Simple as it may seem, brushing (and flossing) can be a bit challenging for many families. Let’s break down the discussion by ages: infants, school-age kids and teens.
For my toddler screenings (beginning by age 1 year) I begin by discussing positioning because I have come across many variations. I use my small teaching dinosaur to demonstrate first what I recommend during this exam. It keeps the tiny toddlers entertained and helps parents to understand what I will be doing before the start of the exam. Parents and kids are inquisitive as to how the first exam will go and it really varies. Most kids will fuss or even cry, but then I have some who are remarkably quiet and just open wide. In the years of seeing wriggly teeny toddlers, I have deducted that my best viewpoint is also the one you should position yourself for. When I examine a baby or toddler (this also pertains to kids too scared to sit in the dental chair), I position myself in front of the parent, preparing for a knee-to-knee exam. This position provides for a stable surface created by our thighs in which your child faces you, legs straddling your waistline, and then their head is reclined into my lap. It’s the position dental professionals take for stabilizing your child, but also for best view and access. I encourage parents to appreciate the following from this position: your child is limited in how they can move away from you, this “cave-like” mouth is now facing upward to a focal light from above, the tongue naturally drops back in the mouth allowing for access to the inner side of the lower teeth, and you have a free hand to move the muscle groups of lips and cheeks away from the area you are targeting in brushing. This position also helps for your young child to get familiar with a reclined position, the same in which is done in the office. If it takes two people on a bed or a floor at home to brush your child, it is the same as with me during a toddler exam in the office. I encourage you to do so if your child is wriggly so you can be quick and efficient by having a partner aid in stabilizing. Make it fun by searching for treasures or superheroes hiding between teeth. Kids enjoy a song too. Just be playful and cheery about it so your kids learn to play along.
This works well for babies and toddlers, but as they get bigger, they like to do it just the same as you. Kids appropriately start to develop autonomy as they grow to be school-age. They want to do it all themselves like the “big kids” that they are. There are great benefits in this development. They are learning the dexterity it requires to brush the front teeth, then moving to the back teeth. Watch your own hand movements in the mirror next time to appreciate the motions taken to move to all areas of the mouth. It seems like a memorized track you are on, but that came from years of brushing and flossing practice. Kids are still learning the dexterity it requires to brush. Flossing is even more tricky to learn. Be patient when I ask that you allow your little ones to brush themselves, but then you go in and brush and floss for them after! Young school-aged kids really cannot floss themselves at this point. It’s the trickiest of the tasks to learn. I tell parents that the easiest position for the school-aged kids is also in a reclined position into your lap with their mouth up. Use a sitting position on a chair or the bed or floor again. You gain the same benefits of getting a real up-close view, but can use your free hand to move the lips and cheeks out of the way. Remember that those cute little lips and cheeks are all muscle groups and sometimes you find resistance in access to areas because kids too can use them to push you out. They may not even realize they are doing it. Most of us say, “open wide”, which helps in getting most areas of the mouth, but the cheek side access could benefit from closing a bit, so the cheek muscles are not so tightly pressed against the teeth, leaving little wiggle room for the brushing motion.
I like to engage older kids and teens in understanding why they need to brush and how to best understand access. They are in an age of changing teeth and gaining more and more permanent teeth (what I refer to as your forever-ever teeth). Teens are just as dependent on an adult for guidance in oral hygiene as younger kids, but for different reasons. They are in an age of development and varying hormones. These hormones can cause differing degrees of gingival concerns which are highly hygiene-dependent. Some parents struggle with this age group and their overall hygiene, not only their oral hygiene. Be patient and keep your exams and cleaning regular to aid in building confidence in them when it comes to maintaining their oral and overall health. This is the latter age for my parents to aid in their children’s brushing and flossing. Gentle reminders can help. Disclosing toothpastes or mouthwashes can benefit them in realizing where they are missing. Keep in mind that crowding may also lend to creating difficult-to-reach areas. Use a mirror during the process and self-evaluate after. I call this the shiny versus matted test. Clean teeth reveal the natural sheen of enamel whereas remaining plaque dulls the sheen, appearing matted. Teens in this age group may be in orthodontics. The appliances may make access a bit trickier. I provide guidance on shifting the lower jaw to make room, using a smaller head toothbrush to get in the tighter spacing, brushing technique variations and platapus flossers (which kids really are finding helpful), as well as a needle and thread floss system. As for the varied technique on brushing with braces, try to visualize the line of brackets and focus on brushing directly over the brackets and then at 45-degree angles from above and below the brackets. The goal is to use the sweeping action of the soft bristles to dislodge debris from the appliances and tooth surfaces. If you can’t brush at school, do rigorous water swishing to expel as much as you can. It’s important to have your orthodontic team aid in evaluating at each adjustment visit and provide tips on improvements, as needed. Helping your teens understand the importance of maintaining oral health is critical to their overall healthy growth and development. The mouth is the entryway to the rest of the body’s system. It is as important to consider the foods you eat as it is the bacterial load you carry in your mouth when discussing overall health.
