Dr Cristina Domínguez: “Start caring for your children’s oral health even before birth.”

Dr Cristina Domínguez, paediatric dentist and lactation expert, explains the key components of children’s oral care and what roles parents and dentists should play.

How would you describe the current state of children’s oral health?

Children’s oral health varies widely across continents, countries and even neighbourhoods. It is influenced by socioeconomic factors, public health policies, cultural beliefs, and other factors. Depending on where dental professionals work, they will come across different conditions of children’s oral health.

But speaking generally, the global prevalence of caries among children is alarming. 17% of one-year-olds have caries. In two-year-olds, the prevalence is 36%, and 43% in three-year-olds. For four-i and five-year-olds, the percentage goes up to 55% and 63% respectively.

This high prevalence turns caries into the number one disease in the world and a crucial public health problem.

Those are alarming numbers. Why do babies and children get so many caries?

The two main risk factors contributing to the high prevalence of caries are inadequate oral hygiene and high sugar intake.

Sugar intake is especially difficult to control without public health measures. Parents often don’t have accurate information about which foods contain sugars.

Oral hygiene seems like it should be easy. But even some dental professionals struggle. Our job, as dental professionals, is to master the proper brushing technique so that we can teach it to parents and they can teach it to their children.

Embarking on the oral care journey

At what age should parents start investing in their children’s oral care?

They can even start before the baby is born. Many oral health problems can be prevented during pregnancy, for example by getting the right micronutrients.

Vitamin D can prevent enamel defects that make children more prone to caries, and folic acid helps prevent cleft lip and palate, leading to a reduced risk of caries.

Even in the womb, the baby can pick up changes in the mother’s diet through changes to the amniotic fluid. If the mom has a particular diet, the baby will also get a taste of this diet, and it will affect their taste predispositions after birth. Let’s say the mom eats a lot of sweets while pregnant. This may predispose the baby to prefer sweeter flavours and put them at more risk of tooth decay in the future. If the mother has a varied and healthy diet, this is known to improve the baby’s acceptance of different foods and flavours in the future.

There is also evidence that babies of women who visit the dentist while pregnant have lower rates of oral disease.

Does breastfeeding play a role in babies’ oral health?

Breastfeeding is essential for the development of facial structures. Unfortunately, feeding bottles don’t have the same benefit. Children who are breastfed have stronger chewing muscles, which helps their chewing skills and lessens the risk of mouth breathing.

“I always tell parents to be gentle with themselves because parenting is hard.”

Breast milk is also important because it prevents imbalances in the microbiome that can lead to dental decay. Breast milk also lets the baby taste what the mother eats, similar to the amniotic fluid. This can also help the baby develop a taste for varied and healthier foods later in life.

When is the first time parents should visit a dentist with their baby?

The official recommendation is by the first tooth or by the first birthday, whichever comes first.

However, I’d go even further. As I explained, even pregnant women should go to the dentist, not only to look after their own oral health but also to prepare for what’s coming and learn how to look after their child’s oral health.

We can talk to them about breastfeeding and about getting the right micronutrients. We can also catch problems with the mother’s oral health that could affect the baby. For example, gingivitis or bleeding gums can increase the risk of premature birth, and babies born prematurely have increased risk of oral health problems. The right time to start caring for your child’s oral health is when you are pregnant.

If that doesn’t happen when the mother is pregnant or right after birth so that we can help with breastfeeding, the next best time is when the baby is about six months old. That’s when parents usually introduce complementary foods. This is when we need to educate them about the importance of chewing and identifying sugar in foods and drinks.

What other moments are important on a child’s oral care journey?

As I mentioned, the journey starts with breastfeeding and continues with the introduction of complementary foods.

The next milestone occurs when baby teeth come through sometime between six months and 2.5 years of age. This period can be especially difficult because it’s when toothbrushing starts. Babies usually fight toothbrushing, and it is a really challenging time for parents. We need to teach them the right brushing technique and useful tips and tricks.

The next milestone is the eruption of the first adult teeth, which happens about six years of age. This is also a risky time because children usually want to be more independent and brush by themselves. Unfortunately, their fine motor skills have not yet been developed properly. It requires a lot of negotiating between parents and their children, but we can help them with that as well.

The last milestone is the beginning of the teenage years, when all milk teeth are replaced by adult teeth. Children at this age start becoming even more independent and often lose interest in brushing. They also start spending more time away from their parents, eating and drinking sugary drinks and other things, which can also be detrimental to their oral health.

What are some signs that can alert parents that their child’s oral health might be in danger?

The earliest sign that something might be wrong is when children struggle to breastfeed or chew properly. As I mentioned before, both breastfeeding and chewing allow the jaw to develop properly. It’s just one more reason parents should focus on oral care as early as possible.

Another sign that people usually don’t identify as a problem is baby teeth that are very close together. Dentition without gaps in small children means that their jaws haven’t developed properly and will not have space for adult teeth.

