For Healthcare Professional use Toddler Factsheet 4.5
from tooth decay
The first teeth usually start to erupt at around six
All drinks should be taken from a cup or glass, not a
months and are all through by three years.
Dental caries (tooth decay) is a softening of the
Tooth brushing should begin once the child's first
enamel which leads to holes in the teeth.
teeth have erupted.
Tooth decay causes discomfort and distress to
10 Toothpaste should always contain fluoride, even if the
drinking water is fluoridated.
There are many causes and risks for developing tooth
11 An easy way to brush a toddler's teeth is from behind.
decay, and prevention is better than treatment.
Toddlers should not run around with a toothbrush in
the mouth in case they fall and suffer an injury.

Diet plays an important part in preventing tooth
decay, especially the limiting of sugary food and

12 If children require medicines they should be sugar-
drinks to four times a day, at meals and one snack.
free, and if none is available they should, if possible,
be taken at mealtimes and not last thing at night.

Water and milk are the only drinks that should be
offered between meals and snacks.

Undiluted fruit juices cause erosion of the dental
enamel and they should always be diluted before

Reviewed and supported by Part of The British Dietetic Association Why the first teeth are important
Infancy and the toddler years are a time when the teeth come through and the child acquires his or her first ‘milk'
dentition. The process usually starts at around six months and is complete by three years. The eruption of the first
teeth can sometimes cause mild discomfort and fever.1
The first teeth are important developmentally, for a child's speech, eating and facial appearance. They establish a space in the mouth for adult teeth, allowing the permanent teeth to grow and develop normally. Early loss of the first teeth can lead to overcrowding when adult teeth appear. This may lead to the child needing orthodontic treatment (braces) in later years. What is dental caries?
Dental caries, also known as tooth decay, is a disease
where acids formed by bacteria in dental plaque
damage the hard tooth structure. This is a destructive
process that leads to decalcification (softening) of the
tooth enamel and dentine with progressive damage
and ultimately to a cavity (hole) in the tooth.
Dental caries can cause toothache, distress and discomfort to toddlers, stop them sleeping and eating, and lead to reduced food intake, behavioural disturbances and parental concerns about appearance.2 the first teeth are as important as
adult teeth
The first teeth are just as prone to dental caries as permanent teeth. It is important to take special care of a child's mouth in order to prevent dental decay and to avoid dental extractions and fillings. Prevalence of
dental caries
in pre-school
By the time they are five years old, over 30 per cent of children in the UK have dental decay.3 In fewer than 10 per cent has the decay been treated and the tooth restored.4 When many teeth are decayed they may be extracted under local or general anaesthetic.
In some parts of the UK dental caries is particularly common. In Scotland, for instance, 14 per cent of children have had a tooth extracted by the age of five5 and dental surgery is the commonest reason for general anaesthesia.6 causes and risk factors for dental caries
There are many risk factors for developing dental caries including excess and frequent dietary sugar intake, low socioeconomic status, poor parental education and low levels of fluoride in the drinking water.7,8 There are SIX ways to prevent dental decay: 1. Remove Dental Plaque. Plaque is the collection
of microorganisms (bacteria) and other material around the teeth. Plaque can be removed by efficient tooth brushing. 5. Avoid Prolonged Bottle-Feeding. Offer all drinks
from cups not bottles. Prolonged bottle-feeding with sugary drinks or milk, particularly when a toddler is allowed to fall asleep with a bottle in his or her mouth, can contribute to dental decay and should be strongly discouraged. 2. Strengthen the Enamel. The enamel that coats
the teeth becomes softened. It can be protected by regular tooth brushing and strengthened by using fluoride toothpaste.
6. Avoid Grazing on Food and Drink. Frequent eating
and drinking is associated with a build-up of plaque 3. Limit Sugar Intake. The sugars in sweet foods
on toddler's teeth.10 Food and drinks other than and sugary drinks are metabolised to acids by water should be restricted to three meals and two to the bacteria in dental plaque. These acids cause three healthy snacks each day. Grazing on food and demineralisation or softening of the enamel. drinks should be strongly discouraged.
This process can be prevented by reducing the frequency of sugar intake to a maximum of four times a day.9 4. Avoid Food and Sweet Drinks at Night. Saliva in
the mouth helps protect against tooth decay. During Treatment of dental decay in toddlers is difficult sleep salivary flow and swallowing decline, making because of their limited understanding and clearance of material in the mouth less frequent. attention span. It is far easier to prevent decay Food and drinks other than water should not be than to treat it. given to toddlers if they wake during the night. Prevention
nutrition and diet

