In a world where information seemingly flows freely, there are still dark corners where a lack of knowledge and skills can cast a shadow over something as vital to overall health as oral health. Good oral health is foundational to proper breathing, speaking, chewing and swallowing, and self-esteem. Oral disease is associated with diabetes, heart and lung disease, stroke, low birth weight and premature births. Prevention of oral disease is accomplished through prenatal parental and caregiver education and early access to professional care. Treatment of oral disease is needed when prevention fails, is much costlier, and has much more limited access. 

This is a tale of two-year-old toddlers whose parents found themselves in uncharted territory when it came to preventing cavities. The barriers they faced were not only caused by their circumstances but also echoed a larger issue: a lack of accurate guidance and proactive, preventive home care.

In the spring of 2023, a West Coast friend visiting her daughter’s family out East near me invited me to dinner.  The parents of two-year-old twins revealed a significant challenge when getting their kids ready for bed:  the toddlers vehemently resisted having their teeth brushed, and the exhausted parents had given up trying. Another revelation: the family’s pediatrician said that dental visits weren't necessary until the age of two. Having recently relocated to the area, they lacked a dentist for themselves, let alone one for their children.

This narrative exposes the complexity of misinformation. The pediatrician's well-intentioned guidance lacked comprehensive information (the first dental visit ideally occurs when the first tooth erupts and no later than age one), while the absence of a family dentist left them adrift. The toddlers' evening routine included going to bed with a bottle of warm milk, which in the absence of effective brushing, further heightened the risk of tooth decay. (Nursing a baby to sleep and at-will nursing through the night both also create an increased cavity risk.) The parents were surprised to learn that such habits could have a detrimental impact on their children's oral health. In fact, cavities (also called “dental caries” or “tooth decay”) are the most common childhood chronic disease in the United States and are caused by acid-producing oral bacteria that thrive on simple sugars and exponentially increase their damage in dry mouths.

The journey to transform this situation began with addressing misconceptions and equipping the parents with actionable steps. A crushed-bristle manual toothbrush and an overly stimulating electric brush unveiled some physical obstacles to proper oral care. I recommended having two soft manual baby toothbrushes, and ideally a silicone fingerbrush. This allows for the parent/caregiver to hold one brush, the child to hold the second, and the finger brush (or the second brush) can be used to help hold the teeth open. Brushes are replaced when the bristles show any fraying. A mild-tasting toothpaste (fruit-flavored or vanilla) with fluoride is best, using a “grain of rice-sized” smear, from eruption of the first tooth to age 3 years. Mouth cleaning can begin even before the first tooth appears - simply wipe gums with a soft cloth (or a baby toothbrush and water) after each feeding.

One of the pivotal lessons was dispelling the notion that a toddler brushing their own teeth sufficed. Comparing it to allowing a child to brush the parent's teeth, highlighting the precision required, exposes the fallacy. Parents must brush and floss for children until around age 10, or until they are able to effectively remove plaque (easily demonstrated with pink disclosing solution). 

I stressed the importance of brushing after meals when the teeth are exposed to sugars. For toddlers, I emphasized that brushing could be linked to meal cleanup, fostering a lifelong habit of oral care. This approach facilitated compliance and shattered the notion that “bookend” brushing (brushing twice a day, on waking and at bedtime) was sufficient. I used a gentle approach by standing behind each child, seated in the highchair after eating, to demonstrate tooth brushing.  By gently cradling their head in my non-brushing arm (which can hold a second toothbrush or a silicone finger brush to gently prop open the mouth), I can use the same brushing motion as I use on myself (the result of standing BEHIND the child, and not in front).  We brush the biting surfaces, the inside surfaces, and the smiling surfaces, in small circular strokes, with the soft bristles planted gently where the white tooth meets the pink gums. The result was astonishing - cooperation, clean teeth, and utterly amazed parents.

Prevention emerged as the cornerstone. The keys to oral health – brushing after meals and snacks, drinking water in between meals, flossing once a day, and daily tongue scraping – were adapted for the twins' age. The analogy of cleaning teeth after meals (when the teeth get “dirty”), akin to washing hands after using the toilet, resonated with everyone, highlighting the simplicity of maintaining excellent oral hygiene.

The story of these toddlers reflects a broader reality: a need for comprehensive oral health education, and accessible, affordable, informed healthcare. Establishing these foundations early and educating parents during pregnancy (think: OBGYNs and nurse midwives) about the significance of their oral health and that of their infants can set the stage for lifelong habits. Consistent reinforcement during infancy (pediatricians, family physicians and nurse practitioners) can mitigate future challenges. Establishing a dental home from the first tooth or first birthday, whichever comes first, is pivotal. Bridging the gap between medical and dental professionals, empowering parents with knowledge to use at home, and ensuring easy access to well-trained dental care providers are crucial steps to minimizing oral disease. This is in addition to community water fluoridation, school-based pit and fissure sealants programs, and the placement of fluoride varnish by primary care providers, starting at the eruption of the first tooth, around six months old.

Ultimately, this tale underscores the transformative potential of education and proactive care at home, proving that the journey toward excellent oral health starts with informed decisions and daily habits. Excellent oral health supports overall health. Breaking the cycle of misinformation and poor habits requires a collaborative effort between healthcare providers, educators, parents, and the community at large. As we all embrace this narrative, we illuminate a path towards strong and healthy smiles, and healthier lives, for generations to come.

About the author:

Dr. Sue Keller is a graduate of Harvard University and earned her doctorate of dental medicine at the University of Connecticut School of Dental Medicine. She has 25 years of experience in private practice general dentistry (24 as a solo practice owner), and is an expert in oral health prevention, care, and treatment, dental wellness coaching, and medical/dental healthcare integration and collaboration.

She is a member of the American Dental Association’s Institute for Diversity in Leadership Class of 2019-2020. Now retired from clinical dentistry, she is the MA Grassroots Representative for OPEN Oral Health Progress and Equity Network, a participant in the National Collaborative for Infants & Toddlers Committee/Peer Groups, and an oral health representative with the Voices Health Leaders for Healthy Kids program.

She is married and is a new empty-nester, with two young adult children. When not pursuing her passions as an oral health prevention champion, she enjoys rowing/sculling, playing symphonic double bass, making pottery, performing musical improv, just learned to sail, and has jumped out of a perfectly good airplane…twice!