Dr Sandra White: Healthy teeth = more fluoride, less sugar

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Dr Sandra White tackles the sugar/fluoride/child oral health debate during the Saving Kids’ Teeth Conference 2017

Dr Sandra White asked: in the context of oral health, is there a crisis? Children’s oral health is improving overall, supported by companies like Oral B and Colgate and the work of dentists and their teams. Yes, she admits, people are eating more sugar but there is also more fluoride about to act as a counterbalance. However, yes, there is a regional crisis.

She remembered how she wept when, as a dentist, she once had to remove 20 rotten teeth from the mouth a three-year-old child. She was a little emotional at the time having become a mother just two months before, but even so the damage was avoidable and in an ideal world the extractions would not have been needed.

The overall picture may be improving but in some areas the situation is remaining static if not becoming worse. Recent research showed that 25% of 5-year-olds suffered from dental decay of which 78% remained untreated. Looking at the situation socio-economically the simple fact remained: the poorer you are the poorer your dental health will be.

Only the blind could fail to see the evident regional inequalities in children’s dental health. There is a significant difference between the South-east of England and the North-west, but if you have a mouth full of rot will you be able to even find a dentist? Access to NHS dentistry varies throughout the UK. In some places there is just one NHS dentist per 1000 population, in others that figure rises to 18. Why? What makes the difference?

On average three days of a child’s schooling are missed due to dental problems; and that does not take into account the detrimental effects of sleepless nights and pain on a child’s concentration. Their education will suffer, reducing their chances to rise out of their socioeconomic situation. And there is a cost to the nation. Every tooth extracted from the mouth of a five-year-old under a general anaesthetic costs the NHS £836.00, an expense that is easily preventable.

The legal responsibility for children’s oral health lies with the 353 local authorities, but they have had their funding squeezed over the last several years. The already complex access situation has been aggravated by the wait for NHS dental contract reform, which is why the Child Oral Health Improvement Programme Board (COHIPB) was established in 2015. Its ambition is to see every child grow up free from tooth decay, and to achieve this it has five key aims:

1: Child oral health is on everyone’s agenda
2: The early years and dental workforce have access to evidence-based oral health improvement training
3: Oral health data and information is used to the best effect by all key stakeholders
4: All stakeholders use the best evidence for oral health improvement
5: Child oral health improvement information is communicated effectively

Dr White asks: What else can we do? She lists supervised toothbrushing at school, applications of fluoride varnish, water fluoridation, and free provision of toothbrushes. She would ban Coke machines from schools to take away the choice. Yes, the image of a Nanny State rears its head, but sometimes it works. Look at seatbelt legislation and the banning of smoking in enclosed public places, both initiatives worked.

Starting well

We need to focus on the 13 highest priority regions of the country where children’s oral health is most at risk. With the creative use of funding it should be possible to establish better preventive practices, while also remembering that we are saving nearly £1000 every time a child doesn’t need an NHS hospital extraction. We should work with high-risk groups: have open days in dental practices and reach out to local partners. And why not reward initiatives by recognising practice champions?

To paraphrase Elvis Presley – we need a little less sugar and a little more fluoride please. Why put a health warning on cigarettes but not high sugar products? The Scientific Advisory Committee on Nutrition (SACN) reviewed the evidence on sugars, and found that:

• High levels of sugar consumption are associated with a greater risk of tooth decay
• The higher the proportion of sugar in the diet, the greater the risk of high energy intake
• Drinking high-sugar beverages results in weight gain and increases in BMI in teenagers and children
• Consuming too many high-sugar beverages increases the risk of developing type 2 diabetes

In light of these findings, SACN recommended:

• Free sugars should account for no more than 5% daily dietary energy intake
• The term free sugars is adopted, replacing the terms Non Milk Extrinsic Sugars (NMES) and added sugars. Free sugars are those added to food or those naturally present in honey, syrups and unsweetened fruit juices, but exclude lactose in milk and milk products
• The consumption of sugar-sweetened beverages (e.g. fizzy drinks, soft drinks and squash) should be minimised by both children and adults

On 22 October 2015 research demonstrated that the marketing of high sugar foods is effective, and such promotional activity in the UK is the highest in Europe. It is also understood that the so-called sugar tax will need to be set between 10-20% to be effective. We will also need a simple gauge and labelling by which to define high sugar foods. Public Health England plans to reduce the nation’s sugar intake by 20% by 2080, but something needs to be done now.

Proven facts:
• Fluoride toothpaste is good for primary and secondary teeth, but do people know?
• Fluoride varnish works and should be used on every child’s teeth, but only 38% of children have received it
• There are 55% fewer hospital admissions for extractions in areas of water fluoridation, and 28% fewer cases of child dental decay
• Water fluoridation is cheap and it does no harm

In conclusion, those people who rail against water fluoridation disseminate “fake news” when they describe it as mass medication and say it breaches human rights. Out with fake news, the truth? Fluoridation means poor kids have rich kids’ teeth, and who wouldn’t want that?

Dr Sandra White is Head of Dental Public Health. As a dentist she worked in clinical practice for 20 years and specialised in working with vulnerable children and adults. A consultant in Dental Public Health Sandra worked with commissioning teams to review, restructure, and procure health improvement and care services in local authorities, NHS and clinical services.
She also leads the team responsible for improving oral health and reducing inequalities.