ORAL HYGIENE
There is a great deal of uncertainty among parents about oral hygiene for babies and infants. The most common elements of uncertainty include when to start oral hygiene, when and what kind of toothpaste to use, and what to do if the child struggles. It is our job to give parents answers and encourage them. This section includes tips about oral hygiene, divided into age groups.
Infants and toddlers (0–3 years)
Brushing the teeth often works well in babies without any problems. They open their mouths as a reflex when lying on their backs in a slightly overstretched position and, as babies will explore everything with their mouths in the oral phase, a toothbrush can be a welcome diversion. Babies and infants can either be laid on the lap with their head on their parent’s knees (Fig 3-1a) or on a changing table so that the parent can brush their teeth (Figs 3-1b and 3-1c).
Fig 3-1 Infant tooth brushing. (a) The child lies on the parent’s lap. With this positioning, really good brushing can be done, especially with little children. (b and c) Brushing an 8-month-old baby’s teeth on a changing table.
Unfortunately, this phase comes to an end with some children or there are phases when oral hygiene is more difficult to carry out. Then parents all report the same thing: the little ones cry, resist, and thrash about. We should encourage parents in these phases to press on caringly but consistently with what daily oral hygiene involves. In the author’s opinion, giving up and skipping brushing cannot and must not be an option. We can be supportive with tips to simplify brushing and prevent possible refusal:
• First, parents can naturally get babies used to mommy and daddy wanting to take a look in their mouth. Using fun gloves specifically designed for this purpose, they can massage the alveolar ridge, for instance, which also helps prevent teething troubles. There are also special dental wipes with xylitol that can be used from day 1 to wipe the baby’s mouth and accustom them to a routine. They taste good and reduce bacteria at the same time. The earlier children get used to it, the easier it will be to maintain this ritual.
• Babies can be given toothbrushes as marvelous teething aids to play with (under supervision, of course). As soon as the infant starts walking, they should not be allowed to walk or run around with their toothbrush in their mouth. They can suffer serious injuries when they fall.
• Once the first tooth actually erupts, it is advisable to have two toothbrushes: one to distract and occupy the child and one for the parents to brush their child’s teeth.
• The teeth should be cleaned twice a day. Whether with fluoride toothpaste or without is dependent on the information provided by the parents in the fluoride history (see section “Fluorides”).
• Parents should be cautious in the anterior dentition around the labial frenum. In nearly all infants this extends deeply. Hence, if parents clean the front teeth horizontally and bump up against the labial frenum, this might be painful for the child. The lift-the-lip technique can be used to avoid this. It involves gently pulling the top lip upward with one hand as the anterior teeth are being cleaned with the other hand (see Fig 3-2).
• Of course, brushing the teeth can be accompanied by singing, little hand puppets, or similar distractions. There are no limits to people’s creativity.
• It is important to establish brushing as a daily ritual. The earlier and the more confidently this is achieved, the faster more difficult phases can be overcome.
• It is not about sticking to a schedule. In the author’s opinion, how long it takes with babies and infants is initially of secondary importance; much more important than time is that all existing teeth are thoroughly cleaned from all sides.
• Often the first primary molar has already erupted when the primary canine starts to erupt. If the molar is brushed normally during this time, the eruption site of the canine might be painfully manipulated. For that reason, it is recommended that the primary molar be brushed crosswise.
• The author recommends brushing children’s teeth while they are lying down. On the one hand you have better lighting for the maxillary arch and therefore a better view, and on the other hand this position is a good desensitizing method for future visits to the dentist.
Fig 3-2 Lift-the-lip technique for atraumatic cleaning of the labial surfaces of the maxillary anterior teeth.
WHEN BRUSHING IS A STRUGGLE
At routine checkups, many parents report that brushing their child’s teeth is a daily struggle and they are helplessly seeking tips and tricks to avoid a “wrestling match.” What worked entirely fine when the child was an infant has suddenly become an ordeal for all concerned. Parents do not always manage to motivate their little ones to brush or have their teeth brushed with patience and fun by including play. Especially with the youngest children, discussions or positive reinforcement with different reward systems are only possible to a limited extent.
Nonetheless, a solution must be found, because not brushing for days or weeks is not an option in terms of the child’s well-being and oral health. The solution is simple: Parents just have to persevere. The more calmly and confidently parents act, the quicker this period of refusal from children is over. Refusal to brush may be a child’s way of expressing desire for independence, which can turn other everyday situations (eg, diaper changing, hair washing, nail cutting, or buckling up in the car) into minor challenges. It is important for parents to understand that this autonomy phase is a completely normal developmental step after the first birthday. It is crucial that children get plenty of praise when they cooperate. This daily ritual does not have to be a struggle. It must be made clear to parents that they alone (and not the child) have to decide what is necessary for their child’s health. If parents cannot manage to brush their infants’ teeth for as long as a minute, how is a dentist meant to carry out a filling treatment?
Preschoolers and kindergartners (3–6 years)
Children of this age group will also have phases now and again when brushing is difficult. The cause of caries can easily be explained in an age-appropriate way to this age group—unlike babies—by using stories; it can also be made clear why cleaning their teeth is so important. This is the perfect time to institute sticker charts at home for positive reinforcement. This is a very good way of tackling difficult times and establishing daily oral hygiene as a positive way to close the day. A few more tips:
• With little children it is advisable to do follow-up brushing as the parent. Most toddlers and young children will want to brush their teeth themselves, but they do not have the dexterity or patience to do the job well. The lift-the-lip technique can still be used with this age group to atraumatically clean the anterior teeth (Fig 3-2). Regardless of whether a manual or electric toothbrush is used for follow-up brushing, ultimately only one thing counts: getting rid of the plaque! For the same reasons as mentioned earlier, it is recommended that the teeth are brushed while the child is lying down.
• Dental floss should be used for the interdental spaces in mouths with crowding and a complete dentition. There are child-themed floss holders for this purpose, which make it easy for flossing to become part of the routine (Fig 3-3).
• Parents should make sure their children have a mirror in the bathroom at the right height for them to be able to see themselves. Parents are often unaware that it is helpful for little ones to see themselves when brushing.
• On the question of whether a manual toothbrush or an electric toothbrush is better, the author recommends choosing the one where the motivation of the child is highest. It is important that children are shown the correct brushing technique for their