Why you should care about childhood tooth decay

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In the spring of 2022, the last thing Nina Yakymyshyna could think about was teeth.

Yakymyshyna was in Kharkiv when Russia began its invasion of Ukraine. She was with her two young sons while her husband was at sea working as a fisherman. The next few months were a blur as she shuttled, with the help of her friends, to a small town near the Russian border and then to a village in western Ukraine.

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She recalls with horror the sight of tanks barrelling through the town. She would then tuck herself and her children in a nook below the ground as rockets screamed above. Finding food at grocery stores was always a problem. They never went a day without a meal, but those were small and spread out.

Worries about her family’s safety tormented Yakymyshyna. Meanwhile, another war was being waged — inside her two-year-old’s mouth, by harmful bacteria slowly gaining ground on his teeth.

Her youngest son Pavlo’s teeth had fallen prey to the pathogens early on. She suspects his dental woes were caused by breastfeeding after she’d cleaned his teeth at night. Around six teeth had been decayed by the time of the Russian invasion. Yakymyshyna was concerned, but she was bound by the need for her family’s safety.

Her worries eased when she reached the village, which was relatively safe and had a dental clinic. However, her son’s teeth were so severely decayed that he needed to be treated using general anesthesia — which would induce a loss of consciousness — a treatment the village’s dental clinic couldn’t offer. Nor could a clinic in Estonia, where she later sought refuge.

It was only in Calgary the next year when she had her son treated. But by then, the damage had been inflicted: seven of his baby teeth had to be extracted, leaving him with around 13, some of which would be thinned out.

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Fighting against attack from ‘sugar bugs’

Early childhood caries, more commonly known as tooth decay, are a silent epidemic destroying children’s teeth. An estimated 514 million children suffer from the infection across the globe, according to the World Health Organization, with a prevalence of 100 per cent in some countries, including Indonesia. Baby teeth, or milk teeth, have also been increasingly decaying among North American residents.

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Tooth decay is the most common chronic childhood disease in Canada and is the leading cause of surgical operations among children. Doctors annually performed 19,000 surgeries on children below the age of five to treat their caries, according to a 2013 report by the Canadian Institute for Health Information (CIHI).

A separate report published by the Canadian Dental Association in 2016 found such treatments cost families and insurers more than $21 million a year (The numbers have yet to be updated). And yet, many dentists argue, oral health is often considered an afterthought.

Tooth decay is a process in which bacteria in the mouth digest sugars stuck on teeth and release acidic substances that dissolve the tooth’s enamel. These pathogens can be swept clean through habits such as flossing and brushing one’s teeth. However, the bacteria grow in strength between intervals.

Dr. Leonard Smith uses a more illustrative explanation.

The 78-year-old pediatric dentist — the first to set up such a practice in Calgary — usually tells his little clients the main culprit behind their problems are monsters called sugar bugs. These bugs live on their teeth and are hungry for sugar, and just like them, they gobble it up and excrete their waste.

“All of a sudden, it clues into them that these bacteria are s—ing in their mouth,” Smith said.

What the kids may not comprehend is how severely these bugs can harm them.

Untreated patients suffer from dental pain, difficulty in eating and speaking, poor appearance and, in turn, low self-esteem. Some researchers suggest a hindrance in the ability to chew one’s food, especially when young, affects the brain’s development in learning, memory, emotional regulation and responses to fear.

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The stress from the pain worsens cognitive functions in early childhood, and the resulting lack of sleep pushes children to seek food at night, throwing them into a vicious cycle that eventually leads to higher doses of medication. Meanwhile, more antibiotics and pain relievers, doctors say, disrupt the balance of the gut microbiome, which is closely linked to the development and functioning of the brain. These challenges increase the risk of contracting other diseases as the younger patients grow older.

If the infection is left unchecked for a long time, the bacteria enter the bloodstream and can cause organ failure, tissue damage and, in extreme cases, death.

Where tooth extraction is the only solution, a child’s problems are far from over. If a baby tooth is removed prematurely, the permanent tooth set to replace it might be blocked by other adult teeth drifting toward the resulting space, dentists say, causing complications that years later will require orthodontic treatment to allow the patient to eat properly.

Even though Smith is semi-retired, he is often troubled by thoughts of tooth decay’s ramifications and why people, according to him, don’t pay enough attention to them. The data so far hasn’t eased his concerns.

‘Greater density of decay than there was previously’

A separate analysis by CIHI found 495 day surgeries per 100,000 people to address tooth decay were performed in Calgary — lower than in many other places — from 2011 to 2015. The issue has only become worse, say dentists in the city.

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“The need has increased — with a growing city, there’s a higher population base, and a greater density of decay than there was previously,” pediatric dentist Dr. Farida Saher said.

However, the cases aren’t simply explained by a rise in population, said Dr. Sarah Hulland, a pediatric dentist who also practises at the Alberta Children’s Hospital.

