4. Maintaining good oral health

4.1 Oral health messages for families

Early childhood is a key time for forming lifelong healthy habits, laying the foundation for good health into the future. As children grow and encounter new experiences, they develop new behaviours and skills. Families play a vital role in shaping these early behaviours, which often continue into adulthood.

The following family-friendly messages are designed to help motivate families to create healthy habits that support their children's wellbeing.

General oral health messages for families

Oral health messages about infant feeding:

Bottle feeding

• Bedtime bottle feeding can increase the risk of tooth decay. Do not put babies and children to bed with a bottle. When children sleep, they have less saliva to protect their teeth from milk increasing the risk of tooth decay.

• Six months is a good time to help babies learn the skills of drinking and swallowing from cups
  Learning to hold and drink from a cup is an important new skill that babies need to learn. Phase out the bottle by 12 months of age.

• Infant bottles should only be used for expressed breastmilk or infant formula

Breastfeeding

• Breastfeeding is a healthy choice for your child and can be continued without concern for their oral health. Focus on simple protective habits like offering tooth‑friendly foods and keeping up with regular brushing.

4.2 Toothbrushing with children

Other products marketed to families

Families may feel tempted to buy products that promise convenience or use marketing to suggest they are superior or easier.  However, research indicates that options like:

• silicone finger brushes,
• and U-shaped “automatic” brushes

are either less effective or lack sufficient evidence of effectiveness in children.

While standard soft bristled toothbrushes are effective and are the general recommendation, dental practitioners may recommend alternative products for some children with a disability.

4.3  How to provide a toothbrushing demonstration

At the 18-month Key Age and Stage visit, MCH nurses conduct a toothbrushing demonstration. This is an important opportunity, as some families may be unaware of the correct technique for brushing their child’s teeth. Each location should have a mouth model and toothbrush available to assist with the demonstration.

This visit is also a key time to advise families to start using a low-fluoride children’s toothpaste.

What to cover in a toothbrushing demonstration

1. Children need help brushing their teeth until they are about 8 years old

   Most children do not have the manual dexterity or focus needed to brush effectively until they are about 8 years of age. In addition, children may need reminders and prompts to achieve twice daily brushing.

   For these reasons, children need an adult to help them brush their teeth until they can do it well by themselves. This might look like taking turns, observing and coaching to make sure all surfaces have been covered.

2. Brush in small circles at a 45-degree angle

   Demonstrate to families the correct angle for placing the toothbrush and the motion to use while brushing. It can be helpful for some people to see this technique demonstrated to understand the correct method.

3. Brush all surfaces of the teeth

   Remind families to brush all surfaces of the teeth, including the back teeth where food can get stuck in the grooves. Don’t forget the gum line where plaque can build up, and the back of the front teeth.

4. Introduce a low fluoride toothpaste from 18 months

   Advise families to start using a low-fluoride children’s toothpaste at this stage. Remind them that fluoride is essential for strengthening and protecting growing teeth.

   For more information see 'Section 9 - Fluoride’

5. Encourage children to spit out toothpaste and avoid rinsing with water

   The fluoride in the toothpaste helps to strengthen teeth and should remain on the teeth after brushing. Avoid rinsing, eating, or drinking immediately after brushing where possible.

   Tip to help young children learn to spit out toothpaste:

   Encourage families to let children practise spitting into a cup or sink without toothpaste. This helps them become familiar with the spitting action before adding toothpaste to the routine.

6. Create a lifelong habit: brush twice a day
   Starting the habit of brushing twice a day as soon as a child's first tooth appears can set the foundation for lifelong good oral health. While children may sometimes resist brushing, it's important for families to remain consistent.

OHV’s ‘6 tips to help kids brush’ handout offers suggestions
to help families with children who resist brushing.

4.4 Tooth friendly snacks and nutrition

The role of sugar in tooth decay

As outlined in 'Section 3 - Tooth decay: Understanding the process’, without sugar, there is no tooth decay. Sugar is in a lot of the foods we eat every day.

