Understanding the Most Common Chronic Disease in Children

February is Children’s Dental Health Month, and though we are nearing the end, I didn’t want to miss the opportunity to discuss the most common chronic disease in children, tooth decay. Many people believe baby teeth are not important. The number of times I’ve heard “It is just a baby tooth, it will fall out anyway” is astounding. If baby teeth weren’t a necessary part of growth, development and overall health, why in the world would we have them? Children’s dental health goes much further than just cavities and loosing baby teeth, many of these issues can contribute to overall health, behavior, and school performance. Of American children, 43.1% have experienced tooth decay in baby teeth and permanent teeth in 2015-2016. [1] So, the question is what causes these cavities in children and why has it remained the most common chronic disease in children for so many years? The following are contributing factors in the development of early childhood caries/cavities.

Nutrition- Almost everyone learned early in childhood that eating too much candy/sugar would cause cavities. Sugar is certainly a contributing factor in tooth decay, let’s talk about sugar intake. When we think of sugar we think of sodas, candy, cookies, cakes and other treats. These are not the only offenders when it comes to sugar. The amount of added sugar in food is astounding. These poor children are inundated with a constant flow of sugar, even in foods thought to be healthy. Carbohydrates are also an issue when it comes to tooth decay. Starchy foods such as bread, noodles and crackers are broken down to sugars in the mouth by enzymes in the saliva. So, beware of starchy foods, they contribute to tooth decay as well. Some healthy choices would be fresh fruits, fresh vegetables, nuts and cheese. Always check the amount of sugar in processed foods and fat free foods, as they are some of the worst offenders. Unfortunately, restricting candy, soda and other sweets is not enough. The food industry has added sugar to so many food items, we are fighting a losing battle.

Streptococcus Mutans- These critters live off all that sugar and carbohydrates I just mentioned. We have a lot of bacteria that lives in our mouths, some good, some bad. S. mutans fall into that bad category. S. mutans are acquired via vertical transmission (passage of a pathogen from mother to child immediately before and after birth) and horizontal transmission (through kissing, sharing of food and drinks) [2,3] Vertical transmission is clearly from the mother, better dental care during and before pregnancy may help in the reduction of these pathogens being transmitted vertically from mother to child. Horizontal transmission can be from a multitude of sources including but not limited to fathers, siblings, and classmates. A study of 42 school children age 6-7 found matching genotypes of S. mutans in schoolchildren in the same class, indicating that classmates may be a source of transmission of S. mutans. [4]

Tongue tie- A tongue tie is a short lingual frenulum (a small fold of mucous membrane extending from the floor of the mouth to the midline of the underside of the tongue). Tongue ties can cause difficulties with sucking, swallowing and speech. It can also lead to improper craniofacial growth, which is associated with pediatric sleep breathing disorders. Pediatric sleep breathing disorders usually cause children to rely on mouth breathing. Improper craniofacial growth, in some cases, cause a decrease in the size of upper airway support. With decreased upper airway support there is an increased risk of upper airway collapsibility during sleep [5]. I wrote a more detailed article on pediatric sleep breathing disorders that you can read here. I know you are wondering how this ties in with cavities in children. Well, tongue tie can lead to improper craniofacial development which can lead to pediatric sleep breathing disorders which leads to our next topic mouth breathing.

Mouth breathing- If your child does not have a tongue tie, however you still notice that they are a mouth breather, be aware that mouth breathing is also a contributing factor to improper craniofacial development. This can lead to the need for orthodontic treatment (braces)t in the future. Aside from being a contributing factor to improper craniofacial growth, mouth breathing is also a contributing factor in the development of cavities, chronic gingivitis and halitosis. [6,7,8] The saliva has a buffering ability to help keep the pH in the mouth neutral. Mouth breathing reduces the flow rate and buffering ability of saliva. Reduced saliva flow causes a more acidic environment, which is ideal for the colonization of S. mutans. [8] The pH in the mouth is very important and not discussed as often as it should with parents of young children.

