Fluoride: What parents need to know - Part 1

Many parents are confused about fluoride.

Is it good or bad for children?

What are the risks and benefits of fluoride?

In this blog post we will answer these and other questions.

What is fluoride?

Fluoride is the 13th most abundant element on the earth's crust. It is found naturally in rocks, soil, water and some foods. The level of fluoride in water varies greatly between different geographical areas. Fluoride can also be emitted into air and water as a waste product of some industries.

Is fluoride good or bad?

In low levels, fluoride is beneficial in protecting teeth from decay. 

If the right level of fluoride is available while teeth are forming it is incorporated into the developing enamel, making it more resistant to acid attack, which is the cause of tooth decay. Teeth that have developed under the influence of fluoride also tend to have shallower grooves, making them less prone to decay. Tooth enamel formation starts from 3 months after conception (in the womb) and is completed by around 8 years old, with the exception of the wisdom teeth.

Studies in both the USA and the UK have demonstrated the ability of an optimum level of fluoride in drinking water (either naturally occurring or added) to significantly reduce dental decay in both children and adults.

Fluoride is also beneficial after teeth come through. The surface enamel of teeth is weakened and dissolved by acid attacks which occur after consuming sugary or acidic food and drinks. However, enamel can remineralise, or repair, itself by taking in minerals from sailva. Low levels of fluoride present in saliva and dental plaque encourage remineralisation and therefore make it less likely that a cavity will be formed. The fluoride also becomes incorporated into the enamel surface making it stronger and more resistant to acid attack.

Recent scientific studies have also shown that fluoride is able to reduce the ability of plaque bacteria to produce acid.

Scientists now believe that the effect of fluoride after teeth erupt into the mouth is more important than during tooth development. These effects explain why the incidence of decay has generally decreased with the introduction of fluoride toothpastes.

So what's the problem with fluoride?

Like many other minerals, fluoride is toxic at very high concentrations, but it is very rare to be exposed to these levels. The problem with fluoride is when you swallow more than the recommended level over a long period of time. The most common problem that is seen with consuming moderate levels of excess fluoride is dental fluorosis.

Dental Fluorosis 

Individuals who are exposed to too high a level of fluoride in early childhood (up to 7 years old) are prone to dental fluorosis, or mottling of the teeth.

In its mildest form, the only sign of fluorosis may be white specks on the enamel surface. Teeth more severely affected show discolouration, often in bands or lines, and pitting. Although they are more resistant to decay, teeth with severe fluorosis have structurally weaker enamel. 

The amount of fluoride in drinking water varies greatly. The level of fluoride in freshwater, for example rivers and lakes, is usually low. However as water seeps through soil and rocks it becomes contaminated with various naturally occurring substances or pollutants. These contaminants also become more concentrated where the groundwater level dips. 

India has become increasingly dependent on groundwater, from wells or bore-wells, to meet demands for drinking water and in some areas, this contains much higher than the recommended level of fluoride.

The optimum level of fluoride in drinking water - to provide dental health benefits and minimise side effects - is 1mg per litre. In India, the permissible level is up to 1.5 mg/l. 

The Indian Department of Drinking Water Supply reported that 203 out of 593 districts have higher than permissible levels of fluoride in water.

As this map shows,almost all states in India have districts where groundwater contains excessive levels of fluoride. Even in Bangalore, the level of fluoride varies between different areas and during different seasons. As water quality is not well regulated, it is not always easy to know the levels of fluoride in a particular area.

In some areas, the level of fluoride in water is excessively high. In these areas skeletal fluorosis may also occur. This causes pain and stiffness in the joints and, in more severe cases, bone deformities.

It is recommended to drink bottled or filtered water and, in high fluoride areas, to avoid food and products containing fluoride. Not all water filters remove fluoride, those which work by reverse osmosis and ion exchange resin are able to remove about 90% of the fluoride. Bone char filters have been found to be even more effective in removing fluoride. It is difficult and expensive to remove fluoride from the ground water supply and, in rural areas, other sources of drinking water are not always easily available. Recharging groundwater using harvested rainwater can be useful in reducing levels of contamination.  

Slides used from: http://www.schools.indiawaterportal.org/wq-test/fluoride-factsheet


In the second part we will look at how fluoride can be used safely to benefit dental health.

