“Teeth are so important in so many ways, forms and fashion,” Tonya Fuqua, D.D.S., director of Child Oral Health at the Center for Children’s Health, led by Cook Children’s Health Care System. “The mouth is the gateway to our body, and it is connected to the rest of our body. And it starts with once a kid is born.”

The assessment also revealed 57% of children (about 651,000) received at least two or more preventive dental visits aligning with the American Academy of Pediatric Dentistry recommendations.

 A Celebration to Sink Your Teeth Into

In honor of National Children’s Dental Health Month in February, the Cook Children’s Save-A-Smile program hosted a celebration this week in collaboration with the Fort Worth District Dental Society, the Texas Dental Association, and the Children’s Oral Health Coalition.

The organizations transformed the Cook Children's Medical Center Fort Worth Atrium into a dental-themed landscape. Patients received age-appropriate oral health kits, participated in arts and crafts, and chose a Build-A-Bear teddy bear or "tooth" to keep as a reminder of good oral hygiene.

“Healthy mouth, healthy body because if your mouth is healthy, that will hopefully lead you to a healthier body,” said Dr. Fuqua.

How many times has your child told you that they brushed their teeth only to find a dry toothbrush when you inevitably go check? How many times did you tell your own parents that you brushed your teeth when you, in fact, did not? Brushing teeth might be the most lied about subject in my home. As far as I know, there has not been a research study on why children lie about brushing their teeth, but it seems to be a universal phenomenon.  Honestly, brushing your teeth is like any other good habit. It must be taught, practiced, and repeated to become a daily habit. Your children do not know or understand the long-term effects of not brushing their teeth, nor do they see an immediate reward for brushing. For all of us, not practicing good oral health has its consequences at least once every six months if you are seeing a dentist. The lack of good oral health can lead to long-term health consequences and years of dental work that can not only be painful but costly. However, children do not have the forethought to know this or the ability to understand it.

This is why it is so important to establish good oral health habits at home. Good oral health is crucial to your child’s overall health and development. As parents, the way we approach oral health in the home can help to establish life-long habits for our children. While it can be difficult and time-consuming to help your children brush their teeth daily, it is a habit that can help prevent them from having to experience difficult and traumatizing dental procedures now or later in life.

Betsy Hillyard, CCLS (Certified Child Life Specialist) and oral health program coordinator at Cook Children’s Center for Community Health has three tips to encourage parents as you establish good oral health habits at home. As parents, modeling good oral health, having realistic expectations, and having the right tools available can help to make the daily practice of oral health easier for children.

1. Model good oral health. As parents and caregivers, much of what we teach our children stems from what we do. If your children don’t see you brushing your teeth, flossing or prioritizing your own oral health, they are not likely going to want to do it. However, children are often motivated by what they see adults doing and often want to do those things simply because an adult is doing them. Allowing your young children to brush their teeth alongside you can be a great way to encourage them while also monitoring their brushing times and techniques. It is also important to start modeling from a very young age. You can start brushing even your baby’s teeth with a toothbrush (no toothpaste) to begin to get them used to it.  Modeling frequency and times will help your children be able to establish their routine. If you brush your teeth 2 times a day every day, before leaving the house and again before going to bed, your children will likely adopt this same routine. It’s important to model whatever your expectations are. This is true for any habit you are trying to teach your children. It is also encouraged that you monitor your child’s oral health routine until they are 9 years old.
2. Have realistic expectations. If oral health has always been a challenge for your family, it is important to start somewhere, and it is never too late to start implementing good oral health practices. If your child is currently not getting their teeth brushed at all during the day, start with making it a priority to get at least one time a day in and increase to 2 times a day. If your children don’t spend enough time brushing their teeth, it may be good to have them try to brush for at least 30 seconds and then adding more time as they accomplish their goals. Take time to celebrate the one time a day or the 30 seconds that your child can brush. The goal would be to work up to 2 minutes of brushing time, 2 times a day. If your child has mastered brushing their teeth, but flossing is not happening, start with a goal of flossing once or twice a week and work your way up to daily. It’s important to keep oral health a positive topic with your kids. Giving them manageable and attainable goals will help to build their confidence. Positive reinforcement is always helpful when establishing a habit. Using brushing incentive calendars is a great way to keep your expectations realistic while rewarding any goals your child accomplishes. Setting a goal like brushing ten times a week and flossing twice could mean a small prize or extra screen time at the end of the week.
3. Have the right tools available to your kids. Brushing your teeth can be much more fun if you love your toothbrush and the flavor of your toothpaste. This is a great place to allow your child to have choices. While it is important to get your child the right sized toothbrush, allowing your child to pick a toothbrush that they love with their favorite color or character can help. Also, it is important to choose a flavor of toothpaste that your child likes. I know my girls often found minty toothpaste to be way too “spicy” for them when they were younger. Just make sure that you choose a toothpaste that is approved by the ADA (American Dental Association). Finding some type of timer that works for your children is also helpful. It can be a simple sand timer or there are apps with brushing timers for kids. When encouraging flossing, I find that for myself and for my girls that flosser holders are much more user friendly than string floss. They also make flossers in fun colors. My girls get flossing done more easily and frequently with flossing holders available. Anything that can aide your child in meeting their brushing and flossing goals is a win!

As always, it can be helpful to use books and videos to help encourage your children’s oral health.

• I Care for My Teeth by Martha E. H. Rustad
• Caring for Your Teeth by Sian Smith
• Daniel Tiger’s Brushing Teeth Song by PBS

Brushing teeth and flossing are habits that help your child’s overall health for their lifetime. While it can be challenging to establish any good habit, it is important to remember that the effort and time you take to help your children will allow them to continue healthy habits into adulthood. If you run into any challenges or difficulties (i.e. thumb sucking, pacifiers, dexterity with the toothbrush, etc) with your child’s oral health, it is important to reach out to your child’s dentist as they can help you navigate this. Happy brushing!

A child’s smile holds enormous potential for fostering emotional well-being, communicating happiness and building connections with others. It can also be a powerful indicator of physical health.

“There is a clear connection between oral health and overall mental and physical health,” said Tonya K. Fuqua, DDS, director of oral health for the Center for Community Health, led by Cook Children’s. “Teeth can be very telling about what is going on in a child’s life, the socioeconomic barriers they face and underlying health issues they may have. That’s why it’s so important for the dental health of children to be as high a priority as their physical health.”

