Oral health care in children
Sarah Greenshields, Lecturer in Children and Young People’s Nursing, Northumbria University,
Newcastle upon Tyne, sarah3.greenshields@northumbria.ac.uk
A
child’s oral health is recognised
as being a contributing factor
to their healthy development.
The World Health Organization
(WHO) defines oral health as being free
from chronic mouth and facial pain, cancers,
infection and other conditions that may
inhibit a person’s ability to chew, bite, smile
or speak (WHO, 2018). Oral health problems
include gum disease, tooth decay (Figure 1),
tooth loss and other oral mucosal diseases.
Tooth decay is the most common oral
disease affecting children and young people
in England and is considered to be mostly
preventable (Public Health England (PHE),
2016a). It is considered to be a public health
priority linked to childhood obesity and
is also connected to factors such as health
inequality.
Poor oral health in children impacts on
both the child and their family. Tooth decay,
otherwise known as dental caries, is the most
common reason for 5–9 year olds in England
to be admitted to hospital (Health and Social
Care Information Centre (HSCIC), 2015).
These admissions are often for the removal of
teeth under general anaesthesia. For example,
in 2015, more than 602 000 children and
young people aged 0–19 years were admitted
to hospital to have teeth removed under
general anaesthesia (HSCIC, 2015).
Children with dental caries suffer a range
of symptoms and difficulties (Box 1). Poor
oral health can be a significant indicator of
wider health and social issues. For example,
dental neglect may be part of a safeguarding
issue, which must be considered by
practitioners.
Dental caries are caused by a range of
complex factors. However, on a basic level
the bacteria in the mouth break down food,
especially carbohydrates, leading to acid
production, which can demineralise teeth.
With continued demineralisation tooth
structures are destroyed, resulting in the
development of cavities, then possibly tooth
loss and systemic infection (WHO, 2018).
980
The National Dental Epidemiology
Programme reports data indicating that the
oral health of 5 year olds across the UK is
improving. However, there remains significant
concern regarding the oral health of the
nation’s children. In 2015, 24.7% of 5 year
olds started school with dental caries (PHE,
2016a). In those children, 3–4 teeth will, on
average, be affected.
As with many areas of health, the wider
determinants need to be considered and
there are variations across the UK. Evidence
suggests that deprivation and ethnicity both
affect the data recorded. Children who attend
specialist schools who have dental caries were
twice as likely to have had one or more teeth
extracted (PHE, 2015).
Brushing children’s teeth
PHE (2017) guidance suggests that, as soon
as the first tooth appears (which is usually
at around 6 months), a child should have
their teeth brushed at least twice a day using
fluoride toothpaste. The recommendations are
to do so in the morning and evening.
The reason for brushing teeth before bed
is that fluoride continues to protect teeth
throughout sleep. Children tend to need
support brushing their teeth effectively until
around the age of 7 years. However, this
depends on a child’s stage of development
and maturity. The guidance (PHE, 2017)
also suggests that, between the ages of 0 and
6 years, children should use toothpastes
containing 1350–1500 parts per million
Figure 1. Dental caries in a 3-year-old
Downloaded from magonlinelibrary.com by 130.209.006.061 on December 2, 2019.
fluoride. The amounts needed are shown
in Figure 2 (a smear of toothpaste for 0-3 year
olds) and Figure 3 (pea-sized for 3-6 year olds).
Health education and promotion
Health education should be given to families
regarding a healthy diet. This includes the
reduction of sweet foods and drinks in the
diet. It is important to highlight to parents
and carers that this includes reducing the
consumption of fruit juices and smoothies.
Practitioners should also consider the sugar
content of prescribed and over-the-counter
medications and seek sugar-free alternatives.
Families should also be informed about
the oral health risks associated with bottle
use. Bottle feeding should be discouraged
from 12 months old (PHE, 2017).Visiting the
dentist should be promoted from the time
the first teeth appear. Dental reviews should
occur as often as advised by the dentist and
are free for children under 18 years of age.
The dentist may apply a fluoride varnish to
children aged over 3 years to protect their
teeth (PHE, 2017).
There is a range of public health
interventions related to oral health (Box 2),
and national and local government policy has
a key role to play (PHE, 2014a). The recent
government action to address childhood
obesity will also impact on oral health, as
both share a common risk factor; the
consumption of sugars. It is argued that if the
nation is to make significant changes in the
oral health of its children, there needs to be a
reduction in the consumption of free sugars
(those added to foods by manufacturers) and
increased access to fluoride. Godson et al
(2018) stated that oral health improvement
should be everyone’s business.
Water fluoridation
© 2019 MA Healthcare Ltd
Evidence from global research has repeatedly
shown that water fluoridation is a safe and
effective public health intervention (PHE,
2014b). This intervention does not rely on
individual behaviour change, which can be
British Journal of Nursing, 2019, Vol 28, No 15

Figure 2. A smear of toothpaste is the
amount to use with 0–3-year-olds
Figure 3. A pea-sized blob of toothpaste
is the amount to use with 3–6-year-olds
challenging. Fluoride reduces the likelihood
of developing dental caries and reduces the
severity of the condition where it exists.