How to help a child who is anxious about the dentist - Part 1

Do you dread taking your child to the dentist? 

Are you worried about how your child will behave? 

Do you put off visiting the dentist until your child has toothache?

Maybe you are anxious yourself and don't know how to help you child overcome their fears?

In this two part blog we will look at ways in which you can make visiting the dentist less stressful, and maybe even enjoyable for you and your child.

Children are not born with a fear of going to the dentist. A small child visiting the dentist for the first time will not know what to expect, apart from what they have picked up from their parents and others around them. Therefore, it is important to try to give your child a positive view of dental health. Depending on your child's age, you can discuss or show them the importance of teeth and looking after them in an appropriate way. They can be encouraged to view the dentist as someone who helps them look after their teeth.

If you are anxious yourself, or have had a bad experience in that past, try not to talk about this in front of your child and advise other family members and friends to do the same. 


A recent study showed that parents' attitudes towards dentistry are often passed on to their children. Children are often listening in on our conversations with others, even while we think they are playing or doing something else. They even pick up on anxieties that we do not speak about by our expressions. If you have fear of the dentist you may find this 4 part blog (click for link) helpful for advice on overcoming your own anxiety.

Finding a child friendly dentist

Of course, it is important to find a dentist who is good with children. Not all dentists are good at, or enjoy, working with children. Find a practice where the dentist and their support staff relate well to your child and work to gain their trust so that your child can feel comfortable with them. The environment is also important in putting your child at ease and the decor should be fun. The waiting area should have toys, books or some form of entertainment to make waiting easier. 

Ask around for recommendations from friends and family or look at reviews from other parents. You can ask dental practices about their experience and expertise in treating children. Pediatric Dentists (or Pedodontists) are specialists in children's dentistry and usually have 3 years further training in Pediatric Dentistry after dental school. If you are in Bangalore, Small Bites in Indiranagar provides exclusive dental care for children. Here, we believe that every child deserves a good start in life with the best preventive dental care.

How can I help my child at home before a visit?

• Try to schedule the appointment at the best time for your child. Small children especially do not do so well if they are tired and hungry. 
• If you or your child are anxious, try to choose a time when the dentist is less busy to minimise waiting and so that there will be more time to discuss any issues and concerns. Even if this means that you have to take time off work it may be worth it for a first visit.
• Be positive. If your child is anxious, listen and show them you understand their concerns but express confidence that they will be okay. 
• Do not use words or scare stories that may upset your child. Even if you say "it's not going to hurt" the main word that your child will hear is "hurt", even though this may not have been in their mind before. 
  
• For young children, you could "play dentist" at home. You and your child can take it in turns to "be the dentist" and check each others teeth. Also try using your child's favourite soft toy or a puppet and "check their teeth." You can buy small plastic mouth mirrors for this, or just use your toothbrush. 
• If your child has a sibling, cousin or friend who is good with the dentist it may be helpful to visit the dentist with them first.
• There are many good children's books and videos available which can help children to understand about going to the dentist.
• If your child has had a difficult time at the dentist in the past, ask them about their concerns. Discuss these with your dentist to find ways to help your child before the next appointment.
• If one parent is particularly anxious, it may be better for the other parent, or another close relative, to bring the child for their appointments.

Ideally, a child's first experience at the dentist should not be for treatment. If at all possible, try to take your child just to see the dental practice and meet the dentist, or at most have a quick check-up, before they have any problems. This will help them to feel comfortable with the environment. 

At Small Bites we also have children's activities (advertised on our Facebook page - click for link) held in the clinic. This is a chance for children to get used to the environment and have fun on a separate day from any appointments. 

If your child, already has pain or problems before they have visited the dentist, don't worry. A good dentist will aim to alleviate the pain at a first visit but do further treatment as your child increases in confidence and cooperation.

Regular visits for check-ups will help your child. It is much better if they do not need treatment every time they have an appointment.

In the second part we will discuss ways that you and your dentist can help your child during their visit and some tips for preventing dental problems.

Is Dental Decay Contagious?

Tooth decay is the single most common chronic childhood disease, despite also being preventable.

Is dental decay a contagious disease? 

Is it possible to catch it from someone else?

In a previous post we discussed what causes dental cavities. 