Fermentable carbohydrates

Carbohydrates are a nutrient found in food, an important source of energy for our bodies. Fermentable carbohydrate are a type of carbohydrate that can be broken down by bacteria in the mouth to produce acid that may contribute to tooth decay. Other carbohydrates don’t break down until they move further down the digestive tract.

Fermentable carbohydrates include not only sweet foods but also carbohydrate-rich staples like bread, rice and pasta. As we chew, these foods start to be broken down into sugars in our mouths. That does not mean families should stop providing these staple foods to children to avoid decay. These foods contain important nutrients for our bodies and our mouths, and not all sugars are equally as likely to cause tooth decay.

Refined starch

Refined starches are processed carbohydrates that have been stripped of fibre and other nutrients. They are rapidly digestible and can quickly break down into sugars in the mouth. Examples include white bread, crackers, and processed cereals.

Free sugars: the highest risk group  

Free sugars are the most likely to cause tooth decay because they are easy for bacterial plaque to feed on and produce acids. Free sugars are:

• Sugars added to foods and drinks by manufacturers, cooks or consumers
• Naturally occurring sugars in honey, syrups, fruit juices and fruit purees
  
  Foods and drinks containing free sugars should be limited, especially between meals. If consumed, they are best eaten at mealtimes.

Why snacking habits matter

When it comes to tooth decay, not only does the type of sugar matter, but also how often teeth are exposed to sugars.

Snacking is a normal part of children’s routines. However, frequent snacking - especially on foods high in free sugars or refined starches  - can increase the risk of tooth decay.

Each time a child eats fermentable carbohydrates, bacteria in the mouth produce acids that soften the surface of the teeth. If the child snacks frequently, there may not be enough time for the teeth to recover between acid exposures.

For more on this process, refer to 'Section 3.5- Frequency of snacking and exposure to sugars: The Stephan Curve’

Guidelines for tooth friendly snacking habits

• By the age of 12 months, families are encouraged to provide 3 meals and 2-3 snacks and have children avoid grazing between these times.
• Encourage families to allow a 1 ½ hour break between each meal and snack, so the teeth can remineralise .
• If snacks are part of the routine, limit them to regular times to avoid grazing.
• Choose snacks that are low in sugar and highly refined starch (e.g. white bread/pasta/rice, many breakfast cereals and some crackers) - fresh fruit and vegetables and dairy foods (or some non-dairy alternatives) are some tooth-friendly options.
• If eating sweet foods, have them alongside a main meal rather than as a snack.
• Offer tap water with meals and snacks. Water helps to wash away food particles and bacteria after eating, and the fluoride in tap water helps to strengthen the tooth surface.

Tooth friendly snack ideas

Offer snacks that are nutritious and low in added sugar, such as:

• Fresh fruit or tinned fruit (tinned in fruit juice, not syrup)
• Vegetables – raw, cooked, canned or frozen – with or without a low-sugar dip like hummus or tzatziki
• Plain yogurt without added sugar
• Cheese and wholegrain crackers
• Wholemeal or wholegrain sandwiches or wraps
• Wholegrain dry crackers

Foods to limit, especially at snack times

Examples of foods and drinks high in free sugars or refined starches include:

• Sweetened breakfast cereals and snack bars
• Fruit strips and muesli bars
• Lollies, chocolate, cakes and biscuits
• Sweet spreads like jam, honey and choc-hazelnut spread
• Ice cream and flavoured yoghurts
• Fruit juice, cordial and soft drinks
• Flavoured milks
• Savoury processed foods such as chips, sausage rolls and meat pies
• Pouched foods, especially fruit-based purees

If sweet foods are offered, it is best to include them with a main meal rather than serving them on their own as a snack.

Choose whole fruit over fruit juice

While fruit juice has useful nutrients, it is also high in free sugars. A child is unlikely to eat four whole oranges but could quite easily drink the sugar from four oranges as one glass of orange juice. Eating whole fruits and vegetables is the best choice for teeth because they also contain nutrients essential  to good overall and oral health.

