From Research Into Practice
December, 2009 edition

Commentary on “Toothpaste Use By Children, Oral Hygiene, and Nutritional Education: An Assessment of Parental Performance”

 By Cynthia C. Gadbury-Amyot, RDH, EdD

Wiener RC; Crout RJ, Wiener MA. Toothpaste use by children, oral hygiene, and nutritional education: an assessment of parental performance. Journal of Dental Hygiene, Vol. 83, No. 3, Summer 2009.

Abstract

Purpose: The aim of this study was to determine oral health habits and educational needs of children as reported by their parents or guardians attending a health fair in West Virginia.

Methods: Parents and/or guardians completed a questionnaire about the oral hygiene care, food and beverage consumption of their children. They also demonstrated the amount of toothpaste applied to their children’s toothbrush. Toothpaste samples were then weighed.

Results: Eighty-seven parents or guardians participated. An average of 0.53 mg of toothpaste was dispensed per brushing, almost double the recommended amount. Most of the parents or guardians (75 percent) indicated their children had brushed twice the day prior to completing the questionnaire. Only 21 percent reported that their children’s teeth had been flossed. Most children had a limited soda, sweet drinks, and fruit juice intake.

Conclusions: Participants were apparently knowledgeable about prevention, the need to limit sugary beverages and the importance of brushing twice a day. They were not as knowledgeable about the need for flossing, providing fruits and vegetables to their children, the significance of not skipping a meal or the appropriate amount of toothpaste to use.

Keywords: Toothpaste, parents, nutrition, children, oral health

Background

Chronic dental disease is a concern for populations of all ages but especially young children, where it is five times more prevalent than asthma and seven times more prevalent than hayfever.[1] While preventive measures such as water fluoridation have the potential to reduce the prevalence of caries, tooth decay remains at epidemic proportions among susceptible populations. A report by the U.S. Department of Health and Human Services, Trends in Oral Health Status: United States 1988-1994 and 1999-2004, provides some disheartening prevalence data on caries rates in children.[2] In persons aged 2 to 5, the caries prevalence rates in primary teeth increased from 24.23 percent in 1988-1994 to 27.90 percent in 1999-2004. Among 6- to 11-year-olds, the prevalence rates of caries increased from 49.90 percent to 51.17 percent. This is certainly not the direction that one would hope to see caries prevalence rates trending.

Oral disease has a significant social and developmental impact, as children lose more than 51 million school hours each year due to dental problems.[1] A serious consequence of poor oral health can be poor nutritional status. Poor nutrition as a result of oral pain can lead to poor concentration and learning and result in diminished quality of life. In extreme cases such as that of the 12-year-old Maryland boy, Deamonte Driver, whose abscessed tooth spread infection to his brain, oral disease can lead to death.[3]

The American Academy of Pediatric Dentistry (AAPD) has published guidelines related to infant oral health care stating that an oral health risk assessment for infants by 6 months of age allows for the incorporation of appropriate preventive strategies as the primary dentition begins to erupt.[4] AAPD identifies several strategies that can serve to reduce or eliminate dental caries in young children. Examples of these strategies, called “anticipatory guidance,” include:

General anticipatory guidance for the mother (or other intimate caregiver)

• Oral hygiene: Toothbrushing and flossing by the mother on a daily basis are important to help dislodge food and reduce bacterial plaque levels
• Diet: Important components of dietary education for the parents include the cariogenicity of certain foods and beverages, role of frequency of consumption of these substances and the demineralization/remineralization process.
• Fluoride: Using a fluoridated toothpaste approved by the American Dental Association and rinsing every night with an alcohol-free, over-the-counter mouth rinse containing 0.05 percent sodium fluoride have been suggested to help reduce plaque levels and help enamel remineralization.
• Caries removal: Routine professional dental care for the mothers can help keep their oral health in optimal condition. Removal of active caries with subsequent restoration is important to suppress maternal Mutans streptococci (MS) reservoirs and has the potential to minimize the transfer of MS to the infant, thereby decreasing the infant’s risk of developing early childhood caries (ECC).
• Delay of colonization: Education of the parents, especially mothers, on avoiding saliva-sharing behaviors (e.g., sharing spoons and other utensils, sharing cups, cleaning a dropped pacifier or toy with the mouth) can help prevent early colonization of MS in their infants.
• Xylitol chewing gums: Evidence demonstrates the mother’s use of xylitol chewing gum can prevent dental caries in her children by prohibiting the transmission of MS.

General anticipatory guidance for the young patient (0-3 years of age) includes the following:

• Oral hygiene: Oral hygiene measures should be implemented no later than the time of eruption of the first primary tooth. Cleansing the infant’s teeth as soon as they erupt with either a washcloth or soft toothbrush will help reduce bacterial colonization. Children’s teeth should be brushed twice daily with fluoridated toothpaste and a soft, age-appropriate sized toothbrush. A “smear” of toothpaste is recommended for children less than 2 years of age, while a “pea-size” amount of paste is recommended for children 2 to 5 years of age. Flossing should be initiated when adjacent tooth surfaces cannot be cleansed with a toothbrush.
• Diet: High-risk dietary practices appear to be established early, probably by 12 months of age, and are maintained throughout early childhood. Frequent nighttime bottle feeding, ad libitum breast-feeding, and extended and repeated use of a sippy or no-spill cup are associated with, but not consistently implicated in ECC. Likewise, frequent consumption of snacks or drinks containing fermentable carbohydrates (e.g., juice, milk, formula, soda) also can increase the child’s caries risk.
• Fluoride: Optimal exposure to fluoride is important to all dentate infants and children. The use of fluoride for the prevention and control of caries is documented to be both safe and effective. Twice daily brushing with fluoridated toothpaste is recommended for all children as a preventive procedure. Professionally applied fluoride, as well as at-home fluoride treatments, should be considered for children at high caries risk based upon caries risk assessment. Systematically administered fluoride should be considered for all children drinking fluoride deficient water (<0.6 ppm). Caution is indicated in the use of all fluoride-containing products. Fluorosis has been associated with cumulative fluoride intake during enamel development, with the severity dependent on the dose, duration and timing of intake. Decisions concerning the administration of additional fluoride are based on the unique needs of each patient.