Connecting the dots between oral and physical health to improve a child’s overall wellness is the purpose of a grant awarded by the American Academy of Pediatric Dentistry (AAPD) Foundation to Cook Children’s Health Care System’s Renaissance Neighborhood Health Center and the Center for Community Health’s Save-A-Smile Program. Cook Children’s is one of only two recipients nationwide to receive the grant.

“The AAPD Foundation is dedicated to making dental care accessible to all children by supporting nonprofit clinics providing routine cleanings, advanced treatments and ongoing care that helps kids in need,” said Douglas Keck, DMD, MSHed, AAPD Foundation president, pediatric dentist, and dental director of a Federally Qualified Health Center in Florida. “Our support of Save-A-Smile and its medical dental interface initiative represents a pivotal step in bridging the gap between oral health care providers and primary health care practitioners. By working together, we aim to provide sustainable compassionate care for children in need.”

The grant supports a three-year pilot project aimed at developing best practices for bridging the gaps between pediatric medical and dental care. It makes way for a community health worker (CHW) to be embedded with Renaissance Neighborhood Health Center to educate and support families while identifying and addressing any barriers that keep them from completing care.

Cook Children’s Renaissance Neighborhood Health Center is a primary health care home for children living in southeast Fort Worth. The center has both a dental and medical clinic under one roof, making it the ideal location to conduct the pilot. Many within the center’s patient population are considered financially vulnerable and qualify for government-supported health programs such as Medicaid and Children’s Health Insurance Program (CHIP). They may also face non-medical drivers of health such as food insecurity, housing issues and adverse childhood experiences.

Making Connections

Juanita Valles is the community health worker assigned to this medical/dental integration project at Renaissance.

“Families tell me their problems and I listen,” Valles said. “Right now, everyone is struggling financially. Sometimes they need transportation to appointments, childcare, clothing, diaper assistance, car seats for the kiddos, household items or even dental care for the parents themselves. That’s where I come in.”

When a family has a need, Valles works to clear the path to make it easier for them to follow through with medical and dental care. She even goes so far as to make in-home visits with her trusty stuffed assistant, Leo the Lion, when working to educate a family and overcome barriers.

“I take Leo with me everywhere I go and use him to show kiddos how to brush their teeth the right way,” she said. “We also teach them to drink lots of water and stay away from sugary drinks.”

Children with untreated dental problems often have difficulty with pain, eating, sleeping, self-esteem, school attendance and grades. Cook Children’s 2021 Community Health Needs Assessment revealed that more than 175,000, or 1 in 7, children living in Cook Children’s eight-county service area were not able to get the dental care they needed. This rate is 9 times higher than national estimates and 5 times higher than state estimates. Stated barriers included inadequate dental insurance coverage, difficulty scheduling and lack of education and resources for dental care.

“You really relieve all barriers by addressing the social service component of why families may not get the dental care they need for their kids,” Dr. Fuqua said. “And the pediatrician’s office is the perfect place to start because children often visit their pediatricians more frequently in their first years of life than they do dentists.”

Leveling Up

Results from year one of the pilot, which began in January 2023, have already triggered system-wide change, Dr. Fuqua says. Dental screening questions were implemented across all of Cook Children’s Health Care System for well-child visits ages 0 to 3. Children in the pilot project who screen positive are connected with the community health worker. Other opportunities to scale-up and implement new solutions for year two include streamlining pilot data collection and analysis, refining criteria for patient referrals to the community health worker and examining system-wide dental screening data.

In the first 10 months of the pilot, more than 1,000 patients responded to dental screening questions during a well-child check and subsequently scheduled a dental appointment at Renaissance. Of those, 429 patients completed initial dental appointments at Renaissance. In that same time, Valles attempted or completed contact with families 247 times and provided tailored oral health instruction in person or by phone to 50 families.

“That's the beauty of this program and having a community health worker,” Dr. Fuqua said. “It's not as simple as just saying, ‘Oh, your kid needs help and here's where to go.’ These families have so many barriers and so many reasons why they haven't gotten a child to the dentist, but Juanita and this program make a way for them.”

About Cook Children's Neighborhood Clinic Renaissance

At Cook Children's Neighborhood Clinic Renaissance, we're here to help you raise a healthy child from infancy through the transition to adulthood. We offer well checks, immunizations, school and sports physicals, injury treatment, and care for both short-term illnesses and longer-lasting conditions.

If your child needs additional help, we can connect you with more than 60 Cook Children's specialty clinics. We're always ready to answer questions and share resources. Feel free to reach out. We're looking forward to your visit with us in Fort Worth. Learn more about our pediatricians, services and support here.

About Save-A-Smile – Cook Children's Center For Community Health

Save a Smile was founded in 2003 by Cook Children’s to address a gap in oral health services for underserved children. Save a Smile is an innovative, nationally recognized, collaborative program dedicated to providing restorative and preventive dental care to children from low-income families in the community through volunteer dentists. Children eligible for the program are pre-kindergarten through sixth grade at high risk for dental disease from schools pre-selected by the Save a Smile program and participating school districts. 

Once per semester, Save a Smile patients receive free treatments from hygiene and dental assistant students at the college while professional dentists also volunteer their time at the event.

The patients received treatments including scaling, polishing, X-rays, fluoride treatment and sealants, plus education on taking care of their dental health at home. If patients needed further treatment, they were identified and will receive referrals for services from volunteer dentists.

Save a Smile has more than 86 volunteer dentists who provide children with comprehensive treatment as needed, whether it’s fillings, surgery, root canals, orthodontics, etc.

Tonya K. Fuqua, D.D.S., is the Director of Child Oral Health under the Center for Children’s Health, Children’s Oral Health Coalition and Save a Smile program.

“We’re excited to partner with such an awesome community organization like Tarrant County College Hygiene School,” Dr. Fuqua said. “We’re seeing about 50 kids today that need our help.”

Depending on the severity of the problem, the age of the child, translation requirements and financial/insurance status, a referral is made to the appropriate volunteer dental provider. Dental care is given in the volunteer dentists' private offices, free of charge to the families. Children with CHIP or Medicaid are connected with a Medicaid/CHIP provider selected through their coverage.

“Usually when we contact the families, the first question they ask us is ‘how much money do I have to pay’ and we tell them this is completely free,” said Lourdes Ramos, Community Health Worker. “Volunteer dentists will volunteer their time and work and it’s completely free.”