Plain dairy is good for children’s teeth

Plain milk, unflavoured yoghurt, cheese (and/or suitable calcium-rich alternatives) provide calcium and other minerals which are good for teeth. Avoid flavoured milks and yoghurts which can contain free sugars.

Nutrition and healthy tooth development

A balanced diet supports not only general health but also the development of strong, healthy teeth. Important nutrients include:

• Calcium, which strengthens the teeth and jawbones
• Phosphorus, which works with calcium to build hard tooth structure
• Vitamin D, which helps the body absorb and regulate calcium and phosphorus

Low levels of vitamin D in children or pregnant women may affect how well children’s teeth form, increasing the risk of decay and fractures. A healthy diet is essential for healthy teeth.

4.5 Resources to support age-based advice and anticipatory guidance in the key ages and stages visits

Oral Health Milestones and Key Messages

This quick guide highlights key oral health milestones and messages to share with families at each Key Age and Stage visit. A double-sided version with QR codes linking to family resources is also available for use during visits. (Note: this resource is not designed to be given to families to take home.)

The Little Teeth Book

The Little Teeth Book is designed to support MCH nurses to talk about oral health with families. It provides simple image-based messages, and can support you with:

• Anticipatory guidance
• A concern you would like to address
• A response to a question raised by a family

The messages are just a starting point for a discussion in which you can provide more detailed information based on your knowledge and experience and adapted for the context of the child and their family.

To order a copy of The Little Teeth Book contact healthpromotion@dhsv.org.au

4.6 Oral health and pregnancy

Pregnancy increases the risk of periodontal disease (gum disease) associated with normal hormone changes. Pregnant people may also be at higher risk of tooth decay if their diet changes (for example, if they crave sugary foods), if they experience morning sickness (vomiting exposes the teeth to acid), or if nausea makes it difficult to brush their teeth.

Research indicates a potential link between severe periodontitis in expectant mothers and an increased risk of premature birth, low birth weight, and other adverse pregnancy outcomes (Raju & Berens, 2021). However, further research is needed to determine whether treating gum disease can positively influence these outcomes (Raju & Berens, 2021).

Common signs of gum disease include:

• bleeding gums
• red gums (instead of pink)
• swollen gums
• bad breath.

During pregnancy, it is important to:

• maintain good oral hygiene practices
• maintain a low-sugar diet
• consume adequate calcium and vitamin D for optimal foetal teeth and bone development
• visit a dental practitioner
• seek dental or medical advice for prolonged vomiting, as this may lead to tooth erosion or dental caries.

Visiting a dental practitioner while pregnant is highly recommended. A regular check-up is an important routine to develop for parents and children.

Pregnant people who have a current concession card will not go on the general waiting list to see a public dental practitioner but will be given the next available appointment.

Key oral health message for pregnancy

Routine dental treatment is safe and recommended during pregnancy. Just be sure to tell your dental practitioner you are pregnant.

Refer to ‘Section 8 – Dental Services’ to learn more about eligibility and access to the public dental system

OHV has created the following resources to share with pregnant people.

4.7 Whole family oral health

When parents and caregivers maintain good oral health, it can have positive impacts on the children in that family.  Oral bacteria can be transferred from person to person. For this reason, family members should avoid putting anything in their baby’s mouth if it has been in their mouth (for example carers sharing spoons or ‘cleaning’ dummies by putting them in their mouth).

Additionally, the types of foods a family eats can influence the oral microbiome, meaning diets with fewer tooth-friendly options may increase susceptibility to dental issues for both parents and children (Pitts et al.2015).
Children also pick up habits from their parents. When parents demonstrate good oral hygiene, make healthy food choices, and attend regular dental visits, children are more likely to adopt these habits themselves.

Oral health message for families

Healthy smiles are a family effort. Caring for your oral health helps protect the whole family, including your little one. Simple habits like regular brushing and having tooth-friendly foods and drinks support everyone’s wellbeing.

4.8 Breastfeeding and oral health

See references for '4. Maintaining good oral health'