Lastly, a common sign of a problem is white spots on the front teeth of young children. People think of caries as black holes, but before that happens, parents can spot white demineralised stains around the gum line.

Some people still believe that milk teeth are not important and that losing them prematurely is no big deal. What would you say?

Nature is wise, and we have milk teeth for a reason. They help us talk and chew. They have an aesthetic function. They maintain the space for adult teeth to come through.

If we lose them prematurely, it will affect chewing, which in turn will affect nutrition and digestion. A missing milk tooth will also cause the other teeth to start moving, which might shift the position of permanent teeth as well.

How do you help parents navigate the oral care journey of their children?

I always tell parents to be gentle with themselves because parenting is hard. I advise them to start from themselves. To not give themselves a hard time because they aren’t doing everything right. It is impossible to be perfect.

But the usual tips are well known. Brush their children’s teeth from the eruption of the first tooth and limit sugar consumption. Brushing is non-negotiable. But just telling this to families is not enough because most of them know this already. We need to find what their barriers to achieving this are, and we need to establish individualised goals.

Maintaining proper oral hygiene in children is often difficult and parents struggle to brush their children’s teeth. What would you advise?

First, I want people to understand that the goal of brushing teeth in babies and young children is not so that they get into the habit. Parents often brush their children’s teeth quickly and carelessly just to help them get into the habit of daily brushing, and hoping they will be able to do it properly in the future. But that is not the goal. The goal is to do it properly so that the mouth is healthy now.

But what if the child cries every time the parent tries to brush their teeth?

Parents often struggle with crying. This is one battle that parents don’t have the strength to fight. But babies also cry when they get their nappies changed, and nobody would think to leave the dirty nappy on. You know you have to do it despite their crying because you know it is important for their health. It should be the same with toothbrushing – toothbrushing is non-negotiable. This does not mean that we will not do everything in our power to make the toothbrushing experience as nice as possible: it’s also our job as dental professionals to help families.

So, from an early age, we need to establish rules and boundaries. Oral health is important, we need to brush the children’s teeth, and we have to do it even if they cry. I know it’s hard, but we work through it and help families deal with this crying. But it’s important to realise that we are doing it for their health and that we are not traumatising them. When parents realise this, their job becomes easier.

Helping children feel safe at the dentist

How do you work with children and babies in your dental practice?

Smaller children need their parents in the surgery because they regulate their emotions through them. Therefore, it’s important to get the parents to trust me first. When they come into my practice with their child, I quickly greet the child and then turn my attention to the parents. Especially if it’s the child’s first time, they will need time to observe the environment and what’s going on.

When I have a nice and relaxed conversation with the parents, the baby will see that I am not a threat. Talking to the parents is also important because it will help them relax. If the baby sees that the parents are relaxed, they will relax as well.

Only then do I look at the child again and explain what we are going to do. I use the technique ‘tell-show-do’. First, I tell them what we are going to do, then I show them, and then we do it.

What do you discuss with the parents?

I find out the reason for their visit, whether it is just a check-up or if they are coming with a particular problem. I ask about their medical history; I find out whether the child has been to a dentist before and what their previous experience was like. I also ask about their brushing habits. Do they brush? How often? Who does the brushing?

I discover what they eat and drink. I ask them what they have for breakfast, what they have for lunch, what they have for dinner, and what they eat in between. And I’m thorough. For example, if they say they have a sandwich for breakfast, I ask what type of bread, what is in the sandwich, and what condiments they use. I usually find out all this information before I even look inside the child’s mouth.

When it comes to the eating habits of children, what are your recommendations for parents?

Before I offer any food recommendations to parents, I have to know about their eating habits. I need to find out how much sugar is in their diet and what consistency of food they give their babies or children.

Depending on what I find, I make a recommendation. If I see there are too many changes needed, I go slowly. You can’t tell somebody they are doing everything wrong. That would only make the parents frustrated. I don’t want to frustrate them; I want to motivate them.

We start with small and manageable changes. I give them options and let them choose which they want to start with. The aim is to work with the families as a team and make small changes as needed.

“You can’t tell somebody they are doing everything wrong. That would only make the parents frustrated. I don’t want to frustrate them; I want to motivate them.”

I also make very specific plans with them and write them all down. And then the next time they come, I ask how it went. If it went well, we can add another small and manageable change.

How do you motivate parents and families to stick to new habits and routines?

I use several techniques. Creating specific ‘if-then’ plans is one. These plans help parents and children do the right thing regardless of their motivation, which usually fluctuates. For example, if parents say they have trouble brushing their children’s teeth in the evening because they all feel tired, we make an ‘if-then’ plan: ‘If I know we will feel tired in the evening, then we will brush sooner, right after dinner.’

Motivational interviewing is another useful technique. By asking specific questions, I can make patients realise that they need to make a specific change. If they reach the conclusion by themselves, without me explicitly telling them, it will make the decision that much more powerful.