Media partners may use this content for news stories and broadcasts with credit to Cook Children's.

RELATED:

Save a Smile Provides Life-Changing Dental Work for 3 Girls (checkupnewsroom.com)

A Bright Smile Begins With A Healthy Mindset: The Overlooked Link Between Dental and Mental Health (checkupnewsroom.com)

Three little girls’ lives were changed when Save a Smile provided more than $11,000 in dental care to restore their smiles. Britani, Skarli and Ashley Ortiz were in so much pain from dental decay that they frequently went to the nurse’s office at school to ask for ice packs. The Save a Smile program at their school identified the Ortiz sisters because each girl had multiple abscesses and was in emergent need of dental care.

Save a Smile, which started in 2003, is in 21 elementary schools in Hurst-Euless-Bedford, Fort Worth and Keller ISDs. Save a Smile provides dental screenings at schools and identifies children who are in emergent need or pain. Save a Smile has provided over $10 million in dentistry to children in the community.

Depending on the severity of the problem, the age of the child, translation requirements and financial/insurance status, a referral is made to the appropriate volunteer dental provider. Dental care is given in the volunteer dentists' private offices, free of charge to the families. Children with CHIP or Medicaid are connected with a Medicaid/CHIP provider selected through their coverage.

The Ortiz sisters were identified as patients in the 2019-2020 school year, but some of their dental procedures were delayed due to the pandemic. After more than 15 appointments and procedures, the girls received their final appointments in June 2022. They are 5, 6, and 7 years old.

“I told my sister to be brave and to not be scared,” Ashley Ortiz, 6, said. “They are very nice people. I was happy to be in this place because they’re so nice.”

Tonya K. Fuqua, D.D.S., is the Director of Child Oral Health under the Center for Children’s Health, Children’s Oral Health Coalition and Save a Smile program. She was also the dentist who volunteered to provide dental care for the girls.

Dr. Fuqua knew the girls were afraid of going to the dentist since they had never been before. She noticed how brave they became by the last appointment.

“I got to see the transformation from dental disease to happy smiles, so I think that warms all of our hearts when we think of it that way,” Dr. Fuqua said. “When we think how the smile connects to the rest of the body, it does impact the child, from not being able to eat or to learn or to not be in pain.”

The Ortiz sisters were some of many children across the country who got behind on dental appointments and care due to the pandemic and dental office closures.

“These teeth that were just going to need fillings or stainless steel crowns now needed extractions,” Dr. Fuqua said. “Even one of the girls needed multiple extractions. That’s sad and that’s where COVID has taken us.”

The 2021-2022 school year was one of the first years that Save a Smile had well over 500 kids identified as a “class one, severe or urgent” category for needing dental care. Dr. Fuqua said that so many children have infections and abscesses. Usually, in previous years, there were 300 to 400 children considered class one.

Save a Smile has more than 86 volunteer dentists who provide children with comprehensive treatment as needed, whether it’s fillings, surgery, root canals, orthodontics, etc.

“We can’t do it without these private-practicing dentists saying yes, to opening up their doors to seeing hundreds of children for thousands of dental appointments and a ton of dental work being done,” Dr. Fuqua said. “We want to keep kids out of our emergency rooms at Cook Children’s and out of our Urgent Cares if we can – not for dental pain.”

Save a Smile community health workers will pick up students and take them to appointments if they don’t have transportation.

Jesusa Campos, Community Health Worker at Save a Smile, connects with families in need and met the three girls.

The girls’ parents were unable to attend the appointments, so Campos was there to coordinate between the parents and the dental offices. Sometimes within one week, Campos picked the girls up from school and drove them to multiple appointments.

She’s happy that the girls are doing better now and that they learned how to take care of their teeth.

“I love being able to help them to strive in life,” Campos said. “I can’t imagine having a toothache and having to go to school every day. I like helping them out and making sure they can continue healthy habits.”

Read the full story here. 

Kaden was born with a lymphatic malformation, the medical term for an abnormal growth of lymph vessels in his head and neck. His enlarged tongue makes it difficult to get to all the areas a toothbrush should effectively reach. Due to this condition, Kaden’s mother and his nurses use Toothette swabs in conjunction with a squirt bottle to clear out his mouth six times each day.

“We can’t get to his teeth really well because the tongue just kind of fills the whole space,” mom Kimberlee Lee said. “We realized we can’t leave food in his mouth at all, ever. He gets food stuck on the roof of his mouth because he can’t move his tongue around.”

Dental care for Kaden’s sister, Joslynn Lee, also requires a degree of finesse and patience. A rare genetic disorder caused strokes that left 7-year-old Joslynn autistic and developmentally delayed with behaviors more aligned with a 3-year-old child. She bites, squirms and resists whenever it’s time to brush her teeth.

Kimberlee says Joslynn responds better when she can watch her reflection in the mirror. And their routine involves music; Kimberlee sings a special toothbrushing song to both distract and calm her wiggly daughter. Singing also helps Joslynn make a connection to the purpose of the toothbrush.       

February is National Children’s Dental Health Month, an occasion to promote awareness of the importance of oral health to overall health. This includes the best oral care practices at home and while at the dentist office. Routine dentistry can be challenging for many children, and even more so for children like Joslynn and Kaden who face extra medical hurdles.

The various sensations that even a routine dental procedure entails – sounds, tastes, tickly tools and bright lights – can be overwhelming for a child with developmental or mental disorders. Patients with autism might need additional patience and care to mediate the sheer amount of sensory immersion they are experiencing all at once. Or a patient with muscular dystrophy might need specialized tools to keep her mouth open during the treatment. Or a patient with epilepsy might have chipped front teeth because of his seizures.

“Patients who have mental, developmental or physical disabilities have a harder time with communication or have difficulty cooperating for oral health practices at home. This all leads to a higher risk of dental problems,” according to Sheela Patel, D.D.S., a pediatric dentist at the Cook Children’s Renaissance Neighborhood Clinic.

“We often encounter families who put off seeing a dentist because they are fearful their child may not be able to cooperate. But it is very important -- especially for the special needs population -- for children to visit the dentist early on so prevention strategies can be created in order to address oral health issues before they cause pain or even infections,” she added.

