Dental Health and Children
Prevention of Dental Diseases, School-Based Health Care Services
The oral health of children is important to their overall well-being. Just as the mouth cannot be separated from the rest of the body, oral health cannot be considered separate from the rest of children's health. Often thought to be only the presence or absence of tooth decay, oral health actually includes all the sensory, digestive, respiratory, structural, and emotional functions of the teeth, the mouth, and associated facial structures.
Like other aspects of children's health, oral health must be considered in the context of social, cultural, and environmental factors. Dental and oral disorders can have a profound impact on children, and the burden of untreated dental health problems is substantial. Untreated dental decay (cavities) can result in pain, infection, tooth loss, difficulty eating or speaking, and poor appearance, all of which present challenges for maintaining self-esteem and attentiveness to learning. Chronic pain can alter a child's ability to sleep and play, and it hinders efforts to show them that their personal actions can make a difference in their own health.
Tooth decay is one of the most common chronic childhood diseases–it is five times more common than asthma. By the first grade, more than 50 percent of children in the United States have dental caries (decay) in their primary teeth, and more than 80 percent of U.S. adolescents have dental decay by age seventeen. Despite the availability of cost-effective preventive measures and improvements in children's oral health in the United States, many children still lack needed dental care–more, in fact, than lack medical care. There are significant and important disparities in oral health and access to dental care for poor and minority children, and for those with unusual health care needs. Hispanic, African-American and Native American children have more severe disease and greater levels of untreated disease than other children. In addition, children from low-income families are much less likely to have access to dental care than their peers, and their disease is almost twice as likely to remain untreated. Sadly, the children at greatest risk for problems resulting from tooth decay are also those least likely to receive dental care. In fact, dental care has become the most frequently reported unmet health need of children.
Prevention of Dental Diseases
Fortunately, most dental diseases can be prevented. The most common oral health problem for children is dental decay, which is preventable by a combination of community, professional, and individual measures, including water fluoridation, professionally applied topical fluorides and dental sealants (protective plastic coatings), regular use of fluoride toothpastes, and healthful dietary practices. Childhood is also a time to form healthful habits to reduce injury to the mouth or face, especially during sporting and recreational activities. Use of protective devices in schools may help young athletes recognize the hazards posed by their athletic interests and as they attain adulthood they may be more comfortable using the devices than if they had not used them at a younger age. A significant proportion of other oral problems, such as destructive gum disease and mouth and throat cancer, do not commonly arise until adulthood, and much of this burden can be attributed to the use of tobacco. Most daily smokers started smoking before age eighteen, and more than 3,000 young persons in the United States begin smoking each day. School programs to prevent tobacco use could become one of the most effective strategies to reduce tobacco use in the United States.
Community water fluoridation is the most effective way to prevent dental caries in all children, regardless of socioeconomic status, race, or ethnicity; and it can reduce cavities in children by up to 40 percent. Yet, more than 100 million people in the United States do not have fluoridated water. Where children do not have fluoridated water and dental screenings have identified them to be at high risk for dental caries, fluoride can be provided through school programs that offer supplemental tablets or rinses, and the importance of brushing with fluoride toothpaste at home every day can be reinforced.
Unfortunately, fluoride has somewhat limited effectiveness on the chewing surfaces of teeth. Not surprisingly, more than 80 percent of tooth decay in schoolchildren is on the chewing surfaces of molar (back) teeth. The use of dental sealants applied to the chewing surfaces can prevent 60 percent of decay on these surfaces, but only about one in four children have at least one sealed tooth. Among poor minority children, less than 5 percent have received dental sealants, except those who attend schools that have programs to assure access to this service.
School-Based Health Care Services
The school is a good setting for programs to assure that children have an opportunity to receive protective dental sealants in a timely manner to prevent tooth decay. Although such programs can be a component of more comprehensive dental programs, it is far more common for school programs to be more narrowly focused on these effective preventive services. Dental sealants can be provided at school or through active referral to participating dentists in the community. Although these programs have been found to be effective among children of varying socioeconomic status and risk of decay, most such programs in the United States target those vulnerable populations less likely to receive private dental care, such as children eligible for free or reduced-cost lunch programs. Accordingly, these programs can not only increase the prevalence of dental sealants, but also reduce disparities in sealant use by race or income.
Health education programs in schools can stress the importance of oral health, increase understanding of the disease process, promote healthful behaviors, and reinforce the value of regular professional care for prevention. Such a role for professional care may not be consistent with the experiences of children who have not received dental care or who only associate it with treatment of toothaches. Instruction of the children and their parents–through educational materials that are taken home–can help alleviate the consequences of some parents' own experiences and dental fears, which may impede their seeking care for their children.
