Breastfeeding and dental health with Gillian Smith DDS

Too often I meet parents who have been told by their dentist that their toddler should stop breastfeeding because it contributes to tooth decay, so when I met this week’s guest, I knew I had to have her on the show to talk more about this issue.

Dr Gillian Smith DDS is a dentist from Bray in Ireland, who specialises in treating children and patients with additional needs. Together we explore why dentists still say that breastfeeding contributes to poor oral health, what actually causes tooth decay in toddlers, and what can be done to treat it.

You can find Gillian on Instagram as @tonguetieclinicbray and at @fitzwilliamclinic

My latest book, ‘Supporting the Transition from Breastfeeding: a Guide to Weaning for Professionals, Supporters and Parents’, is out now.

You can get 10% off the book at the Jessica Kingsley press website, that's uk.jkp.com using the code MMPE10 at checkout.

Follow me on Twitter @MakesMilk and on Instagram  @emmapickettibclc or find out more on my website www.emmapickettbreastfeedingsupport.com

This podcast is presented by Emma Pickett IBCLC, and produced by Emily Crosby Media.

Transcript

This transcript is AI generated.

[00:00:00] Emma Pickett: I'm Emma Pickett and I'm a Lactation Consultant from London. When I first started calling myself Makes Milk, that was my superpower at the time because I was breastfeeding my own two children. And now I'm helping families on their journey. I want your feeding journey to work for you from the very beginning to the very end.

And I'm big on making sure parents get support at the end too. Join me for conversations on how breastfeeding Breastfeeding is amazing and also sometimes really, really hard. We'll look honestly and openly at that process of making milk. And of course, breastfeeding and chest feeding are a lot more than just making milk.

Today I'm really pleased to be joined by Gillian Smith, who is a dentist from Ireland. She does a lot of work with younger children and she also runs a tongue tie clinic alongside an IBCLC colleague. We met last year at the conference for the Lactation Consultants of Ireland and we bonded over a lasagna as we discussed breastfeeding and dental health.

And in this conversation, I hope we're going to answer some questions that parents often have about breastfeeding and dental health, particularly about natural term breastfeeding and dental health. We're going to dispel some myths and I'm going to pick her dental brain if that's okay with Jill. Thank you very much for joining me today, Jill.

Thank you for the invitation. So can I start by asking about your background? So I think we all think we're experts in dentists because almost all of us will be meeting dentists, at least I hope we are. So I think lots of us assume we know how dentists train and we know, you know, what dental work is like, but talk us through the training to become a dentist.

[00:01:45] Dr Gillian Smith: Sure. So, um, certainly in Ireland and most of Europe, you do an undergraduate program in dental science. So I did that in Dublin in the dental hospital and finished in 2008 and lots of people will then go on and do some kind of additional training scheme in the UK. It tends to be vocational trainees or a VT year.

I did what's called a house officer, house doctor year where I went through various hospitals in Ireland in rotations learning about the different areas that dentists can help improve people's oral health. And then, uh, I, I seem to be a continual studier, I never seem to be able to drop the study bug, but I did a postgraduate, uh, course in conscious sedation, so, um, that would be how to sedate people without putting them completely asleep, so they're conscious but they're sedated.

I've also done a postgrad diploma in orofacial pain management. And, uh, I'm hoping to do my IBCLC exam in the coming year or two. So, uh, my mother said to me, she won't talk to me anymore if I do any more courses or exams, but I just have the bug. 

[00:03:00] Emma Pickett: Yeah, well, I'm glad you do because we can take advantage of that.

That's, that's good for us and good for people in the lactation world. Um, I know from our conversation over our lasagna that you do a lot of work with younger children. How did that come about? 

[00:03:14] Dr Gillian Smith: I suppose I've always enjoyed working with kids, you know, it's been just part of who I am. I've worked with kids a lot outside of my professional career, I've done a lot of volunteering with St.

Vincent de Paul, which would be a charity here in Ireland and I managed a children's holiday home for years where we took kids from disadvantaged areas on holidays. I also worked a lot with special needs kids outside of dentistry with Special Olympics or coaching and always enjoyed treating children.

So, you know, I think there's an element in dentistry. You know, everybody graduates at the same level in dental school, but then you sort of find your niche. And certainly for me, I set up a general practice. Inbrae, which is just outside of Dublin, and I gradually built a reputation for working with children and adults and children with additional needs.

So, you know, having the combination of conscious sedation and just enjoying my day to day working with kids and with people who just needed something extra in the behaviour management line, it always appealed to me and that's the way my practice ran or developed. 

[00:04:24] Emma Pickett: And I know, obviously, in recent years, you've become particularly interested in breastfeeding and supporting breastfeeding children.

But before we talk about what you've been doing recently, million dollar question, did you come across breastfeeding as part of your dental training when you were doing your basic training? What's the kind of conversation around breastfeeding when you do your training to be a dentist? 

[00:04:43] Dr Gillian Smith: Uh, well, to be honest.

I suppose that probably varies depending on where you study dentistry, you know, the dental school you're in. The paediatric program in Dublin is excellent and I was lucky to have really good mentors in that area and, and teachers in that field. Um, and, uh, we in Dublin, when we're studying dentistry, do something called problem based learning or PBL.

I don't know if you've heard about that. So it's where you, it's very much self directed learning. So I guess because my interests were children and I was always interested in breastfeeding and early infancy, I would, that was like, it's likely that that interest influenced my learning. But I do remember conversations about breast milk versus formula milk in nursing caries.

And we had to do a dissertation at the end of our five years of dental science and my dissertation was on the link between maternal and infant health. So, you know, I remember even at that early stage being interested in, uh, infant nutrition and early caries and early infancy, tooth decay in early infancy.

So yeah, it was certainly was part of our training. We didn't have lecture based training, so we didn't have a specific lecture, lecture on breastfeeding. And I could be sure that that wouldn't have been worked into the program. But, um, for those of us who were interested, yeah, certainly there were discussions about it.

[00:06:06] Emma Pickett: Okay. I think that everybody agrees, looking at all the sources out there, I think everyone agrees that breastfeeding for the first 12 months is protective against dental decay. I don't think that's necessarily up for debate. Can you help us unpick some of the processes and understand some of the processes that mean that's the case?

Why does breastfeeding for the first 12 months help protect against dental decay? 

[00:06:28] Dr Gillian Smith: So, I think it's probably more correct to say that Until the age of one, uh, it's not associated with an increased risk of caries, but lots of studies have shown that decay rates are lower than formula fed infants up to one year, so the term protective has been used.

Now there may be more to that statement at a cellular level, but That research is very much in the early stages and so, you know, there are studies that have shown that exclusive breastfeeding limits the colonization of the bugs that cause tooth decay, so it's called strep, streptococcus mutants. And so that there was a study done only published last year that showed that the colonization of strep mutants is limited in somebody who's exclusively breastfed versus somebody who's formula fed or can be fed.

There is, again, some, uh, indication, again, in the research, there's only one or two studies that look at the constituents of breast milk, so lactoferrin and IgA, and do they decrease, again, this, the biofilm formation with this bacteria in it. And we know that strep mutant colonization is from the caregiver, so, you know, if we look at that link between mothers and infants.

