Keywords: dentist, orthodontics, decay, cavity, caries, bacteria, sugar, acid, diet, fluoride, gingivitis, grinding, whitening

Introduction

Jordana Huber's article for Canwest News Service quoted Dr. Ian McConnache, past president of the Ontario Dental Association: "Decay in children is the most widespread chronic disease of childhood, much higher than the No. 2 which is asthma. Decay rates in kids are rising again where they have been falling for decades." She writes that Dr. Peter Cooney, Health Canada's Chief Dental Officer, said that a growing rate of tooth decay has occurred in children around the world. (1) David Satcher, the former Surgeon General in the U.S. described the problem of dental disease among children as a silent epidemic which needs immediate care and long-term solutions to provide good oral health care for children. (8)

I've been blessed with better than average teeth, but I remember one summer when I was fifteen and I got a toothache at the beginning of a long weekend. I lived in a small town, far from our dentist who would have been off at his cottage for the weekend anyway, and so I had to put up with the pain of the cavity until Monday when my mom could take me to the dentist. I got a degree of relief from some applied medication that our druggist suggested, but by the end of the three days it seemed that all of my upper and lower teeth on the left side of my mouth must be infected; even my sinuses ached; I was miserable. I can sympathize with anyone who has a painful cavity. Smiles are very important in communication. There's a song that goes,"You can smile, when you can't say a word, you can smile; you can smile anytime anywhere." When I read the statements about the increase in dental carries among children, I thought about my own pain and the importance of good teeth in a winning smile, it seemed to me that the public needs to become more aware and more active in addressing this problem. This paper will focus on the problem of tooth decay among children, but I want to mention that there are other dental problems including gingivitis, broken teeth, poor alignment, bruxism (teeth grinding or clenching), discoloration and thumb-sucking which affect the health and well-being of our children.

Canadian national tooth decay rates have not been accessed since 1972, however Statistic Canada is currently assessing this issue as part of the Canadian Health Measures Survey. This survey will identify the scope of the problem. In the article previously mentioned, McConnache said that there have been sporadic studies across Canada which show access to good care is low among families of low income, First Nations and new immigrants. He cites a Toronto survey among five-year-olds attending public schools, which found that the prevalence of tooth decay has risen from 9.8 percent in 1999-2000 to 11.6 percent in 2005-2006. The percentage of five-year-olds with two or more untreated decayed teeth increased from 9.9 percent to 14.6 percent during this period. He noted that there was an increase in the number of children requiring general anesthetic or hospitalization due to serious infections. McConnache believes that poor dietary practice is the main reason for the increase. The governments of Quebec, Newfoundland and Labrador provide regular dental coverage for children, but most other provinces in Canada provide services based on the financial needs of the family and are usually supplied only in dire circumstances. The Ontario government recently announced that the dental care program for low income families would be expanded to include children up to the age of 18. Included in the proposal is money for funding prevention and education. In North Carolina, U.S.A. nurses in the dentists' offices provide fluoride to the children and educate the parents about dental health during the children's visits to the dentist. Both McConnachie and Cooney point to the North Carolina program as a good example for Canada to follow. (1)

A new system called the Canary System was approved by Health Canada on May 6, 2011. Without x-rays the system can identify cavities between the teeth, cavities as small as 50 microns and as deep as 5 millimeters below the surface. Dr. Stephen Abrams, DDS, President and Founder of Quantum Dental Technology, says that the Canary System uses a low-powered laser-based device that employs heat and light to directly examine the tooth structure. (7)

The Medicaid program in the U.S. is jointly provided by the federal and state governments to families with low incomes and resources who meet certain criteria. It is administrated separately by each state and enrolled children are entitled to comprehensive preventive and restorative dental services. (This is not to be confused with Medicare, which is a social insurance program funded entirely by the federal government that focuses on the older population and people with certain disabilities.) Even so many children do not get the dental care they need.