I provide handled flossers, which are very common in the pediatric dental community. They make flossing much easier by another person, as well as for kids to hold as they are learning more about practicing their oral hygiene. I assess your child to see if they have spacing between their teeth. If they all come into contact, I call this floss-dependent to encourage just how much I want you to floss. Most of the littles have space between their front teeth, but contacts between the molars. I guide my families in demonstrating the flossing technique as well. Flossing allows us to clean these inner walls that the toothbrush can’t reach. It completes the oral hygiene regimen. My advice is to brush and floss morning and evening, but I hear from parents that the flossing advice is very new to them conceptually on their young child. I encourage to get good at night-time flossing and then to add it to their morning routine. The evening wind-down time for bed is a calmer time than the morning rush to learn an additional step in the routine.
Let your older kids see you brushing and flossing as well. It helps for them to learn that this is what all people do to take care of our teeth. Learning to access further back is important as more molars are erupting, beginning with the first ones—the 6-year molars. Notice that the lower jaw is the only part of your mouth that can move. Use this to shift side to side, allowing more space to get to the sides of the molars. I demonstrate this for all my parents and kids to understand how to gain access to the sides of the further back teeth. I help parents and kids to understand the anatomy of the jaw and muscle groups they are presented with in the process. Making funny faces is all part of the game of access when brushing!
Plaque is mostly natural/off-white in color, similar to the color of your teeth. That’s why it’s rather hard for kids to identify easily. Its appearance is rather fuzzy or matted in small amounts, but can be rather noticeable in kids who are really not brushing. You will see the once pink gums turn red and irritated, swollen and puffy, a loss of the regular, uniform marginal scalloping around top part of the teeth. You will see more bleeding when your child brushes or flosses because they are presenting with gingivitis—the early, reversible gingival ailment seen with a decline in brushing and flossing in oral hygiene. With improved brushing, flossing and possibly (depending on age) a prescribed mouthwash of chlorhexidine, a powerful antibacterial mouthwash, their gums will begin to heal and reduce in swelling and inflammation. In having such overgrowth of gum tissue and heavy accumulation of plaque, it is easy for the teeth to experience demineralization under the plaque layer (especially of concern during orthodontics). Upon brushing, you may notice bright white, chalky areas that you cannot remove with more brushing. These are the early signs of cavities which can easily progress to showing cavitation if hygiene is not improved. I tell my families to do the shiny vs matted test after brushing. This means that you inspect your teeth after brushing to see that the natural sheen of clean enamel is seen in all areas. If it appears matted, go back in and brush and floss. Flossing is critical in getting the plaque from between the teeth, following the natural C-shape curve of the gumline in this area of the two abutted teeth. It’s an easy area to see the matted plaque accumulation that the brush bristles themselves can’t reach.
I also fully encourage the use of fluoridated toothpaste. I will discuss fluoride again in another blog, but for now understanding the amount is important. See the image below, provided by our academy, the ADA. My advice to parents is to stick to toothpastes with the ADA seal of approval for validity in what is advertised on the tube. Children younger than 3 years age use a small grain of rice-sized versus a pea-sized amount for kids 3-6 years age.
I demonstrate the amount at my exams based on ages. If parents are reluctant for the use of fluoridated toothpaste, I encourage use for bedtime brushing or alternating evenings, if needed. I’ll elaborate more on the benefits and use of fluoridated hygiene options as well as sealants as a blog on cavity prevention.
As your kids get older, their ability to brush and floss does improve. There are products on the market as mouthwashes or toothpastes that stain the plaque—disclosing agents. These products are useful for the kids starting at approximately 7 to 8 years age onward. They use the disclosing agent to visualize the now brightly-colored plaque and target their brushing to remove it all. It’s a great learning tool and motivates kids to learn the reason we brush. This is an example of a disclosing mouthwash, but there exist various toothpastes and other mouthwash alternatives.
There are various apps and timer games that help for kids to target all teeth by groups for an approximate 2-minute brushing duration. You can’t go wrong with these! Many parents will start using a battery-operated or electric toothbrush. I only suggest you look at the size of the toothbrush head to make sure it is small enough to be useful and that not too much pressure be exerted on the teeth. I still support the use of traditional, soft manual toothbrush as what is gifted at your cleaning and exam visit.
It is critical to fully engage with your dentist and hygienist during your regular 6-month exam and cleaning. Each age group is unique in needs and development of the skill of oral hygiene. Having parental involvement during my exams is critical in gaining confidence in the process!