We know that it is mothers putting things in their own mouth, like teats or bottles or soothers or food, to taste it and see if it's hot or, or, or tastes okay or is clean, uh, before they put it in their infants mouths. We know that that's how infants end up with strep mutants in their mouth. And that's how it colonizes.

So, I'd love to see more studies in this area. You know, I'd love to see a study that looks at the maternal strep mutants in, say, a breastfeeding mother or a baby who's bottle fed and look at their hygiene practices because really what you're talking about is saliva transfer between the mother and the infant.

[00:08:18] Emma Pickett: Yeah, what you're saying about the, the sucking on the teat before you give it to the infant. I've, I've definitely noticed that people, you know, it drops on the floor and people think that licking it is going to make it cleaner and, and be better for baby. And, and I have to say over the years I've had to kind of restrain myself so hard from not running across a playground and going, no, don't 

[00:08:41] Dr Gillian Smith: do that.

And as 

[00:08:42] Emma Pickett: a dentist, let 

[00:08:43] Dr Gillian Smith: me just check how many untreated cavities you have first before you do that. 

[00:08:48] Emma Pickett: Yeah, and it's obviously that's not cool to run across the playground and say that to someone. So I've never have, I must reassure. But have you ever been in a place where you've had to restrain yourself from saying something?

[00:09:00] Dr Gillian Smith: Yeah. And, you know, restrain the healthcare professional. Did you know if you don't have a, you know, good oral health yourself, you're transferring the bugs that cause tooth decay. So, you know, it's a conversation piece. I'm very comfortable. Well, having with somebody when they're in my surgery and they've come to me for help, but outside of that, yeah, you definitely have to 

[00:09:20] Emma Pickett: hold back.

[00:09:21] Dr Gillian Smith: Yeah. 

[00:09:22] Emma Pickett: I mean, I appreciate there's not a lot of research happening partly because there's not a lot of people who care enough to do research around breastfeeding. Is, is it possible to say something about the, the mechanics of breastfeeding, that with bottle feeding, milk pulls around the front teeth in a way, perhaps it doesn't during breastfeeding because the nipples further back in the mouth.

Is that something we can talk about too? 

[00:09:43] Dr Gillian Smith: Yeah. You know, it's interesting, you know, those kinds of things are talked about and I think it's probably again, more theory as opposed to having, you know, hard science to it. I think it's probably important to talk a little bit about what tooth decay is, you know, so tooth decay is where, um, you get, uh, dietary sugars, so it's a disease, we call it a disease, it's called caries, it's called, when dietary sugars that are in the mouth are broken down by these bugs we're talking about, uh, and, That breaking down of the dietary sugars produces an acid and over time the tooth starts to demineralize because of this acid attack, but it's important to understand that it's not linear.

So, you know, the tooth is demineralizing but it's also remineralizing and so in the early stages we can reverse tooth decay and and there are conditions that favor demineralization and there are conditions that favor remineralization. So when you're talking about The factors that favor demineralization you're talking about.

Uh, sugary substances in the mouth, you're talking about, uh, lots of plaque on the teeth, you're talking about poor saliva, uh, flow through the mouth, so that might be at nighttime when you know you're sleep catching flies, or it could be if you have, um, a medical condition that predisposes you to dry, drier mouth, you know, in a small child that could be.

a problem with their upper respiratory tract, you know, where they have big tonsils or big adenoids and so they can't breathe through their nose well. So you can, you can create the favorable conditions for demineralization or progression of the disease, but equally you can create the favorable conditions for remineralization.

So that's, you know, good saliva flow, that's exposure to fluoride, which we know helps prevent tooth decay, reducing the sugary substances. So, you know, if you talk about bottles versus breast and you talk about a breast where the milk is at the back of the mouth, rather than pooling around the teeth, you know, The theory is that that is more favorable than, say, a bottle where the milk is pooling.

But, you know, you'd have to be talking about, say, a baby put to bed with a bottle. where they're having a little bit of milk all through the night, uh, pooling on those front teeth. But we know that babies don't just get milk in a bottle. So, you know, the substrate within the bottle will have varying degrees of risk.

So if the baby's getting orange juice in the bottle or Coca Cola in the bottle, obviously we're not comparing like with like, you know, where they may, may be getting formula milk or, or breast milk in a bottle, you know, so we need more research. And I know that That's a killer of a thing to say because you hear that all the time when you, you know, you want information.

Um, but the bottom line is that for me as a dentist, I get a lot of parents who come in and they're very upset because breastfeeding is being blamed for the tooth decay. Um, and I would take issue with that because the, the point is that for certainly in the under two population, we don't have the research to show that breastfeeding certainly in isolation is the cause of tooth decay.

You know, we know tooth decay is a multifactorial disease. So if a dentist, and I'll go toe to toe with anyone who would like to, but if a dentist wants to, you know, uh, say that breastfeeding is contributing, well, that is the extent of it. There is lots of other factors to consider too, so, you know, we have to take it into consideration that there is more than one thing at play.

[00:13:28] Emma Pickett: Yeah, yeah, I mean what you said about, um, going toe to toe, there are unfortunately a few dentists in England who need you to go toe to toe with them. Yeah. We had a real blip in the UK around the time of the Lancet series in 2016, so we had, so the Lancet series had said loads of really useful things about breastfeeding on a population level and then on an individual level, one of the negative things they did say.

was that, um, you know, breastfeeding beyond 12 months increased the risk of dental decay. And, and they cited this particular meta analysis, which was Tham et al from 2015. Um, and, but actually when you go and look at that study, the authors of that actual study say, and this is actually a quote from them, Only a few studies included in this review controlled for key confounding factors, and this may have resulted in an overestimation of the role of prolonged, frequent, and nocturnal breastfeeding in the development of dental caries.

Until the dietary and oral hygiene details of these children are controlled for, we cannot be certain whether prolonged, frequent, or nocturnal breastfeeding can be principally associated with early childhood caries. So even though the researchers actually said that in their conclusion, the Lancet series took that to support the statement that continuing beyond 12 months caused dental decay.

We had this whole faff because, you know, lots of people were really unhappy about that. Public Health England put out a statement, um, asking dentists to support breastfeeding as the physiological norm and it said, you know, that's against which other behaviours are compared and dental teams should promote breastfeeding.

Um, and, you know, we should be looking at the whole health of the child and the whole oral health of the child. But I, I don't think we've quite recovered in, in England and the UK from that conversation. Um, and there are still dentists who are being told, um, exactly what you said. Um, I've been told if I continue breastfeeding, I'm going to damage my child's teeth.

I mean, have we had anything since then? Is there any more recent research on breastfeeding beyond 12 months? 

[00:15:30] Dr Gillian Smith: There is research being done and, and, and some of that research that's being done is looking at Beyond the 12 months, beyond the 24 months, and, you know, the problem once you go into that sphere is the other confounding factors, so the tooth brushing for a toddler, you know, which we all know is challenging, um, the other things the toddler is eating, um, the parent's strep mutants counts, the infant's strep mutants counts, whether there's other factors with that child's saliva, so there's too many factors that can't really be ruled out for it.