North Carolina has been part of the Give Kids A Smile! program since 2003. February is set aside as National Children's Dental Health Month to provide oral health education to all children regardless of their economic situations. The first Friday in February is devoted to providing education and preventative and restorative care to low-income children who have not had access to care. One out of every five North Carolina children enters kindergarten with untreated dental disease. In 2010, from a population of 2.2 million children (age 0-17), 915,041 were eligible for Medicaid (the joint Federal and State program paying the costs of dental care for low income families) yet only 38% were actually enrolled. An additional 165,835 children were in need of dental care. The reason why so few children utilize the right to comprehensive preventive and restorative dental services is due in large measure to the lack of dental providers who will work under Medicaid. In some areas, less than half of all active dentists participate in Medicaid. Reasons given for lack of participation are low reimbursement rates and the complexity of the forms and administrative requirements. The Give Kids a Smile program functioning in several states is an effort to remedy this problem. With the leadership of the North Carolina Dental Society and thousands of volunteers, North Carolina children have been provided with dental treatment, and prevention and/or educational programs. "During February 2010, more than 1,660 dental professionals and volunteers provided 1.7 million dollars in oral health care to 15,544 children." Providers must meet the requirements and qualifications of Medicaid. (8)

The outer layers of teeth are comprised of several hard layers that protect the inner nerves and blood vessels. The outer layer, the enamel, is not living, but is composed of calcium salts (calcium hydroxyapatite). There are millions of aerobic Streptococci bacteria and anerobic Fusiforms, Vibrious and Spirochaetes bacteria living in our mouths. The bacteria survive by metabolizing sugars and in so doing convert those sugars to acid which dissolves the hydroxyapatite component of the enamel. The bacteria live in the deposit of plaque comprised of food debris, mucin and dead cells adhering to the teeth. The holes formed from the decay of the enamel are called cavities or dental caries. These cavities first appear as white spots on a tooth near the gum line. Active cavities usually look golden-brown in colour. Many factors affect the activities of these bacteria: diet and nutrition, oral hygiene, preventive measures such as fluoridation, the child's genetic susceptibility, saliva flow and its acidity (pH), and lifestyle. (5) (2)

When a cavity forms the dentist must clean away the decayed residue and fill the opening. Dentists have been using amalgam, a pasty alloy of metals including mercury, silver, copper, tin and some other metals to fill teeth for over 150 years. Gold, silver and other alloys may also be used. Another option is a composite filling, a mixture of glass or quartz in a resin medium. Iconomers, transparent materials made of glass power and acrylic acids are currently in use. (9)

Gingivitis

This is an infection of the gums and supporting tissues of the teeth, caused by the bacteria: Fusiforms, Vibrious or Spirochaetes. These bacteria live without air in mature, long- standing plaque in the mouth. Over time the plaque hardens to tartar. The bacteria form toxins and enzymes that inflame the gums and cause them to become red and tender and to bleed. This chronic disease affects about 40% of the world's population including children. There is often an onset associated with hormone changes at puberty, and the condition may reoccur from time to time depending on the health of the teeth. The use of certain medications is associated with gingivitis. Prevention involves superior oral hygiene. Treatment involves good hygiene, periodic scaling and polishing by a dental hygienist or dentist, and often an antibacterial mouth wash is recommended. (2)

Caregiver Actions that Introduce Harmful Bacteria

Parents and caregivers who put the baby's spoon or chop stick in their mouths and then into the baby's mouth risk spreading harmful bacteria from their mouths to the baby's. Dirty teething rings may also carry bacteria. Caregivers should have a supply of clean teething rings on hand for the baby to chew on when one is dropped. (5)

It is the kind of sugar and the length of time the sugar remains in the mouth to be acted on by the bacteria that is crucial, said Dr. Ferne Kraghund, Assistant Professor in the Faculty of Dentistry at Dalhousie University, Halifax, Nova Scotia on a CBC radio program. (Follow reference (1) and listen to her speak.) She explained that when one partakes of sugar we should not rush to brush our teeth immediately, but wait for the bicarbonate in saliva to neutralize the acid formed by the bacterial metabolism of the sugar, otherwise the acid will be swallowed and can upset the stomach. We should limit the frequency of sugar intake. (10)

Articles in the on-line journal "Pediatric Dental Health," Dr. Daniel Ravel, Editor, and from the U.S. Surgeon General's Report identifies important factors parents should know. The natural sugar in fruit and milk does not significantly affect bacterial activity, however, fruit juice is primarily water and sugar and should be taken only with meals. It has little food value and is not a substitute for fruit, which has more nutrients and fibre. 1) A child should be put to bed with only a bottle of water, not fruit juice or formula or milk because of the prolonged length of exposure to the sugar they contain. Toddlers should not be given sippy cups for the same reason, nor should they be given juice as a reward, and older children should not be given juice repeatedly though out the day. 2) Babies should have their gums and first teeth wiped with clean gauze. Forming good oral health habits increases the likelihood of good teeth. Children should be introduced to a tooth brush soon after the age of one, using only a baby tooth cleaner. By the age of three a child can be introduced to a pea-sized drop of toothpaste. Parents should introduce the habit of brushing and flossing after meals and after taking oral medications. Nearly 100% of children's medications contain sucrose (sugar). 3) Children should have their first dental visit within six months of the eruption of their first tooth and should continue to have regular checkups. 4) Parents should provide healthy, balanced meals and avoid fizzy drinks including diet drinks, table sugar, food with sugar added (many processed foods and ready-made meals contain sugar), sweets, carbohydrate-rich pastries, chocolate snacks.

