visits to the dentist help promote oral health

It's free if you're under three Why oral health matters About that sippy cup Healthy smile, happy child Good brushing habits

BY BOB ARMSTRONG
Winnipeg Health Region
Wave, May / June 2010

At the age of six, with eight bright, white permanent front teeth, Storm Lynn Fiddler is an example to her schoolmates of the benefits of oral hygiene and dental care.

But her clean bill of dental health is no accident. Her grandmother, Shirley Declercq, took Storm to see Dr. Bob Schroth, a dentist who practises at the Winnipeg Health Region's Access Downtown, when she was just eight months old.

Applications of fluoride varnish combined with diligent care by her grandmother, who flosses the little girl's teeth every night and makes sure she brushes thoroughly twice a day, have made Storm the poster girl for Manitoba's efforts to curb tooth decay in young children.

And we need a poster girl, because despite a decade of efforts to deal with an epidemic of early childhood tooth decay (known as ECC, for early childhood caries, the technical term for tooth decay), Manitoba still has more than 2,000 children per year requiring dental surgery under general anaesthetic.

Storm did not need such dental surgery, as Schroth was able to address potential issues before they became problems.

Declercq, meanwhile, has become an advocate of oral health for kids. "I volunteer at Storm's school," she says. "I talk to the kids and say, 'Make sure to brush your teeth.' I tell them Storm's teeth are strong."

The tragedy is that the pain of tooth decay and the health and behaviour problems it can cause are preventable.

"It's a disease of poverty, particularly extreme poverty," says Dr. Mike Moffatt, a pediatrician and Executive Director of Research and Applied Learning with the Winnipeg Health Region. "The general population had this problem in the 1950s prior to fluoridated water, toothpaste and rising standards of living," he says.

In the 1950s, after the end of Second World War-era sugar rationing, young baby boomers were the first generation to have plentiful pop and candy. As a result, most people 50 years of age or older have a mouthful of fillings.

Access to fluoride, education about tooth decay and preventive trips to the dentist have meant that, in most cases, the children and grandchildren of baby boomers have much healthier teeth.

But in remote and northern communities, where poverty is combined with limited access to healthy food, a lack of fluoridated water and a shortage of dental care, tooth decay is epidemic in children. High needs areas in Winnipeg are almost as badly affected.

A decade ago, childhood tooth decay became a major problem for the health system as a whole when the waiting list for young children to receive dental surgery grew to 1,500. As unfortunate as that was for children who were flown to Winnipeg to have decayed baby teeth removed under general anaesthetic, it was also becoming a serious problem for the health-care system because of the drain on operating room resources.

A baseline study conducted in 2001 in Winnipeg, Thompson and two First Nations communities showed that more than half of the pre-school children examined had decayed, extracted or filled teeth - an average of 4.2-5.0 per child.

Jeanette Edwards, Regional Director of Primary Health and Chronic Disease with the Winnipeg Health Region, knew something had to be done. "I thought, 'This is 100 per cent preventable,'" reflects Edwards. "I thought we needed to be working upstream, as with many issues in health care, and looking at how we can prevent this problem."

That need to focus on prevention led to a multi-agency, multi-community project eventually named Healthy Smile Happy Child, combining community consultations, education, research and co-operation among health-care professionals. With about $1.8 million over three years from Manitoba Health, the project went province-wide in 2006.

Preliminary results prepared by Schroth and Edwards indicate that Healthy Smile Happy Child has raised the level of understanding and is leading to fewer young children having untreated tooth decay.

But the problem is far from licked.

"We need to see oral health in the context of childhood health and wellbeing," says Schroth, who, in addition to practising as a dentist, has been researching childhood tooth decay prevention and the effects of tooth decay for a PhD in community health from the University of Manitoba.'

In the past, some people assumed decay in baby teeth was not a problem because they weren't permanent. "The attitude was, 'They're just baby teeth - they'll fall out anyway,"' notes Schroth.

But childhood tooth decay has a host of harmful effects on a child's overall health and well-being. The pain of a toothache can affect a child's ability to sleep or to chew food, leading to side-effects ranging from behavioural problems to lack of nutrition and slow or stunted growth. When baby teeth are removed because of decay, that affects the way the permanent teeth will come in, setting up children for future orthodontic difficulties.