To summarise, bacteria (germs) in our mouths convert sugar in food and drink that we consume into acid which damages teeth.

Bacteria live in dental plaque - a sticky film which builds up naturally on our teeth. Dental plaque contains many types of bacteria but only a small number of these cause dental decay. The main type of bacteria which causes dental caries is Mutans streptococci. Studies have shown that individuals with higher levels of Mutans streptococci are at a greater risk of cavities.

Recent research has shown that babies are not born with decay-causing bacteria. Any time after birth bacteria can be passed on from other people, especially mothers and other close caregivers. Once these bacteria are transmitted to a babies mouth, especially after the first teeth come through, they multiply and become established within dental plaque.

Bacteria can enter the baby's mouth by kissing, sharing food utensils, toothbrushes or other habits that transmit saliva.

If parents and other caregivers have cavities and poor oral hygiene they will have higher levels of decay-causing bacteria which can be passed onto their child.

The risk of a child developing cavities will be less if they are not infected with decay-causing bacteria at an early age.

Children can also "catch" bacteria from other children by sharing food and toys, but they are more likely to receive bacteria from their mother and other close relatives before this happens.

What can be done to reduce the risk?

Parents and caregivers can reduce the risk of passing on decay-causing bacteria from their own mouths by:

• cleaning their own teeth well, to reduce the amount of plaque (which contains bacteria)  in their mouths
• avoiding sugary snacks and drinks between meals which can lead to decay 
• visiting the dentist regularly for check-up and getting any cavities filled 
• avoiding sharing items such as food, spoons, cups and toothbrushes with their baby
• kissing the baby on their cheek, rather than the mouth

Questions about Local Anaesthetic

Your dentist has told you that your child needs a local anaesthetic at their next visit. You may be worried and have questions. We will discuss many of the common questions in this blog post:

What is local anaesthetic?

Local anaesthetic is a type of medicine given as an injection to temporarily numb a specific area of the mouth. 

How does it work?

Local anaesthesia blocks pain by stopping pain signals being carried by nerves to the brain. This causes a complete loss of pain sensation to a specific area, without affecting the rest of the body. Pressure sensations may still be felt.

Why is local anaesthetic (LA) used in dentistry?

Although shallow fillings can often be completed without LA, it is required for deeper cavities, treatment involving the nerve of the tooth and tooth extractions, among other procedures. Local anaesthetic makes painless procedures possible and therefore makes treatment easier and more comfortable.

What is the difference between local and general anaesthetia or sedation?

General anaesthesia (GA) is used when a patients needs to be asleep for an operation or procedure - this can only be done by a trained anaesthetist in a fully equipped hospital. 

In conscious sedation, a sedative is given either by mouth (tablet or liquid), injection, or inhalation (gas and air). The patient remains awake and responsive but is more relaxed and less anxious. Local anaesthetic is often used in addition to sedation or GA.

Local anaesthetic does not affect consciousness. Only the specific area of the body being numbed is affected.

Is Local Anaestheic safe?

Local anaesthetics are used routinely every day for dental treatment all over the world, with relatively few problems. 

As with all medication, care and attention must be taken to ensure local anaesthetic is used safely. Good dentists will use safe techniques carefully and inject slowly. To ensure a safe dose a child's size and weight need to be taken into account, as the maximum safe dose is lower for children than for adults.

Allergies to commonly used dental local anaesthetics are extremely rare. Allergies to preservatives used in LA have been known, although they are not common.

Epinephrine (adrenaline) is commonly added to local anaesthetics as it increases the duration of the numbing effect and also reduces bleeding. For patients with significant heart or thyroid problems LA without epinephrine may be used.

From what age can children be given LA?

Very young children are sometimes unable to cooperate for treatment with local anaesthetic. This is because they do not understand the numb feeling or the reason for it. With reassurance and explanation appropriate to the child's age, some children as young 3 years old can accept treatment with local anaesthetic. For young children who unable to cooperate, temporary treatment may be done to make the child comfortable until they are able to accept further treatment. If there is severe infection treatment under general anaesthetic may be required.

What if I or my child are worried about the injection?