Dr. Patel and Shawne Barron, D.D.S., M.S., both practice at the Cook Children’s Renaissance location, the only Cook Children’s neighborhood clinic that offers dentistry services in addition to general pediatric care. Dr. Patel estimates that out of the more than 50 patients treated in the dental clinic each day, typically 20%-30% of those patients have underlying medical conditions or special health care needs. The Lee family makes the drive from their home in Justin for dental services at Cook Children’s Renaissance Dental Clinic in Fort Worth.

The American Academy of Pediatric Dentistry (AAPD) reports that children with special needs tend to run a higher risk for tartar buildup, cavities, gum disease, overcrowding and tooth fractures. The AAPD cites various reasons to explain why these children often face a greater likelihood of oral health problems. Examples of complications include behavioral issues (attention deficit hyperactivity disorder, for instance); intellectual disabilities; and facial birth defects such as cleft lip or cleft palate.

“The more severe their health conditions, the more likely they are to have unmet dental needs,” according to the AAPD.

But the experts at Cook Children’s have some advice regarding strategies to ensure healthy oral care and treatment: Go to a pediatric dentist.  Communicate your child’s likes and dislikes to the clinic staff. Establish a daily brushing routine that fits your child’s needs and sensitivities. The guidance and encouragement can ultimately help keep every child’s smile as healthy as it can be.    

Children should make their first trip to the dentist between 6 months and 1 year of age, said Tonya Fuqua, D.D.S., director of Child Oral Health at the Center for Children’s Health, led by Cook Children’s. The first visit lays the foundation for a good relationship with the dentist and for healthy dental practices at home.

“I can’t tell you how to best help your child unless I meet them, I see them, I ask you questions and learn about your child and their special needs,” Dr. Fuqua said. “We as dentists want to help make toothbrushing the least invasive part of the day. We can give tips and tricks to help support a good dental routine at home with different gadgets, tools and ideas. There’s so much to offer, but a parent won’t know unless they take their child to the dentist and start early.”

 She calls the initial appointment the “happy visit” – a chance for the patient to meet the clinic staff, explore the surroundings, and maybe ride up and down in the exam chair. “The first visit should establish a positive experience for that child so that each time they come back they know that this is a safe and possibly fun place to go,” Dr. Fuqua said.

 To acquaint her patients with a few common dental items, Dr. Fuqua might send them home with mouth mirrors, gloves and masks, encouraging the family to play “going to the dentist.” Create a pretend scenario looking into each other’s mouths and using a flashlight to mimic the dental light on the swing arm above the dental chair. Having that play experience can help decrease anxiety when it’s time for an actual cleaning or checkup, she said.  

 Parents of children with special needs should be sure to update the dentist each time their child’s medication and health history change. The office will need to know any accommodations that might help the appointment go smoother, such as headphones or dimmed lighting. Dr. Fuqua recalled a patient with autism who requested a Taylor Swift playlist. “It made a huge difference,” she said.

Dr. Fuqua welcomes any favorite toy or blanket that helps soothe a child in the dentist chair. Parents may also hold their child’s hand and give words of reassurance during the dental procedures. “You have to find what makes them tick, what makes them engaged and smile, what makes that child happy,” she said.

 Alert the staff to any aversions, such as loud noises or a crowded room that could be upsetting. “You know your child best. Let the dentist know those things that trigger your child to get nervous or worked up, in order to help us know what to avoid.”

 Modifications and role playing at home can help a child with special needs warm up to going to the dentist and receiving dental care. For those with extreme sensitivity to taste and touch, Dr. Fuqua recommends limiting the stimulation. Start with a small toothbrush without toothpaste. Eventually, you can apply the toothpaste when the child is ready. Let the child brush a stuffed animal’s mouth. Read books and watch animated videos. All of these steps can start the process of making oral hygiene both fun and familiar.

 For children with dexterity impairments, a tool can be created by inserting a toothbrush into a tennis ball, making it easier to grasp. This modification not only teaches a level of independence, but also gives those children the confidence that they are capable of doing it on their own. 

 Dr. Patel and Dr. Fuqua understand that families juggling with stress and time constraints. possibly due to their child’s health challenges, might be tempted to make dental care a low priority. “It’s definitely one of those things that parents let slide because it’s just one more thing to deal with,” Dr. Fuqua said. The intense combination of medications and frequent doctor visits for the underlying health condition can be overwhelming. Even with these struggles. families should aim for brushing teeth at least two times a day (morning and before bed). Oral health impacts overall health, so it’s not something to ignore.

 The two dentists at Cook Children’s Renaissance Dental Clinic stay busy but are always accepting new patients. The clinic has seen an annual average of 5,434 dental patient visits since 2019. Depending on the medical issues, the safest way to perform dental procedures for some children is under anesthesia in the operating room. Annual dental surgeries at Cook Children’s averaged almost 1,100 in the past three years.

 Dr. Patel recommends finding a pediatric dentist who is comfortable with your child’s unique and individual needs, and can speak at his or her cognitive level. She attributes the resistant behaviors in some patients to a lack of understanding or an inability to express themselves. For a patient who is nonverbal like Joslynn Lee, the care must be extremely customized.

Kimberlee Lee says her daughter has a sensory processing disorder along with her autism. Joslynn’s desire for control makes brushing her teeth a battle. She won’t allow flossing or pulling a loose tooth.

During a dental appointment, Joslynn doesn’t understand why she has to sit still and can’t bite. As a result, she must be sedated for cleanings or other dental work, Kimberlee said.

At home, keeping little brother Kaden’s teeth clean involves the team of nurses who tend to his tracheotomy and restricted airway. The nurses collaborate with Kimberlee to sponge off his teeth and gums every time he eats. 

Unfortunately, a medication Kaden takes to control his lymphatic malformation makes him prone to mouth sores and tooth decay. At just 4 years old, Kaden has already needed several extractions and caps due to the damage to his enamel. Through all of this, he maintains high spirits at the dental office.  

“He loves the attention,” Kimberlee said. “So for the most part, he really is very cooperative. He’s happy to open his mouth. He’s excited about the little bag with the toothbrush and the new toothpaste and all the little things inside and to get the stickers at the end of the appointment.”

For parents with children who have similar needs, Kimberlee shared a few points that help dental visits go smoother for her family:

Plan ahead and bring whatever makes your child relax. Kaden prefers the iPad, and Joslynn likes fidget toys to keep her hands busy.