Toddlers have small appetites and each day they Parents should check the ingredients list on food need three regular meals with two to three planned labels and be aware of foods that contain ‘hidden' snacks in between. These meals and snacks should sugars. see Factsheet 1.9i be nutritious and parents should be advised to encourage the consumption of nutritious savoury Added sugars include: honey; sucrose; glucose; snacks. Foods with added sugars should be eaten no maltose; dextrose; fructose; hydrolysed starch; corn more than four times per day e.g. at the three meal or maize syrup; molasses; raw / brown sugar; treacle times and one snack. see Factsheet 1.1 Parents and concentrated fruit juice. should encourage savoury tastes.11 Suggestions for nutritious snacks12 see Factsheet 1.9
mouth-sized chunks, cubes or slices of apple, pear, satsuma, orange, banana, kiwi, melon, strawberries, sliced grapes, peaches and plums Raw vegetable sticks or slices
carrot, pepper, celery, cucumber, sliced cherry tomato, radish, broccoli Toast, breads, rolls, baps, bread
French bread with a small amount of butter or spread; mini savoury sticks, plain buns
sandwiches with marmite, cheese, tuna, banana, salad or thin slices of meat; pita bread pockets cut into small slices or toasted with or without butter or spread e.g. olive or sunflower oil spread; breadsticks on their own or with a dip or soft cheese Oatcakes, rice cakes, crackers,
plain or with butter or spread e.g. olive oil or sunflower oil spread, or use a crisp breads, melba toast
savoury spread, such as marmite or peanut butter Natural yogurt or fromage frais
on its own or as a dip or with fruit Muffins, plain, potato or cheese
on their own or with a small amount of butter or spread scones, crumpets, pancakes,
Wholegrain breakfast cereals,
serve with milk and fresh fruit but not cereal bars
Note: Three or four crisps or corn snacks (e.g. Quavers, Golden Lights, Wheat Crunchies, tortilla chips or Twiglets) can be
offered as part of a snack or meal option as an alternative texture and taste (e.g. with a salad dish). However, they are
high in salt and fat and therefore pre-school children should not be given these often or in large amounts.

Toddlers should be offered six to eight drinks There is no evidence that milk taken as part of a per day in a cup or glass, not from a bottle. normal diet is harmful, but there is some evidence see Factsheet 1.1 Lidded cups should have a that prolonged or frequent exposure to milk at night free-flow spout, not a valved one. Toddlers should can still cause tooth decay in toddlers. From the age sip, not suck drinks from as early an age as possible.11 of about 12 months only water should be offered during the night if the child awakens.4 Baby juices and drinks constituted from fruit concentrates should be avoided unless they are Suggestions for drinks12
well diluted and included on one of the four daily occasions when sweet food and drinks are Children should be encouraged to drink plain, still offered. Drinks which are labelled as containing water throughout the day rather than only sweet added substances ending in ‘ose' (e.g. sucrose) are drinks. Water, like other drinks, quenches thirst and potentially damaging to teeth. replenishes body fluid, but water does not spoil the appetite and is not harmful to teeth. It also helps to prevent constipation. Milk and water should be the only drinks taken Other sweet drinks are unsuitable for toddlers and between meals. Breastfeeding may well be continued pre-school children: they contribute to dental caries, into the second year or longer. Cows' milk can be they are a poor source of essential nutrients, they tend the main drink from one year old and whole milk to displace other more nutritious foods, and they can should be given until the child is at least two years lead to overweight and obesity. see Factsheet 3.3 old. A follow-on formula or growing up milk can Unsuitable drinks include fizzy (carbonated) drinks, be considered for toddlers who are nutritionally still sugary drinks, squashes and flavoured waters, vulnerable and do not eat well. From the age of two, cartons of sugared drinks and cordials for milk drinks. semi-skimmed milk can be introduced as a main milk Fizzy, carbonated drinks which are sugar-free are also drink, provided the child is eating well. Fully skimmed harmful to teeth owing to their high acid content.
milk is low in vitamin A and for this reason is not suitable as a drink for children under the age of five years. From five years of age fully skimmed milk can be given if excess weight gain is of concern. When only one type of milk is provided (e.g. in the nursery setting) it should be whole cows' milk because it contains more vitamin A than skimmed milks.
Fruit juices are a good source of vitamin C and are best given with breakfast or a main meal because they help with the absorption of iron. However, all fruit juices are acidic and can cause dental caries and Tea and coffee are not recommended for children therefore should always be served diluted in a cup, under five years because they contain tannin and never a bottle, and at meal or snack times only. These caffeine. Tannin interferes with the absorption of iron should be diluted one part juice to ten parts water.
and caffeine is a stimulant. see Factsheet 4.4 Protecting the teeth
tooth brushing