And that's where it becomes difficult in the research when you're trying to narrow down, is this the breastfeeding or is this something else? And the problem is that, you know, dentists in their education are taught about nursing carries and whether it's because they've been told breastfeeding is, uh, just as damaging or whether it's their own, they're drawing their own conclusions that because the bottle caused problem, well, so does breast milk.

You know, it's, it's difficult to say whether that's happening at a university level in their training or whether they're drawing their own conclusion from, well, the formula does it so breast milk must too. It has a huge impact for parents, you know, I see it every day in my practice where parents are heartbroken because they have been told time and time again how breastfeeding is better for their child's health and I think everybody agrees with that, you know, the, there's unequivocal evidence that for an infant's general health that breastfeeding offers them lots of advantages and then they go to another healthcare professional and they're told, well, this disease was caused by your breastfeeding.

So, um, it's something that as healthcare professionals, we, as we owe it to our families that we're seeing, that we are providing evidence based information. And right now there isn't good, strong scientific evidence to support a statement. that breastfeeding in the under two population increases their risk of tooth decay.

[00:17:40] Emma Pickett: Okay. And would you go as far as to say that if someone says that, you know, as you say, you're going to go toe to toe with them and that is a false statement. Gone to the throne down. So you're saying under twos, over twos quite carefully. Is that because you think if breastfeeding continues over two, we might have risks increasing?

[00:17:59] Dr Gillian Smith: Yes. So there's been two studies. One was published 23, the other was published, let's check my notes here, 24. One in the International Journal of Pediatric Dentistry and another one in, um, the UK. It was in the International Journal of Pediatric Dentistry and they're both birth cohort studies. So they're looking at four year olds.

And they both concluded that prolonged breastfeeding and a high consumption of processed food were associated with early childhood caries. I mean, they say that both seem to affect caries independently, as there was no observed interaction. But I mean, If you're going to narrow it down to the science and you're going to start critiquing a birth cohort study, I, I wouldn't say that that evidence convinces me.

I would say it's still, we don't know. What we do know is that below two, we don't have the science to support it because we have a meta analysis. We've plenty of research looking at under twos. So, you know, we can say that the best available evidence shows that breastfeeding up to the age of two doesn't increase early childhood caries.

The research with low quality evidence suggests that longer duration feeding increased, increases risk. As a healthcare professional, what I would love to see as a dentist, what I'd love to see is see that child before they reach two and talk to the parents about, okay, you're going to keep breath feeding.

That's cool. Let's talk about how we're going to mitigate the risk, if there is a slightly higher risk, because all it is, is possibly a slightly higher risk, and that's what the research is telling us. So what can we do to mitigate the risk? We can Make sure that the toothbrushing is top notch. We can talk about fluoride exposure.

We can talk about medications that child might be on. You know, if they're on inhalers, is that causing dry mouth? If they're on, um, other medication that's affecting their salivary flow, can we talk about that? Are they on medication that might contain sugar? Can we reduce the use of that or can we change to a sugar free version?

You know, and so remove the other risk factors. And, you know, as a parent comes in and said their child has tooth decay, I don't say to them, well, that's it. You just have to stop. Never give them sweets ever again, ever. You know, that doesn't happen. Like realistically, a parent would look at you like you had 10 heads.

Like what I'm going to tell my kids when they go to a birthday party, they can't have anything. That's not realistic. 

[00:20:17] Emma Pickett: Yeah. It's, isn't it funny? No one questions that. Nobody would ever dream of saying to the parent of a six or seven year old, they need no more processed sugar ever. That's it done. But nobody hesitates in saying no breastfeeding because, because we come from a world where breastfeeding beyond babyhood is not valued and people think it's just a silly optional extra that parents should be able to drop at the, you know, without even blinking.

And it's just. You know, I just so appreciate that you realize that's not valuable and you realize that's not in the best interest of everybody and, and we're talking about a whole child here. Let's unpick this a little bit. So maybe 

[00:20:51] Dr Gillian Smith: a whole family more than a whole child. No, sure. 

[00:20:54] Emma Pickett: Yeah. Yeah. And actually that's, yeah, that's important and relationships and the emotional wellbeing of everybody and, and just, yeah.

[00:21:01] Dr Gillian Smith: It's my personal opinion that it is absolutely inappropriate for a dentist to suggest weaning. Number one from the sort of sugar versus breast milk point of view, okay? We don't have the science and we wouldn't tell a child to never have sugar ever again ever so, you know Why are we telling them not to have breast milk again ever?

But more importantly as dentists We're not trained to support somebody through weaning. So, you know, we shouldn't be throwing out a statement So, uh, offhandedly, like, oh, you need to stop breastfeeding, even, even you need to stop breastfeeding at night without realizing the repercussions for that family, the implications for that family, for that child, for that family's sleep, and without the right training and resources to support them through weaning, it's just wholly inappropriate.

[00:21:52] Emma Pickett: Yeah, I like the word inappropriate. That is a good word in this context. Let's, let's talk about hypothetical family. So we've got, let's, let's say we've got little Nina. She's two and a half years old. She's been breastfeeding all her life and she breastfeeds to sleep and she breastfeeds through the night.

And she's visited the dentist who says that she has early signs of decay forming on her upper teeth. First of all, what would that physically look like? If we're looking inside Nina's mouth, what would those very early signs look like? So 

[00:22:23] Dr Gillian Smith: when the tooth starts to demineralize, we talked about demineralizing and remineralizing.

So when a tooth starts to demineralize, the enamel becomes very white, almost chalky white. Some parents will say that the tooth almost looked like that as soon as it erupted, and there can be what's called hypomineralized enamel. So, so children and, and, uh, in their baby teeth and in their adult teeth can have, um, a deficiency of enamel really is kind of a, not a correct way to put it, but maybe a good way to explain it.

It's basically where the enamel structure. is not as strong as it should be, but the rates of that are low and particularly in baby incisors. We don't see it very often at all, but when the tooth comes through and then plaque forms on it and the acid from the strep mutants being broken, breaking down the sugars, starts to demineralize the surface of the tooth that looks chalky white.

[00:23:24] Emma Pickett: Okay. 

[00:23:24] Dr Gillian Smith: So plaque is kind of creamy white and you can scratch it off with your finger or brush it off with a toothbrush. When the tooth starts to demineralize, it's actually the enamel surface that starts to look chalky. 

[00:23:35] Emma Pickett: Okay. So let's imagine that's happening to Nina. She's got those kind of like distinctive white patches on her teeth and a dentist is telling her.

You need to night wean. You shouldn't let her fall asleep on the breast. If you do have a night feed, you've got to brush teeth after a night feed. That's the sort of common experience that parents are telling me when early decay is being seen. Um, now you're saying that the cause of Nina's demineralization could be something, is that genetic that causes that, that hypermineralization?

[00:24:05] Dr Gillian Smith: Yeah, hypermineralization is inherited, yeah. 