Summary of Key Findings in This Article

A convenience sample of West Virginia parents/guardians attending a health fair in West Virginia with children under the age of 15 were recruited for this study. Eighty-seven parents/guardians completed a survey with questions about 1) frequency of brushing, 2) flossing, and 3) type of toothpaste used. They were then asked to demonstrate the amount of toothpaste they typically applied to their child’s toothbrush; this was then measured using an instrument to obtain a total weight. In addition, the parents/guardians were asked to provide a short description of the beverages and food consumed the previous day.
Findings included:

• Mean age of the children was 5.4 years
• 75 percent of children were brushed two or more times a day
• 75 percent used fluoride toothpaste
• Mean amount of toothpaste used by participants measured 0.53+0.07g with a range of 0.11g – 1.41g (approximately twice the recommended amount of 0.25g)
• 21 percent of parents/guardians reported that their children’s teeth were flossed daily
• Median and range of beverage consumption the previous day included:

• Examples of food items consumed the previous day

The authors concluded that a majority of participants in this study were following recommended guidelines by brushing their children’s teeth twice daily but were not flossing daily. A majority of the participants reported using fluoridated toothpaste but were using more than the recommended amount. Exposure to beverages high in sugar was minimal as reported by participating parents/guardians. In contrast, diets high in processed carbohydrates and low in fruits and vegetables were reported. Education related to oral hygiene and dietary considerations is necessary.

What Are the Implications of this Article for Clinical Practice?

While national trends are showing a decline in prevalence of decay in permanent teeth from the 1988–1994 to 1999–2004 National Health and Nutrition Examination Surveys (NHANES), that trend has not been the same in primary teeth where there has been an increased incidence.[2] While this was a small study, it does highlight the need for increased education of parents/guardians when it comes to oral health. It is important for dental hygienists to be familiar with oral health statistics in the states where they live and practice so that they are able to articulate the need for dental hygiene services to all stakeholders.

The AAPD guidelines acknowledge that allied health professionals, and for purposes of this paper dental hygienists, must be involved as partners to achieve the goals of preventive education and oral health care for children at all stages of development. Dental hygienists have the educational background and skills necessary for performing oral health risk assessments and instituting appropriate preventive strategies. Building from research conducted by John Featherstone, dean at the University of California, San Francisco, AAPD has a caries risk assessment tool and training available on their Web site (http://www.aap.org/commpeds/dochs/oralhealth/cme/index.htm). This risk assessment takes into consideration clinical conditions, environmental characteristics and general health conditions and then categorizes the child as low, moderate or high risk. Based on the outcomes of the risk assessment, specific oral health strategies are then recommended.

Conclusion

As practice acts have allowed for expanded scopes of practice for dental hygienists, it is more likely than ever that dental hygienists will have increased access to children. This will allow the dental hygienists to not only provide comprehensive preventive services but also ensure that needed restorative care is made available. The recent approval (May 13, 2009) by the Minnesota legislature of legislation allowing training of an advanced dental therapist has great potential for expanding care to the unserved and underserved. This master’s level educated provider will be licensed to practice and work with a supervising dentist via a collaborative management agreement. These new providers will focus their practice on care for underserved populations in the state and will administer educational, preventive, palliative, therapeutic and restorative services (Minnesota Statute 150A.10 – Allied Dental Personnel).[5] Collaboration among all oral health care providers will be needed to serve all segments of the population.

References

1. U.S. Department of Health and Human Services. Oral health in America: a report of the surgeon general. Rockville, Md.: USDHHS, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
2. Dye BA, Tan S, Smith V, Lewis BG, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. National Center for Health Statistics. Vital Health Stat 11(248). 2007.
3. Otto M. For want of a dentist: Prince George’s boy dies after bacteria from tooth spread to brain. Washington Post. February 28, 2007.
4. American Academy of Pediatric Dentistry. Guideline on infant health care, 2009. Available at http://www.aapd.org/media/Policies_Guidelines/G_InfantOralHealthCare.pdf.  Accessed Oct. 5, 2009.
5. 2009 Minnesota Statues - Chapter 150A. Dentistry. Statute 150A.10 – Allied Dental Personnel. Available at https://www.revisor.leg.state.mn.us/statutes/?id=150A. 10 Accessed Oct. 5, 2009.

Cynthia Gadbury-Amyot, BSDH, EdD, is professor and director of Distance Education and Faculty Development at the University of Missouri-Kansas City School of Dentistry. She has served as director of the Division of Dental Hygiene at the University of Missouri-Kansas City, as well as director of graduate and degree completion studies.

ADHA members can access the full article online by linking directly to the Journal of Dental Hygiene through the Members section of the ADHA Web site. To view journal articles, log in to the Members section of the ADHA Web site and click on the Member Resources link. Scroll down to the Journal of Dental Hygiene link, which will take you directly to a list of all the available issues online.

This column was made possible by an educational grant sponsored by Colgate Oral Pharmaceuticals.