Parents should be advised to start tooth brushing Comfortable and safe positions for the child are as soon as their child's first teeth erupt. They should on the parents' knee, sitting on a changing mat, use a small (child-size) toothbrush with soft bristles. in a baby chair / high chair or sitting in a pram or Toothbrushes should be replaced every three buggy.14 Children should not be allowed to run months or sooner if the bristles splay. A child should around with a toothbrush in the mouth because of go to bed having just had his or her teeth brushed. the risk of injury if they fall. No drinks or food should be given after brushing.
Tooth brushing should be part of the daily routine to establish a healthy future lifestyle. Teeth should be brushed twice daily – in the morning and last thing at night. Fluoride toothpaste should be put onto a dry brush: • up to the age of three: a smear of toothpaste
containing 1000ppm of fluoride • over the age of three: a pea sized amount of
toothpaste containing 1350-1500ppm or fluoride 13 As more teeth come through it is important to develop a system of cleaning them that ensures all A dry brush is more efficient than a wet one, as surfaces are brushed thoroughly. Children should be the bristles are harder and there is less chance of supervised until at least seven years and always told bacteria accumulating. to ‘spit don't rinse' and not to swallow the toothpaste. Excessive rinsing removes the benefit of fluoride.
One of the easiest ways to brush a toddler's teeth is from behind. All children should be registered with a dentist from the moment their teeth erupt.
are supplements
necessary to
Fluoride, vitamin D and calcium are key nutrients in
protecting the teeth. Fluoride strengthens dental
enamel and makes it resistant to attack by the acid
produced by plaque bacteria. In some areas of the UK
fluoride is added to tap water, while in others tap water
naturally contains adequate amounts of fluoride.15
In parts of the UK where fluoride levels are low in tap water dentists may recommend fluoride varnishes, drops or tablets. To check the geographical distribution of fluoridation visit: www.defra.gov.uk/evidence/statistics/environment/inlwater/iwfluoride.htm Some toddlers have low vitamin D levels and a
supplement of vitamins A and D is recommended
for all toddlers.16 see Factsheet 4.4
When children are dispensed medicines they should be sugar-free (SF). If no sugar-free medicines are available then the medicine should, if possible, be given at meal times. Medicines containing sugar should not be given to a child last thing at night if possible.
Toddlers who have a balanced diet, including three
servings of milk, cheese and yogurt each day will
get adequate amounts of calcium. Toddlers with an
allergy to milk proteins will need their diet assessed
by a dietitian and may need a calcium supplement.
family oral hygiene
Two bacteria have been implicated in the soothers, pacifiers,
development of dental caries – Streptococcus mutans and Lactobaccillus. These microorganisms colonise the mouth soon after the teeth erupt and are usually transmitted to the infant by parents or carers sucking If the toddler uses these the parents should be teats, soothers or spoons. If the parents and carers have active untreated caries with high levels of Streptococcus mutans then the child is more likely to • use an orthodontic soother / pacifier / dummy develop dental caries at an earlier age. Parents and carers should have their tooth decay and gum disease • never dip it in anything sweet, for example, jam treated and should brush their teeth twice daily.13 References
1. NHS Clinical Knowledge Summaries: Evidence on teething symptoms 2009. 2. Fayle SA, Welbury RR, Roberts JF. British Society of Paediatric Dentistry: a policy document on management of caries in the primary dentition. International Journal of Paediatric Dentistry 200; 11: 153-157. 3. The NHS Information Centre for health and social care. 2007-2008. Compendium of clinical and health indicators / clinical and health outcomes knowledge base. North West Public Health Observatory, The Dental Observatory.
4. Scottish Intercollegiate Guidance Network. Prevention and Management of dental decay in the pre-school child. Edinburgh: 2005.
5. Renfrewshire Community Health Partnership Committee. Improving the Oral Health of Children in Renfrewshire. Glasgow: 2007.
6. Scottish Executive. Towards better oral health in children. Edinburgh: 2008. 7. Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for dental caries in young children: a systematic review of the literature. Community Dental Care 2004; 21 (Suppl): 71-85. 8. Barnes GP, Parker WA, Lyon TC, Ann Drum M, Coleman GC. Ethnicity, Location, Age, and Fluoridation Factors in Baby Bottle Tooth Decay and Caries Prevalence in Head Start Children. Public Health Reports 1992; 107(2): 167-173. 9. Moynihan P, Petersen PE. Diet, nutrition and the prevention of dental diseases. Public Health Nutr. 2004;7(1A):201-26.