Offer a reward afterward as encouragement.  

Stay calm and positive. “Check your own energy and be able to show up and love and comfort for your child rather than feeding on their fear,” Kimberlee said. “When you’re scared, it ends up making everything worse.”

 Kimberlee advises parents to do their best to implement dental care at home, and be OK if it isn’t perfect.  The key is progress, not perfection.

“In the beginning of having special needs kids, I always felt like if they got a cavity or something was wrong, that it was my fault that I haven’t been taking good care enough of their mouth,” Kimberlee said. “I’m just going to have some grace, and if we have a problem, we have Dr. Patel to help us through it.”

But when you are plagued with mental illness or poor oral health—or a combination of both—it can be hard to turn a frown upside down, and that can have a profound impact on a child’s overall well-being.

“Our children don’t smile if they are hurting,” said Tonya Fuqua, DDS, director of child oral health at Cook Children’s. “If they have oral health disease and pain, or they are embarrassed by their smile, they don’t eat, or talk, or socialize, and they have trouble learning in school or being the best they can be as a kid. It’s the same with their mental health. If they are not in a good state of mind kids disconnect and aren’t the best kid they can be, and a domino effect happens.”

When people think about health, they rarely consider mental and oral health as part of the equation, but the two can be as taxing on the body as any other ailment. In Cook Children’s 2021 Community Health Needs Assessment (CHNA) survey of parents and guardians in the North Texas region, more than 180,000 children ages 0 to 17 went without needed dental care, and more than 63,000 without needed mental health care.

“People don’t realize the importance of oral and mental health to their overall health,” Dr. Fuqua said. “But dental disease is connected to heart health, and if you have cancer and are using certain medications, or you’re an asthmatic and using inhalers, that is going to impact your oral health. It’s the same with mental health. If you have to cope with one of these chronic illnesses, it’s going to impact your mental health, and poor mental health can stress other body systems and lead to other health issues.”

Oral and mental health also have a direct impact on each other. People with severe mental illness often neglect good oral hygiene practices and are 2.7 times more likely to lose their teeth, according to an article published in the Canadian Journal of Psychiatry. Add in an unhealthy coping strategy and your mouth and teeth are at even greater risk of disease.

“There is a clear connection between your emotions and how you handle stress,” said Kim Cox, a clinical therapist and manager of Cook Children’s Save a Smile program. “Sometimes kids handle stress in non-productive ways, like smoking and vaping, for example. That all affects your oral health as well.”

The risk is present in reverse, too. Poor oral health often leads to worsening mental health as people grapple with chronic pain and self-consciousness from an imperfect smile.

Add the stress of the pandemic on top of all of this and it’s easy to understand the recent decline in both mental and dental health among children. Cook Children’s has recorded a record number of suicide attempts in the past 12 months and, according to the CHNA parent survey, more than 170,000 children have had dental problems in the past 12 months. Parents identified the impact of COVID-19 as one of the top three barriers to their children getting the care they needed.

“There has been a marked increase in dental disease since the pandemic,” Dr. Fuqua said. “There is no surprise that when kids are stressed, disconnected or depressed, they eat. This leads to bad habits that can result in increased cavities. Also, when kids are off their routine, like during the pandemic, things go by the wayside, such as brushing and good oral health habits. Then, when kids get lots of cavities, they will not smile or even talk as much because they are embarrassed by the way their teeth look. This is a huge social inconvenience and causes kids to be even more distant and traumatized emotionally.”

Connecting the Dots

More often than not, mental illness and dental disease are treated in a silo. There is little recognition of their ties to and impact on other health issues and body systems, and little coordination between specialties in their treatment, according to Cox.

“If you have heart disease and go see a cardiologist, just because you are going to see a specialist for a specific issue doesn’t mean that part of your body is disconnected from other parts of your body and its function,” Cox said. “But for some reason, oral and mental health are seen that way. Dentists and therapists are seen as treating systems completely disconnected from a person’s overall physical health.”

Both share a similar stigma, too. Embarrassment leads many to suffer in silence.

“I call it the silent epidemic,” Dr. Fuqua said. “Nobody talks about mental health because there’s a stigma attached to it. Nobody wants to admit their child is going through a difficult time or kids don’t speak up about it. We see the same in dentistry. Many are embarrassed to admit they have issues with their teeth.”

A lack of insurance keeps many from getting the dental and mental health care they need, according to the CHNA parent survey. Insurance companies don’t cover services for mental and oral health as robustly as they do for other issues, making treatment unaffordable for many families. Dental insurance, for example, usually provides a capped maximum payout for treatment per year, but many dental procedures and treatments cost well above the typical yearly maximum.

The first step to breaking these shared barriers is for physicians and parents to talk about oral and mental health as much as they talk about diabetes, obesity, asthma, nutrition, childhood vaccinations and viruses.

“We need all of us—dentists, pediatricians and parents—talking about mental and oral health and looking at kids as a whole,” Dr. Fuqua said. “We need to always be in tune and watching for signs and symptoms. Doctors can take a quick look at a child’s teeth at their well-child check and ask them if they are seeing a dentist. Parents can talk to their kids about how their mind and mouth are feeling, and help them understand that their mental and oral health and hygiene are as important as any other part of their body.”

After all, a healthy mouth and mind help make a healthy body, not to mention a big, beautiful and bright smile.

During the early months of the pandemic and related closures, your child may have had a dentist appointment postponed. But now, the office is calling to reschedule that visit. You might be wondering if it is a good idea to visit the dentist right now?

The answer is “YES!”

Your dentist is an important part of your family’s health care team. Regular dental checkups provide a chance for dentists to identify any potential dental problems before they become worrisome. It’s also a great time for your whole family to learn about important habits that support not just a healthy mouth, but a healthy body too! And, don’t forget about that awesome new toothbrush you receive when you visit the dentist!

Children should have their first dental visit when their first tooth comes in, or no later than their first birthday. Then, visit the dentist every 6 months, because prevention is the best way for your child to stay healthy. However, if you see brown or black spots on their teeth or if your child mentions mouth or tooth pain, then call your child’s dentist right away.

So, what can you expect when you visit the dentist, in light of COVID-19?

Dental offices are receiving evidence-based guidance from The American Dental Association (ADA), the U.S. Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) regarding infection control.

