Practical implementation of Dental Check by One in practice

Jemma Hook explores what should take place at a baby's first dental appointment.

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Introduction

The 'Dental Check by One' (DCby1) initiative was launched in 2017 by the British Society of Paediatric Dentistry (BSPD) in partnership with the Office of the Chief Dental Officer for England. The aim of this campaign is to ensure that all babies are seen by a dentist as soon as their first teeth come through, or by their first birthday at the latest.¹ An early dental appointment is also policy in Scotland as part of ChildSmile and in Wales, as part of Designed to Smile.

This is obviously an excellent scheme with many general dental practices now actively encouraging infant patient attendance. Two years on from the professional launch of DCby1 there was an improvement with 2.5% more children aged 0-2 accessing a dentist in the year ending December 2018.

For some clinicians seeing this very young cohort of patients may be a little unfamiliar. Undergraduate dental training is based mainly within dental hospitals and where there may be limited direct contact with patients of this age group. The paediatric patients seen in secondary care teaching environments are most often those who have been referred due to issues with their dentition, cooperation or indeed both. So, exposure to the youngest children may be only achieved through primary care placements and outreach. Yet the Dental Check by One is designed to have a positive, preventative impact before any issues occur. With this in mind, the aim of this article is to explore the 'what, how and why' of a first ever dental appointment for a baby.

What is the overall purpose of a first dental visit?

The overall purpose of a first dental visit is, essentially, delivering oral care advice and prevention in line with Delivering better oral health² (DBOH) (Table 1).

Table 1.

Prevention of dental caries in all children aged up to three years (DBOH Toolkit Summary Guidance Table 1, 2021)

Recommendation	Strength of recommendation
Advice
Breastfed babies experience less tooth decay and breastfeeding provides the best nutrition for a baby's overall health. Support mothers to: • Breastfeed exclusively for around the first six months of a baby's life • Continue breastfeeding while introducing solids from around the age of six months	Strong
For parents or carers feeding babies by bottle: • Only breastmilk, infant formula or cooled boiled water should be given in a bottle • Babies should be introduced to drinking from a free-flow cup from the age of six months • Feeding from a bottle should be discouraged from the age of one year	Good practice
Gradually introduce a wide variety of solid foods (of different textures and flavours) from around the age of six months. Sugar should not be added to food or drinks given to babies and toddlers	Good practice
Parents or carers should brush their children's teeth: • As soon as they erupt • Twice a day • Last thing at night (or before bedtime) and on one other occasion • With a toothpaste containing at least 1,000 ppm fluoride • Using only a smear of toothpaste.	Strong
Minimise consumption of sugar-containing foods and drinks	Strong
Use sugar-free versions of medicines if possible	Good practice
Avoid sugar-containing foods and drinks at bedtime when saliva flow is reduced and buffering capacity is lost	Good practice
Professional intervention
Assign a recall interval ranging from three to 12 months based on oral health needs and disease risk	Conditional

As dental professionals we are of course aware of the key roles of the primary dentition, however, this isn't always recognised by some members of the general population. There may be the perception that 'they are only baby teeth' and 'they will get new ones anyway' inferring that caring for the primary teeth isn't important. So, a key outcome of this first visit is highlighting to caregivers that baby teeth do matter.

Use this as an opportunity to detail the value of the first teeth including functions of eating, speech sounds development, maintaining space for adult dentition, the absence of pain and infection (and the effects this can have on the family such as time off school, work, disturbed sleep etc), contribution to the overall health status and general wellbeing of the child and the aesthetics of a joyful, happy smile!

Why should we encourage a 'Dental Check by 1'?

I like to think of four 'A's' regarding the aims of this visit.

• Assessment

• Advice

• Acclimatisation

• Access

Assessment - to check on dental development and eruption patterns. We can often identify problems early and provide extra care for patients at higher risk. Teething is a major milestone, taking the baby from a cute gummy smile to a little toothy grin. It is a great talking point with new parents and an ideal chance to engage in preventative care chat. We can assess for dental anomalies and take into account any relevant family or medical history that may impact on a child's teething pattern. We can share advice for teething and I find the NICE Clinical Knowledge Summary³ is a useful resource here https://cks.nice.org.uk/topics/teething/ as are the NHS advice pages https://www.nhs.uk/conditions/baby/babys-development/teething/.

Coming from an early age builds familiarity and confidence. Each successive visit can build upon the skills gained, such as graduating from sitting on a parent's knee, to sitting independently.