[00:24:07] Emma Pickett: It's inherited. And is, is it, Could it be something to do with medication? I hear something about antibiotics being taken in pregnancy or antibiotics being There have been 

[00:24:16] Dr Gillian Smith: all sorts of theories, um, the baby teeth, so the teeth you would see in an infant at two and a half, are mineralizing when you're in utero, and so there have been all sorts of theories, you know, was it mothers taking antibiotics in pregnancy or mothers having, uh, spike in temperature or, you know, a viral infection, but none of those theories have been proven and we do see it in families.

So, you know, the, the, where we're moving to on, on hypermineralization is that it's, it's inherited. But, uh, like, like I say, it's rare, you know, it's, it's about 10 to 15 percent of a Caucasian population in the adult teeth. So they're the teeth that start to appear at about six. In the baby teeth, it's harder to say, you know, we don't, certainly in Ireland, we don't have rates of the incidents in the population.

And in baby teeth, it's more common that it affects the primary molars, which are the back teeth. So the teeth that come in at about two and a half in the back, and they're the ones that we see hypomineralized. So they're called hypomineralized second primary molars. So it's exceptionally rare to see it on.

In, in infants on their, um, incisor teeth. 

[00:25:29] Emma Pickett: Okay. A little advert, just to say that you can buy my four books online. You've Got It In You, a positive guide to breastfeeding, is 99p as an ebook, and that's aimed at expectant and new parents. The Breast Book, published by Pintrim Martin, is a guide for 9 14 year olds and it's a puberty book that puts the emphasis on breasts, which I think is very much needed.

And my last two books are about supporting breastfeeding beyond six months and supporting the transition from breastfeeding. For a 10 percent discount on the last two, go to Jessica Kingsley Press, that's uk. jkp. com and use the code MMPE10. Makes milk. Pick it, Emma. 10. Thanks. So let's imagine that Nina and her family have come to see you.

And you've got that, you've got those chalky white patches. I'm guessing, first of all, spoiler alert, you're not going to be telling Nina that she can't breastfeed anymore. What sort of treatment would you be giving her in those early stages? 

[00:26:34] Dr Gillian Smith: Okay, well, the first thing is to identify the disease and then to treat it and then to prevent the progression.

So, like I said, in an ideal world, I would have seen her at one. Or on the appearance of her very first tooth, and I would already have put the preventative strategies in place before the white spots appeared, because that's possible if, you know, as a, as a government and as a, as a state, we could organize that, that would be even more ideal.

But the reality is we don't, and the country is not set up like that, so it's not the world I practice dentistry in. So, when we see it in this early stage, it gives us so much opportunity to prevent it progressing. So we have lots of things we can do, we can put in a rigorous preventative approach and stop these little white patches from getting worse.

And my first thing would be to reassure the parents of that, you know, there's a lot of emotion when children have tooth decay, even more emotion if they're coming to me for a second opinion because they've already been told they have to stop breastfeeding, so they arrive on the defence expecting to be told they need to stop breastfeeding.

and ready to fight that discussion. Um, and so, you know, I would say to the parents, these are baby incisors. They're going to fall out when she's six. We need to keep it all in perspective, and we need to look at what we can do to stop further decay in Nina's mouth, and what we can do to address the small little lesions that are there already.

So, I would be talking to them about diet, and I often do what's called a diet diary where I would get them to write down everything that little Nina eats, breakfast, lunch and dinner. I should have said, I would also have, you know, before they even enter the surgery, I take a medical history form from them and the kind of things I'm asking that are things about the dry mouth medications, which we already mentioned, but also things like sensory processing disorders.

So, you know, lots of. Children, even, even if they haven't got a diagnosis, will struggle with tastes in their mouth. So they mightn't like the taste of toothpaste. They'll say it's spicy. So we're going to break that down. We're going to find a fluoride containing toothpaste that they can tolerate. You know, we're going to talk about behavioral challenges for toothbrushing.

We might talk about dietary restrictions. I would have some kids with aphids, you know, where they, very limited things they can put in their mouth. And I'm going to talk to them about their fluoride exposure. So are they on the well or the mains water supply? I want to figure out, are they getting fluoridated water?

And there'll be parental preferences around fluoride too. You know, some parents will have a, have an issue with fluoride exposure. So then once we have determined how significant the decay is, so if we're talking about just enamel only, where you've got those little white spots, then we know that we can encourage remineralization.

As dentists, we don't actually have to do anything with that. And that might be application of a high dose fluoride varnish, or using something like silver diamine fluoride, which is a combination of fluoride ions and silver ions, and that will actually cause the tooth decay to arrest in front of our eyes.

It's quite amazing as a dentist to watch, you know, it's, it's been around a long time, but it hasn't been commercially available, um, uh, certainly for the whole of my career. Uh, but I haven't certainly in the last maybe five or 10 years, and it's amazing. So if you paint it on, it tastes awful and children hate it, but it stops the cavity from progressing.

And so if we can start there as a baseline. we can move forward. If the decay has progressed into the tooth, then we have to make a decision. Is this something that we are going to need to treat because we want to prevent pain and infection? Or, uh, is it something that we can continue to monitor, uh, put SDF on it so that it doesn't progress and, um, you know, hope that the tooth exfoliates or falls out before it becomes You know, before there's any risk of pain or infection.

And in a two and a half year old, you're not gonna be able to fix that with fillings. You know, two and a half year olds can't cooperate, so maybe it's just put the SDF on it, stop the decay from progressing. And when you do reach. The age of cooperation, which is different for every child, but usually starts at three and a half, three to three and a half, then maybe you could do a small restorative procedure on it.

[00:30:45] Emma Pickett: Okay. So silver diamine fluoride sounds like something that should be in every dental practice. Yeah, in the world because that sounds pretty damn remote. Amazing. 

[00:30:58] Dr Gillian Smith: It's amazing. Actually, you know, it was my other hat on I work within special care dentistry So I would see a lot of people who struggle to tolerate dentistry and you know within the field of special care dentistry We would love to see nurses in medical practices and healthcare settings It's having SDF where they can just paint it on because it is not rocket science to put it on.

You know, it's very little training. You could be taught how to apply this. We look at it in terms of homeless populations and refugee populations, you know, that it should be applied by the healthcare professionals who are seeing these populations to stop decay from progressing to allow time for them to access care, you know, okay.

[00:31:36] Emma Pickett: And you mentioned if a child has got severe decay, you might be waiting for a teeth to come out depending on their age, you might be able to do some sort of filling. You sometimes hear people saying, oh, you've got to treat it because it will impact on their adult teeth or, I mean, what's the relationship if someone has got severe dental decay and baby teeth?

Are we worried about the health of the sort of teeth coming behind that? 

[00:31:57] Dr Gillian Smith: Yeah, if a baby tooth develops infection and the infection is untreated. then, um, there's some evidence to suggest that that can damage the developing adult tooth, depending on the age and state of development of that adult tooth that's developing beneath the baby tooth.

We also know that if you lose the baby tooth prematurely, so if it has to be extracted because of extensive decay, that you lose the space for the next tooth. It's actually called the leeway space, you know. Could do with a bit of leeway. The baby tooth holds the space for the adult successor that's coming next and if you lose that baby tooth early the teeth drift in and, and the adult tooth doesn't have enough space to come up properly so it erupts.

