Healthy Oral Hygiene Habits Established Early in Life

from School Health Reporter, Fall 2004

Jamie Idelberg, RDH, Cleft Palate Clinic Coordinator, The Children's Hospital

In May 2000, David Satcher, MD, PhD, issued the first-ever Surgeon General’s report on oral health in America .

This report focused on the relationship between oral health and overall health throughout life. It was a long-overdue look into the “silent epidemic” of “dental and oral diseases that burden some population groups” and called for “a national effort to improve oral health among all Americans.”

Issues related to oral health were finally validated in the political world, where policymakers were educated on the impact of dental-health issues. The importance of  “tooth-brushing and flossing were acknowledged, along with the need for community programs and education of non-dental healthcare professionals about oral health and disease topics and their role in assuring that patients receive good oral-healthcare.”

As school health nurses, you play an integral role in helping carry out the mandate set forth in that report.

Dental health education is fun. I love being the lady who brings the horse with big teeth, the large toothbrush, Mr. Mouth and Mr. Gross Mouth to schools. The kids giggle, pet and brush Mr. Horse’s teeth, and they love how wide Mr. Mouth can open. They get very quiet or even gasp when Mr. Gross Mouth is presented. The kids are intrigued when I talk about cavities or “holes” in teeth. They always tell me about how and when they brush their teeth and they love making pizza with imaginary nutritious foods.

But I look at these kids as a whole, not just for holes in their teeth. Dental health has far-reaching implications and can go beyond just the teeth. When conducting a dental screening, I look for white or dark spots on teeth, holes in teeth, periodontal health (gums), enlarged tonsils, signs of child abuse, bifid  (split) uvula, speech issues, lumps or bumps, overall tone and appearance and children who are tongue-tied. If we only looked at the teeth, we would miss so much that is easily detected.

One of the most frustrating things I hear is that baby or primary teeth are not important. For years I have provided dental screenings and have seen children with large holes (cavities) in their teeth, in chronic pain, unable to eat because it hurts. Their teachers have told me that the child’s parents are not too concerned because they are baby teeth and will fall out anyway.

As healthcare professionals, it is our responsibility to educate both children and their parents on the importance of primary teeth and why daily oral hygiene is so important. Primary teeth are important for: chewing food, smiling  (everyone wants a nice smile), proper speech production (you need your teeth to make certain speech sounds correctly), and saving space for permanent teeth  (if you lose your baby teeth too soon, other teeth drift forward and there will be crowding when the permanent teeth come in). When parents tell you they are not concerned about their child’s baby teeth, you can tell them otherwise and encourage them to establish a daily oral hygiene routine with their children.

In the initial stages, cavities can appear as white lesions, indicating that the tooth enamel has demineralized and is susceptible to further breakdown. Dark spots on the teeth usually occur on the occlusal surface (chewing) or on the sides of the teeth and indicated that a cavity is present.  Dental care is needed, but usually is not urgent. A large gaping hole in a tooth indicates obvious cavities; the child should receive dental care as soon as possible.

When asked, these children may tell you that it hurts to eat, and they are sensitive to hot and cold temperatures in their mouth. If a child has numerous dark spots and holes in his or her teeth, there can be a lot of bacteria in his or her system from these cavities, and you may notice symptoms of lethargy, lack of appetite and quietness in the classroom. A school nurse should help these children get the dental care they need. It is important to tell parents about the hygiene issue and even request that parents look into the child’s mouth so they can see firsthand what you are talking about. Some parents have never seen inside their child’s mouth and are surprised. They feel guilty and are ready to seek care. Others will dismiss the need for care. These are the parents who need hand-holding to insure proper follow-up.

Periodontal health includes the gums, alveolar bone and the tissue that support the teeth. Healthy gums are pink, firm and stippled in texture (like an orange peel). Causes for concern include red, swollen, puffy, oozing gums and mouth odor. In severe cases it is termed “juvenile periodontitis.”  This would merit a visit to the dentist for a thorough dental cleaning and possible antibiotic treatment.  This is rarely seen in preschool-age children but is seen more commonly in school-age children, especially middle- and high-school students.