Advice - and support regarding toothbrushing, teething, nutrition and habits such as dummy use or digit sucking. This is about really emphasising to the caregivers that tooth decay is a largely preventable disease. This can include sharing guidance from DBOH and the summary tables at the beginning of the document are especially useful (I love my laminated copies in surgery!).

Other relevant resources for this age group are:

• BSPD Position Statement on Infant Feeding https://www.bspd.co.uk/Portals/0/BSPD%20statement%20on%20Infant%20feeding%20Jan%202018i.pdf

• Public Health England foods and drinks aimed at infants and young children: evidence and opportunities for action https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/812204/Foods_and_drinks_aimed_at_infants_and_young_children_June_2019.pdf

• Starting Well Core Resource Pack for Dental Professionals https://www.dropbox.com/sh/1t4xuu3u370y2pm/AAAY7gEIOqY0WMA90VR1SrAqa?dl=0.

Sometimes parents will already know what they should be doing and will perhaps have queries about how they should be doing this. Small humans can be unpredictable, and babies certainly don't come with a manual! Boxes 1 and 2 illustrate my top practical tips for infant tooth brushing techniques and introducing open cups.

Acclimatisation - coming from an early age builds familiarity and confidence with the surgery environment. Each successive visit can build upon the skills gained, such as graduating from sitting on a parent's knee, to sitting independently. If children are not brought until they are of school age, then they often have preconceived fears or could already have a dental issue which may be causing them pain or discomfort. It also promotes a whole family ethos within your practice. Children can learn by modelling from older siblings... a family outing to the dentist can be a fun experience.

Access - being registered with a dental practice is important in case of arising dental problems or emergencies. Once a child becomes mobile, crawling, cruising and then walking, the risk of dental trauma is increased. In the unfortunate event of an accident the parent is likely to find it much easier to get the child checked over if they are already registered at a practice. For the latest guidelines on management of dental trauma in the primary dentition see: https://www.bspd.co.uk/Portals/0/Guidelines/Primary%20Dentition%20Trauma%20Guideline%20COVID-19_NEW%20ns.pdf

https://www.dentaltrauma.co.uk/File.ashx?id=15374.

A whole team approach can be useful with babies, as with all our patients. There may be members of the team who have a "magic touch" with little ones or are empathic new parents themselves.

There may also be issues of safeguarding to consider in any oral injuries noted in a non-ambulatory patient. The under ones are a known vulnerable group for child neglect and abuse.

How can we structure an initial appointment?

As with most recall visits the appointment can be divided into stages of 'information gathering' and 'information giving'. Finding out basic patient details and completing a medical history form is followed by asking about the current oral hygiene regime prior to imparting appropriate guidance and tips. However, with young babies it is key to be adaptable; they may attend awake, asleep, hungry or tired! Parents may be worried if the infant is unsettled; we can help by providing reassurance that it is common for this reaction in a new environment and that regular attendance will help them become more familiar and relaxed. Try to keep it a low pressure, empathetic atmosphere.

How can I examine an infant patient?

Remember that these babies are unlikely to sit still, so be prepared to be adaptable. I find if the baby is content in a car seat or pushchair then it is often easiest to leave them in situ. Don't disturb a happy baby! Distraction with a favoured toy or book can be useful or parents may choose to sing a nursery rhyme or pull silly faces. The purpose of the brief examination is to note which teeth are present/absent and scan for any anomalies and assess the hard/soft tissues. You may or may not get the chance to use a dental mirror. The child can also be examined sitting in a caregiver's arms or parent's lap. Or you can use a 'knee to knee' set up whereby the baby is facing their parent chest-to-chest in a 'koala-like' pose and is lowered backwards into the lap of the dentist; this way the baby maintains a clear view of their familiar adult at all times (Fig. 1).

Fig. 1.

A knee-to-knee examination. Photo credit: BSPD DCby1 campaign. Photographer Nick Wright. Clinician is Sanjeev Sood at King's College Hospital

What can dentists claim from this appointment?

In England, dentists are able to claim a Band 1 for carrying out a dental check, even if the child is deemed pre-co-operative. The avoidance of doubt letter published by the Chief Dental Officer for England in 2017⁴ details:

'What needs to be delivered during the appointment?

What needs to be documented in the patient's records?

What can be claimed?'

What role can the dental team play in DCby1?

A whole team approach can be useful for babies, as with all our patients. There may be members of the team who have a 'magic touch' with little ones or are empathic new parents themselves. Dental nurses can be a great source of distraction or entertainment during the appointment. Any shared practical tips with regards to feeding or toothbrushing are welcomed by caregivers.

As expectant mothers are entitled to receive free NHS dental treatment it may be that they choose to attend for care during this time. If a dental hygienist or dental therapist is providing treatment to a pregnant person then they can include advice for once the baby has arrived.