Tonya Fuqua, DDS, director of Child Oral Health for the Center for Children’s Health, encourages parents to ask any questions they may have about current safety procedures.

“Call the office and ask questions about what procedures are in place to keep your child safe,” Dr. Fuqua said. “Knowing what to expect can help both you and your child feel more comfortable!”

You may also receive a phone call before your appointment to ask questions about your child’s recent health. Dr. Fuqua says that on the day of the appointment, “you may be asked those questions again, and you and your child will most likely have your temperatures checked. Your child may be asked to rinse with a special mouthwash at the dental office, so have fun practicing swishing and spitting at home before the appointment.”

The staff will be wearing personal protective equipment such as face shields, masks, eye protection, gloves and gowns. Let your child know that the people they usually see at the dentist’s office might look different dressed in all that protective equipment, but they are still the same people behind the masks. Looking at staff photos on the office’s web page before the appointment can help your child remember who takes care of them at the dentist.

You can also take a few steps to help support safety at the dental office. If you or anyone in your family are not feeling well, are running a fever or have any other COVID-19 type symptoms, please call the office to let them know before you go in. Because typically only one adult can accompany the child for the appointment, limit others who come with you that day (they will most likely have to wait in the car). Everyone over age 2 should wear a mask at all times and of course, wash your hands before and after the visit.

If your family has let toothbrushing routines slide, now is a good time to get everyone brushing 2 times every day, for 2 minutes each time. Kids can make and decorate brushing charts or calendars to help strengthen those good habits! Floss between your teeth 1 time every day. Children should begin to floss as soon as they have two teeth touching. Other mouth-healthy habits for the whole family include choosing water or unflavored milk instead of sugar-sweetened drinks, eating healthy meals and snacks, and limiting sweets and candy.

Remember, good oral health can lead to good overall health. Things may look a little different at the dentist’s office, but be reassured that your dentist will continue to provide the highest quality of care in the safest manner possible.

More on this topic:

• Dental Care
• Oral Health Education
• Neighborhood Clinic Dental
• Protecting Your Young Athlete From Dental and Facial Trauma
• How to Get Your Kids to Brush Their Teeth

It was reported by the American Academy of Pediatric Dentistry that sports accidents account for 10-39 percent of all dental injuries in children! These injuries can happen to a child’s face and teeth from falls, collisions, contact with hard surfaces and sports equipment. Activities such as riding a bike, skateboarding, hover boarding and jumping on a trampoline can result in injuries that affect the teeth and the face. The upper lip, gums and front teeth are more prone to injury. These teeth are subject to fracture, nerve damage, becoming loose and even falling out.

Not all sports-related injuries can be avoided, but most of them can be prevented! Wearing helmets, facemasks and mouthguards have been shown to greatly reduce the severity of dental and facial trauma. The National Federation of State and High School Associations only mandate mouthguard use for certain sports such as football, ice/field hockey, lacrosse and wrestlers wearing braces. But it is very important that proper protective equipment and mouthguards be worn for all sports that have the risk of injury (baseball, softball, basketball, soccer, volleyball, gymnastics to name just a few).

A mouthguard is made to protect the lips, gums and teeth from damage. They work by absorbing the energy from an impact and dissipating the remaining energy. There are many different types of mouthguards and if you are thinking of getting a mouthguard for your child, it is important that you visit your dentist. The best mouthguards are the ones that are custom made at the dental office. A mold is taken of the teeth and a mouthguard is made that is the right fit and comfortable for your child. If a custom mouthguard is not feasible for you, then there are many other mouthguards that are available over the counter. Even though they may not be a perfect fit, they will still provide offer some protection.

Bottom line, please protect your child’s face and teeth with the proper protective equipment while they are playing sports and having fun!

The CDC states that fluoride found in toothpaste prevents dental tooth decay (caries or cavities), but too much can create discolor and white lines or streaking (dental fluorosis) of the teeth.

Sheela Patel, D.D.S, and Shawne Barron, D.D.S, pediatric dentists for Cook Children’s, give the following advice to parents on how to take care of young children’s teeth:

1. Before teeth appear in your baby’s mouth, wipe down the gums with a warm, damp washcloth after feedings.
2. When the first tooth appears, begin to use a tiny amount of fluoride toothpaste, placing a smear that is the size of a grain of rice on the toothbrush that you are using.
3. After age 3, then begin using a “pea-sized” amount of fluoride toothpaste, and yes, it is always prudent for mom or dad or caregiver to dispense the toothpaste to ensure that the correct amounts are dispensed.
4. We recommend a toothbrush with a small head, soft bristles, and to replace toothbrush every 3 to 4 months, or when any sickness has occurred.

Their suggestions are in line with the guidelines from the CDC and the American Academy of Pediatrics.

The study from the CDC looked at the brushing habits of more than 5,100 children and adolescents aged 3 to 15 from 2013 to 2016.

The survey found:

• Nearly 80 percent of children began toothbrushing after the age of 1.
• Approximately one third brushed once daily
• Nearly 40 percent of children aged 3-6 years used too much toothpaste.

“Good dental health is critical for everyone, regardless of age,” Dr. Patel said. “It's important to remember that the health of you and your children’s teeth and gums can have a direct impact on their overall health. While poor dental hygiene can lead to gum disease, cavities and tooth loss.”

I have more than once used the "you don't want to be the kid that smells" tactic on my kids and once they are school age it usually works to get them to brush their teeth. In elementary school most kids don't care about life long health but they do care about friends and teachers. I prefer not to use star or sticker charts as I find they are more work for parents--but if this works in your family go for it.

Toddlers are another creature entirely. I suggest that parents start cleaning babies teeth early not only for health but to get them used to it. Under 1 year it can be as simple as wiping the teeth with a wet washcloth, but at 1 year I have families starry using a toothbrush. There are lots of little tricks out there to keep toddlers brushing. My favorites are singing or counting while brushing--same song every night--they love routine. Once toddlers get into the "I can do it myself now" stage, get 2 toothbrushes. Let the toddler "brush" with one and the parent can use the other at the same time to really brush. Does all of this fail sometimes--yes. I have I held my toddlers down to brush their teeth--yes. Have I skipped teeth brushing--yes.

For all kids one of the most important things a parent can do to protect the teeth is to keep kids off of sweet drinks--that means no juice--and not letting them fall asleep with a bottle or cup of milk after age 1 year.

