Protecting children’s dental health is a job for joined up healthcare, including community pharmacy input. So how do you start the conversation?

Despite years of improving dental health education, children’s teeth are still not in as good shape as they should be.

According to Public Health England’s (PHE) report Health matters: child dental health, 25 per cent of five-year-old children had tooth decay in 2015, with on average three or four teeth affected. And worryingly, the vast majority of decay was untreated, which can have painful and long-lasting effects for the health of the child in the long run.

Consequences of tooth decay

Looking after the dental health of children under five years is considered part of ensuring every child has the best possible start in life.

Children who have toothache or who need treatment may have pain, infections and difficulties with eating, sleeping and socialising, and those who have high levels of disease in primary teeth have an increased risk of disease in their permanent teeth.

In fact, the Global Burden of Disease study (2010) found that most common disability among five- to nine-year-olds in the UK was caused by poor oral health. An average of 2.24 hours of children’s healthy lives was lost for every child aged five to nine years because of poor oral health, exceeding the level of disability associated with vision loss (1.64 hours), hearing loss (1.77 hours) and type 2 diabetes (1.54 hours).

What’s more, a child’s poor dental health has an impact on their family. The PHE report claims that a quarter of five-year-olds have tooth decay when they start school, and if they have toothache or need treatment this can mean parents or carers may have to take time off work to take them to appointments and look after them.

Oral health is also seen as a marker of wider health and social care issues including poor nutrition and obesity. While the report claims the relationship between obesity, deprivation and dental care is unclear, it says that poor oral health may be indicative of dental neglect – defined as “the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development” – and wider safeguarding issues.

PHE’s recommendations

PHE recommends that there are a number of cost-effective interventions that can help prevent tooth decay in children, save money in the long term and reduce the number of children needing time off school because of tooth decay.

Targeted community fluoride varnish programmes can, for example, result in an extra 3,049 school days gained per 5,000 children.

PHE’s Delivering Better Oral Health: a toolkit for prevention recommends the following:

• Breast milk is the only food or drink babies need for around the first six months of their life, and first formula milk is the only suitable alternative to breast milk
• Bottle-fed babies should be introduced to drinking from a free-flow cup from the age of six months and bottle feeding should be discouraged from 12 months old
• Only breast or formula milk or cooled, boiled water should be given in bottles
• Only milk or water should be drunk between meals and adding sugar to foods or drinks should be avoided
• The average intake of ‘free’ sugars (i.e. those other than sugars naturally present in milk and milk products, or fruit and vegetables) for all age groups from two years upwards should not exceed five per cent of total dietary energy intake
• Parents and carers should always ask for sugar-free medicines
• Targeted supervised tooth brushing with twice-daily application of fluoride toothpaste reduces the incidence and severity of tooth decay in children
• Children aged 0 to six years should brush their teeth at least twice a day with family fluoride toothpaste (containing 1,350 to 1,500 parts per million (ppm) fluoride). Children under three years old should use a smear and three- to six-year-olds a pea sized amount.

A role for pharmacy

Health matters was produced by the Children’s Oral Health Improvement Programme Board – of which the British Dental Association (BDA) is a member. It stresses: ”There is a recognition that oral health is everybody’s business and not just the remit of dentists, and it should be promoted by all health professionals coming into contact with children – midwives, health visitors, pharmacists, school nurses, etc. It’s important that they should have a working knowledge of common issues and refer to a dentist for more detailed advice, treatment and regular check-ups.”

BDA spokesperson Nairn Wilson, who is both emeritus professor of dentistry and past-president of the British Dental Association, says: ”Given the growing body of evidence demonstrating the important role community pharmacists may play in contributing to oral healthcare provision and, as a consequence, improvements in adult oral health, it is believed that community pharmacists could usefully extend their scope of practice in oral and dental matters to contribute to much-needed improvements in child dental health.”

Professor Wilson advocates focusing on oral health in pharmacy and encourages inter-professional working with dental teams. He adds that the impact of this inter-professional working “may be greatest in tackling health inequalities in socially deprived communities in which associations may be found between poor oral health and social care issues, including poor nutrition and obesity.”

However, this still doesn’t mean it is going to be an easy conversation to have, particularly with parents and carers in more deprived areas.

When it comes to pharmacy staff, PHE suggests a simple way to offer oral health advice for parents of young children can be based on the Delivering Better Oral Health – a quick guide to a healthy mouth in children factsheet, and that they should also signpost them to local dental services.

Whichever approach is taken to tackle the conversation, improving child dental health requires a whole systems approach with action across the healthcare sector, and everyone – including community pharmacy – has a valuable part to play.