How can we encourage patient recruitment?

Reception staff can actively remind new and expectant mothers to 'register' the baby when they are booking in their own appointments. If a mother is attending for a routine recall then this is an ideal time to schedule the baby's in too. However, if she is attending for a treatment appointment perhaps it is best to attend at a separate time. This is because treatment visits may be lengthier and noisier which isn't ideal for an infant. It has been said that for a new mother a solo trip to the dentist can be the equivalent relaxation time of a spa trip! The DCby1 coincides perfectly with NHS maternity exemption.

The Early Years Foundation Stage (EYFS) statutory framework now includes the guidance that 'the provider must promote the good health, including the oral health, of children attending the setting',⁵ so collaboration with local childcare providers can be valuable as a source of oral health education and patient recruitment.

The initiative has also attracted the support of health visitors, doctors, and pharmacists. Working with local allied health professionals can be a valuable way to highlight your services to the local patient community. This can work both ways, as if a caregiver mentions to you they have concerns with regards to feeding or weaning their baby or any other health concerns then you, with consent, can liaise directly with the health visitor team.

What further resources are available?

This campaign is well supported by baby supply companies such as Bickiepegs Healthcare and BrushBaby UK. There are free resources available including a patient certificate, practice poster and logos downloadable at https://dentalcheckbyone.co.uk/profession/ to help raise awareness within your practice marketing. The hashtag #DCby1 can be used to promote the scheme on social media.

If you really go for it then there is also the NASDAL 'Dental Check by One Practice of the Year Award' which includes a trophy and prize of £1,000 to recognise a practice that has successfully implemented DCby1 into its core values: https://www.nasdal.org.uk/award/.

The COVID-19 pandemic has had a widely documented impact on the capacity and ability to access NHS dental care. BSPD was quick to adapt their message during these times to 'Dental Check by One…. or thereabouts' to ensure parents did not worry unduly if they were unable to get their baby seen prior to turning one. Even in pre-pandemic times, a 2019 position statement from the Faculty of Dental Surgery (FDS) at the Royal College of Surgeons of England (RCS)⁶ showed that '41.4% of under-18s did not visit an NHS dentist during 2018, rising to 77.0% of young children aged between one and two'. Subsequent figures from the NHS Dental Statistics for England, 2021-22, Biannual Report published in December 2021⁷ showed that for the age range 0-1 years inclusive just 7.4% of infants had received NHS dental care in the preceding 12 months.Now as we have adapted our practices and return to the provision of routine dental care, including regular recalls, this cohort of pandemic-born babies should be able to be seen.

BSPD summarises: 'it is recognised that early visits for children… are vital for delivering key preventive messages, acclimatisation and beginning a positive, lifelong relationship with NHS dentistry'. These babies are our future patient base and it is inspiring to think that we are actively engaging the next generation in oral health as a priority and shaping the future patient profile for our practice.

The author would like to acknowledge Professor Sondos Albadri and Kate Clark of the BSPD team in preparing and contributing to this article.

Author information.

Jemma Hook is a general dental practitioner working in an NHS practice providing all aspects of routine family dental care. She also teaches part time in the paediatric department at the University of Liverpool School of Dentistry. Jemma has two young sons who have made her realise how tricky toothbrushing with little ones can be.

Box 2 Ways to introduce babies to open cups .

Introducing babies to drinking from open cups: practical tips

• Role modelling

• Let them practise handling an empty cup

• Use a baby sized cup designed for mini mouth and hands

• Verbal praise/reassurance

• Encourage finger foods at mealtimes to establish a hand-mouth connection

• Offer very small amounts of liquid initially

• Use an apron bib/cover up or weaning floor mat

• Anticipate dropping or throwing.

Box 1 Practical ideas for infant toothbrushing.

How can I brush my baby's teeth?

• Before teeth come in consider trying baby dental wipes and teething toys to introduce a new texture and encourage opening up of the mouth

• Try having two toothbrushes - one for them to hold and one for you to use

• Distraction: Such as during bathtime, when they are sat up supported in a bath seat, or using a book or toy to entertain

• Sing a special song each time to build an association

• Some babies and toddlers will like watching in themselves in a mirror

• Positioning: Sit baby facing forwards on your lap, then gently lean their head back into your chest. Or even have them lying on the floor with their head resting safely on your knees or on a changing mat. Approaching from behind gives better access and vision than standing in front

• Keep calm!

• You are just aiming for a gentle clean to apply a flat smear of toothpaste. It doesn't need to be a full two minutes when they only have a few teeth.