I have seen many toddlers and young children over the years require anesthesia and surgery to repair decayed teeth. This is entirely preventable with good dental care. Please ask your pediatrician if you need help in carting for your childs teeth or contact one of the Cook Children's dentists.

Related Articles

• 5 Reasons Why Baby Teeth Are Just As Important As Permanent Teeth
• Parents, Stop Giving Your Teething Babies Homeopathic Remedies
• Protecting Your Young Athlete From Dental and Facial Trauma
• 4 teething myths every parent should know
• 5 life-saving reasons to take care of your teeth

The truth is that baby teeth DO matter! Primary teeth, or baby teeth, are very important to a child’s physical, emotional, and social development. Here are five reasons why baby teeth should be taken care of just as we take care of our permanent (adult) teeth.

1. Tooth alignment and position - The primary teeth save space for the adult teeth and guide the adult teeth into their proper position. If the baby tooth is lost early due to tooth decay, the adjacent teeth tend to drift or tip into that space. Therefore, the permanent tooth has less room to come in and can be blocked from erupting into that space.

2. Healthy permanent teeth - The permanent teeth develop very close to the roots of the baby teeth. Baby teeth are much smaller and cavities can spread very quickly through their thin enamel. If cavities are left untreated, the baby tooth can develop and infection or abscess which can hinder tooth development and cause damage to the permanent tooth underneath.

3. Proper health and nutrition - Teeth, of course, are needed for chewing. Dental pain from cavities can lead to nutritional deficiencies if the child is not able to properly chew their food. Also, if cavities are left untreated, there is a great risk of an infection forming. And this infection can spread to other areas of the body and even to the brain. This can turn into an emergency situation very rapidly and the child may need to be hospitalized. Unfortunately, there have been reported cases where children have died from a dental abscess.

4. Speech and facial development – The tongue, lips and cheeks deflect off teeth when forming sounds. The presence and proper positioning of baby teeth assist in the formation of correct pronunciation during speech. The tooth structure also provides support for the developing facial muscles and gives shape to your child’s face.

5. Concentration and self-esteem – If a child is having dental pain, it can greatly affect their ability to pay attention and learn in school. Decayed teeth can also interfere with a child’s social interactions and affect their confidence and self-esteem. This can also lead to children missing school and parents having to miss work if they have to take children into the dentist for emergency appointments.

The bottom line: Teaching your child to develop good oral care habits with their primary teeth is very important! These early habits will help them keep those permanent teeth healthy for life!

About the author

Dr. Patel is a dentist at Cook Children's Neighborhood Clinic on 2600 E. Berry Street in Fort Worth Texas, 76105. Dr. Patel received her dental degree in 2009 from University of Nebraska-Medical Center in Lincoln, Neb. She completed her pediatric residency in 2011 from the Baylor College of Dentistry in Dallas. Dr. Patel is board certified by the American Academy of Pediatric Dentistry. The Neighborhood Clinic offers a dental home for patients from 6-18 years of age the clinic and most CHIP, Medicaid, and commercial insurance plans are accepted. The staff speaks English and Spanish. To learn more, click here or call 817-347-4600.

Every kid goes though it and yet, it’s universally misunderstood. Poor teething. It gets blamed for just about everything and probably causes very few symptoms.

I thought I would clear up some of these misconceptions and I asked Sheela Patel, D.D.S, a pediatric dentist at CookChildren’s to lend her expertise.

Teething Myth No. 1- Teething causes fever (or maybe you’ve heard it blamed for congestion, sleep disturbance, decreased appetite, diaper rash, diarrhea or vomiting).

It doesn’t. Right, Dr. Patel?

“Despite what you may have heard, teething doesn’t directly cause a high fever or even diarrhea,” Dr. Patel said. “Babies tend to put everything in their mouth in an effort to massage their gums, so they may pick up bacteria.”

Here are some symptoms that have been found to be statistically associated with teething:

• Mild temperature increase
• Sleep disturbance
• Salivation
• Rash
• Runny nose
• Appetite loss
• Irritability

You’re thinking, “See, I told you it does cause fever!”

Not so fast.

First of all, the temperature increase was noted to be 0.12 degrees Fahrenheit on the day that the tooth erupted. I’ll leave it up to you to decide if you think having a temperature of 98.6 vs. 98.72 actually makes a difference…

Second, the increase in temperature and the rest of the symptoms associated were found to be present on the day the tooth came and the day after. This was not a 2 week (or 2 month) process leading up to the teeth popping through.

The issue is that all kids teeth. In addition, all kids have occasional sleep disturbances, drool and have runny noses. Trying to determine if the teething causes these symptoms in a particular child is pretty difficult.

Teething Myth No. 2 - It’s too early for them to cut teeth.

The average age for the bottom middle teeth to come out is 4-6 months, but some children teeth before or after.

Some children are born with teeth, called natal teeth. If the teeth are stable in the mouth, nothing needs to be done. There may need to be some extra special care with breastfeeding moms to make sure their latch is not painful, especially during those early feeding days. If the teeth are wiggly, sometimes the pediatrician will pull it or recommend that you see a pediatric dentist to have it pulled.

Teeth can otherwise erupt any time after birth. But remember that the “symptoms of teething” that occur for two months before a tooth erupts are not likely due to teething at all.

Teething Myth No. 3 - They are too old to not have any teeth.

“He still doesn’t have any teeth.” I get this comment all the way from 6 months to 1 year. The right answer, “That’s OK.”

It is exceedingly rare for children to not have any teeth or to have teeth, but for them to never come out. A handful of babies don’t have teeth at their one year check-up but, I promise, they’re coming.

Teething Myth No. 4 - Teething must be treated.

The understanding of teething has changed a lot over time. Infant death used to be commonly associated with teething. Think about it, if a 6-12 month old child died for unexpected reasons, chances are they had a tooth coming in. Because of this, teething used to be treated with things as invasive as lancing the gums in order help them come through.

While we’ve come far enough to know that isn’t necessary. Parents still attribute a significant amount of normal fussiness or waking up at night to teething and treat based on this idea. What’s the problem? Everything we do has potential risks…from teething gels, to essential oils and even Tylenol^® or Motrin^®, while options, should be used with caution. (While I’m on my soapbox, just because something is the “natural” or “organic” variety, doesn’t mean it’s safe.)

