Visiting the dentist and oral health

This advice has been provided by Dr Wendy Bellis, who runs the dentistry service at TreeHouse School. She has 15 years of clinical work almost exclusively in the field of autism.

When should my child first see a dentist?

All children should start visiting the dentist as soon as the teeth appear in the mouth - so from 6 months of age onwards. Some parents are surprised at this! It is important to begin visiting the dentist early so that practical help and advice can be given to you on how to prevent your child’s teeth from developing decay. It also helps everyone get used to the experience so that it becomes routine.

Why is it important to look after my child’s baby teeth?

Baby teeth help children to speak, smile and eat properly. They are also nature’s way of making sure that there is enough space for the adult teeth when they come through. Baby teeth which have decay can cause toothache, infection and bad smells in the mouth.

How often should my child see a dentist?

Children should visit the dentist every 3 to 6 months. However, the dentist may want to see them more often especially in the early days; this will help them to also get to know your child as well as your child getting used to the visits.

Are thumb sucking and dummy/baby bottle habits harmful for a child’s teeth?

Thumb sucking can cause the front teeth to stick out and not meet together properly.  Unfortunately, it is very difficult to stop the habit as many children find thumb sucking very comforting.

Drinking milk or juice from a bottle at night can cause tooth decay in some children. During the night there is very little saliva in the mouth so the sugar in juices (and even cow’s milk) can cause decay if allowed to remain on the teeth over night. That is why brushing teeth before going to bed is so important.

How safe are dental X-rays?

Dental X-rays (radiographs) for children are very safe as the dose of X-rays used is very small and they are usually taken only once or twice a year.  Dentists usually need to take X-rays to help identify if there is decay happening between the teeth - which they cannot see with just their eyes and also to check if the adult teeth are developing well. They may also need to take X-rays if your child has fallen over and damaged their teeth.

What size of the toothbrush should I use?

It is important to use a toothbrush which has a small head – it is easier to get into the corners of the mouth at the back when using a small brush. Also, a brush with a large (adult sized) head is more difficult to control and can make your child gag.

Should children with autism be allowed to brush their own teeth?

Young children should be encouraged to brush their own teeth. However, the reality of the situation is that most children under 6 years of age do not have the required manual dexterity to effectively remove the plaque from their own teeth. Children with autism may have additional problems with motor and perception skills which may make this extremely difficult.

Parents should let their child brush initially but then ‘finish off’ the process to ensure that the plaque is brushed off the teeth. Ordinary (manual) toothbrushes are just as effective at cleaning children’s teeth as electric ones. Many children with autism do not like the vibration associated with electric brushes whilst others love them – it’s all a matter of personal preference!

Positioning when brushing your child’s teeth:

• Always stand or sit behind the child to brush their teeth as you will be able to see into the mouth better and also have more control over your child’s head if they move.
• Using two brushes at the same time may be effective – children often do not like the brush being taken away from them.  Turn taking may be a good way of managing this.

Technique:

• A small headed brush using a circular scrubbing method is the best technique.
• Make sure you place the brush where the tooth goes into the gum to guarantee that you remove the plaque.

There are different types of toothpaste – which one should I use for my child?

It is important that the toothpaste contains fluoride as this will help protect your child’s teeth from decay.

Some children actually dislike brushing because of the taste of the toothpaste rather than the brushing itself. Finding the right toothpaste for your child can be tricky as they may not like the taste or the foaming relating to the paste. There are toothpastes on the market which do not cause too much foam (low foaming) and some children may prefer these.  Adult toothpastes can be used but sometimes the taste can be slightly too minty for some children.  In addition to trying various brands your dentist may also be able to provide advice on alternatives before identifying a preference.

If there are problems you may want to consider brushing initially just with water and then introduce the fluoride paste once the child has accepted the brushing routine.

Is fluoride toothpaste harmful to children with autism?

There are no studies or evidence in the scientific literature to suggest that fluoride in toothpaste is harmful for children with autism.  There is very strong evidence however which shows that children who use fluoride containing toothpastes have fewer decayed teeth.

What about the fluoride level in toothpaste – which one should I use?

If your child is 3-6 years of age they should be using a small amount (a smear) of toothpaste containing 1400 parts per million fluoride (1400ppm). If they are older you should use a pea size amount of the same paste.

3-6 years

6 years +

Is there fluoride in the water in the London area?

London’s water is not fluoridated and there is a very low level of fluoride in the water.  This level is too low to protect your child’s teeth from decay.

Is it alright for my child to swallow the toothpaste as they cannot spit?