Foods that require chewing like raw fruit and vegetables discourage dental disease by stimulating saliva, which dilutes the acid and adds a bicarbonate to counteract the acid. Sugarless gum promotes saliva and helps remove plaque from the tooth surface. The calcium and phosphates in aged cheese promotes salivary flow - which increases food clearance and decreases the acidic environment surrounding the teeth. (6) (5) (2) And now there is an antibacterial candy. A BBC article dated March 14, 2008 describes the work of Dr. Wenyuan Shi, a medical microbiologist at UCLA who has created an anti-germ lollipop. Shi took 2,000 herbs that are available at Chinese medical shops and conducted more than 50,000 experiments looking for a natural enemy of cavity-causing bacteria. He found that licorice root has an anti-bacterial effect. The root must be soacked and the solution left to dry to a powder. This powder can be put into lollipops. Shi proposes that two lollipops a day for ten days, four times a year would offer protection; however he stresses that brushing and flossing are still important for more reasons than cavity fighting. (11)

Fluorine is essential to life since it is a component of the apatite salts that make up bones and teeth. The fluoride compound of fluorine makes the enamel of teeth resistant to the acid formed as a result of the metabolism of sugars by the bacteria in the mouth. Low levels of fluoride ions in saliva exert a surface veneer effect making the tooth more acid resistant. After the sugar is used up, alkaline ions (namely calcium and phosphate ions) in the saliva act to remineralize the enamel damaged by the acid. Water fluoridation, fluoride toothpaste, mouthwash, gel, varnish and fluoridation of salt and milk are procedures being used throughout the world to give fluoride treatment. The fluoride effects depend on the total fluoride intake from all sources including that naturally occurring in some groundwater, particularly in volcanic and mountainous regions, that acquired from air pollution due to coal dust, insecticides or phosphate fertilizers, from certain tea favoured in China, and in certain foods such as barley, cassava, corn, rice, taro, yams and fish protein concentrate. In infants 80% to 90% of the fluoride is absorbed and the rest is excreted in urine. Adults retain about 60% of the fluoride intake, and it is stored in bone, teeth and other calcium rich areas.

Water fluoridation is believed by many as the most effective means of preventing tooth decay. The Centers of Disease Control and Prevention listed water fluoridation as one of ten great public health achievements of the twentieth century alongside vaccination, family planning, recognition of the dangers of smoking, and other achievements. (1) The practice is sanctioned by other national and international organizations including World Health Organization, the U.S. Surgeon General, the American Public Health Association, the European Academy of Pediatric Dentistry, and the national dental associations of Australia, Canada and the U.S. Water fluoridation is practiced in Hong Kong, Singapore, Ireland, Spain, Australia and Brazil. About 10% of the population of the United Kingdom has fluoride-treated water, about 67% of Americans live in areas with water treatment; half of New Zealand inhabitants have treated water; and in Canada the use of adding fluorine varies according to the wishes of local governments. (13) A friend phoned the Tokyo water department and was told that Kyoto, Japan fluoridated water for a short period but found no significant change in the incidence of cavities and stopped the process. Tokyo does not have fluoridated water.

In 1994 the World Health Organization stated that the amount of fluoride added to water should be between 1.0 mg/L of water and 0.5 mg/L and should vary depending upon the temperature which affects water intake. It is obvious that there is no fixed amount that can be sanctioned for all parts of the world. Fluoridation in the U.S. is estimated to be costing $0.95 per person per year in 2011.

When the total fluoride intake is of acceptable quantity, there are no adverse effects. Harris wrote: "Extensive scientific documentation over the past half-century, including severe comprehensive reviews has established a consistently reaffirmation of the safety and efficacy of community water fluoridation." (3) In some areas where water naturally has a high concentration of fluorine, defluoridation is necessary to bring the level of fluorine in the water down to safe limits. This is accomplished by passing the water through granular beds of activated alumina, bone meal, bone char or tricalcium phosphate; by coagulating the fluorine in the water with alum; or by precipitating it with lime. Household water filters do not remove fluorine from the water. Bottled water may not be fluoridated.