For treatment of teething, Dr. Patel recommends that you “provide a firm rubber teething ring to chew on, but avoid the ones that are filled with liquid. Try giving your child a cool, wet washcloth to chew on. You can wet a washcloth, ring out the excess water and place it in the freezer. Make sure to wash it before each use. Give your child cool, softer foods such as applesauce or yogurt.”

Don’t let these common teething myths fool you. If your child has severe symptoms, don’t attribute them to teething. Don’t treat normal behavior with medication. Don’t assume that teething treatments are without risk.

About Sheela Patel, D.D.S

Dr. Patel is a dentist at Cook Children's Neighborhood Clinic on 2600 E. Berry Street in Fort Worth Texas, 76105. Dr. Patel received her dental degree in 2009 from University of Nebraska-Medical Center in Lincoln, Neb. She completed her pediatric residency in 2011 from the Baylor College of Dentistry in Dallas. Dr. Patel is board certified by the American Academy of Pediatric Dentistry. The Neighborhood Clinic offers a dental home for patients from 6-18 years of age the clinic and most CHIP, Medicaid, and commercial insurance plans are accepted. The staff speaks English and Spanish. To learn more, click here or call 817-347-4600.

Good dental health is critical for everyone, regardless of age. It's important to remember that the health of you and your children’s teeth and gums can have a direct impact on their overall health. While poor dental hygiene can lead to gum disease, cavities and tooth loss, the bad news doesn’t stop there.

Several studies show that the bacteria in your mouth from periodontal disease (gum disease) can contribute to various health concerns.

Here are 5 health concerns you may not have realized that are currently being studied:

1.Heart disease - People who develop gum disease as a result of poor dental health, have a higher risk of also developing heart disease. The bacteria that causes gum disease can cause inflammation as it travels through the blood stream which in turn can cause a stroke or heart attack. And those individuals who already have existing heart conditions are even more prone to developing endocarditis (an infection of the heart) which can be life threatening.

2.Respiratory disease - Scientists have found that bacteria in the mouth can be taken into the lungs and cause respiratory diseases such as pneumonia.

3.Pregnancy - New research suggests a possible link between gum disease and babies born with low birth weight or premature babies. And optimal oral hygiene during pregnancy may decrease the amount of cavity-causing bacteria that can be transmitted to the new baby.

4.Alzheimer’s - There is current ongoing research that states that the bacteria originating from gum disease can travel to areas of the brain which can trigger Alzheimer’s later in life.

5.Malnutrition - Gum disease and pain can often lead to people not getting the adequate amount of calories and protein needed to maintain a healthy diet. Therefore it is not uncommon for children and elderly to suffer from malnutrition if they are experiencing dental pain.

So make sure you take care of those pearly whites for a great smile and healthy body!

a) Nails on a chalk board.

b) 6 a.m. alarm clocks.

c) Your child’s teeth grinding.

Sorry that there’s no “all of the above.”

Around 25 percent of kids grind their teeth at some point. It most often occurs at night but can occur during the day (usually they are not conscious that they are doing it.) The most common ages are from 7-10 years and most grow out of it without any problems arising.

We don’t really know the cause of teeth grinding although it has been linked to stress and one study showed it to be more common in kids who talk in their sleep or wet the bed.

Most children do not have complications related to grinding their teeth. Some complications that have been reported are: jaw pain, headaches (more common in adults) and damage to teeth.

Treatment for teeth grinding can be very frustrating as there are no quick fixes. Since stress can be a related factor, try to have open dialogue with your children about factors that could be causing them stress. Mouth guards are not frequently used in children because they are not likely to help and making one to fit is difficult because children grow so quickly.

If the teeth grinding continues, talk with your pediatrician or dentist to see if there are new treatments available.

“Proper dental care actually begins before the baby’s first tooth appears,” said Tonya Fuqua, DDS, director for the Save a Smile program, led by Cook Children’s. “As soon as the baby’s born, it’s extremely important to make sure that parents begin wiping the child’s mouth and gums with a nice clean baby wash cloth. The cloth should be soft and easy to get wet.”

The early cleaning with the cloth removes any remaining milk from babies’ mouths and helps them become accustomed to something going in their mouth for cleaning. So when babies begin getting teeth and brushing starts, they will be used to the parents placing their hands in the mouth for brushing.

Once you see the first baby tooth, you can begin using a toothbrush. You aren’t doing a lot, but you are introducing that feel of the bristles in the mouth so that as the baby develops more teeth, he or she will be used to a toothbrush in the mouth. Make sure you are using a soft bristled, age appropriate toothbrush. As your child has more teeth, a routine should be established of brushing two times a day, the morning and at bedtime. Dr. Fuqua gave us 10 other helpful tips parents should know about when caring for their child’s teeth:

1. Know the rules of twos. You should always brush your children’s teeth twice a day – every morning and every night for two minutes, regardless of how many teeth are in his or her mouth.
2. Did you know: A baby should never be put to bed with a bottle or sippy cup filled with anything other than water.
3. When should you schedule your first dental appointment? Find a dental home and take your child to the dentist by age 1 or earlier if you notice problems.
4. How dangerous is tooth decay (cavities)? Tooth decay (cavities) are the No. 1 long-lasting disease in young children – even more than asthma.
5. Can you catch a cavity? Germs that cause tooth cavities can be passed from parent or caregiver to a child. Choosing healthy behaviors from an early age will help prevent tooth decay (cavities) and improve a child’s overall health throughout his or her lifetime.
6. How do you prepare your child for visiting the dentist? Read your child a book about going to the dentist, schedule a tour of the offices before the first visit and role play at home on what to expect for the visit.
7. How long should you supervise your child’s brushing and flossing? As general rule, keep up with your child’s brushing and flossing activity until he or she is about 9 years old.
8. Which toothbrush should you get for your child? Choose a soft or extra soft toothbrush with the right size handle and head for his or her mouth.
9. How often should a toothbrush be changed? Every 3 to 4 months, when the bristles become worn or after there has been an illness.
10. What toothpaste should you use for your child? Use a rice-sized smear of fluoride toothpaste when the first tooth appears around 6 months until age 3. Then use a pea-size amount of fluoride toothpaste.

For more information:

The Children's Oral Health Coalition is working hard in the community to educate parents on the importance of caring for their children’s mouth and the impact their children’s oral health can have on their overall health. Find dental health resources here.