Maybe doesn't erupt or erupts out of position. So sometimes we think about a space maintainer, which is a device to hold the space open, you know, which we would use in older children. But again, if you see a one and a half or a two year old with early decay on their incisors, there is so much you can do to prevent any of those consequences.

I, I told a mum yesterday that I was doing this podcast and she said, um, well, you know, I was told that it was my breastfeeding causing the problem by Two or three dentists and of course, I didn't want to see a dentist then because I didn't want to be told again It was my breastfeeding causing the problem but if I had been told I can breastfeed but do A, B and C and mitigate the risk, well then the Consequences of the decay progressing wouldn't have occurred.

[00:33:41] Emma Pickett: Yeah I mean that is that is the key point, isn't it? People just stop asking for help and you say that they're not good children's not going to be getting the treatment that they need which Is crucial Can I ask you a little bit more about the dietary stuff? So you've, you've got taken Nina's sort of food diary history and you've looked at her patterns.

What are some of the things that parents need to think about when we're worrying about dental decay for, let's say, under threes? I mean, it sounds obvious. Obviously, we're not going to be giving them, you know, boiled sweets and Coca Cola, but what are some of the things that maybe people don't realize are risk factors?

[00:34:12] Dr Gillian Smith: Well, uh, you know, we talked about modifiable risk factors and non modifiable risk factors. So the modifiable ones are diet and fluoride exposure, but the non modifiable are things like their socioeconomic status. whether they're getting, uh, fluoride in a well, or, you know, it's in their water supply, or it's not in their water supply.

Access to healthcare. So maybe people don't have the financial means to access the dentists who are going to apply this fluoride, the fluoride varnish and, and medications, you know, if kids. already have existing medical conditions that make it difficult to brush their teeth, or they're on medication that can't be changed.

You know, I'd have a cohort of patients who are epileptic, and so, you know, you can't remove the anti epileptic medication that's often sugar containing. And then we talked a bit about quality of tooth enamel, you can't change that, and saliva, and we can test saliva, and we can see Uh, whether your saliva is, uh, protective against tooth decay or less protective against tooth decay, but we can't modify it.

So the testing is really expensive and kind of irrelevant. It's not done in clinical practice, it's only really done in research settings. And because, you know, while it's interesting from a caries risk point of view, we can't change it. So it's of little value. You know, if somebody has tooth decay, we know their risk is high, so we're going to employ the, uh, strategies to reduce that risk anyway.

[00:35:35] Emma Pickett: Okay. And then in terms of the modifiable, thinking about, um, for foods that, I mean, it's, you know, it sounds daft, but I can remember learning when I was an early parent that, you know, raisins and dried fruit was a bad plan. People think it's healthy, but not the case. Is there anything else people need to be aware of?

[00:35:54] Dr Gillian Smith: Yeah, we, we, we have a sort of a running joke in the practice. It's because we see so many, um, kids with raisins and dried mango and, you know, dried apricots and the dried fruit is really a feature where parents, unfortunately, you know, knowledge is power, are not aware that it's going to cause tooth decay, you know, so in their book they're giving their kid a healthy alternative.

Um, and probably nutritionally it's better than giving them sweets or jellies, but because it's sticky and, uh, when you dry a fruit you lose all the protective effect of the pulp and the water, and all you've left is the sticky stuff. Um, it's gonna hang around and stay on a tooth for a long period of time.

Other things that we find parents get caught out by is things, are things like, uh, fruit juices, um, and smoothies. And I'll often hear from parents, but I make my own smoothies. And, you know, a lot of the shop bought smoothies don't contain any added sugar, but there is a lot of sugar in fruit and once you, uh, dry it or press it or juice it, you release all of the sugars, which normally in a, in a normal stage of digestion would be in a juice when it's in your stomach or your intestine and not when it's hitting your mouth.

So you have much more available sugars to the strep mutants and the bugs in your mouth. when you already press it or juice it or dry it before you even put it into your body. So I think a lot of parents, again with the best will in the world, are trying to give their kids, you know, healthy juices to try and get fruit or veggies into them.

And nutritionally it's probably good for them, but it's not good news for the teeth. 

[00:37:31] Emma Pickett: What favourite toddler snack recommendations? 

[00:37:34] Dr Gillian Smith: Well, 

[00:37:37] Emma Pickett: I won't 

[00:37:38] Dr Gillian Smith: talk personally about my own toddlers, but, um, you know, I think we have a traffic light system which we give to kids because we try and get kids buy in when we're talking to them about diet.

And so we talk to them about eating five times a day, so breakfast, lunch, and dinner, and two snacks. Um, because you want to give your mouth a break, you want to give your teeth a break, and you want to give your mouth a break, you don't want to be eating all through the day. We see, you know, increased decay rates in the grazers, the kids who eat a little bit all through the day.

And when we're talking about snacks, we have a, a green list, so we give them a list. food, which would be, you know, a piece of fruit or vegetables or breadsticks or crackers or bread rolls or, um, any of the food that you're eating unprocessed, you know, I mean, it sounds kind of simple or basic, but that's really what you want.

You want the stuff that you're not doing too much preparation or too much work for somebody else hasn't done before it arrives in your house. Um, and then things that we would urge caution with would be the things like the smoothies, the juices, the yogurts, kids yogurts, which tend to be laced with sugar, you know, and again are marketed as healthy.

And I'll teach a parent how to look at the sugar content of foods. So to look at the information at the back and scroll down through, see carbohydrates of which sugars and look at the content of sugar, you know, four to five grams, that's a teaspoon of sugar. If that kid's yogurt has 14 grams of sugar, that's three teaspoons of sugar.

Would you give them three teaspoons of sugar as a snack? Probably not. But you might give them a yogurt. And I really, you know, Jamie Oliver's talked a lot about warnings on food, you know, clear labeling. I really think, particularly food that's marketed to children, should come with a warning with just a little symbol on the front of how many teaspoons of sugar is in this.

You know, in a serving because a lot of the kids foods that are marketed at children have lots of sugar in them and parents don't see it, you know, they don't realize it. 

[00:39:35] Emma Pickett: Yeah. And there's some very sneaky stuff going on when it says like no added sugar and instead it's processed grape juice or apple juice.

And one thing First Steps Nutrition Trust have been talking about in the UK is, um, The pouches and how all these pouches that say, you know, spinach and another vegetable, but you drill down and it's actually apple, pureed apple and, and lots of kids sucking out of a pouch. I mean, what would the action of that do for sort of dental decay risk?

Well, I 

[00:40:02] Dr Gillian Smith: mean, once you put the sugar ready to go, ready to break down, you know, it's already processed, the strep mutants don't need to do any work, do they? You know, it's just available to them. It's in the biofilm. Um, and so it creates the ideal conditions for tooth decay. We had a similar issue with pouches here, and I have a social media account, I think it was Facebook at the time, because it was a couple of years ago, for my practice.

And I took a picture of a can of Coke, and a picture of one of the pouches. And I put up that the pouch had the same sugar content per 100ml as full fat Coke. And the picture was shared within a day or two over 15, 000 times. And I had the company who makes the pouches on to me. Ooh. I said. Well, I didn't actually say anything negative.