All water supplies contain some naturally
occurring fluoride. Currently, in the
UK, about 10% of the population drink
fluoridated water compared with 70% of the
population in the US (PHE, 2016b). When
comparing children who reside in areas
where water is fluoridated with those where
it is not, the data is stark. Five year olds in
fluoridated areas were 28% less likely to have
had tooth decay in their baby teeth than
those in non-fluoridated areas and 12 year
olds in fluoridated areas were 21% less likely
to have had tooth decay in their permanent
teeth than those in non-fluoridated areas
PHE, 2016b).
The debate regarding fluoridation usually
centres around cost, benefit and ethical
implications.
Making every contact count
All nurses have an important role in ‘making
every contact count’ (NHS England, 2016).
This should include having the knowledge
© 2019 MA Healthcare Ltd
and skill to promote evidence-based
messages and to support families to take
action on their oral health. This will also
require a nurse to consider assessing and
supporting behaviour change.
British Journal of Nursing, 2019, Vol 28, No 15
At times, practitioners will need to have
the confidence to refer children and their
families to local dental services. Research
indicates that this remains a challenge, for
example one-third of health visitors have
never received oral health training (Oge et
al, 2018).
Public Health England’s health guidance
on child oral health provides some useful
information (PHE, 2019).
Conclusion
Poor oral health can lead to number of health
problems—in children this is primarily dental
caries. Routine oral hygiene and advice
regarding sugar intake can support the oral
health of a child. It is important to recognise
that children should grow up with good
oral health and that dental caries are mostly
preventable. BJN
Department of Health. Healthy child programme: from
5-19 years old. 2009. https://tinyurl.com/y6x5fyak
(accessed 26 July 2019)
Godson J, Csikar J, White S. Oral health of children
in England: a call to action! Arch Dis Child.
2018;103(1):5–10. https://doi.org/10.1136/
archdischild-2017-312725
Health and Social Care Information Centre. Hospital
episode statistics (archived). 2015. https://tinyurl.com/
y38jf7fm (accessed 26 July 2019)
National Institute for Health and Care Excellence. Oral
health: local authorities and partners. Public health
guideline PH55. 2014. https://www.nice.org.uk/
guidance/ph55 (accessed 26 July 2019)
NHS England. Making every contact count: consensus
statement. 2016. https://tinyurl.com/y6hanuob
(accessed 26 July 2019)
Oge OA, Douglas GVA, Seymour D, Adams C, Csikar
J. Knowledge, attitude and practice among Health
Visitors in the United Kingdom toward children’s oral
health. Public Health Nurs. 2018;35(1):70–77. https://
doi.org/10.1111/phn.12381
Public Health England. Local authorities improving oral
health: commissioning better oral health for children
and young people. An evidence-informed toolkit for
local authorities. 2014a. https://tinyurl.com/qzeuo95
(accessed 26 July 2019)
Public Health England. Water fluoridation: health
monitoring report for England 2014. 2014b. https://
tinyurl.com/lnez4nl (accessed 26 July 2019)
Public Health England. Dental public health
epidemiology programme. Oral health survey of five-
year-old and 12-year-old children attending special
support schools 2014. A report on the prevalence and
LEARNING POINTS
■■ Understand the problems associated with poor oral health in children
■■ Know how to ‘make every contact count’ by advising parents about a diet that will
promote oral health
■■ Be able to advise on correct brushing techniques and toothpastes for children
■■ Know when to refer children to dental services
Downloaded from magonlinelibrary.com by 130.209.006.061 on December 2, 2019.
AT A GLANCE
Box 1. Symptoms and challenges
■■ Pain
■■ Infection
■■ Difficulties eating
■■ Disturbed sleep
■■ Missed school due to dental appointments
■■ Impact on confidence, which affects
socialising
■■ Fear and anxiety of undergoing dental care,
which has lifetime consequences
■■ Loss of deciduous teeth and/or first
permanent molars can introduce the need for
or complicate future orthodontic treatment,
with cost implications for the NHS and
missed schooling for the child
Box 2. Interventions for the wider
population
■■ Oral health training for the wider
professional workforce so that it can be
incorporated into all health and social care
contacts
■■ Targeted provision of toothbrushes and
fluoride toothpaste in at-risk groups
■■ Supervised tooth brushing in targeted
childhood care settings
■■ Healthy food and drink policies in nurseries
and primary education
■■ Fluoridation of the water supplies
■■ Influencing government policies
Source: Department of Health, 2009; National Institute
for Health and Care Excellence, 2014a; Public Health
England, 2014a
severity of dental decay. 2015. https://tinyurl.com/
y3pl4gyj (accessed 26 July 2019)
Public Health England. National dental epidemiology
programme for England: oral health survey of five-
year-old children 2015. A report on the prevalence
and severity of dental decay. 2016a. https://tinyurl.
com/y66snyn2 (accessed 26 July 2019)
Public Health England. Improving oral health: a
community water fluoridation toolkit for local
authorities. 2016b. https://tinyurl.com/yy3z6s9o
(accessed 26 July 2019)
Public Health England. Delivering better oral health: a
quick guide to a healthy mouth in children. 2017.
https://tinyurl.com/yyykwkd2 (accessed 26 July
2019)
Public Health England. Child oral health: applying all our
health. 2019. https://tinyurl.com/yyrfbrfp (accessed
26 July 2019)
World Health Organization. Oral health. 2018. https://
tinyurl.com/y2wqwyvt (accessed 26 July 2019)
981