High concentrations of fluorine can cause dental fluorsis, a discoloration of the teeth. Children ages one through eight are susceptible. This is a cosmetic adversity but does not adversely affect the health of the child. Extremely high amounts may cause skeletal fluorosis as had happened in India where there is naturally a high concentration of fluoride. In this condition, the bones thicken and harden impairing joint movement, and making the bones more apt to break. The extremely affected person experiences painful movement and nausea, the stomach lining may rupture and the thyroid gland may secrete uncontrolled amounts of parathyroid hormone, which regulates calcium deposits in bone. (13) (15)

Fluoridation of water has been practiced since 1901, first in research studies. It became the official policy of the U.S. Public Health in 1951 and became widely used without adverse health risks. The use is still contested by many groups based on ethical and political beliefs. Some argue that fluoridation of water is compulsory medication of the population. Others argue that water fluoridation isn't safe because there is no way to monitor the total intake of fluorine an individual is consuming from drinking water and other sources. Another view is that fluoride protection does not come from ingesting fluoride in water but through direct absorption through topical application. Claims that fluoridation causes cancer have been researched by many organizations including the Royal College of Physicians in the U.K, that found "no evidence that fluoride increased the incidence or mortality of cancer in any organ." In 1991 The U.S. Public Health Service establish a subcommittee to study fluorine as related to cancer. "Two annual studies failed to establish an association between fluoridation and cancer." Studies are still ongoing. Large reductions in cavities have convinced most public health professionals that fluoride treatments have benefits. (12) (13) (4) (15) Dr. Darryl Smith, President of the Canadian Dental Association, who endorses fluoridation, told Martin Mittelsteady, a Globe and Mail Reporter, " It's among the greatest public-health measures that has ever been put in place, right up there with vaccination." "Currently about half of the Children of Canada younger than 11 don't have cavities." (14)

About 3,000 American and Canadian teenagers wear braces. There are two types of these appliances: ones that are attached to the teeth and ones that are removable. Their use may be employed for cosmetic reasons or because of difficulty chewing. They are employed to straighten teeth, correct an irregular bite, close a gap, or to bring the teeth and lips into alignment and are involved in cosmetic and implant dentistry after a tooth has been knocked out and replaced. Prolonged thumb sucking or use of a pacifier may cause the upper teeth to protrude and require orthodontic care later. While the brace is in place the child's teeth gradually move and become fixed in sockets. After the brace is removed, a retainer is usually employed to hold the teeth in place for a time. (16)

Bruxism (Teeth Grinding or Clenching)

Bruxism occurs while the child is sleeping and the child is usually not aware of the habit. Causes include teeth out of alignment, a response to pain such as an earache or teething, as a way of alleviating stress and nervous tension, and some hyperactive kids experience teeth grinding. Usually there are no adverse effects, however, some children develop headaches or earaches, and some find that the grinding has worn down the tooth enamel or caused the teeth to chip. In severe cases there are facial pain and/or jaw problems. Children usually outgrow bruxism unless it is caused by stress that is not alleviated. Parents can help the child identify the stress and when possible eliminate it, encourage the child to take a hot bath or shower before getting into bed, listen to soothing music or read a book before lights out. In some cases the dentist may prescribe a night guard, a plastic removable device molded to the child's teeth. It is similar to the mouthpiece worn by football players. (17)

Discoloured Teeth

Teenagers are concerned about stains on their teeth from consuming fruits, tea and coffee. By brushing with baking soda five minutes a day for a week or swishing diluted hydrogen peroxide solution in the mouth two times a day for a week teenagers can whiten their teeth without costly visits to the dentist. (18)

For children and adults good oral health is essential, but today in parts of the world there is an increase in dental caries and other dental diseases among children. Good oral hygiene, brushing and flossing, can enhance the chances of having good teeth. Avoiding refined sugar and sugar-added foods, frothy drinks and fruit juices cuts the risks of having cavities. Fluoride treatment is endorsed by many oral health professionals and international organizations as a means of decreasing the number of cavities among children and adults. To avoid harmful consequences, the total amount of fluoride intake to which a person is exposed must be within acceptable limits. We need to give all children access to good dental education, treatment and restorative care.