I mean, you can read it on the back of the pack. This is how much sugar is in and you know, there's 33 grams of sugar in a, or 35 grams of sugar, whatever it is in a 330 mil can of Coke. So in a hundred mils there's this much, and in a hundred mils of this smoothie pouch there's this much. You know, it was, it was purely factual.

Um, What were they trying to 

[00:41:10] Emma Pickett: get you to do? I'm curious as to, were they asking you to take the picture down or they were asking Yeah, it was sort of like, 

[00:41:15] Dr Gillian Smith: well, what, what do you, you know, sort of. They didn't act, there wasn't any legal element to it, but it was sort of, well, this is slanderous, you know, well, actually, nope, it's perfectly factual.

[00:41:26] Emma Pickett: God, Timmy, that's basic. I can't believe anyone thought to write that letter to you. That's just gonna fire you up, if anything. So, so let's imagine that you're talking to Nina's family. And I know you've had this conversation lots of times, especially when people are coming to you for that second and third opinion.

You know, parents often feel really guilty and it just, it just causes, it's just one person mumbling that breastfeeding was a factor and they just feel absolutely devastated that they have caused this. I mean, what sort of things do you say to a parent who's in that place? 

[00:41:59] Dr Gillian Smith: Um, it's probably one of the hardest things that I face as a clinician.

I find watching parents squirm, I just find it gut wrenching and, you know, having breastfed. When it comes to breastfeeding, you know, I feel that emotion. It's still raw for me as a parent. And we all do that mom guilt, you know, hands up like, uh, it's default, but you know, you're having that conversation with them and you're telling them that this is preventable.

It's really hard to watch them squirm, you know, um, but I try and empathize and, uh, you know, counsel that this is where we are now and, uh, we have the information we have now and we've, our focus needs to be on moving forward. So what can we do with what we have now and to prevent more. And I, I try to encourage self compassion, you know, I try to say to them, look, to remember that the reason that you feel guilty is because you care.

And that's really important. Um, and that it's important to, to strike the balance between caring and keeping perspective, you know, and that can be difficult and can take time. Um, and I'll, I'll talk to them and say, look, as a profession and as a state, we need to do better, more education and early intervention because.

If I lay the blame at the door of those who could have made this information available to you earlier, made it more readily available to you, that can help. And you know, most importantly, I'll say to them, this is the most common disease of childhood worldwide, globally. Tooth decay is the most common disease of childhood.

So you're not alone. You know, your child won't be the first or the last. human being to experience tooth decay. 

[00:43:42] Emma Pickett: Yeah, I mean, that answer was obviously a general answer about, you know, all the reasons why parents feel guilty when a child has tooth decay. But specifically when it comes to breastfeeding, are you saying, would you say to them, I'm sorry you have been told that breastfeeding was the cause of this.

That's not something I would say to you. Do you go that far? 

[00:44:02] Dr Gillian Smith: I would And I suppose I have gradually developed a reputation for, you know, breastfeeding moms talk and for being a dentist who will talk to them and talk to them through the science. And, you know, I think sometimes the parents are underestimated in their own ability to research and to access information.

And I will sit down with them and talk to them about it and say, look, there is no clear cut research that shows. that breastfeeding will increase your child's risk of tooth decay. You know, actually the research shows that in under once you're less likely to get tooth decay if you're breastfed and that as it stands right now we don't have the research that cohesively coherently says to us.

[00:45:00] Emma Pickett: I'm guessing it must be quite sticky for you because just from the geography of where you live you must be getting the same people coming, you know, you must be the second opinion of quite a lot of your local colleagues. So I'm, I'm not going to ask you to put yourself on the spot here, but you know, there must be Joe Bloggs, who's not called Joe Bloggs, who, um, regularly is telling parents breastfeeding is to blame and you're coming a long second.

Do you, do you meet Joe Bloggs in a local conference and pin him against the wall? I mean, how are you managing this? 

[00:45:28] Dr Gillian Smith: Um, so I'm very, uh, politically active within dentistry for want of a better term. I am a former secretary of the Irish Dental Association. I'm currently the secretary of the Irish Society of Disability and Oral Health.

So I'm very involved in my community of dentists. And if anybody wants to talk to me about this topic, I will happily talk to them about it. And if they want to, uh, say, well, I see tooth decay in breastfeeding toddlers, I'll say, well, I see tooth decay in breastfeeding toddlers, but I also see tooth decay in toddlers who aren't breastfeeding.

And we know that we have to practice evidence based clinical, we have to have an evidence based clinical practice. And there isn't the evidence. So, you know, if you want to challenge me on this, if you want to sit down and we'll have a debate on it, I will happily do that, but there is not, there is no evidence, so if you're going to go on your anecdotal assessment and.

of toddlers and tooth decay, then you're going against what is recommended from our very, the very beginning of our training in dental school, that what we recommend to people and the treatment that we conduct or we carry out is evidence based. 

[00:46:50] Emma Pickett: Yeah. Have you ever had a conversation with anybody about changing breastfeeding patterns?

I'm just thinking if, if Nina had quite severe decay, would it be a good idea for her to reduce nighttime breastfeeding if this, this, if she was on the breast regularly throughout the night? I mean, have you ever needed to have that conversation or even then you're not happy to go there, go ahead with that?

[00:47:09] Dr Gillian Smith: So it has yet to occur. I haven't ever had a conversation with a parent about it. And if I had a toddler where tooth decay was continuing to. progress and we had addressed lots of other factors like diet, increasing fluoride, um, you know, that the child's oral hygiene was impeccable. I might maybe broach the subject of reducing feeding on demand at night where the, you know, child has dry mouth and a substrate on the teeth.

You know, I would be very reluctant to do it. And if I did, I would be trying to encourage that parent to do that in conjunction with an IBCLC. And I would be trying to ensure that I was as supportive as possible and that it was gradual. And it would only be if the child was over two. So, you know, I haven't to date.

You know, we're talking about a hypothetical situation. And I would like to think that as a team, between me and the parent, that we could protect the breastfeeding and look at other factors. You know, that are involved, um, and, and try and reduce the risk of tooth decay that way rather than interfering with their breastfeeding journey.

[00:48:28] Emma Pickett: Yeah. Yeah. So it's your absolute last resort and you haven't even needed to get to that last resort yet. And I just wish that was what was coming out of the mouth of all the dentists I ever come across because so many, the first thing they'll say is breastfeeding. They'll say that before anything else.

[00:48:43] Dr Gillian Smith: And in my experience, and, you know, I can't say what happened in another dentist's consultation, only what the mums come in and say to me, is that beyond the breastfeeding, nothing else was discussed. Now maybe it was, and that mum doesn't remember, or maybe it wasn't. It doesn't really matter, does it?

Because if that's the, um, feeling of a parent when they come out, that they didn't talk about anything else except me stopping breastfeeding, whether the dentist did or didn't. That's all that mother hears, that just shows the impact of those words. You know, now, maybe they didn't, but you know, who's to say.

They didn't remember the other stuff 

[00:49:20] Emma Pickett: anyway. They didn't remember it anyway. It wasn't an effective conversation if anything was said. 