“The best pseudo-metric — and I stress pseudo-metric — would be that the number of pediatric dentists in Calgary over the past 10 to 15 years has easily doubled, and we’re still overwhelmingly busy; and the population has not doubled,” Hulland said.

“It implies that either the kids weren’t getting treated before or there’s just a significantly more demand for the need for the care. And I think that the latter is reasonable to extrapolate.”

A bus with dental equipment and hygienists, operated by the non-profit The Alex, visits schools in high-needs communities in the northeast and southeast quadrants of the city, examining 20 schoolchildren a day, five times a week.

Shannon Hawryluk, a dental hygienist with the organization, said 50 per cent of the children examined on average have untreated active decay, and nearly a third of them have urgent needs, meaning they’re experiencing pain or have visible signs of abscesses.

Hulland finds the resurgence of tooth decay concerning and decades ago, she put herself on the path to treating the ailment — something she recalled with an amusing anecdote.

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“When I went to dental school, I was the weirdo keener in my class who said, ‘Pediatrics is so awesome!’ ” she said. “And my classmates are looking at me and they’re going, ‘Caries are dead. Why are you going into pediatrics?’ ”

That was in the early 1990s.

“It wasn’t long after I graduated from pediatric dentistry, you started to see an uptick.”

Dentists point to a mix of factors that have culminated in the growth of this disease.

The most important on the list is a profusion of sugar.

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Sugar’s problematic ubiquity degrades dental health

The pathogens in our mouths thrive on refined carbohydrates, especially at night when salivary glands below the tongue and the interior of our cheeks shut down, weakening defences against bacteria.

These bugs aren’t the only ones who love sugar.

What started as a preservative in the 1950s became an essential ingredient in food products as many got hooked on it, said Sylvain Charlebois, director of the Agri-Food Analytics Lab at Dalhousie University. Sugar became ubiquitous — in the foods we ate and the drinks we sipped, threatening us with diabetes, obesity and rotten teeth.

Charlebois estimates more than 75 per cent of processed foods available in grocery stores contain added sugar. And among those are products children munch on.

Take, for example, Goldfish crackers: The wafers break down into mushy balls that stick to children’s teeth, along the gum lines. “You have to really play with your tongue to get it unstuck, which feeds the bacteria associated with getting cavities,” Hulland said.

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Coinciding with sugar’s supremacy in foods was the rise of the two-income household and a subsequent drop in affordability, which made it more convenient to feed processed snacks to one’s kids.

Then the pandemic arrived and brought everyone closer to their kitchen.

“The kids made best friends with the pantry and the refrigerator,” Hulland said.

“Parents are tired. Kids are always there. It’s just really easy. The kid says they’re hungry, you give them food — it’s hard. It’s not a finger-pointing exercise; it’s just an explanation and facts of reality.”

Back-and-forth on fluoridation complicates matters

As processed sugars made their way into our food, Calgary fiercely debated on fluoridation in our drinking water. The contentiousness of the debate over fortifying water with fluoride, which helps in strengthening the teeth’s resistance to the acidic byproducts of the pathogen, stretches back nearly 70 years.

Calgary fluoridated its water in 1991 for the first time after its residents had resisted in four plebiscites on the issue. However, in 2011, the city voted to stop fluoridation, handing a victory to the practice’s opponents, who believed the chemical wasn’t necessary for drinking water and raised the risk of health concerns, including cancer — claims that are inconclusive. Doctors have been sounding the alarm for a decline in people’s dental health ever since.

“The science shows that low-dose, frequent application of fluoride is the best way to prevent caries,” Hulland said.

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Researchers at the University of Calgary in 2019 found nearly 65 per cent of Grade 2 children had at least one cavity in their baby teeth — 10 percentage points higher than in Edmonton, where the water is fluoridated.

Calgarians voted in 2021 to reintroduce fluoride in the city’s drinking water supply, but the process has since faced delays.

A lack of fluoride has now revived the need for educational programs in schools and other institutions that over time became redundant, said University of Toronto dentistry professor, Dr. Michael Glogauer, “because you’ve now removed some of the key elements that led to the reduction in dental caries.”

Smith, Saher, Hulland and Glogauer all agree the need for education among parents across all classes has become increasingly important. However, they have also found the issue is highly prevalent among people in the lower socioeconomic sections of society, especially as immigration has ticked up.

Barriers — including language, and housing and employment insecurity — drive many immigrants away from seeking dental care, research says.

Studies have also found families experiencing poverty have a high chance of contracting tooth decay. The risk of infection, which can be transmitted through close contact, is heightened by financial stress, inadequate access to health care and poor dietary choices owing to a lack of affordability.

However, childhood caries sometimes are a symptom of larger societal problems of neglect and abuse.