10. Habibian M, Roberts GJ, Lawson M, Stevenson R, Harris S. Dietary habits and dental health over the first 18 months of life. Community Dentistry & Oral Epidemiology. 2001; 29: 239-246. 11. Levine RS, Stillman-Lowe. The scientific basis of oral health education. 6th Edition. 2009.
12. Scottish Executive. Nutritional guidance for early years. Edinburgh: 2005. www.scotland.gov.uk. 13. Department of Health: Delivering better oral health: an evidence-based toolkit for prevention. London: Department of Health; 2009. 14. NHS Health Scotland. http://www.healthscotland.com/uploads/documents/12231-FirstTeethHealthyTeeth.pdf (accessed April 2010).
15. Department of Health. Birth to Five. London: COI: 2009.
16. Department of Health. Weaning and the Weaning Diet. Report of the Working Group On The Weaning Diet of the Committee on Medical Aspects of Food Policy. Report on Health and Social Subjects 45. London: HMSO; 1994.
Additional copies of this Factsheet can be downloaded from www.infantandtoddlerforum.org The information contained within this Factsheet represents the independent views of the members of the Forum and copyright rests with the Forum members.
Page suitable for photocopying for healthcare professionals to give to parents
Protecting toddlers from tooth decay
gUidance & tiPs for Parents
You can protect your toddler's teeth and prevent tooth decay by regular brushing with a fluoride toothpaste, and sensible eating and drinking habits.
Regular effective tooth brushing to remove plaque
Take care with sweet food and drinks
Start brushing your toddler's teeth as soon as they erupt Always dilute fruit juices because they are both sweet and and register him or her with a dentist.
acidic and can damage teeth. Serve them in a cup, never in a bottle. An easy way to brush your child's teeth is from behind. Comfortable and safe positions for your toddler can be on Never leave a bottle of milk or a sweet drink with your your knee, sitting on a changing mat, in a high chair or in a toddler when you put him or her down to sleep.
pram or buggy.
Begin using a cup or free-flow beaker for drinks from about As more teeth come through, develop a system of cleaning six months or so, and stop using bottles around 12 months. them that ensures all surfaces are brushed thoroughly twice Never give sweet drinks in a bottle because sucking slowly on sweet drinks increases the risk of tooth decay. Toddlers should be encouraged to enjoy brushing their Water or milk are safe drinks between meals and snacks. own teeth, but children should be supervised until at least Give only water at night to toddlers. seven years and always taught to ‘spit don't rinse', because excessive rinsing removes the benefit of fluoride.
Limit foods and drinks containing sugar to four times a day, e.g. at the three meals and one snack. The other snacks Fluoride toothpaste to strengthen tooth enamel
should be savoury snacks with no sweet food or drinks.
Brush teeth, twice a day with a small soft dry brush using a Do not allow grazing on food and drinks throughout the toothpaste containing fluoride day. Only offer your toddler food at three meals and two to • up to the age of three use a smear of toothpaste
three snacks each day.
containing 1000ppm of fluoride If your child uses a pacifier, soother or dummy make sure • over the age of three use a pea sized amount of
it is an orthodontic dummy and never dip it in anything toothpaste containing 1350-1500ppm of fluoride mouth-sized chunks, cubes or slices of apple, pear, satsuma, orange, banana, kiwi, melon, strawberries, sliced grapes, peaches and plums Raw vegetable sticks or slices
carrot, pepper, celery, cucumber, sliced cherry tomato, radish, broccoli Toast, breads, rolls, baps, bread
French bread with a small amount of butter or spread; mini savoury sandwiches sticks, plain buns
with marmite, cheese, tuna, banana, salad or thin slices of meat; pita bread pockets cut into small slices or toasted with or without butter or spread e.g. olive or sunflower oil spread; breadsticks on their own or with a dip or soft cheese Oatcakes, rice cakes, crackers,
plain or with butter or spread e.g. olive oil or sunflower oil spread, or use a crispbreads, melba toast
savoury spread, such as marmite or peanut butter Natural yogurt or fromage frais
on its own or as a dip or with fruit Muffins, plain, potato or cheese
on their own or with a small amount of butter or spread scones, crumpets, pancakes, plain

Wholegrain breakfast cereals, but
serve with milk and fresh fruit not cereal bars
Where possible use a sugar-free medicine
If your child is prescribed a medicine, ensure that it is a sugar-free (SF) medicine if possible. If there is no sugar-free option give the medicine at meal times. Practical help and information on nutrition and developmentSupported by an educational grant from Danone UK ITF177 - June 2010

Source: http://www.jackintheboxbournemouth.co.uk/files/8613/4667/7800/Protecting_Toddlers_from_Tooth_Decay.pdf

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