[00:49:24] Dr Gillian Smith: Exactly. So once you say stop breastfeeding, nothing else is heard. And so, you know, I would never, especially on the first consultation, talk about breastfeeding cessation.

And like you say, it's never been necessary beyond that. Because I think, number one, we don't have the evidence. Number two, the impact of those words is so, uh, striking and, uh, devastating for a mother that they don't hear anything else beyond it. And, uh, you know, I hear again from parents that once they've heard that, they are reluctant to go back for treatment.

So it's completely counterproductive to mention it in a discussion. 

[00:50:04] Emma Pickett: And as you say, they're not going back for treatment, so they're not getting, you know, the magic SDF or whatever might help, they're just, you know, the situation's going to get worse. Um, so, um, this is a slightly embarrassing question here, but the Irish health system, you could don't have an NHS as such.

So is it semi private, semi public? What's the situation in Ireland? So we don't have an NHS. We have 

[00:50:28] Dr Gillian Smith: the HSE, which is the public service, which strictly speaking is supposed to be responsible for children's dental health in Ireland. But lots of people are, uh, opt to go privately because that service, unfortunately, over the last number of years, certainly since I qualified, has imploded, you know, virtually just has It's become completely dysfunctional as a system.

There are excellent dentists working within the system, but as a, uh, setup, it is not fit for purpose, the dental, the dental side of the HSE. They are also responsible for special care patients, so, you know, I see it within my special care dentistry service too. And um, in, just before COVID, maybe 2020, we were given a new national oral health policy.

And the new national oral health policy was a plan to move the care of all children's teeth over to the private dental practitioners, where the state would pay the private dentists to look after children. The problem was that they didn't consult with the private dentists before they enacted this policy and since it was enacted or since it was published nothing has happened.

There is no scheme, there is no setup, no children are seen in private practice where they're paid for by the state. Gosh, that's nearly five years ago. Nothing. Yeah, so there's this kind of terrible position where the HSE is being whittled down, you know, the services are reducing all the time and the personnel is being reduced all the time because they're, in theory, it's moving to private practice, yet there's no scheme in place within private practice.

And the private practitioners have said loudly and clearly that they don't want this policy. They're not trained to deal with children, they don't have space in the practices to deal with it, and the remuneration that the state have talked about in terms of what they would pay dentists to see these kids is laughable.

You know, you couldn't run a financially viable business with it. 

[00:52:32] Emma Pickett: Yeah, I mean the situation in England is pretty dire with dental care as well. I don't know, I'm sure you're aware, you know, we've got loads of practices that don't have capacity and, you know, you can't even register children for NHS care.

So the silver diamine fluoride, that's something that is available in every dental surgery or really not? I'd 

[00:52:51] Dr Gillian Smith: like to say it should be, but I doubt it, you know, but you could ask for it. The American Association of Pediatric Dentistry recommends that children are seen on the appearance of their first tooth.

And the British Society of Paediatric Dentistry recommend that children are seen by age one. They had a whole campaign, the British Society of Paediatric Dentistry, that you'd be seen by the age of one. And if, if that could happen, the amount of tooth decay that could be prevented would be significant.

You know, we, uh, if we could, like, new mums are so open, and there's plenty of research out there to show how new mums are really open to health related changes in their behaviour. You know, they want the best for these, these little people and so when they are so receptive to the right information If it can be delivered at the right time, then we really would see a change in children's oral health You know tooth decay is absolutely preventable but We are failing children.

[00:53:59] Emma Pickett: Can I just ask you about teeth brushing, because I know this is something lots of people really struggle with and, and the idea of causing a child distress or, or you know, just feels really uncomfortable. Particularly if you're in that very loving, you know, attachment, parenting vibe. It may seem, it may seem even harder.

And, and obviously, you know, we know toothbrushing matters and also we could be talking about children who are neurodiverse, who for whom toothbrushing is really quite stressful. Do you have any tips for toothbrushing with little people? 

[00:54:26] Dr Gillian Smith: Yeah, I love this question. Parents often say to me, Oh, they won't let me brush their teeth.

And they scream the house down, and it's really stressful. And so, I think that's a big part of this picture too, you know, that the tooth brushing is maybe just too hard sometimes, and too stressful, and you don't want to disturb the peace. Woe betide the angry toddler. But, we wouldn't leave them with a dirty nappy.

And we wouldn't leave them with a dirty face. Because they would wreak havoc with their skin and if we don't clean their teeth, it's going to have repercussions, too It's just maybe not as immediately obvious. So as much of it as it is a challenge, it's a challenge we're working on as family and finding Finding that work around, finding the solution to be able to do it.

You know, we find a way to change a nappy, maybe involve another older child or a parent. We find a way to clean the faces. Um, but, um, I, I think as a parent, if your child knows that this is not negotiable, A little bit like changing a nappy, you know, they know it's going to happen, that mom is not going to be won over on this one, or dad, um, it's going to have to be changed, then they will accept it as part of the routine, you know, and kids love routine.

So my first thing would be make it fun, uh, so whether that's music or singing or dancing. YouTube has some really crazy toothbrushing sounds, but they're great fun for kids and they're all absorbing, you know, so they, they, flashing images and, maybe not for the kids with epilepsy, but you know, they're great.

They're, they're, there's a big beat to them and really engaging. Pick a toothbrush that is small and has a really soft, soft brush. You want it gentle. You don't want anything that's going to cause them any discomfort or too big a head. Their mouths are tiny. You know, a lot of the, a lot of them even, Toothbrushes that are marketed for small children look for smaller, you know, the smaller the better and give them a toothbrush as well So I would always say give them the toothbrush.

What does a toddler do with something you give them? They stick it straight in their mouth So then they have felt the sensation of a brush in their mouth and they have done that Autonomously, you know, they've had the sensation of it and the feeling of it before you go sticking it in their mouth I would also say do not do it in the bathroom.

Kids are squirmy and when they don't want something they're even more squirmy and a stick shaped object and a tiled floor and a sink and a toilet while the kid's moving around and you're trying to get something into their mouth is just a recipe for disaster. Somebody's going to get hurt and then that kid's memory is this hurts.

So do it on a bed or a flat surface like the carpeted floor. Uh, do it downstairs if it's easier. Don't wait till the very last minute before they go to bed when you're trying to have a calm routine. Don't make it stressful and upsetting before you're trying to wind them down. So, do it downstairs. And have two adults, ideally.

Now, I appreciate that's not realistic in every family, but if you can have two adults, that's gonna be the easiest way to do it. If you can't have two adults, an adult and an older kid can help. And so, you want to have the infant, I can send you a link to a great video on this, but you want to have the person who's doing the toothbrushing with the infant's head in your lap, or between your knees, if you know what I mean.

So, if you're kneeling up on a bed or on the floor, their head is between your knees, um, or on your lap, with the head sort of sinking down into your lap a little bit. Just so that if they move right or left, they're contained, you know, they can't go too far to the right or too far to the left. Um, and then the other person's job is to clap with their hands, or sing a song, or tickle their feet, or tickle their tummy, or count.