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Domestic abuse connected to poor childhood dental health

More than a decade ago, pediatric dentist Smith began examining children in family shelters, including Inn from the Cold. (The shelter declined to comment for this story.)

There, Smith said he would meet mothers, many of them survivors of domestic abuse, whose children had severe tooth decay. The women would confide in him, saying the father of their children wouldn’t let them take their kids to the dentist. In some cases, Smith said, they acknowledged they weren’t aware of the importance of oral health and the consequences of neglecting its concerns.

“They would be embarrassed because they weren’t taught what not to do,” he said, recalling some of his interactions.

“The children are given pain medication that starts with just Tylenol or Advil, and then as the child gets older, that doesn’t work for them anymore.” Smith hypothesizes that a higher tolerance for pain relief medication among children contributes to addiction later in life.

An American study that sampled more than 6,000 people found appropriate use of opioids before graduating high school raised the chance of future misuse of the substance by 33 per cent.

However, the relationship between the use of other analgesics in childhood and addiction — which also depends on other factors, including trauma and parental relationships — isn’t studied enough, said Monty Ghosh, an addictions specialist at the University of Alberta.

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Kim Ruse, however, cautions about placing blame on survivors of abuse. Most of them are overwhelmed with fear for their and their children’s safety when they enter the shelter’s doors, said the CEO of FearIsNotLove, which operates the Calgary Women’s Emergency Shelter and runs several educational and counselling programs for men and women.

“They’ve often been holding things together the best they can for a long time,” Ruse said. “So, they’re typically exhausted.”

In many cases, caring for their children poses a risk to their safety. Ruse recalled a story of a woman during the pandemic who hid a burner phone in a park so she could talk to the shelter, as all her communication was being monitored by her abuser.

“The level of controlling behaviours existing in some of these relationships impact every way you parent,” Ruse said. Then, there is the issue of logistics.

“Many women will lose access to their car when they leave. And let’s say they have three children and they’ve got doctors’ appointments across the city, and then a dental appointment on the other side of the city, and therapy in between — we sometimes spend a lot of time judging that victim without realizing they’ve lost access to certain resources that would have helped them maintain those routines.”

Mitigating childhood tooth decay in these instances would also mean addressing forces that drive unhealthy relationships. It would involve lengthy and painful conversations on how to establish an environment of care and safety. In the short term, however, Ruse believes support for parents to access and afford dental care is crucial.

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Challenges in affording care aren’t limited to people vulnerable to abuse. Hulland routinely encounters parents at the Alberta Children’s Hospital who say they’re unable to pay for their child’s treatment. She then connects them with resources or doctors who would provide such services for a reduced fee.

The federal government has tried to alleviate this problem by introducing the controversial Canada Dental Care Plan, which reimburses patients for a portion of their treatment costs, although it may not include the full amount.

Dentists have said the program is riddled with issues, including placing the burden of co-ordinating with the federal government on dentists and providing them with lower-than-expected remuneration.

However, slightly under half of the country’s dental health care providers, including denturists, dental hygienists, and assistants, have backed the federal program. Many in Alberta say the current framework, whose income thresholds in some cases are slightly more than a third of the federal program’s, puts many out of access to care. For now, Hulland said dentists are accepting clients under the federal program based on individual cases.

Others believe the main solution is prevention. Services such as the dental bus run by The Alex are helpful, however, Smith believes schools should instate programs in their curriculums to educate children about how to prevent tooth decay. He has written to several federal and provincial ministers, to no avail. Now, he’s in the developmental stages of trying to build a program with the help of a communications firm.

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“We should teach the kids of today why their oral health is important, so when they become parents in the future, they’ll have enough knowledge to prevent the problem,” Smith said. “And it costs nothing to prevent other than maybe the cost of a toothbrush.”

‘Better to prevent these problems than to fix everything’

Yakymyshyna had trouble sleeping at night after she learned her son would have more than half of his baby teeth removed under general anesthesia. She knew she couldn’t have done anything differently while escaping the Russian invasion of Ukraine. But she wished she had known earlier about the best ways to maintain oral hygiene.

She worried how her son would eat after losing so many teeth, some of which had to be dressed in metal crowns. As doctors operated on her son, she stood outside with her fingers entwined. After the operation, the doctor approached her and assured her of her son’s safety.

For a few days, her son felt dizzy, and his mouth bled a little. She fed him mashed potatoes and pureed fruits for a few weeks. Soon, he began making light of his situation by showing off his new silver teeth to his friends.

Slowly, he gained his ability to chew. “Now, he even can eat a raw carrot,” Yakymyshyna laughed.

What has stayed, however, is Yakymyshyna’s attention to teeth. She flosses her and her children’s teeth every day and visits a dentist as regularly as her insurance paid for by the provincial government allows.

“I thought cavity in milk teeth isn’t a problem, but it’s a very big problem,” she said.

“It’s better to prevent these problems than to fix everything.”

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