Yes, it is alright!  Most young children cannot spit very well anyway. The level of fluoride in the paste has been set to take this into consideration. It is also good to keep the fluoride paste next to the teeth for as long as possible as it will help to make the teeth harder and more resistant to tooth decay. In fact, we no longer teach children to rinse their mouths after brushing (you may have been taught this when you were a child).

Should I encourage my child to rinse their mouth after brushing?

No!  In the past people were taught to brush their teeth and then rinse their mouths. We no longer teach children to do that now, the reason being that when you rinse after brushing you spit the useful fluoride paste into the sink. The fluoride in the paste cannot then strengthen the teeth as it is no longer in the mouth. Children who do not rinse but who do just spit out after brushing have fewer decayed teeth than those who rinse and spit. Most children under the age of 3-4 years are unable to rinse well anyway. This may be especially true for some children with autism. So the rule is ‘spit, not rinse’!

Should we brush in the morning, at night or both?

Ideally both, however, it is especially important to brush at night. Very little saliva is produced at night so the plaque and food debris will remain undisturbed on the teeth and gums while the child sleeps which may increase the risk of decay and gum disease.

My child seems quite sensitive to brushing. What can I do to help increase tolerance to brushing?

Every child is different but gradually introducing the toothbrush may help increase tolerance to tooth brushing. For example, modelling tooth brushing yourself as your child watches, then encouraging them to try with their own toothbrush; letting the child try gently touching the area around the mouth (eg. cheeks, chin, lips) with the toothbrush before gradually moving towards the mouth area (e.g., lips, tongue).

It is probably not a good idea to use toothpaste at this stage. Remember that some children do not like brushing because of the toothpaste rather than the brushing itself. Toothpaste is important as it contains fluoride. You may wish to brush your child’s teeth with water initially and then apply the paste with the brush (or your finger, if this is possible) to the biting surfaces of the teeth after you have cleaned the plaque off the teeth.

Which foods and drinks containing sugar cause tooth decay?

Many foods and drinks contain sugar that causes tooth decay. Foods that contain sugar include:

• sweets and chocolate
• cakes and biscuits 
• pastries and fruit pies
• puddings
• sugary breakfast cereals
• jam
• honey
• ice cream
• fruit in syrup
• dried fruit
• sweet sauces and syrups

Drinks that contain sugar include:

• fresh fruit juice such as orange and apple juices
• some soft drinks such as squashes, cordials and fizzy drinks
• some milk-based drinks such as milkshake mixes

Remember!

• Honey, fresh fruit juice and dried fruit all contain sugars that can cause tooth decay. Although ‘natural’ they are not safe for teeth and can cause decay if eaten frequently between meals as a snack.
• Eating sugary food at mealtimes is less harmful to the teeth than eating them ‘between meals’. During mealtimes there is more saliva (spit) in the mouth which helps to clear the sugar. So if a child eats sugary foods mid morning, mid afternoon or at other times the sugar is more harmful.  Try to find an alternative savoury or fruit snack which is acceptable to your child, especially if you are using food as a reinforcer.

I have been told that I should not brush my child’s teeth immediately after they drink orange juice – why is this?

Fruit juices can be very acidic, especially when not diluted. The acid in the fruit juice can strip away the tooth enamel (especially baby teeth), making the teeth sensitive and weak. If your child drinks fresh juice, it is important to dilute it with at least 50% water and not to brush the teeth for at least 30 minutes afterwards.

I am worried about taking my child to the dentist as their behaviour is sometimes difficult - what should I do?

Preparation and communication is key to ensuring that dental visits go well and are positive experiences for all. Talk to your dentist about your child before the visit. It may also be possible to arrange for your child to have a series of preparation visits as a means of desensitising your child to the dental experience.

If the dentist is unable to spend some time preparing your child then you may wish to change your dentist to one who can accommodate your needs.

What communication aids can I use to help with dental visits?

Use whatever your child will understand. For instance, communication symbols, visual schedules (e.g., pictorial, written), social stories, and even drawings may be useful in preparing children for the dental experience.

Ensure also that any communication system your child uses is readily available to them so that they can communicate effectively throughout the dental experience. This might include Pictorial Exchange Communication System (PECS); Communication Books; Makaton sign; other augmentative and alternative communication (AAC) devices.

Communicating with the dental staff is also very important; explain to them what will work best for your child (eg. using visuals; speaking clearly using just words or short phrases). They too wish to make sure that the dental experience goes well so ensure that you help prepare them with the tools and support they will need since every child is different.