A look for any unusual lumps or bumps inside the oral cavity or on the outside including the neck area is important.  I recently saw a 5-year-old girl with a huge eruption cyst over an erupting first permanent molar. This appears as a bluish cyst/sac that surrounds the crown of the erupting tooth and soft, fluctuant swelling of the alveolar ridge.  An eruption cyst is common particularly with premature eruption of teeth, molars and canine teeth. There is usually no treatment required, but a referral to see the dentist is always the safe thing to do.

Other things that also may be identified during a dental screening include a short lingual frenum, which may indicate that a child is tongue-tied.

The way to assess this is to ask the child to stick out his or her tongue. If the child can barely get the tongue past the lips or cannot elevate it to the top of his or her mouth, he or she may have restricted tongue mobility. In some cases this can affect speech. It is hard to make certain sounds if the tongue does not move properly. If this condition is noticed, it is important to ask the teacher if there are speech concerns with that child and if so, if the child is seeing a speech therapist.

This condition may warrant a referral to the dentist to determine if a frenum-release procedure is necessary. Also look at the uvula and make sure it is not bifid or split. A bifid uvula is the classic symptom of a submucous cleft palate.  This kind of cleft affects the muscles that attach in the middle of the soft palate, but not the skin covering. The cleft often is associated with hypernasal speech, and children may have a history of feeding difficulties as infants.  If this condition is detected, a referral to the speech pathologist or the child’s primary-care physician is suggested.

While looking in the back of the throat, notice the tonsils. Large tonsils may be an indication of the body fighting an infection. They also can be a sign of obstructive sleep apnea (OSA).

“Obstructive sleep apnea (OSA), a diagnosis that is often missed, is most often caused in children by enlargement of the tonsils and/or adenoids,” said Greg Allen, MD, pediatric ENT at The Children’s Hospital. “Although these children usually snore when asleep, daytime symptoms are often missed or misdiagnosed. These symptoms may include excessive daytime sleepiness, headaches, poor attention span and poor school performance. This occurs quite frequently, and patients with enlarged tonsils and snoring should be encouraged to discuss this with their primary-care physician.”

During a dental screening, it also is important to look for signs of child abuse or sexual abuse, including ripped or torn frenums, bite marks, bruising of the hard palate, burns on the mucosa or other unexplained oral lacerations.  The source of the injuries always must be investigated. If there is any suspicion of abuse, it must be reported to the proper authorities.

Dental health education programs in schools can be the key to giving children the knowledge base for good dental health and oral-hygiene habits and also to let parents know the value of dental health. A dental program can take place in preschool and elementary school and should include an education component, explaining how to properly brush teeth, how often to brush, how long to brush, how much toothpaste should be used, consequences of poor oral hygiene and how often and important routine dental visits are.

Daily tooth-brushing in the classroom is a must. If kids brush their teeth well at least once a day, it will decrease their chances of getting cavities and will help maintain gingival health. Schools with brushing programs need fewer referrals for urgent or non-urgent dental care. Talk with parents about the importance of good oral health and how it can impact their child’s overall health.

“During the last 50 years, there have been dramatic improvements in oral health, and most middle-aged and younger Americans expect to retain their natural teeth over their lifetime,” Dr. Satcher said in the Surgeon General’s report. This brings home the need to start dental-health education early and make it a priority for all children and their families.

Creating Your Own Classroom Dental Program

• If funds are not available to purchase toothbrushes, ask parents to send one for their child.
• Brush once a day in the classroom, preferably after a meal.
• Teach children to brush for at least 60 seconds.
• Use a pea-size amount of toothpaste. Toothpaste is used for the fluoride and taste;  the cleaning action really comes from the mechanical brushing of the teeth.
• Teach children to brush at least twice a day.
• Teach children that the most important time to brush is at night, right before going to bed.
• Teach children that they should see a dentist for routine/preventative care every six months.
• Instill in both children and parents the importance of routine daily oral hygiene practices.