Treating children in a dental surgery is one of the most challenging practices of dentistry. There are so many factors that have to be managed with children – communication (age-dependent), the parents' role, treatment options, the child's cooperation and finally, compliance.
Caries and more recently tooth wear, are prevalent diseases affecting children in the UK and there have been various teams, strategies, policies and interventions that have promoted the importance of oral hygiene but yet, carious teeth in young children is the greatest cause of hospital admissions for 5 to 9 year-olds in England.
Ways to predict the good from the bad
I once saw a 16 year-old who was accompanied by her. She was experiencing pain and had broken down teeth. When I asked the patient a question, she had a sunken demeanor and would not talk.
Her father however gave responses like "she doesn't brush her teeth even though we say her teeth will fall out," and "she only eats biscuits, sweets and fizzy drinks. We leave a sandwich out but she won't eat it."
I have even had to refer a 6 year-old child for extractions due to gross caries on deciduous teeth.
From my experiences, several factors can help you to determine the 'good from the bad':
How does the child look by their general appearance, facial expressions and overall demeanor? A happy child may indicate cooperation.
I recently came across a child who looked 'scruffy' and was very uncooperative in his body language. I later learned from the mum that he has been diagnosed with mild autism.
2) The parents
My experiences with parents have told me a lot about the prognosis of the child's dentition from their level of cooperation.
I've found that if parents are more involved and get good cooperation from their children, the prognosis is usually better. If parents play an active role in their child's habits and engage with them in learning about decay, erosive foods and drinks, then the children's teeth are usually better.
3) Attendance patterns
You can learn a lot from noticing how many appointments were missed, cancelled and attended.
4) Diet and tooth-brushing habits
Ask parents to bring along the child's toothbrush and ask the child to show you how they brush.
Analysing the child's dietary and tooth-brushing habits give you an overview of what future issues may arise and evolve.
I read recently about the controversy around how carious teeth in children relate to child neglect and in some ways, I agree with this.
It can be argued that cases of gross caries, fractured teeth and infections relate to upbringing. And yes, it is the parents' direct responsibility to manage the child's dentition – their own dentition, demeanor, attendance patterns and habits can influence a child's.
I have seen some parents who have had to go through a lot of dental work as a child and do not want this for their own, and so their cooperation and attendance play a positive influential role on the prognosis of the child's teeth.
Perhaps the parents' contribution is directly proportional to the outcome of their child's oral health.
Communication is a term used so frequently in dentistry and throughout dental school but knowing its impact is something you can witness first-hand.
When I treated a child with autism, I had to figure out how to use different strategies to communicate and engage with him. He used blinking as a form of 'yes' and I could improve our communication just from using a mirror so he could see what I was doing.
A full check-up and fluoride varnish was done successfully, to the surprise of his mother. I ended the appointment by giving him a disposable mirror to go home and see his teeth whilst he brushed – this was something that I hoped would positively influence his oral hygiene habits. It felt like a real breakthrough!
What I have learned
In my experiences so far, I can say that despite the growing awareness of oral hygiene, along with mass advancements in technology and knowledge, there is still a high number of cases showing children having to undergo invasive dental treatment, purely based on poor oral hygiene perhaps coincident to the conditions of the UK.
Pockets of deprived areas still exist and some are affected by a domino effect, with habits passed from generation to generation.
In practice, it's important to establish the underlying determinant and guide the parent and/or child to manage that as much as they are able to. Yes, there are factors that are outside of your control, and yes, you are going to be ignored, told off, have no influence on some parents…but repetition and consistency is better than doing nothing.
I used to think the statement 'prevention is better than cure' was far-fetched and impossible. But with a little bit of patience, understanding, a little bit more time in these cases, education and tailored treatment can help prevent the knock-on effect of caries – and hopefully fewer children with missing teeth and pain.
Sara Misra, foundation dentist