Schroth and Moffatt also point to a link between childhood tooth decay and iron and vitamin D deficiency. Poor nutrition contributes to childhood tooth decay, but it may also be true that young children with decayed teeth aren't getting the nutrition they need because of their pain.

There's evidence, notes Schroth, that young children with decayed teeth gain height and weight more slowly than their peers with healthy teeth.

More research is needed on the links between childhood tooth decay and other health and behaviour problems, but dealing with decay does appear to have a number of positive effects.

"Parents report that after the dental surgery, sleeping improves, eating improves, behaviour improves," says Schroth.

Parents and caregivers are the first line of defence against childhood tooth decay, and prevention is ultimately a societal job, requiring co-operation and education within and among health-care professions.

The Manitoba Dental Association joined in the effort to keep teeth healthy by launching a Free First Visit program this year, says Dr. Joel Antel, chair of the MDA's Communications Committee.

A first visit, within six months of the eruption of the first tooth, gives the dentist a chance to spot problems before they become too serious, to answer parents' questions about dental care and help children get used to seeing a dentist, says Antel.

The MDA is working to educate the profession that first visits are recommended at an early age, he adds. Though early visits have been recommended by the Canadian and American Dental Associations since the early 1990s, some dentists still believe in the old guideline of a first visit at age three. "The problem with starting at age three is that the child might already have problems by then," says Antel.

Indeed, because enamel on baby teeth is thinner, by that age many children with childhood tooth decay already need teeth to be pulled.

Preventing tooth decay in young children may involve modifying standard pieces of advice. Until now, Health Canada has been advising parents to refrain from giving their children fluoride toothpaste before the age of three because of the risk of flurosis - a condition caused by excessive fluoride that can cause white marks on the teeth.

However, new guidelines soon to be released by the Canadian Dental Association and Health Canada will recommend the supervised use of a smear of fluoride toothpaste for high-risk children beginning with the first baby tooth.

"We'd rather children have a few minor white spots on their adult teeth than need a general anaesthetic for dental surgery because of severely decayed baby teeth," says Schroth.

Given the shortage of dentists in many communities, preventing childhood tooth decay also requires flexibility from health professions. Allowing doctors and nurses to apply fluoride varnish helps to ensure that the children who need help the most will have a better chance of avoiding tooth decay. In the North especially, doctors and nurses have a role to play in spreading the word about dental care and decay.

Even the way to inform the community about childhood tooth decay has required a team approach. In working with communities to design posters and other educational materials, the program developed a poster that shows graphically that filling a baby bottle with juice is like giving a child a big stack of sugar cubes. It's an eye-catching image. But using the image of a baby bottle raised eyebrows because of the fear that it would seem as if health professionals were promoting bottle feeding.

However, notes Edwards, the communities most affected by childhood tooth decay wanted the eye-catching image because it communicated most clearly the effects of one common source of decay-causing sugars - sweet drinks in bottles. In northern communities, even restaurants joined in the fight when paper restaurant placemats were used to convey healthy mouth tips.

As part of the project, workshops were held to give daycare staff, social and family support workers, health professionals and caregivers the chance to learn more about the causes and prevention of tooth decay.

Tooth decay is caused by a rise in the acid level in the mouth - a by-product of bacteria consuming sugars in food and drink. Typically, after eating, the saliva in the mouth will gradually reduce the acidity in the mouth. But when children are given bottles filled with juice or pop, the teeth are continuously bathed in sugar. It's even worse when they are given a bottle in bed, notes Schroth, because during sleep, saliva production is lower.

That can lead to more extreme cases of childhood tooth decay, where the baby teeth are decaying even as they are coming in. Though studies indicate an improvement in knowledge about the causes and prevention of childhood tooth decay, the practices that contribute to it are still around. "Take a quick trip to Polo Park and you'll see kids in strollers with bottles," says the MDA's Antel.

Moffatt admits that fighting childhood tooth decay requires a long-term approach that includes nutrition education, improved dental care for pregnant women, promotion of breast feeding and ultimately dealing with the social conditions that are the common denominator of many preventable diseases.

"Working to assuage poverty is the biggest thing we can do," he says.

	About Wave Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books. Read the May / June 2010 issue of Wave