Homecare- Brush twice a day and floss once a day, you’ve heard it your whole life. This applies to children of all ages as well. I started cleaning my daughter’s mouth when she was an infant, as a training tool for the future. I used a wet cloth and cleaned her upper and lower arch. I believe starting early made it much easier to brush and floss her teeth as they erupted. Most young children do not have the dexterity to brush and floss on their own. I use the rule, when they can tie their shoe on their own, then they can brush on their own. Fluoridated toothpaste is now recommended from the time the first tooth erupts. A rice size amount for children 0-3 years of age and pea size amount for 3 years of age and up. I know fluoride is a controversial subject, I don’t want to go into the details of why fluoride is safe here. For parents not comfortable with using fluoride for any reason, I recommend a toothpaste with xylitol. I would like to add in addition to proper brushing and flossing, never put your child to bed with a bottle or sippy cup that contains anything other than water. This is a huge contributing factor to tooth decay, especially on the front teeth. After you brush their teeth at night, water is the only thing they should ingest.

Regular dental visits- The American Academy of Pediatric Dentistry (AAPD) recommends that a child go to the dentist by age 1 or within six months after the first tooth erupts. [9] Baby teeth have less enamel than permanent teeth, which causes decay to advance much more rapidly. A study published in the Journal of Clinical Pediatric Dentistry revealed it takes approximately 8 months for a cavity to progress from the outer enamel to the dento-enamel junction, when the cavity reaches this junction a restoration is usually required. The same study found it takes an additional 1 year and 4 months to reach the inner part of the dentin, which could lead to the need for extraction or root canal/pulpotomy at this point many children start experiencing pain. [10] This rapid process makes 6 month recalls for children an imperative part of preventing and treating tooth decay early.

Tooth decay is caused by a complex interaction between genetics and environment. Often, it is caused by multiple factors. This complex interaction is one of the reasons tooth decay is so prevalent. Finding the right preventative measures for each factor is important in the control of tooth decay. If your child seems to always have a cavity or multiple cavities at each dental visit, be sure to discuss the above factors with your dentist and/or hygienist. We all want healthy children; a healthy mouth is a crucial part of overall health in children and adults.

Resources

1. Mary Otto. Federal data brief updates on decay rates among U.S. children. Association of Health Care Journalists. Retrieved from https://healthjournalism.org/blog/2018/05/federal-data-brief-updates-on-decay-rates-among-u-s-children/

2. Binks C, Duane B. Mother-to-child Transmission of Streptococcus Mutans. Evid Based Dent. 2015 Jun; 16(2):39-40. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26114782

3. Berkowitz RJ. Mutans Streptococci: Acquisition and Transmission. Pediatr Dent. 2006 Mar-Apr;28(2): 106-9.Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16708784

4. Pilar Baca, Ana M. Castillo, Maria J. Liebana, Francisca Castillo, Antonio Martin-Platero, and Jose Liebana. Horizontal Transmission of Streptococcus Mutans in Schoolchildre. Med Oral Patol Oral Cir Bucal. 2012 May; 17(3): e495-e500. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3476088/

5. Christian Guilleminault, Shehlanoor Huseni, and Lauren Lo. A Frequent Phenotype for Paediatric Sleep Apnoea: Short Lingual Frenulum. ERJ Open Res. 2016 Jul; 2(3): 00043-2016. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5034598/

6. Surtel A, Klepacz R, Wysokinska-Miszczuk J. The Influence of Breathing Mode on the Oral Cavity. Pol Merkur Lekarski. 2015 Dec;39(234):405-7. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26802697

7. Mehdi Bakhshaee, Sara Jafari Ashtiani, Mana Hossainzadeh, Samineh Sehatbakhsh, Mona Najaf Najafi, and Maryam Salehi. Allergic Rhinitis and Dental Caries in Preschool Children. Dent Res J (Isfahan). 2017 Nov-Dec; 14(6): 376-381. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5713060/

8. Stefano Mummolo, Alessandro Nota, Silvia Caruso, Vincenzo Quinzi, Enrico Marchetti, and Giuseppe Marzo. Salivary Markers and Microbial Flora in Mouth Breathing Late Adolescents. Biomed Res Int. 2018 Mar 5. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5859862/

9. The American Academy of Pediatric Dentistry. Retrieved from https://www.aapd.org/resources/parent/faq/

10. Tickotsky N, Petel R, Araki R, Moskovitz M. Caries Progression Rate in Primary Teeth: A Retrospective Study. J Clin Pediatr Dent. 2017; 41(5):358-361. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28872992