Anxiety about injections is common and understandable. Finding a good dentist who is understanding and sympathetic will go a long way in reducing anxiety.  Relaxation or distraction techniques can be used. For very anxious patients, conscious sedation with inhaled nitrous oxide and oxygen may be an option. Talk to your dentist about your anxieties but try not to convey your worries to your child. In our experience at Small Bites we have found that the children are often are less anxious than their parents!

How can the dentist make it easier for my child?

Local anaesthetic should ideally be used when a child is cooperative and has accepted other treatment well.

Explanation and reassurance are very important. For a young child the dentist may say that they are going to give some special medicine or "sleepy juice" to make the tooth go to sleep for a while, so that they don't feel any pain while the tooth is fixed. Older children with more understanding may be told that this involves an injection.

A numbing gel placed on the gum for a couple of minutes before the injection often works very well, so that the injection is hardly felt. At Small Bites we also use a very fine needle which minimizes pain or discomfort during injection. 

It is necessary to wait 5 or 10 minutes to give the local anaesthetic time to work before starting treatment.

How long does the numb feeling last for?

This will depend on the technique used but usually between 1 and 3 hours. It should be explained to the child that their lip/cheek (and sometimes also tongue) will feel strange. The affected area will feel swollen/bigger but not look any different.

What precautions should I take after my child has had local anaesthetic?

Tell you child that the numb feeling will take some time to wear off. Care should be taken that they do not bite their lip or tongue during this time. Hot food and drink and any food that they need to chew should also be avoided until the feeling has returned.

If you have any other questions you can either talk to your dentist or leave a comment below.

Protecting our children from abuse - Part 2

In the second post in our series on protecting children from abuse we will look at signs that may indicate a child is being abused and what to do if you know, or suspect that abuse has occurred.

What is Child Sexual Abuse?

Child sexual abuse involves persuading or forcing a child to take part in sexual activities, exposing a child to adult sexuality or encouraging a child to behave in sexually inappropriate ways.

If we don't make a fuss about the abuse, won't a child forget it?

Children do not forget abuse, it can cause devastating emotional, physical and social effects for the child, even into adulthood. Adult survivors of child sexual abuse may develop harmful sexual behaviours, experience inability to trust close family and friends and have marital problems. If abuse is not reported once discovered, not only will the abuse continue, but the abuser is also likely to harm other children.

Signs could indicate abuse

The majority of children do not report abuse. They may feel too scared, fear that they will not be believed, or have been threatened by their abuser not to tell anyone. Changes in a child's behaviour may be the first sign that something is wrong. 

One or two of the following changes may be a normal part of development but more should raise suspicion of possible abuse:

• Nightmares or sleeping problems
• Becoming withdrawn or unusually clingy
• Changes in personality, become more insecure
• Problems with studies or missing school
• Excessive anger
• Sexual language or behaviour (inappropriate for the child's age)
• Going back to younger behaviours eg. thumb sucking, bed-wetting
• Sudden changes in eating habits
• Become secretive, not talking
• Shows signs of fear of, or avoids being alone with, a particular adult. 

If you suspect or discover that a child is being sexually abused, get professional advice (see options below).  Seek medical advice immediately if you see physical signs of abuse, such as unexplained soreness/bruising of genitals or symptoms of sexually transmitted diseases eg. an unusual discharge.


What to do if a child discloses that they have been abused

A very small proportion (estimated to be 12%) of abused children report it. Even then, the reporting is often ambiguous as they may be too shy to narrate the incident clearly, or a younger child may not have the vocabulary to explain what has happened.

Your response is crucial. If the adult does not believe the child, or makes them feel ashamed, they may never risk telling anyone again and the abuse will continue. 

For example, a child may say, "I don't like that Uncle."

If the adult replies "How can you speak like that, don't be so rude!" the child will feel scared and not give any further information.

However, if the adult responds, "I see, what happened?" the child is able to reveal the reason, which may, or may not arouse suspicion.

An abused child wants two things:

• to be believed
• for the abuse to stop

If a child confides in you about abuse

• Acknowledge the child's feelings and praise them for having the courage to come and tell you.
• Tell the child it is not his or her fault. Do not blame or accuse the child, even if they did not report the abuse when it started - the abuser is the one at fault.
• Do not ask the child to "forgive" "forget" or "adjust"
• Do not confront the alleged abuser - it may give them an opportunity to silence, confuse or threaten the child about speaking out. It may also place the child in danger.
• Tell the child that you would like to take the help of other trusted adults (eg. close family members, child welfare services, medical professionals or police) to help, with the child's permission. 
• Do not tell other people who are not directly required to help and support the child.