For kids who are neurodiverse, counting really helps because they know when it's going to end. So we're going to count to five and then we're going to stop. And obviously, you know, pre language, that's a That's difficult, but they will gradually begin to realise we count to five and we stop. We count to five and we stop and we get a break.

Or use a short song like Happy Birthday to You so they know when it's going to end. And afterwards, spit out but don't rinse out. So you want to keep some toothpaste in contact with the teeth, so don't worry about rinsing. So you don't need to be in a bathroom because they're not going to spit anyway before six.

And you're only using a tiny smear of toothpaste on the toothbrush. Again, for the Neurodiverse kids, we use an unflavored toothpaste, like, or nurse, or we use tooth ouse. Tooth ouse plus, which has a, you can get in in different flavors, uh, too fruity and melon and strawberry and that kind of thing. Um, and, um, sometimes it can help if you hold a mirror above the toddler so they can watch and see what's happening.

'cause then they, you know, almost can see what's happening to themselves. Uh, sometimes it can help to show a toy. Some people use YouTube or, or, or videos for them to watch. Um, but, uh, in, certainly in my house, it was always singing. God love my children because I don't have a great singing voice, but that's what they got subjected to along with toothbrushing.

[00:59:33] Emma Pickett: Thank you. That was super helpful. Yeah. If you don't mind sending that video link through, I will put it in the show notes for the episode. So people can have a look. And 

[00:59:40] Dr Gillian Smith: there are some brilliant, um, books and videos you can get, you know, about brushing. So even before you come at them with the toothbrush.

You can do preparation work and, and again for the kids who are neurodiverse, that's going to be really helpful, you know. Let them see you doing it. That's another thing I would always say to parents. Let them watch you brush your teeth or an older child brush their teeth. Let them brush their teddy's teeth.

You know, we practice going to the doctor, we practice going to the dentist. You know, playing is helpful. And some people like reward charts, you know, that can work. Um, I had one parent who gave me a great tip on brushing. It's a little bit older maybe than the, the population of kids we're talking about, but to play a game that you explain why you're brushing their teeth.

So you talk about how you're cleaning off the food from the day and when you're cleaning their teeth, you pretend to find it. So you say, Oh, I think I see a Rice Krispie. Uh, Oh, Oh, look, I see a bit of carrot up here. And then, you know, you can throw in a crazy thing like, Oh, I think I see a pig, you know, like kids enjoy that kind of humor.

You know, you can. I think, I think I can see a ladybird back here, you know, and so you can kind of have a, have a bit of fun with them and they get a giggle over that. 

[01:00:47] Emma Pickett: Yeah, that sounds cool. Um, I know that you do tongue tie, uh, tongue tie clinic and you talked a little bit about dry mouth and, um, you know, that, that, how that could increase the risk of dental decay.

What's the relationship between tongue tie and dental health? 

[01:01:03] Dr Gillian Smith: Um, I suppose, you know, some people talk about, uh, if you have a tongue tie you can't clean your, clear food from your mouth, you know, or clean your teeth with your tongue because of the oral restriction, but this is anecdotal, you know, there's no science in that area.

I hate the term lip tie, because again we have no scientific evidence to show that the upper midline frenulum causes a problem. But, uh, that upper midline bit of skin between the two front teeth can make it tricky to clean a toddler's teeth, because it's meant to be low and fleshy and in between the two front teeth in a toddler.

But there's a simple workaround for that, so rather than brushing the upper teeth, upper incisors in a toddler horizontally, turn the toothbrush vertically and brush one, and then go to the other side of the frenulum and brush the other, up and down, rather than across. And then you won't traumatize that little frenulum.

Um, and the other issue that tongue tie can cause, and actually I saw an eight year old with it today, where the tongue tie is pulling on the gum. So if the tongue tie is very, um, anteriorly placed, so right at the tip of the tongue. As they move the tongue, they pull on the gum that supports the two lower incisor teeth, and that can cause a periodontal issue, so we'll probably have to look at releasing that so that the gum isn't damaged, or the interdental papilla, which is the little triangle of gum between the two teeth, isn't damaged on his front teeth.

But, uh, I'd say that's about it from a tongue tolerant. 

[01:02:26] Emma Pickett: Okay, thank you. Thank you so much for your time today, Jill. I'm really, really, really appreciative. I can hear how passionate you are about this and I'm really grateful on behalf of all the breastfeeding families that you've supported because I know what a difference you make.

If you could speak to all the dentists in the world, so you've got a matrix download and you can put something in their brains right now, what would you want them to know about breastfeeding and working with breastfeeding families? 

[01:02:50] Dr Gillian Smith: Okay, well, number one, there's ample evidence for the health benefits associated with breastfeeding for both infants and their moms.

in terms of their general health. It's indisputable and we should be encouraging breastfeeding in line with international recommendations like the WHO, uh, that mums exclusively breastfeed their infants for optimal growth development in the house. But number two, when it comes to tooth decay, as dentists, it's our job to identify the disease and treat it appropriately.

And that needs to be done with informed consent. So we have a role in preventing the disease too, but any recommendations we make around preventing more disease has to be firmly rooted in science. And currently there is very little evidence to show that breastfeeding on demand increases the risk of tooth decay below the age of two.

So, in my opinion, a good clinician will listen to families, respect their choices, and that family's own values and their health related goals, which might not always align with ours, but that's their health related goals. We need to be patient or person centered, and that should be our goal. I really believe that, um, you know, our care should support people to develop their knowledge, their skills, and their confidence, uh, to effectively manage a disease for them or their child and make their own informed decisions for their health.

You know, we have to tailor our treatment plans to each individual. We can't just. Tar them all with the same brush. It's person centered care. Crucially, we have to treat everybody with dignity, compassion and respect. 

[01:04:29] Emma Pickett: Yeah, three cheers for that. And if someone leaves your practice distressed, obviously the idea of your child having decay is distressing and we might not be able to get rid of that distress immediately.

But they should certainly leave their feeling hope and leave their feeling ideally that they've connected with a practitioner who listens to them and helps them understand what's important to them. And as you say, that may well be that breastfeeding is very important to that family. So no one should ever say in a 20 minute appointment, stop breastfeeding.

It's just not. It's not compassionate. It's not scientific. It's not based on reality or evidence and it should not be happening. 

[01:05:03] Dr Gillian Smith: We should respect that choice. You know, that person's made a choice to breastfeed. We should recognize the health benefits and support them, you know, recognize those benefits and continue to inform ourselves with scientific developments in the area.

You know, if there, if, if and when there is research to support breastfeeding as an increased risk of decay, well, then we just talk about it as increased risk. Like we do about everything else that increases risk. But without bias and judgment 

[01:05:31] Emma Pickett: three cheers for that. Thank you so much for your time to judge.

Oh, I really appreciate it. Thanks

Thank you for joining me today You can find me on instagram at emma pickett Ibclc and on twitter at makes milk. It would be lovely if you subscribe Scribed because that helps other people to know I exist and leaving a review would be great as well. Get in touch if you would like to join me to share your feeding or weaning journey, or if you have any ideas for topics to include in the podcast.

This podcast is produced by the lovely Emily Crosby Media.