When preventive measures fail to completely stop disease, schools can assure that tooth decay is treated early so that it does not negatively affect learning and quality of life. Some schools have programs of screening and referral, which are not only helpful to the individual children referred for care, but also provide information that enables the public health system to target, organize, and evaluate programs. In addition, some schools have health centers on the grounds, which have been critical providers of health services for young people, particularly those who are uninsured. Central to the effectiveness of these centers are partnerships with community-based providers and collaboration with parents and school administrators.
Through the initiatives described here, schools can make important contributions to the quality of life of low-income, minority, migrant, and immigrant children, who frequently have difficulty accessing information and services for both the prevention of disease and dental care. When these children do not get the dental care they need, their already difficult lives can become even more stressful, and they may be less likely to overcome obstacles, achieve their dreams, and contribute to society.
Dental-Health Education Curriculum for Schoolchildren
The ideal dental-health education curriculum would encourage students to think about the relationships between knowledge, choice, behavior, and enhanced human health. Knowledge and choice equals power, and having power and engaging in appropriate behavior can lead to enhanced human health. In addition to acquiring knowledge, students need to develop the skills to incorporate healthful behaviors into their lives. Behaviors that promote oral health and prevent disease include brushing teeth with fluoride toothpaste, reducing the number of times sugar-rich foods are eaten, and resisting tobacco use. Curricula should be age-appropriate for both children's cognitive abilities and the main health risks they face at each stage of development.
During the preschool years, development of the habit of using fluoride toothpaste twice per day and acquisition of a positive attitude about visiting the dentist are the most important outcomes of education about oral health. Parental participation may be particularly important for children from disadvantaged homes, where parents may not otherwise appreciate the importance of these behaviors.
During the primary school years, the dental-health education curriculum can support the type of learning that frames experiences for children in a way that builds on their prior knowledge and encourages them to explore and seek answers to new concepts by themselves. Ideally, such a curriculum should link lessons with the National Science Education Standards developed by the National Academy of Sciences for grades K–4. Children at this age can learn to brush plaque from their teeth, and to protect their teeth with a toothpaste containing fluoride. In addition, these children should receive dental care within a year after the eruption of their first permanent molars (age six or seven), so that protective sealants can be placed on the chewing surfaces. These children are old enough to understand that eating several times during the day can create as many problems as eating too many sugary or starchy foods, especially if they eat those foods as between-meal snacks. Curricula should help students see that choices they make can affect their overall oral health.
During adolescence, when children increasingly make their own decisions regarding both self-care and diet, the health education curriculum should reinforce oral hygiene, prevention of tobacco use, and healthful dietary practices. Interest in the social advantages of a healthy mouth can make students more receptive to information about oral hygiene techniques, as they can be shown that appropriate use of the toothbrush and dental floss can make their teeth more attractive, prevent bleeding gums, and reduce halitosis (bad breath). These are the years to reinforce healthful lifestyle behaviors that will have important consequences for maintaining oral health with minimal need for expensive dental care repair–behaviors that will provide benefits for a lifetime.
The oral health of children is essential to their overall well-being. Education in schools prepares girls and boys to accept responsibility for their own health and to engage in personal care that will maintain and improve health. The use of precious classroom time to teach personal self-care skills, using the classroom to deliver fluoride products, and using the school setting to screen and refer children for needed dental services can be justified by the impact on children's health and welfare. Dental health problems can profoundly affect children, impairing their performance as students, lowering self-esteem, and slowing personal development. In addition, failure to prevent dental diseases has a large effect on school attendance. It is estimated that more than 50 million school hours are lost nationally each year due to dental-related illness or care, a loss that could be sharply reduced with more timely receipt of preventive services.
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CENTERS FOR DISEASE CONTROL AND PREVENTION. 2001. "Impact of Targeted, School-Based Dental Sealant Programs in Reducing Racial and Economic Disparities in Sealant Prevalence Among Schoolchildren–Ohio, 1998–1999." Morbidity and Mortality Weekly Report 45 (34):736–738.
CENTERS FOR DISEASE CONTROL AND PREVENTION. 2001. "Promoting Oral Health: Interventions for Preventing Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries: A Report on the Recommendations of the Task Force on Community Preventive Services." Morbidity and Mortality Weekly Report 50 (RR-21):1–13.
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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. 2000. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health.
RHODE ISLAND DEPARTMENT OF EDUCATION. 2002. "Oral Health Education Tools and Resources." <www.health.state.ri.us/disease/primarycare/oralhealth/resource-list-schools.htm>.
WILLIAM R. MAAS
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