Childline has a national toll-free number - 1098 - which an adult who is concerned about a child, or children in distress, can call for help and advice.

In Bangalore, 3 new Collaborative Child Response Units (CCRU) have recently been set up at M.S. Ramaiah Hospital, Bangalore Baptist Hospital and KIMS Hospital. They liaise between children, their families, doctors and other authorities to provide medical, psycho-social and legal assistance. More CCRU's are to be set up in other districts of Karnataka.

It is possible to contact the CCRU's directly, but they also receive referrals from the police, child welfare services and Childline.

Due to the recent "Protection of Children from Sexual Offences Act - 2012"  it has become mandatory for any person having knowledge of a child being sexually abused to report the same to the Special Juvenile Police Unit or local police. A child need never go to a police station, police will come in plain clothes to visit the child and record the statement in the child's own words.

Protecting children is every adult's responsibility.

In the next section, we will discuss guidelines for keeping children safe in various situations, both at home and outside. 

Which foods cause tooth decay?

Your child's diet is one of the most important factors in developing dental decay and small changes can make a big difference. 

In the previous blog post we looked at how foods containing sugar combine with bacteria in plaque to produce acid. If the teeth are subjected to frequent or long periods of acid attack, decay becomes likely to occur.

Most people are aware that children who eat too many sweets and candies are likely to get cavities. However, any foods that are are high in refined carbohydrates (starch), such as crackers and chips, can cause decay if the foods remain stuck to the teeth for long periods of time, as the starch breaks down into sugar. In fact, one good way to determine if a snack is good for a child is to check their teeth 20 minutes after consumption. If the teeth are still filled with food, the risk for dental decay will be higher. These foods should be eaten only rarely and teeth should be brushed afterwards.

There are a lot of "hidden sugars" in processed food. If you read the ingredients, they may be labelled as sucrose, glucose, lactose, or fructose - these are all types of sugar. In addition to containing high levels of sugar, many children's breakfast cereals also stick onto the teeth. Even diet soda drinks and concentrated fruit juices can cause decay as they are acidic.

It is not realistic to ban your child from eating sweets. altogether. Instead, limit consumption of sweets and candy to maximum of once a day, preferably at the end of a meal. Those treats that dissolve and clear from the mouth quickly eg. a milk chocolate bar, are better than hard candies, lollipops or sticky caramels. Sweets should be eaten in one go, rather than continually snacking on them.

Children do get hungry and need to snack. Choose healthy snacks such as fresh fruit and vegetables, nuts, cheese. For drinks in between meals go for water or milk without added sugar.

What causes dental cavities?

When you consume any food or drink containing carbohydrate, or sugar, the bacteria in the plaque on your teeth metabolise it, producing an acid attack which lasts for at least 20 minutes. The acid dissolves the outer surface layer of the teeth (enamel).

The acid attack will be much longer if the food remains stuck onto the teeth, or if snacking continues over a period of time, eg. eating a bag of sweets one by one, or continuously licking a lollipop. Also, If babies or toddlers fall asleep with a bottle, or whilst nursing, the milk will remain on their teeth for a longer period of time.

If food and drinks containing sugar are limited to mealtimes, with sugar free snacks and drinks in between, the teeth can recover from these short periods of acid attacks. In the early stages of decay (before a cavity is formed), the enamel can repair itself by taking in minerals from saliva. Fluoride also helps to strengthen the enamel in this process.

However, with frequent snacks and drinks containing sugar, cavities become much more likely to occur.

Once the enamel layer crumbles, a cavity is formed, bacteria enter and the decay process spreads rapidly.

To prevent dental decay, the aim should be to reduce the amount of time that any food containing sugar is present in the mouth. Drinking water or rinsing after eating can help. Try to make snacks and drinks, between meals, sugar free as far as possible. 

 

Regular, thorough brushing to remove plaque build-up from the teeth will also help but, as it is not possible to prevent plaque from building up again after brushing, diet is of extreme importance in preventing cavities.